Examination Findings

A detailed history of the onset of symptoms—traumatic event or insidious onset of symptoms—and the level of athletic participation before and after injury should be elicited from the athlete. An assessment of possible referred hip pain from low back pain or abdominal or gynecologic disorders should also be considered. Risk factors for avascular necrosis (AVN) and stress fractures should be obtained in the history as well. Mechanical symptoms of the hip related to a single traumatic event or from repetitive trauma from athletic activity may be exacerbated by athletic participation and daily activities. Physical findings of a labral tear may include an abnormal gait with shortened stance phase; reproducible groin pain elicited with forced flexion/adduction and internal rotation (impingement test) [9] or flexion/abduction and external rotation test, and limitations of terminal motion of the hip. Plain radiographs that include

Fig. 14. Synovitis with capsular laxity after traumatic posterior hip dislocation.

Fig. 15. (A) Osteochondral loose body in the fovea, and (B) removal.

anterior-posterior (AP) pelvis and AP and lateral views of the involved hip should be used to assess for structural/developmental abnormalities or arthritic conditions, and to rule out stress fractures and avulsion fractures. High clinical suspicion for labral tears should further be evaluated with an MR arthrogram. MR arthrography is highly sensitive to detect labral pathology. MRI findings consistent with AVN should also be considered, although chondral injuries can also mimic AVN changes on the MRI. Criteria for tears on an MR arthrogram include contrast extending into the labrum or acetabular/labral interface, blunted appearance, and displacement.

Athletes who have symptomatic labral tears should consider a course of activity modification, anti-inflammatory medication, and possible physical therapy. If symptoms persist past 4 weeks, hip arthroscopy should be considered.

Snapping iliospoas tendonitis can be disabling to the athlete. These symptoms can be seen in ballet dancers and skaters, including hockey players. Loud audible popping or clicking can be reproduced by the patient and the examiner [20]. If painful, these symptoms can be mistaken for a labral tear. The patient should be examined in a supine position and opposite hip flexed (Thomas test). The hip should then be actively flexed and extended and the examiner's hand placed on the anterior portion of the hip to assess for snapping. Dynamic fluoroscopy may also confirm the diagnosis [21].

Iliotibial band syndrome and trochanteric bursitis in the athlete can cause pain at the level of the greater trochanter with activity. This syndrome is common in runners. On examination, point tenderness over the greater tro-chanter is reproduced; excessive adduction and abduction also reproduce the symptoms. The iliotibial band in these patients can also snap over the greater trochanter, and may give the patient the sensation of hip subluxation and dislocation. MRI may show signs of bursitis and gluteus medius tendonitis, but generally is limited for diagnosing this condition.

Isolated extra-articular disorders of the hip do respond to conservative management, which includes physical therapy, a course of anti-inflammatories, and activity modification. Steroid injections can also help to reduce the inflammation. If symptoms do not improve, arthroscopic intervention may be beneficial.

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