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

Outline

• Gender differences

• Hip Injuries

– Labral tear

– Iliopsoas tendinopathy

– Gluteal tendinopathy

– Stress fracture

• Gluteal Injuries

– Ischiofemoral impingement

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

Pelvic Structural Differences

• Female

– Greater iliac flare

– Wider pubic angle

– Wider ischial tuberosity

– Pubic symphysis shorter

– Wider fibrocartilage disc

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

Dynamic Alignment

Landing Mechanics

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

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

Hip Pain

Intra-articular Extra-articular

Clinical Assessment

Imaging

Diagnostic Injection

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

Labrum

• Blood supply

– Mostly avascular

– May be peripheral blood

vessels

– ? Healing potential

• Nerve supply

– Obturator nerve

– Branch of nerve to quadratus

femoris

• 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

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

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%

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

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

Iliopsoas Tendon

• Directly anterior to the anterosuperiorcapsulolabral complex at 2 o’oclock

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

Examination

Ilizaliturri and Camacho-Galindo. Sports Med Arthrosc Rev. 2010.

Ultrasonography

• Dynamic evaluation

• Color Doppler

• Contralateral exam

• Infrequent tendinopathy

w/ snapping hip

– Pelsser et al. 2001.

• Guided injection

Blankenbaker D. Skeletal Radiol. 2006

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

Femoral Neck Stress Fracture

• Diagnosis frequently delayed

• Compression side

– WBing restriction

– Conservative care

• Tension side

– High risk nonunion,

displacement

– Surgical fixation

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%

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.

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

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

Lateral Hip Pain

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.

Biomechanics

• Rotator cuff of hip

– External rotators

– Abductors

– Joint compression

Neumann DA. JOSPT 2010

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

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

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.

Treatment

• Individualized Program

– Activity modification

– NSAID trial, topical

– Physical Therapy

• Abductor strengthening

• Isolated from TFL, Iliopsoas

• Core, pelvic stabilization

• Motor retraining

– Role of injection

• 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.

Case

• 32 F runner glut pain

– Sitting intolerance

• Exam

– Gastroc asymmetry

– Absent achilles

• Eval

– MRI spine, pelvis

– EMG

– U/S

• Treatment

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

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

THANK YOU