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ip and Pelvic Problems in Athletesichael K. Shindle, MD, Benjamin G. Domb, MD, and Bryan T. Kelly, MD

In the athletic population, the differential diagnosis of hip pain is quite broad and mustinclude intra-articular pathology, extra-articular pathology, and central pubic pain associ-ated with athletic pubalgia. In addition to an appropriately performed history and physicalexamination, advanced imaging techniques, including magnetic resonance imaging (MRI)and ultrasound, often are required to narrow the differential diagnosis. MRI is an excellentmodality to image the pelvis and hip because of its ability to screen the pelvis for otheretiologies of pain, its superior soft-tissue contrast, which allows visualization of thearticular cartilage, fibrocartilaginous labrum, and myotendinous junctions, and its lack ofionizing radiation. During the last decade, the management of hip injuries has evolvedsubstantially as a result of the advancement in techniques and flexible instrumentation forhip arthroscopy. Currently, a variety of hip pathologies may be addressed arthroscopically,including labral tears, loose bodies, femoroacetabular impingement, coxa saltans, ligamen-tum teres injuries, and capsular laxity. This article will focus on common etiologies of hipand pelvis pain in the athletic population with an emphasis on the use of hip arthroscopyto treat these disorders.Oper Tech Sports Med 15:195-203 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS hip arthroscopy, labral tears, femoroacetabular impingement, hip instability

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ip injuries are very prevalent in the athletic population.Although they are most commonly related to extra-ar-

icular muscular strains or sprains, intra-articular lesions af-ecting the acetabular labrum, articular cartilage, and capsu-ar and ligamentous structures are frequently the cause ofecalcitrant hip pain that may be difficult to accurately diag-ose.1 The management of hip injuries has evolved substan-ially with the advancement in diagnostic tools, such as mag-etic resonance imaging (MRI) and with new techniques andexible instrumentation for hip arthroscopy. Hip injuries cane divided into extra-articular, intra-articular, or central pu-ic pain associated with athletic pubalgia. Labral tears, fre-uently associated with femoroacetabular impingement (FAI),re the most common cause of disabling intra-articular hipain in the athletic population.2,3 Currently, various hip pa-hologies can be addressed arthroscopically, including labralears, loose bodies, FAI, coxa saltans, ligamentum teres inju-ies, and capsular laxity.4 This article will focus on commontiologies of hip pain in athletes with an emphasis on the usef hip arthroscopy to treat these disorders.

ospital for Special Surgery, New York, NY.ddress reprint requests to Bryan T. Kelly, MD, ATTN: Katrina Dela Torre,

aMSN, Belaire Building, 525 East 71st Street, New York, NY 10021.

060-1872/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1053/j.otsm.2007.10.003

istory andhysical Examination

he differential diagnosis of hip pain is quite broad in thethletic population (Table 1). Without an appropriateorkup, hip pain in an athlete should not be attributed touscle strains or soft tissue contusions. A detailed history

nd physical examination are required in an attempt to nar-ow the differential diagnosis (Table 1). A key goal of physicalxamination is to determine if the pain is of intra-articular orxtra-articular origin. The history should include the quali-ative nature of the discomfort (clicking, catching, stiffness,nstability, decreased performance, and weakness), the loca-ion of the discomfort, onset of symptoms, and any history ofrauma or developmental abnormality. In addition, risk fac-ors for avascular necrosis or stress fractures should be as-essed as well as any details that suggest referred or systemicauses of hip pain.4

Palpation of specific regions of the hip may localize ten-erness with extra-articular pathology, but rarely with intra-rticular pathology.5 It should be noted that intra- and extra-rticular pathologies commonly coexist, which may complicatehe workup and diagnosis. A complete neurovascular exam-nation should be performed, and gait, posture, muscle con-ractures, limb-length inequality, and scoliosis should be

ssessed. Active and passive range of motion should be

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196 M.K. Shindle, B.G. Domb, and B.T. Kelly

valuated with patient in the seated, supine, and prone posi-ions.5

Specific tests that can be performed include the Thomasest to evaluate for the presence of a hip flexion contracture.6,7

ain with log rolling of the lower extremity is suggestive ofntra-articular hip pain.7,8 The flexion-abduction-external ro-ation (FABER) test is performed by placing the ankle on theffected side across the unaffected thigh (figure-of-4 posi-ion). Classically, a painful FABER test has been felt to suggestathology of the sacroiliac joint when the symptoms are re-erred posteriorly.7 Patients with anterior hip pain in thisosition may have injury or irritation to the anterior capsule,

abrum, or psoas. FAI or labral tears may be associated with

able 1 Differential Diagnosis of Hip Pain

raumatic Nonmusculoskeletal causesSubluxation/dislocation Psoas muscle abscessStress fracture/fracture SpineHematoma HerniaContusion Endometriosis

Ovarian cystPeripheral vascular disease

abral Pathology Unknown etiologyFemoroacetabular

impingementTransient osteoporosis of

the hipHypermobility Bone marrow edema

syndromeTraumaDysplasia

nfectious/tumor/metabolic Synovial proliferativedisorders

Septic arthritis Pigmented villonodularsynovitis

Osteomyelitis Synovial chondromatosisBenign bone and soft-

tissue neoplasmsChondrocalcinosis

Malignant bone andsoft-tissueneoplasms

Metastatic bone diseasenflammatory Metabolic

Rheumatoid arthritis Paget’s diseaseReiter’s syndrome Primary

hyperparathyroidismPsoriatic arthritishondral pathology Extra-articular pathologyLateral impaction Coxa saltans

(internal/external)Avascular necrosis Psoas impingementLoose bodies Abductor tears (Rotator cuff

tears of the hip)Chondral shear injury Athletic pubalgiaOsteoarthritis Trochanteric bursitis

Ischial bursitisapsule Pathology Osteitis pubisLaxity Piriformis syndrome

Adhesive capsulitis Sacroiliac pathologyynovitis/inflammation Tendonitis (hip flexors,

abductors, adductors)

ain in the position of flexion–adduction–internal rotation m

FADDIR test or impingement test) as well as groin pain orlicking.9

maging Studiesenger and coworkers demonstrated that in 87% of patientsith labral tears, there is evidence of osseous abnormalitiesetected on plain radiographs.10 In an athlete presenting withip pain, we routinely obtain an anteroposterior (AP) pelvis,alse profile view, and Dunn lateral view (elongated neckateral).11 The AP pelvis view should be obtained in slightnternal rotation and with standardized pelvic inclination.iebenrock and coworkers recommend that the correct pel-ic inclination is indicated by the distance between the pubicymphysis and sacrococcygeal joint (approximately 32 mmn men and 47 mm in women).12 It is important to note thatariations in pelvic inclination or rotation may change thepparent anteversion of the acetabulum. An increase in pelvicnclination will cause an apparent decrease in anteversion,hereas decreased inclination will cause an apparent in-

rease in anteversion.12 The osseous landmarks should bedentified, including the iliopectineal line, the ilioischial line,nterior and posterior acetabular walls, the sourcil (acetabu-ar roof), and tear drop. The cortical integrity and trabecularattern of the femoral neck should be carefully evaluatedo exclude a nondisplaced fracture. Radiographic indiceshould include the femoral neck-shaft angle, the center-edgengle of Wiberg (Fig. 1), and the Tönnis angle (Fig. 2).13 AP-rays should also be evaluated for signs of acetabular retro-ersion (Fig. 3).13 A false profile view is useful for evaluatingnterior femoral head coverage and a Dunn lateral view (90°exion, 20° abduction) is useful for identifying a CAM lesionr an abnormally shaped anterior head–neck junction.11

In most cases, an MRI is indicated to evaluate the ace-abular labrum, articular cartilage, and to screen the pelvisor other etiologies of pain. At our institution, the axialroton density and coronal inversion recovery body coil

igure 1 An AP radiograph showing the method for measuring theenter-edge angle of Wiberg. The center-edge angle is normally25°, with 20° to 25° considered borderline. (Reprinted with per-

ission from Shindle et al.13)

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Hip and pelvic problems in athletes 197

mages are followed by the use of a surface coil techniqueith cartilage–sensitive, intermediate-echo time, fast-

pin-echo pulse sequences in the coronal, sagittal, andblique axial (SWISS protocol) planes, with high in-planend slice resolution.

Evaluation of patients with osseous abnormalities can of-en be facilitated with a computed tomography scan withhree-dimensional reconstructed images. These images allowccurate assessment of CAM and pincer lesions as well asemoral and acetabular version. A complete appreciation forhe bony anatomy is necessary for preoperative planning andurgical decision making.

Finally, fluoroscopically guided intraarticular injection isn invaluable tool to determine whether hip pain is due to anntraarticular derangement. Byrd and coworkers have dem-nstrated that pain relief to an intraarticular injection is a0% reliable indicator of an intraarticular abnormality.14

abral Tearsnjuries to the acetabular labrum are the most consistentathologic findings identified during hip arthroscopy.15 The

abrum is a fibrocartilaginous structure that provides sometructural resistance to lateral and vertical motion of the fem-ral head within the acetabulum and has an important seal-ng function which limits fluid expression from the jointpace to protect the cartilage layers of the hip.16-18 Mechanicalymptoms and restricted range of motion are usually presentith labral tears. Patients with clinical signs, MR findingsonsistent with a labral tear, and persistent hip pain forore than 6 weeks are candidates for hip arthroscopy.15

o optimize the outcome results, the etiology for labralathology should be identified. Common etiologies in-lude trauma, FAI, dysplasia, psoas impingement, and

igure 2 An AP radiograph showing the method for measuring theönnis angle of the hip; a normal Tönnis angle is �10°. Increasedönnis angles are associated with lateral subluxation of the hip and

ncreased contact pressures of the femoral head on the anterosupe-ior weight bearing zone of the acetabulum. (Reprinted with per-ission from Shindle et al.13)

traumatic instability.4,14 e

Labral tears in the athletic population occur mainly in thenterior–superior zone in association with FAI and traumaticvents occurring during contact sports. In these athletes,ome combination of a bony predisposition for mechanicalverload (ie, FAI or dysplasia, or both) and aggressive sport-ng activities that aggravate the underlying osseous anatomy,ncrease the likelihood of intraarticular injury. Seldes andoworkers19 has described 2 histological types of labral tears.type 1 labral tear is a detachment at the fibrocartilaginous

abrum-cartilage junction (Fig. 4), while a type 2 tear is anntrasubstance tear (Fig. 5).19,20 Labral tears associated withAM impingement are more commonly type 1 tears affecting

he transition zone cartilage and articular surface of the la-rum. Pincer lesions, on the other hand, are usually associ-ted with type 2 tears secondary to crushing of the labrumgainst the neck of the femur.

In our experience, some patients have history and physicalxamination findings consistent with coxa saltans and haveymptomatic relief with sonography-guided iliopsoas injec-ions.21 In this population, the labral pathology may occur inn atypical direct anterior location in the absence of bonybnormalities. We believe this direct anterior injury may beelated to compression of the anterior capsulo-labral com-lex by the psoas tendon as it crosses the anterior acetabularim. Labral debridement or repair combined with fractionalengthening of the psoas has led to subjective improvementn symptoms in the short term. However, longer follow-up isequired to validate this procedure.

For surgical treatment, we prefer the supine position,hich has been well described.6,8,22 We use an anterior and

n anterolateral portal, as well as posterolateral, distal lateralccessory, and other portals as needed.15 To maximize vi-ualization, we use a combination of 70° and 30° scopes.fter a systematic diagnostic arthroscopy is performed, the

abrum and capsule-labral junction are probed to rule outetachment. If required to improve visualization, a partial

igure 3 An AP radiograph of the pelvis shows the crossover signndicative of a retroverted acetabulum. In a retroverted acetabulum,he anterior acetabular rim (dashed line) crosses over the posteriorcetabular rim (solid line). (Reprinted with permission from Shindle

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ynovectomy is performed with a radiofrequency device. Theajority of the vascular supply to the labrum is provided

rom the capsular contribution whereas the articular surfacef the labrum has a limited synovial covering and decreasedascularity.23 The goal of surgical treatment of labral tears iso eliminate any unstable tissue by debridement or repair,hile preserving as much healthy tissue as possible to allow

he labrum to maintain its role as a suction seal and secondaryoint stabilizer.20 When possible, a tear at the articular marginhould be repaired with suture anchors to the acetabular rimFig. 6).20 Frayed or degenerative labral tears should be de-rided to stable edges with a combination of RF probes andotorized shavers.

emoroacetabular Impingementwo distinct types of FAI have been described, CAM andincer.24-26 Although the 2 types of FAI can occur in isola-ion, it has recently been shown that combined impingementccurs in 86% of cases.27 Cam impingement is the result of anbnormally shaped femoral head, which contacts a normalpherical acetabulum, most commonly in hip flexion andnternal rotation. When the aspherical head–neck junction ofhe femur enters the acetabulum, it displaces the labrumoward the capsule and applies disproportionate load to thedjacent articular cartilage of the acetabulum. This leads tohondral delamination and detachment of the labrum fromhe acetabular rim.

Pincer impingement involves an abnormal acetabulumith retroversion or overcoverage of the femoral head. This

etroversion or overcoverage causes impingement of the la-rum between the acetabulum and the femoral neck, result-

ng in crushing, degeneration, and eventual ossification of theabrum. Chondral injuries are generally less severe than inam impingement.28,29

Philippon and coworkers have demonstrated that FAI is aajor cause of hip pain, reduced range of motion and de-

reased performance in the athletic population.15,28 Such in-

igure 4 Type I labral tear with full-thickness detachment off the rimf the acetabulum.20

uries are common in a broad range of sports, including m

ockey, ballet, football, and soccer. In 33 competitive iceockey players undergoing hip arthroscopy, 27 (81%) re-uired decompression of FAI.28 Athletes usually present withnterior groin pain exacerbated by hip flexion, and physicalxamination reveals the “impingement sign.” MRI usuallyemonstrates an anterosuperior labral tear, and an anterosu-erior cartilage defect (Fig. 7).During hip arthroscopy, the standard portals are estab-

ished and the intraarticular pathology is addressed while theip is under traction. This may include labral debridement orepair, microfracture, and chondroplasty. Anterior overcov-rage secondary to a pincer lesion can also be treated arthro-copically, either from the central or peripheral compart-ents.28 First, the margins of the pincer lesion must be

efined by probing with a flexible instrument. This lesion issually associated with a flattened, degenerative or cystic

abrum. In small pincer lesions in association with a camesion, addressing only the cam lesion may provide sufficientlearance.28 However, larger pincer lesions require bony re-ection. This “rim trimming” procedure may necessitate de-achment of the labrum overlying the pincer lesion. Resectionan generally be considered complete when the crossoverign is eliminated on fluoroscopy. Resecting greater than 5m of acetabular rim is not recommended, as it may cause

nstability.28 After this resection, the labrum should be reat-ached to the acetabular rim using suture anchors as previ-usly described in this chapter.For decompression of the femoral–head neck junction, we

ecommend a distal lateral accessory portal.15 After tractionas been slowly released and the knee is flexed to 45°, therthroscope is placed in the anterior portal and a skin incisions made approximately 4 cm distal and 1 cm anterior to thenterolateral portal.28 While the hip is flexed and in neutralotation, the arthroscope placed anteriorly and distally overhe femoral head peripheral to the labrum, providing excel-ent visualization of the head-neck junction. A long motor-zed burr is used under fluoroscopy to perform osteoplasty ofhe CAM lesion. The hip may be flexed and extended, ab-

igure 5 Arthroscopic images demonstrating repair of a type II labralear with an intrasubstance split in the tissue. (Reprinted with per-

ission from Ranawat and Kelly.20)

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ucted and adducted, and internally and externally rotated toetermine the appropriate positioning.28 After osteoplasty,

oint clearance should be assessed by flexing the hip beyond0° and internally rotating under direct visualization. Theuperior and posterolateral aspects of the femoral head-neckunction should be avoided because branches of the medialircumflex artery perforate the joint capsule and course alonghis region of the femoral neck. A resection of less than 30%f the head–neck junction is recommended because this haseen shown to not alter the load bearing capacity of theemoral neck.30 Philippon and coworkers report that burringo a depth of approximately 5 to 8 mm has been a safe andffective procedure.28

ip Instabilityip instability can be traumatic or atraumatic in nature.raumatic instability ranges from subluxation to dislocation.ip dislocations are most commonly associate with dash-oard injuries in motor vehicle accidents, but also have beeneported in American football, rugby, skiing, jogging, basket-all, soccer, biking, and gymnastics.31-33 The initial phase ofanagement involves rapid reduction and, when indicated,

spiration of hemarthrosis, to minimize long-term complica- h

ions such as osteonecrosis. The secondary phase focuses onefinitive care of injured structures.34-36 Most hip disloca-ions sustained during athletic activities are pure dislocationsnd, due to the low energy mechanism, usually have no as-ociated fractures or small acetabular rim fractures. Thus,urgical stabilization is often not warranted and active andassive range of motion can begin as soon as tolerated by theatient. Hip arthroscopy is playing a growing role in treat-ent of femoral head pathology, loose bodies, chondral in-

uries and labral pathology associated with hip dislocations.he optimal timing of the procedure is debatable due to theoncern over the effects of traction during the acute phase ofnjury. If a loose body is not present, we feel that hip arthro-copy should be delayed for at least 6 weeks so that a repeatRI can be performed to rule out the presence of early os-

eonecrosis before placing the hip in traction. However, if aignificant loose body is present, hip arthroscopy is an optionnd may decrease the incidence of posttraumatic arthritis.37

Traumatic posterior hip subluxation has a more subtleresentation and may occur with seemingly minimal trauma.he physician should have a high index of suspicion for an

ntra-articular injury even after minor trauma. The mecha-ism is often similar to a hip dislocation with a fall on a flexed

igure 6 Using fluoroscopic assistance, placement of a suture an-hor on the anterior-superior acetabulum is performed for a typelabral tear (A) (Reprinted with permission from Ranawat andelly.20) One limb of the suture is passed between the detached

abrum and the bony acetabulum using a penetrator (B). Theuture is then passed back through the labrum to create a verticalattress suture in the labrum and is tied using standard arthro-

copic knot tying techniques (C).

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valuation should include an AP pelvis and Judet views tovaluate for a “posterior lip fracture.” The evaluation shouldlso include an MRI that may demonstrate the characteristicriad of findings described by Moorman and coworkers:emarthrosis, posterior acetabular lip fracture, and iliofemo-al ligament disruption (Fig. 8).38 The presence of a significantemarthrosis may warrant aspiration under fluoroscopy to de-rease intracapsular pressure. An MRI is also useful to detectsteonecrosis and help determine which patients may returnafely to sports activity. A general treatment algorithm for theanagement of traumatic hip instability is outlined in Fig. 9.13

Atraumatic instability may arise from overuse injurieseading to microinstability or from generalized ligamentousaxity. Overuse injuries are common in athletes who partici-

ate in sports involving repetitive hip rotation with axial t

oading, such as golf, figure skating, football, baseball, ballet,artial arts, and gymnastics. The history provides the great-

st clue to the diagnosis because athletes can usually describehe motion that reproduces the pain.13,39 The labrum or il-ofemoral ligament may be damaged or stretched by theseepetitive forces. This can lead to painful labral injury, cap-ular redundancy, and subsequent microinstability. Withompromised static stabilizers, including the capsule, il-ofemoral ligament and labrum, the hip must rely more on itsynamic stabilizers. This can result in a cascade of disorders.or example, the resulting chronically contracted or tightsoas major can in turn cause low back pain, coxa saltans,nd a crushing injury to the direct anterior labrum.40

The spectrum of atraumatic instability also includes pa-

igure 7 A fast-spin-echo magnetic resonance image of a patientith combined cam-type and pincer-type femoroacetabular im-ingement. The coronal image (A) demonstrates osseous offset athe head-neck junction (white arrow) and ossification of a tornuperior labrum (white arrowhead). A coronal scout view dem-nstrating the orientation of the oblique axial view (B). Theblique axial view of the right hip accentuates the osseous offset athe femoral head-neck junction (C). (Reprinted with permissionrom Shindle et al.29)

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ous laxity, or, in the extreme form, in patients with connec-ive tissue disorders such as Ehlers–Danlos syndrome or

arfan’s syndrome.39

The treatment of atraumatic hip instability is still debat-ble. Initial treatment should consist of conservative treat-ent with antiinflammatories and physical therapy in an at-

empt to break the cycle of painful capsule-labral irritation. Ifain is persistent and intraarticular anesthetic injection pro-ides relief, arthroscopic treatment may be considered. Theoals of arthroscopy are anatomic restoration of the labrumnd a reduction in capsular laxity. This may be accomplishedy thermal modification of collagen in the hip capsular tissueombined with labral repair versus debridement. Focal ther-al capsulorrhaphy is performed using three passes in a

ornfield pattern with a flexible probe at a temperature of

7°C and power of 40 W.39 If capsular redundancy is still t

resent after this procedure, then capsular plication shoulde performed to imbricate the medial and lateral limbs of the

liofemoral ligament.

ehabilitationsuccessful outcome of hip arthroscopy is highly dependent

n postoperative rehabilitation. Depending on the extent ofony resection and the presence of labral refixation, patientsre restricted to 20 pounds foot-flat weight-bearing activityor between 10 days and 4 weeks. Our protocol includesontinuous passive motion for the first 4 weeks for 2 to 4ours per day. Starting immediately postoperatively, patientsre encouraged to ride a stationary bike with a high seat tovoid pinching. A slow progression to full strength and ac-

igure 8 MRI of a posterior hip subluxation demonstrating a pos-erior acetabular lip fracture (A), anterior capsulolabral injurynd chondral shear injury of the femoral head (B), and loose bodyn the peripheral compartment with a large hemarthrosis (C).Reprinted with permission from Shindle et al.13)

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ivity occurs over a three to four month period. This avoids

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ver activation or aggressive loading of the hip flexors, ab-uctors, and adductors, as these muscle groups are highlyusceptible to fatigue and tendonitis postoperatively. Al-hough full return to sporting activity is anticipated by 5 to 6onths, patients may continue to see improvement in their

ymptoms for up to a year postoperatively.

onclusionshere is a vast array of hip and pelvic problems that mayffect an athlete and decrease performance. Hip arthroscopys a rapidly evolving field that offers minimally invasive treat-

ent options for a wide spectrum of pathology. In the shorterm, many disorders have been treated successfully. Furthertudy is necessary to establish the indications and long-termffectiveness of these procedures.

eferences1. Burnett RS, Della Rocca GJ, Prather H, et al: Clinical presentation of

patients with tears of the acetabular labrum. J Bone Joint Surg Am

igure 9 Treatment algorithm for athletic hip dislocation or sublux-tion. (Reprinted with permission from Shindle et al.13)

88:1448-1457, 2006

2. Byrd JW, Jones KS: Hip arthroscopy in athletes. Clin Sports Med 20:749-761, 2001

3. Philippon M: Arthroscopy of the hip in the management of the athlete,in McGinty J (ed): Operative Arthroscopy. Philadelphia, Lippincott-Raven, 2003, pp 879-883

4. Kelly BT, Williams RJ 3rd, Philippon MJ: Hip arthroscopy: Currentindications, treatment options, and management issues. Am J SportsMed 31:1020-1037, 2003

5. Martin H: Clinical examination of the hip. Op Tech Orthop 15:177-181, 2005

6. Byrd J: Investigation of the symptomatic hip: Physical examination, inByrd J (ed): Operative Hip Arthroscopy. New York, Thieme, 1998, pp25-41

7. Hoppenfeld S: Physical examination of the hip and pelvis, in Hoppen-feld S (ed): Physical Examination of the Spine and Extremities. Nor-walk, Appleton & Lange, 1976, p 143

8. Byrd JW: Hip arthroscopy by the supine approach. Instr Course Lect55:325-336, 2006

9. Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: Acause for osteoarthritis of the hip. Clin Orthop Relat Res 417:112-120,2003

0. Wenger DE, Kendell KR, Miner MR, et al: Acetabular labral tears rarelyoccur in the absence of bony abnormalities. Clin Orthop Relat Res426:145-150, 2004

1. Manaster BJ, Zakel S: Imaging of femoral acetabular impingement syn-drome. Clin Sports Med 25:635-657, 2006

2. Siebenrock KA, Kalbermatten DF, Ganz R: Effect of pelvic tilt on ace-tabular retroversion: A study of pelves from cadavers. Clin Orthop RelatRes 407:241-248, 2003

3. Shindle MK, Ranawat AS, Kelly BT: Diagnosis and management oftraumatic and atraumatic hip instability in the athletic patient. ClinSports Med 25:309-326, ix-x, 2006

4. Byrd JW, Jones KS: Diagnostic accuracy of clinical assessment, mag-netic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med 32:1668-1674, 2004

5. Kelly BT, Weiland DE, Schenker ML, et al: Arthroscopic labral repair inthe hip: Surgical technique and review of the literature. Arthroscopy21:1496-1504, 2005

6. Ferguson SJ, Bryant JT, Ganz R, et al: The influence of the acetabularlabrum on hip joint cartilage consolidation: A poroelastic finite elementmodel. J Biomech 33:953-960, 2000

7. Ferguson SJ, Bryant JT, Ganz R, et al: The acetabular labrum seal: Aporoelastic finite element model. Clin Biomech (Bristol, Avon) 15:463-468, 2000

8. Ferguson SJ, Bryant JT, Ganz R, et al: An in vitro investigation of theacetabular labral seal in hip joint mechanics. J Biomech 36:171-178,2003

9. Seldes RM, Tan V, Hunt J, et al: Anatomy, histologic features, andvascularity of the adult acetabular labrum. Clin Orthop Relat Res 382:232-240, 2001

0. Ranawat AS, Kelly BT: Function of the labrum and management oflabral pathology. Oper Tech Orthop 15:239-246, 2005

1. Adler RS, Buly R, Ambrose R, et al: Diagnostic and therapeutic use ofsonography-guided iliopsoas peritendinous injections. AJR Am JRoentgenol 185:940-943, 2005

2. Byrd JW: Hip arthroscopy. J Am Acad Orthop Surg 14:433-444, 20063. Kelly BT, Shapiro GS, Digiovanni CW, et al: Vascularity of the hip

labrum: a cadaveric investigation. Arthroscopy 21:3-11, 20054. Ito K, Minka MA 2nd, Leunig M, et al: Femoroacetabular impingement

and the cam-effect. A MRI-based quantitative anatomical study of thefemoral head-neck offset. J Bone Joint Surg Br 83:171-176, 2001

5. Lavigne M, Parvizi J, Beck M, et al: Anterior femoroacetabular impinge-ment: Part I. Techniques of joint preserving surgery. Clin Orthop RelatRes 418:61-66, 2004

6. Notzli HP, Wyss TF, Stoecklin CH, et al: The contour of the femoralhead-neck junction as a predictor for the risk of anterior impingement.

J Bone Joint Surg Br 84:556-560, 2002

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2

2

3

3

3

3

3

3

3

3

3

3

4


7. Beck M, Kalhor M, Leunig M, et al: Hip morphology influences thepattern of damage to the acetabular cartilage: Femoroacetabular im-pingement as a cause of early osteoarthritis of the hip. J Bone Joint SurgBr 87:1012-1018, 2005

8. Philippon MJ, Schenker ML: Arthroscopy for the treatment of femoro-acetabular impingement in the athlete. Clin Sports Med 25:299-308, ix,2006

9. Shindle MK, Foo LF, Kelly BT, et al: Magnetic resonance imaging ofcartilage in the athlete: current techniques and spectrum of disease.J Bone Joint Surg Am 88:27-46, 2006 (suppl 4)

0. Mardones RM, Gonzalez C, Chen Q, et al: Surgical treatment of femo-roacetabular impingement: Evaluation of the effect of the size of theresection. J Bone Joint Surg Am. 87:273-279, 2005

1. Giza E, Mithofer K, Matthews H, et al: Hip fracture-dislocation infootball: A report of two cases and review of the literature. Br J SportsMed 38:E17, 2004

2. Lamke LO: [Traumatic dislocations of the hip. Follow-up on cases from

the Stockholm area]. Acta Orthop Scand 41:188-198, 1970

3. Mitchell DG, Steinberg ME, Dalinka MK, et al: Magnetic resonanceimaging of the ischemic hip. Alterations within the osteonecrotic, via-ble, and reactive zones. Clin Orthop Relat Res 244: 60-77, 1989

4. Yang EC, Cornwall R: Initial treatment of traumatic hip dislocations inthe adult. Clin Orthop Relat Res 377:24-31, 2000

5. Paus B: Traumatic dislocations of the hip; late results in 76 cases. ActaOrthop Scand 21:99-112, 1951

6. Proctor H: Dislocations of the hip joint (excluding ‘central’ disloca-tions) and their complications. Injury 5:1-12, 1973

7. Mullis BH, Dahners LE: Hip arthroscopy to remove loose bodies aftertraumatic dislocation. J Orthop Trauma 20:22-26, 2006

8. Moorman CT 3rd, Warren RF, Hershman EB, et al: Traumatic posteriorhip subluxation in American football. J Bone Joint Surg Am 85-A:1190-1196, 2003

9. Philippon MJ: The role of arthroscopic thermal capsulorrhaphy in thehip. Clin Sports Med 20:817-829, 2001

0. Bellabarba C, Sheinkop MB, Kuo KN: Idiopathic hip instability. Anunrecognized cause of coxa saltans in the adult. Clin Orthop Relat Res

355: 261-271, 1998

Hip and Pelvic Problems in AthletesHistory and Physical ExaminationImaging StudiesLabral TearsFemoroacetabular ImpingementHip InstabilityRehabilitationConclusionsReferences

hip and pelvic problems in athletes · the differential diagnosis of hip pain is quite broad in the...

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