Hip Pathology in the Adolescent athlete

1
Hip Pathology in the Adolescent athlete Dr.EMAD
KARIM
2

• This article will review the more common causes
  of hip and groin pain in the adolescent athlete,
• as well as advances in diagnostic and therapeutic
  interventions.

3

• Risk factors to adolescent hip pathology include
• musculoskeletal balance
• open physes and growing

4
Physical examination

• Patients with intra-articular hip pain place a
  hand in the shape of a C around the hip.
• Groin pain often has an intraarticular etiology
  lateral hip pain is usually associated with
  extraarticular causes.
• Isolated posterior buttock pain is often related
  to lumbar and sacroiliac joint dysfunction.

5
Physical examination of the hip includes The four
layers osseous, cartilaginous, muscular, and
neural. The examination includes evaluation of
gait and physical tests in the standing, supine,
lateral, and prone positions. Trendelenburg
patterns manifest as lateral trunk flexion while
shifting weight over the stance leg.
6
The (FABER) test is used to diagnose injuries to
the labrum. The anterior impingement test is
performed with the patient in the supine
position the hip is flexed to 90, and a dynamic
assessment of the hip joint is performed with
flexion,adduction, and internal rotation. The
scour test is performed with the patient in the
supine position. The hip is brought to 90 of
flexion and abducted, followed by compression
with internal and external rotation.
7
Acetabular Labral Tears Injury is a source of hip
pain. 5 Injury may occur as a result of
hypermobility or repetitive mechanical stresses
with excessive flexion and rotation.
Underlying bony disorders of the hip, such as
hip dysplasia, femoral retroversion, coxa valga,
and slipped capital femoral epiphysis, can place
the labral tissue at a greater risk of tear.
8
Acetabular labral tears commonly found in the
anterior superior aspect of the
acetabulum. These tears usually present with
sharp anterior hip and groin activity related
pain. Pain is described as sharp or pinching and
is usually with locking. anterior impingement
and FABER test may be positive. Magnetic
resonance arthrography is the most reliable study
.
9
T2-weighted axial magnetic resonance
arthrogram demonstrating a tear of
the anterosuperior labrum (arrow).
10
Nonsurgical treatment for labral tears

intra-articular injections (diagnostic and
therapeutic). rest, activity modification,Oral
anti-inflammatory medication,and physical therapy.
11
Hip arthroscopy It is the preferred surgical
approach for the management of isolated labral
tears.
safe and effective? good results
12
Study 30 patients underwent arthroscopic
debridement. At 17-month follow-up significant
improvements were found in the Harris hip score
(preoperative, 57.6 postoperative, 89.2). Three
of the patients in this group experienced a
recurrent labral tear.
13
Femoroacetabular Impingement (FAI) is a
process by which a nonspherical femoral head
exists within a hemispheric acetabulum, leading
to labral and chondral pathology and hip
arthritis. Patients present with anterior groin
pain, which is worsened by flexion and rotation
of the hip. Round lucencies
seen in the femoral neck due to a herniation of
synovium through a cortical defect.
14
Surgical management of FAI is aimed at
correcting the abnormal osseous anatomy.
Both arthroscopic and open
techniques have been successful.
A peripheral compartment arthroscopic view of an
adolescent hip following femoral osteoplasty for
the management of impingement. The proximal
femoral physis is visualized.
15
Coxa saltans is classified as intra
articular,internal, or external. The
intra-articular variant is the result of labral
tears,loose bodies, or cartilage flaps with in
the hip joint. Coxa saltans external is usually
associated with snapping of the iliopsoas tendon
band or the anterior border of the gluteus
maximus muscle over the greater trochanter.
16
Patients with symptomatic internal snapping hip
syndrome often present with anterior groin pain
and snapping. A dynamic external rotation test
may reproduce snapping or pain. Recurrent
snapping of the psoas tendon may cause
impingement on the labrum and lead to labral
tears.
17
Treatment
nonsurgical
treatment of symptomatic coxa saltans externa
consists of stretching, physical therapy,
(NSAIDs), and corticosteroid injections. Surgical
intervention open surgery or arthroscopic to
lengthen the iliopsoas tendon band and manage
associated trochanteric bursitis
18
Apophyseal Avulsions commonly encountered around
the adolescent hip because of the inherent
weakness of the remaining open physis combined
with repetitive stress to the epiphyseal plate.

These injuries result
from indirect trauma caused by a sudden forceful
muscular contraction
19
Avulsion injuries are commonly seen in athletes
whose sports require rapid acceleration and
deceleration. Study In 203 avulsion fractures
ischial tuberosity 54 anterior inferior iliac
spine fractures 22, and anterior superior iliac
spine fractures 19. Patients present with
acute pain and swelling that follows a sudden,
noncontact traumatic incident.

tenderness to palpation and pain with
passive stretch of the muscle attached to the
avulsed fragment.

20
Radiographic evaluation is to confirm the
diagnosis and allows to assess the size of the
avulsed fragment and the amount of fracture
displacement. The initial management rest,
ice,NSAIDs, and protected weight bearing with
crutches until symptoms resolve physical
therapy. surgical indications are for ischial
tuberosity fractures with gt2 cm displacement and
for symptomatic nonunion, chronic pain, and
impaired function.
21
Arthroscopic images of iliopsoas tendon
lengthening.
A, The iliopsoas tendon (arrow)
identified via a transcapsular approach in the
central compartment. B, The tendinous portion is
lengthened under direct visualization (arrow).
22
AP radiograph of a 13-year-old boy with right
anterior superior iliac spine avulsion fracture
(arrow).
23
AP radiograph of a 14 years-old girl
demonstrating a right lesser trochanteric
avulsion fracture (arrow).
24
AP radiograph (A) and AP (B) and lateral (C)
three-dimensional CT images demonstrating
evidence of subspine impingement from a previous
anterior inferior iliac spine avulsion fracture
(arrow), which later required arthroscopic
decompression and labral repair
25
Hip Instability

classified as traumatic or atraumatic Traumatic
hip dislocation generallyresults from an axially
applied force against a flexed knee with the hip
in the neutral or adducted position. Generally
follows a high-energy trauma, and associated
injuries are common. clinicaly severe pain and
the hip held in the flexed, adducted, and
internally rotated position.
26
Hip Instability
Plain radiographs confirm the diagnosis, and
emergent reduction is indicated. Following
reduction,plain radiographs and CT or MRI are
indicated to confirm a congruent reduction and to
evaluate for intra-articular pathology.
27
Management of hip instability

restricted weight bearing
for 6 weeks postreduction management. consider
capsular or other soft-tissue laxity as a cause
of persistent hip instability.
Initially,this is
managed with physical therapy.
28
Management of hip instability
Arthroscopic thermal capsulorrhaphy hasalso been
proposed. In patients with a nonconcentric
reduction or notable acetabular fracture of the
posterior wall, surgical intervention should be
undertaken.
Arthroscopy has been
used to remove loose bodies.
29
Summary It is the role of the pediatric
orthopaedic surgeon and sports medicine provider
to properly diagnose and manage Hip pathology in
the adolescent athlete. Appropriate workup and
management can be often used effectively in
adolescent athlete. Nonsurgical management
includes activity modification, physical therapy
and anti-inflammatory medication Surgical
management of both intra- and extra-articular
hip pathology can safely be used when clinically
indicated.
30
THANK YOU