1. 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

2. 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

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

4. 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

5. 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.

6. 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.

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

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

9. MRI, CT scans, and bone scans- negative

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

11. Snapping Iliopsoas tendon
Final Diagnosis...
Snapping Iliopsoas tendon

12. 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)

13. Pain referred from trigger points in the iliopsoas muscle.

14. 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.

15. 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.

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

17. 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.

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

19. 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.

20. 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.

21. 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.

22. Thank You