Hips don’t lie Prof. Dr. K. Peers Fysische Geneeskunde en Revalidatie Sportgeneeskunde UZ Leuven Hips don’t lie, … … actually, they do. Prof. Dr. K. Peers Fysische Geneeskunde en Revalidatie Sportgeneeskunde UZ Leuven from eminence to evidence medicine – Complex pathology & DD – Clear diagnostic terminology – Valid outcome Thorborg – Hölmich 2013 UZ Leuven • Binnen driehoek • Lateraal van driehoek • Mediaal van driehoek • Superieur van driehoek ahv anamnese – KO – TO UZ Leuven terminologie liespijn in de wereld Adductor related pain Sportman’s hernia Gilmore’s groin Pubalgia Intrinsic hip pathology Osteitis pubis Thorborg presentation 2012 UZ Leuven UZ Leuven from eminence to evidence medicine – Complex pathology & DD – Clear diagnostic terminology – Valid outcome Thorborg – Hölmich 2013 UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven heup & liespijn Musculotendineus Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven Hip and groin pain: musculotendinous vs articular clinical decision • high prevelance of asymptomatic structural abnormalities • Highly equivocal correlation with or prediction of pain from musculotendinous or articular pathology UZ Leuven • presence of a cam deformity represents a significant risk factor for the development of hip pain • PPV - 4 yrs = 0,125 – – – radiographically identified cam lesion but asymptomatic clinical follow-up and surgical intervention only if • persistent hip pain • physical examination findings consistent with impingement, • additional imaging is performed to assess cartilage, soft tissue, and osseous structures of the hip. UZ Leuven • Normale MRI • MRI strain adductor – symptomatic – asymptomatic UZ Leuven comprehensive structural and functional clinical evaluation UZ Leuven muscle/ tendon joint nerve bone UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven • Geïsoleerde klinische testen heup: – Niet gerapporteerde diagnostische waarde – Lage specificiteit UZ Leuven • • • • • • • • • • • • • Adductor related pain Iliopsoas related pain Rectus abdominis related pain Snapping iliopsoas Piriformis related pain Pelvic floor related pain Sacrotuberal ligament pain Sacroiliac joint disfunction Pain of thoracolumbar origin Hip arthrosis Stress fracture Hernia Sports hernia UZ Leuven • • • • • • • • • • • • • Adductor related pain Iliopsoas related pain Rectus abdominis related pain Snapping iliopsoas Piriformis related pain Pelvic floor related pain Sacrotuberal ligament pain Sacroiliac joint disfunction Pain of thoracolumbar origin Hip arthrosis Stress fracture Hernia Sports hernia UZ Leuven • Musculotendinous injury groin – Adductor related – Abdominal muscle related – Iliopsoas related – Rectus femoris related – Clinical diagnosis – Imaging relatively related and not predictive – Conservative therapy mainstream UZ Leuven • asymptomatic players – prospective - hockey • in general remain asymptomatic 2-4 years • few players miss any games because of hip and pelvis pathology incidentally found on MRI • Young (± 16 yr) elite • • • • Cleft muscle/tendon Oedema muscle/tendon Disruption tendon Inguinal canal bulging • No prediction of symptoms injury or surgery UZ Leuven • Pubic bone and adductor oedema • Symptoms or no symptoms? UZ Leuven • MRI (sagittal) view on abdominal muscle injury UZ Leuven • • • • Professional football players Symptomatic R. femoris subtotal rupture, ¾ rupture r. abdominis insertion Exercise therapy two months UZ Leuven • Musculotendinous injury groin – Adductor related – Rectus femoris related – Abdominal muscle related – Iliopsoas related – Clinical diagnosis – Imaging relatively related and not predictive – Conservative therapy mainstream UZ Leuven Effectiveness of active physical training as treatment for longstanding adductor-related groin pain in athletes: randomised trial Per Hölmich et al., The Lancet, 1999 • 68 athletes with median 40 weeks groin pain – randomisation Active Training and PhysioTherapy (8-12 weeks) – 4 months blinded evaluation Return to sport: Subjective asssessment Active Training Physio Therapy excellent 23 4 good 2 6 fair 3 6 poor 6 18 much better 22 13 better 7 14 not better 0 3UZ Leuven • Only one RCT on exercise groin pain – Anterior complex – Posterior complex – Lateral complex UZ Leuven Holmich Lancet 1999 – SJSM 2010 UZ Leuven • Holmich Lancet 1999 – SJSM 2010 UZ Leuven • Holmich Lancet 1999 – SJSM 2010 UZ Leuven PATELLAR TENDINOPATHY: LOOKING OUTSIDE THE TENDON… Ebonie Rio, Dawson Kidgell, G Lorimer Moseley, Jill Cook. UZ Leuven EXERCISE REDUCES PAIN IMMEDIATELY AND AFFECTS CORTICAL INHIBITION IN PATELLAR TENDINOPATHY Ebonie Rio, Dawson Kidgell, Jill Cook. Rio E et al. Br J Sports Med 2014;48:A57-A58 Single leg decline squat (tendon pain) pre and post interventions. UZ Leuven • Holmich Lancet 1999 – SJSM 2010 UZ Leuven • Holmich Lancet 1999 – SJSM 2010 UZ Leuven • Holmich Lancet 1999 – SJSM 2010 UZ Leuven • Type of exercise specity • Adductor specific program • Activity & strengthening other key muscle groups UZ Leuven Casus: 40-jarige marathonloper en leerkracht LO • 1 jaar liespijn rechts – – – – – Inguinale hernia links RX – US – MRI - Botscintigrafie 2 x infiltratie CS Lokale antalgische fysiotherapie Geen oefentherapie – KO consistent met adductoren en abdominale insertietendinopathie – Stabiliteitstesten positief UZ Leuven UZ Leuven Symptomatic effect of CS UZ Leuven UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven • Sportman’s hernia UZ Leuven • athletic pubalgia, sports hernia, incipient hernia, Gilmore’s groin, groin disruption and sportmen’s groin • Inguinal disruption • ID can be defined as pain, either of an insidious or acute onset, which occurs predominantly in the groin area near the pubic tubercle where no obvious other pathology, such as a hernia, exists to explain the symptoms. UZ Leuven at least three out of the five clinical signs: 1. Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint tendon; 2. Palpable tenderness over the deep inguinal ring; 3. Pain and/or dilation of the external ring with no obvious hernia evident; 4. Pain at the origin of the adductor longus tendon 5. Dull, diffused pain in the groin, often radiating to the perineum and inner thigh or across the midline UZ Leuven • The initial history and examination remains a key with a full physiotherapy rehabilitation regime undertaken prior to any surgery contemplated. • Imaging is recommended for all patients with ID as it will be important to exclude other conditions that may cause chronic groin pain. • Any surgery should be carried out as part of a dedicated team; the role of surgery is to release the abnormal tension in the inguinal canal and reconstruct the weakness in the posterior wall when other conservative approaches have failed. UZ Leuven • A clearer algorithm on what specific findings on MRI would constitute a definition of ID; • Evidence-based treatment algorithm on the length of conservative measures and physiotherapy regimes followed by indications for surgery and if possible the type of surgery recommended; • Physiotherapy regime descriptions to suit differing surgical techniques should be explored and commented on. • Differing surgical techniques should be tested in multicentred RCT by surgeons possessing expertise in open and laparoscopic techniques. UZ Leuven UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven • • • Asymptomatisch – gem. 34 jaar ± 25 % cyste ± 85% labrumscheur UZ Leuven UZ Leuven • Adductor related groin pain + structural FAI can be successfully treated conservatively • Alfa angle > 55° is risk factor • Untreated FAI did not cause OA after 8-12 years UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven Stressfracturen bekken-heupregio RX-botscintigrafie-MRI-CT – Femurhals – Pubis-tak – Sacrum UZ Leuven • Stressfracturen bekken/heupregio – Patiëntprofiel • Sport – female (athlete triad) – Pijnprofiel • Mechanische belastingspijn • Nachtelijke pijn – Klinisch onderzoek – Beeldvorming UZ Leuven • Osteitis pubis ? UZ Leuven • Hockey speler met acute liespijn bilateraal • Instabiliteit • Uitzonderlijk UZ Leuven • Synchondrose ischiopubische tak tractieletsel m. quadratus femoris UZ Leuven Ischiopubic synchondrosis Linksvoetig Rechtsvoetig Bilateraal (23) 5 18 Links (7) - 7 Rechts (2) 2 - Unilateraal Herneth et al in AJR 2004 UZ Leuven Adductor tendinopathie < 13-14 jaar ? • Therapeutische implicatie • Vermijden van niet geïndiceerde operatie UZ Leuven • Avulsiefracturen: SIAI (r.femoris), SIAS (sartorius), tuber ischiadicum (hamstrings) UZ Leuven • Avulsiefracturen: SIAI, SIAS, tuber ischiadicum – Zeldzame complicatie bij 16-jarige keeper – Secundaire incisie van iliopsoas UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven Zenuwentrapment • N. ilioinguinalis • N. obturatorius • N. femoralis • N. cut fem lateralis • N. ischiadicus • N. piriformis UZ Leuven Zenuwentrapment/ Sensitisatie • Pijnprofiel • EMG – zenuwgeleiding – naaldEMG • Proefinfiltratie • Medicatie • Gerichte oefentherapie • Neurolyse UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven • Arterieel entrapment (a.iliaca) – Uiterst progressieve onset – Inspanningsgebonden pijn – Progressieve endofibrose – Enkel/arm index met provocatieve test – Angiografie, MR/CT angiografie – Angioscopie – Endarterectomie en veneuze patchplastie UZ Leuven • unilaterale lies-bovenbeenpijn – – – – CT LWZ: normaal NMR LWZ: geen afwijkingen EMG onderzoek: normaal MR Angio: OL normaal – E/A index: na inspanning: • Arm Links 161 mmHg • Enkel Re: Tib.post. 138 mmHg (index 0.85) • Enkel Li:Tib.post. 38 mmHg (index 0.25) – CT angio met heupflexie: sterk verdacht voor endofibrose in proximale helft van linker art. iliaca externa – Endarterectomie AIE en veneuze patchplastie links (autologe VSM) UZ Leuven heup & liespijn – Musculotendineus – Articulair – Osteogeen – Neurogeen – Vasculair – Andere oorzaken UZ Leuven from eminence to evidence medicine – Clear diagnostic terminology – Valid outcome – Complex pathology Thorborg – Hölmich 2013 UZ Leuven muscle/ tendon joint nerve bone UZ Leuven UZ Leuven
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