Page 1
Your name and credentials
Female Athlete Hip Injuries:
Exploring the CORE of
Patterns and Prevention
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
Massachusetts General Hospital Sports Medicine
Kelly C. McInnis DOIrene Davis, PhD, PT, FAPTA, FACSM, FASBDavid Nolan, PT, DPT, MS, OCS, SCS, CSCS
Page 2
Outline
• Gender differences
• Hip Injuries
– Labral tear
– Iliopsoas tendinopathy
– Gluteal tendinopathy
– Stress fracture
• Gluteal Injuries
– Ischiofemoral impingement
Page 3
Pelvic Structural Differences
Male
• Narrower, heart-shaped inlet
• Narrower sciatic notch
• Muscular impression more
distinct
Female
• Open, circular inlet, less depth
• Anterior pelvic tilt
• Broader sciatic notch
• Bones more slender; muscular
impressions less distinct
Page 4
Pelvic Structural Differences
• Female
– Greater iliac flare
– Wider pubic angle
– Wider ischial tuberosity
– Pubic symphysis shorter
– Wider fibrocartilage disc
Page 5
Hip Joint
• Female
– Greater risk of dysplasia
– Femoral, acetabular anteversion
– Smaller femoral head
• Possible increased contact
pressures
– Greater trochanteric distance
side to side
– Coxa vara
– Femoral neck architecture
Page 8
Female Athlete Injuries
Hip and Pelvic
• Acetabular labral tear
• Iliopsoas tendinopathy
• Gluteus medius / minimustendinopathy
• Trochanteric bursitis
• Stress fracture
• Osteitis Pubis
• Sacroiliac Joint Dysfunction
• Piriformis pain
• Ischiofemoral impingement
• Proximal hamstring injury
Knee
• Anterior Cruciate Ligament
• Patellofemoral disorders
• Iliotibial Band Syndrome
Page 9
Hip Pain
Intra-articular Extra-articular Referred
Labral•Trauma
•Hypermobility
•Impingement
•Dysplasia
•Degenerative
Chondral•Osteoarthritis
•Lateral Impact
•Dislocation
•Subluxation
•AVN
•Synovial
•Chondromatosis
Capsular•Capsular Laxity
•Iliofemoral lig.
attenuation
•Adhesive
Capsulitis
•Synovitis
•Ligamentum
teres injury
Muscle
Tendon
Bursa
Ligament
Sports Hernia
Nerve
Bone
Lumbar
Radiculopathy
Sacroiliac joint
Visceral
OB / GYN
Page 10
Hip Pain
Intra-articular Extra-articular
Clinical Assessment
Imaging
Diagnostic Injection
Page 11
Labrum
Function
• Extension of Bony
Acetabulum
• Shock absorber
• Suction Seal
– Weber 1837, Takechi et al. 1982
Tear
• Loss of Suction Seal
– Synovial fluid “leak”
– Decrease hydrostatic pressure
– Increase cartilage
compression
– Relative instability
Page 12
Labrum
• Blood supply
– Mostly avascular
– May be peripheral blood
vessels
– ? Healing potential
• Nerve supply
– Obturator nerve
– Branch of nerve to quadratus
femoris
Page 13
• Histology of pain receptors
• Distribution on labrum,
ligamentum teres and
capsule
– Nociceptin, Substance P,
Neuropeptide Y
• Highest concentration
anterosuperior at
chondrolabral junction
13Haversath M et al. 2013
Page 14
Labral Tear
• Active young adults
• Women > men– Dance, gymnastics, soccer, runners
• Hypermobility; Beighton score
• Females more commonly atraumatic
• Abnormal joint morphology– Dysplasia, instability, internal snapping hip, FAI
– Females milder FAI but more symptomatic
• Females worse self-reported outcomes post op
• Neuromuscular risk factors?
• Precursor to OA
Page 15
Do all Labral Tears
Cause Pain?
• 70 asymptomatic patients, mean age 26 , 67% female– 3T MRI
– Labral tears in 38%
• 45 patients, mean age 38 – Labral tears in 70%
• Military – Labral tears in 86%
• College and Pro Ice Hockey– Labral tears in 56% and 86%
Page 16
Diagnostic Accuracy of Clinical Assessment, MRI,
MRA, and Intra-Articular Injection in Hip
Arthroscopy Patients. AJSM. Byrd and Jones. 2004.
• Intra-Articular Injection– 7 % false-negative
– 2 % false-positive
– 90 % accurate
• Most reliable indicator of intra-articular abnormality
Page 17
Nonoperative Treatment
• Relative rest, NSAID trial
• Role of Focused PT
– Balance of hip / core strength, flexibility
• Encourage posterior pelvic tilt
– Gluteus medius
– Neuromuscular modifications
• Injection
• Unclear potential for labral healing
• Recurrence of symptoms
• Close follow up; re-imaging
Page 18
Iliopsoas Tendon
• Directly anterior to the anterosuperiorcapsulolabral complex at 2 o’oclock
Page 19
Iliopsoas Tendon
• Anatomy
– Neutral tendon position
• Iliopsoas bursa
– Communication w/ hip capsule 15%
• Function
– Hip flexion, erect posture
• Internal snapping hip
– 10% population; 50% in adolescent ballet dancers; hypermobility
– 50% + intraarticular pathology
• Risk for labral tear
Page 20
Examination
Ilizaliturri and Camacho-Galindo. Sports Med Arthrosc Rev. 2010.
Page 21
Ultrasonography
• Dynamic evaluation
• Color Doppler
• Contralateral exam
• Infrequent tendinopathy
w/ snapping hip
– Pelsser et al. 2001.
• Guided injection
Blankenbaker D. Skeletal Radiol. 2006
Page 22
Treatment
• Physical Therapy
– Balance of Hip extensors / flexors
• NSAIDs, activity modification
• Injection
• Recession of Iliopsoas
– Pelvic Brim
– Transcapsular release (50/50)
– Lesser trochanter (60% tendon/40% muscle)
– Mixed outcomes
Blomberg JR et al. AJSM. 2011
Page 23
Femoral Neck Stress Fracture
• Diagnosis frequently delayed
• Compression side
– WBing restriction
– Conservative care
• Tension side
– High risk nonunion,
displacement
– Surgical fixation
Page 24
FNSF
• 25 Injuries; 95.2% were runners
– Averaged 25.6 mi/wk (range 10-75)
– 47.6% had a prior stress fracture
• Presentation
– Anterior or anterolateral pain +/-
groin radiation
– Exam
– Low BMD 36%
– Vit D insufficient (< 32) in 17%
• Prognosis
– Grade 4: 20 wks to return to running
Ramey L and McInnis KC. AMSSM. 2015.
Females 88%
Page 25
Gluteus Medius Strength
• Strain gauge studies
– Neutralizes tensile stress
through femoral neck
– Key to hip biomechanics
– Need strong, reactive glut
med, resistant to fatigue
– May be modifiable risk
factor for femoral neck
stress fracture;
intraarticular pathology
Egol et al. CORR. 1998.
Page 26
Pubic Stress Fracture
• 1-7% of all stress fractures
• Groin pain; often misdiagnosed
• Medial portion of pubic ramus or jxn b/t inferior
pubic ramus and ischial ramus
– May be adductor magnus load as hip is extended
• Mixed training in military; women increased stride
length
• Distance runners
Page 27
Iliac Stress Fracture
• 49F marathon runner w/hip and groin pain
– 3 mon prior: TAH and bowel resection
– + hop test, SIJ provocative tests
– Tenderness over iliac crest
• MRI
– Stress fracture at mid-body ilium, edema in iliacus and glut min
• NWBing 4 wks, PT, RTR 3 months
• BMD normal, Ca/Vit D normal
• Very rare, usually insufficiency fractures
• Few case reports in runners
Page 29
Trochanter Anatomy
• Hip rotator cuff– 4 facets
– Tendon attachments• Gluteus medius, minimus
• piriformis, obturator externis /
internus
– 3 bursa• Sub glut max
• Sub glut med
• Sub glut min
Pfirrmann et al. Radiology. 2001.
Page 30
Biomechanics
• Rotator cuff of hip
– External rotators
– Abductors
– Joint compression
Neumann DA. JOSPT 2010
Page 31
Peritrochanteric Pain
• Female 4:1– Increasing in athletes
– Wider pelvis, femoral anteversion
– Weak gluteals
• Lateral hip pain
• Former thinking– Trochanteric bursitis
• Recent imaging studies – Gluteus medius / min tendinopathy
– Less frequent bursitis
Page 32
Gluteus Medius / Minimus
Tendinopathy
• Insidious onset
• Degenerative, progressive tears
• Interstitial partial tears most common
– ¼ middle-aged women, 1/10 men
• Tenderness at trochanter
• Pain w/ sidelying
• Pain w/ resisted abduction, passive adduction
Page 33
Dynamic Testing
Lequesne et al. Gluteal tendinopathy in refractory greater trochanter pain
syndrome: diagnostic value of two clinical Arthritis Rheum. 2008.
Silva F. et al. Journal of Clinical Rheumatology. 14(2); April 2008.
Page 34
Treatment
• Individualized Program
– Activity modification
– NSAID trial, topical
– Physical Therapy
• Abductor strengthening
• Isolated from TFL, Iliopsoas
• Core, pelvic stabilization
• Motor retraining
– Role of injection
Page 35
• 8 Level IV studies reviewed
• 90% women; average symptom 2yrs
• Gluteus medius partial tears most common
– Both medius and minimus occurred 1/3 of pts
• Good to excellent functional outcomes and
pain reduction
• Complications rates low
– 13% open (DVT, PE, infection, 1 fracture)
– 3% endoscopic (superficial infection)
– Risk of retear 9% in open repair; none reported in endoscopic repair
Voos et al. AJSM. 2009.
Page 36
Case
• 32 F runner glut pain
– Sitting intolerance
• Exam
– Gastroc asymmetry
– Absent achilles
• Eval
– MRI spine, pelvis
– EMG
– U/S
• Treatment
Page 37
Ischiofemoral Impingement
• Groin, buttock pain
– Possible sciatic neuralgia
• IFS narrows w hip add/ER
• Risks
– Less trochanter fractures
– Intertroch osteotomy
– OA w superomed migration
– Prox hamstring enthesopathy
– Bone lesions
• PT, guided injection, surgery
Page 38
Summary
• Structure, characteristic movement patterns and
hypermobility contribute to several common female
athlete hip and pelvic injuries
• Importance of kinetic chain, neuromuscular control
about the pelvis, motor retraining
• Gluts are KEY
• Prevention best treatment