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Brukner & Khan's Clinical Sports Medicine

Brukner & Khan's Clinical Sports Medicine



Brukner and Khan's Clinical Sports Medicine is the bible of sports medicine. The text explores all aspects of diagnosis and management of sports-related injuries and physical activity. Buy NOW and ...

Brukner and Khan's Clinical Sports Medicine is the bible of sports medicine. The text explores all aspects of diagnosis and management of sports-related injuries and physical activity. Buy NOW and receive 12 months FREE access to the Clinical Sports Medicine website featuring over 4 hours of video clips on assessment, treatment and rehabilitation, plus interviews with leading experts.



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    Brukner & Khan's Clinical Sports Medicine Brukner & Khan's Clinical Sports Medicine Document Transcript

    • sa m pl e pa ge s on ly
    • Brukner & Khan’s Clinical SportsMedicineFOURTH E DI TION ly on s ge pa e pl m sa
    • We dedicate this fourth edition to the Clinical Sports Medicine community—to each clinician, educator, and policy maker committed to improving health through the power of physical activity. ly on s ge pa e pl m sa
    • Brukner & Khan’s Clinical SportsMedicineFOURTH E DITION Brukner Bahr Blair Cook ly Crossley on McConnell McCrory s noakes ge khan pa e pl m sa
    • NoticeMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment anddrug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in theirefforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.However, in view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor anyother party who has been involved in the preparation or publication of this work warrants that the information contained hereinis in every respect accurate or complete. Readers are encouraged to confirm the information contained herein with other sources.For example, and in particular, readers are advised to check the product information sheet included in the package of each drugthey plan to administer to be certain that the information contained in this book is accurate and that changes have not beenmade in the recommended dose or in the contraindications for administration. This recommendation is of particular importancein connection with new or infrequently used drugs.First published 1993Second edition 2001Revised second edition 2002Third edition 2006Revised third edition 2009Text © 2012 McGraw-Hill Australia Pty LtdAdditional owners of copyright are acknowledged in on-page credits.Every effort has been made to trace and acknowledge copyrighted material. The authors and publishers tender their apologiesshould any infringement have occurred.Reproduction and communication for educational purposesThe Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is thegreater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that theinstitution (or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and beengranted a licence. For details of statutory educational and other copyright licences contact: Copyright Agency Limited, Level 15,233 Castlereagh Street, Sydney NSW 2000. Telephone: (02) 9394 7600. Website: www.copyright.com.auReproduction and communication for other purposesApart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of thispublication may be reproduced, distributed or transmitted in any form or by any means, or stored in a database or retrieval system,without the written permission of McGraw-Hill Australia including, but not limited to, any network or other electronic storage.Enquiries should be made to the publisher via www.mcgraw-hill.com.au or marked for the attention of the permissions editor atthe address below. lyNational Library of Australia Cataloguing-in-Publication DataAuthor: Brukner, Peter.Title: Brukner & Khan’s Clinical Sports Medicine / Peter Brukner, on Karim Khan.Edition: 4th ed.ISBN: 9780070998131 (hbk.)Notes: Includes index. Previous ed.: Clinical Sports Medicine, 2007. sSubjects: Sports medicine. ge Sports injuries.Other Authors/Contributors: Khan, Karim.Dewey Number: 617.1027 paPublished in Australia byMcGraw-Hill Australia Pty LtdLevel 2, 82 Waterloo Road, North Ryde NSW 2113Publisher: Fiona Richardson eSenior production editor: Yani SilvanaProduction editor: Jess Ní Chuinn plPublishing and digital manager: Carolyn CrowtherEditorial coordinator: Fiona Collison mCopy editor: Jill PopeIllustrator: Vicky Earle (anatomical figures)Proofreader: Mary-Jo O’Rourke saIndexer: Russell BrooksCover design: Georgette HallInternal design: David RosenmeyerTypeset in 9/11.5 pt Scala by Midland Typesetters, AustraliaPrinted in China on 80gsm matt art by iBook Printing Ltd
    • Foreword to the first edition (1993)Sport in Australia is ingrained in the national consciousness more widely, deeply, and indelibly than almostanywhere else in the world. When a prominent sportsperson sustains a sporting injury, either traumaticallyor from overuse, becomes excessively fatigued, or fails to live up to expectations, this assumes national impor-tance. It is even more relevant nowadays with greater individual participation in sporting activities. The sametype of problems occur for recreational athletes, middle-aged people wanting to become fit, or older peoplewishing to sustain a higher level of activity in their later years. In Clinical Sports Medicine the authors take sport and exercise medicine out of the realm of the elite athleteand place it fairly and squarely where it belongs—as a subspecialty to serve everyone in the community whowishes to be active. The book is organized in a manner that is sensible and usable. The chapters are arranged according tothe anatomical region of the symptom rather than diagnostic categories. This results in a very usable text forthe sports physician, general/family practitioner, physiotherapist, masseur, or athletic trainer whose practicecontains many active individuals. Practical aspects of sports medicine are well covered—care of the sporting team and concerns that aclinician might have when traveling with a team. In all, this is an eminently usable text which is timely in itsproduction and will find an important place among clinicians involved in the care of active individuals.John R Sutton MD, FRACPProfessor of Medicine, Exercise Physiology and Sports MedicineFaculty of Health SciencesUniversity of SydneyPast President, American College of Sports Medicine lyThis foreword was written by the late Professor John Sutton before his untimely death in 1996; it is retained in this ontextbook out of profound respect for this champion of the integration of science, physical activity promotion, and multi-disciplinary patient care. s ge pa e pl m sa v
    • Foreword to the fourth editionHumans were not designed to sit at desks all day and in front of televisions all evening, and this physicalinactivity is related to a host of health-related issues. Increasing physical activity is one very powerful way tomitigate many of the health issues we face today, and programs such as the Healthy People 2020 initiative andthe Exercise is Medicine campaign encourage individuals to remain active throughout their lifetime. As people become more involved in sport and exercise, sports medicine becomes increasingly important,and Clinical Sports Medicine has understandably become what we in the US refer to as the “PDR” (Physicians’Desk Reference) of sports medicine. For my UK colleagues the translation is “BNF” (British National Formu-lary). This text is extremely comprehensive, covering fundamental principles of biomechanics, diagnosis andtreatment, regional musculoskeletal injuries, and medical problems. The text also addresses those practicalissues of sports medicine that are often missing from other texts, such as dealing with athletic teams, coveringendurance events, and working with the elite athlete. The organization of the text makes it remarkably easy to use, including such features as color-coded booksections, flow diagrams to reinforce concepts, and tables that clearly organize information. Vicky Earle’sanatomical drawings are truly among the best in the business. All these features put an astounding wealthof information at the reader’s fingertips. This information has been assembled by a group of over 100 expe-rienced and world-class physical therapists, physicians, and scientists. These co-authors provide up-to-datereferences when available, and clearly state when evidence is lacking. This updated, fourth edition includes 200 new photos/graphics and 13 new chapters on current topics,including Integrating evidence into clinical practice, Principles of activity promotion, and Medical emergen-cies in sport. The editors continue to add to the clinically relevant topics with one of my favorites being whatI call “How to manage the patient who has seen everyone and wants a cure from you!” (Chapter 41). An innovative and exciting addition to this edition is the integration of the Clinical Sports Medicine master- lyclasses that allow you, through videos and podcasts on the Clinical Sports Medicine website, to learn directlyfrom the experts. These masterclasses will be continually updated and they provide a remarkably dynamic oncomponent to the text. It is exciting to watch Clinical Sports Medicine evolve substantially with each edition. The editors’ focus ofthis text is to “help clinicians help patients” and they have clearly hit their mark. This book is an absolute must- shave for any sports medicine professional. geProfessor Irene Davis, PT, PhD, FACSM, FAPTA, FASB paDirector, Spaulding National Running CenterDepartment of Physical Medicine and RehabilitationHarvard Medical School eSpaulding-Cambridge Outpatient Center plCambridge, MA, USA m savi
    • Brief contents Part A Fundamental principles 1 Sports and exercise medicine: addressing the world’s greatest public health problem 2 2 Sports and exercise medicine: the team approach 6 3 Integrating evidence into clinical practice to make quality decisions 11 4 Sports injuries: acute 15 5 Sports injuries: overuse 25 6 Pain: why and how does it hurt? 41 7 Beware: conditions masquerading as sports injuries 54 8 Clinical aspects of biomechanics and sporting injuries 61 9 Principles of injury prevention 11310 Recovery 13811 Principles of diagnosis: clinical assessment 14512 Principles of diagnosis: investigations including imaging 15713 Treatments used for musculoskeletal conditions: more choices and more evidence 16414 Core stability 21015 Principles of rehabilitation 22716 Principles of physical activity promotion for clinicians 254 Part B Regional problems17 Sports concussion 27218 Headache 290 ly19 Facial injuries 30020 Neck pain 313 on21 Shoulder pain 34222 Elbow and arm pain 39023 Wrist pain 413 s24 Hand and finger injuries 435 ge25 Thoracic and chest pain 44926 Low back pain 463 pa27 Buttock pain 49228 Hip-related pain 51029 Groin pain 545 e30 Anterior thigh pain 579 pl31 Posterior thigh pain 59432 Acute knee injuries 626 m33 Anterior knee pain 684 sa34 Lateral, medial, and posterior knee pain 71535 Leg pain 73536 Calf pain 761 vii
    • Br ie f contents37 Pain in the Achilles region 77638 Acute ankle injuries 80639 Ankle pain 82840 Foot pain 84441 The patient with longstanding symptoms: clinical pearls 878 Part C Special groups of participants42 The younger athlete 88843 Women and activity-related issues across the lifespan 91044 The older person who exercises 93645 Military personnel 94346 The athlete with a disability 960 Part D Management of medical problems47 Medical emergencies in the sporting context 97248 Sudden cardiac death in sport 99649 Managing cardiovascular symptoms in sportspeople 102450 Respiratory symptoms during exercise 103851 Gastrointestinal symptoms during exercise 105652 Renal symptoms during exercise 106353 Diabetes mellitus 107054 Exercise to treat neurological diseases and improve mental health 108255 Joint-related symptoms without acute injury 109356 Common sports-related infections 110257 The tired athlete 111858 Exercise in the heat 113259 Exercise at the extremes of cold and altitude 1146 ly60 Quick exercise prescriptions for specific medical conditions 1158 on Part E Practical sports medicine61 The preparticipation physical evaluation 1176 s62 Screening the elite sportsperson 1185 ge63 Providing team care 120364 Traveling with a team 1208 pa65 Medical coverage of endurance events 122166 Drugs and the athlete 122867 Ethics and sports medicine 1261 e pl m saviii
    • ContentsForeword to the first edition v Co-authors xxxviForeword to the fourth edition vi Other contributors xliiPreface xxxi Acknowledgments xlivAbout the authors xxxiii Guided tour of your book xlvEditors xxxv PART Fundamental principles 4 Sports injuries: acute 15 A Bone 161 Sports and exercise medicine: Fracture 16addressing the world’s greatest public Periosteal injury 17health problem 2 Articular cartilage 17 Joint 18The burden of physical inactivity and sedentary Dislocation/subluxation 18behavior 2 Ligament 18 The one trillion dollar argument (US alone!) 2 Muscle 20Physical fitness—more health benefits than Strain/tear 20smoking cessation or weight loss 2 Contusion 21 The molecular mechanisms that explain the Myositis ossificans 21 health benefits of physical activity 2 Cramp 22Putting it all together—the economic imperative 4 Tendon 22 Practical challenges 4 Bursa 23 The darkest hour is just before the dawn 4 Nerve 23 ly Skin 232 Sports and exercise medicine: theteam approach on 6 5 Sports injuries: overuse 25The sports and exercise medicine team 6 Bone stress 25 Multiskilling 6 Mechanism 26 s The sports and exercise medicine model 7 Risk factors 26 geThe challenges of management 7 Skeletal sites 28 Diagnosis 8 Clinical diagnosis 28 pa Treatment 9 Imaging diagnosis 28 Meeting individual needs 9 Low-risk and high-risk stress fracture 29The coach, the athlete, and the clinician 9 General principles of stress fracture treatment 30 e“Love thy sport” (and physical activity!) 9 Osteitis and periostitis 31 pl Apophysitis 313 Integrating evidence into clinical Articular cartilage 31 mpractice to make quality decisions 11 Joint 31 saLife before evidence-based practice 12 Ligament 31Sackett and the McMaster contribution 12 Muscle 31This seems obvious—so what is the problem? 13 Focal tissue thickening/fibrosis 32 ix
    • Conte nts Chronic compartment syndrome 32 Bone and soft tissue tumors 54 Muscle soreness 32 Rheumatological conditions 56Tendon 33 Disorders of muscle 57 Tendon overuse injury (tendinopathy) 33 Endocrine disorders 57 A contemporary model of a continuum of Vascular disorders 58 tendon pathology 33 Genetic disorders 58 Other terms associated with overuse tendon Granulomatous diseases 59 injuries 36 Infection 59Bursa 37 Pain syndromes 59Nerve 37Skin 37 8 Clinical aspects of biomechanics Blisters 37 and sporting injuries 61 Infections 37 “Ideal” lower limb biomechanics—the basics 61 Dermatitis 38 Lower limb joint motion 61 Skin cancers 38 Ideal neutral stance position 64But it’s not that simple … 38 “Ideal” biomechanics with movement—running 65 Pain: where is it coming from? 38 Loading (heel strike to foot flat) 66 Masquerades 38 Midstance (foot flat to heel off ) 67 The kinetic chain 38 Propulsion (heel off to toe off ) 68 Initial swing 696 Pain: why and how does it hurt? 41 Terminal swing 69What is pain? 41 Angle and base of gait 69What is nociception? 42 Influence of gait velocity 69 State-dependent sensitivity of primary Comparing heel and forefoot strike patterns 70 nociceptors 43 Influence of fatigue on running biomechanics 71 State-dependent sensitivity of spinal Lower limb biomechanical assessment in the nociceptors 44 clinical setting 71 lyThe brain decides 45 Structural (“static”) biomechanicalThe brain corrects the spinal cord 45 assessment 73 onWhen pain persists, the brain changes 47 Functional lower limb tests—single-legTreating someone in pain—a complex system stance, heel raise, squat, and landing fromrequires a comprehensive approach 47 a jump 77 sClinical approach to referred pain—often Dynamic movement assessment geneglected in clinical teaching 48 (e.g. running biomechanics) 82 Radicular pain 49 Sport-specific assessment 83 pa Somatic pain 49 Summary of the lower limb biomechanical Clinical assessment of referred pain 51 assessment 83Clinical summary 52 Clinical assessment of footwear—the Footwear e Assessment Tool 83 pl7 Beware: conditions masquerading Fit 83as sports injuries 54 General structure 83 m Motion control properties 83How to recognize a condition masquerading sa Cushioning 85as a sports injury 54 Wear patterns 85Conditions masquerading as sports injuries 54x
    • ContentsConditions related to suboptimal lower limb Appropriate training 128biomechanics 85 Principles of training 128Management of lower limb biomechanical Training methods 130abnormalities 86 Adequate recovery 134 Foot orthoses 86 Taping 91 10 Recovery 138Biomechanics of cycling 92 Warm-down or active recovery 138 Set-up and positioning on the bike 92 Deep-water running 139 Bike set-up in other forms of cycling 96 Cold water immersion (ice baths) 139 Aerodynamics and wind resistance 97 Massage 139 Pedaling technique 97 Compression garments 140 Assessment 97 Lifestyle factors 140 Rehabilitation 98 Nutrition 140 Conclusion 99 Glycogen replacement 140Upper limb biomechanics 99 Protein replacement 141 The biomechanics of throwing 99 Co-ingestion of carbohydrate and protein 141 Normal biomechanics of the scapula in Rehydration 142 throwing 102 Psychology 142 Abnormal scapular biomechanics and The function of the autonomic nervous physiology 103 system 143 Clinical significance of scapular Effect of exercise on the autonomic nervous biomechanics in shoulder injuries 104 system 143 Changes in throwing arm with repeated Techniques that aid psychological recovery 143 pitching 104 Common biomechanical abnormalities 11 Principles of diagnosis: clinical specific to pitching 105 assessment 145 Biomechanics of swimming 105 Biomechanics of tennis 106 Making a diagnosis 145 ly Biomechanics of other overhead sports 107 History 146 on Allow enough time 1469 Principles of injury prevention 113 Be a good listener 146 Know the sport 146Systematic injury prevention 113 s Circumstances of the injury 146Warm-up 116 ge Obtain an accurate description ofTaping and bracing 121 symptoms 146 Taping 121 History of a previous similar injury 147 pa Bracing 122 Other injuries 147Protective equipment 122 General health 147Suitable equipment 123 e Work and leisure activities 147 Running shoes 123 Consider why the problem has occurred 147 pl Running spikes 124 Training history 147 Football boots 125 m Equipment 148 Ski boots 125 Technique 148 sa Tennis racquets 126 Overtraining 148Appropriate surfaces 127 Psychological factors 148 xi
    • Conte nts Nutritional factors 148 Cardiovascular investigations 161 History of exercise-induced anaphylaxis 148 Respiratory investigations 161 Determine the importance of the sport Pulmonary function tests 161 to the athlete 148 The diagnosis 162Examination 148 Develop a routine 148 13 Treatments used for musculoskeletal Where relevant, examine the other side 148 conditions: more choices and more Consider possible causes of the injury 148 evidence 164 Attempt to reproduce the patient’s symptoms 148 Evidence for treatment effectiveness is Assess local tissues 148 continually changing 164 Assess for referred pain 149 Acute management 165 Assess neural mechanosensitivity 149 Rest 165 Examine the spine 149 Ice 165 Biomechanical examination 149 Compression 166 Functional testing 149 Elevation 166 The examination routine 149 Immobilization and early mobilization 166 Protected mobilization 16712 Principles of diagnosis: Continuous passive motion 167investigations including imaging 157 Therapeutic drugs 167 Analgesics 167Investigations 157 Topical analgesics 168 1. Understand the meaning of test results 157 Nonsteroidal anti-inflammatory drugs 2. Know how soon changes can be (NSAIDs) 168 detected by investigations 157 Topical anti-inflammatory agents 174 3. Only order investigations that will Corticosteroids 174 influence management 157 Nitric oxide donor 176 4. Provide relevant clinical findings on Sclerosing therapy 177 ly the requisition 157 Prolotherapy 177 5. Do not accept a poor quality test 157 on Glucosamine sulfate and chondroitin 6. Develop a close working relationship sulfate 178 with investigators 157 Hyaluronic acid therapy (Hyalgan, Synvisc, 7. Explain the investigations to the patient 158 s Ostenil, Orthovisc) 178Radiological investigation 158 ge Antidepressants 179 Plain X-ray 158 Local anesthetic injections 179 Computed tomographic (CT) scanning 158 Traumeel 180 pa Magnetic resonance imaging (MRI) 158 Bisphosphonates 180 Ultrasound scan (for diagnosis) 159 Blood and blood products 180 Radioisotopic bone scan 160 e Autologous blood injections 180Neurological investigations 161 Platelet-rich plasma 180 pl Electromyography 161 Heat and cold 181 Nerve conduction studies 161 m Cryotherapy 181 Neuropsychological testing 161 Superficial heat 183 saMuscle assessment 161 Contrast therapy 184 Compartment pressure testing 161xii
    • ContentsElectrotherapy 185 Efficacy of core strengthening exercise 223 Ultrasound 186 Prevention of injury and performance TENS (Transcutaneous electrical nerve improvement 223 stimulation) 187 Treatment of low back pain 224 Interferential stimulation 188 Effectiveness in sports injuries 224 High-voltage galvanic stimulation 188 Conclusion 224 Low-voltage galvanic stimulation 188 Neuromuscular stimulators 188 15 Principles of rehabilitation 227 Point stimulators 189 Keys to a successful rehabilitation program 227 Laser 189 Explanation 228 Diathermy 189 Provide precise prescription 228 Magnetic therapy 189 Make the most of the available facilities 228Extracorporeal shock wave therapy 190 Begin as soon as possible 228Manual therapy 190 Components of exercise programs for Joint mobilization 191 rehabilitation 228 Joint manipulation 192 Muscle conditioning 228 Joint traction 193 Cardiovascular fitness 235 Soft tissue therapy 193 Flexibility 235 Muscle energy techniques 196 Proprioception 238 Neural stretching 197 Functional exercises 240Acupuncture 198 Sport skills 240Dry needling 198 Hydrotherapy 242Hyperbaric oxygen therapy 200 Deep-water running 242Surgery 200 Correction of biomechanical abnormalities 243 Arthroscopic surgery 200 Stages of rehabilitation 243 Open surgery 201 Initial stage 243 Intermediate preparticipation stage 24314 Core stability 210 ly Advanced stage 244Anatomy 212 Return to sport 245 on Osseous and ligamentous structures 212 Secondary prevention 246 The thoracolumbar fascia 212 Progression of rehabilitation 246 Paraspinals 212 Type of activity 246 s Quadratus lumborum 213 Duration of activity 246 ge Abdominals 213 Frequency 246 Hip girdle musculature 213 Intensity 246 pa Diaphragm and pelvic floor 213 Complexity of activity 246Assessment of core stability 213 Monitoring rehabilitation programs 246Exercise of the core musculature 215 Psychology 247 e Decreasing spinal and pelvic viscosity 215 Emotional responses to injury 247 pl Use of biofeedback and real-time Psychological strategies to facilitate ultrasound in retraining core control 216 recovery 247 m Stabilization exercises 216 Conclusion 250 sa Functional progression 219 Core strengthening for sports 223 xiii
    • Conte nts16 Principles of physical activity Migraine 293promotion for clinicians 254 Cluster headache 295 Cervical headache 295Who should receive exercise counseling? 255 Mechanism 295Are there medical contraindications to being Clinical features 296active? 255 Exercise-related causes of headache 297Executing the prescription 256 Primary exertional headache 297 Practical steps with the consultation 256 Exertional migraine 297Exercise guidelines 257 Post-traumatic headache 298 Aerobic activity 257 External compression headache 298 Defining intensity 258 High-altitude headache 298 Resistance training 259 Hypercapnia headache 299 Flexibility 267 Follow-up 267 19 Facial injuries 300An overlooked element of motivation 267Summary 268 Functional anatomy 300 Clinical assessment 300 Soft tissue injuries 301 PART Regional problems Nose 303 B Epistaxis (nosebleed) 303 Nasal fractures 30317 Sports concussion 272 Septal hematoma 303Definition of concussion 273 Ear 304Prevention of concussion 273 Auricular hematoma 304The initial impact: applied pathophysiology 274 Lacerations 304Management of the concussed athlete 274 Perforated eardrum 304 On-field management 274 Otitis externa 304 Determining when the player can return Eye 305 ly safely to competition 277 Assessment of the injured eye 305The risk of premature return to play and Corneal injuries: abrasions and foreign onconcussion sequelae 281 body 306 Risk of further injury 281 Subconjunctival hemorrhage 307 Eyelid injuries 307 s Second impact syndrome 281 Concussive convulsions 281 Hyphema 307 ge Prolongation of symptoms 281 Lens dislocation 307 Chronic traumatic encephalopathy 281 Vitreous hemorrhage 307 pa Mental health issues 282 Retinal hemorrhage 307Children and concussion in sport 282 Retinal detachment 308 Orbital injuries 308 e18 Headache 290 Prevention of eye injuries 308 pl Teeth 309Headache in sport 290 Prevention of dental injuries 309 mClinical approach to the patient with headache 291 Fractures of facial bones 309 History 292 sa Fractures of the zygomaticomaxillary Examination 293 complex 310Vascular headaches 293xiv
    • Contents Maxillary fractures 310 Glenoid labrum injuries 360 Mandibular fractures 311 Clinically relevant anatomy 360 Temporomandibular injuries 311 Making the diagnosis 360Prevention of facial injuries 312 Treatment 361 Dislocation of the glenohumeral joint 36220 Neck pain 313 Anterior dislocation 362 Posterior dislocation of the glenohumeralClinical perspective 313 joint 363Assessing patients with neck pain 315 Shoulder instability 364 History 315 Anterior instability 364 Physical examination 317 Posterior instability 367Treatment of neck pain 326 Multidirectional instability 367 Education 326 Adhesive capsulitis (“frozen shoulder”) 367 Posture 326 Treatment 367 Exercise therapy 328 Fracture of the clavicle 368 Manual therapy 331 Middle-third clavicular fracture 368 Soft tissue techniques 332 Distal clavicle fractures 368 Neural tissue mobilization 332 Acromioclavicular joint conditions 369 Dry needling 332 Acute acromioclavicular joint injuries 369 Stress management 332 Chronic acromioclavicular joint pain 371Neck pain syndromes 333 Referred pain 372 Acute wry neck 333 Less common causes of shoulder pain 373 Acceleration–deceleration injury 334 Biceps tendinopathy 373 Cervicogenic headache 334 Rupture of the long head of the biceps 373 Acute nerve root pain 334 Pectoralis major tears 373 Stingers or burners 335 Subscapularis muscle tears 373Conclusion 336 Nerve entrapments 373 Thoracic outlet syndrome 375 ly21 Shoulder pain 342 Axillary vein thrombosis (“effort” onFunctional anatomy—static and dynamic 342 thrombosis) 376 Static stabilizers 342 Fractures around the shoulder joint 376 Dynamic stabilizers 343 Principles for shoulder rehabilitation 377 s Scapulohumeral rhythm 343 Make a complete and accurate diagnosis 377 geClinical perspective 344 Early pain reduction 377 A practical approach to shoulder pain 344 Integration of the kinetic chain into History 345 pa rehabilitation 377 Examination 345 Scapular stabilization 378 Shoulder investigations 352 Early achievement of 90° of abduction eImpingement 353 and improved glenohumeral rotation 378 Primary external impingement 354 pl Closed chain rehabilitation 381 Secondary external impingement 354 Plyometric exercises 382 m Internal impingement 355 Rotator cuff exercises 383Rotator cuff injuries 357 Putting it all together—specific rehabilitation sa Rotator cuff tendinopathy 357 protocols 384 Rotator cuff tears 359 Acute phase 384 xv
    • Conte nts Recovery phase 385 Subacute onset and chronic wrist pain 426 Functional phase 386 History 426 Criteria for return to play 387 Examination 426 Extra-articular conditions 42722 Elbow and arm pain 390 Injuries to the distal radial epiphysis 430 Articular causes of subacute and chronicLateral elbow pain 390 wrist pain 431 Clinical assessment 391 Numbness and hand pain 431 Lateral elbow tendinopathy 393 Other causes of lateral elbow pain 400 24 Hand and finger injuries 435Medial elbow pain 401 Flexor/pronator tendinopathy 401 Clinical evaluation 435 Medial collateral ligament sprain 401 History 435 Ulnar neuritis 402 Examination 436Posterior elbow pain 403 Investigations 437 Olecranon bursitis 403 Principles of treatment of hand injuries 438 Triceps tendinopathy 404 Control of edema 438 Posterior impingement 404 Exercises 439Acute elbow injuries 404 Taping and splinting 439 Investigation 404 Fractures of the metacarpals 439 Fractures 405 Fracture of the base of the first metacarpal 439 Dislocations 406 Fractures of the other metacarpals 441 Acute rupture of the medial collateral Fractures of phalanges 442 ligament 407 Proximal phalanx fractures 442 Tendon ruptures 407 Middle phalanx fractures 442Forearm pain 407 Distal phalanx fractures 442 Fracture of the radius and ulna 407 Dislocation of the metacarpophalangeal joints 442 Stress fractures 408 Dislocations of the finger joints 443 ly Entrapment of the posterior interosseous Dislocations of the PIP joint 443 nerve (radial tunnel syndrome) 408 Dislocations of the DIP joint 443 on Forearm compartment pressure syndrome 409 Ligament and tendon injuries 443Upper arm pain 409 Sprain of the ulnar collateral ligament of Myofascial pain 409 the first MCP joint 443 s Stress reaction of the humerus 409 Injuries to the radial collateral ligament ge of the first MCP joint 44423 Wrist pain 413 Capsular sprain of the first MCP joint 444 pa PIP joint sprains 444Acute wrist injuries 413 Mallet finger 445 History 413 Boutonnière deformity 446 e Examination 415 Avulsion of the flexor digitorum Investigations 418 pl profundus tendon 447 Fracture of the distal radius and ulna 420 Lacerations and infections of the hand 447 m Fracture of the scaphoid 420 Overuse conditions of the hand and fingers 447 Fracture of the hook of hamate 423 sa Dislocation of the carpal bones 424 Scapholunate dissociation 425xvi
    • Contents25 Thoracic and chest pain 449 Treatment 480 Stress fracture of the pars interarticularis 480Thoracic pain 449 Clinical features 480 Assessment 449 Treatment 481 Thoracic intervertebral joint disorders 453 Spondylolisthesis 482 Costovertebral and costotransverse joint Clinical features 483 disorders 454 Treatment 483 Scheuermann’s disease 455 Lumbar hypermobility 484 Thoracic intervertebral disk prolapse 455 Structural lumbar instability 484 T4 syndrome 455 Sacroiliac joint disorders 484 Postural imbalance of the neck, shoulder Rehabilitation following low back pain 484 and upper thoracic spine 456 Posture 484Chest pain 456 Daily activities 485 Assessment 457 Sporting technique 485 Rib trauma 458 Core stability 485 Referred pain from the thoracic spine 458 Specific muscle tightness 487 Sternoclavicular joint problems 459 Conclusion 488 Costochondritis 460 Stress fracture of the ribs 460 27 Buttock pain 492 Side strain 461Conclusion 461 Clinical approach 492 History 49226 Low back pain 463 Examination 494 Investigations 496Epidemiology 463 Referred pain from the lumbar spine 497Clinical perspective 463 Sacroiliac joint disorders 498 Conditions causing low back pain in Functional anatomy 498 which a definitive diagnosis can be made 464 Clinical features 500 Somatic low back pain 465 ly Treatment 501 Functional (clinical) instability in low Iliolumbar ligament sprain 502 on back pain 467 Hamstring origin tendinopathy 503 History 468 Fibrous adhesions 503 Examination 468 Ischiogluteal bursitis 504 s Investigations 468 Myofascial pain 504 geSevere low back pain 472 Less common causes 504 Clinical features of severe acute low Quadratus femoris injury 504 pa back pain 472 Stress fracture of the sacrum 505 Management of severe acute low back Piriformis conditions 505 pain 472 Posterior thigh compartment syndrome 506 eMild-to-moderate low back pain 473 Proximal hamstring avulsion injuries 506 pl Clinical features 474 Apophysitis/avulsion fracture of the Treatment of mild-to-moderate low back ischial tuberosity 507 m pain 474 Conditions not to be missed 507 Chronic low back pain 477 saAcute nerve root compression 478 Clinical features 480 xvii
    • Conte nts28 Hip-related pain 510 Factors that increase local bone stress 550 Clinical approach 552Functional anatomy and biomechanics 510 History 552 Morphology 511 Examination 553 Acetabular labrum 511 Investigations 558 Ligaments of the hip 512 Acute adductor strains 559 Chondral surfaces 513 Recurrent adductor muscle strain 559 Joint stability and normal muscle function 513 Adductor-related groin pain 559Clinical perspective: making sense of a complex Early warning signs 560problem 516 Treatment 560 Femoroacetabular impingement (FAI) 516 Iliopsoas-related groin pain 565Factors that may contribute to the Epidemiology 566development of hip-related pain 518 Clinical concepts 566 Extrinsic factors 518 Treatment 567 Intrinsic factors 519 Abdominal wall–related groin pain 567Clinical assessment 521 Posterior inguinal wall weakness History 521 (sports hernia, sportsman’s hernia) 567 Examination 522 Gilmore’s groin 568 Investigations 525 Laparoscopic inguinal ligament release 568Labral tears 526 Tear of the external oblique aponeurosisLigamentum teres tears 527 (hockey groin) 568Synovitis 528 Inguinal hernia 569Chondropathy 529 Rectus abdominis injuries 569Rehabilitation of the injured hip 530 Pubic bone stress–related groin pain 569 Unloading and protecting damaged or Treatment 571 potentially vulnerable structures 530 Less common injuries 572 Restoration of normal dynamic and Obturator neuropathy 572 neuromotor control 530 Other nerve entrapments 572 ly Address other remote factors that may be Stress fractures of the neck of the femur 572 altering the function of the kinetic chain 534 on Stress fracture of the inferior pubic ramus 573Surgical management of the injured hip 534 Referred pain to the groin 574 Rehabilitation following hip arthroscopy 535Os acetabulare 536 s 30 Anterior thigh pain 579Lateral hip pain 538 ge Greater trochanter pain syndrome (GTPS) 538 Clinical approach 579 Gluteus medius tendon tears 540 History 579 pa Examination 58029 Groin pain 545 Investigations 581 Quadriceps contusion 582 eAnatomy 545 Treatment 583 plPrevalence 547 Acute compartment syndrome of the thigh 586Risk factors 547 Myositis ossificans 587 mClinical overview 548 Quadriceps muscle strain 587 Local overload causing failure of various sa Distal quadriceps muscle strain 588 structures 548 Proximal rectus femoris strains 589 What role does bone stress play? 549xviii
    • ContentsDifferentiating between a mild quadriceps Compartment syndrome of the posteriorstrain and a quadriceps contusion 590 thigh 621Less common causes 590 Vascular 621 Stress fracture of the femur 590 Lateral femoral cutaneous nerve injury 32 Acute knee injuries 626 (“meralgia paresthetica”) 591 Functional anatomy 626 Femoral nerve injury 592 Clinical perspective 627 Referred pain 592 Does this patient have a significant knee injury? 62731 Posterior thigh pain 594 History 627Functional anatomy 594 Examination 629Clinical reasoning 595 Investigations 633 History 596 Meniscal injuries 634 Examination 597 Clinical features 635 Investigations 599 Treatment 635 Integrating the clinical assessment and Rehabilitation after meniscal surgery 636 investigation to make a diagnosis 600 Medial collateral ligament (MCL) injury 638Acute hamstring muscle strains 600 Treatment 638 Epidemiology 600 Anterior cruciate ligament (ACL) tears 639 Types of acute hamstring strains 600 Clinical features 639 Management of hamstring injuries 603 Surgical or non-surgical treatment of theRisk factors for acute hamstring strain 615 torn ACL? 647 Intrinsic risk factors 615 Surgical treatment 650 Extrinsic risk factors 616 Combined injuries 652Prevention of hamstring strains 616 Rehabilitation after ACL injury 652 Nordic drops and other eccentric exercises 616 Problems encountered during ACL Balance exercises/proprioception training 616 rehabilitation 656 ly Soft tissue therapy 617 Outcomes after ACL treatment 657 A promising clinical approach for the Mechanism of ACL injury as a step toward on high-risk athlete 617 prevention 659Referred pain to posterior thigh 618 Posterior cruciate ligament (PCL) tears 668 Trigger points 618 Clinical features 668 s Lumbar spine 618 Treatment 669 ge Sacroiliac complex 619 Lateral collateral ligament (LCL) tears 669Other hamstring injuries 620 Articular cartilage damage 669 pa Avulsion of the hamstring from the Classification 669 ischial tuberosity 620 Treatment 671 Common conjoint tendon tear 620 Acute patellar trauma 673 e Upper hamstring tendinopathy 620 Fracture of the patella 673 pl Lower hamstring tendinopathy 621 Patellar dislocation 674Less common causes 621 Less common causes 675 m Nerve entrapments 621 Patellar tendon rupture 675 sa Ischial bursitis 621 Quadriceps tendon rupture 675 Adductor magnus strains 621 Bursal hematoma 677 xix
    • Conte nts Fat pad impingement 677 Excessive lateral pressure syndrome 723 Fracture of the tibial plateau 677 Biceps femoris tendinopathy 724 Superior tibiofibular joint injury 677 Superior tibiofibular joint injury 724 Ruptured hamstring tendon 677 Referred pain 725 Coronary ligament sprain 677 Medial knee pain 725 Patellofemoral syndrome 72533 Anterior knee pain 684 Medial meniscus abnormality 726 Osteoarthritis of the medial compartmentClinical approach 685 of the knee 726 History 685 Pes anserinus tendinopathy/bursitis 727 Examination 687 Pellegrini-Stieda syndrome 728 Investigations 689 Medial collateral ligament grade 1 sprain 728Patellofemoral pain 689 Posterior knee pain 728 What is patellofemoral pain syndrome? 689 Clinical evaluation 728 Functional anatomy 690 Popliteus tendinopathy 730 Factors that may contribute to pain 690 Gastrocnemius tendinopathy 731 Treatment of patellofemoral pain 693 Baker’s cyst 731Patellofemoral instability 700 Other causes of posterior knee pain 732 Primary patellofemoral instability 700 Secondary patellofemoral instability 700 35 Leg pain 735Patellar tendinopathy 700 Nomenclature 701 Clinical perspective 735 Pathology and pathogenesis of patellar Role of biomechanics 736 tendinopathy 701 History 738 Clinical features 701 Examination 738 Investigations 701 Investigations 743 Treatment 702 Medial tibial stress fracture 745 Partial patellar tendon tear 707 Assessment 746 lyLess common causes 707 Treatment 746 Fat pad irritation/impingement Prevention of recurrence 747 on (insidious onset) 707 Stress fracture of the anterior cortex of the tibia 747 Osgood-Schlatter lesion 708 Treatment 747 Sinding-Larsen–Johansson lesion 708 Medial tibial stress syndrome 748 s Quadriceps tendinopathy 708 Treatment 749 ge Bursitis 709 Chronic exertional compartment syndrome 750 Synovial plica 709 Deep posterior compartment syndrome 752 pa Anterior and lateral exertional34 Lateral, medial, and posterior compartment syndromes 753knee pain 715 Outcomes of surgical treatment of e exertional compartment syndrome 754Lateral knee pain 715 pl Rehabilitation following compartment Clinical approach 716 syndrome surgery 755 m Iliotibial band friction syndrome 718 Less common causes 755 Lateral meniscus abnormality 722 sa Stress fracture of the fibula 755 Osteoarthritis of the lateral compartment Referred pain 755 of the knee 723 Nerve entrapments 756xx
    • Contents Vascular pathologies 756 Autologous blood and platelet-rich plasma 794 Developmental issues 756 Medications 794 Periosteal contusion 756 Adjunctive non-operative treatments 794 Combined fractures of the tibia and fibula, Electrophysical agents 794 and isolated fractures of the tibia 756 Surgical treatment 795 Isolated fibula fractures 757 Insertional Achilles tendinopathy, retrocalcaneal bursitis and Haglund’s disease 79536 Calf pain 761 Relevant anatomy and pathogenesis 795 Clinical assessment 796Clinical perspective 761 Treatment 796 History 763 Achilles tendon rupture (complete)—diagnosis Examination 763 and initial management 797 Investigations 766 Rehabilitation after initial management ofGastrocnemius muscle strains 766 Achilles tendon rupture 797 Acute strain 766 Timing the return to jogging and sports 799 “Tennis leg” 768 Longer term rehabilitation issues 799 Chronic strain 769 Posterior impingement syndrome 800Soleus muscle strains 769 Sever’s disease 801 Accessory soleus 769 Less common causes 801Less common causes 770 Accessory soleus 801 Vascular causes 770 Other causes of pain in the Achilles region 802 Referred pain 772 Nerve entrapments 772 38 Acute ankle injuries 806 Superficial compartment syndrome 773Conditions not to be missed 773 Functional anatomy 806 Clinical perspective 80737 Pain in the Achilles region 776 History 807 Examination 808Functional anatomy 776 ly Investigations 810Clinical perspective 777 Lateral ligament injuries 811 on History 778 Treatment and rehabilitation of lateral Examination 778 ligament injuries 812 Investigations 782 Less common ankle joint injuries 816 sMidportion Achilles tendinopathy—basic Medial (deltoid) ligament injuries 816 gescience and clinical features 783 Pott’s fracture 816 Histopathology and basic molecular Maisonneuve fracture 817 biology 783 pa Persistent pain after ankle sprain—“the Predisposing factors—clinical 784 problem ankle” 817 Clinical features 784 Clinical approach to the problem ankle 817 e Practice tips relating to imaging Achilles Osteochondral lesions of the talar dome 818 tendinopathy 785 pl Avulsion fracture of the base of the fifthMidportion Achilles tendinopathy—treatment 785 metatarsal 819 m Targeted eccentric exercise including the Other fractures 819 Alfredson program 786 sa Impingement syndromes 822 Nitric oxide donor therapy 788 Tendon dislocation or rupture 822 Injections 788 Anteroinferior tibiofibular ligament injury 823 xxi
    • Conte nts Post-traumatic synovitis 824 Stress fracture of the base of the second Sinus tarsi syndrome 824 metatarsal 864 Complex regional pain syndrome type 1 825 Fractures of the fifth metatarsal 865 Metatarsophalangeal joint synovitis 86639 Ankle pain 828 First metatarsophalangeal joint sprain (“turf toe”) 867Medial ankle pain 828 Hallux limitus 868 Clinical perspective 828 Hallux valgus (“bunion”) 869 Tibialis posterior tendinopathy 830 Sesamoid injuries 869 Flexor hallucis longus tendinopathy 832 Plantar plate tear 870 Tarsal tunnel syndrome 833 Stress fracture of the great toe 872 Stress fracture of the medial malleolus 834 Freiberg’s osteochondritis 872 Medial calcaneal nerve entrapment 835 Joplin’s neuritis 872 Other causes of medial ankle pain 835 Morton’s interdigital neuroma 872Lateral ankle pain 835 Toe clawing 872 Examination 836 Corns and calluses 873 Peroneal tendinopathy 836 Plantar warts 874 Sinus tarsi syndrome 837 Subungual hematoma 873 Anterolateral impingement 838 Subungual exostosis 874 Posterior impingement syndrome 839 Onychocryptosis 875 Stress fracture of the talus 839 Referred pain 839 41 The patient with longstandingAnterior ankle pain 840 symptoms: clinical pearls 878 Anterior impingement of the ankle 840 Tibialis anterior tendinopathy 841 Diagnosis—is it correct? 878 Anteroinferior tibiofibular joint injury History 879 (AITFL) 842 Examination 881 Investigations 882 ly40 Foot pain 844 Time to revisit treatment 883 Is there a persisting cause? 883 onRear foot pain 844 Obtain details of treatment 883 Clinical perspective 846 Make the multidisciplinary team available 885 Plantar fasciitis 847 Keeping professional ethics in mind 885 s Fat pad contusion 850 Summary 885 ge Calcaneal stress fractures 851 Lateral plantar nerve entrapment 851Midfoot pain 852 PART pa Special groups of participants Clinical perspective 852 C Stress fracture of the navicular 853 e Extensor tendinopathy 855 42 The younger athlete 888 Midtarsal joint sprains 855 pl The uniqueness of the young athlete 888 Lisfranc joint injuries 856 Nonlinearity of growth 888 m Less common causes of midtarsal joint pain 859 Maturity-associated variation 888Forefoot pain 861 sa Unique response to skeletal injury 889 Clinical perspective 861 Management of musculoskeletal conditions 890 Stress fractures of the metatarsals 862 Acute fractures 890xxii
    • Contents Shoulder pain 892 Older adult 926 Elbow pain 893 Menopause 926 Wrist pain 893 Osteoporosis 926 Back pain and postural abnormalities 894 Coronary heart disease 928 Hip pain 895 The pelvic floor and continence issues 928 Knee pain 897 Exercise guidelines 929 Painless abnormalities of gait 899 Foot pain 900 44 The older person who exercises 936Guidelines for participation and injury Successful aging 936prevention 901 The cardiovascular system 936 Resistance training: a special case 901 The respiratory system 937Nutrition for the younger athlete 902 Diabetes 937 Energy 903 Osteoarthritis 937 Protein 903 Bone health and prevention of fall-related Carbohydrates 903 fractures 937 Fat 903 Psychological function 937 Vitamins and minerals 904 Risks of exercise in the older person 937Thermoregulation and hydration 904 Reducing the risks of exercise 937Violence in youth sport 904 Exercise prescription for the older person 938The “ugly parent” syndrome 905 The inactive older person 938Coaches’ role 905 The generally active older person 938 Interaction between medication and exercise43 Women and activity-related in the older person 939issues across the lifespan 910 Medications affecting the renin–angiotensinOverview 910 system 939 Sex and gender differences 910 Beta blockers 939 The lifespan approach to women and Diuretics 939 ly physical activity 911 Other cardiac drugs 939Girlhood 911 Nonsteroidal anti-inflammatory drugs 939 onAdolescence 912 Medications affecting the central nervous Effect of the menstrual cycle on system 940 performance 913 Insulin and oral hypoglycemic drugs 940 s Menstrual irregularities associated with ge exercise 914 45 Military personnel 943 Complications of exercise-associated Special culture among military personnel 943 pa menstrual cycle irregularities 916 Epidemiology of military injuries 944 Treatment of exercise-associated Common military injuries 945 menstrual cycle irregularities 918 e Overuse injuries of the lower limb 946 Eating disorders and intense athletic Blister injuries 946 pl activity 919 Parachuting injuries 947Adult women 919 m The aging defense forces 948 Injuries 919 Injury prevention strategies in the military 948 sa Breast care 920 Injury surveillance 948 Exercise and pregnancy 922 Females and injury risk 949 Postpartum exercise 925 xxiii
    • Conte nts Body composition 951 Definitive care 976 Previous injury 952 The primary survey in detail 976 Weekly running distance 952 Basic life support 976 Running experience 953 Airway with cervical spine control 977 Competitive behaviors 954 Breathing and ventilation 986 Warm-up/stretching 954 Circulation and hemorrhage control 988Conclusion 954 Disability (and neurological status) 991 Exposure and environment control 99246 The athlete with a disability 960 Appropriate use of analgesia in trauma 994 Recommended general and emergencyHistorical perspective 960 medical equipment 994Health benefits of physical activity 961 Choosing a suitable sport 961 48 Sudden cardiac death in sport 996The sportsperson with a physical disability 962 Spinal cord injury and sports medicine 962 Incidence of sudden cardiac death 996 The sportsperson with a limb deficiency 964 Sex and race as risk factors 997 The sportsperson with cerebral palsy 965 Which sports carry the highest risk 998 The sportsperson classified as Les Autres 965 Etiology of sudden cardiac death in athletes 998The sportsperson with visual impairment 965 Overview 998The sportsperson with an intellectual SCD due to congenital or genetic structuralimpairment 966 heart disease 1000Classification 966 SCD due to congenital or geneticAdapting performance testing and training for abnormalities predisposing to primarydisabled sportspeople 967 electrical disorders of the heart 1005Winter sports and common injuries 968 SCD due to acquired cardiac abnormalities 1008Anti-doping issues 968 Evaluation of an athlete for conditions causingTravel with teams 968 sudden cardiac death 1008 History 1008 ly Physical examination 1009 Management of medical 12-lead ECG/EKG 1009 PART on problems Echocardiography 1009 D Further investigations 1009 Purpose of screening 1013 s47 Medical emergencies in the Primary prevention of SCD in athletes— gesporting context 972 pre-participation cardiovascular screening 1013The role of the physiotherapist in emergency Secondary prevention—responding when pacare 972 an athlete has collapsed 1014Emergency care principles 972 Recognition of sudden cardiac arrest 1014 Preparation 973 Management of sudden cardiac arrest 1014 e Triage 973 Cardiopulmonary resuscitation 1015 pl Primary survey 973 Early defibrillation 1015 Resuscitate and stabilize 975 m Focused history 975 sa Secondary survey 975 Reassessment 976xxiv
    • Contents49 Managing cardiovascular Pathophysiology 1043symptoms in sportspeople 1024 Etiology 1043 Clinical features 1043Cardiovascular symptoms: potentially life Diagnosis 1043or death decisions 1024 Bronchial provocation challenge tests 1044The clinical approach to potentially important Treatment 1047cardiac symptoms 1025 Conditions that may mimic exercise-inducedClinical approach to symptoms associated bronchospasm 1049with cardiac conditions 1025 Sinus-related symptoms 1051 Syncope/near-syncope 1026 Investigations 1051 Unexplained seizure activity 1027 Management of sinusitis 1051 Exertional chest pain 1028 Other exercise-related conditions 1052 Palpitations 1028 Exercise-induced anaphylaxis 1052 Excessive fatigue or dyspnea with exertion 1029 Cholinergic urticaria 1052Clinical approach to physical examination Exercise-induced angioedema 1052findings 1029Specific physical examination findings 1030 51 Gastrointestinal symptoms during Hypertension 1030 exercise 1056 Heart murmur 1031 Marfan syndrome 1031 Upper gastrointestinal symptoms 1057Non-invasive cardiovascular testing 1032 Treatment 1057 Electrocardiogram (ECG/EKG) 1032 Gastrointestinal bleeding 1057 Echocardiography and associated tests for Treatment 1058 structural disease (cardiac CT, MRI) 1033 Abdominal pain 1058 Genetic testing when there is a family Diarrhea 1058 history of early sudden cardiac death? 1033 Treatment 1059Temporary and permanent disqualification Exercise and gastrointestinal diseases 1059from sports 1035 Lactose intolerance 1059 lySummary 1035 Celiac disease 1059 Irritable bowel syndrome 1059 on50 Respiratory symptoms during Non-steroidal anti-inflammatory drugsexercise 1038 (NSAIDs) and the gastrointestinal tract 1059 Prevention of gastrointestinal symptoms sCommon respiratory symptoms 1038 that occur with exercise 1060 ge Shortness of breath and wheeze 1038 Limit dietary fiber intake prior to Cough 1039 competition 1060 pa Chest pain or tightness 1039 Avoid solid foods during the last threeAsthma 1040 hours prior to the race 1061 Epidemiology 1040 Select the pre-event meal carefully 1061 e Clinical features 1040 Prevent dehydration 1061 pl Types of asthma 1040 Avoid fat and protein intake during Precipitating factors 1041 exercise 1061 m Risk factors 1041 Sample pre-event diet 1061 Asthma management 1042 sa Consult a sports psychologist 1061Exercise-induced bronchospasm 1042 Epidemiology 1042 xxv
    • Conte nts52 Renal symptoms during exercise 1063 54 Exercise to treat neurological diseases and improve mental health 1082Clinical anatomy and physiology 1063Exercise-related renal impairment 1064 Stroke 1082 Rhabdomyolysis and myoglobinuria 1064 Effects of physical activity on stroke Other exercise-related renal impairment 1065 mortality 1082Clinical approach to the athlete presenting Effect of physical activity in the treatmentwith hematuria 1065 of stroke patients 1082Clinical approach to the athlete presenting What exercise or physical activity programwith proteinuria 1065 should be used? 1083Non-steroidal anti-inflammatory drugs Parkinson’s disease 1083(NSAIDs) and the kidney 1066 Does physical activity prevent the onsetExercise and the patient with renal impairment 1066 of Parkinson’s disease? 1083 Exercise for patients with renal Does physical activity reduce symptoms transplantation 1067 of Parkinson’s disease? 1083Prevention of renal complications of exercise 1067 What exercise or physical activity program should be used? 108453 Diabetes mellitus 1070 Multiple sclerosis 1084 Does physical activity prevent the onset ofTypes of diabetes 1070 multiple sclerosis or cause exacerbations? 1084 Type 1 diabetes 1070 Does physical activity reduce symptoms Type 2 diabetes 1070 of multiple sclerosis? 1084Clinical perspective 1070 What exercise or physical activity program Diagnosis 1070 should be used? 1085 Pre-exercise screening for people with Special considerations for exercise in diabetes 1071 patients with multiple sclerosis 1085 Complications 1071 Dizziness 1085Treatment 1071 Does physical activity prevent the onset Pharmacotherapy in diabetes 1071 ly of dizziness 1086 Dietary management 1072 Does physical activity reduce dizziness onExercise and diabetes 1073 symptoms 1086 Benefits of exercise 1074 What exercise or physical activity program Exercise and type 1 diabetes 1074 should be used 1086 s Exercise and type 2 diabetes 1075 Mild cognitive impairment and dementia 1086 ge Diabetes and competition 1075 Does physical activity prevent the onset Diabetes and travel 1075 of cognitive impairment and dementia 1087 pa High-risk sports 1075 Does physical activity minimize the Exercise and the complications of diabetes 1075 progression of cognitive impairment andComplications of exercise in the diabetic reduce dementia symptoms 1087 esportsperson 1078 Mechanisms that underpin the effect of pl Hypoglycemia 1078 exercise 1087 Diabetic ketoacidosis in the athlete 1079 Depression 1088 m Musculoskeletal manifestations of Does physical activity prevent the onset diabetes 1079 sa of mood disorders? 1088Conclusion 1080 Does physical activity reduce depression symptoms? 1089xxvi
    • Contents What exercise or physical activity program 57 The tired athlete 1118 should be used? 1089 Clinical perspective 1119Anxiety 1089 History 1119 Does physical activity prevent the onset of Examination 1120 anxiety disorders/symptoms? 1089 Investigations 1120 Does physical activity reduce anxiety Overtraining syndrome 1120 symptoms? 1090 Development of the overtraining What exercise or physical activity program syndrome 1120 should be used? 1090 Clinical perspective 1121 Central fatigue and overtraining 112455 Joint-related symptoms without Monitoring of overtraining 1125acute injury 1093 Prevention of overtraining 1125The patient with a single swollen joint 1093 Treatment of the overtrained sportsperson 1126 Clinical perspective 1093 Viral illness 1126The patient with low back pain and stiffness 1096 Nutritional deficiencies 1126 Clinical perspective 1096 Depletion of iron stores 1126The patient presenting with multiple painful Glycogen depletion 1127joints 1097 Inadequate protein intake 1127 Clinical perspective 1097 Chronic fatigue syndrome 1127The patient with joint pain who “hurts all over” 1099 Definition 1127Ordering and interpreting rheumatological Etiology 1128tests 1100 Symptoms 1128 Rheumatoid factor 1100 Management 1128 Erythrocyte sedimentation rate 1100 Chronic fatigue syndrome and the Antinuclear antibodies 1100 sportsperson 1129 HLA B27 1100 Other causes of tiredness 1129 Serum uric acid 1101 Summary 112956 Common sports-related infections 1102 58 Exercise in the heat ly 1132 onExercise and infection 1102 Mechanisms of heat gain and loss 1133 Exercise and the immune system 1102 Clinical perspective 1133 s Exercise and clinical infections 1103 Heatstroke—a temperature above 41°C ge Infection and athletic performance 1104 (106°F) 1135Common infections in athletes 1105 Management of heatstroke 1135 Skin infections 1105 pa Is hospital admission indicated? 1136 Respiratory and ear nose and throat Complications of heatstroke 1136 infections 1108 Exercise-associated collapse 1137 e Gastrointestinal and liver infections 1110 Management of exercise-associatedOther infections 1113 pl collapse/exercise-associated postural Human immunodeficiency virus (HIV) 1113 hypotension (EAPH) 1137 m Sexually transmitted infections 1114 Cramps 1138 Tetanus 1114 Management of cramps 1138 saPreventative measures and reducing risk of Fluid overload: hyponatremia 1138infections 1114 xxvii
    • Conte nts Management of exercise-induced 60 Quick exercise prescriptions for hyponatremia (EAH) and exercise- specific medical conditions 1158 associated postural hypotension (EAHE) 1139 Introduction 1158 Etiology of EAH and EAHE 1139 Obesity 1160Other causes of exercise-related collapse in Cardiovascular disease 1160hot weather 1141 Myocardial infarction 1161Heat acclimatization 1142 Post–cardiac surgery 1161 Cardiac insufficiency 116259 Exercise at the extremes of cold Hypertension 1163and altitude 1146 Hyperlipidemia 1164Generation of body heat 1146 Chronic obstructive pulmonary disease 1164Heat loss 1146 Asthma 1164 Minimizing heat loss 1146 Diabetes 1165Measurement of body temperature 1147 End-stage renal disease 1166Effects of hypothermia 1147 Cancer 1166 Cardiovascular effects 1147 Arthritis 1167 Respiratory effects 1147 Low back pain 1168 Other effects 1147 Promotion of bone health and prevention ofGeneral principles of managing hypothermia 1147 fall-related fractures (for patients diagnosed Clinical features of hypothermia 1148 with osteoporosis) 1168Methods to achieve rewarming 1148 Parkinson’s disease 1169 Passive rewarming 1148 Depressive symptoms 1169 Active rewarming 1148 Other rewarming methods 1148Treatment of hypothermia in sport 1149 PART Practical sports medicine Treatment of mild hypothermia 1149 E Treatment of moderate hypothermia 1149 61 The preparticipation physical ly Treatment of severe hypothermia 1149 Treatment of immersion hypothermia 1149 evaluation 1176 onFrostbite 1150 Objectives 1176 Superficial frostbite—management 1150 Setting the tone 1176 Deep frostbite—management 1150 s Specific objectives 1176Prevention of cold injuries 1150 Who should undergo the PPE? 1178 geExercise and physical activity at altitude 1151 Who should perform the PPE? 1178 Itinerary—ascent rate 1151 When to perform the PPE? 1178 pa Previous altitude history 1151 Where to conduct the PPE? 1178 Patient characteristics and previous medical What to include in the PPE? 1179 history 1152 History 1179 e General preventive measures 1153 Physical examination 1179 pl Prophylactic medications 1154 Diagnostic tests 1179 Specific issues for sportspeople 1155 What is “clearance”? 1181 mSummary 1155 Conclusions 1182 saxxviii
    • Contents62 Screening the elite sportsperson 1185 Prevention of jet lag 1213 Timed light exposure and avoidance 1214Aims of screening an elite sportsperson 1185 Timed melatonin pills 1215 Additional benefits of screening 1185 Pre-travel sleeping schedule 1215 When should sportspeople be screened? 1186 Synergistic approach 1215The screening protocol 1186 Symptomatic treatment for jet lag 1217The medical screening 1192 The medical room 1217 Cardiovascular screening 1192 Illness 1218 Medical health 1193 Traveler’s diarrhea 1218 Baseline data collection 1194 Upper respiratory tract infections 1218Musculoskeletal screening 1194 Injury 1218 Which tests? 1194 Drug testing 1218 Imaging 1195 Local contacts 1218 Injury prevention 1195 Psychological skills 1218Performance screening 1198 Personal coping skills—sustainability 1218Advantages and disadvantages of screening 1199 Professional relationship with the 65 Medical coverage of endurance sportsperson 1199 events 1221 Education 1199 Problems 1199 Race organization 1221 The medical team 122263 Providing team care 1203 First-aid stations 1222 Medical facility at the race finish 1223The off-field team 1203 Conclusion 1225 Coaching and fitness staff 1203Pre-season assessment 1204 66 Drugs and the athlete 1228Educate team members—health literacy 1204Other essentials 1204 Non-approved substances at all times (in and Facilities 1204 out of competition) 1228 ly Record-keeping 1204 Prohibited substances all times (in and on Confidentiality 1205 out of competition) 1229 The “team clinician’s bag” 1205 Anabolic agents 1229 Being part of the “team chemistry” 1206 Peptide hormones, growth factors and s related substances 1237 ge64 Traveling with a team 1208 Beta-2 agonists 1241 Hormone antagonists and modulators 1242Preparation 1208 Diuretics and other masking agents 1242 pa Things to do before travel 1208 Prohibited methods at all times (in and Assessing team members’ fitness prior out of competition) 1243 to departure 1209 e Enhancement of oxygen transfer 1243 Advice for team members 1209 Chemical and physical manipulation 1244 pl The medical bag 1210 Gene doping 1245 Clinician’s hip bag 1212 m Prohibited substances in-competition 1248 Self-preparation 1212 Stimulants 1248 saAir travel and jet lag 1212 Narcotics 1250 Pathophysiology 1212 Cannabinoids 1251 xxix
    • Conte nts Glucocorticosteroids 1251 67 Ethics and sports medicine 1261Substances prohibited in particular sports Conflict of interest 1261in-competition 1252 The clinician’s duty: the team or the Alcohol 1252 sportsperson? 1263 Beta blockers 1252 Local anesthetic injection andTherapeutic use of a prohibited substance administration of analgesics 1263(therapeutic use exemption) 1252 Short-term gain, long-term pain 1264Permitted substances 1253 Informed consent 1264Recently deleted drugs 1253 Guidelines for resolution of conflict of Caffeine 1253 interest 1265Non-intentional doping in sports 1254 Confidentiality 1265Drug testing 1254 The media 1266 Testing procedure 1254 Performance-enhancing drugs 1266The role of the team clinician 1256 Infectious diseases 1268 Ethics in sport 1268 Index 1271 ly on s ge pa e pl m saxxx
    • Preface“Helping clinicians help patients” has been the clear focus of Clinical Sports Medicine from its inception.This fourth edition (CSM4) builds unashamedly on its 20-year history. Twenty-year history? The more than100 contributing authors average 15 years of practical experience each, so you are holding well over 1500 yearsof distilled clinical wisdom in your hand! If you will permit us some level 5 evidence (expert opinion—see all-new Chapter 3), CSM4 provides clini-cians in sports and exercise medicine and physiotherapy/physical therapy at least five major benefits:• The wholehearted commitment from leading clinical faculty from all over the English-speaking world means that CSM4 provides the reader with an authoritative text—you can trust these authors.• At 1270 pages and 67 chapters, CSM4 already carries 25% more pages than the best-selling third edition. Our ruthless editing to focus on clinical relevance means this edition contains 40% new material. CSM4 provides a comprehensive base for your clinical library. We provide some specific examples below.• With more than 1000 color images (photos and graphics), the book paints a million words (1000 pictures each painting 1000 words!) over and above its 1270 pages! More than 200 of those images are new to this edition—customized for CSM4’s learners—further extending the book’s clarity and usability.• Every copy of CSM4 comes with a code that gives you online access to more than four hours of assess- ment and treatment video and audio material. Called Clinical Sports Medicine masterclasses, this material is integrated with the text and will be free of charge to book owners for 12 months from registration at www.clinicalsportsmedicine.com. You have “the expert in the room.”• Reflecting the expanding evidence base for our field, we include an introduction to evidence-based practice (Chapter 3). All authors aimed to incorporate the best available level of evidence via text, tables, and current references. The online content of CSM4 will benefit from regular updates, adding further to the usefulness of this text for busy clinicians. lyIn short, CSM4 provides excellent value as an authoritative clinical foundation for physiotherapists, medicalpractitioners, osteopaths, massage therapists, podiatrists, sports/athletic trainers, sports therapists, fitness onleaders, and nurses. It has also proven popular for students in sports physiotherapy, medicine, and humanmovement studies/kinesiology. sEditors and authors geAs the task of editing a book of this magnitude was beyond the two of us, the CSM4 reader now benefits fromthe wisdom and productivity of seven sports and exercise medicine greats—Roald Bahr, Steven Blair, Jill Cook, paKay Crossley, Jenny McConnell, Paul McCrory, and Timothy Noakes. The quality of our chapter authors, representing more than 14 countries, grows with each edition. Amongour all-star cast, we are particularly grateful to Håkan Alfredson, Elizabeth Arendt, Carl Askling, Kim Bennell, eJohn Drezner, Richard Frobell, Per Holmich, Mark Hutchinson, Gwen Jull, Pekka Kannus, Ben Kibler, plNicola Maffulli, Lorimer Moseley, George Murrell, Kevin Singer, and Willem van Mechelen. m sa xxxi
    • Pre fa ceNew chaptersThe new chapters in this edition are:Chapter 1 Sports and exercise medicine: addressing the world’s greatest public health problemChapter 3 Integrating evidence into clinical practice to make quality decisionsChapter 4 Sports injuries: acuteChapter 5 Sports injuries: overuseChapter 16 Principles of physical activity promotion for cliniciansChapter 23 Wrist painChapter 24 Hand and finger injuriesChapter 28 Hip-related painChapter 45 Military personnelChapter 47 Medical emergencies in the sporting contextChapter 48 Sudden cardiac death in sportChapter 52 Renal symptoms during exerciseChapter 54 Exercise to treat neurological diseases and improve mental healthA plethora of new, clinically relevant contentHere is just a sampler of new approaches to specific “hot topics” with a few of the contributing authors:• The all-new Chapter 28 Hip-related pain clarifies the concept of femoroacetabular impingement (FAI), its diagnosis and management• The latest concussion guidelines based on the Zurich consensus meeting (with Paul McCrory)• A fully revamped discussion of neck pain (with Gwen Jull)• Further tips on management of tendinopathies (with Jill Cook, Hakan Alfredson, and Ben Kibler)• Discussion of whether ACL injuries should be managed operatively or conservatively (with Richard Frobell and Liza Arendt)• A revolution in pain science and its implications for clinical practice (with Lorimer Moseley)• How to prevent hamstring problems from being a major burden—prevention and treatment strategies ly (with Carl Askling and Anthony Schache) on• A practical approach to leg pain, including compartment pressure testing (with Mark Hutchinson and a demonstration on the masterclasses website)• How to manage the patient who has seen everyone—and now wants a miracle cure from you (with s Jim Macintyre) ge• Prevention of sudden cardiac death and a practical approach to sports cardiology (with Jon Drezner and Sanjay Sharma) pa• Exercise in the heat as well as prevention of hyponatremia (with Tim Noakes)• Drugs—based on latest WADA guidelines We could have made this list much longer but instead we use a toll-free part of the Clinical Sports Medicine emasterclasses website (www.clinicalsportsmedicine.com) to take you on a tour. pl No single profession has all the answers required to treat the ill or injured sportsperson and to provideexercise advice as needed. CSM4 was created by a champion team of co-authors and critical reviewers tre- mmendously committed to the vision of “Helping clinicians help patients.” We are confident that whatever yourtraining, Clinical Sports Medicine fourth edition will reinforce and refine existing knowledge and techniques, saand introduce useful new approaches for your clinical practice as well as for your teaching of our wonderfulvocation. Enjoy this first hybrid print and digital Clinical Sports Medicine.xxxii
    • About the authors Team physician Socceroos, 2007–10, Asian Cup Finals 2007, World Cup Finals 2010 Australian Olympic Team, Atlanta 1996, Sydney 2000 Australian Commonwealth Games teams, Edinburgh 1986, Kuala Lumpur 1998 Australian team, World Student Games, Edmonton 1983, Kobe 1985, Zagreb 1987 Australian Athletics team 1990–2000, World Championships Tokyo 1991, Gothenburg 1995, Seville 1999 Australian team, World Cup Athletics, Havana 1992 Australian Mens Hockey team 1995–96 Australian team, World Swimming Championships, Madrid 1986 Melbourne Football Club (AFL) 1987–90Peter Brukner Collingwood Football Club (AFL) 1996OAM, MBBS, DRCOG, FACSP, FASMF, FACSM, FFSEM Editorial boards Clinical Journal of Sport MedicineSports physician The Physician and SportsmedicineHead, Sports Medicine and Sports Science, Liverpool Football Club, UK Current Sports Medicine ReportsFounding Partner, Olympic Park Sports Medicine British Journal of Sports Medicine Centre, Melbourne, Australia Editor lyAssociate Professor, Centre for Health, Exercise and Sports Medicine, The University of Melbourne Sport Health 1990–95 onHonorary Fellow, Faculty of Law, The University of Co-author Melbourne Food for Sport 1987Adjunct Professor, School of Human Movement s Studies, The University of Queensland Stress Fractures 1999 geAdjunct Professor, Liverpool John Moores University, Drugs in Sport—What the GP Needs to Know 1996, UK 2000 The Encyclopedia of Exercise, Sport and Health 2004 paVisiting Associate Professor, Stanford University, USA 1997 Essential Sports Medicine 2005Executive Member, Australian College of Sports Clinical Sports Anatomy 2010 e Physicians 1985–2000 Awards plPresident, Australian College of Sports Physicians 1991–92, 1999–2000 Medal of the Order of Australia 2006 mBoard of Trustees, American College of Sports Inaugural Honour Award, Australian College of Sports Medicine 2000–02 Physicians 1996 saState and Federal Council Member, Sports Medicine Citation Award, American College of Sports Medicine Australia 1984–90 2000 xxxiii
    • Abou t th e a uth o r s Research Evaluation Committee, American College of Sports Medicine 2005–07 Scientific Subcommittee, Aspetar Hospital, Doha, Qatar 2011– Team physician Olympic Games Sydney 2000, Basketball Competition Venue Australian Women’s Basketball (The Opals) 1991–96 The Australian Ballet Company 1991–96 The Australian Ballet School 1991–96 Australian team, World Student Games 1993 Australian team, Junior World Cup Hockey 1993 Editorial boards BMJ (International Advisory Board) 2008–Karim Khan Scandinavian Journal of Medicine and Science in SportMD, PhD, MBA, FACSP, FSMA, DipSportMed, FACSM, 2007– FFSEM(Hon) British Journal of Sports Medicine (North American Editor) 2005–07Sports physician Journal of Science and Medicine in Sport 1997–2001Professor, University of British Columbia, Vancouver, Canada (Department of Family Practice and School Year Book of Sports Medicine 2008–10 of Kinesiology); Associate Member, Departments of Clinical Journal of Sport Medicine 2003–06 Physical Therapy, and Orthopaedics Editor-in-chiefExecutive Associate Director, Centre for Hip Health and Mobility, Vancouver, Canada British Journal of Sports Medicine 2008–Principal Fellow with title Professor, School of Sport Health 1995–97 ly Physiotherapy, The University of Melbourne, Co-author Melbourne, Australia Physical Activity and Bone Health 2001 onVisiting Professor, School of Human Movement Studies, The University of Queensland, Brisbane, The Encyclopedia of Exercise, Sport and Health 2004 Australia Selected awards sClinical Professor, Centre for Musculoskeletal Studies, Prime Minister’s Medal for Service to Australian Sport ge School of Surgery, University of Western Australia, 2000 Perth, Australia Sports Medicine Australia Fellows’ Citation forExercise is Medicine Committee, American College Service 2005 pa of Sports Medicine Honorary Fellowship, Faculty of Sports and ExerciseMedical Education Committee, American College of Medicine (Ireland) 2011 Sports Medicine 2002–04 e pl m saxxxiv
    • EditorsRoald Bahr PhD Mechanical Engineering and Physiotherapy, TheProfessor of Sports University of Melbourne; Australian Olympic Team Medicine, Norwegian Physiotherapist, Sydney 2000 School of Sport Sciences, Oslo Sports Trauma Jenny McConnell AM, Research Center; Chair, FACP, BAppSci(Physio), Department of Sports GradDipManTher, Medicine, Olympic MBiomedEng Training Center, Norway Director, McConnell and Clements Physiotherapy, Sydney, Australia; Visiting Senior Fellow, Centre forSteven Blair, PED Health, Exercise and SportsProfessor, Department Medicine, The University of of Exercise Science Melbourne, Australia and Epidemiology and Biostatistics, Public Paul McCrory MBBS, Health Research Center, PhD, FRACP, FACSP, University of South FFSEM, FACSM, FASMF, Carolina, USA GradDipEpidStats Associate Professor, Centre for Health, ExerciseJill Cook PhD, and Sports Medicine, GradCertHigherEd, The University of GradDipManip, BAppSci Melbourne, Australia; (Phty) Brain Research Institute, Florey NeurosciencesProfessor and Principal Institutes, The University ly Research Fellow, of Melbourne; Australian Centre for Research into Department of Sports Injury and its Prevention (ACRISP)—an IOC on Physiotherapy, School Research Centre Collaboration of Primary Health Care, Monash University, Timothy Noakes OMS, s Melbourne, Australia MBChB, MD, DSc, ge FACSM(Hon), FFSEM (UK)Kay Crossley BAppSci(Physio), PhD Sports Physician and pa Exercise Physiologist,Physiotherapist, Olympic Discovery Health Professor Park Sports Medicine of Exercise and Sports Centre, Melbourne, Science, University of Cape e Australia; Associate Town and Sports Science Professor, School of pl Institute of South Africa, Health and Rehabilitation Cape Town, South Africa Sciences, The University m of Queensland; Principal Research Fellow, Dept sa xxxv
    • Co-authorsJason Agosta BAppSc (Podiatry) Carl Askling PhD, PTPodiatrist, private practice, East Melbourne; Vice-President, Swedish Sports Trauma Research Podiatrist, Essendon Football Club and Melbourne Group; Swedish School of Sport and Health Storm (Rugby League) Sciences and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm,Håkan Alfredson MD, PhD SwedenOrthopaedic Surgeon, Professor Sports Medicine Unit, University of Umeå, Sweden Christian Barton PT, PhD Research Supervisor, Queen Mary University ofHashel Al Tunaiji MBBS, MSc London, Centre for Sports and Exercise MedicineSport Medicine Physician; Postdoctoral Fellow, Centre for Hip Health and Mobility, University of Simon Bell FRCS, FRACS, FAOrthA, PhD British Columbia (UBC), Vancouver, Canada; Family Associate Professor, Monash University and Medicine, UBC, Abu Dhabi, United Arab Emirates Melbourne Shoulder and Elbow Centre,Julia Alleyne BHSc(PT), MD, CCFP, FACSM, Orthopaedic Surgery, Melbourne, Australia; Head DipSportMed(CASM) of the Upper Limb Unit, Orthopaedic Department, Division of Surgery, Monash Medical Centre,Associate Clinical Professor; Chair Sport Medicine Monash University; President of the Victorian Fellowship, Department of Family and Community Shoulder and Elbow Society; Senior Research Medicine, University of Toronto; Medical Director, Fellow, Centre for Health, Exercise and Sports Sport CARE, Women’s College Hospital, Toronto; Medicine, The University of Melbourne Chair, Education Commission FIMS; Canadian Olympic Committee, Medical Staff, Salt Lake City Kim Bennell BAppSc(Physio), PhD 2002, Turin 2006, Beijing 2008, Vancouver 2010, Professor, Centre for Health, Exercise and Sports Chief Medical Officer London 2012 Medicine, Department of Physiotherapy, TheJock Anderson MBBS, FRANZCR, FRACSP(Hon) University of MelbourneAssociate Professor, University of New South ly Chris Bradshaw MBBS, FACSP Wales; Member International Skeletal Society and Australasian Musculoskeletal Imaging Group; Head Physician, Olympic Park Sports Medicine on Director of Medical Imaging at Sydney 2000 Centre, Geelong Campus; Team Physician, Geelong Olympic and Paralympic Games; Director of Football Club (AFL); Former Team Physician Fulham Medical Imaging for Rugby World Cup, Australia Football Club (EPL), Track and Field Australia, s 2003 Olympic Games, Sydney 2000; ACSP Board of ge Censors, Board of ExaminersElizabeth Arendt MD, FACSM Shane Brun PhDOrthopaedic Surgeon; Professor, Vice Chair pa Department of Orthopaedic Surgery, University of Associate Professor, Musculoskeletal and Sports Minnesota, USA; Past Team Physician USA Soccer Medicine, Clinical Skills Unit, School of Medicine and USA Women’s Hockey; Task Force on Women’s and Dentistry, James Cook University, Townsville, e Issues, NCAA Medical Safeguards Committee; Australia pl Current chair of AAOS Women’s Health Issues Advisory Board Dennis Caine PhD Professor, University of North Dakota, Department of mMaureen C. Ashe BScPT, MSc, PhD Physical Education, Exercise Science and Wellness, saAssistant Professor, University of British Columbia; Grand Forks, USA; Associate Editor, British Journal of Family Practice, Vancouver, Canada Sports Medicinexxxvi
    • Co -authorsNick Carter MB ChB, MRCP Jennifer Davis PhDConsultant in Rheumatology and Rehabilitation, Canadian Institutes of Health Research Postdoctoral Medical Defence Services, Medical Rehabilitation Fellow; Health Economist/Epidemiologist, Centre, Headley Court, UK University of British Columbia, Centre for Clinical Epidemiology and Evaluation, SchoolNavin Chandra MRCP, MBBS, BSc of Population and Public Health, Vancouver,Cardiology Specialty Registrar, Cardiology, London Canada Deanery, North-West Thames, London, UK Tony J Delaney RFD, MBBS, FACSPJacqueline Close MBBS, MD, FRCP, FRACP Sports Physician, Narrabeen Sports and ExerciseConsultant Geriatrician, Prince of Wales Hospital, Medicine Clinic, Academy of Sport, Sydney; Visiting Department of Geriatric Medicine, Sydney, Senior Specialist, Sports Medicine Clinic, 1st Health Australia; Principal Research Fellow, Neuroscience Support Battalion, Holsworthy Military Area and Research Australia; Conjoint Associate Professor, Fleet Base East Health Centre, New South Wales, The University of New South Wales Australia; Chair, Australian Defence Force Sports,Phil Coles BAppSc(Physio), MSc(Sports Physio) Rehabilitation and Musculoskeletal Consultative Group; Past Senior Medical Officer, 1st CommandoHead of Physical Therapies Department, Regiment Liverpool Football Club, UK; APA Titled Sports Physiotherapist; CSP Jon Drezner MDNatalie Collins BPhysio(Hons I), PhD Associate Professor, Department of Family Medicine,NHMRC Postdoctoral Research Fellow, Department University of Washington, Seattle, USA; Vice- of Mechanical Engineering, The University of President, American Medical Society for Sports Melbourne; Physiotherapist, Olympic Park Sports Medicine; Team Physician, Seattle Seahawks and Medicine Centre, Melbourne, Australia UW HuskiesWendy L. Cook MD, MHSc, FRCPC Jiri Dvorak MDGeriatrician, Clinical Instructor, Division of Geriatric FIFA Chief Medical Officer; Senior Consultant, ly Medicine, Faculty of Medicine, University of British Spine Unit, Schulthess Clinic Zurich; Associate Columbia, Vancouver, Canada Professor Neurology, University of Zurich, on SwitzerlandRandall Cooper BPhysio, MPhysio, FACPSpecialist Sports Physiotherapist, Olympic Park Lars Engebretsen MD, PhD Sports Medicine Centre, Melbourne, Australia; Professor, Department of Orthopaedic Surgery, s Physiotherapist, Australian Winter Olympics team, Oslo University Hospital and Faculty of Medicine, ge Torino, Italy 2006 University of Oslo and Oslo Sports Trauma ResearchSallie Cowan BAppSci(Physio), GradDipManipTher, Center, Norway; Head Physician Norwegian Olympic Center (Olympiatoppen); Head Scientific pa PhD Activities, International Olympic Committee (IOC);Senior Research Fellow, Musculoskeletal Physiotherapist, School of Physiotherapy, Past President ESSKA The University of Melbourne, Australia e Peter J. Fazey PT, MT, FACP plGavin Davis MBBS, FRACS (Neurosurgery) Specialist Musculoskeletal Physiotherapist, TheAssociate Professor Neurosurgery, Cabrini Hospital, Centre for Musculoskeletal Studies, School of m Melbourne, Australia; Chairman, Department of Surgery, Faculty of Medicine, Dentistry and Surgical Specialties, Cabrini Hospital; Consultant Health Sciences, University of Western Australia; sa Neurosurgeon, Austin and Box Hill Hospitals; President of the Australian College University of Notre Dame, Australia of Physiotherapists xxxvii
    • Co -au thor sBruce B. Forster MSc, MD, FRCPC Sandy Hoffmann, MD, FACSM, CAQProfessor and Head, Department of Radiology, Associate Clinical Professor Sports Medicine, Idaho Faculty of Medicine, University of British Columbia, State University; Team Physician, Idaho State Vancouver, Canada; Regional Medical Director, University, Pocatello, Idaho, USA Medical Imaging, Vancouver Coastal Health Per Holmich MDRichard Frobell PhD Orthopaedic Surgeon, Associate ResearchAssistant Professor, Department of Orthopedics, Professor, Copenhagen University Hospital, Medical Faculty, Lund University, Sweden Arthroscopic Center Amager; Associate Professor ofAndrew Garnham MBBS, FACSP Anatomy, University of Copenhagen, DenmarkConjoint Clinical Senior Lecturer, School of Exercise and Nutrition Sciences, Deakin University, Karen Holzer MBBS, FACSP, PhD Burwood, Australia; Past President of the Sports Physician, Melbourne, Australia; NHMRC Australasian College of Sports Physicians Senior Research Fellow, Department ofRobert Granter BSocSci, Respiratory Medicine, Royal Melbourne Hospital; AdDipRemMass(Myotherapy) Australian Team Doctor, World Track and Field Championships, Helsinki 2005, and OlympicSoft Tissue Therapist, Victorian Institute of Sport, Games, Beijing 2008 Melbourne, Australia; Head of Massage Therapy Services, Australian Olympic Team 1996 and 2000; Mark R. Hutchinson MD, FACSM Head of Massage Therapy Services, Melbourne Professor of Orthopaedics and Sports Medicine 2006 Commonwealth Games and Head Team Physician, University of Illinois atPeter T. Gropper MD, FRCSC Chicago, Chicago, Illinois; Head Team Physician, WNBA Chicago Sky; Volunteer Event Physician,Clinical Professor, Department of Orthopedic LaSalle Bank Chicago Marathon, Chicago, Illinois, Surgery, University of British Columbia, Vancouver, USA Canada Zafar Iqbal MBBS, BSc, DCH, DRCOG, MRCGP, lyCallista Haggis, MAP MSc(SEM), DipPCRResearch Consultant, Centre for Hip Health and on First Team Doctor, Liverpool FC; Sports and Exercise Mobility, University of British Columbia, Vancouver, Medicine Physician, Liverpool, UK Canada Gwendolen Jull MPhysio, PhD, FACPPeter Harcourt MBBS, DipRACOG, FACSP, FSMA s Professor, Division of Physiotherapy, School of HealthSports Physician; Medical Director, Victorian Institute ge and Rehabilitation Sciences, The University of of Sport; Australian Olympic Games Medical Team Queensland, Brisbane, Australia 1992–2004; Head, Commonwealth Games Medical pa Team, 2006 Pekka Kannus MD, PhDMatthew Hislop MBBS, MSc, FACSP Chief Physician, Injury and Osteoporosis Research Center, UKK Institute, Tampere, Finland; AssociateSport and Exercise Medicine Physician, Brisbane e Professor (Docent) of Sports Medicine, University Sports and Exercise Medicine Specialists, of Jyväskylä, Finland; Visiting Professor, Department pl Brisbane, Australia; Joint Team Physician, Brisbane of Orthopedics and Rehabilitation, University of Broncos (NRL); Team Physician, Reds Rugby Vermont College of Medicine, Burlington, Vermont, m Academy USA saxxxviii
    • Co -authorsJon Karlsson MD, PhD Theresa Lee, PhD, MBBS (Hons 1), FRANZCRProfessor of Orthopaedics and Sports Traumatology, Consultant Radiologist, PRP Diagnostic Imaging, Senior Consultant, Professor, Sahlgrenska Sydney, Australia University Hospital, Department of Orthopaedics, Mark Link MD, FACC, FHRS Gothenburg, Sweden Professor of Medicine, Tufts University School ofJoanne Kemp BAppSci(Physio), MSportsPhysio Medicine, Tufts Medical Center, Cardiac ArrhythmiaAPA Sports Physiotherapist; Principal Physiotherapist Center, Boston, MA, USA and Director, Bodysystem Physio, Hobart, Tasmania, Teresa Liu-Ambrose PhD, PT Australia; PhD Candidate, The University of Assistant Professor, University of British Columbia, Melbourne, Australia School of Rehabilitation Sciences, Division ofW. Ben Kibler MD, FACSM Physical Therapy; Head, Exercise and Cognitive Function Unit, Centre for Hip Health and Mobility,Medical Director, Lexington Clinic Sports Medicine Vancouver, Canada Center, The Shoulder Center of Kentucky, Section of Orthopedic Surgery, Lexington Clinic, Lexington, Zuzana Machotka MPhysio(Musc and Sports), KY, USA BPhysio Clinical Researcher/Physiotherapist, InternationalMary Kinch HDST(PhysEd), BAppSc(Physio) Centre for Allied Health Evidence, University ofPhysiotherapist, Olympic Park Sports Medicine South Australia, Adelaide, Australia; Australian Centre, Melbourne, Australia; APA Titled Sports Paralympic Winter Team Physiotherapist; Clinical Pilates Physiotherapist Jim Macintyre MD, MPE, FACSM, DipSportsMedZoltan Kiss MBBS, FRACP, FRANZCR, DDU Primary Care Sports Medicine, Center of OrthopedicSenior Fellow (Hon), Faculty of Medicine, Dentistry and Rehabilitation Excellence, Jordan Valley and Health Sciences, The University of Melbourne, Medical Center, West Jordan, Utah Australia; Consultant Radiologist, Melbourne, Erin M Macri BSc(Kin), MPT ly Australia Registered Physical Therapist; Masters of Science onMichael S. Koehle MD, MSc, CCFP, Candidate in Experimental Medicine, University DipSportMed(CASM) of British Columbia, Centre for Hip Health andSport Physician, Clinical Assistant Professor, Allan Mobility, Vancouver, Canada s McGavin Sports Medicine Centre, Department Nicola Maffulli MD, MS, PhD, FRCS(Orth) ge of Family Practice, University of British Columbia, Professor of Sports and Exercise Medicine, Vancouver, Canada Consultant Trauma and Orthopaedic Surgeon, Queen Mary University of London, Barts and The paJonas Kwiatkowski, BSc London School of Medicine; Centre for SportsResearch Assistant, Vancouver General Hospital, and Exercise Medicine, Mile End Hospital, Centre for Hip Health and Mobility, Vancouver, London, UK e Canada Michael Makdissi BSc(Hons), MBBS, PhD, FACSP plAndrew Lambart BAppSc(Physio) Sports Medicine Physician, Olympic Park SportsPhysiotherapist, Olympic Park Sports Medicine m Medicine Centre, Melbourne, Australia; NHMRC Centre, Melbourne, Australia; Team Physiotherapist, Training Fellowship, Melbourne Brain Centre, sa Hawthorn Football Club (AFL); Australian Olympic Florey Neurosciences Institute, The University of Team Physiotherapist, Athens 2004 Melbourne, Australia xxxix
    • Co -au thor sChris Milne BHB, MBChB, DipObst, DipSportsMed, Anthony Schache BPhysio(Hons), PhD FRNZCGP, FACSP Physiotherapist, Olympic Park Sports MedicineSports Physician, Anglesea Sports Medicine, Centre and Richmond Football Club (AFL), Hamilton; Olympic Team Physician, New Zealand Melbourne, Australia; Research Fellow, Hugh Williamson Gait Laboratory, Royal Children’sHayden Morris MBBS, DipAnat, FRACS Hospital, Melbourne and Centre for Health ExerciseOrthopaedic Surgeon, Olympic Park Sports Medicine and Sports Medicine, The University of Melbourne, Centre, Melbourne, Australia AustraliaLorimer Moseley PhD Alex Scott BSc(PT), PhD, RPTProfessor of Clinical Neurosciences and Chair of Assistant Professor, Department of Physical Therapy, Physiotherapy, University of South Australia, University of British Columbia, Vancouver, Canada Adelaide, Australia; Visiting Senior Research Fellow, Neuroscience Research Australia Sanjay Sharma BSc, MD, FRCP, FESC Professor, St George’s University of London,George Murrell MBBS, DPhil Department of Cardiovascular Sciences, London,Professor and Director, Department of Orthopaedic UK; Medical Director, London Marathon; Surgery, St George Hospital Campus, The University Consultant Cardiologist for Cardiac Risk in the of New South Wales, Sydney, Australia Young; Cardiology Advisor for the English Institute of Sport, Lawn Tennis Association and EnglishBabette Pluim MD, PhD, MPH, FFSEM (UK, Ire) Rugby LeagueSports Medicine Physician, Royal Netherlands Lawn Tennis Association, Amersfoort, the Netherlands; Catherine Sherrington MPH, BAppSc, PhDDeputy Editor, British Journal of Sports Medicine NHMRC Senior Research Fellow, Musculoskeletal Division, The George Institute for Global Health,Joel M. Press MD Sydney, AustraliaProfessor, Physical Medicine and Rehabilitation, Feinberg/Northwestern School of Medicine; Karin Grävare Silbernagel PT, ATC, PhD ly Medical Director, Spine and Sports Rehabilitation Postdoctoral Researcher, Spencer Laboratory, Centers, Rehabilitation Institute of Chicago, USA; Department of Mechanical Engineering, University on Reva and David Logan Distinguished Chair of of Delaware, USA Musculoskeletal Rehabilitation Kevin P. Singer PhD, PTMichael Pritchard BMedSci, MBBS (Hons), FRACS Physiotherapist; Professor and Head of the Centre s (Orth) for Musculoskeletal Studies, School of Surgery, The geOrthopaedic Surgeon, St Johns Hospital, Hobart, University of Western Australia, Perth, Australia Australia Meena M. Sran BSc(PT), MPhysioSt(Manips), PhD paDouglas Race BPE, MA candidate Researcher and Physiotherapist, BC Women’sResearch Technician, Bone Health Research Group, Hospital and Health Centre, Movement Essentials Department of Orthopedic Engineering, University Physiotherapy; Vice-President, International e of British Columbia, Vancouver, Canada Organization of Physical Therapists in Women’s pl Health, Vancouver, CanadaStephan Rudzki MBBS, GradDipSportSc, MPH, PhD, FACSP Cameron Stuart BASc mBrigadier, Australian Defence Force, Joint Health Research Assistant, Centre for Hip Health and sa Command; Director General Army Health Services, Mobility, University of British Columbia, Vancouver, Canberra, Australia Canadaxl
    • Co -authorsHasan Tahir BSc, MBBS, Dip SEM, FRCP Evert Verhagen PhDConsultant Physician in Acute Medicine and Assistant Professor, VU University Medical Center, Rheumatology, Whipps Cross University Hospital EMGO Institute for Health and Care Research, NHS Trust; Department of Rheumatology, Clinical Department of Public and Occupational Health, Lead for Acute Medicine, Biological Therapies and Amsterdam, The Netherlands Research; Professor of Medicine, St Matthew’s University Hospital, London, UK Bill Vicenzino PhD, MSc, BPhysio, GradDipSportPhysioLarissa Trease BMedSci(Hons), MBBS(Hons), Professor of Sports Physiotherapy and Head of FACSP Physiotherapy, School of Health and RehabilitationSport and Exercise Medicine Physician, Olympic Park Sciences, The University of Queensland, Brisbane, Sports Medicine Centre, Melbourne, Australia; Chief Australia Medical Officer, Australian Paralympic Team, Beijing 2008. Nick Webborn MBBS Sports Physician and Medical Adviser to the BritishMichael Turner MB BS, MD, FFSEM (UK and Ireland) Paralympic Association; The Sussex Centre for SportChief Medical Adviser, Lawn Tennis Association, and Exercise Medicine, University of Brighton, UK Eastbourne, UKWillem van Mechelen MD, PhD, FACSM, FECSS Charlotte Yong-Hing MDDepartment Head of Public and Occupational Department of Radiology, Vancouver General Health, Co-director EMGO Institute, VU University Hospital, University of British Columbia, Canada Medical Center, Amsterdam, The Netherlands Vanessa Young BSc, MBChB (Otago) Wellington Hospital, Wellington, New Zealand; International Exchange Scholar 2010, Centre for Hip Health and Mobility, Vancouver, Canada ly on s ge pa e pl m sa xli
    • Other contributorsAlex Bennett MRCP, PhD Nick Gardiner BSc(Hons) Sports Therapy, PGCHE,Consultant Rheumatologist, Defence Medical MSST Rehabilitation Centre, Headley Court, UK BSc Sports Therapy Course Leader at London Metropolitan University(LMU); Founder of FitMario Bizzini PT, PhD For Sport, Sports Therapy and Injury Clinic, London,Research Associate, FIFA—Medical Assessment and UK Research Centre (F-MARC) and Schulthess Clinic, Zurich, Switzerland Pierre Guy MD, MBA Associate Professor and Clinician-Scientist/Michael Bresler MD Orthopedic Surgeon, Department of Orthopaedics,Section Chief, Department of Musculoskeletal Center for Hip Health and Mobility University of MRI, Vice Head for Clinical Operations, Assistant British Columbia, Vancouver, Canada Professor of Radiology, University of Illinois College of Medicine, University of Illinois Medical Center, Astrid Junge PhD Chicago, Il, USA Head of Research, FIFA—Medical Assessment and Research Centre (F-MARC) and Schulthess Clinic,Malcolm Collins PhD Zurich, SwitzerlandChief Specialist Scientist, South African Medical Research Council; Associate Professor, UCT/MRC Carol Kennedy BScPT, MClSc(manip), FCAMPT Research Unit for Exercise Science and Sports Treloar Physiotherapy Clinic, Vancouver, Canada Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Syx Langemann BFA South Africa Blackframe Studios Photography, Vancouver, CanadaEmma Colson BAppSc(Physio), Moira O’Brien FRCPI, FFSEM, FFSEM(UK), FTCD, GradDipManipPhysio FECSS, MAAPA Sports and Musculoskeletal Physiotherapist, Professor Emeritus of Anatomy, Trinity College Topbike Physio, Melbourne, Australia Dublin, Ireland; Osteoporosis and Sports Medicine lyRobert Jan de Vos MD, PhD Consultant at Euromedic Dundrum, Rockfield Medical Campus, Ballaly, Dundrum, Dublin; onSports Physician (Registrar), The Hague Medical President, Irish Osteoporosis Society Centre, Department of Sports Medicine, Leidschendam, The Netherlands John Orchard BA, MD, PhD, FACSP, FACSM, FFSEM (UK) sScott Fraser BSc, PT, DipSport Physiotherapy Sports Physician, Adjunct Associate Professor, geAllan McGavin Sports Medicine and Physiotherapy University of Sydney, School of Public Health, Centre, War Memorial Gym, University Boulevard, Sydney, Australia Vancouver, Canada pa Nadia PiccoAngie Fearon PhD Candidate, BAppSc(Phyiso), MPhysio Senior Graphic Designer, Digital Printing and Graphic Services, The Media Group, University of British eAustralian National University, College of Medicine, Columbia, Vancouver, Canada Biology and the Environment; The Canberra pl Hospital, Trauma and Orthopaedic Research Unit, Cyrus Press MD Canberra, Australia m Chief Resident, University of Illinois Medical Center, Department of Orthopaedic Surgery, Chicago, Il, sa USAxlii
    • O ther contr ibutorsCraig Purdam MSports Physio The illustratorHead of Physical Therapies, Australian Institute of Sport, Canberra, Australia; Olympic Team Vicky Earle B Sc (AAM), MET, Cert TBDL Physiotherapist 1984–2000; Adjunct Professor, University of Canberra; APA Specialist Sports PhysiotherapistAnn Quinn PhD, MSc, BAppSc, DipEd, DipNutr.Peak Performance Specialist; Director, Quintessential Edge, London, UKAaron Sciascia MS, ATC, NASM-PES Program Coordinator, Lexington Clinic Sports Medicine Center; Coordinator of The Shoulder Center of Kentucky, USAIan Shrier MD, PhD, DipSportMed, FACSMAssociate Professor, Department of Family Medicine, McGill University; Centre for Clinical Epidemiology and Community Studies, SMBD-Jewish General Hospital, Montreal, Quebec, Canada; Past-President, Canadian Academy of Sport and Exercise MedicineAndy Stephens BAppSci(Physio) Medical Illustrator, The Media Group, University ofPhysiotherapist, Olympic Park Sports Medicine British Columbia, Vancouver, Canada Centre, Melbourne, Australia Vicky is a highly experienced medical illustrator whoKent Sweeting BHlthSc(Pod)(Hons) has been involved in the design and production ofPodiatrist and Director, Performance Podiatry and a wide variety of surgical procedural and medical ly Physiotherapy; Lecturer, Queensland University illustrations that have been used in journals, books, of Technology, School of Public Health, Brisbane, conferences, lectures, and legal presentations. on Australia Her keen interest in Clinical Sports Medicine stemsPaul Thompson MD, FACC, FACSM not only from a great appreciation of the human body and its capabilities, but also from a decadeMedical Director of Cardiology and The Athletes’ s of racing experience as a championship rower Heart Program, Preventive Cardiology, Hartford and paddler—and knowing first-hand the many ge Hospital, Connecticut, USA injuries that accompany these activities.Susan White MBBS(Hons), FACSP, FASMF paSports Physician, Olympic Park Sports Medicine Centre, Melbourne, Australia; Chief Medical Officer, Swimming Australia; Member, Medical e Commission, Australian Olympic Committee; pl Medical Director Australian Team, Youth Olympic Games 2010 m sa xliii
    • Acknowledgments No need to apologize, let me look at what needs to be done. Immediate email response from an extremely busy co-author when asked to contribute to this fourth edition.This completely updated print and online resource is unashamedly founded on the previous three editions.To date, this text has satisfied more than 80 000 clinicians and provided core material for students who fo-cus on the care of active people in Australia, New Zealand, Africa, Asia, Europe, and the Americas. Japanesereaders have their own translation. The overwhelming support for this clinically based textbook means we areparticularly indebted to our partners in all previous editions. Specific thanks for the fourth edition go to chapter co-authors listed with their affiliations on pages xxxvi–xli.Expert co-authors provide the crucial innovation and timeliness that Clinical Sports Medicine users demand.We are both humbled and privileged to be sharing cover authorship with seven amazing colleagues andfriends—Drs Cook, Crossley, McConnell, Bahr, Blair, McCrory, and Noakes (ladies first, of course). We wouldlove to have listed more names on the cover but the designer overruled us on that one! A further 109 co-authorsmade this book happen. It takes a community to create Clinical Sports Medicine—and we are grateful for everysingle member of that hardworking international community. Because this edition fully embraces digital media, we especially acknowledge those co-authors who contrib-uted to this innovation. Particular thanks go to Dr Mark Hutchinson, and the team in Chicago, for providingcritical and substantial content for the online masterclasses. Vicky Earle has gained international recognition for her artwork; thank you for continuing to translateclinical innovation in ways that jump to life for users. The University of British Columbia (Department ofFamily Practice—Faculty of Medicine as well as Faculty of Education) provided essential support (KK), as didthe Olympic Park Sports Medicine Centre, The University of Melbourne and Liverpool Football Club (PB). lyClinical Sports Medicine benefits from the continuity, consistency, and integration honed over two decades,and from the expertise and freshness of cutting-edge international chapter authors. We seek out the world’s onbest and we appreciate their responding to our calls! It has been a pleasure to work with every member of theClinical Sports Medicine 4th edition team. We give special thanks to our publishing team, who efficiently developed Brukner and Khan dreaming sinto the book you hold in your hands: publishing director Nicole Meehan, who has been a visionary leader; gepublishers Elizabeth Walton and Fiona Richardson; production editors Yani Silvana and Jess Ní Chuinn; andfreelance editor Jill Pope. McGraw-Hill’s support of all our crazy ideas has allowed us to generate a few good paones; thanks for your judgment and filtering! Within the authors’ multi-faceted production team in threecountries, Zuzana Machotka and Callista Haggis earn special thanks—for their skill, attention to detail, andgood humor even under pressure. Finally, axiomatically, the most profound thanks we reserve for our long- esuffering friends and families: Diana and Heather, we both know that words are not enough! pl m saxliv
    • Guided tour of your bookThe principal text in its field, this fourth edition of Clinical Sports Medicinecontinues to provide readers with quality, up-to-date content. The engagingmaterial has been contributed by leading experts from around the world.Look out for these key features, which are designed to enhance your learning.Integrated learning resourcesNew to this editionis the ClinicalSports Medicinewebsite containingmasterclasses withvideo and audiocontent. ly on The authors have worked with specialists to For easy reference, a summary of the online film key clinical procedures, including video content (where relevant) is given at the end clips demonstrating physical examinations, of P A R Tchapter.Fundamental pr inciples each A s key rehabilitation exercise programs, and joint ge CliniCal sports mediCine 4. Nilsson J, Thors injections. Much of this video content has been mAsTeRclAsses at different spee W commissioned for this edition. w w w. c l i n i c a l s p o r t s m e d i c i n e . c o m Acta Physiol Sca pa • Listen to the interview with chapter authors. 5. Franz JR, Paylo • See demonstration of biomechanical assessment. coordination of www www.clinicalsportsmedicine.com. • See a demonstration of the original low-Dye technique locomotion. Ga augmented with reverse sixes and calcaneal slings 6. Pohl MB, Buckl e Wherever this icon appears in the book, go anchored to the lower leg. coupling due to pl running. Clin B to the website to view a video or listen to a Recommended websiTes 334–41. podcast. Access is via the pincode card located Barton CJ, Bonanno D, Menz HB. Development and 7. Mann RA, Baxt m evaluation of a tool for the assessment of footwear Foot Ankle 1981 in the front of the book. characteristics: www.ncbi.nlm.nih.gov/pmc/articles/ 8. Williams KR. B sa PMC2678108/?tool=pubmed Rev 1985;13:389 9. Ferber R, Davis Recommended ReAding differences in lo Barton CJ, Bonanno D, Menz HB. Development and running. Clin B evaluation of a tool for the assessment of footwear 10. Riley PO, Della characteristics. J Foot Ankle Res 2009;23(2):10. lower extremity Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, xlv speed. Gait Post Cullison TR. The effect of foot structure and range 11. Rodgers MM. D of motion on musculoskeletal overuse injuries. Am J
    • Gu ide d tou r o f yo ur bookFirst-class contentAs with previous editions the emphasis is on treatment and rehabilitation. The chapters in Part B, whichaddress regional problems, are heavily illustrated with clinical photos, relevant imaging, and anatomicalillustrations. ly on s ge pa e pl m saxlvi
    • Guided tour of your bookThe list of world-renowned contributorshas grown even longer in this edition andbrings a truly global perspective to the book. Practice pearls are a valuable feature that provide clinical tips and important information to keep in the forefront of your mind. Co-authors Jason Agosta BAppSc (Podiatry) Carl Askling PhD, PT PRAC in the large majority of hamstring strains, the Podiatrist, private practice, East Melbourne; Vice-President, Swedish Sports Trauma Research injured muscle is biceps femoris (reported as TICE P Podiatrist, Essendon Football Club and Melbourne Group; Swedish School of Sport and Health Storm (Rugby League) Sciences and Department of Molecular Medicine Håkan Alfredson MD, PhD Orthopaedic Surgeon, Professor Sports Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden EARL 76–87%).5 semimembranosus injury is Unit, University of Umeå, Sweden Hashel Al Tunaiji MBBS, MSc Christian Barton PT, PhD Research Supervisor, Queen Mary University of uncommon; semitendinosus injury is rare. London, Centre for Sports and Exercise Medicine Sport Medicine Physician; Postdoctoral Fellow, Centre for Hip Health and Mobility, University of Simon Bell FRCS, FRACS, FAOrthA, PhD British Columbia (UBC), Vancouver, Canada; Family Associate Professor, Monash University and Medicine, UBC, Abu Dhabi, United Arab Emirates Melbourne Shoulder and Elbow Centre, Julia Alleyne BHSc(PT), MD, CCFP, FACSM, Orthopaedic Surgery, Melbourne, Australia; Head DipSportMed(CASM) of the Upper Limb Unit, Orthopaedic Department, Division of Surgery, Monash Medical Centre, Associate Clinical Professor; Chair Sport Medicine Monash University; President of the Victorian Fellowship, Department of Family and Community Shoulder and Elbow Society; Senior Research Medicine, University of Toronto; Medical Director, Fellow, Centre for Health, Exercise and Sports Sport CARE, Women’s College Hospital, Toronto; Medicine, The University of Melbourne Chair, Education Commission FIMS; Canadian Olympic Committee, Medical Staff, Salt Lake City Kim Bennell BAppSc(Physio), PhD Chapter 3 2002, Turin 2006, Beijing 2008, Vancouver 2010, Professor, Centre for Health, Exercise and Sports Integrating evidence into Chief Medical Officer London 2012 Medicine, Department of Physiotherapy, The Jock Anderson MBBS, FRANZCR, FRACSP(Hon) University of Melbourne Associate Professor, University of New South Wales; Member International Skeletal Society and Australasian Musculoskeletal Imaging Group; Chris Bradshaw MBBS, FACSP Head Physician, Olympic Park Sports Medicine clinical practice to make quality decisions Director of Medical Imaging at Sydney 2000 Centre, Geelong Campus; Team Physician, Geelong Olympic and Paralympic Games; Director of Football Club (AFL); Former Team Physician Fulham Medical Imaging for Rugby World Cup, Australia Football Club (EPL), Track and Field Australia, 2003 Olympic Games, Sydney 2000; ACSP Board of Censors, Board of Examiners wit h C ath er ine S h er r ington Elizabeth Arendt MD, FACSM Shane Brun PhD Orthopaedic Surgeon; Professor, Vice Chair Randomized trials are for clinicians who are uncertain as to whether they are right or not— Department of Orthopaedic Surgery, University of Associate Professor, Musculoskeletal and Sports and I am certain I am right. Sir ian Chalmers, quoting an unnamed orthopedic surgeon Minnesota, USA; Past Team Physician USA Soccer Medicine, Clinical Skills Unit, School of Medicine and USA Women’s Hockey; Task Force on Women’s and Dentistry, James Cook University, Townsville, Issues, NCAA Medical Safeguards Committee; Australia this chapter opens with an exercise we use to arthritis. the students are given the information in Current chair of AAOS Women’s Health Issues introduce the concept of evidence-based practice to the box (below) and are asked to suggest a treatment Advisory Board Dennis Caine PhD final-year students in human movement sciences/ for Mrs J. Professor, University of North Dakota, Department of kinesiology (i.e. non-clinicians). if you are an experi- in our student exercise we call for a vote and Maureen C. Ashe BScPT, MSc, PhD Physical Education, Exercise Science and Wellness, enced clinician or an expert on evidence-based prac- every year the first ballot results in option 1 (surgery) Assistant Professor, University of British Columbia; Grand Forks, USA; Associate Editor, British Journal of tice you may want to skip over this chapter! receiving about 80% of the votes! We then lead an Family Practice, Vancouver, Canada Sports Medicine the “case” for the students to consider involves open-class discussion and emphasize that the quality Mrs J, a 55-year-old woman. Students are told she of the data should carry more weight than the clinical presents with persistent knee pain due to osteo- training of the person providing the advice. Students xxxvi Which evidence carries most weight? Wo m e n and ac tiv it y-re late d issu e s ac ro ss th e life sp an Chapter 43 You are asked to advise Mrs J, a 55-year-old woman 3. A published study examined patients who had with knee osteoarthritis, as to whether or not knee presented with knee pain to a specialist in oste- syndrome. Cochrane Database Syst Rev 2009;4(2): arthroscopyeis a goode s You have your own per- R e f R e n C idea. oarthritis two years earlier. One group of patients CD001396. sonal opinion,BA, Birch LL. Five-year-old following four 1. Abramovitz and you obtain the girls’ ideas had undergone arthroscopic surgery, the other 15. Yonkers KA, Brown C, Pearlstein TB et al. Efficacy of pieces ofdieting are predicted by their mothers’ dieting. about further information. Which of the four had not. Patients who had undergone surgery a new low-dose oral contraceptive with drospirenone options carries the most weight with you? Would you J Am Diet Assoc 2000;100(10):1157–63. reported playing more golf and tennis than those who had not undergone disorder. Obstetsurgery. The in premenstrual dysphoric arthroscopic Gynecol ly advise that J, Alen M, Nicholson P et al. Growth patterns 2. Wang Q surgery is a good idea? 2005;106(3):492–501. 1. Dr distal radius and tibialsurgeon, advises in a 2-year at X, an expert knee shaft in pubertal girls: favor of paper concluded that surgery was associated 16. Steiner M, Hirschberg AL, Bergeron R et al. Luteal surgery because “IBone Miner Reshundreds of these longitudinal study. J have done 2005;20(6):954–61. with superior outcomes compared to conserva- phase dosing with paroxetine controlled release (CR) in operations and obtained good or excellent results 3. Bailey DA, Heather AD, McKay HA et al. Calcium tive management. the treatment of premenstrual dysphoric disorder. Am J in over 90% of them.” The surgeon offers you and 4. A physiotherapy student obtained ethics approval accretion in girls and boys during puberty: Obste Gynecol 2005;193(2):352–60. your friend the phone numbers of patients who to attend doctors’ offices and recruit patients with on a longitudinal analysis. J Bone Miner Res 2000;15(11):The importance of evidence-based practice can provide testimonials. You call a few of these 17. knee osteoarthritis. The surgeon decided to allo- Benagiano G, Carrara S, Filippi V. Safety, efficacy 2245–50. patients and they all vouch for surgery. cate patient satisfaction with continuous daily or “no and patients randomly to either “surgery” 4. Bailey DA, Wedge JH, McCulloch RG et al. administration of levonorgestrel/ethinylestradiol oral 2. A published study of cases done by another surgery.” Two years later, the student interviewed Epidemiology of fractures of the distal end of the radius surgeon, Dr Y, shows that 75% of patients who have the patients again and found that 2009;3: contraceptives. Patient Prefer Adherence both groups of in children as associated with growth. J Bone Joint Surgis emphasized, with a new chapter on this had this type of surgery reported improvements. 131–43. patients (those who had had surgery and those Am 1989;71A(8):1225–31. 18. who had not) had similar levels of pain and function. Krishnan S, Kiley J. The lowest-dose, extended-cycle Overall 75% of patients had an “excellent or good” 5. Faulkner RA, McCulloch RG, Fyke SL et al. outcome. Patients were recruited and interviewed Both groups had pain scores with continuousout of combined oral contraceptive pill of around 50 Comparison of areal and estimated volumetric bone ethinyl estradiol in the United States: a review of the two years after the surgery. 100 where 100 is severe pain.topic. In addition, there is a comprehensive list density values between older men and women. literature on ethinyl estradiol 20 μg/levonorgestrel s Osteoporosis Int 1995;5(4):271–5. 100 μg + ethinyl estradiol 10 μg. Int J Womens Health C 6. Torstveit MK, Sundgot-Borgen J. Participation in 2010;2:235–9. leanness sports but not training volume is associated 19. Wanichsetakul P, Kamudhamas A, Watanaruangkovit P 11of references at the end of every chapter. with menstrual dysfunction: a national survey of ge et al. Bone mineral density at various anatomic bone 1276 elite athletes and controls. Br J Sports Med sites in women receiving combined oral contraceptives 2005;39(3):141–7. and depot-medroxyprogesterone acetate for 7. Thomis M, Claessens AL, Lefevre J et al. Adolescent contraception. Contraception 2002;65(6):407–10. growth spurts in female gymnasts. J Pediatr 20. Rome E, Ziegler J, Secic M et al. Bone biochemical 2005;146(2):239–44. markers in adolescent girls using either depot 8. Warren MP, Brooks-Gunn J, Fox RP et al. Osteopenia medroxyprogesterone acetate or an oral contraceptive. in exercise-associated amenorrhea using ballet dancers J Pediatr Adoles Gynecol 2004;17(6):373–7. pa as a model: a longitudinal study. J Clin Endocrinol Metab 21. De Souza MJ. Menstrual disturbances in athletes: 2002;87(7):3162–8. a focus on luteal phase defects. Med Sci Sports Exerc 9. Bennell KL, Malcolm SA, Thomas SA et al. Risk 2003;35(9):1553–63. factors for stress fractures in track and field athletes – 22. Prior JC, Vigna YM. Ovulation disturbances and a twelve-month prospective study. Am J Sports Med exercise training. Clin Obstet Gynecol 1991;34(1): 1996;24(6):810–18. 180–90. 10. Loud KJ, Gordon CM, Micheli LJ et al. Correlates of 23. Williams NI, Bullen BA, McArthur JW et al. Effects of stress fractures among preadolescent and adolescent short-term strenuous endurance exercise upon corpus girls. Pediatrics 2005;115(4):e399–406. luteum function. Med Sci Sports Exerc 1999;31(7): e 11. Frankovich RJ, Lebrun CM. Menstrual cycle, 949–58. contraception, and performance. Clin Sports Med 24. Petit MA, Prior JC, Barr SI. Running and ovulation 2000;19(2):251–71. positively change cancellous bone in premenopausal 12. Janse de Jonge XA. Effects of the menstrual cycle on women. Med Sci Sports Exerc 1999;31(6):780–7. pl exercise performance. Sports Med 2003;33(11):833–51. 25. Malina RM, Spirduso WW, Tate C et al. Age at 13. Bryant M, Cassidy A, Hill C et al. Effect of consumption menarche and selected menstrual characteristics in of soy isoflavones on behavioural, somatic and affective athletes at different competitive levels and in different symptoms in women with premenstrual syndrome. sports. Med Sci Sports Exerc 1978;10(3):218–22. Br J Nutr 2005;93(5):731–9. 26. Nattiv A, Puffer JC, Green GA. Lifestyles and health m 14. Wyatt KM, Dimmock PW, O’Brien PM. Selective risks of collegiate athletes: a multi-center study. Clin J serotonin reuptake inhibitors for premenstrual Sport Med 1997;7(4):262–72. 931 931 sa xlvii
    • sa m pl e pa ge s on ly
    • ly Part A on Fundamental s ge principles pa e plmsa 1
    • Chapter 1Sports and exercise medicine:addressing the world’s greatestpublic health problemwith Je nnifer Davis and steven B la i r Exercise in the prevention of coronary heart disease: today’s best buy in public health. Jeremy Morris, 1994the three previous editions of Clinical Sports Medicine benefits than smoking cessation or losing weight.5focused on how to practice sports and exercise medi- numerous systematic reviews expound the manycine. this chapter takes us back one step to “why?” health benefits of physical activity, but systemicWhy practice sports and exercise medicine? reviews are complex, predictable, and unemotional— a perfect combination for boring the general publicThe burden of physical inactivity and and policy makers alike.sedentary behavior However, brief slogan-like (“sticky”) messagesWhere to start? surf the web, read any magazine, (see also Chapter 16 for more on “sticky messages”)look around you as you walk down the street. the are useful in helping convince people that physi-problem of physical inactivity is not subtle, and this cal activity is a remarkable medical therapy. somechapter aims to provide a launching pad for the include:sports clinician—a key agent in the war against phys- • For health, daily walking (30 minutes) is eight timesical inactivity. as powerful as losing weight. • Physical activity provides twice the health benefits as lythe one trillion dollar argument giving up smoking.5, 6(Us alone!) on • Low fitness kills more Americans than doesthe year 2000 seems like antiquity, but even then ‘smokadiabesity’—smoking, diabetes, and obesityphysical inactivity cost the Us $1 trillion annually.1 combined.7this information gained enormous exposure and the sfundamental data and methods that underpin those these sticky messages reflect data from steven gecalculations still apply. Methods to analyze economic Blair’s epidemiological study at the Cooper instituteburden of disease have been refined,2 updated, and in texas (fig. 1.1).5 note that “attributable fraction”expanded3 to include many additional costs. thus, the refers to the proportion of deaths in the population pacosts of physical inactivity can only have increased in that are due to the specific risk factor. it differs fromthe past decade (table 1.1). note that a week of physi- “individual level” risk profiling.cal inactivity is estimated to incur the same health ecosts as a week of smoking.4 the molecular mechanisms that explain pl the health benefits of physical activityPhysical fitness—more health benefits experimental and mechanistic data shows howthan smoking cessation or weight loss m physical activity promotes health at the cellular andHaving identified that physical inactivity is a problem, subcellular level. some examples of exercise-induced sawe can look for a solution. How can the problem of health benefits at the molecular level that manyphysical inactivity be addressed? Physical activity! it patients find interesting and that can help motivateis known that physical fitness provides more health some are shown in the box opposite.2
    • Spor ts and exercise medicine Chapter 1 Table 1.1 Conditions precipitated by physical inactivity and resulting health care costs in the US Unhealthy condition Annual cost of condition in US$ A Hypertriglyceridemia Hypercholesterolemia Hyperglycemia Insulin resistance Increased thrombosis 286.5 billion Increased resting blood pressure Increased risk of myocardial ischemia Increased incidence of lethal ventricular arrhythmias Decreased cardiac stroke volume and maximal cardiac output Obesity 238 billion Type 2 diabetes 98 billion Breast and colon cancer 107 billion for all cancers Osteoporosis 6 billion Sarcopenia 300 billion for all disabilities Back pain 28 billion Gallstone disease 5 billion Decreased psychological wellbeing (cost not known) Total 1000 billion = 1 trillion ADAPTeD FrOm BOOTH eT AL. 1 This was published in 2000 so is likely to be an underestimate today. 18 Men Examples of exercise-induced health benefits at the 16 ly Women molecular levelAttributable fraction (%) 14 Preventing type 2 diabetes on 12 running on a treadmill stimulates key enzymes for 10 energy sensing/signaling, including an important one 8 called AmP kinase (AmPK). This protein helps remove s 6 fatty acids during muscular contraction and limits ge 4 fatty acid biosynthesis. exercise also enhances muscle 2 membrane glucose transport capacity by recruiting a critical transport protein, GLUT-4, to the sarcolemma and pa 0 T tubules where the protein can be active. Increasing s ity er n l es ro es io ok et the expression of GLUT-4 in skeletal muscle can be es te tn ns ab Sm es Ob rte Di ol w considered a crucial way of “mopping” glucose out of the pe ch Lo e Hy gh bloodstream and into muscle and, hence, reducing the Hi pl demand for insulin.8 Figure 1.1 Attributable fractions (%) for all- Brain function m cause deaths in 40 842 (3333 deaths) men and 1. Both resistance training and endurance (aerobic) 12 943 (491 deaths) women in the Aerobics Center training can improve brain function. Convincingly, sa Longitudinal Study. The attributable fractions are adjusted for age and each other item in the figure continued BLAIr5 3
    • PA r T A Fun damental pr inciples continued in various forms can make it very difficult for an individual to be active. although clinicians are an the improvement in brain function can be shown important part of the team that promotes physical using functional magnetic resonance imaging (fmrI) activity, society will need to make a concerted effort (Fig.1.2). at various levels. this multilevel approach has been 2. Animal studies show that improvements in brain codified as the socioecological model of behavior function arise through improved blood flow and via change (fig. 1.3).11 particular hormones, including insulin-like growth Consider the difference in likelihood of physical factor 1 (IGF-1) and “brain derived neurotrophic activity for roald in norway and a nameless inhabit- factors” (BDNF). ant of a mythical urban wasteland. roald’s govern- ment provides tax benefits for healthy behavior and he lives close to a large forest with attractive walking paths. He can ride to work safely on a dedicated bike lane. His community promotes free public cross- country skiing by grooming and lighting the paths. His friends consider skating to be a great social activity. all levels of school-age children do at least 30 minutes of exercise each day as part of the school curriculum. all five elements of the socioecologi- cal model are working toward roald and his family having an active lifestyle. the darkest hour is just before the dawn this chapter is written in a spirit of optimism. the Figure 1.2 Sophisticated contemporary brain human race has faced major challenges previously in imaging, including functional mrI and “connectivity” public health and this problem—physical inactivity— mapping (illustrated), demonstrates that brain is remediable. the remainder of this book is dedi- function improves with exercise training cated to keeping people active by preventing and treating musculoskeletal conditions in those who want to be active and by prescribing therapeutic exer-Putting it all together—the economic cise for those who have medical conditions.12imperative“exercise—the best buy in public health” concluded ly onJeremy Morris. a recent success story? not at all!that was the title of a 1994 paper!9 the evidence has Social environment Individual factors factorspiled up since then: personal, regional, and national seconomic benefits accrue to those who are physi-cally active.6, 10 But how can we encourage adoption geof this most powerful behavior—physical activity asmedicine! Individual behavior paPractical challengesPhysical activity was not a societal burden when sur- Physical Public and evival depended on it. Because we have engineered environment regulatory factorsphysical activity out of contemporary society, sedent- plary behavior is an easier choice. similarly, poverty Figure 1.3 Socioecological model of physical activity m sa4
    • Spor ts and exercise medicine Chapter 1 4. Khan KM, Davis JC. a week of physical inactivity has reCOmmeNDeD weBSITeS similar health costs to smoking a packet of cigarettes.British Journal of Sports Medicine: www.bjsm.bmj.com Br J Sports Med 2010;44(6):395. Aexercise is Medicine: www.exerciseismedicine.org 5. Blair sn. Physical inactivity: the biggest publicinternational society of Physical activity and Health: health problem of the 21st century. Br J Sports Med www.ispah.org 2009;43(1):1–2. 6. Muller-riemenschneider f, reinhold t, nocon M et al. reCOmmeNDeD reADING long-term effectiveness of interventions promotingBlair sn. Physical inactivity: the biggest public health physical activity: a systematic review. Prev Med problem of the 21st century. Br J Sports Med 2008;47(4):354–68. 2009;43(1):1–2. 7. Khan KM, tunaijia H al. as different as venus andBooth fW, Chakravarthy Mv, Gordon se, spangenburg ee. Mars: time to distinguish efficacy (can it work?). Br J Waging war on physical inactivity: using modern Sports Med 2011;45(10):759–60. molecular ammunition against an ancient enemy. 8. Booth fW, Chakravarthy Mv, Gordon se et al. Waging J Appl Physiol 2002;93(1):3–30. war on physical inactivity: using modern molecular reFereNCeS ammunition against an ancient enemy. J Appl Physiol 1. Booth fW, Gordon se, Carlson CJ et al. Waging 2002;93(1):3–30. war on modern chronic diseases: primary 9. Morris Jn. exercise in the prevention of coronary heart prevention through exercise biology. J Appl Physiol disease: today’s best buy in public health. Med Sci Sports 2000;88(2):774–87. Exerc 1994;26(7):807–14. 2. Katzmarzyk Pt, Janssen i. the economic costs 10. Muller-riemenschneider f, reinhold t, Willich sn. associated with physical inactivity and obesity Cost-effectiveness of interventions promoting physical in Canada: an update. Can J Appl Physiol activity. Br J Sports Med 2009;43(1):70–6. 2004;29(1):90–115. 11. sallis J, Owen n. ecological models. in: Glanz K, 3. Davis JC, Marra Ca, robertson MC et al. economic lewis f, rimer B (eds). Health behavior and health evaluation of dose-response resistance training in older education. san francisco: Jossey-Bass, 1997:403–24. women: a cost-effectiveness and cost-utility analysis. 12. Khan KM, Weiler r, Blair sn. Prescribing exercise in Osteoporos Int 2011;22(5):1355–66. primary care. BMJ 2011;343:d4141. ly on s ge pa e pl m sa 5 5
    • Chapter 3Integrating evidence intoclinical practice to makequality decisionswi th C at Herine sHerrinGtOn Randomized trials are for clinicians who are uncertain as to whether they are right or not—and I am certain I am right. sir ian Chalmers, quoting an unnamed orthopedic surgeonthis chapter opens with an exercise we use to arthritis. the students are given the information inintroduce the concept of evidence-based practice to the box (below) and are asked to suggest a treatmentfinal-year students in human movement sciences/ for Mrs J.kinesiology (i.e. non-clinicians). if you are an experi- in our student exercise we call for a vote andenced clinician or an expert on evidence-based prac- every year the first ballot results in option 1 (surgery)tice you may want to skip over this chapter! receiving about 80% of the votes! We then lead an the “case” for the students to consider involves open-class discussion and emphasize that the qualityMrs J, a 55-year-old woman. students are told she of the data should carry more weight than the clinicalpresents with persistent knee pain due to osteo- training of the person providing the advice. students Which evidence carries most weight? You are asked to advise mrs J, a 55-year-old woman 3. A published study examined patients who had ly with knee osteoarthritis, as to whether or not knee presented with knee pain to a specialist in oste- arthroscopy is a good idea. You have your own per- oarthritis two years earlier. One group of patients on sonal opinion, and you obtain the following four had undergone arthroscopic surgery, the other pieces of further information. which of the four had not. Patients who had undergone surgery options carries the most weight with you? would you reported playing more golf and tennis than those s advise that surgery is a good idea? who had not undergone arthroscopic surgery. The ge 1. Dr X, an expert knee surgeon, advises in favor of paper concluded that surgery was associated surgery because “I have done hundreds of these with superior outcomes compared to conserva- operations and obtained good or excellent results tive management. pa in over 90% of them.” The surgeon offers you and 4. A physiotherapy student obtained ethics approval your friend the phone numbers of patients who to attend doctors’ offices and recruit patients with can provide testimonials. You call a few of these knee osteoarthritis. The surgeon decided to allo- e patients and they all vouch for surgery. cate patients randomly to either “surgery” or “no pl 2. A published study of cases done by another surgery.” Two years later, the student interviewed surgeon, Dr Y, shows that 75% of patients who have the patients again and found that both groups of m had this type of surgery reported improvements. patients (those who had had surgery and those Overall 75% of patients had an “excellent or good” who had not) had similar levels of pain and function. sa outcome. Patients were recruited and interviewed Both groups had pain scores of around 50 out of two years after the surgery. 100 where 100 is severe pain. 11
    • PA r T A Fun damental pr inciplesreview the options and many begin to see the limita- ‘Evidence-based practice’ is the integration oftions of options 1, 2, and 3. the evidence in option 4 best research evidence with clinical expertiseis designed to mimic an important randomized trial and patient values—Dave Sackettthat addressed this question.1 (We deliberately avoidthe word “randomized” as students are sensitized tothis being important, even before they really under-stand study design.) Patient concerns the aim of this introduction to the course is forstudents to link quality of evidence and decisionmaking. this sounds axiomatic, but our experienceover many years reinforces that at first students fail EBP*to distinguish “evidence” from “eminence.” students Best Clinicalfind this practical exercise much more meaning- research expertise evidenceful than a soporific lecture on “research methods.”students are then primed to engage with the lit-erature with a view to making “quality decisions”together with patients. Figure 3.1 Schematic illustration of how clinical skills, evidence from research, and patient desire shouldLife before evidence-based practice overlap to provide the “quality decision” for the patientClinicians trained after the year 2000 might be sur- * evidence-based practiceprised that the term “evidence-based medicine” first PubMed, the “best evidence” is that a well-conductedappeared in 1991.2 Professor Paul McCrory describes randomized controlled trial (rCt), systematic review,that dark period before as a time of “eminence-based or meta-analysis (fig. 3.2) suggests that arthroscopypractice” but he jests. nevertheless, a certain amount is no better than placebo. the pieces of evidence pro-of clinical training relied on wisdom passing down vided in options 1 to 3 in the boxed item on page 11from mentor to mentor. When clinical trials were represent a much lower level of evidence—data withfew, the opinionated veteran was king. this is under- much greater potential for bias and, hence, poten-standable in an emerging field. tially flawed conclusions. However, “evidence” is not synonymous with randomized trials alone. if there isSackett and the McMaster contribution a question about clinical prognosis, or patient expe-Dr David sackett and colleagues from McMaster ly riences, the best evidence comes from other studyUniversity3–5 described a pedagogical approach to designs.6 (see also recommended reading.)evidence-based practice (fig. 3.1). this type of health on Different study designs provide different qualitycare reflects “the conscientious, explicit and judicious evidence (fig. 3.2). the levels in this figure mapuse of current best evidence in making decisionsabout the care of individual patients. evidence- sbased practice integrates individual clinical expertise gewith the best available clinical evidence from sys-tematic research.”5 since the mid 1990s, evidence- Systematicbased practice has been facilitated by the Cochrane reviews ce pa enCollaboration (www.cochrane.org), which conducts vid feand publishes high-quality systematic reviews of ran- yo Randomized controlled tdomized trials of effects of interventions to address a ali trials (RCTs) e Quwide range of health problems. Cohort studies pl applying sackett’s approach to the case of Mrs J(boxed item p. 11), we note that many patients with that Case-controlled studies mclinical presentation have been encouraged to have Case series/reportsimmediate arthroscopy, based on “expert opinion.” sathey have not been provided with the full range of Background information/expert opinionoptions that have been evaluated in research. armedwith the information that is freely available through Figure 3.2 Hierarchy of study designs12
    • I ntegrating e vidence into clinical prac tice Chapter 3closely, but not perfectly, to the Oxford “levels of evid- original definition of evidence-based practice.7ence” shown in table 3.1. We use the Oxford levels of Unfortunately, some “radical” advocates of pseudo-evidence in this book. evidence-based practice forget the importance of the patient’s wishes and your clinical evaluation,Table 3.1 Levels of evidence and they focus purely on the evidence component. if given license, those folk (usually non-practicing) ALevel of evidence Study design disempower clinicians who work with real people;Level 1 Systematic review of homogenous these radicals devalue clinicians’ previous experience rCTs, individual rCT with narrow and patient wishes. if you are a clinician, don’t be confidence interval disempowered. embrace evidence-based practice asLevel 2 Individual cohort study or low- additional value for your patients. quality rCT Evidence-based practice helps you distinguishLevel 3 Individual case-control studies, PrAC evidence from propaganda (advertisement), TICe P non-consecutive cohort study probability from certainty, data from assertions, rational belief from superstitions, and, ultimately, eArLLevel 4 Case series science from folklore.8Level 5 expert opinion By incorporating new evidence, your skills are continually updated—you are not stuck in a timeThis seems obvious—so what is the warp where you practice today as you did in your yearproblem? of graduation!evidence-based practice has intrinsic appeal; however, in summary, the health professions combine theexecution is the challenge. there are not enough art of caring for people with the best that scienceindividual rCts, let alone systematic reviews or has to offer. the healing part can be likened to themeta-analyses, to provide a body of evidence for every community “shaman”—or healer. the patient’s per-clinical encounter. for example, your patient might spective and wishes are critical to reaching a “qualitybe an elite athlete who earns over Us $150 000 per decision.” the days of paternalism should be behindweek; however, unfortunately, the relevant rCt was us. and remember that the plural of “anecdote” isconducted in recreational athletes whose only reward not “data”!9was pleasure. in summary, the purpose of this chapter is to also, clinical trials only provide data on “average provide a perspective on evidence-based practice and lyeffects” of interventions; your clinical experience to encourage interested readers to follow up with theirmeans you can adjust those average effects to esti- own searches on the topic. Use the recommended onmate what might happen in an individual patient. reading below. evidence-based practice and clini-for example, a highly motivated individual might be cal reasoning form key parts of the curriculum forexpected to do better than average with an exercise students in all health disciplines; this chapter is not sintervention—where compliance is important. meant to provide a comprehensive text for that! enjoy ge in your office, you need to marry three things— your evidence-based practice classes and rememberthe patient’s wishes, the clinical evaluation you that the key is to integrate clinical acumen with theperformed to make a diagnosis, and the evidence evidence to meet the patient’s needs (fig. 3.1)! that pa(fig. 3.1). these elements were all part of sackett’s way you’ll make quality clinical decisions! e pl m sa 13
    • PA r T A Fun damental pr inciples 4. sackett Dl, rosenberg WM. On the need for evidence- reCOmmeNDeD weBSITeS based medicine. Health Econ 1995;4(4):249–54. Centre for evidence-Based Medicine: www.cebm.net 5. sackett Dl, straus s, richardson WM et al. Evidence- the Cochrane Collaboration: www.cochrane.org based medicine: how to practice and teach EBM. london: Churchill livingstone, 2000. reCOmmeNDeD reADING 6. Herbert r, Jamtvedt G, Mead J et al. Practical evidence- Herbert r, Jamtvedt G, Mead J et al. Practical evidence-based based physiotherapy. edinburgh: elsevier, 2005. physiotherapy. edinburgh: elsevier, 2005. 7. sackett Dl, rosenberg WM, Gray Ja et al. evidence- based medicine: what it is and what it isn’t. BMJ reFereNCeS 1996;312(7023):71–2. 1. Kirkley a, Birmingham tB, litchfield rB et al. 8. Dawes M, summerskill W, Glasziou P et al. sicily a randomized trial of arthroscopic surgery statement on evidence-based practice. BMC Med Educ for osteoarthritis of the knee. N Engl J Med 2005;5(1):1. 2008;359(11):1097–107. 9. McCrory P. research realpolitik. Br J Sports Med 2. Guyatt G. evidence-based medicine. ACP Journal Club 2002;36(1):1. 1991;a-16:144. 3. sackett Dl. evidence-based medicine. Lancet 1995;346(8983):1171. ly on s ge pa e pl m sa1414
    • Chapter 28Hip-related painwith Joanne keMP, kay Crossley, a nThony sChaChe,a nd M ike Pr iTChardBo says he felt his hip come out of the socket, so he popped it back in, but that’s just impossible, no one’s that strong. Bo Jackson’s trainer after the american football and baseball all-star dislocated his hip when tackled during the 1990 nFl playoffsuntil recently, the hip joint was not thought to be a a reduced ability to participate in sporting or physi-significant cause of problems in the athletic popula- cal activities as well as pain and also reduced functiontion, although hip disorders have long been recog- during activities of daily living. There is also consider-nized in the pediatric population (Perthes disease, able evidence that hip pathologies are strong contribu-slipped femoral epiphysis) and older people (osteo- tors to hip, groin, and pelvic pain in young adults.12, 13arthritis). it was not until the advent of, firstly, Mri, Burnett et al.14 demonstrated that 92% of patientsand then hip arthroscopy, that it was realized that the with an arthroscopically confirmed labral tear com-incidence of hip labral and acetabular rim pathology plained of moderate to severe groin pain. Philipponwas high, and that anatomical variants such as femo- et al.10 described labral tears and Fai in 100% of pro-roacetabular impingement (Fai) were a common fessional national hockey league (nhl) ice hockeyunderlying cause of groin pain. players presenting for hip arthroscopy or the treat- hip pain is a common cause of activity restriction ment of longstanding hip and groin pain. injury toin sportspeople. hip and groin pain is the third most the ligamentum teres of the hip has been cited as the lycommon injury reported in the australian Football third most common cause of hip and groin pain inleague (aFl),1 accounting for between 5 and 15% the sportsperson.15–17 onof all football-related injuries;2 it is also prevalent in in this chapter, we:many other sports, including tennis, football of all • review the functional anatomy of the hipcodes, and hockey. • provide a clinical approach to assessment of what is s The likelihood of a sportsperson sustaining an often a longstanding problem geinjury to the hip joint can be increased by the demands • detail the pathologies and management of the manyof the sport, in particular, sports that require repeti- important conditions that are now recognized totive hip flexion, adduction, and rotation.2–4 hip joint pa cause pain around the hip region.injury can also be caused by the inherent individualanatomical variations within the joint, such as Fai or This chapter should be read in conjunction with thedevelopmental dysplasia of the hip (ddh).5–11 chapter on groin pain (Chapter 29). e The range of motion of the hip is critical in deter- Functional anatomy and biomechanics plmining the likelihood of intra-articular damageduring sporting activity. The demands of range of The hip has three functions: mmotion vary between all sporting activities and the • It allows mobility of the lower limb.levels of activity. as range of motion decreases, the • It transmits loads between the upper body, trunk, sarisk of impingement-related damage increases, espe- and lower limb.cially with contact sports. • It also provides a stable base in weight-bearing intra-articular hip pathologies contribute to both activities.510
    • H ip -related pain Chapter 28The anatomical structure of the hip allows it toperform these functions. The hip joint is supported by a number ofdynamic and passive supports—these include itsbony morphology, passive restraints such as capsuleand ligaments, and a complex system of interplayingmuscle groups. The biomechanics of the hip joint aregenerally under-reported in the literature and so arepoorly understood. an appreciation of the functionalanatomy of the hip and the role of the various struc-tures surrounding the hip will assist in this under-standing (Fig. 28.1). BMorphology BThe hip joint (femoroacetabular joint) is a tri-planarsynovial joint, formed by the head of femur inferi-orly and the acetabulum superiorly. The acetabulumsits within the bony pelvis and is normally anteverted Figure 28.1 Anatomy of the hip and groin area(forward-facing) by approximately 23°18 (Fig. 28.2a (a) Plain X-ray of the pelvisoverleaf). The acetabulum also faces inferiorly andlaterally. The head and neck of the femur are also ante-verted—this refers to the most superior aspect of thefemoral head and the femoral neck (Fig. 28.2b over-leaf). This angle is normally between 10° and 15° inadults. The head of femur also faces superiorly andmedially. a reduction in either femoral or acetabularanteversion is considered to increase the risk of hippathology. The relationship between the head and neck of lythe femur, called the head–neck offset, is also veryimportant when discussing the hip joint. This refers onto the difference between the greatest diameter of thespherical femoral head and the diameter of the neckmeasured around the femoral neck axis in any plane s(Fig. 28.2c overleaf) and is normally approximately20 mm in people without hip pain.8 a reduced gehead–neck offset19 (also referred to as a cam lesion) isconsidered to increase the risk of hip pathology and pawill be discussed in detail below. The morphological structure of the hip jointallows the hip to achieve its three planes of move- (b) The hip joint ement, being flexion and extension, adduction andabduction, and external and internal rotation. pl to the bony acetabular rim. The acetabular labrum is thinnest in its anterior aspect. macetabular labrum The blood supply of the labrum enters though theThe acetabulum forms the socket of the hip joint, adjacent joint capsule. only the outer one-third of saand is lined with articular cartilage. The acetabular the labrum is vascularized.20 nocioceptive free nervelabrum (Fig. 28.3 on page 513) is a ring of fibrocar- endings are distributed throughout the acetabulartilage and dense connective tissue which is attached labrum, suggesting a pain-producing capacity.21, 22 511
    • PA R T B R egio nal problemsFigure 28.2 (a) CT showing acetabular anteversion18 2 Normal offset (between lines 1 and 2) Decreased offset 1 2 1(b) Transverse views of a normal hip (upper figure) anda dysplastic hip (lower figure)19 ly(1) Angle of torsion—rotation of the femoral neckrelative to the shaft (transcondylar axis), normally on10–15° of anteversion. Dysplastic hips usually have Normal offsetincreased angle 1 and 2) (between lines Decreased offset(2) Acetabular anteversion angle—the anterior sdirection of the acetabulum, is normally 20–40° of (c) Femoral head–neck offset19 geanteversion. Dysplastic hips usually have increased The head–neck offset is the distance between theangle but it may be decreased most superior aspect of the femoral head (line 1) and the femoral neck (line 2). Line 3 is first drawn through pa The acetabular labrum has several functions. These the long axis of the neck, then parallel lines are drawnare primarily to deepen the acetabulum, to distribute representing the superior aspect of the femoralthe contact stress of the acetabulum over a wider area head (line 1) and the femoral neck (line 2). The offset e(increasing contact area by 28%)23 and assisting in is the distance between lines 1 and 2. A decreased plsynovial fluid containment and distribution.22–24 offset (lower figure) leads to reduced clearance and subsequent impingement mligaments of the hipThe transverse acetabular ligament (Fig. 28.3) transverse acetabular ligament is under greatest load satraverses the acetabular notch, connecting the ante- in weight-bearing, widening the acetabular notchrior and posterior edges of the labrum. The deepest and placing the transverse acetabular ligament underlayer of labral tissue blend into this ligament. The a tensile load.24512
    • H ip -related pain Chapter 28 anterior inferior iliac spine rectus femoris ligament iliofemoral ligament labrum B B acetabulum transverse acetabular ligament ligamentum teres ischial tuberosityFigure 28.3 Transverse acetabular ligament, acetabularlabrum, and ligamentum teres (resected) Figure 28.4 Capsular ligaments of the hip The ligamentum teres (Fig. 28.3) is an intra-articular ligament, arising from the fovea of the headof the femur, becoming triangular in shape, with The ischiofemoral ligament arises from the pos-an anterior and posterior branch, which insert into terior surface of the acetabular rim and labrum, andthe anterior and posterior aspect of the transverse extends into the femoral neck just proximal to the lyacetabular ligament respectively.25 it is covered by the greater trochanter (Fig. 28.4). its fibers run in a spiralsynovium within the hip.15 pattern and are also taut in hyperextension. on The ligamentum teres is also rich in free nerve The iliofemoral, pubofemoral, and ischiofemoralendings, which are mechanoreceptors.26 The liga- ligaments act to restrain hyperextension, which is ofmentum teres was originally thought to be a his- particular relevance in relaxed standing. stological vestige which becomes redundant early gein childhood; however, it is now assumed that the Chondral surfacesligamentum teres plays an important proprioceptive Both articular surfaces of the hip are lined withrole, especially in weight-bearing activities.15 articular cartilage. These chondral surfaces rely upon pa The iliofemoral ligament (y ligament of Bigelow) adequate function of the synovium and movementreinforces the anterior capsule and originates from of synovial fluid within the joint to provide nutrition,the anterior iliac spine, fanning into an inverted because articular cartilage is avascular. as both the ey shape to insert into the intertrochanteric line acetabular labrum and ligamentum teres have been pl(Fig. 28.4). it is taut in hyperextension and also pro- reported to attach to the synovium, they may alsovides stability in relaxed standing. play a role in the nutrition and normal function of m The pubofemoral ligament arises from the ante- articular cartilage within the hip joint.rior surface of the pubic ramus and inserts into the saintertrochanteric fossa (Fig. 28.4). it is taut in abduc- Joint stability and normal muscle functiontion and extension, and also reinforces the anterior The bony morphology, acetabular labrum, ligamen-capsule. tum teres, other ligaments, and capsule of the hip 513
    • PA R T B R egio nal problemsjoint all provide passive stability to the hip joint. sectional area (PCsa) relative to muscle fiber lengthdynamic stability is provided by a complex inter- (MFl) (i.e. PCsa [cm²] : MFl [cm] >1.0) generateplay between various muscles surrounding the hip large forces over small length changes and, hence,joint. The concept of deep hip stabilizers, the “hip are considered to be joint stabilizers29 (Table 28.1).rotator cuff,” has been present for some years,27 but in contrast, those muscles with smaller PCsa rela-has grown in popularity in recent years. in particular, tive to muscle fiber length (i.e. PCsa [cm²] : MFlthe primary hip stabilizers are thought to provide a [cm] <1.0) are considered to be “prime movers” of aposterior, medial, and inferior force on the femur to joint. Generally the hip muscles tend to act as eithercontrol the position of the head of femur within the joint stabilizers or prime movers. however, there areacetabulum. ultimately, the dynamic control provided two muscles with both large PCsa and large MFlby the deep hip stabilizers has potential to minimize (gluteus maximus and adductor brevis), which sug-stress on vulnerable structures, such as the antero- gests that these muscles are required to act as bothsuperior acetabular labrum, and the anterosuperior stabilizers and prime movers.acetabular rim (Fig. 28.5). The six short hip external rotators (sher) (obtu- recent reports have described the roles of hip rator internus and externus, superior and inferiormuscles, with respect to muscle morphology, gemellus, quadratus femoris and piriformis) haveprimary action of joint movement, and lines of the capacity to provide hip joint compression and,action in relation to the axes of joint movement27–29 hence, dynamic stability during most weight-bearing(Fig. 28.6). some muscles have greater capacity to and non-weight-bearing activities.28, 30 The gluteusgenerate torque over larger ranges of motion (prime medius is the dominant hip abductor, and is themovers), while other muscles are better placed to act primary lateral stabilizer of the hip during one-legas dynamic hip joint stabilizers. stance activities.29 detailed descriptions of muscle morphology have For the patient with hip pain and/or pathology,increased the understanding of the potential roles the clinician should also consider the lines of actionsof individual muscles to act as dynamic hip stabil- for each of the deep hip stabilizers.28 For example,izers.29 Muscles with a larger physiological cross- although all of the sher have capacity to provide ly on s ge pa e pl m saFigure 28.5 Muscle attachments around the greater trochanter514
    • H ip -related pain Chapter 28 superficial deep anterior pectineus Primary Hip gluteus minimus Movement gluteus piriformis medius superior gemellus abduction obturator internus gluteus inferior gemellus maximus quadratus femoris external rotation extension B B rectus femoris adduction semimembranosus flexionFigure 28.6 Muscles around the hip showing their primary direction of movementTable 28.1 Hip muscles with primary function as hip stabilizer—primary and secondary actions(a) Stabilizers (PCSA [cm²] : MFL [cm] >1.0) Primary action Secondary action Gluteus maximus Extension Adduction External rotation ly Gluteus medius Abduction Extension External rotation (posterior fibers) on Internal rotation (anterior fibers) Gluteus minimus Abduction Flexion External rotation (posterior fibers) s Internal rotation (anterior fibers) ge Piriformis External rotation Abduction Quadratus femoris External rotation Adduction pa Obturator internus External rotation Inferior gemellus External rotation e Superior gemellus External rotation pl Obturator externus External rotation Adduction m Pectineus Adduction Internal rotation Semimembranosus Extension sa Rectus femoris Flexion Abduction(a) Primary action and line of action in relation to axis of movement of hip joint in the anatomical position28, 29 515
    • PA R T B R egio nal problemsdynamic hip stability in the anatomical position, other studies report symptom duration of greaterthe quadratus femoris also has a line of action that than 2 years.19 Byrd and Jones16 reported an averageis inferomedial. Therefore it has a greater capacity of 7 months from initial assessment, and multipleto resist superior translation of the hip. similarly, other diagnoses being made, before a definitive diag-the gluteus maximus and four shers (piriformis, nosis of hip pathology was made.gemellus inferior and superior, obturator internus) hip pain also commonly coexists with other groin-have a line of action that is posteromedial, and may related pathology, such as adductor symptoms, iliop-be able to resist anterior force of the hip.31 soas symptoms and pubic symptoms. This makes in contrast, although the gluteus medius is an definitive diagnosis and provision of appropriateimportant lateral stabilizer of the hip, its line of action management programs difficult and often multi-is both medial and superior28 making it the greatest factorial35 (see also Chapter 29).contributor to both medial and superior hip contact Causes of hip injuries and pain are shown inforce during walking.31 Furthermore, the anterior fibers Table 28.2. hints for differentiating hip pain fromof gluteus medius and minimus become hip internal lateral thigh pain are shown in the box below.rotators when the hip is flexed.32, 33 The relevance ofthese factors to the rehabilitation of the patient with Femoroacetabular impingementhip pain and pathology is described below. Femoroacetabular impingement (Fai) describes a morphological variant seen in approximately 20% ofClinical perspective: making sense of a the general population—it is not in itself pathology.12complex problem There are three types of Fai described.Pain related to the hip joint is commonly seen in ath-letic populations. of sportspeople with longstandingadductor-related groin pain, 94% have radiological Hints for differentiating hip joint and lateralsigns of Fai.34 of sportspeople with hip and groin thigh painpain, 22% have labral tears and 55% of people with • Groin or anterior pain plus loss of range of mechanical symptoms of the hip have confirmed movement, clicks, or catching generally means jointlabral pathology.19 pathology. however, despite this prevalence, hip-related • Lateral thigh pain plus full range of movement (once pain and associated pathologies have not been well muscle spasm is taken into account) generally meansmanaged in the athletic population until recently. lateral soft tissue structures.Weir et al.34 reported a mean duration of hip and • Both groin and lateral pain plus some joint lygroin pain in sportspeople of 22 weeks, with the restruction/signs generally means both.maximum duration 250 weeks (5 years), while many onTable 28.2 Causes of hip injuries/painCommon Less common Not to be missed sAnterior pain geSynovitis Os acetabulare Synovial chondromatosisLabral tear Ligament teres tear Avascular necrosis of head of paChondropathy Stress fracture femurOsteoarthritis Hip joint instability (hypermobility or Slipped capital/upper femoral developmental dysplasia of the hip epiphysis (SUFE) Perthes e Traction apophysitis (AIIS—rectus femoris; ASIS— sartorius; lesser trochanter—iliopsoas) Tumor plLateral painGreater trochanter pain Referred pain from lumbar spine Fracture of neck of femur m syndrome Nerve root compressionGluteus medius tears and Tumor sa tendinopathyTrochanteric bursitis516
    • H ip -related pain Chapter 28 The first type is impingement due to a cam lesion(Fig. 28.7b), sometimes referred to as a Ganz lesion.This describes the reduction in femoral head–neckoffset described previously, which results in addi-tional bone being seen at the head–neck junction.This additional bone is also referred to as the “bump.”Cam lesions are most commonly seen on the ante-rior, superior, or anterosuperior aspect of the femoralneck, and are seen in 78% of people with Fai.36 The second type of Fai seen is referred to as“pincer impingement” (Fig. 28.7c). This refers tobony change seen in the acetabulum and is seen in B B42% of people with Fai.36 This can either manifest (c) Pincer lesion—bone spur extends from the acetabular surface as a deep acetabulum, which is most commonly seen anteriorly,12, 37 or as a retroverted acetabulum, which leads to an apparent deeper anterior acetabular wall. The third type of Fai seen is the mixed presenta- tion where both cam and pincer lesions are seen; this is seen in 88% of people with Fai.36 it is unclear whether the development of cam deformity is due to overactivity at the epiphyseal plate between the femoral head and neck during periods of rapid growth in adolescents caused by repetitiveFigure 28.7 Hip joints with and without femoroace- torsional forces at the hip; or whether it is due totabular impingement (FAI) genetic tendencies. There is now some evidence that ly(a) Hip without FAI Fai has a familial pattern, with siblings being three times more likely to have Fai than controls.38 on PRAC FAI in itself is not a pathology, it is simply a variation of bony structure within the normal range seen.38–40 TICE P s EARL Of the 20% of the population with FAI, only 23% of these people complain of hip pain.36 ge Fai, however, can result in pathology causing pain when the hip joint is placed into a position of pa impingement in a repetitive fashion during sport- ing activities, or in a single major traumatic incid- ent such as a motor vehicle accident, or a large fall e when the hip is in the position of impingement. The pl incidence of radiological signs of Fai in sportspeople with longstanding adductor-related groin pain has m recently been reported as being 94%.34 The most common position of impingement is sa(b) Cam lesion flexion with internal rotation and sometimes adduc-Additional bone arises as a “bump” from the femoral tion.2, 10, 39, 40 With most cam and pincer lesionssurface located on the anterior or superior aspect of the hip, 517
    • PA R T B R egio nal problemsthese positions are most likely to bring these surfacestogether and cause impingement. several authors have postulated an associationbetween Fai and an increased likelihood of devel-oping other intra-articular hip pathologies—theseprimarily being labral tears, chondropathy, and ulti-mately osteoarthritis of the hip.5, 6, 8, 11, 38 As there is no conclusive evidence at this stage that PRAC indicates that all sportspeople with morphological features of FAI will develop hip pathology, TICE P EARL prophylactic surgery to correct deformities in athletes who do not have signs of hip pathology is not recommended. The early identification of Fai in sportspeople withhip and groin pain is essential. unfortunately, there isno gold standard in clinical diagnosis of Fai. Clinicalsigns that are often reported to indicate the presenceof Fai include reduced range of hip internal rota-tion, particularly when the hip is flexed, and a positiveFadir (flexion, adduction, internal rotation) test. Positive Fadir testing is common in Fai-relateddamage and radiological examination is required.Plain radiographs can be useful and, generally, a cor-rectly centered plain aP view of the pelvis, along withextended lateral femoral neck X-rays taken at 45° and90°—the “dunn views”—will indicate the presenceof the morphological features of Fai when read by Figure 28.9 Hip impingement during footballan experienced radiologist (Fig. 28.8). sportspeople who present with Fai and have on a day-to-day basis, as well as during athletic pur-hip or groin pain should be encouraged to avoid the suits. For example, in footballers, this may involve lyposition of impingement as much as possible. This playing in a different position which requires lessposition of impingement is usually flexion, internal time changing direction and getting down low to the onrotation and adduction, or any combination of these ball. it may also involve reducing the time spent on(Fig. 28.9). This may involve activity modification the field. Maximizing dynamic neuromotor control around the hip also assists in achieving this goal. s Normal Cam ge Factors that may contribute to the development of hip-related pain Certain factors may contribute to the development pa of hip-related pain. These factors all alter the loads on the hip joint, thus placing structures within and around the hip joint under duress, which may e Pincer Mixed eventuate in pain. These contributing factors can be pl classed as either extrinsic or intrinsic factors. m extrinsic factors extrinsic factors include the type of sports played, sa particularly those involving repeated combined hipFigure 28.8 Radiological appearances of the types flexion, abduction and adduction, and loaded rota-of FAI tional or twisting movements. extrinsic factors may518
    • H ip -related pain Chapter 28also include the volume of sport and activity under- participate in the sport without the risk of hip pain.taken, footwear worn, and type of surface played This should be assessed in both a neutral range ofupon. of these extrinsic factors, the type of sport and hip flexion, and at 90° of hip flexion.volume of load undertaken are probably the most This range can be assessed reliably with either animportant when evaluating the sportsperson with inclinometer or goniometer, with the patient pronehip-related pain. for hip neutral, and sitting for 90° of flexion, with repeated hip flexion, abduction and adduction, the contralateral thigh stabilized (Fig. 28.10b onand rotation and twisting are reported throughout the page 521).literature as influencing the likelihood of the develop-ment of hip pathology. The clinician must examine Reduced hip extensionthese loads in detail and modify them accordingly for reduced hip extension may predispose to hip pain,sportspeople who experience hip-related pain. as it is possible that loads are placed on the anterior B B margins of the joint as the sportsperson attempts tointrinsic factors gain more range during the end stage of stance inintrinsic factors can also influence the development running and gait. The anterior margins of the jointof hip pain and pathology. These factors may also are considered to be highly vulnerable to injury, andalter loads within the joint, predisposing the hip must be protected from overload. hip extensionto injury. intrinsic factors are considered as either range of motion can be measured reliably in supine“local” or “remote,” and both must be considered for position at the end of the plinth, with an inclinom-comprehensive assessment of the sportsperson with eter (Fig. 28.10c on page 521).hip-related pain. identifying these factors via thor-ough assessment is essential if the clinician is to suc- Increased femoral adduction/internal rotationcessful modify the loads within the joint to protect during functional taskspotentially vulnerable structures. increased femoral adduction and/or internal rotation during functional tasks may place the hip in a posi-local factors tion of impingement, thus increasing loads on vulner-The following local factors may contribute to the able joint margins such as the acetabular labrum anddevelopment of hip-related pain. These are shown acetabular chondral rim. This is especially importantTable 28.3 overleaf. for the patient with lost range of motion. increased femoral adduction motion should beReduced hip flexion assessed in both static and dynamic activities, such as lyreduced hip flexion may indicate the presence of Fai. a single-leg squat, walking, and running. videotapingin sportspeople with hip pain, this must be assessed the sportsperson performing functional tasks may onto ensure the sportsperson has adequate range of hip assist the clinician in identifying increased adduc-flexion to meet the demands of the sport, particularly tion/internal rotation (Fig. 28.10d on page 521).sports that involve repetitive end-range flexion (e.g. sfootball, gymnastics). remote factors ge hip flexion can be assessed reliably in supine The following remote factors may contribute to theposition, with the contralateral thigh stabilized with development of hip-related pain.a seatbelt (Fig. 28.10a on page 521), using either a pagoniometer or inclinometer. any pain experienced at Proximal factorsthe end range of flexion must be noted. increased pelvic tilt and/or lumbar hyperextension may increase the load on the anterior margins of the eReduced hip internal rotation hip, due to the more distal placement of the anterior plreduced range of hip internal rotation may also indi- acetabular rim. This increased load may be a sourcecate the presence of morphological changes such of increased hip pain and eventually anterior hip mas Fai, slipped upper femoral epiphysis (suFe), pathology. The clinical assessment of pelvic symme-Perthes, or dysplasia that may predispose the sport- try and lumbar spine is outlined in Chapter 26. sasperson to hip pathology. Many sports demand inadequate control of the lumbopelvic segmentscertain ranges of hip internal rotation, and these may result in a number of asymmetries, which alterranges must be established if a sportsperson is to the loads on the hip joint. in particular, lateral pelvic 519
    • PA R T B R egio nal problemsTable 28.3 Local factors that can contribute to the development of hip-related pain Possible mechanisms— Possible mechanisms— Factor structural functional Confirmatory assessmentsReduced hip flexion range Cam lesion Plain X-ray AP pelvis of motion Pincer impingement Dunn view 45°/90° Dysplasia Positive FADIRReduced hip internal Acetabular retroversion Plain X-ray AP pelvis rotation range of motion Reduced femoral head–neck Dunn view 45°/90° offset (cam lesion) Pincer impingement Femoral retroversion Osteoarthritis changes (osteophytes) Reduced strength hip Hand-held dynamometry internal rotators Tight gluteals and piriformis Muscle length tests Muscle spasmReduced hip extension Acetabular anteversion Plain AP X-ray range of motion Dysplasia Tightness hip flexors, Muscle length tests quadriceps Reduced hip extensor Hand-held dynamometry, strength and manual muscle tests Posterior pelvic tiltIncreased femoral Developmental dysplasia of Plain X-ray AP pelvis adduction/internal the hip Dunne view rotation motions Acetabular or femoral anteversion Reduced hip abductor Hand-held dynamometry, ly strength and manual muscle tests on Reduced hip extensor strength Reduced hip external rotator strength s Reduced neuromotor Single-leg balance challenge, ge control/proprioception and force platform patilt may increase load on both the lateral and medial for the individual’s sport must be considered, as thisstructures of the hip joint, due to the increased may predispose certain athletic groups to fatigue andadductor and internal rotation moment seen on the subsequently altered load on the hip joint. estance leg. pl Control of the hip and lumbopelvic control can Distal factorsbe assessed using the single-leg squat (Chapter 8), increased subtalar pronation may lead to an increase mother single-leg activities, and gait- or sports-specific in tibial internal rotation. This may lead to an over-activities. in some cases, the sportsperson should load on the iliotibial band and the lateral structures saalso be videotaped while running, particularly when of the hip. increased iliotibial band tension leads tofatigued, as altered control may become more pro- increased compression over the greater trochanter,nounced. The demands on the lumbopelvic region and the development of gluteus medius and minimus520
    • H ip -related pain Chapter 28 B BFigure 28.10 Assessment of local factors(a) Measurement of hip flexion range of motion (usinga simple inclinometer) (d) Increased femoral adduction and internal rotation moment tendinopathy, and trochanteric bursitis. increased tibial internal rotation may also create increased internal rotation of the femur, thus heightening load on the hip, particularly in sportspeople with an increased risk of impingement. The clinical assess- ment of the subtalar joint is outlined in Chapter 40. adequate range of ankle dorsiflexion during the ly stance phase of gait is essential in order to mini- on mize excessive loads further up the kinetic chain. if this movement is limited, the gait pattern may be altered to achieve onward forward propulsion of the(b) Measurement of hip internal rotation range of sportsperson. one adaptation commonly seen is an smotion in sitting increase in hip adduction and rotation at the middle ge of the stance phase of gait. This may increase load on the hip joint in similar ways to those outlined above. pa The clinical assessment of ankle dorsiflexion range of motion is outlined in Chapter 38. Clinical assessment e history pl it is important to obtain a full history from the patient prior to undertaking a physical examination m or obtaining any investigations. This history should include: sa • age, general health, past medical history (including(c) Hip extension range of motion presence or absence of childhood conditions such as 521
    • PA R T B R egio nal problems “clicky hips,” slipped upper femoral epiphysis (SUFE) examination or infantile dysplasia) and medications Examination of the hip is in the Clinical Sports Medicine• weight and height (BMI)—BMI >25 can increase www severity of symptoms of osteoarthritis and masterclasses at www.clinicalsportsmedicine.com. tendinopathy, as well as increase joint loads examination involves:• exact mechanism of injury (if known), including onset as sudden or insidious 1. Observation• time since onset of symptoms (a) standing• pattern of symptoms since onset (worsening, (i) general lower limb alignment improving or not changing) (ii) femoral alignment• family history—there may be a genetic (iii) pelvic symmetry predisposition to FAI and osteoarthritis of the hip38 (iv) muscle tone and symmetry• presence of mechanical symptoms such as locking, (b) walking clicking, or giving way—suspect labral or possibly (i) pain ligamentum teres pathology (ii) limp• location of pain—hip pathology may present as (iii) lateral pelvic stability—Trendelenburg groin, lower back, lateral hip, buttock, or thigh pain,41 sign and secondary sources of pain such as muscle spasm (c) supine may be present, complicating the assessment (i) leg length• nature of pain (intensity, severity, constancy, time of 2. Active movements day, latency)—will provide clues as to presence of (a) hip flexion/extension inflammation, synovitis, bursitis, or tendinopathy in (b) hip abduction/adduction addition to intra-articular pathology (c) hip internal/external rotation at both neutral• neurological signs and low back pain—the lumbar and 90° flexion spine can refer pain to the hip and should be (d) bent knee fall-out eliminated as a potential primary source of pain 3. Passive movements• aggravating factors—be specific regarding position (a) adductor muscle stretch (Fig. 28.11a) of hip and potential for impingement during these (b) anterior impingement test (hip quadrant)— activities, how long it takes for these activities to flexion, adduction, internal rotation (Fig. 28.11b) provoke pain, and latent pain (c) internal rotation at 90° flexion• current level of activity (frequency and intensity of (d) flexion, abduction, and external rotation (FABER lower limb loading)—tendon-related pain may need ly or Patrick’s test) (Fig. 28.11c) to be assessed over a period of three days (e) quadriceps muscle stretch on• factors easing pain—be specific regarding positions (f ) psoas muscle stretch/impingement (Thomas of ease as well as time required for pain to ease position) (Fig. 28.11d overleaf )• current sporting history—including level of sport 4. Tests of muscle function (community, state, national, and position played s within the team); certain positions will place the hip (a) adductor squeeze test (Fig. 28.11e overleaf ) ge under more load, such as midfield in AFL football (b) hand-held dynamometry of hip muscle strength• previous sporting history—certain sports played bilaterally may increase the likelihood of a hip injury (e.g. (i) flexion/extension pa dancing, gymnastics, martial arts, tennis, hockey) (ii) adduction/abduction• desired level of future sporting activity—this is (iii) internal/external rotation important to establish in order to determine level of (c) Real-time ultrasound assessment of deep hip e intervention as well as future risk of injury stabilizers and deep core pl• activities of daily living—including occupation, (d) de-rotation test42 (Fig. 28.11f overleaf ) length of time spent sitting, amount of hip flexion 5. Palpation m and rotation and degree of manual labor within (a) adductor muscles/tendons/entheses occupation, family situation including the presence (b) pelvis including pubis symphysis, ischial sa of young children tuberosities, proximal hamstring attachment• any past treatment, including investigations, (c) iliopsoas in muscle belly and at anterior hip conservative treatment, or surgical intervention. joint (Fig. 28.11g overleaf )522
    • H ip -related pain Chapter 28 (d) superficial hip abductors including tensor fascia lata, gluteus medius, superior gluteus maximus (e) greater trochanter and tendons of gluteus medius and minimus6. Functional movements (a) single-leg squat (Fig. 28.11h on page 525) (b) hopping (to reproduce pain) (c) forward hop (d) step up and down on the affected leg (observe stability, pain level, and pain location) (Fig. 28.11i on page 525) (e) side step up and down on the affected leg (f ) hip hitch (in neutral, internal, and external B rotation), keeping the knee extended (Fig. 28.11j on page 525) B (g) kicking (if appropriate) (h) balance and proprioception (b) Passive movement—anterior impingement (hip quadrant: flexion, adduction, and internal rotation— FADIR). This is a combined movement that is performed if hip range of motion is normal in single planes ly on s ge pa e (c) Passive movement—flexion, abduction, and external pl rotation (FABER or Patrick’s test). Range of motion, apart from extreme stiffness/laxity, is not that relevant. Some m caution needs to be exercised, as it is possible to sublux an unstable hip in this position. Pain felt in the groin is saFigure 28.11 Examination of the patient with hip- very non-specific. Pain in the buttock is more likely to berelated pain due to sacroiliac joint problems. However, pain felt over(a) Passive movement—adductor muscle stretch the greater trochanter suggests hip joint pathology 523
    • PA R T B R egio nal problems(d) Passive movement—psoas stretch (Thomasposition). Pain in the hip being stretched suggests psoasabnormality. Pain in the hip being compressed can besignificant for anterior impingement of the hip joint (f) De-rotation test In 90° flexion, the hip is taken into external rotation, and the patient asked to return the leg to the axis of the table against resistance. The test result is positive when the usual pain is reproduced ly on s ge pa(e) Resisted movement—squeeze test. Examiner places efist between knees as shown. Patient then adductsbilaterally against the fist pl m We emphasize that each individual clinician needs PRAC to develop his or her own technique for examining sa TICE P this joint. Between the masterclasses online and EARL this outline, you see a range of options you can (g) Palpation of iliopsoas in muscle belly and at anterior incorporate into your practice. hip joint524
    • H ip -related pain Chapter 28 B B(h) Functional movements—single-leg squat. Notepain, degree of femoral adduction and internal rotation,and lateral pelvic stability—Trendelenburg sign (j) Hip hitch (in neutral, internal and external rotation), keeping the knee extended investigations X-ray, Mri, and ultrasonography are the mainstay of imaging for diagnosis of hip pathology. Plain X-rays ly are often overlooked by clinicians, but usually should be the first investigation ordered as they can provide on valuable information. Fai can often be seen on an aP view of the pelvis and dunn views of the hip (Fig. 28.8). similarly these X-rays can also guide the s clinician to the presence of osteoarthritis, and abnor- ge malities in morphology such as acetabular dysplasia, acetabular retroversion or anteversion, the presence of os acetabulare, and not-to-be-missed pathologies pa such as a slipped upper femoral epiphysis, Perthes disease, tumors, fractured neck of femur, and avas- cular necrosis. unfortunately a plain radiograph e does not provide information about soft tissue injur- pl ies such as labral, chondral, or ligamentum teres pathology. m CT scans are generally not utilized as a diagnos- tic tool for hip pathology, as most diagnostic infor- sa mation is usually obtained by clinical examination,(i) Functional movements—step up and down (observe a plain radiograph, and Mri. however, surgeonsstability, pain) will often obtain specific CT scans preoperatively to 525
    • PA R T B R egio nal problemsassist them in planning surgery for the treatment symptoms following an injection generally confirmsof Fai. The Pod (Pritchard–o’donnell) “position the presence of intra-articular pathology, although aof discomfort” protocol CT gives surgeons specific negative response does not necessarily indicate thatthree-dimensional images (Fig. 28.12) providing no pathology is present, and further investigationinformation regarding impingement sites, femoral and management may still be warranted.head–neck morphology and version, acetabularoverhang and version, and joint space loss anterosu- Labral tearsperiorly. surgeons may obtain specific CT scans pre- Tears of the acetabular labrum (Fig. 28.13) are seenoperatively to assist them in planning surgery for the commonly in the athletic population, with 22% oftreatment of Fai. sportspeople with groin pain having labral tears, and Mri is commonly used in the diagnosis of soft 55% of patients with mechanical symptoms and hiptissue injuries of the hip. Pathologies such as labral pain having labral tears.19, 22, 43–45 The etiology of labraltears, ligamentum teres tears, tendon and bursae tears is well described in the literature.pathology and, occasionally, chondral defects may be The presence of both Fai5, 8, 10, 37, 46 and develop-seen on an Mri scan. unfortunately the sensitivity mental dysplasia of the hip (ddh)47, 48 has beenand specificity of Mri to these injuries is not high, repeatedly shown to increase the risk of a labraland false-negative results are often noted. tear. This is thought to be due to impingement of due to the depth of the joint, diagnostic ultra- the labrum in the presence of Fai and increasedsound is not especially useful for the diagnosis of shear forces on the outer joint margins including theintra-articular hip pathology; however, it can be useful labrum, in the presence of ddh.in determining the presence of bursae of the greater The prevalence of labral tears in the us andtrochanter or iliopsoas tendon, and tendinopathy of europe is greatest anteriorly.19, 22, 43, 49 various causesthese regions. real-time ultrasound can be used to for the high number of anterior labral tears haveassess the function of the deep lumbar and hip sta-bilizing muscles. diagnostic injections of local anesthetic are usedfrequently in the hip to determine the presence ofintra-articular pathology of the hip. These are generallyperformed under imaging guidance. a reduction in ly on s ge pa e plFigure 28.12 The POD (Pritchard–O’Donnell) “position torn acetabular mof discomfort” protocol CT gives surgeons specific3-dimensional images providing information regarding labrum saimpingement sites, femoral head–neck morphologyand version, acetabular overhang and version, and joint Figure 28.13 Labral tearspace loss anterosuperiorly (a) Pathology526
    • H ip -related pain Chapter 28 Fadir (Fig. 28.11b) and FaBer (Fig. 28.11c) are often described as being appropriate for the diagno- sis of labral pathology. radiological investigations remain unreliable, with Mra the only investigation having a reasonable degree of sensitivity and specificity19 (Fig. 28.13b). labral tears are often suspected, but not con- firmed until patients present for hip arthroscopy, which remains the gold standard for diagnosis of labral pathology.19, 22 sportspeople with labral pathology may respond to conservative management, and this should usually B B be trialed prior to undergoing surgery, except possibly in those patients with large bumps who are engaging in activity that demands more range of motion than(b) MR arthrogram (MRA) the sportsperson safely achieves before impinge-with gadolinium contrast leaking through a labral tear ment. Management should be directed to unloading(circle) the damaged labrum, which is almost always ante- rior and/or superior.been postulated, including reduced thickness of the repetitive hip flexion, adduction or abduction,labrum anteriorly, the prevalence of Fai lesions seen and rotation at the end of range should be avoidedanteriorly resulting in anterior impingement, and through activity modification. improving hip jointcommon functional activities, especially those with neuromotor control via activation of the deep stabi-repetitive twisting and pivoting of the hip.10 lizing muscles, initially in an unloaded and then a The reduced bony support seen anteriorly in the progressively loaded manner, appears to assist in thehip due to the anteverted position of the acetabu- unloading of the labrum.lum, which results in higher shear forces on anterior Gait retraining may also be undertaken to mini-soft tissue structures, is also a likely cause of labral mize excessive hip extension at the end of stance phasepathology. it has been shown that in the last 20–30% of gait, as increased hip extension has been dem-of the stance phase of gait, and in more than 5° of onstrated to increase the loads on anterior hip jointhip extension, increased forces are placed on anterior structures.52 neuromotor control of the hip should be lysoft tissue structures by the head of femur.19, 50 maximized and any remote factors influencing the Tears of the acetabular labrum are usually classi- mechanics of the hip should be addressed. onfied as type i or type ii tears.22, 51 Type i is described asa detachment of the labrum from the articular hyaline Ligamentum teres tearscartilage at the acetabular rim. Type ii is described as Tears of the ligamentum teres (Fig. 28.14 overleaf) scleavage tears within the substance of the labrum. are seen frequently in sportspeople undergoing hip geThe location of these tears relative to the vasculariza- arthroscopy, and are being reported more frequentlytion of the labrum must be considered when estab- in the literature. studies have found up to 70% oflishing the potential for healing of the tear, and the sportspeople undergoing hip arthroscopy for Fai and pamost appropriate type of intervention. labral tears also have tears of the ligamentum teres.10 The identification of labral tears in patients Tears of the ligamentum teres are classified as:remains difficult. The patient often complains of • type I—a partial tear emechanical symptoms such as locking, clicking, • type II—a complete rupture plcatching, and giving way. The location of pain is • type III—a degenerate ligament.53usually reported to be within the anterior hip or in mthe anterior groin region, although some patients The mechanism of injury for ligamentumreport pain in the posterior buttock. teres most commonly involves forced flexion and sa Clinical examination is also difficult, as most clin- adduction, and often internal or external rotation.53ical tests have poor sensitivity and specificity regard- Twisting motions and hyperabduction injuries haveing the type and location of pathology, although the also been reported to cause a tear to this ligament. 527
    • PA R T B R egio nal problems Figure 28.15 Position from which to internally and externally rotate the hip in the ligamentum teres testFigure 28.14 Ligament teres tear The hip is then extended by 30 degrees. From this posi-With the likelihood of the ligamentum teres playing tion (full flexion minus 30 degrees), the hip is moveda large proprioceptive and stabilization role of the into full abduction and then adducted 30 degrees (fullhip becoming increasing recognized, the prompt abduction minus 30 degrees). The hip is then inter-diagnosis and management of these injuries in the nally and externally rotated through full range. Thesportsperson is essential. likewise, any surgical pro- presence of pain is considered a positive test.cedure that sacrifices the ligamentum teres through often ligamentum teres pathology is not con-open dislocation should be carefully considered. firmed until a sportsperson presents for surgery, The symptoms of a ligamentum teres tear appear but it should be suspected in episodes involving theto be similar to other intra-articular hip pathologies, mechanism of injury mentioned above. The princi-with most patients complaining of deep groin and/or ples of management of ligamentum teres pathologymedial/anterior thigh pain, catching, reduction in are similar to those for labral pathology, with a par-range of motion, and night pain.53, 54 ticular emphasis on regaining neuromotor control, Clinically these patients will also often present excellent proprioception, and avoiding positions that lywith significant increased tone of the adductor place the ligament under most stress through activitymuscle group, and an injured ligamentum teres modification. onwhen touched with a radiofrequency probe intra- The sportsperson with a ligamentum teres injuryoperatively can generate an adduction moment force often presents with extremely overactive long adduc-powerful enough to reduce the hip while in traction.55 tors, which can be a source of considerable addi- sThese patients also present with reduced strength of tional discomfort. This should also be managed with gethe hip external rotators and extensors. appropriate myofascial techniques, trigger point dry There are presently no established radiological needling, and gentle stretching.or clinical tests that reliably identify tears of the liga- pamentum teres, and hip arthroscopy is the gold stand- Synovitisard in diagnosis of these tears. however, Pritchard synovitis (Fig. 28.16) is often seen in sportspeopleet al. have recently developed a clinical test that may with other intra-articular hip pathology—whether ehave clinical utility.56 Fai, labral tears, ligamentum teres tears or chon- pl The test aims to place the femoral head and dropathy. one surgical study found synovitis coexist-neck into a position that avoids bony and soft tissue ing in 70% of sportspeople with hip joint pathology.2 mimpingement, while placing traction on the ligamen- it is rarely seen as a primary entity. synovitis cantum teres by moving the hip through a full range of cause considerable pain in the hip joint, with night sainternal and external rotation. pain and pain at rest being common presentations. The test is performed with the patient’s hip flexed synovitis is a concern to the clinician becauseto full flexion without tilting of the pelvis (Fig. 28.15). of the pain and the associated changes in muscle528
    • H ip -related pain Chapter 28 B BFigure 28.16 Synovitisactivation that are seen around the hip in the pres- Figure 28.17 (a) Chondral lesion (acetabular side)ence of pain. in addition, the implications of synovialdysfunction on cytokine production, nutrition, andhydration of articular cartilage, which may alreadyshow signs of chondropathy, are significant for thelong-term health of the hip joint. Management should be aimed to addressing theother coexisting pathology, restoring normal neuro-motor control around the hip, modifying loads, andalso anti-inflammatory treatment such as oral non-steroidal anti-inflammatory drugs (nsaids) or intra-articular injection.Chondropathy lyChanges to the chondral surfaces of the hip areoften seen in conjunction with other hip pathologies on(Fig. 28.17). it is well reported that the presence ofFai,5, 6, 11, 39 decreased acetabular anteversion,7 labralpathology,19, 48 and developmental dysplasia of the (b) Arthroscopic view of severe chondral damage ship (ddh)6, 7, 48 will lead to an increased risk of chon- secondary to FAI gedropathy and ultimately osteoarthritis of the hip. inpatients with significant labral pathology, chondral considering that this is also the location for theloss is often up to 70% of the full thickness—or majority of cam and pincer lesions, and the majority paouterbridge grade iii or iv.57 of labral tears. a study examining hip pathology in aFl football- developmental dysplasia of the hip (ddh) alsoers found that full-thickness chondral loss of >30% involves a reduction in the bony coverage of the eof the acetabular depth anteriorly was found in 52% femoral head by the acetabulum; thus the anteri- plof players, who also all had labral tears and Fai.2 it orly directed forces of the femoral head will be con-is also proposed that the presence of longstanding centrated on a smaller surface area on the anterior msynovitis may also affect the nutrition of chondral aspect of the joint.surfaces, possibly exacerbating chondral damage. The clinical diagnosis of chondropathy may be sa The majority of chondral lesions are seen on the confirmed with plain radiographs, although earlyanterior or superior aspect of the acetabular rim, at chondral changes will not visible. Mri may iden-the chondrolabral junction.2, 57 This is not surprising tify earlier chondral lesions, although the extent of 529
    • PA R T B R egio nal problemschondropathy is often only evident on hip arthros- conditions of the hip. We then outline the applica-copy.2, 57 tion of these principles of management to patients Chondropathy is difficult to manage and may post–hip arthroscopy surgery.be difficult to confirm in the early stages withoutarthroscopic confirmation. if suspected, the man- unloading and protecting damaged oragement again is similar to that of labral pathol- potentially vulnerable structuresogy, as the majority of chondral lesions of the hip The most effective way to unload and protect spe-occur in the anterior aspect of the acetabular rim cific structures of the hip varies slightly for differentat the chondrolabral junction. as such, this region pathology, based on the understanding of the func-should be unloaded in the same fashion as labral tional anatomy and biomechanics of the hip. Whenpathology, with an emphasis on regaining normal addressing the loads on structures outlined below,neuromotor control of the hip. recent evidence has the principles of management of neuromotor controlshown atrophy in inferior gluteus maximus and and remote factors should also be applied. Managinghypertrophy in gluteus medius in osteoarthritis, with the load of the hip can be particularly difficult as theatrophy also occurring in gluteus medius in severe sportsperson has to walk about simply for activitiesosteoarthritis.58, 59 of daily living. Thus it is vital that their ability to attempts to minimize synovitis should also be walk, stand, and perform everyday activities such asmade, as the synovium and synovial fluid play an getting in and out of a chair is managed in such a wayimportant role in articular cartilage nutrition. obesity that these activities do not aggravate the underlyingand lack of exercise aggravate the symptoms of osteo- pathology.arthritis. The outcomes of hip arthroscopy for indi-viduals with significant chondral loss are generally restoration of normal dynamic andworse than for those with no chondral loss.10, 17, 60, 61 neuromotor controlWhere chondral surface damage is found, conserva- restoration of dynamic and neuromotor controltive measures should be attempted first, and in around the hip follows the same principles as othersome cases the sportsperson should be counseled to joints.modify the amount of weight-bearing activities theyundertake. Phase 1: deep hip stabilizer retraining The short hip external rotator (sher) muscles areRehabilitation of the injured hip those with the greatest capacity to provide dynamicrehabilitation of the injured hip requires careful con- stabilization of the hip (see above). retraining of lysideration of the interplay between pain and loading these deep hip stabilizers may be undertaken in the(including progression of exercises and activities). early stages of rehabilitation. as it does with other onimportantly, due to its role in all activities of daily pain conditions,66, 67 clinical observation indicatesliving, including simple activities such as sit-to- that pain appears to inhibit effective activation ofstand, standing, and walking, it is hard to “rest” the the sher muscles. Therefore, pain must be well ship. it is vital that the patient and the clinician have controlled. gea good understanding around monitoring joint loads The initial step involves educating the patient inand the loading response. the role of the sher muscles to provide dynamic hip The general principles of management of hip stability, and the location and actions of these muscles. papathology are straightforward and consistently The second step involves facilitating independentreported in the small amount of literature avail-able concerning rehabilitation of the hip.10, 19, 62–65 eunfortunately there is no evidence available other Three key principles of rehabilitation plthan clinical commentaries that evaluate the effec- 1. Unload and protect damaged or potentiallytiveness of particular principles of rehabilitation of vulnerable structures within and around the joint. mthe hip. 2. Restore normal dynamic and neuromotor control The three most commonly reported principles of around the hip joint. sarehabilitation are shown in the box. 3. Address other remote factors that may be altering This section discusses each of these general prin- the function of the kinetic chain.ciples, and then applies them to commonly seen530
    • H ip -related pain Chapter 28contraction of these muscles. This is often best com-menced in 4-point kneeling (Fig. 28.18a), wherethe patient is taught to activate the sher musclesand then perform an isometric external rotationcontraction against minimal resistance. The aim isto produce a low-level tonic hold of these muscles.in this position (90° hip flexion), the contributionfrom the larger external rotator (gluteus maximus)is reduced (see the section about joint structure andmuscle function earlier in this chapter), thus ena-bling more specificity of activation for the shermuscles. B B Both the patient and the clinician must be confid- Figure 28.18 Deep hip stabilizer strengtheningent that the deep hip stabilizers are activated and a exercisesreal-time ultrasound machine may assist with provid- (a) Activation of the SHER muscles in 4-point kneeling feedback. Progression of the retraining includes with theraband and resistance. The degree of difficulty providing different levels of resistance, number of can be progressed by decreasing or increasing therepetitions, and speed of movements. other progres- level of resistance, changing the speed of activationsions include increasing the amount of hip flexion, and increasing the number of repetitions. Theand decreasing the support (i.e. lifting one hand) challenge to the core can also be increased byto increase the balance demands and challenge to lifting one hand off the floor in this position, and thelumbopelvic stability. degree of hip flexion or extension, and abduction or Further progressions include activation of the deep adduction can be altered based on the needs of thehip stabilizers (Fig. 28.18b) in a variety of degrees of sportspersonhip range of motion and in various functional posi-tions as the activity of the sportsperson demands, andcan be assessed using a real-time ultrasound in thesevarying positions. For example, a sportsperson whoperforms regularly in positions of hip flexion such asa deep squat should ultimately perform muscle acti-vation in this position.Phase 2: Gluteus maximus retraining ly onGluteus maximus plays an important role in gen-erating extension and external rotation torque, andhas the potential to provide hip stabilization by sresisting anterior hip force.28, 31 Facilitation of inde- gependent gluteus maximus contraction may be best (b) Progression of activation of deep hip stabilizers intocommenced prone (Figs 28.19a, b overleaf), where a closed chain position, ensuring adequate deep hipthe patient is taught to perform an isometric exter- pa external rotators, gluteus maximus, lateral pelvic, andnal rotation contraction against minimal resistance core stability(low-level tonic hold of these muscles). as with thesher muscles, feedback may assist in ensuring that ethe muscle is activated. since the gluteus maximus a real-time ultrasound in these varying positions. For plis more superficial, feedback may be provided by pal- example, hip abduction and external rotation, or hippation, surface eMG biofeedback, or real-time ultra- adduction and internal rotation for a sportsperson msound machine. who performs cutting maneuvers, or in hip flexion The activation of the gluteus maximus should be for a sportsperson who is required to perform in a saundertaken in a variety of degrees of hip range of deep squatting position. it should be then progressedmotion determined by the functional demands the from open chain to closed chain and then functionalathlete’s activity requires, and can be assessed using positions. 531
    • PA R T B R egio nal problems example, hip abductors (predominantly gluteus medius) should be targeted for those with reduced hip abduction strength. strengthening exercises need to be targeted to the needs of the individual, progressed according to patient responses, and targeted to the sporting/ physical requirements. For example, a sportsperson who regularly jumps and lands (such as a netballer or gymnast) should incorporate these actions into their rehabilitation program (Fig. 28.20b). exercises are frequently commenced in prone (to ensure specificity and isolation of muscle activations)Figure 28.19 Gluteus maximus retraining exercises— or in 4-point kneeling and then progressed into func-examples of activation of gluteus maximus, in tional/weight-bearing positions, bilaterally and thencombination with SHER muscles in prone. Real-time unilaterally (Figs 28.20c–e).ultrasound assessment can also be undertaken in thisposition Phase 4: Functional and sports-specific(a) Prone—knee extension activity once good neuromotor control of the deep hip sta- bilizers and global hip muscles has been regained, functional and sport-specific activities should be assessed, and then undertaken, both to retrain these(b) Knee flexion ly onPhase 3: Generalized strengtheningexercises sGeneralized hip strengthening exercises should only gebe commenced when the patient and clinician areconfident that the key stabilizing muscles can beactivated and the activation maintained. during this paphase, the aim is to restore muscle function (strength,endurance) and proprioception. This phase remainslow-impact (Fig. 28.20a). exercises should initially ebe undertaken with specific activation of the deep plstabilizers prior to commencing the exercise. Thisensures that the sportsperson has adequate control Figure 28.20 Generalized hip strengthening exercises mof the hip prior to placing it under load, which will (a) An example of low-impact functional retraining ofassist in protecting vulnerable or damaged structures deep hip stabilizers, ensuring adequate activation of sawithin the hip. these muscle groups in a challenging situation without Generalized hip strengthening exercises should excessive impact or load through vulnerable hipbe undertaken, based on clinical assessment. For structures532
    • H ip -related pain Chapter 28 B B(b) A jumping and landing task ensuring adequateactivation of deep hip, lateral pelvic, and core stabilizersat take-off and landingmovement patterns but also ensure the sportspersoncan cope with these activities without failing. any retraining of functional activities should focuson pre-activation of the deep hip stabilizers, adequate lycontrol of the lumbar spine and pelvis during theactivity, and correct alignment of the femur during onweight-bearing tasks (Fig. 28.21 overleaf). retraining of hip stabilizers should be per-formed in the positions that place the hip at great- sest risk of overload, such as direction change andpivoting, deep squatting, and kicking. They should gealso be undertaken in a repeated fashion, again toensure the sportsperson does not fail in a controlled paenvironment.Criteria for returning to sport eThe decision regarding a patient’s readiness toreturn to sport is made using clinical judgment of plthe individual’s functional capacity. in the absenceof robust scientific evidence, the following criteria mare suggested: (c) and (d) Two examples of later-stage functional sa• performance on the one-leg hop test (or other activities with concurrent SHER muscle activation, core single-leg functional tests) at least 90% of the activation, and functional balance and proprioceptive uninjured side (if unilateral symptoms) challenges 533
    • PA R T B R egio nal problems address other remote factors that may be altering the function of the kinetic chain as outlined previously, a number of remote factors (e.g. lumbopelvic control) are likely to influence the rehabilitation of hip pain and pathology. Therefore, all potential contributing factors should be addressed and treated appropriately. Surgical management of the injured hip hip arthoscopy is the gold standard for the diagnosis of early chondral, labral, or ligamentum teres pathol- ogy, and has indications ranging from diagnostic purposes through to removal of loose bodies, labral tears, chondral lesions, Fai, version abnormalities, and dysplasia. hip arthroscopy has evolved substantially over the last 10 years, with improved technique and dedicated instrument design. it is now commonly performed to manage intra-articular hip pathologies, including labral tears.68 hip arthroscopy has revolutionized hip surgery, since this minimally invasive procedure is associated with considerably less morbidity than open procedures.(e) Examples of later-stage functional exercises open surgical indications include femoral andincorporating deep hip and core stability with acetabular osteotomies for dysplasia and for treat-proprioceptive and neuromotor control retraining ment of unusual Fai morphology. internationally, the number of hip arthroscopy procedures now per- formed is growing rapidly, with 30 000 procedures• performance on strength tests at least 90% of the performed in 2008, with this number expected to ly uninjured side (if unilateral symptoms) increase by 15% annually.69• performance on strength test indicates balance The basic principles of arthroscopic hip surgery on of muscle strength (e.g. external rotation strength are to treat damaged tissues to allow the healing similar to internal rotation strength; flexion similar to process to be maximized. This often involves debri- extension, abduction similar to adduction). dement of the irreparable tissue, and stimulation of a s ge pa e pl m saFigure 28.21 Retraining of functional activities—single-leg hop for distance534
    • H ip -related pain Chapter 28healing response. The joint is assessed for mechani- Three systematic reviews have examined out-cal optimization to assist with healing and help comes following hip arthroscopy.60, 61, 70 They eachprevent further damage through mechanical insult. concluded that short-term outcomes are generallyrange of motion is critical in this assessment. promising for hip arthroscopy treatment of Fai Clinically, patients presenting for hip arthroscopy and labral pathology, although outcomes are gener-surgery tend to be grouped into two categories: ally poorer if significant chondropathy is observed; further long-term studies are required.• those diagnosed with soft tissue pathology resulting Ten-year outcome studies examining outcomes from bony morphological variations, requiring in hip arthroscopy have reached similar conclusions reshaping on one or both sides of the joint to to the systematic reviews, mostly finding good out- increase the available range of motion prior to comes unless significant chondral loss is present, B impingement with a number of those with significant chondral• those not requiring bony intervention but presenting with soft tissue injuries requiring intervention. loss eventually progressing to joint replacement surgery.17, 71, 72 These studies looked at all pathologies, B and are somewhat limited by the enormous change The first group includes patients with Fai which in surgical technique that has occurred in the lastmay be cam, pincer, or mixed impingement. This decade.group have coexisting labral pathology, ligamentum Two specific studies looked at outcomes of hipteres pathology, or chondral lesions. arthroscopy in elite sportspeople.2, 10 The populations PRAC included were aFl footballers and nhl ice hockey Incidental findings of FAI-related morphology players, both of which have a high rate of hip and groin TICE P without typical associated pain need no pain. Both studies examined Fai and labral pathol- intervention, merely education and observation. EARL ogy and found good short-term outcomes, patient The second group includes those with soft tissue satisfaction, and return-to-sport levels, although eachpathologies, but without morphological change study was limited by the short follow up of two years.requiring surgical intervention. soft tissue patholo- Further longer term follow-up in sportspeople needsgies include labral pathology, ligamentum teres to be undertaken in order to conclusively understandpathology, chondral lesions, synovial pathology, loose the outcomes of these procedures in sportspeople.bodies, crystalline hip arthropathy, infection, and anycombination of these. Patients with these lesions may rehabilitation following hip arthroscopy lyhave co-existing issues such as dysplasia or hyper- rehabilitation following hip arthroscopy has beenmobility which predispose them to such injuries, described in the literature in a number of clinical onbut do not require surgical intervention. This group commentaries, and essentially follows the samealso includes patients with essentially normal mor- conservative principles of management outlinedphology but who undergo a massive single episode above.62, 64, 73 The individual pathology treated during sof excessive range (usually rotation) which causes hip arthroscopy must be considered when design- getrauma to the associated soft tissues. ing a postoperative rehabilitation program to ensure hip arthroscopy is a demanding procedure with the hip is adequately unloaded and protected whilea steep learning curve requiring advanced training. healing. This generally involves a period of partial- padebridement of labrum, ligamentum teres, and weight-bearing as tolerated on crutches until a pain-chondral surfaces require less recovery time and less free normal gait pattern is achieved.rehabilitation than more complex procedures (e.g. Generally osteochondroplasties performed for the elabral refixation and associated rim excision, and correction of Fai must be protected for at least six plfemoral head–neck reshaping for cam deformity). weeks, as should microfracture surgery performed The body of evidence examining outcomes fol- for chondral defects. mlowing hip arthroscopy is growing rapidly, although labral debridement and repairs should be pro-most studies are case series (level iv) evidence. The tected for 4–6 weeks, ensuring the sportsperson samajority of the literature focuses on outcomes follow- avoids potential positions of impingement throughing surgery for Fai, labral pathology, chondropathy, activity modification and normalization of neu-or combined pathology. romuscular control around the hip. 535
    • PA R T B R egio nal problems injuries to the ligamentum teres should be pro- and bone. The gap between the stable acetabulumtected for six weeks by avoiding end-range positions and the rim fragment had a vertical orientation. allthat place the ligament under stress, and ensuring patients had been exposed to a physically demandingexcellent neuromotor and proprioceptive control profession or contact sport, and in 15 hips no memo-around the hip. rable traumatic episode was present. The mechanism during this initial protective phase, the sports-person should commence active rehabilitation of thedeep hip stabilizers, initially in an isolated fashion,and then progressing into functional activity in a safemanner. during this time the therapist should alsoaddress any overactivity of the secondary stabilizerssuch as the long adductors, the proximal gluteals,tensor fascia lata, and the hip flexors. once this protective phase is complete, the sports-person should undertake a dynamic rehabilitationprogram ensuring full strength of all muscle groupsaround the hip, normal function of the whole kineticchain, and sport-specific activity. a full assessmentof the muscle strength and function around the hipusing real-time ultrasound and hand-held dynamom-etry at this time can also assist in providing targetedexercise programs to address any ongoing residualdeficits in strength or muscle activation. Generallymost sportspeople return to full sport betweenthree and five months postoperatively following hiparthroscopy, although this varies depending on thelevel and type of sport played, as well as the specificpathology and surgery performed.Os acetabularean os acetabulare (or os acetabuli) is defined as “a lyseparated fragment of bone at the rim of the hipsocket.” They have traditionally been regarded as an onunfused secondary ossification centre. The orienta-tion of the cartilaginous growth plate is more parallelto the joint surface (Figs. 28.22 a, b). s PRAC In sportspeople, an os acetabulare is seen in ge TICE P conjunction with FAI and is thought to be a fatigue fracture (Figs 28.22c, d). EARL pa The separation line is perpendicular to the jointsurface. similar fatigue fractures had previouslybeen described in severely dysplastic hips. e in a study of 495 patients treated surgically for plFai,74 a large osseous fragment at the anterolateralrim was found in 18 hips. all patients presented radi- mographically with a femoral head showing an aspher-ical extension producing a “cam” impingement. Figure 28.22 Os acetabulare (arrows) sasixteen hips had a retroverted acetabulum, indicat- (a) X-ray (b) CT scan of true os acetabulare showinging anterior overcover. Preoperative Mris confirmed orientation of the cartilaginous growth plate is morea fragment composed of labrum, articular cartilage, parallel to the joint surface536
    • H ip -related pain Chapter 28 B B(c) and (d) are MRIs of os acetabulare due to fatigue fracture. Note the separation line perpendicular to jointsurface ly on(e) The labrum and articular cartilage can be damaged sat the site of the os acetabulare and can be unstable to (f) Toothpaste-like calcific debris may be removed from geprobe the labrum paleading to this acetabular rim fragment is thought to probe. during labral takedown and rim excision, thebe fatiguing due to femoro-acetabular impingement. os acetabulare is removed, and the labrum refixed toThe aspheric portion of the head is jammed into the the rim of the acetabulum. if the fragment of bone eacetabulum and with time causes a stress fracture of is very large, removal may result in insufficient bony plthe area of overcoverage of the anterior acetabulum. coverage. in these cases, refixing of the fragment is The treatment of symptomatic os acetabulare is preferred. mcommonly achieved during hip arthroscopy. during occasionally, toothpaste-like calcific debrisacetabular rim assessment, the labrum and articular (Fig. 28.22f) similar to calcific tendinopathy of the sacartilage is probed. it is common for the labrum and shoulder is removed from the labrum, and is thoughtarticular cartilage to be damaged at the site of the to represent a response to labral injury, which canos acetabulare (Fig. 28.22e) and can be unstable to mimic os acetabulare on plain X-ray. 537
    • PA R T B R egio nal problemsLateral hip pain side at night is the most distressing symptom,with anGie Fearon although pain with, or following, weight-bearinglateral hip pain is a common presentation particu- activities is likely to be identified. as with otherlarly among distance runners and women over the tendon problems, the cumulative load over threeage of 40. Traditionally lateral hip pain was thought days needs to be drawn from the patient in order toto be due to trochanteric bursitis. however, it appears identify the aggravating factors.that tendinopathy of the gluteus medius and/or Palpation of the greater trochanter produces theminimus and bursa pathology probably co-exist. The “jump sign”—the person nearly leaps off the bed.term “greater trochanter pain syndrome” (GTPs) is range of movement tests for flexion, adduction,now used to describe this condition.75, 76 abduction, and the rotations in 0° and 90° flexion are normal or slightly increased, although muscle spasmGreater trochanter pain syndrome (GTPs) may affect these. The FaBer test is frequently posi-The anatomy of the greater trochanter and its associ- tive, while ober’s test (Chapter 34) may or may notated tendons and bursae is shown in Figure 28.23. be positive.There are two bursae around the greater trochanter. resisted external rotation and abduction musclesThe gluteus medius bursa lies beneath the tendon tests are reported to aid with the diagnosis; howeverof the gluteus medius and medial to the greater there is very limited evidence to support this. Thetrochanter. The trochanteric bursa is lateral to the de-rotation test (Fig. 28.11f) may assist.greater trochanter. The step up and down test (Fig. 28.11i) may help Gluteus medius tendinopathy presents with ten- differentiate between tendinopathy, tears, and hipderness to palpation of the gluteus medius muscle, osteoarthritis. Those with more severe GTPs reportand can be triggered by sudden falls, prolonged higher levels of pain with stepping up forwards ontoweight-bearing on one extremity for long periods,activity overuse, or sporting injuries. Most commonly, the step, and down sideways off the step. Those withthis situation is observed in middle-aged women who less severe presentation have pain with the hip hitchhave commenced unaccustomed exercise (e.g. vigor- with external and/or internal rotation. a report ofous walking or joining a gymnasium). groin pain with these activities is likely if the person Patients report pain over the greater trochanter has hip joint pathology (e.g. chondropathy, osteoar-which may extend into the lateral thigh, and even the thritis) in addition to lateral hip pain.lateral leg. The pain tends to be episodic but worsen- a Trendelenburg gait, and weakness may being over time. Frequently, pain lying on the affected present. differentiating between pain inhibition and ly true weakness is important. These symptoms specifi- cally affect runners, possibly due to the tilting of the on pelvis with running. gluteus diagnostic ultrasound can be performed to deter- minimus mine if fluid is present in the bursa or thickening s gluteus medius exists about the bursa, and to look for echogenic ge changes that are consistent with tendinopathy and gluteus medius tears.77, 78 Magnetic resonance imaging (Mri) dem- onstrates tendinopathy and tears of the gluteus pa bursa trochanteric medius79, 80 (Fig. 28.24). bursa Treatment e gluteus maximus The principles of treating GTPs are similar to the pl (cut) treatment of other tendinopathies: m greater • Control pain by minimizing the compression on the trochanter greater trochanter and managing the load on the sa tendons.Figure 28.23 The anatomy of the greater trochanter • Strengthen the gluteal muscles.81and its associated tendons and bursae • Treat the comorbidities.82538
    • H ip -related pain Chapter 28 with excessive camber when resuming their running program. shock wave therapy has been shown to be effec- tive in the treatment of GTPs.81, 83 recalcitrant cases may respond to a local corticos- teroid injection. a peritendinous ultrasound-guided corticosteroid injection has been shown to be an effective treatment of gluteus medius tendinopathy; 72% of the patients showed a clinically significant improvement in pain level, which was defined as a reduction in the vas pain score of ≥30%.84 however, another study demonstrated that less than 50% of B B subjects had a positive outcome three months after the injection.81 it is essential that a corticosteroid injection is only regarded as one part of the treatment—as a means toFigure 28.24 MRI appearances of gluteus medius reduce pain and enable the patient to commence aabnormalities muscle strengthening and postural control program,(a) Tendinopathy which is the key to the treatment process. Strengthening the gluteal (and other lower leg/ trunk) muscles The following exercises are designed to enhance the control and strength of the gluteal muscles in people with GTPs, and can be taught in addition to lumbopelvic control work (Chapter 14). importantly, in people with GTPs, positions of hip adduction may be associated with increased pain and hence exer- cises such as “clams” into hip adduction may be best avoided. in prone, with the leg slightly abducted, knee flexed ly 90°, the patient is instructed to medially and laterally rotate their hip within pain limits. Gaining excellent on control of this movement through range—including lateral rotation—provides both concentric and eccen- tric activity of gluteus medius and minimus muscles s in an unloaded situation. This exercise should be ge(b) Tendon tear repeated in varying degrees of hip flexion (prone over pillows or a bolster), as this targets the anterior fibers of gluteus minimus and medius and the middle fibers paManaging pain of gluteus medius. Progression of this exercise is toin the acute phase, treatment of GTPs consists of add ankle weights (using response to load as a guide).relative rest, ice, iliotibial band soft tissue work to hip extension and abduction in prone over pillows eimprove compliance, taping, gaining good gluteal (hip flexion) and/or bilateral bridging (knees and feet plmuscle control, and nsaids and paracetamol. apart to reduce hip adduction) is also useful (Fig.Patients should be checked for hip abduction and 28.18 on page 531). mrotation control in activities of daily living (e.g. hip abduction strengthening should be avoided ingetting out of a chair, climbing stairs, and standing). the initial stages of GTPs because it provokes symp- saas the patient improves, sport-specific activities such toms. hip abduction should only be commencedas running, jumping, and hopping should be ana- when the patient has good control of the deep hiplyzed. runners should avoid banked tracks or roads stabilizers, and it should commence in positions of 539
    • PA R T B R egio nal problemship abduction initially. as the acute stage resolves, be addressed as outlined above.82 Furthermore,hip abductor strengthening is important and may be referred pain from the spine should be assessed andachieved in the aquatic environment. treated as appropriate. as the patient gains control and strength of glutealmuscles, the clinician should progress the difficulty Gluteus medius tendon tearsof exercises. options include single-leg standing with Gluteus medius and minimus tendon tears arecontralateral hand on a bench or backing against a common in older patients. This can be confirmedwall (Fig. 28.25a) to gain static pelvic control, pro- on Mri85 (Fig. 28.24b). in patients where the teargessing to no assistance (Fig. 28.25b), and more chal- remains symptomatic despite conservative manage-lenging balance exercises (Fig. 28.25c). rubber-band ment, various surgical options are currently avail-type (resistance) exercises need to be introduced able. up to 60% obtain relief from an arthroscopicvery carefully, and the response monitored care- bursectomy, although some patients will go on to afully. Pilates-style sliding boards have also been used repair of the tendon.86, 87(Fig. 28.25d). Examination of the hip is in the Clinical Sports Medicine wwwTreat the comorbidities masterclasses at www.clinicalsportsmedicine.com.hip-related comorbidities (e.g. osteoarthritis, labraltears) frequently coexist with GTPs, and they should ly on s ge pa e pl m sa540
    • H ip -related pain Chapter 28 B B (c)(a) ly on s ge pa e pl m sa(b) (d)Figure 28.25 Examples of exercises that provide increasingly greater challenges to improve strength and control ofgluteal muscles 541
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