Sports medicine disorders of the hip: Anterior-Medial

Author(s): Timothy Tiu, MD, FAAPMR, CAQSM, Natalia Miranda-Cantellops, MD

Originally published:09/16/2015

Last updated:12/08/2019

1. DISEASE/DISORDER

Definition

Anterior and medial hip disorders affecting athletes’ hip include dysfunction and/or pain affecting the anteromedial structures of the hip. These problems may be approached with “The Layer Concept,” a classification system that best determines the primary pain generator.1 The 4 layers include osseous (bone), inert (capsule/labrum), contractile (muscles/tendons), and neuromechanical (referred pain from peripheral neurovascular structures and spine).

Etiology

Etiologies of anteromedial hip disorders may range from intraarticular to extraarticular disorders. These include direct injury to the labrum, capsule or tendon, or problems secondary to bony abnormalities such as femoroacetabular impingement (FAI), which can affect the labrum, cartilage, and capsule. FAI is an anatomical abnormality at the femoral head neck junction or acetabular rim, where range of motion of the joint leads to impact at these two regions. Extra-articular impingement seen in this region includes sub-spine (anterior inferior iliac spine (AIIS) impingement. Acute and chronic musculotendinous overuse injuries of the anterior and medial regions, especially affecting the hip flexors and adductors are other common disorders affecting this unique patient population. Stress reactions and fractures of the femoral neck and pelvis are another group of repetitive overuse disorders in the setting of altered bone turnover may be the cause of anteromedial pain in athletes.31,32 Compression neuropathies, such as ilioinguinal, genitofemoral, or obturator neuropathies and referred pain from disorders of the spine or pelvic floor, are other potential etiologies.2,3

Epidemiology including risk factors and primary prevention

Although there is no known published data on the overall incidence and prevalence of all anteromedial hip disorders in the general population, there is, however, data regarding athletes and sports related hip pain. Studies have shown that groin related injuries in sports with rapid directional changes, kicking, and twisting, such as in ice hockey, soccer, and rugby, account for 5-18 % of injuries.4,5,62,65 Position played also plays a role in the type of injury that may occur. For example, ice hockey goaltenders may be more prone to intraarticular hip injuries than other positions. 66e specifically, labral injuries have been reported in these aforementioned sports and also in golfers, rowers, dancers, karate practitioners, basketball, and baseball players.4-8 According to Epstein et al’s 2012 retrospective study of NHL players, the “cumulative incidence rate of [both hip and groin injuries was] 19.87 injuries per 100 players per year.9,10 In Feeley et al’s 2008 study of the NFL from 1997 to 2006, muscle strains (most common hip flexor), hip contusions, and intra-articular injuries (labral tears, fractures, and dislocations/subluxations) made up 59, 33, and 5% of all NFL injuries, respectively. Although representing only 5% of all injuries, intra-articular hip injuries accounted for the most time lost.4 All of these sports are prone to these type of injuries given the high mechanical stresses and loads placed on the joint, combined with motions such as cutting and extremes of hip flexion and internal rotation.2-4,11

In regards to Cam impingement, there is data to suggest that cutting sports (soccer, basketball, hockey), particularly during the growth years, may lead to increased Cam type deformities and impingment.5,12-14  With studies showing up to 68% of Cam type deformity in young male athletes.68Thus, it is important that younger pre-adolescent athletes participating in sports such as soccer or basketball be educated on avoiding extreme flexion, deep squats, and lunges to prevent the development of such femoroacetabular abnormalities at the time of skeletal maturity. 5,12-14 For young athletes participating in sports such as baseball, other recommendations to prevent these abnormalities include rotating playing positions on the field.

Risk factors for the most common anteromedial hip disorders are listed below:

  1. Intra-articular hip osteoarthritis: include FAI, obesity, and advancing age15,16
  2. Stress reaction or stress fractures: include tobacco or alcohol use, osteopenia/osteoporosis, female athlete triad, female military recruits, endurance sports such as track and field, skaters 31,32
  3. Labral tears: female sex, history of Legg-Calve-Perthe’s disease; developmental hip dysplasia, instability, decreased femoral or acetabular version, decreased head-neck offset2,17
  4. FAI: labral tear, developmental hip dysplasia, age, cutting sports (basketball, soccer, football); young, active males-cam lesions, middle age females-pincer lesions17-20
  5. Athletic pubalgia or Core muscle injury: increased among football, hockey, soccer, and tennis players2,21,22
  6. Iliopsoas impingement and coxa saltans (also known as internal snapping syndrome): increased among ballet dancers and patients with rheumatoid arthritis2,7,23
  7. Sub-spine (AIIS) impingement: prior AIIS avulsion injury, acetabular overcoverage and femoral retroversion2,17

Patho-anatomy/physiology

Different mechanisms will be outlined for the most common diagnoses seen:

  1. Osteoarthritis (osteochondral layer): occurs due to abnormal joint mechanics and loading, which leads to decreased joint space narrowing, bony sclerosis, and articular cartilage loss. FAI, labral tears, hip dysplasia, and acetabular retroversion are proposed to be precursors to this non-inflammatory process, especially in younger patients before the age of 55. 15,16,24,25
  2. FAI (osteochondral layer): anatomical abnormality at the femoral head neck junction or acetabular rim with range of motion of the hip leads to impingement.

Cam type impingement is caused by an abnormal shaped femoral head or neck contacting the acetabular rim during flexion and internal rotation activities. The anterosuperior acetabular cartilage is most affected. 18,19,24-26

Pincer type impingement is caused by overcoverage of the acetabulum over the femoral head. Repeated contact leads to circumferential cartilage damage, but also posteroinferior labral degeneration (from contra-coup mechanism) and acetabular deepening.18,19,24-26

  1. Labral tears (inert layer): According to one model from McCarthy et al., labral damage results from repeated impingement due to FAI and/or stress on the joint from developmental hip dysplasia at extreme ranges of motion. Articular cartilage damage is part of and contributes to this process if delamination of the articular cartilage occurs.27-30
  2. Rectus femoris or iliopsoas tendinopathy (contractile layer): results from improper training, repetitive loading, or trauma.2,3,23
  3. Iliopsoas impingement (contractile layer): Psoas tendon snaps over the iliacus as the hip moves from flexion, abduction, and external rotation to extension and internal rotation. Dynamic ultrasound studies have demonstrated that the psoas tendon glides over the medial part of the iliacus and the superior pubic ramus during the return of the hip into a neutral position.3,23
  4. Athletic pubalgia or core muscle injury (contractile layer): no actual hernia exists, but shearing forces placed across the pubic symphysis from the adductors, rectus abdominae, and stresses of the inguinal wall musculature may predispose athletes to unilateral groin pain.2,21,22
  5. L1 or L2 radiculopathies or obturator neuropathy (neuromechanical): compression of spinal nerve root and peripheral nerve secondary to commonly, a disc herniation or local trauma, respectively.2,17,30
  6. Ischiofemoral impingement: narrowing of space between the lesser trochanter and ischial tuberosity that leads to the compression of the quadratus femoris muscle. This may lead to pain in groin area that increases with weight bearing.68,69

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Acute muscle strains tend to resolve with basic conservative care (relative rest, ice, compression, and elevation), whereas tendinopathies may continue to progress to chronic phases without proper eccentric strengthening programs. With hip osteoarthritis, progression is seen with further decreases in joint space, increased osteophyte formation, and bony sclerosis (severity may be graded with the Tonnis grading scale), though this may not always correlate clinically with increased pain or decreased function.15,16 Injuries resulting from untreated stress fractures tend to be more symptomatic at initial onset, but may resolve quickly and only be reproduced with specific activities. However, in the case of femoral neck stress fractures, compression sided fractures should be worked up and monitored with limited weight bearing to start, whereas tension sided stress fractures should be immediately evaluated by an orthopedic surgeon due to an increased risk of fracture and displacement.31,32

Specific secondary or associated conditions and complications

FAI and labral tears may increase the risk for the development of early hip osteoarthritis.2,15,18,19 Associated conditions may include hip abductor dysfunction, chronic lower back pain, and poor flexibility in the quadriceps, hamstring, and tensor fasciae latae and iliotibial band tendons.2,17,21 Biomechanical changes in the hip may lead to the development of lumbar pathology, otherwise known as a secondary hip-spine syndrome.79

2. ESSENTIALS OF ASSESSMENT

History

A comprehensive history should include onset and duration of symptoms, quality and character of pain or dysfunction, location, radiating symptoms, exacerbating and alleviating factors, whether the disorder is affecting the athlete’s sport participation or performance, education (if in school), and functional activities. A past history of similar injuries, nutrition, and menses history (for females) are also relevant details.

Physical examination

The physical exam should be carried out in 4 different positions (standing, sitting, supine, and prone). The standing exam assesses for “general body habitus, gait, lumbopelvic alignment, ligamentous laxity, and Trendelenberg testing for functional hip abductor weakness. The seated exam checks for any abnormalities in skin, vasculature, and lymph, while hip internal and external range of motion can be examined in this position.”33 In addition, this is a good position for the neurologic examination. Here, both lower extremity sensory testing with light touch and pinprick, reflexes, and dural tension testing in the form of the Seated Slump test are assessed.

The supine position is the most important, where complete passive range of motion, manual muscle strength, and provocative testing may be performed. Provocative maneuvers such as FADIR (hip flexion, adduction, internal rotation), FABER (flexion, abduction, external rotation), sub-spine impingement (straight hip flexion), Thomas test (to assess for iliopsoas tightness), and both passive and resisted straight leg tests may be used additionally to help narrow the differential diagnosis and determine what structures would need targeted therapy.17,33,34 In the side-lying position, passive adduction maneuvers can be performed to assess for contractures of the tensor fascia latae, gluteus medius, and gluteus maximus. Hip abductor strength should be tested in slight extension and internal rotation of the femur to prevent iliotibial band and tensor fasciae latae compensation. Lastly, the prone exam is used to assess the posterior hip structures such as the hamstrings and to assess for femoral version. At each position, the examiner should palpate the anteromedial structures of interest (ie: pubic symphysis, ASIS, AIIS, rectus femoris, adductors) , as well as lower lumbar paraspinals and posterolateral hip structures such as the greater trochanter, tensor fasciae latae, and posterior superior iliac spine (PSIS) to rule out referred pain sources.33

Functional testing can be performed to dynamically evaluate range of motion, strength, and proprioception.  Importantly, this assessment includes evaluation in all three planes of motion (ie: frontal, sagittal, and transverse). Two of the most common forms of functional testing include the single leg squat (SLS) and step-down tests (SDT).  In the SLS test, the patient is standing with the contralateral knee flexed.  The patient then attempts to perform a squat on the ipsilateral lower extremity.  In the SDT, the patient stands on a stool with the contralateral hip slightly flexed and the knee in extension.  The patient then attempts to lower the contralateral foot to the floor in a controlled fashion. This form of assessment may reveal kinematic and biomechanical deficiencies not otherwise evident in traditional, static evaluations.70

Clinical functional assessment: mobility, self care cognition/behavior/affective state

Although this varies from disorder to disorder, activities such as transitional movements, walking, stair climbing, and deep squats are the most commonly reported to be aggravated with most anteromedial hip disorders. Alternative modes of exercise such as a stationary bike or switching to a cross-training program may be necessary while an injured athlete undergoes a specific lower extremity rehabilitation program.

Laboratory studies

No laboratory studies are routinely required unless an infectious or rheumatologic etiology is suspected.  In such cases, a basic cell blood count may show leukocytosis with elevated inflammatory markers (eg: erythrocyte sedimentation and C-reactive protein levels).  Inflammatory or infectious disorders of the pelvis may need to be ruled out in unusual cases. A full rheumatologic panel may be ordered if necessary.

Imaging

Initial work-up should include plain films of the hip (AP, elongated femoral neck), as well as the lumbar spine to rule out an overlapping spine disorder.17,35 MRI of the hip may be ordered if there is suspicion for a symptomatic labral tear or to assess for a specific tendon or muscle tear (eg: rectus femoris), or fracture.36,37 MR arthrography (MRA) is considered the best imaging modality to assess for labral tears, but this is debated.36-38 The costs vs benefits of such a study may also need to be determined.64

Musculoskeletal ultrasound has proved to be useful for both diagnostic and interventional purposes.39 Sonopalpation may help diagnose and reveal the location of an injury if pressure at a specific location reproduces the patient’s pain.62 This may be useful for planning injection procedures. Ultrasound can help correlate findings in real time and attain dynamic images in various positions, including valsalva in the evaluation of athletic pubalgia. This also gives the physician increased patient interaction.63  Iliopsoas impingement, bursitis, tendinopathies, and intra-articular hip effusions may be visualized using this dynamic, real-time imaging modality.39,40 It should be noted, however, that ultrasound alone does not adequately image the hip joint itself or the cartilaginous labrum, compared to MRI.

Supplemental assessment tools

Existing hip research tools have primarily focused on patients with hip fractures or arthritis such as the Harris Hip Scores. The most common measure used is the Modified Harris Hip Score. The Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group developed a 33 question survey tool that was applicable to a number of common bony or labral hip pathologies.41 However, it is not applicable to muscular or referred pain from spine or knee sources. The Hip Outcome Score (HOS) has been validated for hip labral injuries.42 Other outcome measures include the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form-36, Hip Disability and Osteoarthritis Outcome Score (HOOS), Non-Arthritic Hip Score (NAHS), and the Copenhagen Hip and Groin Outcome Score (HAGOS).41-45

Early prediction of outcomes

There are factors which may help predict a positive outcome in patients with anteromedial hip sports-related injury. For example, patients with an acetabular labral tear without hip OA are more likely to have a positive outcome.29 As with the management of other musculoskeletal conditions, the principles of close follow-up, compliance with prescribed treatment, and a solid, physical therapy program will generally alleviate and improve patient’s symptoms stemming from anteromedial hip pain.

For patients who require operative management, younger age, female sex, hip dysplasia, instability, and residual intra-and extra-articular impingement were identified as risk factors for revision arthroscopic or open hip preservation surgery in a cross sectional study of 147 patients.61

Environmental

Environmental factors include whether the sport is played indoor or outdoor, the type of surface or terrain, and any related clothing, equipment, or gear that is used.  Hip motion, especially, extremes of flexion and internal rotation, can affect the condition of the hip.  Athletes should be counseled on modifying these environmental factors in the management of their hip conditions. Reducing training during growth years, cross training, or adding orthotics to patients with pes planus may be considered.

Social role and social support system

When athletes or patients are not actively engaging in their preferred sport or exercise, depressive or anxious symptoms may arise. Thus, it is important to educate and counsel athletes, families, and personal trainers/coaches regarding alternative sports and exercises they may safely participate in, while they are being treated.

Professional issues

Education and open communication with the athlete’s family, friends, athletic trainers, and coaches is necessary to prevent recurrent injury and to maintain effective physician-team rapport. Special precautions must be taken with college or professional athletes, as there may be a financial incentive or institutional pressure to have the athlete return to play before he or she is ready to. In such cases, emphasis must be placed on the athlete’s health and safety before team commitments.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

There are no available consensus statements or treatment guidelines for most of the disorders discussed above. There is, however, an abundance of literature to support the surgical management of certain conditions including FAI and labral tears.  Unfortunately, there are no double blinded, randomized controlled trials comparing the efficacy of physical therapy and conservative care versus surgical intervention in the treatment of these and other anteromedial hip disorders.46 Although surgical studies do promote the use of activity modification and physical therapy as the initial treatment, there is no agreed upon “best practice” when treating athletes with anteromedial hip pain and dysfunction.4,17,46-50

Conservative treatment usually involves rest, NSAIDs, heat and/or ice.  In FAI, as well as the other anteromedial hip disorders discussed above, rehabilitation efforts should focus on core muscle strengthening, and treating the imbalance between the hip and abdominal muscles.   Improving range of motion of the hip external rotation and abduction in extension and flexion has shown to be beneficial.66,78

Treatment for osteitis pubis also begins with conservative management focusing on physical therapy.  A recent study evaluated the use of shock wave therapy versus sham shock wave therapy directly to the pubis and reported promising results with earlier return to sport with the use of shock wave therapy.67

In ischiofemoral impingement, the reduced space between the lesser trochanter and ischial tuberosity may cause a leg length discrepancy.   Conservative management with the use of insoles or shoe modifications have been proposed as.68   For the treatment and management of athletic pubalgia, a position statement was put forth by the British Hernia Society in 2014.50 They advised at least a 2 month program consisting of active, supervised physical therapy emphasizing core and lumbopelvic stabilization and strengthening (initially isometric then progressing to eccentric and concentric) exercises, cross training, and appropriate injections (not specific, but ilioinguinal nerve blocks were cited) prior to any surgical consultation.51 There is a current push in the United States to describe this condition as a core muscle injury.52

With respect to return to play, assessing the athlete’s level of pain and its effect on functional activities is important.32 General treatment includes a thorough work up of risk factors and treatment followed by relative rest, activity modification, and weight bearing precaution, with activity titrated using pain as a guide during an average period of 4 to 8 weeks depending on the severity of the stress fracture.32 While the stress fracture is allowed to heal, athletes should be encouraged to cross train such as swimming, cycling, or aqua-running, counseled on nutrition, and to be screened for low bone mineral density.32 Athletes who have pain from FAI and labral injuries may improve with a focused rehabilitation program that avoids motions that aggravate and reproduce symptoms.

At different disease stages

In the acute to subacute setting, anteromedial hip disorders may be approached with activity modification (eg: avoidance of deep hip flexion and internal rotation to prevent impingement symptoms), rest for a limited time away from the sport, modalities such as ice or heat, a short course of oral anti-inflammatory medications, and an emphasis on an appropriate physical therapy and home exercise program.4,18,19

Most patients with anteromedial hip dysfunction (especially FAI) will have weakness with hip adduction, abduction, flexion, [and/or] external rotation, as well as have disturbances with core trunk and lumbopelvic stability and control.4,17,21,46 Hence, the physical therapy prescription should address such strength deficits found on physical exam, accompanied with the goal of improving their lumbopelvic range of motion, proprioceptive training, and reducing pain during sport-specific functional tasks.17 It is very important to include both hip and spine stability exercises before the patient is progressed to sport specific training.17,21,53

If patients do not improve with non-operative management, then their diagnosis should be reconsidered and further work-up done as necessary.  On the other hand, they are unable to advance their rehabilitation program because of pain, other conservative treatments are available.  For intra-articular lesions (osteochondral or inert layer disorders) such as hip osteoarthritis, FAI, or labral tears, an image guided intra-articular hip injection consisting of a combination of local anesthetic with or without corticosteroid may be used both diagnostically and therapeutically to alleviate pain and help the athlete continue in physical therapy or return to play sooner. They also appear to hold a prognostic value in predicting the need for surgical interventions.2,4 Extra-articular or contractile layer disorders (eg: psoas impingement syndrome) may similarly benefit from an image-guided bursa or tendon sheath injection. Initial injections may be performed with local anesthetic and corticosteroid, but may be transitioned to more novel treatments such as platelet rich plasma (PRP) (with or without percutaneous needle tenotomy) if the underlying dysfunction is due to tendinopathy, keeping in mind that PRP is still considered experiemental.3,54-57

Chronic disorders can be managed similarly, but often require a longer recovery process.   In chronic intra-articular conditions secondary to hip osteoarthritis, ultrasound guided viscosupplementation injections, although not yet approved for hip OA by the Food and Drug Administration, may be used and preferred over repeat corticosteroid injections.58-60

Coordination of care

It is crucial that a multidisciplinary team approach involving the patient’s physician(s), family, athletic trainers, coaches, and physical therapists is used to maximize healing before returning to play.  It is important that communication remains consistent and that the athlete’s diagnosis(es) are always kept in mind.

Patient & family education

As discussed earlier, proper education regarding an athlete’s diagnosis, available treatment options, prognosis, injury prevention, and expected return to play should be communicated to both the athlete and his or her family.  In addition, at follow up visits or in the training room, gentle reminders should also be used to reinforce avoidance of specific lower extremity motions and the maintenance of a home exercise program to prevent re-injury.

Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based

Besides monitoring the severity and frequency of pain, efficacy of conservative treatment is based on a number of factors such as improvements in core and pelvic girdle muscle weakness, lumbopelvic range of motion, and the ability to perform sport specific tasks with minimal discomfort.

Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Providers should keep in mind to examine both the spine and knee, as pain patterns at the anteromedial hip may be referred. Initial work-up may include imaging of such regions depending upon patient presentation.

Incorporate functional tests, such as the SLS and SDT, into your physical examination for dynamic evaluation of range of motion, strength, and proprioception.

The core encompasses the lumbar spine through the thighs. The iliopsoas is the only muscle that has its origin in the spine and crosses the hip joint. It works both as a spine stabilizer and hip flexor. All of these elements must be addressed to return athletes to sport.

Focused hip flexor concentric strengthening can exacerbate symptoms. Focus on strengthening the abductors and core stability. Eccentric and isometric exercises can be initiated as the pain subsides.

Femoral neck stress fractures can mimic hip impingement. Always keep it in mind when a patient with risk factors for a stress fracture has multiple impingement signs encountered on physical exam.

If pelvic floor dysfunction/pain is part of the differential diagnosis, a more detailed social history should be elicited including any history of physical or sexual abuse, as well as any past psychiatric illness.

4. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

The current medical literature does not contain any double blinded, randomized controlled studies assessing the benefits of a structured rehabilitation program versus surgical intervention for patients or athletes with anteromedial hip disorders.46  There is also no data as to whether structured rehabilitation programs modify the natural history of degenerative joint changes found in symptomatic FAI.18

Regenerative medicine procedures, such as PRP or stem cell injections, have the potential for both pain relief and healing of damaged tissue.58-60,71-75 More high-quality research is required, including comparing these injections to other physical and pain-relieving modalities, surgery and the need for long-term follow up.

5. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

The use of musculoskeletal ultrasound to assess for dynamic impingement, tendinosis, and for guidance of interventional procedures has shown promise as part of the spectrum of conservative management of patients and athletes who decline surgery or are not ideal surgical candidates. 39

In addition, PRP injections may be beneficial for improving pain from rectus femoris or iliopsoas tendinopathies and potentially for intra-articular conditions such as hip osteoarthritis, when combined with a supervised rehabilitation program.39,58-60

In addition to evidence for the clinical benefit of PRP in OA,58-60,71 there is also evidence that it may help in the treatment of acetabular labral tears76 and, when, combined with bone marrow- derived mesenchymal stem cells, in osteonecrosis of the hip74. Stem cell injections on their own may be clinically effective not only in OA72,73, but also in osteonecrosis of the hip.75,77

REFERENCES

  1. Draovitch P, Edelstein J, Kelly BT. The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment. Curr Rev Musculoskelet Med. 2012;5:1–8.
  2. Anderson K, Strickland SM, Warren R. Hip and Groin Injuries in Athletes. Am J Sports Med. 2001;Jul-Aug;29(4):521-33.
  3. Davenport KL, Moley PJ, Kelly BJ. Extra-articular Hip Conditions and Sports Injuries. In: Kim YJ, Mamisch TC, eds. Hip Magnetic Resonance Imaging. New York, NY: Springer. 2014:113-125.
  4. Feeley T, Powell JW, Muller MS, Barnes RP, Warren RF, Kelly BT. Hip Injuries and Labral Tears in the National Football League. Am J Sports Med. 2008;36(11):2187-95.
  5. Siebenrock KA, Kaschka I, Frauchiger L, Werlen S, Schwab JM. Prevalence of cam-type deformity and hip pain in elite ice hockey players before and after the end of growth. Am J Sports Med. 2013;41(10):2308-13.
  6. Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007;15:908–914.
  7. Smoljanovic T, Bojanic I, Hannafin JA, Hren D, Delimar D, Pecina M. Traumatic and overuse injuries among international elite junior rowers. Am J Sports Med. 2009;37:1193–1199.
  8. Boykin RE, McFeely ED, Ackerman KE, Yen YM, Nasreddine A, Kocher MS. Labral injuries of the hip in rowers. Clin Orthop Relat Res. 2013 Aug;471(8):2517-22.
  9. Epstein DM1, McHugh M, Yorio M, Neri B. Intra-articular hip injuries in national hockey league players: a descriptive epidemiological study. Am J Sports Med. 2013;41(2):343-8.
  10. Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med. 1999;9(3):151-156.
  11. Tyler TF1, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001 Mar-Apr;29(2):124-8.
  12. Siebenrock KA1, Behning A, Mamisch TC, Schwab JM. Growth plate alteration precedes cam-type deformity in elite basketball players. Clin Orthop Relat Res. 2013;471(4):1084-91.
  13. Agricola R, Heijboer MP, Ginai AZ, Roels P, Zadpoor AA, Verhaar JA, Weinans H, Waarsing JH. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: a prospective study with minimum 2-year follow-up. Am J Sports Med. 2014 Apr;42(4):798-806.
  14. Nepple JJ, Vigdorchik JM, Clohisy JC. What Is the Association Between Sports Participation and the Development of Proximal Femoral Cam Deformity? A Systematic Review and Meta-analysis. Am J Sports Med. 2015;1-9.
  15. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock K. Femoroacetabular impingement: A cause for osteoarthritis of the hip. CORR. 2003;417:112-120.
  16. Siverling S, O’Sullivan E, Garofalo M, Moley P. Hip osteoarthritis and the active patient: will I run again? Curr Rev Musculoskelet Med. 2012;5:24–31.
  17. Skendzel JG, Weber AE, Ross JR, Larson CM, Leunig M, Kelly BT, Bedi A. The approach to the evaluation and surgical treatment of mechanical hip pain in the young patient: AAOS exhibit selection. J Bone Joint Surg Am. 2013 Sep 18;95(18):e133.
  18. Bedi A, Kelly BT. Femoroacetabular Impingement. J Bone Joint Surg Am. 2013;95(1): 82 -92.
  19. Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008;24(10):1135-45.
  20. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clinical Orthopaedics and Related Research. 2009;467(3):638-644.
  21. Voos JE, Mauro CS, Kelly BT. Femoroacetabular Impingement in the Athlete: Compensatory Injury Patterns. Oper Tech Orthop. 2010;20:231-36.
  22. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy. 2012 Oct;28(10):1388-95.
  23. Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ (2008) The snapping iliopsoas tendon: new mechanisms using dynamic sonography. Am J Roentgenol 190:576–581.
  24. Sankar WN, Matheney TH, Zaltz I. Femoroacetabular impingement: current concepts and controversies. Orthop Clin North Am. 2013;44(4):575-89.
  25. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J. Bone Jt. Surg. (Brit). 2005;87:1012-1018.
  26. Martin DE, Tashman S. The biomechanics of femoroacetabular impingement. Operative Techniques in Orthopaedics. 2010;20(4):248–254.
  27. Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006 Apr;25(2):279-92.
  28. McCarthy JC, Noble PC, Schuck MR, et al. The Otto E Aufranc Award: the role of labral lesions to development of early degenerative hip disease. Clin Orthop. 2001;393:25–37.
  29. Groh GM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-117.
  30. Bradshaw C, McCrory P, Bell S, Brukner P. Obturator nerve entrapment. A cause of groin pain in athletes. Am J Sports Med. 1997;25(3):402-8.
  31. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med. 2010;29:399-416.
  32. Diehl JJ, Best TM, Kaeding CC. Classification and Return-to-Play Considerations for Stress Fractures. Clin Sports Med. 2006;25:17–28.
  33. Martin HD, Kelly BT, Leunig M, Philippon MJ, Clohisy JC, et al. The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Arthroscopy. 2010 Feb;26(2):161-72.
  34. Maslowski E, Sullivan W, Forster Harwood J, et al. The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. PM&R. 2010;2(3):174-81.
  35. Clohisy JC, Carlisle JC, Beaulé PE, Kim YJ, Trousdale RT, Sierra RJ, Leunig M, Schoenecker PL, Millis MB. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90 Suppl 4:47-66.
  36. Mintz DN, Hooper T, Connell D, et al. Magnetic resonance imaging of the hip: detection of labral and chrondral abnormalities using noncontrast imaging. Arthroscopy. 2005;21(4):385e93.
  37. Gold SL, Burge AJ, Potter HG. MRI of Hip Cartilage. CORR. 2012;470:3321-31.
  38. Blankenbaker DG, De Smet AA. Hip Injuries in Athletes. Radiol Clin N Am. 2010;48:1155-78.
  39. Finnoff JT, Hall MM, Adams E, Berkoff D, Concoff AL, Dexter W, Smith J. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. Br J Sports Med. 2015;49(3):145-50.
  40. Adler RS, Buly R, Ambrose R, Sculco T. Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections. AJR Am J Roentgenol. 2005 Oct;185(4):940-3.
  41. Mohtadi NG, Griffin DR, Pedersen ME, et al. The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33). Arthroscopy. 2012;28(5): 595-610.
  42. Martin RL, Kelly, BT, Philippon MJ. Evidence of validity for the hip outcome score. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2006;22(12):1304-1311.
  43. Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scand J Rheumatol. 2003;32(1):46-51.
  44. Christensen CP1, Althausen PL, Mittleman MA, Lee JA, McCarthy JC. The nonarthritic hip score: reliable and validated. Clin Orthop Relat Res. 2003;(406):75-83.
  45. Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med. 2011;45(6):478-91.
  46. Wall, Peter DH, et al. Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM&R. 2013;5(5):418-426.
  47. Yazbek PM, et al. Nonsurgical treatment of acetabular labrum tears: a case series. J Orthop Sports Phys Ther. 2011;41(5):346-53.
  48. Emara K, Samir W, Motasem EL, Ghafar KA. Conservative treatment for mild femoroacetabular impingement. J Orthop Surg (Hong Kong). 2011;19:41-45.
  49. Hunt D, Prather H, Harris Hayes MH, Clohisy JC. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM&R. 2012;4:479-487.
  50. Meyer WC, Yoo E, Devon ON, Jain N, Horner M, Lauencin A, Zoga. Understanding “Sports Hernia” (Athletic Pubalgia): The Anatomic and Pathophysiologic Basis for Abdominal and Groin Pain in Athletes. Operative Techniques in Sports Medicine. 2012;20:33-45.
  51. Sheen AJ, Stephenson BM, Lloyd DM, et al. ‘Treatment of the sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014;48(14):1079-87.
  52. Meyers WC, Havens BK, Horner GJ. Core muscle injury (a better name than “athletic pubalgia” or “sports hernia”). Current Orthopaedic Practice. July/August 2014;25(4):321–326.
  53. McGill S. Core training: Evidence translating to better performance and injury prevention. Strength & Conditioning Journal. 2010;32(3):33-46.
  54. Housner JA, Jacobson JA, Misko R. Sonographically guided percutaneous needle tenotomy for the treatment of chronic tendinosis. J Ultrasound Med. 2009;28(9):1187-92.
  55. Finnoff JT, Fowler SP, Lai JK, Santrach PJ, Willis EA, Sayeed YA, Smith J. Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection. PM&R. 2011;3(10):900-11.
  56. Sánchez, Mikel, et al. Platelet-rich plasma in muscle and tendon healing. Operative Techniques in Orthopaedics 22.1 (2012):16-24.
  57. Dave RB, Stevens KJ, Shivaram GM, McAdams TR, Dillingham MF, Beaulieu CF. Ultrasound-guided musculoskeletal interventions in American football: 18 years of experience. American Journal of Roentgenology. 2014;203:W674-W683.
  58. Sánchez M et al. Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology. 2011;51(1):144-150.
  59. Battaglia M, Guaraldi F, Vannini F, et al. Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus hyaluronic acid for hip osteoarthritis. Orthopedics. 2013;36(12):e1501-8.
  60. Kon E, Mandelbaum B, Buda R, Filardo G, et al. Platelet-rich plasma intra-articular injection versus hyaluronic acid viscosupplementation as treatments for cartilage pathology: from early degeneration to osteoarthritis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2011;27(11):1490-1501.
  61. Ricciardi BF, Fields K, Kelly BT, Ranawat AS, Coleman SH, Sink EL. Causes and risk factors for revision hip preservation surgery. Am J Sports Med. 2014;Nov;42(11):2627-33.
  62. Lee, S. C., Endo, Y., & Potter, H. G. (2017). Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features. Sports Health: A Multidisciplinary Approach,9(5), 428-435.
  63. Morley, N., Grant, T., Blount, K., & Omar, I. (2016). Sonographic evaluation of athletic pubalgia. Skeletal Radiology,45(5), 689-699.
  64. Ghaffari, A., MD, Davis, I., MD, Storey, T., MD, & Moser, M., MD. (2018). Current Concepts Acetabular Impingement. Radiologic Clinic of North America,56(6), 965-982.
  65. Serner, A., Eijck, C. H., Beumer, B. R., Hölmich, P., Weir, A., & Vos, R. D. (2015). Study quality on groin injury management remains low: A systematic review on treatment of groin pain in athletes. British Journal of Sports Medicine,49:813.
  66. Kuhn, A. (2016). The Hip in Ice Hockey: A Current Concepts Review. Arthoscopy,32(9), 1928-1938.
  67. Via, A. G., Frizziero, A., Finotti, P., Oliva, F., Randelli, F., & Maffulli, N. (2019). Management of osteitis pubis in athletes: Rehabilitation and return to training – a review of the most recent literature. Open Access Journal of Sports Medicine,10, 1-10.
  68. Chahla, J., Sherman, B., Philippon, M. J., & Gerhardt, M. (2019). Hip Injuries in Kicking Athletes. Operative Techniques in Sports Medicine,1-7.
  69. Nakano, N., Yip, G., & Khanduja, V. (2017). Current concepts in the diagnosis and management of extra-articular hip impingement syndromes. International Orthopaedics,41(7), 1321-1328.
  70. McGovern, Ryan P., et al. “Evidence-based procedures for performing the single leg squat and step-down tests in evaluation of non-arthritic hip pain: a literature review.” International journal of sports physical therapy 13.3 (2018): 526.
  71. Singh, Jaspal Ricky, et al. “The Effectiveness of Autologous Platelet-Rich Plasma for Osteoarthritis of the Hip: A Retrospective Analysis.” Pain Medicine (2019).
  72. Emadedin, Mohsen, et al. “Long-term follow-up of intra-articular injection of autologous mesenchymal stem cells in patients with knee, ankle, or hip osteoarthritis.” (2015): 336-344.
  73. Mardones, Rodrigo, et al. “Mesenchymal stem cell therapy in the treatment of hip osteoarthritis.” Journal of hip preservation surgery 4.2 (2017): 159-163.
  74. Houdek, Matthew T., et al. “Stem Cells Combined With Platelet-rich Plasma Effectively Treat Corticosteroid-induced Osteonecrosis of the Hip: A Prospective Study.” Clinical orthopaedics and related research 476.2 (2018): 388-397.
  75. Pak, Jaewoo. “Regeneration of human bones in hip osteonecrosis and human cartilage in knee osteoarthritis with autologous adipose-tissue-derived stem cells: a case series.” Journal of medical case reports 5.1 (2011): 296.
  76. De, AJ Luigi, et al. “Use of Platelet Rich Plasma for the Treatment of Acetabular Labral Tear of the Hip: A Pilot Study.” American journal of physical medicine & rehabilitation (2019).
  77. Zhao, Lei, et al. “Stem Cell Therapy for Osteonecrosis of the Femoral Head: Current Trends and Comprehensive Review.” Current pain and headache reports 22.6 (2018): 41
  78. Elattar, Osama, Ho-Rim Choi, Vickie D. Dills, and Brian Busconi. “Groin Injuries (Athletic Pubalgia) and Return to Play.” Sports Health: A Multidisciplinary Approach8, no. 4 (2016): 313-23.
  1. Offierski, C. M., and I. MacNab. “Hip-spine syndrome.” Spine3 (1983): 316-321.

Original Version of the Topic

Peter J. Moley, MD, Richard G. Chang MD, MPH. Sports medicine disorders of the hip: Anterior-Medial. 09/16/2015.

Author Disclosure

Timothy Tiu, MD, FAAPMR, CAQSM
Nothing to Disclose

Natalia Miranda-Cantellops, MD
Nothing to Disclose

Related Articles