Evan Peck, MD
Section of Sports Health
Department of Orthopaedic Surgery
Cleveland Clinic Florida
Disclosures
 Financial disclosures: Neither I, Evan Peck, nor any
family member(s), have any relevant financial
relationships to be discussed, directly or indirectly,
referred to or illustrated with or without recognition
within the presentation.
 Off-label use disclosures: None.
Objectives
 Be aware of the broad differential diagnosis of hip
pathology in the athlete.
 Recognize clinical clues that may aid in identifying the
etiology of hip pain.
 Understand the strengths and weaknesses of common
imaging modalities for the evaluation of hip pain.
Hip Pain: Overview
 Intraarticular (IA) pathology.
 Soft tissue injuries.
 Bone injuries.
 Nerve entrapment injuries.
 Infection.
 Pediatric-specific conditions.
 Referred: Spine, GI, GU, GYN,
etc.
Miller 2014
Intraarticular Pathology
 Degenerative joint
disease (DJD).
 Focal chondral injuries.
 Femoroacetabular
impingement: Cam,
pincer, combined.
 Labral tears.
 Loose bodies.
 Ruptured ligamentum
teres.
Miller 2014
Soft Tissue Injuries
 Bursitis: Trochanteric, ischial, iliopsoas, iliopectineal.
 Contusions: Iliac crest, quadriceps, groin.
 Myositis ossificans.
 Muscle/tendon injuries: Iliopsoas, quadriceps,
adductors, abductors/gluteals, hamstrings, external
obliques.
 Snapping hip syndrome: External, internal,
intraarticular (?), posterior.
 Sacroiliac sprain or dysfunction.
 Hernias: Inguinal, femoral.
 Athletic pubalgia.
Miller 2014
Bone Injuries
 Traumatic fractures: Pelvis,




acetabular, femoral
head/neck,
peritrochanteric, femoral
shaft.
Hip dislocation.
Stress fractures: Pelvic,
sacral, femoral neck.
Osteitis pubis.
Avascular necrosis (AVN).
Miller 2014
Nerve Entrapment Injuries
 Sciatic.
 Obturator.
 Pudendal.
 Ilioinguinal.
 Femoral.
 Lateral femoral
cutaneous.
 Lumbosacral radicular
(referred).
Miller 2014
Pediatric Conditions
 Apophysitis and avulsion
fracture.
 Slipped capital femoral
epiphysis (SCFE).
 Legg-Calve-Perthes
disease.
Miller 2014
Clinical Approach: Overview
Intraarticular
H&P,
X-rays
Red
Flags?
N
Extraarticular
Y
Urgent
Testing,
Imaging,
and/or
Referrals
Referred/
Spine
Diagnosis(es):
Interventions,
Possible
Advanced
Imaging
Clinical Approach: History
 Delineate region of pain to narrow differential
diagnosis.
 Sudden onset (with or without trauma) vs insidious?
 Worse with activity?
 Mechanical symptoms?
 Actual hip pathology vs referred pain source?
 Exclude the most worrisome etiologies such as cancer,
fracture, infection, and myelopathy.
 Be mindful of polyarthralgia and
rheumatic/inflammatory disease.
Clinical Approach: Physical Exam
 DJD, hip effusion, muscle contracture, or SCFE may
cause loss of hip IR (test seated to stabilize pelvis).
 Resisted SLR, log roll, anterior impingement, posterior
impingement, Patrick, McCarthy, scour maneuvers all
suggestive of IA hip pain source; none have high
sensitivity or specificity.
 Passive SLR: (+) at 0-30o  radicular; (+) at >30o  SIJ.
 Sensory loss or any foot/ankle weakness not expected
with hip pathology (think lumbosacral radiculopathy or
other nerve entrapment).
Reiman 2013, Troum 2004
Imaging: X-rays
 Tonnis angle: AP view.
 Horizontal line and tangent
from lowest point of
sclerotic zone of acetabular
roof to lateral edge of
acetabulum.
 0-10o: Normal.
 >10o: Increased; suggests
structural instability.
 <0o: Decreased; suggests
pincer-type FAI.
Clohisy 2008
Imaging: X-rays
 Alpha angle: Best with
modified Dunn (45o hip
flexion) view.
 Line from center of
femoral head through
center of neck, and line
from center of head to
head/neck junction.
 <42o: Normal.
 >42o: Increased;
suggests cam-type FAI.
Clohisy 2008
Imaging: X-rays
Imaging: Ultrasound
 Useful for evaluating
muscle, tendon, and
nerve pathology.
 Limited value for
diagnosing IA pathology,
although
“sonoarthrography”
improves conspicuity of
labral tears.
Long 2013, Sofka 2006
Gluteus medius tendinosis
Imaging: MRI/MRA
 Labrum tears:
 MRI:
 Sensitivity 66%.
 Specificity 79%.
 MRA:
 Sensitivity 87%.
 Specificity 64%.
 Be careful to distinguish
normal variants from
pathology.
Smith 2011
MRA T1 coronal
Diagnostic Intraarticular Hip Injection
 High correlation
between hip chondral
damage and relief from
IA injection.
 Low correlation
between labral
tears/FAI and relief
from IA injection.
 Concurrent
 LACK of relief from IA
extraarticular pathology
injection predicts poor
has no effect on
functional improvement
injection response.
following arthroscopic
Ayeni 2014, Kivlan 2011, Krych
surgery.
2014
Iliopsoas Tendinopathy
 Iliopsoas
myotendinous
junction located
directly anterior to
capsulolabral
complex at 2:00-3:00
position.
 Coincides with most
frequent region of
acetabular labrum
injury.
Alpert 2009
Greater Trochanteric Pain Syndrome
 “Rotator cuff of hip:”
 Gluteus medius.
 Gluteus minimus.
 “Deltoid of hip:”
 Gluteus maximus.
 Tensor fascia lata.
 “Soft acromion of hip:”
 Iliotibial band.
 Bursae: Subgluteus
maximus (greater
trochanteric), subgluteus
medius, subgluteus
minimus.
Posterior–Anterior
Greater Trochanteric Pain Syndrome
 MRI findings:
 83.3% GMed pathology.
 62.5% GMed tendinosis.
 45.8% GMed tear.
 8.3% trochanteric bursitis.
 4.2% AVN.
 Trendelenburg sign best
clinical indicator of gluteus
medius tear (sensitivity
72.7%/specificity 76.9%) vs
resisted ABD or IR pain.
Bird 2001
Hamstring Injuries
 Acute injury most likely during
terminal swing phase, with nearmaximal activation and near-maximal
length.
 Usually biceps femoris at
myotendinous junction.
 Weakness with hip extension and
knee flexion.
 Complete rupture (1.5%), avulsion
fracture, or apophyseal avulsion
retracted >2 cm: Surgical
consultation.
Heiderscheit 2005, Saartok 1998, Woods
2004
Hamstring Injuries
Snapping Hip Syndrome
 Internal:
 Iliopsoas tendon may
slide over bony
prominences (anterior
brim, femoral head,
lesser trochanter), OR
due to sudden release of
most medial iliacus
fibers from between the
tendon and the superior
pubic ramus.
Guillin 2009
 External:
 Iliotibial band, fascia
lata, or gluteus maximus
over greater trochanter.
 Intraarticular:
 Unclear if true entity.
 Posterior:
 Proximal hamstring
tendon over ischial
tuberosity.
Athletic Pubalgia
 Pain with resisted hip adduction




and abdominal contraction.
17 injury patterns described.
High correlation with FAI.
May be related to uneven forces
on the adductor longus (AL)rectus abdominis (RA) common
aponeurosis.
? entrapment of genital branches
of ilioinguinal or genitofemoral
nerves.
Akita 1999, Feeley 2008, Meyers 2008
Athletic Pubalgia
 MRI: RA pathology.
 68% sensitive, 100%
specific.
 MRI: AL pathology.
 86% sensitive, 89%
specific.
 Secondary cleft sign: Fluid
signal extending from
anteroinferior insertion of
RA into AL origin.
Slavotinek 2005
Femoral Neck Stress Fractures
 Clinical: Discuss training
history, +antalgic gait, +hop
test.
 Compression sided (inferior):
 Stage 1: No fatigue line.
 Stage 2: Fatigue line <50%.
 Stage 3: Fatigue line >50%.
 Usually non-operative
(PWB).
 Tension sided (superior):
 Surgery required.
Shin 1997
Avascular Necrosis of Femoral Head
 Mean age at presentation:





38 yo.
Leads to 5-18% of THAs.
Interruption of blood
supply to bone.
+/- trauma.
X-rays often normal; MRI
changes are seen very early
(5 d).
Usually results in eventual
collapse of necrotic
portion.
Lavernia 1999
Summary
 Hip pain has a broad differential diagnosis of both
intraarticular and extraarticular etiologies as well as
numerous potential causes of referred pain.
 A confluence of historical and physical examination findings
helps narrow the differential diagnosis.
 Clinicians must be alert to “red flag” findings prompting
urgent attention.
 Imaging is a valuable tool in the evaluation of hip pain, but
each modality has important limitations.
References
Miller MD et al, Eds. DeLee and Drez's Orthopaedic Sports Medicine: Principles and
Practice, 4th Ed. Philadelphia, PA: Elsevier; 2014.
Reiman MP et al. Diagnostic accuracy of clinical tests of the hip: a systematic review with
meta-analysis. Br J Sports Med. 2013 Sep;47(14):893-902.
Troum OM et al. The young adult with hip pain: diagnosis and medical treatment. Clin
Orthop Relat Res. 2004 Jan;(418):9-17.
Clohisy JC et al. A systematic approach to the plain radiographic evaluation of the young
adult hip. J Bone Joint Surg Am. 2008 Nov;90 Suppl 4:47-66.
Long SS et al. Sonography of greater trochanteric pain syndrome and the rarity of primary
bursitis. AJR Am J Roentgenol. 2013 Nov;201(5):1083-6.
Sofka CM et al. Sonography of the acetabular labrum: visualization of labral injuries during
intra-articular injections. J Ultrasound Med. 2006 Oct;25(10):1321-6.
Smith TO et al. The diagnostic accuracy of acetabular labral tears using magnetic resonance
imaging and magnetic resonance arthrography: a meta-analysis. Eur Radiol. 2011
Apr;21(4):863-74.
Ayeni OR et al. Pre-operative intra-articular hip injection as a predictor of short-term
outcome following arthroscopic management of femoroacetabular impingement. Knee
Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):801-5.
References
Kivlan BR et al. Response to diagnostic injection in patients with femoroacetabular
impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy.
2011 May;27(5):619-27.
Krych AJ et al. Limited therapeutic benefits of intra-articular cortisone injection for patients
with femoro-acetabular impingement and labral tear. Knee Surg Sports Traumatol
Arthrosc. 2014 Apr;22(4):750-5.
Alpert JM et al. Cross-sectional analysis of the iliopsoas tendon and its relationship to the
acetabular labrum: an anatomic study. Am J Sports Med. 2009 Aug;37(8):1594-8.
Bird PA et al. Prospective evaluation of magnetic resonance imaging and physical
examination findings in patients with greater trochanteric pain syndrome. Arthritis
Rheum. 2001 Sep;44(9):2138-45.
Heiderscheit BC et al. Identifying the time of occurrence of a hamstring strain injury during
treadmill running: a case study. Clin Biomech (Bristol, Avon). 2005 Dec;20(10):1072-8.
Saartok T. Muscle injuries associated with soccer. Clin Sports Med 1998;17:811-7.
Woods C et al. The football association medical research programme: an audit of injuries in
professional football—analysis of hamstring injuries. Br J Sports Med 2004;38:36-41.
Guillin R et al. Sonographic anatomy and dynamic study of the normal iliopsoas
musculotendinous junction. Eur Radiol. 2009 Apr;19(4):995-1001.
References
Akita K et al. Anatomic basis of chronic groin pain with special reference to sports hernia.
Surg Radiol Anat. 1999;21(1):1-5.
Feeley BT et al. Hip injuries and labral tears in the national football league. Am J Sports
Med. 2008 Nov;36(11):2187-95.
Meyers WC et al. Experience with "sports hernia" spanning two decades. Ann Surg. 2008
Oct;248(4):656-65.
Slavotinek JP et al. Groin pain in footballers: the association between preseason clinical and
pubic bone magnetic resonance imaging findings and athlete outcome. Am J Sports Med.
2005 Jun;33(6):894-9.
Shin AY et al. Fatigue Fractures of the Femoral Neck in Athletes. J Am Acad Orthop Surg.
1997 Nov;5(6):293-302.
Lavernia CJ et al. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999 JulAug;7(4):250-61.
Thank You
pecke@ccf.org