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Peter H. Seidenberg • Jimmy D. Bowen
David J. King
Editors

The Hip and Pelvis in Sports

Medicine and Primary Care
Second Edition
Editors
Peter H. Seidenberg, MD, FAAFP, Jimmy D. Bowen, MD, FAAPMR,
FACSM, RMSK CAQSM, RMSK, CSCS
Professor of Orthopedics and Rehabilitation Advanced Orthopedic Specialists
Professor of Family and Community Medical Director for Sports Medicine
Medicine Southeast Missouri State University
Program Director - Primary Care Sports Cape Giardeau, MO, USA
Medicine Fellowship
Penn State University
State College, PA, USA

David J. King, MD
Motion Orthopedics
Team Orthopedic Surgeon for the St. Louis
Cardinals in affiliation with Mercy
St. Louis, MO, USA

ISBN 978-3-319-42786-7 ISBN 978-3-319-42788-1 (eBook)

DOI 10.1007/978-3-319-42788-1

Library of Congress Control Number: 2016954321

© Springer International Publishing Switzerland 2010, 2017

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Preface to the First Edition

What a great opportunity it is to participate in the body of information advancing the

study of musculoskeletal medicine. As a physician, the readers can attest that didac-
tic presentations of musculoskeletal complaints are at a minimum during under-
graduate training. The advancement of individual clinical understanding of this field
many times is left to the practitioner. Out of imagination, passion, or frustration, we
the musculoskeletal practitioners seek to improve our abilities to provide better
clinical diagnostic endeavors. The hip and pelvis is an area in musculoskeletal and
sports medicine that provides continued mystery. It is the last great bastion of the
unknown. Our hope in bringing together many excellent clinician authors is to pro-
vide the basis for improved approach to the patient and athlete who have complaints
involving the hip and pelvis. Each chapter begins with a clinical case which is prob-
ably similar to the patients you see in your practices. Each chapter provides an
approach to the diagnosis of hip and pelvis pain and dysfunction that hopefully is
easily applicable to your daily activities as a practitioner. Most importantly, we hope
that the material contained within this book helps you provide improved care, satis-
faction, and function for your patient athletes.

Jimmy D. Bowen

v
Preface to Second Edition

It is hard to believe 7 years has passed since our first edition of this text. Initially, we
wanted to present a comprehensive, clinically based approach to a subject matter
that was relatively unknown or misunderstood by all but the most adept musculo-
skeletal providers or evaluators. With this new edition, it is recognized that aware-
ness and expertise in this area have greatly increased over the years since the first
edition’s publication. Much-needed research, education, evaluation, and procedural
advancements have occurred, all to the benefit of the evaluators and ultimately the
suffering athletic patients. It could be argued that we are still scratching the surface
and/or approaching the end of the beginning in the understanding of the hip and
pelvis in sports and primary care.
Part of this recognition necessitated the addition of an accomplished orthopedic
provider specializing in this area as an additional editor. We are very fortunate to
have Dr. David King providing his guidance and expertise in the new edition.
The goal of this edition was not to change the unique format of the presentation
within the text, but to bring the information up to date and make it more informative
within the sphere of continually advancing medical enterprise. We hope that readers
will find this helpful as they continue to improve the care and function for their
clients, patients, and athletes.

State College, PA, USA Peter H. Seidenberg

Cape Giardeau, MO, USA Jimmy D. Bowen
St. Louis, MO, USA David J. King

vii
Contents

1 Epidemiology of Hip and Pelvis Injury. . . . . . . . . . . . . . . . . . . . . . . . 1

Brandon D. Larkin
2 Physical Examination of the Hip and Pelvis . . . . . . . . . . . . . . . . . . . . 9
Devin P. McFadden and Chad A. Asplund
3 Functional and Kinetic Chain Evaluation of the Hip and Pelvis . . . 37
Per Gunnar Brolinson, Mark Rogers, and Joseph Edison
4 Gait Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Adam M. Pourcho, Sean Colio, and Jimmy D. Bowen
5 Radiology of Hip Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Donald J. Flemming, Eric A. Walker
6 Adult Hip and Pelvis Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Peter H. Seidenberg, Michael Pitzer, and Michael Kenneth Seifert
7 Hip and Pelvis Injuries in Childhood and Adolescence. . . . . . . . . . . 143
Mark E. Halstead
8 Specific Considerations in Geriatric Athletes. . . . . . . . . . . . . . . . . . . 159
Rochelle M. Nolte and William F. Mann
9 Hip and Pelvis Injuries in Special Populations . . . . . . . . . . . . . . . . . 171
Dorianne R. Feldman, Tiffany Vu, Marlís González-Fernández,
and Brian J. Krabak
10 Functional Therapeutic and Core Strengthening . . . . . . . . . . . . . . . 185
Gerard A. Malanga, Steve M. Aydin, Eric K. Holder, and Ziva Petrin
11 Manual Medicine of the Hip and Pelvis . . . . . . . . . . . . . . . . . . . . . . . 215
Charles W. Webb
12 Taping and Bracing for Pelvic and Hip Injuries . . . . . . . . . . . . . . . . 241
Alfred Castillo, Lance Ringhausen, and Peter H. Seidenberg

ix
x Contents

13 Nonsurgical Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Michael D. Osborne, Tariq M. Awan, and Mark Friedrich B. Hurdle
14 Treatment Options for Degenerative Joint Disease of the Hip . . . . . 281
Adam T. Liegner, Heather M. Gillespie, and William W. Dexter
15 Surgical Interventions in Hip and Pelvis Injuries . . . . . . . . . . . . . . . 303
Matthew C. Bessette and Brian D. Giordano

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
List of Editors and Contributors

Editors

Jimmy D. Bowen, MD, FAAPMR, CAQSM, RMSK, CSCS Advanced

Orthopedic Specialists, Medical Director for Sports Medicine, Southeast Missouri
State University, Cape Giardeau, MO, USA
David J. King, MD Motion Orthopedics, Team Orthopedic Surgeon for the
St. Louis Cardinals in affiliation with Mercy, St. Louis, MO, USA
Peter H. Seidenberg, MD, FAAFP, FACSM, RMSK Professor of Orthopedics
and Rehabilitation, Professor of Family and Community Medicine, Program
Director - Primary Care Sports Medicine Fellowship, Penn State University, State
College, PA, USA

Contributors

Chad A. Asplund, MD, MPH Department of Health and Kinesiology, Georgia

Southern University, Stateboro, GA, USA
Tariq M. Awan, DO Department of Orthopedics, Medsport Sports Medicine
Program, University of Michigan, Ann Arbor, MI, USA
Steve M. Aydin, DO Department of Physical Medicine and Rehabilitation,
Musculoskeletal Medicine at Manhattan Spine and Pain Medicine, Northwell
Health – Hofstra School of Medicine, New York, NY, USA
Matthew C. Bessette, MD Department of Orthopedic Surgery, Cleveland Clinic,
Cleveland, OH, USA

xi
xii List of Editors and Contributors

Per Gunnar Brolinson, DO, FAOASM, FAAFP, FACOFP Sports Medicine;

Primary Care Sports Medicine Fellowship; Virginia Tech and US Ski Team, The
Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
Alfred Castillo, MS, ATC Sports Medicine, Bowling Green State University,
Bowling Green, OH, USA
Sean Colio, MD Department of Physical Medicine and Rehabilitation, Swedish
Spine, Sports, and Musculoskeletal Center, Swedish Medical Group, Seattle, WA,
USA
William W. Dexter, MD, FCSM Maine Medical Center, Department of Sports
Medicine, Portland, Portland, ME, USA
Joseph Edison, DO Primary Care Sports Fellow, Blacksburg, VA, USA
Dorianne R. Feldman, MD, MSPT Department of Physical Medicine and
Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD,
USA
Donald J. Flemming, MD Department of Radiology, Penn State Milton S. Hershey
Medical Center, Hershey, PA, USA
Heather M. Gillespie, MD, MPH, FACSM Maine Medical Partners, Orthopedics
and Sports Medicine, South Portland, ME, USA
Brian D. Giordano, MD Department of Orthopedics and Rehabilitation,
University of Rochester Medical Center, Rochester, NY, USA
Marlís González-Fernández, MD, PhD Department of Physical Medicine and
Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD,
USA
Mark E. Halstead, MD Departments of Pediatrics and Orthopedics, Washington
University in St Louis, St Louis, MO, USA
Eric K. Holder, MD Department of Physical Medicine and Rehabilitation, Thomas
Jefferson University Hospital, Philadelphia, PA, USA
Mark Friedrich B. Hurdle, MD Department of Pain Medicine, Mayo Clinic,
Jacksonville, FL, USA
Brian J. Krabak, MD, MBA, FACSM Departments of Rehabilitation, Orthopedics
and Sports Medicine, University of Washington and Seattle Children’s Hospital,
Seattle, WA, USA
Brandon D. Larkin, MD Primary Care Sports Medicine, Advanced Bone & Joint,
St. Peters, MO, USA
Adam T. Liegner, MD, MPH Maine Medical Center, Department of Sports
Medicine, Portland, ME, USA
List of Editors and Contributors xiii

Gerard A. Malanga, MD New Jersey Sports Medicine, LLC, Rutger’s School of

Medicine, Cedar Knolls, NJ, USA
William F. Mann, MD, MPH Department of Sports Medicine, United States
Navy, Philadelphia, PA, USA
Devin P. McFadden, MD, FAAFP Sports Medicine Fellow, Department of Family
Medicine, Uniformed Services University, Bethesda, MD, USA
Rochelle M. Nolte, MD, FAAFP United States Public Health Service, Metropolitan
Correctional Center, Health Services Unit, San Diego, CA, USA
Michael D. Osborne, MD Department of Pain Medicine, Mayo Clinic,
Jacksonville, FL, USA
Ziva Petrin, MD Department of Physical Medicine and Rehabilitation, Thomas
Jefferson University Hospital, Philadelphia, PA, USA
Michael Pitzer, MD Department of Family Medicine and Population Health,
Virginia Commonwealth University, Richmond, VA, USA
Adam M. Pourcho, DO Department of Physical Medicine and Rehabilitation,
Swedish Spine, Sports, and Musculoskeletal Center, Swedish Medical Group,
Seattle, WA, USA
Lance Ringhausen, ATC Department of Athletics, McKendree University,
Lebanon, IL, USA
Mark Rogers, DO, CAQSM, FAAFP Primary Care Sports Medicine Fellowship;
Department of Family Medicine, Virginia Tech and Pulaski Yankees (Minor League
Affiliate of NY Yankees), Blacksburg, VA, USA
Michael Kenneth Seifert, MD Internal Medicine Resident, Department of Internal
Medicine, Virginia Commonwealth University, Richmond, VA, USA
Tiffany Vu, DO Department of Physical Medicine and Rehabilitation, The Johns
Hopkins University School of Medicine, Baltimore, MD, USA
Eric A. Walker, MA, MHA, MD Department of Radiology, Penn State Milton
S. Hershey Medical Center, Hershey, PA, USA
Charles W. Webb, DO AFC Urgent Care, Tigard, OR, USA
Chapter 1
Epidemiology of Hip and Pelvis Injury

Brandon D. Larkin

Clinical Pearls
• Injuries to the hip and pelvis are common among both athletes and the general
population.
• The incidence and etiology of hip and pelvis injury vary depending on patients’
age, gender, anatomy, injury history, and the sport in which they participate.
• Hip and pelvis injury and pain are most common in adolescents and older adults.
• Field-based explosive and contact sports carry the highest risk of hip and pelvis
injury.
• Women are twice as likely to suffer from hip pain as men.
• A history of previous injury is the single most important risk factor in injury of
the hip and pelvis, followed by age and hip muscle weakness.

1.1 Case Presentation

1.1.1 Chief Complaint and History

A 17-year-old female high school basketball player presents with pain in the lateral
aspect of the right hip that radiates down the lateral thigh. She reports a painful
“snapping” sensation as she runs down the court. Initially, she noted this pain only
while running during practices and games, but it has recently begun to bother her
during normal ambulation.

B.D. Larkin, MD (*)

Primary Care Sports Medicine, Advanced Bone & Joint, St. Peters, MO 63376, USA
e-mail: [email protected]

© Springer International Publishing Switzerland 2017 1

P.H. Seidenberg et al. (eds.), The Hip and Pelvis in Sports Medicine and
Primary Care, DOI 10.1007/978-3-319-42788-1_1
2 B.D. Larkin

1.1.2 Physical Examination

Examination of the right hip reveals no obvious deformity. There is tenderness to

palpation of the greater trochanter. Range of motion of the hip is full in flexion,
extension, abduction, adduction, internal rotation, and external rotation. While
lying on the left side, passive internal and external rotation of the right hip repro-
duces symptoms. There is a positive Trendelenberg test bilaterally.

1.2 Introduction

Hip and pelvis injuries are typically not the most common etiology for pain in the
lower extremity in athletes nor in the general population. However, many of these
conditions carry significant associated morbidity that makes them important in the
scope of musculoskeletal care. The diagnosis is often challenging, as hip and pelvis
pain is often secondary to numerous pathologic processes. Twenty-seven to ninety
percent of patients presenting with groin pain are eventually found to have more
than one associated injury [1]. In children and adolescents, those with hip pain have
a higher prevalence of pain in the lower back and lower extremity joints, further
clouding the diagnosis [2]. Additionally, in patients presenting with hip pathology,
the hip is not initially recognized as the source of pain in 60 % of all cases [3]. An
individual’s predisposition to injury and the type of injury sustained vary greatly on
the basis of age and type of recreational activity.
Hip pain is often caused by sports-related injury. Ten to twenty-four percent of
injuries sustained during athletics or recreational activities in children are hip related
[4], and 5–6 % of adult sports injuries originate in the hip and pelvis [3, 5]. Pain may
result from either acute injury or chronic pathology due to excessive or repetitive
activity that places significant demand on the hip and pelvis. The hip bears a tre-
mendous burden during typical weight-bearing activities of daily living. Hip load-
ing is further increased by up to 5–8 % during exercise, leading to elevated risk of
injury [6]. As a significant element of the body’s core musculature, the pelvis also
provides an important biomechanical foundation for the lower extremities and is
often a hidden contributor to pain in more distal joints.
This chapter will consider the incidence of hip and pelvis pain and injury in the
general population as well as in selected subsets. It will also discuss factors that
have been shown to increase the risk of injury to this region, including both ana-
tomic features and characteristics of specific sport participation.

1.3 Age

The age of the patient is the single most important factor in determining the etiology
of hip and pelvis pain. In very young children, there is rarely a significant acute
injury, but several common orthopedic entities involving this region may initially
1 Epidemiology of Hip and Pelvis Injury 3

present with exercise-associated pain. As a child grows, skeletal development

occurs in a predictable pattern with the appearance of apophyses and epiphyses and
their eventual fusion. During growth, these are areas of relative weakness, and avul-
sion injuries to the developing apophyses are more common than those involving
the musculotendinous unit. During adolescence, ossification continues, but the
immature skeleton remains more prone to injury as the high physical demands of
sports participation exceed the capacity of the musculoskeletal system. Additionally,
rapid increases in muscular power related to hormonal changes accentuate the mis-
match between muscular and physeal strength.
In children and adolescents, the most common disorder that causes hip pain is
transient synovitis. In addition, Legg–Calve–Perthes disease has been shown to
have an incidence of 1.5–5 per 10,000 children of ages 2–12 years. Slipped capital
femoral epiphysis, with an incidence of 0.8–2.2 per 10,000, is also an oft-encountered
etiology for hip pain that usually presents in the early adolescent period.
Developmental hip dysplasia, noted in 1.5–20 cases per 1000 births in developed
countries, depending on the diagnostic modality used and timing of the evaluation,
may lead to hip pain later in life [2]. Each entity should be considered not only in
the investigation of hip pain in the limping child, but also in complaints of knee pain
in this population. Each is discussed further in this text. (Please see Chap. 7—Hip
and Pelvis Injuries in Childhood and Adolescence.)
The epidemiologic data regarding incidence of hip and pelvis injury in children
have been studied at length, often in association with investigation of injury inci-
dence at other anatomical sites. Data have been further divided into acute and
chronic injury, with acute injury occurring much more commonly in this popula-
tion. In retrospective studies, injuries to hip and thigh in children encompassed
17–25 % of all acute, but only 2.2–4.8 % of chronic injuries [7]. Sports injuries to
the hip and groin have been noted in 5–9 % of high school athletes [1, 5].
Investigation involving primary school through high school-aged individuals in
the general population has found an incidence of hip pain in 6.4 % [2]. This can be
further divided into 4 % in the primary school-aged population, compared with
7.8 % in the high school group. These data portend a higher risk in the older child of
suffering from hip pain. Interestingly, in the same study, 2.5 % of the subjects were
found to have clinical evidence of hip pathology on examination, the most com-
monly noted findings being pelvic obliquity, limb length discrepancy, and snapping
hip. In only 0.6 % of those who reported hip pain was any pathology noted by a
physician on physical examination. This may suggest that objectively dysfunctional
hips are relatively common in the school-aged and adolescent population, but that
these pathologic features do not typically result in pain. One may further conclude
that most hip pain in this population is functional, as examination findings are typi-
cally lacking in those who do report pain.
Among adults, the spectrum of hip and pelvis injury evolves. As these patients
age, the risk of pain from hip osteoarthritis increases substantially. The prevalence
of hip and pelvis pain in adults from all etiologies ranges from 2.8 % to 22.4 %, and
reports of pain tend to increase with age [2]. In the athletic population, increased
age is a risk factor for players of field-based sports in sustaining a groin or hip
injury, likely due to decreased elasticity of collagen tissue in older individuals [8, 9].
4 B.D. Larkin

Over the age of 60, fully 14.3 % of adults report significant activity-limiting hip
pain [10]. This has an effect beyond the bothersome joint, as those who suffer from
hip pain have poorer self-rated overall health scores, as well as increased knee and
back pain and reduced muscle power. Climbing/descending stairs and walking tend
to elicit the most severe pain [11]. Morning stiffness is also common in the older
population with hip pain, affecting 30 % of those reporting hip pain [11].

1.4 Sport

Participation in athletic activity of any kind has been shown to increase the risk of
hip and pelvis injury, as well as the eventual development of hip osteoarthritis [12].
Men with high long term exposure to sports had a relative risk of developing hip
osteoarthritis of 4.5 when compared to those with lower exposure [12]. In those
with exposure to high physical loads from both sports and occupation, the relative
risk increased to 8.5 for the development of hip osteoarthritis when compared to
those with low physical loads in both activities [12].
Overall, hip and groin injuries are more prevalent in athletes participating in
explosive or contact sports [7]. Such injuries are seen in a wide variety of sports,
including those that feature cutting activities and quick accelerations and decelera-
tions, such as football and soccer, those with repetitive rotational activities, such as
golf and martial arts, as well as dancing, running, and skating [1, 6].
By far, dancers possess the highest incidence of hip and pelvis injury among
athletes. Ballet dancers are at particularly high risk, as most studies note that the hip
is implicated in between 7 % and 14.2 % of all injuries in this population [13]. Often,
these athletes substitute proper technique with exaggerated external rotation of the
lower extremity, placing further stress on the hip joint and pelvis.
Runners and soccer players are also at higher risk than other athletes. The inci-
dence of hip and groin injury in these participants has been found to be 2–11 % and
5.4–13 %, respectively, of all reported injuries [4]. The most common injuries that
involve these sites in runners are adductor strains and iliac apophysitis [14]. The
injuries to the groin in soccer athletes fall on a spectrum, and may range from mild
adductor and hip flexor strains to the often debilitating “sports hernia.” Adductor
and iliopsoas-related injuries are the most common among professional soccer play-
ers, representing almost three quarters of all cases of hip and groin injury [15]. More
than half of the injuries to the hip and groin in this population classify as moderate
or severe, resulting in a mean absence per injury of 15 days [15].
Seven percent of all injuries to participants in high school football involve the hip
and thigh, compared to 20 % involving the knee and 18 % involving the ankle [16].
Injuries such as hip pointers and thigh contusions are common in this population.
Track and field, rugby, martial arts, and racket sports have been implicated as being
hazardous to the hip joint itself, specifically for the later development of hip osteo-
arthritis [3, 12].
1 Epidemiology of Hip and Pelvis Injury 5

1.5 Gender

Injuries of the hip and pelvis are more commonly suffered by women in direct com-
parisons with men, regardless of age or sport. Most studies note incidences of hip
pain in women that are twice that in men. In a study of primary and high school-
aged children, 8.2 % of all girls reported hip pain, compared with 4.4 % of the boys
[2]. In the adult population, the risk of hip pain in women is more than double that
in men [10, 17].
In a comparison of injuries in high school basketball athletes, injuries to the hip
and thigh ranked third in female students compared with fourth in male students.
Incidences of ankle and knee injuries were much more common in both groups,
with facial injuries also more common than hip and thigh injuries in boys [18].
Isolated injuries of the pelvis were noted in less than 1 % of both genders.
In regard to injuries specific to the groin, the converse is true. There is moderate
evidence that men have a higher relative risk of groin injury (2.45) than do women
who play the same sport [19].
Specific hip joint pathologies more likely to cause pain differ between genders.
In chronic hip and groin pain, men demonstrate a higher percentage of cases of
femoroacetabular impingement in comparison with women, who are affected more
commonly by tears of the labrum [20].
The etiology of the increased incidence of hip pain in women is likely because of
both anatomic and functional factors. The anatomic differences of the lower extrem-
ities in women are well described in the literature. Regarding the hip, larger femoral
anteversion may predispose women to hip pain. Furthermore, during running,
female subjects have a higher degree of hip abduction, hip internal rotation, and
knee abduction compared to men [2, 21]. This increased motion is likely to at least
partly contribute to higher injury statistics in this region. In addition, acquired
anatomic laxity secondary to hormonal changes in pregnancy may contribute to
increased incidence of hip and pelvis complaints in women.

1.6 Anatomic Features

Multiple anatomic structures in and around the hip joint and pelvis are known to
cause pain, often with significant overlap. Thus, chronic hip and groin pain poses a
difficult diagnostic challenge. Recent consensus has settled on classifying entities
for hip and groin pain into one of five areas: adductor-related pain, iliopsoas-related
pain, inguinal-related pain, pubic-related pain, and hip joint-related pain [22]. Other
musculoskeletal causes such as hernias or nerve entrapments are also mentioned.
In a young, active, adult population, hip joint pathology is the most common
source of pain, affecting 56 % of active individuals in one large-scale study [20].
Further analysis implicates femoroacetabular impingement as the most common