The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain

Abstract

Context: In active individuals with femoroacetabular impingement (FAI), the resultant reduction in functional range of motion leads to high impaction loads at terminal ranges. These increased forces result in compensatory effects on bony and soft tissue structures within the hip joint and hemipelvis. An algorithm is useful in evaluating athletes with pre-arthritic, mechanical hip pain and associated compensatory disorders.

Evidence acquisition: A literature search was performed by a review of PubMed articles published from 1976 to 2013.

Level of evidence: Level 4.

Results: Increased stresses across the bony hemipelvis result when athletes with FAI attempt to achieve supraphysiologic, terminal ranges of motion (ROM) through the hip joint required for athletic competition. This can manifest as pain within the pubic joint (osteitis pubis), sacroiliac joint, and lumbosacral spine. Subclinical posterior hip instability may result when attempts to increase hip flexion and internal rotation are not compensated for by increased motion through the hemipelvis. Prominence of the anterior inferior iliac spine (AIIS) at the level of the acetabular rim can result in impingement of the anterior hip joint capsule or iliocapsularis muscle origin against the femoral head-neck junction, resulting in a distinct form of mechanical hip impingement (AIIS subspine impingement). Iliopsoas impingement (IPI) has also been described as an etiology for anterior hip pain. IPI results in a typical 3-o'clock labral tear as well as an inflamed capsule in close proximity to the overlying iliopsoas tendon. Injury in athletic pubalgia occurs during high-energy twisting activities in which abnormal hip ROM and resultant pelvic motion lead to shearing across the pubic symphysis.

Conclusion: Failure to recognize and address concomitant compensatory injury patterns associated with intra-articular hip pathology can result in significant disability and persistent symptoms in athletes with pre-arthritic, mechanical hip pain.

Strength-of-recommendation taxonomy sort: B.

Keywords: athletic pubalgia; compensatory injury; femoroacetabular impingement; hip; iliopsoas impingement.

Figure 1.

Layered, anatomic approach to the hip.

Figure 2.

Schematic drawing illustrating typical findings in posterior hip instability in the setting of mechanical impingement from cam lesion (red line) in flexion and internal rotation, including anterior labral injury (red arrow) and posterior capsulolabral lesion (black arrow).

Figure 3.

Coronal magnetic resonance imaging STIR (short inversion time inversion recovery) sequence demonstrating edema at the pubic symphysis and findings consistent with osteitis pubis. This 30-year-old man presented with left groin and central pubic pain secondary to femoroacetabular impingement and compensatory motion at the pubic symphysis.

Figure 4.

The sacroiliac joint and ligamentous anatomy. Reprinted with permission from the American Academy of Orthopaedic Surgeons.

Figure 5.

Coronal T2-weighted magnetic resonance image of the lumbosacral region demonstrating contact of the right L5 transverse process with the sacrum. Image adapted with permission from the Associação Arquivos de Neuro-Psiquiatria Dr Oswaldo Lange.

Figure 6.

T1-weighted axial image of the pelvis. The anterior loss of femoral offset and mechanical impingement in flexion and internal rotation may predispose to a “levering effect,” resulting in posterior capsulolabral injury (arrow) and secondary instability.

Figure 7.

Anteroposterior radiograph of the hip demonstrating a focal rim lesion (arrow) creating cephalad retroversion.

Figure 8.

(a) Three-dimensional computed tomography (CT) scan demonstrating prominent anterior inferior iliac spine (AIIS) resulting in subspine impingement and restriction in hip flexion. (b) Sagittal CT image demonstrating AIIS dimensions and point of pathologic contact on the femoral neck (arrow) with terminal flexion and rotation of the hip.

Figure 9.

Arthroscopic image demonstrating the iliopsoas impingement sign with inflammation of the capsule and labrum (arrow) in the 3-o’clock position on the acetabulum.

Figure 10.

The iliocapsularis muscle, which originates on the anterior joint capsule and iliopectineal eminence and inserts slightly distal to the lesser trochanter. Reprinted with permission from Bedi et al.

Figure 11.

To address a symptomatic iliopsoas tendon via a transcapsular approach, an anterior capsulotomy approximately 1 cm in length is made directly anterior to the labral injury (dark arrow) using the beaver blade or radiofrequency ablation device. Through this capsular window (white arrow), the tendinous portion of the iliopsoas (arrowhead) can be visualized and lengthened.

Figure 12.

Posterior pubalgia: proximal hamstring syndrome. Patients with symptomatic femoroacetabular impingement (FAI) and restricted internal rotation may develop a compensatory posterior tilt of the pelvis, which leads to chronic hamstring shortening and predisposition to chronic hamstring tendinopathy. Computed tomography images (left) of the right hip demonstrate FAI and a proximal hamstring avulsion fracture. Coronal magnetic resonance images (right) demonstrate a complete proximal hamstring avulsion with retraction and adjacent hematoma.