Bilateral Hip Pain in a Female High School Soccer Athlete Dale Blair, MS, CSCS, ATC Kristin Wright Michael Hansen, MPT, ATC Wenatchee High School Wenatchee, Washington

History 16 year old soccer athlete presented with hip pain and audible bilateral “snapping” Symptoms were first noticed in April 1996 Patient was unable to report a specific etiology and the onset of the symptoms was vague

History During fall soccer, pain persisted and she limited her activities. She underwent physical therapy for 3 years. Discontinued PE, sports and other activities.

Physical Signs and Symptoms Patient suffered from constant anterior hip pain. The pain with functional activities was evident when the hip moved from a flexed to extended position and was accompanied by and audible snap

Physical Signs and Symptoms Range of motion limited, hip flexors weak and painful She experienced pain radiating to the upper anteromedial aspect of the thigh and suffered from low back and L4-5 dermatome pain.

Diagnostic Imaging/ Laboratory tests MRI of spine - normal MRI of hip and pelvis - revealed no soft tissue damage MR arthrography under x-ray guidance - ruled out labral tear.

Diagnostic Imaging/ Laboratory tests Bone scan - negative X- rays of hip and back - show no bony abnormality Diagnostic ultrasound - showed anterior snapping bilaterally

X-rays of the pelvis and hip show no bony abnormality.

MRI, CT scans, and bone scans- negative

Differential Diagnosis Acetabular labrum injury Entrapment or irritation of lateral femoral cutaneous nerve Referred pathology from low back Fibromyalgia Reflex neurovascular dystrophy

Snapping Iliopsoas tendon Final Diagnosis... Snapping Iliopsoas tendon

Discussion The conjoined iliopsoas tendon passes lateral to the iliopectineal eminence and medial to the joint capsule of the hip to insert on the lesser trochanter of the femur. With extension of the flexed, abducted and externally rotated hip, the iliopsoas moves in a medial direction. (Keskula et al., 1999)

Pain referred from trigger points in the iliopsoas muscle.

Discussion (con’t) The normal lateral or medial excursion of the iliopsoas is interrupted, resulting in painful snapping of the iliopsoas over the femoral head and hip capsule. The iliopsoas bursa, which lies between the anterior capsule of the hip and the iliopsoas tendon may become inflammed and painful with repetitive snapping.

Attachment of the right psoas major, psoas minor and iliacus muscles. The psoas major crosses many articulations including those of the lumbar spine and the lumbosacral, sacroiliac, and hip joints. The psoas minor crosses all of these except the hip joint.

Treatment- Conservative Anti-inflammatory medications Patient underwent 3 years of physical therapy Corticosteroid injection of the hip

Treatment- Conservative Physical therapy with a focus on stretching, progression of activities, modalities and functional modes of exercise which include: restoring normal pain-free range of motion and strength returning to pain-free functional capabilities identifying and modifying contributing factors.

Treatment-Surgical Surgical lengthening of the iliopsoas tendon Evaluated in the context of patient goals, functional status, patient pain and prior treatment outcomes.

Treatment-Surgical Patient underwent right iliopsoas release in December 1998. Snapping slightly decreased but pain persisted Experienced numbness in anteromedial thigh and lower leg. Unable to return to activities In November 1999, she underwent bilateral iliopsoas releases.

Right hip specimen with muscle bellies of iliacus and psoas retracted laterally. The tendinous portion of the iliopsoas is shown tented over the anterior femoral head.

Disposition of Case Patient continues to experience pain. Surgery decreased the intensity of the snapping, but the frequency remains same. She has been unable to return to any activity including sports or marching band. She continues doing physical therapy on an out-patient basis.

Thank You