Hip & Groin Pain
Adductor Muscle Strains
Adductor muscle strains are a common injury in sports that involve sudden changes of direction. Examination findings are usually, localised tenderness, pain on passive abduction and pain on resisted adduction or combined flexion/adduction.
A typical treatment regimen consists of :-
(i) 0-48 hours – RICE protocol, active pain-free exercises
(ii) After 48 hours – depending on the size / grade of the muscle tear, gradually increase strengthening of abduction and adduction movement patterns using therabands, pulleys, light weights. Start stability exercises (e.g. pulleys with other leg, one-leg squats).
(iii) After 7-21 days – Functional strengthening, including cycling, pool running, jogging, swimming
(iv) After 21 days – Sport-specific drills, including running (straight line), running (figure of eight), rapid changes of direction, kicking (different forces and skills of kicking).
The clinical features of impingement tend to be pain on most shoulder movements and activities above 90 degrees elevation and in sports people during overhead activities such as throwing or tennis serving.
Treatment is aimed at settling down the symptoms through soft tissue techniques, electrotherapy, taping, exercises and postural education or corticosteroid injection.
Recurrent Adductor Muscle Strain
In these cases, extra rehabilitation time through the stages should be provided, together with a detailed analysis of sporting technique to decide if their are any technical abnormalities affecting the rate of progress.
Acute Adductor Tendinopathy
Examination findings include local tenderness over the adductor origin and over the pubic tubercle, with pain on passive hip abduction and resisted hip adduction.
Treatment of an acute presentation includes a few days relative rest from the aggravating activity, followed by a gradual progression of adductor strengthening.
It is important to examine the lumbar spine as there is frequently an association between iliopsoas tightness and stiffness of the lumbar spine from which the muscle originates.
Treatment consists of avoiding aggravating activities, stretching of the psoas muscle and strengthening involving resisted hip flexion exercises. Often, mobilisation of the lumbar intervertebral joints at the origin of the iliopsoas muscles will result in an improvement of symptoms.
Hip Joint Injuries
The hip may be inflamed as a generalised rheumatological disorder. Osteoarthritis of the hip may also been seen in the older patient. The pain of the osteoarthritic hip may be worse in the mornings or after activity.
In children between 5 and 12 years, Perthes’ disease should be considered, while in older adolescents between the ages of 12 and 16 years, a slipped capital femoral epiphysis may cause hip pain. A young patient with a slipped capital femoral epiphysis may present with very litle pain, but with a painless limp.
It is unusual to find a case of an injured hip that does not have coexisting iliopsoas dysfunction. The probable causes of this presentation are due to direct irritation of the iliopsoas as it crosses the anterior aspect of the hip joint; and the iliopsoas being overloaded as a hip flexor due to restriction in hip movement. Examination findings would normally include; myofascial tightness in the iliopsoas muscle on abdominal palpation; and restricted hip extension on modified Thomas testing.
Evidence of dysplasia includes a short or angled roof, and signs of acute-chronic impingement, such as an os acetabulae, femoral bossing, Ganz lesions and impingement cysts. A ‘Ganz lesion’ is a thickening or bump on the superior femoral neck in response to chronic impingement in this area. The thickening of the bone then causes worsening impingement and a vicious cycle develops. The thickened bone often needs to be surgically resected.
MRI scanning of the hip to detect any intra-articular pathology is also useful. Injection of the hip joint with local anaesthetic with post-injection assessment of pain is very accurate by examining the hip pre- and post-injection.
Arthroscopy of the hip joint remains the most sensitive and specific investigation. In patients presenting with pain in the areas described, the clinician should maintain a high index of suspicion for labral injury, irrespective of the results of investigative imaging.
The natural history of an untreated acetabular labral tear is slow but progressive degeneration to degenerative hip joint disease. Treatment of these injuries involves arthroscopic debridement of the torn part of the labrum, which generally produces good results, especially in those with minimal or no associated chondral damage.
There are two bursae around the greater trochanter. The gluteus medius bursa and the trochanteric bursa. Gluteus medius tendinopathy and bursitis often exist together. The site of tenderness in these conditions is typically immediately above the greater trochanter and pain can be reproduced on stretching the gluteus medius.
Treatment for these conditions involves initial rest from aggravating activities, stretching and strengthening of the gluteus medius. Corticosteroid injection may be required and should be placed into the area of maximal tenderness above and behind the greater trochanter. As the condition is often associated with biomechanical abnormality, muscle tightness or excessive lateral tilt of the pelvis, pelvic stability exercises may play an important role in treatment.
Specific Concerns for Adolescents
Acute avulsion fractures and chronic apophysitis occur in adolescents as a result of excessive muscle contraction. The most common site is the attachment of the long head of the rectus femoris from the anterior inferior iliac spine.
Avulsion fractures present as an acute onset of anterior hip pain with a marked loss of function. On examination, there is localised tenderness and restriction of movement. In most cases, these should be treated conservatively as for a severe rectus femoris strain. Surgical reattachment of the avulsed fragment is usually not necessary but may be required when the fragment is separated from the bone by greater than 3cm. Rehabilitation is required for up to three months in these cases.