CHAPTER 57 • PELVIS, HIP, AND THIGH 341arthroscopy become more refined we are able to better
differentiate these entities (Meyers et al, 2000).- The most common cause of snapping hip syndrome is
irritation of the greater trochanter by the iliotibial
band. The iliotibial band is a large flat tendinous struc-
ture that originates on the anterior superior portion of
the iliac crest, crosses over the greater trochanter of the
femur, and inserts onto the lateral condyle of the tibia.
Iliotibial band syndrome is seen in athletes who
undergo repetitive knee flexion, such as runners and
cyclists. Athletes will have pain over the greater
trochanter of the femur, the lateral thigh, or radiating
pain down to the knee. Patients often report hip insta-
bility symptoms. If severe enough, the snapping sensa-
tion will occur during normal ambulation. Once this
area becomes inflamed, running or rising from a seated
position may hurt continuously.
HAMSTRING SYNDROME
- Hamstring syndrome, described in track athletes,
involves severe pain in and around the ischial tuberos-
ity which radiates down the posterior aspect of the
thigh to the popliteal area. Any activity which puts the
hamstring in stretch can create this radiating pain.
Sprinting, hurdling, and even sitting for long periods
will cause pain. Physical examination elicits exquisite
tenderness at the ischial tuberosity and, at times,
reproduction of sciatic pain with percussion of the
nerve at the ischial tuberosity. Resisted leg extension
will reproduce the pain. The sciatic nerve is thought to
be entrapped between the semitendinosus and the
biceps femoris by a fibrous band that constricts the
two muscles (Busconi, Wixted, and Owens, 2003).
ATHLETIC PUBALGIA
- The term athletic pubalgiarefers to a chronic inguinal
or pubic area pain in athletes, which is noted with
exertion. The pattern of symptoms in these patients,
operative findings, and results of studies, all suggest
that the lower abdominal/inguinal pain is not due to
occult hernia. Only a small percentage of patients are
found to have occult hernia at the time of surgery.
When this does occur, the occult hernia is usually
found on the side opposite the principal symptoms. - The rectus tendon insertion on the pubis seems to be
the primary site of pathology. Most patients describe
a hyperextension injury in association with hyper
abduction of the thigh. The location of pain suggests
that the injury involves both the rectus abdominis and
adductor longus muscles. Other tendinous insertion
sites on the pubic bone may also be involved (Meyers
et al, 2000).DIAGNOSIS- The athletes have lower abdominal pain with exertion.
A minority of patients have pure adductor related pain
that is disabling. Most of the patients remember a dis-
tinct injury during exertions. Usually, the abdominal
pain involves the inguinal canal near the insertion of
the rectus abdominis muscle on the pubis. The pain
often causes a majority of patients to stop competing
in sports.
•MRI findings in athletic pubalgia are often nonspe-
cific. On the other hand 12% of patients have MRI
findings that clearly indicate a problem at the rectus
insertion site. The relatively small incidence of a spe-
cific diagnosis by imaging studies suggests that the
problem may be an attenuation of the muscle or
tendon due to repeated microtrauma. The finding in
the MRI, of adductor longus inflammation, is consis-
tent with athletic pubalgia.
TREATMENT
•Generally, the acute management of groin pain sus-
pected to be athletic pubalgia consists of conservative
management. This includes rest, ice, compression,
anti-inflammatory medications, and massage. When
the process continues over several months and the ath-
lete cannot return to previously expected activity
because of pain, an operation should be considered.
Surgical treatment of athletic pubalgia requires a
broad surgical reattachment at the inferolateral edge
of the rectus muscle with its fascial investments to the
pubis and adjacent anterior ligaments. Also performed
is an anterior and lateral release of the epimysium of
the adductor fascia in order to expand this compart-
ment. The epimysium is the layer of connective tissue
that encloses the entire muscle. This kind of fascial
release is often very successful in relieving the adduc-
tor symptoms in athletic pubalgia.REFERENCES
Anderson K, Strickland SM, Warren R: Hip and groin injuries in
athletes. Am J Sports Med29:521–533, 2001.
Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and
treatment. J Am Acad Orthop Surg8:344–353, 2000.
Busconi B, McCarthy J: Hip and pelvic injuries in the skele-
tally immature athlete. Sports Med Arthrosc Rev4:132–158,
1996.
Busconi BD, Wixted JJ, Owens BD: Differential diagnosis of the
painful hip, in McCarthy JC (ed.): Early Hip Disease: Advances