Clinical Examination of the Athletic

Brett A. Bralya,*, Douglas P. Beall, MDbc, Hal D. Martin, DOd aUniversity of Oklahoma College of Medicine, PO Box 26901, BSEB 100, Box 396, Oklahoma City, OK 73190, USA

bThe Physicians Group, 610 NW 14th Street, Oklahoma City, OK 73103, USA cUniversity of Oklahoma Health Sciences Center, 1100 N. Lindsay, Oklahoma City, OK 73104, USA Oklahoma Sports Science and Orthopedics, 6205 North Santa Fe Avenue, Suite 200, Oklahoma City, OK 73118, USA

The hip assumes an essential role in most sports-related activities. The hip is not only responsible for distributing weight between the appendicular and axial skeleton, but it is also the joint from which motion is initiated and executed. It is known that the forces through the hip joint can reach three to five times the body's weight during running and jumping [1,2]. Considering the amount of demand athletes place on their hips, orthopedic surgeons will evaluate them as patients having hip pain.

Ten percent to 24% of athletic injuries in children are hip related, and 5% to 6% of adult sports injuries originate in the hip and pelvis [3]. Ballet dancers are most likely to have a hip-related injury, and runners, hockey players, and soccer players are also prone to hip injuries [3]. Athletes participating in rugby and martial arts have also been reported as having increased incidence of degenerative hip disease [4-10]. Hip pain often stems from some type of sports-related injury [11-14]. In patients presenting with hip pathology, the hip is not recognized as the source of pain in 60% of all cases [15].

Hip pain has been documented in three categories: anterior-, lateral-, and posterior-based hip pain [16], with multiple etiologies. A short physical examination, complete with a history and evaluation of present illness, is fundamental and necessary in determining the source and cause of the presenting complaint. The results of these two assessment techniques will direct which radiological examination to consider. The history of present illness and physical assessment should be adequate if the physician suspects a specific diagnosis, and radiographic examination should be enough for a conclusive diagnosis to be made [1,4].

Diagnosing hip pain in athletes has been difficult for physicians in the past because of the parallel presenting symptoms shared with back pain, which may exist concomitantly or independently of hip problems [17]. Radiating pain below the knee, palpable pains in the hip and back, and weakness or sensory limitations

* Corresponding author. 14321 North Pennsylvania Avenue, Suite E, Oklahoma City, OK 73134.

E-mail address: [email protected] (B.A. Braly).

0278-5919/06/$ - see front matter doi:10.1016/j.csm.2005.12.001

© 2006 Elsevier Inc. All rights reserved.

blur the lines in appropriately differentiating between the hip and back [17-22]. Low back pathology involving the paravertebral muscles can lead to an abnormal soft tissue balance, causing an irregular tension absorbed by the hip joint, which leads to knee pain, groin pain, leg length discrepancies, and limited ranges of motion in the hip [23]. Muscle contractures of the hip flexors or extenders as well as leg length discrepancy have also been identified as factors that can cause hip and low back pain to present together [24-28]. Brown and colleagues [17] proposed that limited internal rotation associated with a limp and groin pain were the physical signs to make the distinction of hip-related pathology. The biggest problem facing physicians treating hip-related pathologies is the absence of a valid diagnosis [29].

The physical examination of the hip is evolving as the ability to understand normal and pathological conditions of the hip progresses. The physical examination of the hip is designed to detect a wide variety of pathologies, and has been developed by many generations of surgeons, therapists, and physicians [30-32]. The examination of the hip is optimally performed in a systematic and reproducible fashion in order to facilitate accurate diagnoses and treatment recommendation. The benefit of understanding the osseous, ligamentous, and musculotendonous contribution to the underlying pathology cannot be overestimated. Surgical and nonsurgical treatment outcomes will depend on a consistent method of evaluation to understand which treatments produce the optimal results for a particular type of patient. Conditions related to genitourinary, gastrointestinal, neurologic, and vascular systems, though unlikely in a sports-related injury, can compound the complexity of the assessment. This complexity also emphasizes the importance of a thorough examination.

An 11-point physical evaluation is a tool presented here to help organize the structure ofthe physical examination ofathletes in a simple, reproducible manner, in order to differentiate between hip and back pathology and categorize the hip pain presented. The evaluation aids in the diagnosis of anterior, lateral, and posterior etiologies of the hip in regards to the osseous, ligamentous, and musculo-tendonous structures. An organized approach, with a systematic structure as used in evaluating other joints, will benefit both the patient and the physician.

The 11-point examination is described below in five parts: the standing, seated, supine, lateral, and prone examinations. The technique of the physical examination is discussed, along with the diagnostic tools that may further the investigation of suspected pathology.

A verbal history including mechanism, time of injury, location, and severity of pain should be obtained. The focus of this article is to describe the physical element of the examination. It should be noted that with any clinical examination the reproduction of pain or limited movement constitutes a positive test sign.

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