What is this? What is this? Name of the lecture today Hip Pointer • A hip pointer injury is a deep bruise caused by impact or trauma to your hip, or to the iliac crest of your pelvis. • pain can be intense. Hip Pointer • Because the hip is so close to the surface of the body, there isn’t much padding in an impact situation – • deep bruising in both the bone and surrounding muscle. • Hip bruises, and other bone bruises, are more severe than regular muscle bruises • often take a long time to recover. Epidemiology Frequency • United States • No specific statistics for the frequency of hip pointer injuries are available; however, hip injuries generally comprise 5-9% of high school athletic injuries. Cause • The primary cause of hip pointers is a direct blow or fall onto the iliac crest or greater trochanter. • Risk factors include participation in contact sports and wearing limited or no padding or protective equipment in the region. Mild to severe hip pointers are extremely common in all sports that involve full contact with others and/or their equipment or the potential for collisions, such as: • • • • • • martial arts baseball football rugby ice hockey field hockey Functional Anatomy • The anterior iliac crest region of the hip and the greater trochanter of the femur have a minimal amount of overlying fatty tissue or muscle and are more susceptible to contusion and injury than more protected regions of the body. Functional Anatomy • The iliac crest has multiple muscle origins and insertions, including the sartorius, the tensor fascia lata, the internal and external obliques, and a portion of the rectus femoris muscle. Differentials • • • • • • • • • • • • compartment syndrome AVN of femoral neck Femoral Neck Fracture Femoral Neck Stress Fracture Hip Dislocation Hip Fracture Hip Tendonitis and Bursitis Iliotibial Band Syndrome Osteitis Pubis Sacroiliac Joint Injury Slipped Capital Femoral Epiphysis Snapping Hip Syndrome Femoroacetabular impingement History • Obtain a detailed history, including the mechanism of injury and the patient's description of his or her symptoms. • A hip pointer is usually an acute injury, and the patient can typically recall a precipitating event, although some may present 24-48 hours after the initial injury. • Hip pointer injuries are usually caused by a direct blow to the iliac crest or greater trochanter in contact sports such as football or hockey. • A hip pointer may also be caused by a fall onto the hip in sports such as soccer or skiing. • Typically, the patient presents with the sudden onset of hip pain in the iliac crest or greater trochanteric region after sustaining trauma. • The pain is localized and may be exacerbated with activities such as running, jumping, twisting, or bending. • The pain can limit range of motion (ROM) at the hip joint and/or rotation of the trunk if the abdominal musculature is in Physical exam • Physical examination in a person with a suspected hip pointer should include abdominal examination to exclude trauma to intra-abdominal organs. • Examination should consist of visual inspection, palpation, passive and active ROM assessment, sensory testing, and gait analysis. • Contusion or swelling may be evident upon visual inspection. The athlete usually reports increased pain with palpation of the affected iliac crest or greater trochanter. Limited ROM of the hip secondary to pain may also occur. Physical Exam • Motor strength of the hip flexor and extensors should be intact. • Strength of the hip abductors and external rotators may be limited by pain if the contusion includes the sartorius muscle and/or the iliotibial tract. • Sensation should be intact to light touch, although this portion of the examination may be limited if the patient has severe pain. • Initial gait analysis may also be limited secondary to pain, but it provides a baseline from which to evaluate recovery. Laboratory Studies • Typically, laboratory studies are not useful in the diagnosis of hip pointers. Imaging Studies • Plain radiographs: Order radiographs if fracture or myositis ossificans is considered possible. • Computed tomography (CT) scans: Consider obtaining CT scans if the patient has continued pain or if his or her pain exceeds that expected from examination findings. CT scans can help clinicians to diagnose deep hematoma or internal injuries (eg, spleen). • Bone scans: Order a bone scan to exclude a stress response or fracture if initial radiographic findings are normal and the symptoms do not resolve or improve. Consultations • Emergent consultation with an orthopedic surgeon is necessary if neurovascular compromise is considered possible in a patient with a hip pointer. • Consider consultation with an orthopedic surgeon for patients who have avulsion fractures or unresolved pain lasting longer than 2 weeks. • Consult with a surgeon for patients with intraabdominal injuries. Medical Issues/Complications • The formation of a hematoma, with increasing pain and possible cutaneous neurologic compromise, may be an early complication of a hip point, usually arising within the first 24 hours. • Additional complications can include development of myositis ossificans. • Failure to diagnose a fracture or an intra-abdominal injury frequently leads to complications. Hip Pointer • If the injury is mild: • The athlete has a good range of motion in the hip and abdominals. • Swelling is limited. • The athlete shows a normal gait. • Recovery time is one week Hip Pointer • If the injury is moderate: • The athlete has an abnormal gait. • The athlete has a decreased range of motion in the hip and abdominals. • The athlete has noticeable bruising and swelling. • • Recovery can take up to two weeks Hip Pointer • If the injury is severe: • The athlete has great pain when walking and during hip and trunk movements. • The athlete has a lot of bruising and swelling. • • Recovery can take three to four weeks Procedures • If a significant hematoma is present, then aspiration can provide some pain relief and help prevent development of myositis ossificans or pressure and compression of local nerves (eg, lateral femoral cutaneous nerve). • Injection of a local anesthetic (eg, lidocaine) may provide short-term pain relief from a hip pointer. • Compartment pressures can be measured if a thigh or gluteal compartment syndrome is considered possible. Rehabilitation Program • Initial therapy of a hip pointer injury consists of ice, antiinflammatory and pain medication, compression, and relative rest of the affected hip until symptoms improve. • Crutches can be used in the initial treatment phase if walking or bearing weight on the affected leg is painful. • As the pain decreases, ROM and active resistance exercises for the hip may be initiated. Patients may also begin strength and aerobic conditioning, as tolerated. Other Treatment • Aspiration of a hematoma, if present, may provide some pain relief. Injection of a local anesthetic (eg, lidocaine, bupivacaine) may provide short-term pain control. • No evidence supports or refutes the use of corticosteroid injections in hip pointer injuries. • Corticosteroid injections may provide relief if greater trochanteric bursitis develops. Rehabilitation Program Physical Therapy • Rehabilitation programs should focus on returning the athlete back to his or her sport. Rehabilitation exercises should emphasize sport-specific strength and motions. • Additional padding at the injury site may help limit recurrence or reinjury (padding that is 0.25-0.5-inch thick may alleviate pain and allow the athlete to return to play sooner). Rehabilitation Program Physical Therapy • The maintenance phase of the rehabilitation program should focus upon reducing the chance of re-injury. • Additional padding or protection added to the hip may limit the risk of re-injury. Medication Summary • The goals of pharmacotherapy in patients with hip point injuries are to reduce morbidity and to prevent complications. • When the athlete returns to participation, extreme care should be taken to protect the injured hip with proper padding (below). • A good way to prevent a hip pointer is to make sure hip pads are large enough to come up over the crest of the hip bone. • Football hip pads can be used by athletes for most sports to protect and prevent hip injuries. Hint? Proper wearing of equipment Treating hip pointers • Hip pointers can be very painful and debilitating. • Ice and crutches are the recommended immediate treatment. • Electrical stimulation to relieve pain can also be used with the ice. Ice is continued for 20 minutes, every hour, until the pain resolves. • The athlete can gradually return to jogging and sport-specific drills as the pain allows.