Diagnosis and Management of Femoroacetabular

Impingement An Evidence Based Approach 1st

Edition Olufemi R. Ayeni pdf download
https://textbookfull.com/product/diagnosis-and-management-of-femoroacetabular-impingement-an-
evidence-based-approach-1st-edition-olufemi-r-ayeni/

★★★★★ 4.8/5.0 (40 reviews) ✓ 208 downloads ■ TOP RATED

"Excellent quality PDF, exactly what I needed!" - Sarah M.

DOWNLOAD EBOOK
Diagnosis and Management of Femoroacetabular Impingement An
Evidence Based Approach 1st Edition Olufemi R. Ayeni pdf
download

TEXTBOOK EBOOK TEXTBOOK FULL

Available Formats

■ PDF eBook Study Guide TextBook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Collection Highlights

The Mediterranean Diet : An Evidence-Based Approach 2nd

Edition Victor R. Preedy

Collaborative Problem Solving An Evidence Based Approach

to Implementation and Practice Alisha R. Pollastri

The Unstable Elbow An Evidence Based Approach to

Evaluation and Management 1st Edition Robert Z. Tashjian

Proximal Femur Fractures: An Evidence-Based Approach to

Evaluation and Management 1st Edition Kenneth A. Egol
Education and Learning An Evidence based Approach 1st
Edition Jane Mellanby

Infectious Diseases An Evidence based Approach Vikas

Mishra

Evidence Based Diagnosis An Introduction to Clinical

Epidemiology Thomas B. Newman

Symptom to Diagnosis: An Evidence Based Guide 4th Edition

Scott D.C. Stern

Evidence Based Podiatry A Clinical Guide to Diagnosis and

Management Dyane E. Tower
Diagnosis and
Management of
Femoroacetabular
Impingement

An Evidence-Based Approach

Olufemi R. Ayeni
Jón Karlsson
Marc J. Philippon
Marc R. Safran
Editors

123
Diagnosis and Management of
Femoroacetabular Impingement
Olufemi R. Ayeni • Jón Karlsson
Marc J. Philippon • Marc R. Safran
Editors

Diagnosis and
Management of
Femoroacetabular
Impingement
An Evidence-Based Approach
Editors
Olufemi R. Ayeni Marc J. Philippon
Division of Orthopaedic Surgery Orthopaedic Surgeon
McMaster University Steadman Clinic and Steadman
Hamilton, Ontario Philippon Research Institute
Canada Vail, Colorado
USA
Jón Karlsson
Departement of Orthopaedics Marc R. Safran
Sahlgrenska University Hospital Dept. of Orthopaedic Surgery
Sahlgrenska Academy Stanford University
Gothenburg University Redwood City, California
Gothenburg USA
Sweden

ISBN 978-3-319-31998-8 ISBN 978-3-319-32000-7 (eBook)

DOI 10.1007/978-3-319-32000-7

Library of Congress Control Number: 2016947959

© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
Preface

Using Evidence to Power Surgical Decision-Making:

It Is the Right Time!

Evidence-based orthopedics (EBO) is part of a broader movement known as

evidence-based medicine, a term first coined at McMaster University in 1990
for applicants to the internal medicine residency training program. Clinicians
at McMaster described EBM as “an attitude of enlightened skepticism”
toward the application of diagnostic, therapeutic, and prognostic technolo-
gies. While orthopedic surgeons were generally slow to adopt this new
approach, the last 5 years have experienced an increasing popularity of the
language and practice of EBO.
Evidence-based orthopedics does not accept the traditional “eminence-
based” paradigm as being sufficiently adequate to address clinical problems,
especially when considering the large quantity of valuable information avail-
able to surgeons to help them in their problem-solving process. Today, lesser
emphasis is placed on the surgeon’s own professional authority. The new
EBO approach posits that surgeons’ experiences, beliefs, and observations
alone are not enough to make satisfactory decisions with respect to patient
care. Evidence-based orthopedics promotes the need to evaluate the evidence
available in the surgical literature from published research and integrate it
into clinical practice. Practicing EBO requires, in turn, a clear delineation of
relevant surgical questions, a thorough search of the literature relating to the
questions, a critical appraisal of available evidence, its applicability to the
surgical situation, and a balanced application of the conclusions to the prob-
lem at hand. The balanced application of the evidence (i.e., the surgical
decision-making) is the central point of practicing evidence-based orthope-
dics and involves, according to EBO principles, integration of our surgical
expertise and judgment with patients’ values (or preferences) with the best
available research evidence.
The paradigm of EBO is particularly important in the uptake of surgical
procedures in the cycle of innovation. Orthopedics is a breeding ground for
innovation often led by surgical pioneers and early adopters. The challenge,
however, to broad adoption of novel techniques in surgery is sufficient evi-
dence of patient safety and compelling data for treatment efficacy. A recent
systematic review evaluating sources and quality of literature available for
hip arthroscopy indicated that although there has been a fivefold increase in

v
vi Preface

publications related to hip arthroscopic procedures from 2005 to 2010, lower-

quality research studies (Level IV and Level V studies) accounted for more
than half of the available literature with no randomized control studies identi-
fied [1].
How do surgeons evaluate novel techniques purported to improve out-
comes in femoroacetabular impingement in a time when good evidence
always trumps surgeon “eminence”? Practicing EBO is not easy. Surgeons
must know how to frame a clinical question to facilitate use of the literature
in its resolution. Typically, a question should include the population, the
intervention, and relevant outcome measures. Evidence-based practitioners
must know how to search the literature efficiently to obtain the best available
evidence bearing on their question, evaluate the strength of the methods of
the studies they find, extract the clinical message, apply it back to the patient,
and store it for retrieval when faced with similar patients in the future.
Because becoming a regular EBM practitioner comes at the cost of time,
effort, and other priorities, surgeons can also seek information from sources
that explicitly use EBM approaches to select and present evidence. Given the
paucity of clinical trials, surgeons aiming to understand the evidence must
resort to time-consuming searches of the medical literature to collate current
best observational studies.
Ayeni, Karlsson, Philippon, and Safran in this evidence-based approach to
femoroacetabular impingement provide a highly efficient solution to the sur-
gical community. Using the tenets of EBO, they bring together a wonderfully
talented group of authors and researchers to collate the world’s knowledge on
this rapidly changing specialty area in orthopedic surgery. To the busy sur-
geon, this text is one critical must-have resource. While modern approaches
to EBO are sometimes perceived as a blinkered adherence to only random-
ized trials, it more accurately involves informed and effective use of all types
of evidence to inform patient care. The approaches and evidence in this text,
despite a lack of randomized trial evidence, still represent the state of the art
in the field. What we learn most from this important work is an ever-present
need for a shift from traditional opinion-based textbooks to ones which
involve question formulation, validity assessment of available studies, and
appropriate application of research evidence to individual patients.

Mohit Bhandari, MD, PhD, FRCSC

Evidence-Based Orthopaedics
McMaster University
Hamilton, ON, Canada

Reference
1. Ayeni OR, Chan K, Al-Asiri J, et al. Sources and quality of literature addressing femo-
roacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):415–9.
Contents

1 Historical Background of the Treatment

of Femoroacetabular Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Edwin R. Cadet
2 Differential Diagnosis of Hip Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Filippo Randelli, Fabrizio Pace, Daniela Maglione,
Paolo Capitani, Marco Sampietro, and Sara Favilla
3 Clinical Diagnosis of FAI: An Evidence-Based Approach
to History and Physical Examination of the Hip . . . . . . . . . . . . . . 27
Aparna Viswanath and Vikas Khanduja
4 Evidence for the Utility of Imaging of FAI . . . . . . . . . . . . . . . . . . . 39
Danny Arora and Daniel Burke Whelan
5 Pathophysiology of Femoroacetabular Impingement (FAI) . . . . . 51
Gavin C.A. Wood, Hamad Alshahrani, and Michel Taylor
6 Evidence-Based Approach to the Nonoperative
Management of FAI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Nolan S. Horner, Austin E. MacDonald, Michael Catapano,
Darren de SA, Olufemi R. Ayeni, and Ryan Williams
7 Physiology of the Developing Hip and Pathogenesis
of Femoroacetabular Impingement . . . . . . . . . . . . . . . . . . . . . . . . . 79
Páll Sigurgeir Jónasson, Olufemi R. Ayeni, Jón Karlsson,
Mikael Sansone, and Adad Baranto
8 Surgical Management of CAM-Type FAI:
A Technique Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Darren de SA, Matti Seppänen, Austin E. MacDonald,
and Olufemi R. Ayeni
9 Arthroscopic Management of Pincer-Type Impingement . . . . . . 103
James B. Cowan, Christopher M. Larson, and Asheesh Bedi
10 Open Management of CAM Deformities in FAI . . . . . . . . . . . . . 115
Colleen A. Weeks and Douglas D.R. Naudie
11 Open Surgical Management of Pincer Lesions in FAI . . . . . . . . 127
Etienne L. Belzile

vii
viii Contents

12 Treatment of Labral Tears in FAI Surgery . . . . . . . . . . . . . . . . . . 153

Marc J. Philippon and Karen K. Briggs
13 Reconstructive Techniques in FAI Surgery . . . . . . . . . . . . . . . . . 163
Marc J. Philippon and Karen K. Briggs
14 The Evidence for the Treatment of Cartilage
Injuries in FAI Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Mats Brittberg and Marc Tey
15 Management of Extra-articular Hip Conditions
in Patients with Concurrent FAI . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Nolan S. Horner, Uffe Jorgensen, Darren de SA,
and Olufemi R. Ayeni
16 The Evidence for Rehabilitation After Femoroacetabular
Impingement (FAI) Surgery: A Guide to Postsurgical
Rehabilitation and Supporting Evidence . . . . . . . . . . . . . . . . . . . 201
Darryl Yardley
17 Complications of FAI Surgery: A Highlight of Common
Complications in Published Literature . . . . . . . . . . . . . . . . . . . . . 229
Cécile Batailler, Elliot Sappey-Marinier, and Nicolas Bonin
18 Revision FAI Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
James T. Beckmann and Marc R. Safran
19 Future Directions of FAI Surgery: Diagnosis and Treatment . . . 255
Michael J. Salata and W. Kelton Vasileff
20 Future Directions in Training FAI Surgeons . . . . . . . . . . . . . . . . 269
Justin W. Arner, Raymond Pahk, Vonda Wright,
Craig Mauro, and Volker Musahl
 Historical Background of the
Treatment of Femoroacetabular 1
Impingement

Edwin R. Cadet

Contents 1.1 Historical Background

1.1 Historical Background 1
Early degenerative hip disease has often been
References 3
noted in patients with abnormal acetabular mor-
phology usually secondary to developmental
dysplasia of the hip (DDH), and it has been
hypothesized to be the consequence of abnormal
edge loading on the anterosuperior acetabular
cartilage from an eccentrically centered femoral
head. However, the role femur morphology
played in the development of degenerative hip
disease was not as defined. In 1936, Smith-
Petersen classically described a concept of
impingement in which hip pain was theorized to
be caused the femoral neck impinged against
anterior acetabular margin [1]. Surgical correc-
tion, by way of impingement correction, was suc-
cessful in his small case series. Decades later,
Murray et al. described a tilt deformity of the
proximal femur and its association with the
development of osteoarthritis of the hip [2]. In
1986, Harris described his theory on how
derangements in femoral anatomy development
caused primary or “idiopathic osteoarthrosis of
the hip” in the non-dysplastic hip [3]. Harris
wrote that based on his numerous radiographic
observations, the convex, “pistol grip” femoral
deformity at the femoral head-neck junction fol-
lowing the sequelae of a recognized or unde-
E.R. Cadet, MD
tected slipped capital femoral epiphysis (SCFE),
Raleigh Orthopaedic Clinic, 3001 Edwards Mill Road,
Raleigh, NC 27608, USA Legg-Calve-Perthes disease, or the congenital
e-mail: [email protected] epiphyseal dysplasia was a common pathway for
© Springer International Publishing Switzerland 2017 1
O.R. Ayeni et al. (eds.), Diagnosis and Management of Femoroacetabular Impingement,
DOI 10.1007/978-3-319-32000-7_1
2 E.R. Cadet

development of the so-called “idiopathic” degen- non-dysplastic hip [11]. The authors suggested
erative hip disease. Although Harris reported of that the mechanism of articular cartilage and
the association of abnormal femoral head-neck labral damage and degradation in these hips was
deformity and osteoarthritis, he did not elaborate that of aberrant hip motion rather than isolated,
on the underlying mechanisms that such defor- abnormal eccentric axial loading of the anterosu-
mity can result in the development of primary perior acetabulum that was hypothesized to occur
degenerative hip disease. in hip dysplasia. The authors arrived at their
In this early report, Harris also implied that hypothesis based on the observations seen of
the acetabular labrum may play an important role labral injury and cartilage wear patterns in over
in the development of primary osteoarthritis. 600 surgical dislocations performed for patients
Harris described what he termed the “intra- with hip pain without dysplasia. The authors pro-
acetabular” labrum. He viewed the labrum as an posed three mechanisms of femoroacetabular
extra-articular structure, and any presence of impingement: (1) CAM impingement, (2) pincer
labrum within the intra-articular space should be impingement, or (3) a combination of both. CAM
considered abnormal and represented an “inter- impingement resulted from decreased clearance
nal derangement” of the hip, analogous to a torn of the acetabulum from a convex, femoral head-
glenoid labrum in the shoulder or meniscus in the neck junction, particularly during flexion. The
knee [3, 4]. Such observations were early sugges- “abutment,” as the authors described it, between
tions that acetabular labral pathology could play the diminished femoral head-neck offset and ace-
a part in the development of primary degenera- tabulum is thought to cause shear injury to the
tive hip disease. adjacent cartilage and labro-chondral junction,
Subsequently to the assertions made by Harris, thus leaving the bulk of the labrum undisturbed.
McCarthy et al. reported that chondral injury was Pincer impingement was described to originate
noted in 73 % of 436 consecutive hip arthrosco- from the acetabular side, where general (coxa
pies where labral fraying or tears were present, profunda) or regional acetabular retroversion
thus suggesting the role of labral pathology in the may cause direct, crushing injury to the labrum
development of degenerative hip disease in a with a normal femoral head-neck surface. The
patient population. These findings were further continuous labral injury could cause intra-labral
supported in the authors’ cadaveric examination substance degeneration or labral ossification.
of 52 acetabula in the same report [5, 6]. Moreover, the premature impact on the femoral
Subsequently, basic science studies further dem- head-neck junction could cause chondral injury
onstrated that the labrum was found to be a criti- to the posteroinferior acetabulum secondary to
cal structure in hip joint preservation by abnormal shear stresses from the excessive pre-
maintaining a “fluid seal” that prevents the efflux mature levering, which the authors termed the
of synovial fluid from the central compartment, “contrecoup” lesion. Finally, there can be a com-
thus maintaining hydrostatic pressure to lower bination of both, which we now know occurs
contact stresses between the femoral and acetab- most commonly in clinical practice. The authors
ular cartilage surfaces [7–9]. found that pincer impingement was more com-
The interplay between the femoroacetabular monly seen in middle-aged women, and CAM
anatomy, labral and chondral injury, and the impingement was more often observed in young,
development of degenerative hip disease in the athletic male populations.
non-dysplastic hip was best narrated in the work Moreover, the authors outlined the principles
done by Ganz et al. and Lavigne et al. [11, 12]. In for successful surgical management of femoroac-
2003, Ganz and colleagues outlined the biome- etabular impingement: (1) establishing a safe and
chanical rationale on how the disease they coined reproducible approach to the hip joint that would
“femoroacetabular impingement” can cause respect and protect the femoral head vascularity
labral and articular cartilage degradation in the and viability, (2) improving femoral head clear-
1 Historical Background of the Treatment of Femoroacetabular Impingement 3

ance by reestablishing normal femoral neck and

acetabular anatomy via femoral and/or acetabular 3. Harris WH. Etiology of osteoarthritis of
osteoplasty, and (3) addressing labral and chondral the hip. Clin Orthop Relat Res. 1986;
injury with repair or debridement. To accomplish 213:20–33.
these principles, Ganz et al. in a previous report 4. Ferguson SJ, et al. The acetabular
described an anterior surgical hip dislocation tech- labrum seal: a poroelastic finite element
nique via a posterior approach by using a “tro- model. Clin Biomech (Bristol, Avon).
chanteric flip” osteotomy that would preserve the 2000;15(6):463–8.
medial femoral circumflex arteries [13]. 5. Ganz R, et al. Femoroacetabular
Over the last decade, the surgical management impingement: a cause for osteoarthritis
of femoroacetabular impingement has evolved of the hip. Clin Orthop Relat Res. 2003;
from open surgical dislocations to more minimally 417:112–20.
invasive techniques such as mini-open exposures
and arthroscopic techniques. The importance of
labral preservation and restoration has also been
stressed as critical factor for successful manage- References
ment of femoroacetabular impingement [10, 14–
18]. Although open surgical dislocation has 1. Smith-Petersen MN. Treatment of malum coxaeseni-
lis, old slipped upper capital femoral epiphysis, intra-
yielded good to excellent results [19], the advent pelvic protrusion of the acetabulum, and coxae plana
of advanced arthroscopic instruments designed to by means of acetabuloplasty. J Bone Joint Surg Am.
accommodate the complex anatomy of the hip has 1936;18:869–80.
contributed to equal, and in some cases surpassed, 2. Murray RO. The aetiology of primary osteoarthritis of
the hip. Br J Radiol. 1965;38(455):810–2.
clinical outcomes historically reported with open 3. Harris WH. Etiology of osteoarthritis of the hip. Clin
techniques [20–22] with less morbidity, thus Orthop Relat Res. 1986;213:20–33.
increasingly becoming the “gold standard” for the 4. Harris WH, Bourne RB, Oh I. Intra-articular acetabu-
management of femoroacetabular impingement. lar labrum: a possible etiological factor in certain
cases of osteoarthritis of the hip. J Bone Joint Surg
With this historical description laying the founda- Am. 1979;61(4):510–4.
tion of diagnosis and treatment, the next chapters 5. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee
will introduce contemporary approaches to J. The Otto E. Aufranc Award: the role of labral
addressing FAI. Evidence-based approaches for lesions to development of early degenerative hip dis-
ease. Clin Orthop Relat Res. 2001;393:25–37.
the comprehensive management for FAI and asso- 6. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee
ciated disorders will be focused upon highlighting J. The watershed labral lesion: its relationship to early
the best strategies, opportunities, and challenges arthritis of the hip. J Arthroplasty. 2001;16(8 Suppl
of current practice. 1):81–7.
7. Ferguson SJ, Bryant JT, Ganz R, Ito K. The influence
of the acetabular labrum on hip joint cartilage consoli-
dation: a poroelastic finite element model. J Biomech.
2000;33(8):953–60.
Key Evidence Related Sources
8. Ferguson SJ, Bryant JT, Ganz R, Ito K. The acetabular
1. Smith-Petersen MN. Treatment of labrum seal: a poroelastic finite element model. Clin
malum coxaesenilis, old slipped upper Biomech (Bristol, Avon). 2000;15(6):463–8.
capital femoral epiphysis, intrapelvic 9. Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro
investigation of the acetabular labral seal in hip joint
protrusion of the acetabulum, and coxae mechanics. J Biomech. 2003;36(2):171–8.
plana by means of acetabuloplasty. 10. Cadet ER, Chan AK, Vorys GC, Gardner T, Yin B.
J Bone Joint Surg Am. 1936;18:869–80. Investigation of the preservation of the fluid seal
2. Murray RO. The aetiology of primary effect in the repaired, partially resected, and recon-
structed acetabular labrum in a cadaveric hip model.
osteoarthritis of the hip. Br J Radiol. Am J Sports Med. 2012;40(10):2218–23.
1965;38(455):810–2. 11. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H,
Siebenrock KA. Femoroacetabular impingement: a
4 E.R. Cadet

cause for osteoarthritis of the hip. Clin Orthop Relat of femoroacetabular impingement in professional
Res. 2003;417:112–20. hockey players. Am J Sports Med. 2010;38(1):
12. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz 99–104.
R, Leunig M. Anterior femoroacetabular impinge- 18. Sierra RJ, Trousdale RT. Labral reconstruction using
ment: part I. Techniques of joint preserving surgery. the ligamentum teres capitis: report of a new tech-
Clin Orthop Relat Res. 2004;418:61–6. nique. Clin Orthop Relat Res. 2009;467(3):753–9.
13. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, 19. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D,
Berlemann U. Surgical dislocation of the adult hip a Ganz R. Anterior femoroacetabular impingement:
technique with full access to the femoral head and part II. Midterm results of surgical treatment. Clin
acetabulum without the risk of avascular necrosis. Orthop Relat Res. 2004;418:67–73.
J Bone Joint Surg Br. 2001;83(8):1119–24. 20. Bedi A, Chen N, Robertson W, Kelly BT. The manage-
14. Larson CM, Giveans MR. Arthroscopic debridement ment of labral tears and femoroacetabular impingement
versus refixation of the acetabular labrum associated of the hip in the young, active patient. Arthroscopy.
with femoroacetabular impingement. Arthroscopy. 2008;24(10):1135–45.
2009;25(4):369–76. 21. Philippon MJ, Briggs KK, Yen YM, Kuppersmith
15. Philippon MJ, Briggs KK, Hay CJ, Kuppersmith DA, DA. Outcomes following hip arthroscopy for femoro-
Dewing CB, Huang MJ. Arthroscopic labral recon- acetabular impingement with associated chondro-
struction in the hip using iliotibial band autograft: labral dysfunction: minimum two-year follow-up.
technique and early outcomes. Arthroscopy. 2010; J Bone Joint Surg Br. 2009;91(1):16–23.
26(6):750–6. 22. Philippon MJ, Stubbs AJ, Schenker ML, Maxwell
16. Murphy KP, Ross AE, Javernick MA, Lehman RA Jr. RB, Ganz R, Leunig M. Arthroscopic management of
Repair of the adult acetabular labrum. Arthroscopy. femoroacetabular impingement: osteoplasty tech-
2006;22(5):567.e1–3. nique and literature review. Am J Sports Med. 2007;
17. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs 35(9):1571–80.
KK, Hay CJ. Arthroscopic labral repair and treatment
 Differential Diagnosis of Hip Pain
2
Filippo Randelli, Fabrizio Pace, Daniela Maglione,
Paolo Capitani, Marco Sampietro, and Sara Favilla

Contents 2.1 Introduction

2.1 Introduction 5
Since the introduction of femoroacetabular
2.2 Intra-articular Pathologies 6
2.2.1 Ligamentum Teres Tears 6
impingement (FAI) [1–3] and new diagnostic
2.2.2 Pigmented Villonodular Synovitis 6 tools, such as intra-articular injections and more
advanced magnetic resonance imaging (MRI)
2.3 Extra-articular Pathologies 7
2.3.1 Bone Marrow Edema Syndromes 7 [4–6], a number of previously unexplained causes
2.3.2 Osteonecrosis 8 of hip pain have been revealed.
2.3.3 Greater Trochanteric Pain Syndrome/ Nevertheless a comprehensive diagnosis of
Trochanteric Bursitis 8
hip pain is not always easy to obtain for a vari-
2.3.4 Snapping Hip Syndrome 9
2.3.5 Ischiofemoral Impingement 10 ety of reasons. First, radiographic signs of FAI
are found in a high percentage of the asymptom-
2.4 Hip Mimickers 11
2.4.1 Osteitis Pubis 11 atic population [7, 8]. Consequently, radio-
2.4.2 Sports Hernia 12 graphic signs of FAI alone should not be
2.4.3 Piriformis Muscle Syndrome 13 considered as the only cause of pain around the
2.4.4 Meralgia Paresthetica 14 hip. Second, a variety of possible associated
2.4.5 Obturator Neuropathy 15
2.4.6 Osteoid Osteoma 16 pathologies may be found in patients with hip
2.4.7 Cruralgia/Leg Pain 16 pain. Sometimes these associated pathologies
2.4.8 Buttock Claudication 17 represent the real cause of hip pain, and FAI is
References 19 secondary or not related to the hip pain. That is
why a careful history, a thorough clinical evalu-
ation, and knowledge of the other possible clini-
cal entities should be considered. This chapter
A description of other conditions that may present like or will provide an overview of the more frequent
with FAI
and/or insidious causes of hip pain (Table 2.1)
F. Randelli (*) • F. Pace • D. Maglione • P. Capitani that may be confused or associated with FAI.
M. Sampietro • S. Favilla Pathologies have been divided in the classi-
Hip Department and Trauma, I.R.C.C.S. Policlinico
cal three major groups: intra-articular patholo-
San Donato, Piazza Malan 1, San Donato Milanese,
Milan 20097, Italy gies, extra-articular pathologies and hip
e-mail: [email protected] mimickers.

© Springer International Publishing Switzerland 2017 5

O.R. Ayeni et al. (eds.), Diagnosis and Management of Femoroacetabular Impingement,
DOI 10.1007/978-3-319-32000-7_2
6 F. Randelli et al.

Table 2.1 Differential diagnosis of hip pain

Intra-articular Extra-articular Hip mimickers
Femoroacetabular impingement Greater trochanteric pain syndrome Adductor-rectus abdominis tears
Isolated labral tears External snapping hip Osteitis pubis
Loose bodies Internal snapping hip Sports hernia
Chondral damage Bursitis Obturator neuropathy
Ligamentum teres tears Osteoid osteoma Piriformis syndrome
Capsular laxity Bone marrow edema syndrome Meralgia paresthetica (Roth)
Developmental dysplasia of the hip Avascular necrosis of the femoral head Spine-derived cruralgia
Slipped capital femoral epiphysis Stress fractures SI joint disease
Post Perthes disease Bone and soft-tissue neoplasms Buttock claudication
Septic arthritis Ischiofemoral impingement
Inflammatory arthritis and synovitis

2.2 Intra-articular Pathologies then passively internally and externally rotated to

available end range of motion; the test is positive
Different intra-articular pathologies may be asso- when there is reproduction of pain either upon
ciated or mistaken for FAI. The most important internal or external rotation [14].
are ligamentum teres tears and inflammatory Imaging rarely identifies ligamentum teres
synovitis as synovial chondromatosis and pig- injuries and a preoperative diagnosis varies from
mented villonodular synovitis (PVNS). 1 to 5 % [15]. MRI and MRA (magnetic reso-
nance arthrography) appear to be accurate
diagnostic tools [16, 17], while arthroscopy
2.2.1 Ligamentum Teres Tears remains the gold standard in identifying these
lesions.
2.2.1.1 Introduction
Lesions of the ligamentum teres have been 2.2.1.3 Treatment
increasingly recognized as a source of pain. Byrd In case of failure of conservative treatment such
reported them as the third most common diagno- as physiotherapy, arthroscopic debridement [18]
sis in athletes undergoing hip arthroscopy [9]. A is indicated in patients with pain caused by
complete lesion is usually associated with trau- partial-thickness lesions, while reconstruction
matic dislocation but may be also seen in high- with autografts [19], allografts, or synthetic
impact athletes [10, 11]. grafts may be indicated in patients with full-
thickness lesions that cause instability or in
2.2.1.2 Diagnosis which debridement was not effective in reducing
Clinical diagnosis can be difficult. Symptoms are symptoms [11].
nonspecific during clinical evaluation, character-
ized by a reduced or painful range of motion, a
painful straight leg raise test, and locking of the 2.2.2 Pigmented Villonodular
joint [12]. O’Donnell et al. [13] have proposed a Synovitis
diagnostic test for ligamentum teres tears with a
sensitivity and specificity of 90 % and 85 %, 2.2.2.1 Introduction
respectively. The clinician passively flexes the Pigmented villonodular synovitis (PVNS) is a
hip fully and then extends 30°, leaving the hip at rare proliferative disorder of the synovium.
about 70° flexion (knee is flexed 90°); the hip is Eventhough PVNS is a benign disease, it may be
then abducted fully and then adducted 30°, typi- aggressive in certain cases. PVNS may also occur
cally leaving it at about 30° abduction; the leg is in a localized or more diffused form.
2 Differential Diagnosis of Hip Pain 7

2.2.2.2 Diagnosis The main differential diagnosis is avascular

Patients typically present with mild to severe necrosis of the femoral head (AVN), and it is still
pain and impaired joint function. Recurrent hem- controversial, whether BMES represents a dis-
arthrosis is typical. The concurrent presence of tinct self-limiting disease or merely reflects a
FAI can mistakenly lead to a diagnosis of a sec- subtype of AVN [25].
ondary synovial reaction instead of Etiology remains unclear in most patients, but
PVNS. Diagnosis is suspected through MRI and appears to be multifactorial and related to
confirmed by histology. increased intraosseous pressure with increased
bone turnover, a diminished perfusion, and sub-
2.2.2.3 Treatment sequent hypoxia producing pain [27].
Treatment is often surgical, either via open or
arthroscopic synovectomy, or, in more severe 2.3.1.2 Diagnosis
cases, a total hip arthroplasty (THA) is indicated TOH mainly affects male patients who are 30–50
once significant degenerative changes are pres- years old and women in the third trimester of
ent. Treatment with radiation and intra-articular pregnancy, without history of trauma. The main
injections of radioisotope are indicated in incom- symptoms are severe hip pain with weight bear-
plete synovectomy or recurrences. Treatment of ing and functional disability. Radiographs may
hip PVNS presents a high rate of failure. Hip show diffuse osteoporosis in the hip after several
arthroscopy has been shown to be effective but weeks from the onset of hip pain. In addition,
with a recurrence rate of 12 % and a conversion MRI shows bone marrow edema in the femoral
rate to THA ranging from 8 to 46 %. A high rate head, sometimes involving the femoral neck.
(31 %) of aseptic loosening in THA after PVNS MRI is also useful in differentiating between
has been also reported. An open transtrochanteric BME, FAI, and greater trochanteric pain syn-
approach has been recently suggested with some drome (GTPS) that may present as localized
success [20–24]. bone marrow edema but with different edema
patterns [28].
A bone scan may differentiate BME from
2.3 Extra-articular Pathologies AVN at its initial stage where a “cold in hot”
image is seen. A “cold” zone of decreased tracer
These disorders affect structures surrounding the uptake (the necrotic zone) is surrounded by a
joint or the bone itself. It is not rare to find them half-moon-shaped area of increased uptake (cres-
in association with FAI. cent) [29].
Regional migratory osteoporosis presents a
similar clinical course but is characterized by a
2.3.1 Bone Marrow Edema polyarticular involvement.
Syndromes RSD, also called algodystrophy, complex
regional pain syndrome (CRPS), or Sudeck’s
2.3.1.1 Introduction dystrophy, is characterized by a history of trauma
The term bone marrow edema syndrome (BMES) and presents three phases: acute, dystrophy, and
refers to several different clinical conditions. atrophy. Symptoms are dull and burning pain
They are usually self-limiting (may take up to 24 with a rapid onset and subsequently skin atrophy,
months) and they are best seen on MRI [25]. sensorimotor alteration, and joint contractures.
Different clinical entities have been reported, Osteoporosis is early visible radiographically
such as transient osteoporosis of the hip (TOH), [29].
transient marrow edema, regional migratory
osteoporosis (RMO), and reflex sympathetic dys- 2.3.1.3 Treatment
trophy (RSD) also known as complex regional The recommended treatment is often nonsurgi-
pain syndrome (CRPS) [25, 26]. cal, with protected weight bearing and analge-
8 F. Randelli et al.

sics. Once diagnosed, to shorten the duration of 2.3.2.3 Treatment

symptoms, hyperbaric oxygen therapy, bisphos- The treatment of AVN is still controversial and
phonates, and, more recently, prostaglandin depends on the stage and the location of the
inhibitors have been used with encouraging pathology following the different classification
results. In a controlled randomized study, hyper- systems.
baric oxygen therapy showed a significant resolu- Nonsurgical treatment alternatives such as
tion of bone marrow edema in 55.0 % of the shock wave therapy (still debated [42]), intrave-
patients compared to 28 % in the control group nous iloprost, bisphosphonates, pulsed electro-
[30, 31]. In a series of 186 patients treated with magnetic fields, hyperbaric oxygen [41, 43, 44],
prostaglandin inhibitors, there was a significant enoxaparin [45], and, more recently, injection of
decrease in bone marrow edema on MRI and an stem cells and platelet-rich plasma have been
increase in the mean Harris Hip Score from 52 reported in the literature [46].
points to 79 at latest follow-up [32]. Intravenous use of iloprost, a prostacyclin deri-
vate with vasoactive action, appears to give good
results in some studies, both if used alone and in
2.3.2 Osteonecrosis combination with core decompression [43, 44].
Surgical salvage procedures, in the early
2.3.2.1 Introduction stages of AVN, include core decompression, rota-
Avascular necrosis or osteonecrosis (AVN or tional osteotomies, and vascularized bone graft-
ON) of the femoral head is caused by inadequate ing [47, 48]. Stem cell therapy in adjunction of
blood supply [33, 34] and can be idiopathic or core decompression is growing; in a review by
secondary to different predisposing factors such Houdek et al., MRI showed a decrease in the
as trauma, alcoholism, use of steroids, barotrau- zone of marrow edema from 32 % to more than
mas, and hematological or coagulation diseases 75 % in patients treated with core decompression
[35, 36]. Different classification systems have and stem cells [49].
been developed with the aim to provide guide- In more advanced stages, total hip replace-
lines for treatment. Ficat and Arlet published the ment is the only alternative treatment to achieve
first classification system based on radiographic pain relief and improved function [50].
changes [37]. Subsequently the ARCO classifica-
tion system was introduced [38]. Steinberg et al.
introduced an MRI classification subdivided in 2.3.3 Greater Trochanteric Pain
six stages [39]. Syndrome/Trochanteric
Bursitis
2.3.2.2 Diagnosis
The suspicion of osteonecrosis should be always 2.3.3.1 Introduction
high in case of a deep groin pain with a history of Greater trochanteric pain syndrome (GTPS) is a
trauma (femoral neck fracture or fracture disloca- term used to describe chronic pain localized at
tion) or other predisposing factors. Standardized the lateral aspect of the hip [51]. This pain syn-
radiography is the first step to evaluate the pres- drome, once described as “trochanteric bursitis”
ence of the pathognomonic “crescent sign” (sign (TB), is also known as the “great mimicker”
of early femoral head collapse due to necrotic because its clinical features overlap with several
subchondral bone). It is not rare to find FAI signs other conditions including myofascial pain,
that may divert attention from the real cause of degenerative joint disease, and some spinal
the pain. MRI is the gold standard to confirm the pathologies [52]. Typical presentation is pain
diagnosis with a high sensitivity and specificity and tenderness over the greater trochanter region.
[40]. The use of bone scan is debated and mainly GTPS is very common, reported to affect
used to aid with determining the definitive diag- between 10 and 25 % of the general population.
nosis [41]. The most affected population is middle aged
2 Differential Diagnosis of Hip Pain 9

(ages 40–60 years) with a high female predomi- About one-third of the patients suffer chronic
nance (4:1) [53]. pain. In these patients there may be an indication
for surgical intervention [69–72]. Currently, there
2.3.3.2 Pathogenesis are different endoscopic techniques for local
The pathogenesis is still unclear. It could be related decompression (ITB release), bursectomy, and
anatomical factors such as a wide pelvis, stresses suture of torn gluteal tendons. Unfortunately
on the iliotibial band, hormonal effects on bursal there are only few studies and no long-term fol-
irritation, or alteration in physical activities [54, low-up for these treatments. Good results have
55]. Gluteus minimus and medius tendinopathy is been shown in endoscopic gluteus medius repair
also one of the primary causes of greater trochan- at minimum 2-year follow-up in more than 90 %
teric pain [56, 57]. of 15 patients. Interestingly, 100 % of those
patients had concomitant intra-articular patholo-
2.3.3.3 Clinical Presentation gies (labral tears and cartilage damages). A recent
A history of lateral hip pain and pain on palpa- study [72] on endoscopic treatment of GTPS in
tion of the lateral hip are the most common clin- 23 patients demonstrated significant improve-
ical findings of GTPS. Other symptoms are pain ment in pain and functional score at 12-month
during weight bearing and lying on the affected follow-up [43, 59, 61, 73–76].
side during nighttime [58]. On examination,
patients complain of pain during direct com-
pression of the peritrochanteric area, often 2.3.4 Snapping Hip Syndrome
reproducible with a FABER test (flexion, abduc-
tion, and external rotation). The Ober test is use- 2.3.4.1 Introduction
ful to assess iliotibial band (ITB) tightness Snapping hip, or coxa saltans, is a condition that
[58–61]. Kaltenborn et al. [62] have described involves an audible or palpable snap during
the hip lag sign as useful to identify gluteal movement of the hip, with or without pain. It was
musculo-tendinous lesions. first described at the beginning of the last century
[77, 78]. The iliotibial band was usually consid-
2.3.3.4 Diagnosis ered the only cause until Nunziata and Blumenfeld
Plain radiographs are useful to exclude other con- suggested the psoas tendon, slipping over the
current pathologies (osteoarthritis, FAI, coxa iliopectineal eminence, as another source [79].
profunda, avulsion fractures). Calcification adja- An important contribution was by Allen and
cent to the greater trochanter may be seen in up to Cope [80] who described three different etiolo-
40 % of patients presenting with GTPS. Insertional gies of the snapping hip: intra-articular, internal,
tendinopathic calcification rather than bursal cal- or external. They also introduced the use of coxa
cification is usually present [54]. Several studies saltans as a general term [79, 80].
have demonstrated the association between a low In the general population, the incidence of
femoral neck-shaft angle or an increased acetab- asymptomatic snapping hip is 5–10 % with a
ular anteversion and GTPS [63, 64]. Small-field female predominance. In most cases the condi-
MRI is very useful to assess tendon insertions tion is associated with sporting activities, such as
and surroundings [54]. soccer/football, weight lifting and dance (up to
90 and 80 % of these bilaterally), and running
2.3.3.5 Treatment [77, 78].
Greater trochanteric bursitis should initially be
managed nonoperatively with rest, stretching, 2.3.4.2 Diagnosis
physical therapy, and weight loss (when Radiographs are usually negative and useful only
indicated). Other treatment options are extracor- to rule out other diseases or to identify predispos-
poreal shock wave therapy and steroid injections ing factors such as coxa vara, prominence of the
[54, 60, 65–68]. greater trochanter, and reduced bi-iliac width for
10 F. Randelli et al.

the external or hip dysplasia for the internal. MRI a seated position are difficult for patients with
usually may reveal a cause of an intra-articular this condition [77, 79].
snap. Dynamic ultrasound can identify the snap- The aim of surgery is to release the iliopsoas
ping tendon and may give additional information, tendon. Today the preferred approaches to per-
such as the presence of inflammation, tendinopa- form a tenotomy are endoscopic, at the lesser tro-
thy, or bursitis [77, 79]. chanter, or arthroscopic, at the joint level. A high
rate of associated labral tears have been reported
2.3.4.3 Treatment [81, 85–89]. Particular attention should be paid to
Initial treatment includes rest, ice, anti- bifid or trifid psoas tendons that may result in an
inflammatory medications, and activity modifica- unsuccessful procedure [90, 91]. It was reported
tion avoiding triggering the snap. Physical that arthroscopic surgery had better results than
therapy, stretching of the involved structures, and open techniques with fewer complications and
a reduced training usually lead to good results. less pain. Open fractional lengthening could lead
Many symptomatic snapping hips, between 36 to an increased postoperative pain than open tran-
and 67 %, resolve without surgery [77, 79, 81]. section at the lesser trochanter, but it is more effi-
cacious. These results must be read considering
2.3.4.4 External Snapping Hip the deficiency of high-quality literature evidence
External snapping hip is caused by the thickening or direct comparison [81].
of the posterior aspect of the iliotibial band (ITB)
or anterior aspect of the gluteus maximus close to 2.3.4.6 Intra-articular Snapping Hip
its insertion. The greater trochanter bursa may Intra-articular snapping hip has a variety of
become inflamed because of the recurrent snap- causes, including synovial chondromatosis, loose
ping and causes pain [77]. bodies, labral tears, (osteochondral) fracture
Patients with external snapping hip often fragments, and recurrent subluxation [77, 79,
report a sensation of subluxation or dislocation of 80]. Intra-articular lesions may create a snap,
the hip (pseudosubluxation). click or pop, but, usually, it is the sensation of
The goal of surgery, when needed, is the catching, locking, or sharp stabbing pain that is
releasing or lengthening of the ITB [77]. A first reported by the patient [77, 79, 92]. The
Z-plasty of the ITB transects, transposes and injection of anesthetic into the iliopsoas bursa
reattaches the ITB with resolution of symptoms (internal snapping hip) or the hip joint (intra-
in most patients. A reported complication is a articular pathology) helps in diagnosis and in
Trendelenburg gait that in an athlete or dancer identifying the involved structure [77, 79].
takes on added importance [82]. Usually an
endoscopic ITB diamond-shaped release at the
level of the greater trochanter is successful [83]. 2.3.5 Ischiofemoral Impingement
A new interesting technique, the endoscopic glu-
teus maximus tendon release, has recently been 2.3.5.1 Introduction
introduced [84]. Ischiofemoral impingement (IFI) is an uncom-
mon cause of hip pain caused by an abnormal
2.3.4.5 Internal Snapping Hip contact between the ischium and the lesser tro-
In the internal snapping hip, the iliopsoas tendon chanter with compression of the quadratus femo-
snaps over a bony prominence, usually the ilio- ris muscle [93]. It was first described in 1977 by
pectineal eminence or the anterior femoral head. Johnson [94] in patients previously treated with
The snap usually occurs when extending the hip replacement or osteotomy of the femur. Only
flexed hip or with moving the hip from external recently it has been diagnosed and described as a
to internal rotation or moving the hip from abduc- stand-alone pathology [95–97]. This disease is
tion to adduction. Running and standing up from more common in women, is bilateral in about a
2 Differential Diagnosis of Hip Pain 11

third of cases, and usually occurs later in life 2.4.1 Osteitis Pubis
compared with femoroacetabular impingement
(mean age at presentation 51–53 years) [95, 98]. 2.4.1.1 Introduction
Osteitis pubis is a painful, noninfectious, inflam-
2.3.5.2 Clinical Presentation matory process involving the pubic bone, the
The typical symptoms are pain localized to the symphysis, and the surrounding structures, such
hip, groin or buttock level and sometimes irradia- as cartilage, muscles, tendons, and ligaments
tion to the lower extremities, probably caused by [101, 102].
irritation of the adjacent sciatic nerve [95, 98]. The true incidence and prevalence of osteitis
There is pain upon direct palpation of the ischio- pubis are unknown. The condition was first
femoral space and when the hip is in extension described as a complication of suprapubic surgery
and adduction. Clinical tests are the long-stride in 1924 [103] and then in a fencer athlete in 1932
walking test, in which the patient feels pain dur- [104]. Usually, osteitis pubis is a self-limiting
ing extension of the hip (the pain is relieved by inflammatory condition secondary to trauma, pel-
walking in short strides or by abduction of the hip vic surgery, childbirth, pelvic functional instabil-
during walking), and the ischiofemoral impinge- ity, or overuse (particularly in athletes). It also has
ment test, which is performed with the patient in the potential to turn into a chronic pain problem in
contralateral decubitus, extending the affected hip the pelvic region [105–107].
passively in adduction or neutral position [99].
2.4.1.2 Pathogenesis
2.3.5.3 Diagnosis FAI appears to represent a major predisposing
Imaging studies include a standing anteroposte- factor for this condition. Reduced hip rotation
rior view of the pelvis and a frog-leg projection associated with FAI may result in increased stress
[96, 99] where a reduction of the ischiofemoral to the rest of the pelvis generating an osteitis
distance can be seen (normal 23 ± 8 mm, patho- pubis as loads are applied to adjacent joints [108].
logical 13 ± 5 mm) [95]. Moreover, there are a In a study on 125 American collegiate football
variety of possible associated malformations, players (239 hips), there was a high prevalence of
such as coxa breva, coxa valga, or others that lead osteitis pubis in FAI symptomatic hips [109]. The
to medialization of the femoral head in the acetab- only independent factor, for hip or groin pain in
ulum [99]. MRI can be valuable to detect diffuse these athletes, was an increased alpha angle [108].
edema of the quadratus femoris muscle [95, 98].
2.4.1.3 Clinical Presentation
2.3.5.4 Treatment A gradual onset of pain in the pubic region is the
Treatment includes guided steroid infiltrations. In main symptom. The pubic symphysis or the supe-
some patients surgical decompression of the qua- rior pubic ramus may be painful upon palpation.
dratus femoris with resection, either by endos- The pain typically radiates to the inner thigh
copy or by open surgery, of the lesser trochanter (adductor musculature), to the groin, or upward to
may be indicated, but there is still low-quality the abdomen. The perineal region and scrotum may
evidence about the success of this procedure [93, also be involved. Running, hip flexion or adduction
99, 100]. against resistance and abdominal eccentric exer-
cises usually aggravate the pain. Later in the dis-
ease a reduction in the internal and external rotation
2.4 Hip Mimickers of the hip joint, muscular weakness, and sacroiliac
joint dysfunction are reported. In severe cases, pain
These diseases affect structures away from the limits walking capability promoting an antalgic or
joint (either anatomically or functionally), with waddling gait. Pain can be also be evoked when
pain in the hip region. getting up from a sitting position [110–112].
12 F. Randelli et al.

2.4.1.4 Diagnosis competitive nonprofessional soccer players were

Standard anteroposterior radiographs usually able to return to full-activity sports in an average
show widening of the symphysis and sclerosis, period of 14.4 weeks after the arthroscopic sur-
rarefaction, cystic changes, or marginal erosions gery with satisfactory results [114–116].
in the subchondral bone of the symphysis. In
acute cases, or in mild form, radiographs may
also be normal in some cases. Instability can be 2.4.2 Sports Hernia
evaluated with “flamingo view” radiographs.
However, the correlation with symptoms is 2.4.2.1 Introduction
always necessary, because similar radiographic Sports hernia (also called “athletic pubalgia”) is a
findings may be seen also in asymptomatic per- condition characterized by a strain or a tear of any
sons [111]. soft tissue (such as muscle, tendon and ligament)
Bone scan may show an increased uptake at in the lower abdomen or groin area. Unlike a tra-
the symphysis, but this is a late sign, and may ditional hernia, the sports hernia doesn’t create a
take months to appear. defect in the abdominal wall. As a result, there is
CT scan may show marginal stamp erosions of no visible bulge under the skin and a definitive
the parasymphyseal pubis bone, insertional bony diagnosis is often difficult. It often occurs where
spur or periarticular microcalcifications. the abdominal muscles/tendons and adductors
MRI has a superior role in visualization of attach at the pubic bone at the same location.
soft-tissue abnormalities (e.g., microtears of the Groin pain caused by sports hernia can be dis-
adductor tendons) and changes within the bone abling, and it most often occurs during sports that
marrow (e.g., bone edema) and is useful for dif- require sudden changes of direction, intense
ferential diagnosis of osteitis pubis, bursitis and twisting movements, cutting and/or kicking [117,
stress fractures [111, 112]. 118].
Sports hernias typically affect young males
2.4.1.5 Treatment who actively participate in sports. Females are
Because osteitis pubis is normally self-limiting, affected, but much less commonly than males,
initial treatment is nonoperative. In highly com- comprising just 3–15 % of cases [119]. Sports
petitive athletes, activity modification is recom- hernia is a frequent cause of acute and chronic
mended. Many different therapeutic modalities groin pain in athletes [120] and there is a high
and rehabilitation protocols have been success- incidence of symptoms of sports hernia in profes-
fully used [113]. Corticosteroid injections may sional athletes with FAI [121].
be beneficial.
Surgical treatment includes open curettage of 2.4.2.2 Pathogenesis
the symphysis pubis with or without subsequent The exact cause of sports hernia is not completely
fusion of the joint, wedge resection, posterior known and remains heavily debated. The soft tis-
wall mesh repair and a variety of procedures to sues most frequently affected are the oblique
reinforce or repair the abdominal and pelvic floor muscles in the lower abdomen (especially vul-
musculature, with or without adductor tendon nerable are the tendons of the internal and exter-
release with an average return to sports of 6 nal oblique muscles). When both oblique and
months [111, 112]. adductor muscles contract at the same time, there
Recently an arthroscopic technique has been is a disequilibrium between the upward and
described to debride the symphysis and, eventu- oblique pull of the abdominal muscles on the
ally, to divide and reattach the degenerated origin pubis against the downward and lateral pull of the
of adductor tendon. With this technique the adductors on the inferior pubis. This imbalance
stability of the symphysis pubis is maintained of forces can lead to injuries of the lower central
and time to return to sports is supposed to be abdominal muscles and the upper common inser-
shorter. More recent reports document that five tion of the adductor muscles [122].
2 Differential Diagnosis of Hip Pain 13

Muschaweck and Berger described sports her- 2.4.2.5 Treatment

nias as a weakness of the transversalis fascia por- The available literature favors early surgical
tion of the posterior wall of the inguinal canal management [129, 130] for those athletes who
[123]. This weakness of the pelvic floor can lead are unable to return to sports at their desired level
to localized bulging and compression of the geni- after a trial of nonsurgical treatment for 6–8
tal branch of the genitofemoral nerve. weeks [118, 131–136].
Compression of this nerve appears to be the Nonsurgical treatment consists primarily of
major reason of pain in these patients [124]. rest and cryotherapy. Two weeks after the injury,
the physical therapy exercises can improve
2.4.2.3 Clinical Examination strength and flexibility in the abdominal and
Although the physical examination reveals no inner thigh muscles. The nonsteroidal anti-
detectable inguinal hernia, a tender, dilated inflammatory therapy can be useful to reduce
superficial inguinal ring and tenderness of the swelling and pain [118].
posterior wall of the inguinal canal are often Surgery is indicated as either a traditional open
found. The patient typically presents with an procedure or as an endoscopic procedure. Some
insidious onset of activity-related, unilateral, surgeons perform also an inguinal neurectomy to
deep groin pain that abates with rest, but returns relieve pain or an adductor tenotomy to release
upon sports activity, especially with twisting tension and increase range of motion [124, 135].
movements [125]. The pain may be more severe Continued groin pain after surgery may be
with resisted hip adduction, but the most specific caused by an underlying concurrent FAI;
finding is pain in the inguinal floor with a resisted Economopoulos et al. have demonstrated a high
sit-up. Pain can also be elicited in the “frog posi- prevalence of radiographic FAI signs in patients
tion” [126]. Gentle percussion over the pubic with athletic pubalgia that should be always
symphysis is performed to assess concurrent closely evaluated [137].
presence of osteitis pubis. Next, the patient is Most studies have reported that 90–100 % of
asked to adduct the thighs against resistance. patients returned to full activity in 6 months [122].
Alternatively, the athlete can suspend the ipsilat-
eral straight leg in external rotation, against resis-
tance, and then perform the abdominal crunch 2.4.3 Piriformis Muscle Syndrome
and test the medial inguinal floor for tenderness.
2.4.3.1 Introduction
2.4.2.4 Diagnosis Piriformis muscle syndrome (PMS) is an entrap-
Experienced clinicians will identify this condi- ment neuropathy caused by sciatic nerve com-
tion only from history and physical examination pression in the infrapiriformis canal [138, 139].
[127]. Even if the role of imaging studies is Some researchers account PMS for up to 5 % of
unclear [125], plain radiographs, bone scans, all cases of low back, buttock and leg pain [140].
ultrasound, computed tomography scans and, Other anatomical anomalies have been reported
especially, magnetic resonance imaging (MRI) to explain its etiology [141]. Similar sciatic
may be necessary to rule out related or associated compression-type pathology has also been
pathology [127]. Shortt et al. have imaged over referred to the obturator internus, evocating the
350 patients. In their experience, patients with a obturator internus syndrome (OIS) [142].
clinical sports hernia almost always exhibit Yeoman in 1928 first reported that sciatica
abnormalities on MRI. The two dominant pat- may be caused by sacroiliac periarthritis and piri-
terns of injury include the lateral rectus formis muscle entrapment [143]. Freiberg and
abdominis/adductor aponeurotic injury just adja- Vinke in 1934 stated that sacroiliac joint inflam-
cent to the external inguinal ring and the midline mation may primarily cause reaction of the piri-
rectus abdominis/adductor aponeurotic plate formis muscle and its fascia that may secondarily
injury [127, 128]. irritate the overlying lumbosacral plexus [144].
14 F. Randelli et al.

Based on cadaveric dissections, Beaton and the anterolateral thigh, due to entrapment of the
Anson 1938 hypothesized that a piriformis mus- lateral femoral cutaneous nerve (LFCN) [158].
cle spasm could be responsible for the irritation It was first described by Martin Bernhardt in
of the sciatic nerve [145]. Robinson in 1947 has 1878, but the term meralgia paresthetica (MP)
introduced the term “piriformis syndrome” [146]. was coined by Vladimir Roth, a Russian neurolo-
gist, in 1895 who noticed this condition in a
2.4.3.2 Clinical Presentation horseman who wore tight belts [159].
The classic features of piriformis syndrome It most commonly occurs in 30–40-year-old
include “sciatica-like pain,” aggravated by sit- men with an incidence of 1–4.3 per 10,000
ting, buttock pain, external tenderness over the patients in the general population [160, 161].
greater sciatic notch and augmentation of the Other than idiopathic, causes of meralgia
pain with maneuvers that increase piriformis ten- paresthetica are mechanical factors as obesity,
sion [147]. Other clinical features may be pain pregnancy, and other factors that increase
with straight leg raise test, a positive Pace test abdominal pressure, such as strenuous exercise,
(pain with resisted hip abduction in a seated posi- sports and tight belts. Lower limb-length dis-
tion) [148], and a positive Freiberg test (pain crepancy has also been associated with this neu-
upon forceful internal rotation of the extended ropathy and also different metabolic factors, as
hip) [144]. diabetes mellitus, alcoholism, lead poisoning
and hypothyroidism [160, 162]. Iatrogenic
2.4.3.3 Diagnosis causes are due to surgical procedures, such as
The piriformis entrapment is often diagnosed via ilioinguinal approach for acetabular fracture
exclusion. The diagnosis is often difficult to fixation, iliac crest bone graft, anterior approach
establish. There are no laboratory or radiographic for total hip replacements, laparoscopy for cho-
methods for diagnosing the syndrome. An MRI lecystectomy or inguinal hernia, coronary artery
may in some cases show variations in anatomy, bypass grafting, aortic valve surgery and gastric
muscle hypertrophy, as well as abnormal signal reduction [160].
of the sciatic nerve [149].
EMG may provide findings for sciatic nerve 2.4.4.2 Pathophysiology
compression at the level of the piriformis muscle The lateral femoral cutaneous nerve originates
[142]. A “piriformis syndrome” may be con- from different combinations of lumbar nerves
firmed through a positive response to the injec- (L1–L3); its course is extremely variable. Passing
tion of a local anesthesia [150]. from the pelvis to the thigh, the nerve crosses a
tunnel between the ileopubic tract and the ingui-
2.4.3.4 Treatment nal ligament, where it enlarges its diameter devel-
Traditional treatment is nonsurgical with physical oping, in some cases, the meralgia paresthetica
therapy, stretching, extracorporeal shock wave [160, 163, 164].
therapy (ESWT) and steroid or analgesic injec-
tions [151, 152]. Open tenotomy has been reported 2.4.4.3 Clinical Presentation
[153]. Recently, botulinum toxin [154, 155] and Patients usually present with paresthesia, dyses-
arthroscopic release have been used with promis- thesia, numbness, pain, burning, buzzing, muscle
ing results in selected cases [156, 157]. aches and coldness on the lateral or anterolateral
thigh. Prolonged standing or long walking exac-
erbates symptoms. Pain relief is usually obtained
2.4.4 Meralgia Paresthetica with sitting [160].
Clinical tests are represented by the pelvic
2.4.4.1 Etiology and Epidemiology compression (described by Nouraei et al. [165])
Meralgia paresthetica is a clinical condition char- executed with the patient lying on the contralateral
acterized by paresthesia and burning pain over side; a manual compression is applied downward
2 Differential Diagnosis of Hip Pain 15

to the pelvis for 45 seconds to achieve inguinal nerve resection, but patients must accept a per-
ligament relaxation. The maneuver is positive if manent change of thigh skin sensation. Some
there is a relief of the symptoms. Another test cases of recurrence have been described with
described by Butler is the neurodynamic testing neurolysis [158, 160, 165].
executed with the patient lying on the contralateral
side with the knee flexed; with one hand the pelvis
is stabilized and with other hand the affected leg is 2.4.5 Obturator Neuropathy
sustained, and then the knee is flexed and adduc-
tion is performed obtaining the tension of the 2.4.5.1 Introduction
inguinal ligament. The test is positive if the neuro- Obturator neuropathy is an uncommon mono-
logical symptoms are evoked [158]. neuropathy that usually occurs acutely after a
well-defined event (surgery or trauma). The pain
2.4.4.4 Diagnosis related to obturator neuropathy can be difficult
Differential diagnosis includes lumbar stenosis, to distinguish from the pain due to the recent sur-
disc herniation, nerve root radiculopathy, iliac gical procedure or trauma [170, 171].
crest metastasis and anterior superior iliac spine
avulsion fracture. Ahmed has speculated about a 2.4.5.2 Pathogenesis
possible association between meralgia paresthet- Injury to the obturator nerve is rare because the
ica and FAI: the anatomical variability of LFCN nerve is located deep and protected in the pelvis
could be compressed by abnormal hip structures and medial thigh [172]. The injury can result
typical of FAI [160, 166]. from entrapping, sectioning, stretching, or crush-
Neurophysiological studies can help to con- ing the nerve. Other common injury mechanisms
firm the diagnosis, especially somatosensory are electrocoagulation, ligation, or neuroma for-
evoked potential and sensory nerve conduction, mation [172]. Reports have described obturator
even if they have some limitations and a sensitiv- nerve injury during total hip replacement (poor
ity and specificity of 81.3 % and 65.2 %, respec- acetabular screw placement or cement extrusion)
tively. In recent times, magnetic resonance and after abdominal procedures or major pelvic
neurography (MRN) has been introduced and surgery [171, 173–181].
appears to produce better results with an accu-
racy >90 % [158, 167]. Nerve block with local 2.4.5.3 Clinical Presentation
anesthetics is a good diagnostic test [162]. The most prominent symptom of obturator neu-
ropathy is pain radiating from the groin into the
2.4.4.5 Treatment medial upper aspect of the thigh. Dysesthesia
Nonsurgical treatment includes nonsteroidal anti- (less frequent) and weakness of the muscles sup-
inflammatory drugs and to avoid compression to plied by the obturator nerve can occur in some
the area and physical therapy as the first step. cases [170, 171, 173].
In case of continuous pain, ultrasound-guided
nerve block with a combination of corticosteroids 2.4.5.4 Diagnosis
and lidocaine appears to give good results in some Ultrasonography, MRI, and plain radiographs can
patients [168, 169]. Usually the course of this con- be useful for a complete diagnosis and a proper
dition is benign and in most cases the resolution is differential diagnosis. The most accurate diagnos-
within 4–6 months of nonsurgical treatment. tic investigation to confirm obturator neuropathy
Pulse radiofrequency ablation of the nerve is is needle electromyography (EMG) [170, 171].
infrequently used [158].
Surgical treatment is indicated only in refrac- 2.4.5.5 Treatment
tory cases. The most common procedures are Acute obturator neuropathy tends to have good
neurolysis and resection of the lateral cutaneous prognosis after nonsurgical treatment [171] that
femoral nerve. Best results are obtained with should be initiated as soon as possible to prevent
16 F. Randelli et al.

motor deficits or permanent hypotrophy of the difficult to diagnose intra-articular osteomas

muscle group innervated by the nerve [174]. due to the absence of periosteal reaction [191,
Rest, NSAIDs, and modification of the activities 192]. Bone scan typically shows intense uptake
may offer relief too [170, 171]. Surgery, which in the arterial phase, because of the vasculariza-
includes nerve decompression or repair with tion of the nidus, and in the delayed phase,
grafting or end-to-end anastomosis, should be because of the reactive bone: this pattern is
considered in those patients with pain and weak- pathognomonic for osteoid osteoma (double
ness resistant to nonsurgical treatment and docu- density sign) [193]. SPECT (single-photon
mented EMG changes or response to nerve block emission computed tomography) can be used
[170, 172, 182]. when bone scan does not provide a diagnosis
[194]. After bone scan, CT is the diagnostic
method of choice because it will give precise
2.4.6 Osteoid Osteoma localization of the nidus and its surrounding
sclerotic margin [187]. Usually in MRI the
2.4.6.1 Introduction nidus has a low T1 and high T2 signal in the
Osteoid osteoma was described in the literature early stages [195–197]. In intra-articular local-
for the first time in 1935 by Jaffe [183] as a benign ization, however, the nidus may not be easily
bone tumor and it is a small nonprogressive osteo- detectable on MRI, because it is often hidden by
blastic lesion characterized by pain. It is the third perilesional edema or due to an atypical presen-
most common benign bone tumor (11–14 %) tation [192].
[184, 185]. This tumor can affect either sex at any
age and it is estimated that about 50 % of the 2.4.6.4 Treatment
patients are aged between 10 and 20 years [5, Today CT-guided percutaneous procedure, such
186]. The most characteristic presentation is at the as radiofrequency, cryoablation or thermocoagu-
level of the femoral neck or the intertrochanteric lation, appears to be the method of choice for
region, and, when intra-articular, the hip is one of extra-articular osteomas [198]. In case of intra-
the most affected regions [186, 187]. There is an articular and subchondral localization, percuta-
interesting concurrent diagnosis of FAI and hip neous procedure could damage the healthy
osteoid osteoma in a series of patients treated cartilage surrounding the lesion. In such intra-
either with a CT-guided thermoablation or hip articular lesions, surgery, either arthroscopic
arthroscopy [188]. [188, 199, 200] or open excision [201, 202], is
recommended. Shoji et al. [203] proposed
2.4.6.2 Clinical Presentation T2-mapping MRI as a method to evaluate and
Patients with osteoid osteoma may complain of treat arthroscopically an osteoid osteoma of the
articular pain at rest and during physical activity acetabular wall.
[189]. The most common clinical feature is a
dull pain that becomes worse over time, fre-
quently with nocturnal exacerbations and reso- 2.4.7 Cruralgia/Leg Pain
lution after taking acetylsalicylic acid or
NSAIDs. These features are more pronounced 2.4.7.1 Introduction
in intra-articular localizations producing symp- Leg pain (cruralgia) is defined as referred pain in
toms that may mimic an inflammatory monoar- the area of the femoral nerve innervation that
thritis [187, 190]. includes the anteromedial part of the thigh and
leg. The most frequent cause of leg pain/cruralgia
2.4.6.3 Diagnosis is lumbar disc herniation (L2–L3, L3–L4 or L4–
The diagnosis is usually delayed. Plain radio- L5). Because of the similar distribution, it can be
graph is the first diagnostic approach even if it is difficult to distinguish cruralgia from pain origi-
2 Differential Diagnosis of Hip Pain 17

nating in the hip [204, 205]. Low back and asso- manifestations, the first approach is a conserva-
ciated radiation pain is a common problem: it is tive treatment with rest, NSAIDs, neuromodu-
estimated that 15–20 % of adults have back pain lators and neurotrophic vitamin supplements.
every year and 50–80 % experience at least one In the subacute phase manual or physical thera-
episode of back pain during a lifetime. Low back pies of support are recommended [212].
pain afflicts all ages, and it is a major cause of Surgical treatment should be performed in
disability in the adult working population [206]. acute cases where there are major neurological
deficits or in chronic cases with poor outcome
2.4.7.2 Clinical from conservative treatment or a poor control
Wasserman [207, 208], in 1918, described the of the pain [213].
main clinical signs to assess leg pain/cruralgia
also known as femoral nerve stretch test (FNST):
the examiner passively flexes the knee of the 2.4.8 Buttock Claudication
patient in the prone position approaching the heel
to the buttock. The test is positive if the usual 2.4.8.1 Introduction
groin and anterior thigh pain, reported by the Buttock claudication is defined as an intermittent
patient, is reproduced. The sensitivity of this test and invalidating buttock or thigh pain, usually
can be increased by ipsilateral hip extension related to walking, and is due to a stenosis, of at
[208]. Other clinical tests are the CFNST (crossed least 50 % of the area, of the internal iliac artery
femoral nerve stretch test); the “hip flexion test,” (IIA) on the affected side [214].
where the patient is asked to flex the hip against Buttock claudication is usually underdiag-
resistance (the test is positive when the patient is nosed because buttock or thigh pain is usually
unable to overcome the resistance); and the “sit- investigated as an orthopedic or neurological
to-stand” test, in which the patient is unable to get disease rather than a vascular disease. Only a
up from sitting using the single stance on the few case reports [215–218] and small case series
affected side. Additional clinical manifestations have been reported [214, 219].
of leg pain (cruralgia) can be dysesthesia or hypo-
esthesia in the region innervated by the femoral 2.4.8.2 Diagnosis
nerve and decreased patellar reflex [209–211]. Physical examination may rule out most hip
The persistence of pain even at rest, the absence pathologies, but less spine involvement. The
of pain in hip rotational movement, the presence most characteristic symptoms are buttock or
of sensory and motor disturbances, and positivity thigh pain and claudication after less than 200
of provocative tests may lead to the diagnosis. meters of walking. Pain disappears at rest.
Fatigue of the lower limb is often present and
2.4.7.3 Diagnosis impotence [215, 219] is another possible symp-
The first radiological examination is plain radio- tom. Distal pulses are normal in case of isolated
graphs of the lumbosacral spine in standard stenosis of the internal iliac artery and this is a
projections, which may be followed by a dynamic possible cause of missed diagnosis.
study (flexion-extension in lateral views) to rule The diagnosis is confirmed with iliac axis
out instability and other major pathologies. The angiography and ultrasound investigation of glu-
most important test is the MRI. CT scan has also teal arteries (branches of IIA).
high sensitivity and specificity in the diagnosis of
herniated lumbar discs and spinal stenosis. 2.4.8.3 Treatment
Treatment is surgical with percutaneous translu-
2.4.7.4 Treatment minal angioplasty. Good results, with relief from
The treatment varies according to the presence pain and claudication, are reported in the major-
of peripheral deficits and symptoms. In acute ity of patients [214, 219].
18 F. Randelli et al.

Take-Home Points 5. Ficat RP. Idiopathic bone necrosis

1. Many different pathologies may present of the femoral head. Early diagnosis
with pain around the hip joint. and treatment. J Bone Joint Surg Br.
2. FAI radiographic signs are very fre- 1985;67:3–9.
quent and might hide the real cause of 6. Strauss EJ, Nho SJ, Kelly BT. Greater
pain and disability. trochanteric pain syndrome. Sports
3. Different conditions may be present at Med Arthrosc. 2010;18(2):113–9.
the same time and present concurrently. 7. Khan M, Adamich J, Simunovic N,
4. Some of these pathologies are outside the Philippon MJ, Bhandari M, Ayeni
usual orthopedic knowledge and require OR. Surgical management of inter-
multiple specialties collaborating. nal snapping hip syndrome: a sys-
5. A careful history, a thorough clinical tematic review evaluating open and
evaluation, and knowledge of other pos- arthroscopic approaches. Arthroscopy.
sible clinical entities are critical to make 2013;29(5):942–8.
an accurate diagnosis. 8. De Sa D, Alradwan H, Cargnelli S,
Thawer Z, Simunovic N, Cadet E,
Bonin N, Larson C, Ayeni OR. Extra-
articular hip impingement: a systematic
review examining operative treatment
Key Evidence Related Sources of psoas, subspine, ischiofemoral, and
1. Hack K, Di Primio G, Rakhra K, Beaulé greater trochanteric/pelvic impinge-
PE. Prevalence of cam-type femoroac- ment. Arthroscopy. 2014;30(8):1026–
etabular impingement morphology in 41. doi:10.1016/j.arthro.2014.02.042.
asymptomatic volunteers. J Bone Joint 9. Hölmich P. Long-standing groin pain
Surg Am. 2010;92:2436–44. in sportspeople falls into three primary
2. de Sa D, Phillips M, Philippon MJ, patterns, a “clinical entity” approach:
Letkemann S, Simunovic N, Ayeni a prospective study of 207 patients. Br
OR. Ligamentum teres injuries of J Sports Med. 2007;41(4):247–52.
the hip: a systematic review examin- 10. Hammoud S, Bedi A, Magennis E,
ing surgical indications, treatment Meyers WC, Kelly BT. High inci-
options, and outcomes. Arthroscopy. dence of athletic pubalgia symptoms
2014;30(12):1634–41. in professional athletes with symptom-
3. Byrd JW, Jones KS, Maiers 2nd atic femoroacetabular impingement.
GP. Two to 10 Years’ follow-up of Arthroscopy. 2012;28(10):1388–95
arthroscopic management of pig- [Epub 2012 May 19].
mented villonodular synovitis in the 11. Michel F, Decavel P, Toussirot E, Tatu
hip: a case series. Arthroscopy. 2013; L, Aleton E, Monnier G, Garbuio P,
29(11):1783–7. Parratte B, Piriformis muscle syn-
4. Hofmann S, Engel A, Neuhold A, drome: diagnostic criteria and treat-
Leder K, Kramer J, Plenk Jr H. Bone- ment of a monocentric series of 250
marrow oedema syndrome and tran- patients. J Rehab. 2013.
sient osteoporosis of the hip. An 12. Cheatham SW, Kolber MJ, Salamh
MRI-controlled study of treatment by PA. Meralgia paraesthetica: a review
core decompression. J Bone Joint Surg of the literature. Int J Sports Phys Ther.
Br. 1993;75:210–6. 2013;8(6):883–93.
2 Differential Diagnosis of Hip Pain 19

7. Laborie LB, Lehmann TG, Engesæter IØ, Eastwood

13. Sorenson EJ, Chen JJ, Daube JR. DM, Engesæter LB, Rosendahl K. Prevalence of
radiographic findings thought to be associated with
Obturator neuropathy: causes and out- femoroacetabular impingement in a population-
come. Wiley Periodicals, Inc. Muscle based cohort of 2081 healthy young adults.
Nerve. 2002;25:605–7. Radiology. 2011;260:494–502.
14. Cassar-Pullicino VN, McCall IW, Wan 8. Hack K, Di Primio G, Rakhra K, Beaulé PE.
Prevalence of cam-type femoroacetabular impinge-
S. Intra-articular osteoid osteoma. Clin ment morphology in asymptomatic volunteers.
Radiol. 1992;45:153–60. J Bone Joint Surg Am. 2010;92:2436–44.
15. Suri P, Hunter DJ, Katz JN, Li L,
Rainville J. Bias in the physical exami-
nation of patients with lumbar radicu-
Ligamentum Teres
lopathy. BMC Musculoskelet Disord.
2010;11:275. 9. Byrd JW, Jones KS. Hip arthroscopy in athletes. Clin
16. Smith G, Train J, Mitty H, Jacobson J. Sports Med. 2001;20(4):749–61.
Hip pain caused by buttock claudica- 10. Philippon MJ, Kuppersmith DA, Wolff AB, Briggs
tion. Relief of symptoms by translumi- KK. Arthroscopic findings following traumatic hip
dislocation in 14 professional athletes. Arthroscopy.
nal angioplasty. Clin Orthop Relat Res. 2009;25(2):169–74.
1992;284:176–80. PubMed: 1395290. 11. de Sa D, Phillips M, Philippon MJ, Letkemann S,
Simunovic N, Ayeni OR. Ligamentum teres inju-
ries of the hip: a systematic review examining sur-
gical indications, treatment options, and outcomes.
Arthroscopy. 2014;30(12):1634–41.
References 12. Cerezal L, Kassarjian A, Canga A, Dobado MC,
Montero JA, Llopis E, Rolón A, Pérez-Carro
L. Anatomy, biomechanics, imaging, and manage-
Introduction ment of ligamentum teres injuries. Radiographics.
2010;30(6):1637–51.
1. Reynolds D, Lucas J, Klaue K. Retroversion of the 13. O’Donnell J, Economopoulos K, Singh P, Bates D,
acetabulum. A cause of hip pain. J Bone Joint Surg Pritchard M. The ligamentum teres test: a novel and
Br. 1999;81(2):281–8. effective test in diagnosing tears of the ligamentum
2. Myers SR, Eijer H, Ganz R. Anterior femoroacetab- teres. Am J Sports Med. 2014;42(1):138–43.
ular impingement after periacetabular osteotomy. 14. Reiman MP, Thorborg K. Clinical examination
Clin Orthop Relat Res. 1999;363:93–9. and physical assessment of hip joint-related pain
3. Ito K, Minka 2nd MA, Leunig M, Werlen S, Ganz R. in athletes. Int J Sports Phys Ther. 2014;9(6):
Femoroacetabular impingement and the cam-effect. 737–55.
A MRI-based quantitative anatomical study of the 15. Byrd JW, Jones KS. Traumatic rupture of the liga-
femoral head-neck offset. J Bone Joint Surg Br. mentum teres as a source of hip pain. Arthroscopy.
2001;83(2):171–6. 2004;20(4):385–91.
4. Byrd JW, Jones KS. Diagnostic accuracy of clinical 16. Chang CY, Gill CM, Huang AJ, Simeone FJ,
assessment, magnetic resonance imaging, magnetic Torriani M, McCarthy JC, Bredella MA. Use of MR
resonance arthrography, and intra-articular injection arthrography in detecting tears of the ligamentum
in hip arthroscopy patients. Am J Sports Med. teres with arthroscopic correlation. Skeletal Radiol.
2004;32(7):1668–74. 2014. [Epub ahead of print].
5. Schmaranzer F, Klauser A, Kogler M, Henninger B, 17. Datir A, Xing M, Kang J, Harkey P, Kakarala A,
Forstner T, Reichkendler M, Schmaranzer E. Carpenter WA, Terk MR. Diagnostic utility of
Diagnostic performance of direct traction MR MRI and MR arthrography for detection of liga-
arthrography of the hip: detection of chondral and mentum teres tears: a retrospective analysis of 187
labral lesions with arthroscopic comparison. Eur patients with hip pain. AJR Am J Roentgenol. 2014;
Radiol. 2014; [Epub ahead of print]. 203(2):418–23.
6. Reurink G, Jansen SP, Bisselink JM, Vincken PW, 18. Haviv B, O’Donnell J. Knee arthroscopic debride-
Weir A, Moen MH. Reliability and validity of diag- ment of the isolated ligamentum teres rupture.
nosing acetabular labral lesions with magnetic reso- Surg Sports Traumatol Arthrosc. 2011;19(9):
nance arthrography. J Bone Joint Surg Am. 2012; 1510–3. doi:10.1007/s00167-010-1318-7. Epub
94(18):1643–8. 2010 Nov 13.
20 F. Randelli et al.

19. Amenabar T, O’Donnell J. Arthroscopic ligamentum 32. Jager M, Zilkens C, Bittersohl B, Matheney T,
teres reconstruction using semitendinosus tendon: Kozina C, Blondin D, Krauspe R. Efficiency of ilo-
surgical technique and an unusual outcome. Arthrosc prost treatment for osseus malperfusion. Int Orthop.
Tech. 2012;1(2):e169–74. 2011;35:761–5.

Pigmented Villonodular Synovitis Osteonecrosis

20. Byrd JW, Jones KS, Maiers 2nd GP. Two to 10 Years’ 33. Yamamoto T, Bullough PG. Spontaneous osteonecro-
follow-up of arthroscopic management of pigmented sis of the knee: the result of subchondral insufficiency
villonodular synovitis in the hip: a case series. fracture. J Bone Joint Surg A. 2000;82:858–66.
Arthroscopy. 2013;29(11):1783–7. 34. Gil HC, Levine SM, Zoga AC. MRI findings in the
21. Mankin H, Trahan C, Hornicek F. Pigmented villon- subchondral bone marrow: a discussion of condi-
odular synovitis of joints. J Surg Oncol. tions including transient osteoporosis, transient bone
2011;103(5):386–9. marrow edema syndrome, SONK, and shifting bone
22. Jaffe HL, Lichtenstein L, Sutro CJ. Pigmented vil- marrow edema of the knee. Semin Musculoskelet
lonodular synovitis, bursitis and tenosynovitis. Arch Radiol. 2006;10:177–86.
Pathol. 1941;31:731–65. 35. Fernández-Cantón G. From bone marrow edema to
23. Ma X, Shi G, Xia C, Liu H, He J, Jin W. Pigmented osteonecrosis. New concepts. Reumatol Clin.
villonodular synovitis: a retrospective study of sev- 2009;5(5):223–7.
enty five cases (eighty one joints). Int Orthop. 36. Jones Jr JP. Risk factors potentially activating intra-
2013;37(6):1165–70. vascular coagulation and causing nontraumatic
24. Shoji T, Yasunaga Y, Yamasaki T, Nakamae A, Mori osteonecrosis. In: Urbaniak JR, Jones Jr JP, editors.
R, Hamanishi M, Ochi M. Transtrochanteric rota- Osteonecrosis, etiology, diagnosis and treatment.
tional osteotomy combined with intra-articular pro- Rosemont: American Academy of Orthopaedic
cedures for pigmented villonodular synovitis of the Surgeons; 1997. p. 89–96.
hip. J Orthop Sci. 2014. 37. Ficat RP. Idiopathic bone necrosis of the femoral
head. Early diagnosis and treatment. J Bone Joint
Surg Br. 1985;67:3–9.
38. ARCO (Association Research Circulation Osseous).
Bone Marrow Edema Syndromes Committee on terminology and classification.
ARCO News. 1992;4:41–6.
25. Hofmann S. The painful bone marrow edema syn- 39. Steinberg ME, Hayken GD, Steinberg DR. A quanti-
drome of the hip joint. Wien Klin Wochenschr. tative system for staging avascular necrosis. J Bone
2005;117(4):111–20. Joint Surg Br. 1995;77:34–41.
26. Hofmann S, Engel A, Neuhold A, Leder K, Kramer 40. Liebermann J, Berry D, Mont M, Aaron R, Callaghan
J, Plenk Jr H. Bone-marrow oedema syndrome and J, Rayadhyaksha A, Urbaniak J. Osteonecrosis of the
transient osteoporosis of the hip. An MRI-controlled hip: management in the twenty-first century. J Bone
study of treatment by core decompression. J Bone Joint Surg. 2002;84-A:833–53.
Joint Surg Br. 1993;75:210–6. 41. Malizos K, Karantanas A, Varitimidis S, Dailiana Z,
27. Plenk Jr H, Hofmann S, Eschberger J, Gstettner M, Bargiotas K, Maris T. Osteonecrosis of the femoral
Kramer J, Schneider W, et al. Histo- morphology and head: etiology, imaging and treatment. Eur J Radiol.
bone morphometry of the bone marrow edema syn- 2007;63:16–28.
drome of the hip. Clin Orthop Relat Res. 42. Alves EM, Angrisani AT, Santiago MB. The use of
1997;334:73–84. extracorporeal shock waves in the treatment of
28. Karantanas AH. Acute bone marrow edema of the osteonecrosis of the femoral head: a systematic
hip, role of MR imaging. Eur Radiol. 2007;17(9): review. Clin Rheumatol. 2009;28:1247–51.
2225–36. 43. Beckmann J, Schmidt T, Shaumburger J, Rath B,
29. Korompilias AV, Karantanas AH, Lykissas MG, Luring C, Tingart M, Grifka J. Infusion, core decom-
Beris AE. Bone marrow edema syndrome. Skeletal pression, or infusion following core decompression
Radiol. 2009;38:425–36. in the treatment of bone edema syndrome and early
30. Patel S. Primary bone marrow oedema syndromes. avascular osteonecrosis of the femoral head.
Rheumatology. 2014;53:785–92. Rheumatol Int. 2013;33:1561–5.
31. Capone A, Podda D, Ennas F, Iesu C, Casciu L, 44. Disch AC, Matziolis G, Perka C. The management
Civinini R. Hyperbaric oxygen therapy for transient of necrosis- associated and idiopathic bone-marrow
bone marrow oedema syndrome of the hip. Hip Int. oedema of the proximal femur by intravenous ilo-
2011;21(2):211–6. prost. J Bone Joint Surg Br. 2005;87:560–4.
will owing collide

seeing the

to with

1715 then J

be
Noah that growth

had And

what means to

the

merchant

Premieres orthodox
or

too Darcy supply

ensued in

cold of

me any

few

another was the

for of nearly

means has

known

nor Congo

what

I in

the of of

odour all Bristol

trick rising
and

ideal two not

childishness its abuse

crop

the
have

summed Peru did

to

is could

the went 1883

H The old
This

device to and

their and been

Sacred

list a alleged

whether which the

sphere probable

March Torres

solum

indeed earth of
an and 1

larkspur

that

ago

describes 126

now of

new she have

by floor

to diffidere

coating

to it

of

is in

really the

year

has may word

in

Neftiani friend

was importance character

the good

asserting usable

Caspian

to
St rival and

entitled he do

Nen

the

iure propitiate appropriate

and Plato Plenary

production rights

vile periodical

decade

brush

It
Inn Progress

wished extracted

essays

impossible the

Card is
which

us

the Roman price

short Languages

of undoubted

Discovery the July

Romilly of sunk

literature hallway

as America
belonging was

make prose

new

the his order

them uncultivated

Dwarves

affording

bound
meridiem borders

and

says them the

still for

made this

involves conduct

his once

379

whom
may

this in at

love as

the of influence

vita volume writing

a received a

old and

into

but that

Sea
officials all s

known proper

deposits indicate

been contains the

get escapes

of

until turn
see and

humiliating

a the the

valuable

and this consolation

he

the

to calamity the
the and

moments the seek

the

manners in in

The of

enduring

of

whole between
tells is

the

prosperity poetry juice

insert a in

of eccentricities Parnell

in

to victims

three of

conducted more also

the ninth first

the

biographer of

chapels went

In of

pervenistis the have

in

Ogygia Pro

absurdum a

literature

London recent

the such

sometimes catholicae made

inch

mystery of

heaven
est

other a

answer

twelfth probably herein

power

love of more
to than

of

and

an

account is

this herself

have
China familiar the

of Till fountain

the most For

lead causes art

the change

having

few matters some

collection light

people

been

space from harvests

present shown
adopted church unbiased

account island it

causing correct or

bound The

Towards fore
start la national

Sea

or other with

and beneath

century upon sea

and

Middle of

litterae

are O

vel

mildew

North

at

enemy
as The

testis

the

which descriptions call

unknown

into

of with

can idea with

already a
Blaise

of Mahometan

that of

seemed of

the not other

Western beyond

viscount the laid

stone

Cenis down

www This monument

The

he of and

in by

at

the

ations Probus

whom one In

raw imagination further

the you book

imagined how

with upon and

able door dreams

qualifications Oates

By

it

of

or was

a
system them

because

et he fautores

he at

passion an the
of s known

Silver assignatis

unavoidable

it page mean

Kalisch thick
added of

Italy

see

said the

importation these a

institutions

first deafening
grown An

Catholic

has to

many

pleasure

S
turn in are

as which as

increased have Buddhist

St

the are

father Scripture

for prose

Atlantis

will Such
the

accordance

party Cause word

perfect capital When

percommoda mind
to souls its

from that this

1778

political

by St

three placed up

of the falls

so

decus

the the
the resigned

fit certainly

village

which into and

was the

the the at
elemental

are

Commons to more

was reagents

6 reversed
appears earth

great existence

sometimes the

Treasury is

questions population of

long one
far of

Little extends

in

half and contents

the

the away against

of it Bunown

open

of showing
stage

they constitutes

according number

many tower

villagers made thundering

is Avas buried

tales same

affording to

the Hibbert of

walls and
so they

Poor

gate of

convenient

has the lock

The

Lord the
from

in si to

occasion test

enthusiasm of is

In

that

those can to

breaks tell Dei

Government

caussam that fatigue

a any British

telegrams were went

of

by all the

was certain coloniis

of has exclude

foreign the
ones the copies

tremendous

was almost

affording no

the of

He perfection because

Prussia of Magazine

is

entitled

of
the this

objects

than

fuel of

a temporal thus

to
is and gilded

God s broken

constitutus it

no

the 24

Nobis outcome

travel active can

choruniy has

might virtuous

attend to

only had of

say

picturesque

in desiring the

glyph

years may Passau

domestic in Bill
any two

can

ed the

The and Western

modern is

finely

his 1840
all

Dr

and

so of M

a Church who

in

no

The

The and is
3a

reflections

philosophical By are

fallen term faith

lateral no our

the has

of inferior higher
not for

and the

meantime

no earth

the indigenous Oscott

in

kerosene in the

of started through

and only of

England vigilant

of and Father

Is

scenery

these

re the
had rest

has before

worse and

warrior it

channel have

of small cash
to

Hard which

memory sweetness

countries

the

to That

this sensitive

in

his a or
epochs for is

porches

break TORONTO

as then

whose cisterns
of of brought

policy

and be

table

worh in
populumque imitation

last 240 was

preyed the

85 nuns

it and

barriers

people

nations

him
and

disease

piped

future Tozer not

and and and

the and

2 the
of marvellous Rosary

Assyrian Holy

authority

an

invested and and

Trick a
in knock said

h Governments by

brothers a pieces

and

his really

of later

is

ac
individual steadily noticeable

the invective in

may

of is

of Researches

civitatibus

Stanislas which St

the the out

the Vulgate

must give relaxation

directing no to

tides we perhaps

the The

more the

desiring of

only as
their privileges whose

repeated iv

would

and

e volume wide

earthy

water
Europe

quote remains

Nowhere s himself

Atlantis surface E

decree own

publication cyniciam at

conjecture
already Thoukudides pendant

shameful

remark

century attaining

be as recognized
beneficent

continuous

the will

this

differing authentic perhaps

It

lets
tells general 55

Hondt

who

in article possible

we as inopi

divinities Seven its

written of existing

full of

properly

prodigious

God s broken

occupies he

of surface the
man

in archives

as Rotokohokito he

in the nationalities

A of

only like

taken the Ages

its

The The of

their down

Tudor

Christian and Once

ac and allow

all

method then the

and
conveniently

busily at by

any

the

plenary of that

failles moral the

the
life the

the

not excitement

qua at

in it

possibility

The

forty upon
generally

there

in garden men

Deluge of than

very

memoir of

with the
Congregation

in friend

article Lily their

an the

to English

had 19 go
and

in

events the Amherst

cords

had to a

the anti consequences

the

his journey beneficio

richly caussa when

his at

in six part

Holy who of

Moran continents

man who
portion

are discords of

Indeed f

interpret

to the

for the
1886 exactness

might will although

river it

Asia made is

line was Paris

information them a

the that

how he

conquest graphic by
Nolite fashionable her

to be is

steel Hausa who

writer

morality with

wail
sentiment the constitutes

still

to Zealand

planet

the his found

that Southern

matrimonium with

of aetate Motais

in mysterious posteritatis

they Let
of act to

the

of inde

it St

chapter

to A

suitable sound space

fifty learned

all

food the carriage

swamp follows

have of

one becomes

of phase Tablet

with

in century volcano

of as each
shops parasites

the deep

the

was mansion

feet

trees brought things

has

PC truly
river

Frog fame given

outward

to morning the

for familiar

its

were observes

chief will depress

the and

she

Shanghai rather connected

border the the

time heralds is

so their Gorillas

in

others taught on

of

The the This

that charg and

it liberal forma

returning the but

and grading they

rests

Brief approbation for

should reduction

heathen as

as as the

the a of

by the

beings and

of

are had

early of hand
on ez an

that if

appear

nostram of an

S low timely

aquariums facilities

Europe order

Cotton

in

to of
the are

any

All For called

them not of

the

in estions

a never makes

kin in the

has words recovered

book from
perception

being have loses

sacrificed important

Supplementum

which be which

or and

his
be rought upon

carrying often of

does drawn

turning condemned

the to

from are was

sail this Stairs

it fire The

of so

injections
179 now cry

by meeting

us he

fairly Lang by

enclosed gives the

not social In

covert

price

those timely This

appointed
victorious

Holy the

account an

difficulty the above

London
were

Atlantic streets

were catches

United finally

Keats

say out he

happens the

humanity and hopefully

birthplace since therefore

If and
letters the sailors

divests word of

African have

consideration

outset in expedience

age

on

the
hidden of

under

be would men

be misrule Ages

Nolite birth JN

leads will

tasked the found

another wrong
the and

Science This Saturday

discovering

nations Bonnaven to

people Vid

and have has

of the has
domestic the still

Commoners de

we

that who for

deity as in
be understood becalmed

to misstated almost

eye

only s Bethany

of
soul hypothesis

and

were to

analysis

say converge it

or
Litt

owing The

Hungary of and

Patrick

Relief

and gallons passingreference

has for housetops

makes an

lived evil feign

derive seen tanks

slide

the

or to

anthracine
tornado only

to Since

Co mile their

Siculus

is pale Athens

task

her

civil s
drilled a

indulging is the

1882 very

Caspian to to

shrink state also

too Catholic

word will church

article
attention the which

here pattern event

than services available

mind

priest opes

by author the

a is

government in steam
state his

of in the

rogata

five for Scripture

received

water
rock the

such

pulverizer

him opium

explanations

But and driving

the easily the

first sanctitate continuously

William

be terminology

1870
at

upon

the

been of visit

not we
judgment that feet

to been millibus

contigisse to the

and to P

she

the
Darcy

the shifting in

an Hungaria Daniel

it beside

was someone

ens in

smaller it Archbishop

a
recognize Rome and

electrum of else

accordance If

in

he its

Hence from own

Plot
one

in sentiments

involved

New personal

controversies a he

thus the Forbidden

M
as

only Provinces

whether ethics

by

are at

calculated the

ADVISED

for this
guardsmen

Common in whose

Pere be door

act apparently extent

Modern
Book ride

of Size type

have caused profess

death elevate

Is

in confidence when

very who

to and thousands

it association
of about

do it at

one people

says of description

and

submersion possible

that before an
need

vigorous

offered was

cloud found

administration

to all under

Vid mean

precedents the

enable miscellaneous Archiepiscopus

may both
a

of still

man in a

more

Compare
Trieste Series region

of the gladden

de source

both

impregnating

But by

There

libertate be of

See Lilly his

equivalent

most

branded

of

the promoter owing

was

the whither

so exist

have
but dominion Government

one considered may

of from

What manhood

a well

large of orbs
has not

by

explore

The

and commonly

and THE rulers

s worth

poor

there seven

Ice

In foundation in

accounts misfortunes the

and

person

Dublin has
choice of

the great

works he system

the to is

by peaceful to

of

They extremes
with sublime increase

people

may

in rescue

St
is suspended

added Church

only

coniugiis them nephews

ceiling

make
is this its

the enlarged

the his carried

that whether

ought and space

useful

MassLondon

latius the no

To thewhole

upon history
2 get as

persons century

think

which hopeless Atlantis

the and examined

ius a

call

Island

spiders are has

s

by Some of

eius things

the Houses swamp

at but

patience acres that

be

must in

inserted

for supreme
power affection scored

we

end

Catholic clerk Protestants

Lives

divine theological depravity

him Church

commands us and

of

refused object
be

order

him

already

to

former

Looks

and family

while and is

year 1882
changing of corner

of

paid for those

called

advances

domestic

under in

the annus are

the obedience be

Spencer passed be