Transcript History - Wenatchee Schools

Bilateral Hip Pain in a Female
High School Soccer Athlete
Dale Blair, MS, CSCS, ATC
Kristin Wright
Michael Hansen, MPT, ATC
Wenatchee High School
Wenatchee, Washington
History
• 16 year old soccer athlete presented with hip
pain and audible bilateral “snapping”
• Symptoms were first noticed in April 1996
• Patient was unable to report a specific
etiology and the onset of the symptoms was
vague
History
• During fall soccer, pain persisted and she
limited her activities.
• She underwent physical therapy for 3 years.
• Discontinued PE, sports and other activities.
Physical Signs and Symptoms
• Patient suffered from constant anterior hip
pain.
• The pain with functional activities was
evident when the hip moved from a flexed
to extended position and was accompanied
by and audible snap
Physical Signs and Symptoms
• Range of motion limited, hip flexors weak
and painful
• She experienced pain radiating to the upper
anteromedial aspect of the thigh and
suffered from low back and L4-5
dermatome pain.
Diagnostic Imaging/ Laboratory tests
• MRI of spine - normal
• MRI of hip and pelvis - revealed no soft
tissue damage
• MR arthrography under x-ray guidance ruled out labral tear.
Diagnostic Imaging/ Laboratory tests
• Bone scan - negative
• X- rays of hip and back - show no bony
abnormality
• Diagnostic ultrasound - showed anterior
snapping bilaterally
• X-rays of the pelvis and hip show no bony
abnormality.
• MRI, CT scans, and bone scans- negative
Differential Diagnosis
• Acetabular labrum injury
• Entrapment or irritation of lateral femoral
cutaneous nerve
• Referred pathology from low back
• Fibromyalgia
• Reflex neurovascular dystrophy
Final Diagnosis...
Snapping Iliopsoas tendon
Discussion
• The conjoined iliopsoas tendon passes
lateral to the iliopectineal eminence and
medial to the joint capsule of the hip to
insert on the lesser trochanter of the femur.
• With extension of the flexed, abducted and
externally rotated hip, the iliopsoas moves
in a medial direction. (Keskula et al., 1999)
• Pain referred from trigger points in the
iliopsoas muscle.
Discussion (con’t)
• The normal lateral or medial excursion of
the iliopsoas is interrupted, resulting in
painful snapping of the iliopsoas over the
femoral head and hip capsule.
• The iliopsoas bursa, which lies between the
anterior capsule of the hip and the iliopsoas
tendon may become inflammed and painful
with repetitive snapping.
• Attachment of the right
psoas major, psoas
minor and iliacus
muscles.
• The psoas major crosses
many articulations
including those of the
lumbar spine and the
lumbosacral, sacroiliac,
and hip joints.
• The psoas minor crosses
all of these except the
hip joint.
Treatment- Conservative
• Anti-inflammatory medications
• Patient underwent 3 years of physical
therapy
• Corticosteroid injection of the hip
Treatment- Conservative
• Physical therapy with a focus on stretching,
progression of activities, modalities and
functional modes of exercise which include:
– restoring normal pain-free range of motion and
strength
– returning to pain-free functional capabilities
– identifying and modifying contributing factors.
Treatment-Surgical
• Surgical lengthening of the iliopsoas tendon
– Evaluated in the context of patient goals,
functional status, patient pain and prior
treatment outcomes.
Treatment-Surgical
• Patient underwent right iliopsoas release in
December 1998.
– Snapping slightly decreased but pain persisted
– Experienced numbness in anteromedial thigh
and lower leg.
– Unable to return to activities
• In November 1999, she underwent bilateral
iliopsoas releases.
• Right hip specimen with muscle bellies of iliacus
and psoas retracted laterally.
• The tendinous portion of the iliopsoas is shown
tented over the anterior femoral head.
Disposition of Case
• Patient continues to experience pain.
• Surgery decreased the intensity of the
snapping, but the frequency remains same.
• She has been unable to return to any activity
including sports or marching band.
• She continues doing physical therapy on an
out-patient basis.
Thank You