Good evening, everyone. It's T. Sean Lynch from Columbia University in New York, and we're going to be talking about five pearls for the evaluation of the athlete with hip pain. Here are my disclosures, none of which are relevant to the content of this talk. So hip pain can be serious in the athlete because it can cause a loss of playing time, which requires an extensive rehabilitation and even in the past would have caused early retirement. The diagnosis and management can be difficult because these athletes can have chronic symptoms, which can often be generalized and ambiguous. So the first pearl, don't get overwhelmed when evaluating these patients. This is a long list of your differential diagnosis when evaluating with the athlete with hip pain. But I'm going to stop right there. I don't want to lose you guys in the first couple of minutes. Let's try to make it a little bit simpler. So when an individual comes in with hip pain more times than not, their pain is going to be coming from their interarticular hip or their extraticular hip. Also want to keep in mind the core and the low back, the bowel, the bladder, the reproductive organs, as well as the knee. Pearl number two, listen to the athlete. They'll lead you down the path of righteousness. Athlete that comes in with hip pain can sometimes be complicated. And the way that I like to think about it is that this is very similar to Times Square. Lots of people coming into and out of bright lights, loud noises. So location, location, location is going to be really important. So let's simplify it. So when an athlete comes in with pain in their suprapubic region along their pubic symphysis, want to consider a status pubis, which is a non-infectious inflammation of the pubic symphysial joint. Pain that's along their beltline, thinking more of a core muscle or rectus abdominis injury. Pain along the medial groin. Want to think about an adductor muscle strain. Pain that's present about the anterior aspect of their hip. Usually thinking about some type of interarticular process, whether it's a labral tear in our running athlete population. I might want to think about a stress injury as well. Very rarely are athletes going to be coming in with hip flexor tendonitis. So if you have an athlete that comes in with a diagnosis of hip flexor tendonitis, start thinking about that there might be something more going on. Pain about the lateral aspect of the hip will be coming from gluteus tendon injury or potentially hip bursitis. And then pain that's coming from in a radiating fashion from front to back with radicular symptoms down into the lower extremity. You want to think about lumbar spine. This is a review paper here that we put together a few years ago on our pearls of evaluating athletes with athletic hip injuries. And this is present in the American Journal of Orthopedics. Here's our third pearl. Six-pack for your six-pack. So this is a way to think about how to evaluate your athlete in an efficient manner. So in terms of our adductor muscle injuries, we'll typically have pain along their adductor muscle as well as its insertion. They'll have pain with passive stretch as well as pain with resisted adduction. In terms of osteopus, which is that non-infectious inflammation of the pubic symphysial joint, will typically be tender to palpation right over their pubic symphysis. And you can also reproduce some of this pain by what's performing a springs test in which you put your hand on either side of their joint. And you can push down and cause that articular cartilage to grind up against the two bones and reproduce the discomfort. In terms of a core muscle injury, typically we will see these in young athletic males. But I'll tell you, I've been seeing it more commonly in the female athletic population as well too. They'll have a deep groin or lower abdominal discomfort that's present with activity and gets better with rest. They'll have pain over their pubic tubercle or conjoined tendon, pain with resisted sit-up, and pain with resisted adduction. In terms of femoral acetabular impingement, these individuals will come in with limited range of motion, particularly with flexion as well as internal rotation. They'll have impingement testing, which will bring the hip up to 90 degrees. And by bringing the leg across the body, as you just saw, we're going to be forcing that femoral head up against the acetabulum to reproduce the pain that they have been experiencing. In terms of Faber testing, I can reproduce pain about the anterior aspect of their hip, but also can measure the distance from the fibular head to the table, which can also reproduce, which also can be indicative of a CAM lesion. And then finally, resisted straight leg raise to kind of get a sense of if there's any involvement of the lumbar spine. Pearl number four, image is everything. So I'll tell you, a good set of radiographs can give me far more information than what we might get from an MRI. So x-rays are critically important when evaluating these athletes when they come into the training room or the office. MRI can be helpful in those individuals in which you're trying to rule out interarticular pathology. At our institution, we typically use a 3-Tesla magnet, so we don't need to utilize an orthogram. But this is a picture of a previous one that was taken. And then CT scan for preoperative planning purposes, if there's any bony morphology that you're trying to elucidate in the form of an os acetabuli, as you see in this image right here. But I'll give you a word of caution about our radiographs. So this is a study that was done at Avail back in 2012. They took individuals 15 to 65 years of age, no hip pain, put them into an MRI scanner. And what they found was that over 70% of those individuals had MRI abnormalities, with labral injuries being the most common at just under 70%. Average alpha ankle was just over 60 degrees, and males were more common than females to have CAM lesions at almost nine times. And then finally, pearl number five. The hip bone is connected to the, well, everything. So at the center of all these soft tissue muscle injuries around the core and the lower extremity is really femoral acetabular impingement. And a way to look at this, this is a video from Pat Birmingham in terms of some of the work that he did. When you see the presence of a CAM lesion, with that CAM lesion banging into the acetabulum, you can see that there can be shearing anteriorly at the pubic symphysis, as well as shearing posteriorly at the SI joint. So that's why it's not uncommon for these athletes to also complain of suprapubic or SI joint discomfort when dealing with femoral acetabular impingement. This is a study that was done by Chris Larson, looking at his athletes with both the interarticular as well as extraarticular hip pain. When they treated just the isolated athletic pubalgia, a quarter of them were able to return to play. When they treated the interarticular FAI, 50% of them were able to return to play. And when you dealt with both of them, almost 90% of these athletes were able to return to play. This was a study that was done by Brian Kelly, looking at a group of professional athletes. What they found was that athletes with isolated athletic pubalgia were not able to return to play until their FAI was addressed. And they found that 60% of athletes had resolution of their athletic pubalgia with FAI surgery. So in conclusion, stay calm when evaluating these athletes. Listen to what they tell you, and typically where they're having the discomfort will lead you down the path of righteousness in terms of your workout. Make sure to examine confidently. A lot of times, sports medicine providers and physical therapists and athletic trainers can get very overwhelmed when dealing with the hip. Hopefully the pearls that we provide to you will help provide you some confidence when evaluating the office. And just because a patient or athlete has X-ray findings doesn't necessarily mean that's causing symptoms. So make sure that you correlate. And finally, the core is the core for a reason. So thank you so much. Sorry, I can't join everyone in Chicago. Hopefully we'll be able to join each other soon and wish everyone a great holiday season and see everyone in 2021. Thank you.

hip pain

athletes

diagnosis

management

chronic symptoms