possible presence and extent of muscular hemorrhage
because an increase in muscular hemorrhage often
results in more severe symptoms and longer time
before returning to sport (Busconi, Wixted, and Owens,
2003).HIPPOINTER
•Pain and hemorrhage over the iliac crest has been
referred to as a hip pointer. These injuries include con-
tusions, avulsion of the iliac apophysis, periostitis, or
avulsion of the muscles that insert onto the iliac crest.
On physical examination, the patient will have super-
ficial or muscular hemorrhage, which will be painful
on palpation. It is important to note by touch a defect,
which would indicate an avulsion injury. Patients will
have difficulty with rotation and side bending of the
trunk. Anterior-posterior and oblique X-rays of the
pelvis will rule out an avulsion fracture, periostitis, or
an acute fracture of the iliac wing.
THIGHCONTUSIONS
- Thigh contusions are common athletic injuries, most
often encountered in football from direct trauma.
These injuries can involve significant muscular
damage, hematoma formation, and swelling.
Therefore, the athlete can be extremely uncomfort-
able. Initial treatment is rest, ice, and compression to
minimize hematoma formation. Immobilization in
flexion and initiation of early flexion exercises have
been recommended to decrease myositis ossificans
formation and improve functional outcome (Ryan
et al, 1991).
BURSITIS
- Bursitis about the hip is a common condition second-
ary to inflammation of one of the three major bursae
about the hip: the trochanteric bursa, the iliopsoas
bursa, and the ischiogluteal bursa. These bursae facil-
itate the gliding of musculotendinous or ligamentous
structures. Bursitis may be secondary to direct injury,
overuse of the adjacent musculotendinous structures,
or degenerative changes in these structures. Because
bursae are lined by true synovial tissue, bursitis also
can occur with systemic disease, causing synovitis. - The trochanteric bursa is a large bursa that lies
between the greater trochanter and the overlying junc-
tion of the gluteus maximus and tensor fascia lata, as
these merge to form the fascia lata and iliotibial tract.
This is the most common bursitis in athletes and is
common in runners. - Ischiogluteal bursitis, inflammation of the bursa
between the ischial tuberosity and the overlying gluteus
maximus, is usually associated with injury or with
occupations requiring long periods of sitting. The
patient complains of pain over the ischial tuberosity
that is aggravated by sitting, and the pain may radiate
into the posterior thigh.- Iliopsoas bursitis is another relatively common bursi-
tis in athletes. This bursa located between the iliop-
soas muscle and the pelvis proximally and the hip
capsule and psoas tendon distally. Communication
between the hip joint and psoas bursa is common. - Corticosteroid injections may provide temporary symp-
tomatic relief. Use of local anesthetics can also provide
diagnostic confirmation (Anderson, Strickland, and
Warren, 2001).
PIRIFORMIS SYNDROME•Yeoman in 1928 first described a syndrome involving
compression of the sciatic nerve by the piriformis
muscle. The compression of the nerve occurs as it
exits deep to the piriformis muscle. Patients will com-
plain of pain and symptoms in the sciatic nerve distri-
bution. A history of past acute trauma to the buttock is
often present. Patients will have difficulty sitting or
participating in activities that cause hip flexion and
internal rotation (ice skating). On physical examina-
tion, tenderness can be present over the piriformis
tendon in the gluteal area. Pain is elicited by forced
internal rotation on an extended thigh, or pain and
weakness on resisted abduction and external rotation
of the thigh (Pace’s sign). Rectal or vaginal examina-
tion may produce pain in the piriformis area. An MRI
can be helpful to demonstrate sciatic nerve inflamma-
tion in the area of the piriformis tendon (Meyers et al,
1999).SNAPPING HIP SYNDROME- Snapping hip syndrome is a collection of extra-articu-
lar and intra-articular pathologies that can be painful
and disabling to the athlete. Extra-articular snapping
of the hip joint can be caused by ( 1 ) the iliopsoas
tendon as it passes over the iliopectineal eminence or
the lesser trochanter of the femur; ( 2 ) the iliofemoral
ligaments over the femoral head; ( 3 ) the long head of
the biceps femoris over the ischial tuberosity; and ( 4 )
the iliotibial band over the greater trochanter of the
femur. It can be very difficult to distinguish these enti-
ties from more disconcerting intra-articular lesions
such as tears of the anterior labrum, synovitis, and
loose bodies that can also create a snapping or click-
ing sensation in the hip; however, as CT, MRI, and hip
340 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE