Patient Selection

On examination, log rolling the leg back and forth is the most specific maneuver for hip pathology because this rotates only the femoral head in relation to the acetabulum and capsule, not stressing any of the surrounding neurovascular or musculotendinous structures. More sensitive examination maneuvers include forced flexion combined with internal rotation or abduction combined with external rotation. Flexion with internal rotation is sometimes referred to as the impingement test [3]. However, a joint irritated by a variety of conditions will typically be painful with this maneuver, and thus it is not specific for impingement alone. It is postulated that abduction with external rotation translates the femoral head anteriorly, exacerbating symptoms associated the anterior labral pathology or subtle instability. These maneuvers may normally be uncomfortable, so it is important to compare the asymptomatic to the symptomatic side. Most important is not simply whether the maneuver is uncomfortable, but whether it recreates the type of pain that the athlete experiences with activities. Sometimes there may be an accompanying click or pop. These may be indicative of pathology, but often occur in normal hips.

Radiographs are an integral part of the assessment process. Subtle findings may be indicative of significant intraarticular pathology, and the bony morphology can be evaluated for variants such as dysplasia and impingement implicated in hip joint pathology. Conventional MRI is improving, but even high-resolution studies have up to a 42% false negative interpretation [4]. Also, even with imaging evidence of pathology, the clinician must determine whether these findings explain the athlete's symptoms. Gadolinium arthrography combined with MRI has a greater sensitivity. Along with the contrast, bupivicaine should always (!) be used as the injection diluent. Whether or not the athlete experiences significant pain relief from the anesthetic effect of the injection is the most reliable indicator of the presence of joint pathology.

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