|










2Adductor strain
2Hamstring strain
2IT band strain
2Piriformis syndrome
2Trochanteric bursitis
2CDH
2osteitis pubis
2Coxa vara & valga
2Perthe¶s disease
2AVN
 |  


 |  


2 An adductor (groin) strain is a common problem among many individuals
who are physically active, especially in competitive sports.
2 The most common sports that put athletes at risk foradductor strains are
football, soccer, hockey, basketball, tennis, figure skating, baseball,
horseback riding, karate, and softball.1
2 Hip adductor injuries occur most commonly when there is a forced push-
off (side-to-side motion). High forces occur in the adductor tendons when
the athlete must shift direction suddenly in the opposite direction. As a
result, the adductor muscles contract to generate opposing forces.
2 One common cause of adductor strain in soccer players has been
attributed to forceful abduction of the thigh during an intentional
adduction. This type of motion occurs when the athlete attempts to kick
the ball and meets resistance from the opposing player who is trying to
kick the ball in the opposite direction. To a lesser extent, jumping also
can cause injury to the adductor muscles, but, more commonly, it
involves the hip flexors. Overstretching of the adductor muscles is a less
common etiology
Pathophysiology

2 The hip adductors are a powerful muscle group. They consist of the
adductor magnus, minimus, brevis, and longus. The gracilis and
pectineus muscles also are included. All of the adductor muscles are
innervated by the obturator nerve (L2-L4) except the pectineus, which
is innervated by the femoral nerve (L2-L4). The adductor magnus also
is innervated by the tibial nerve (L4-S3).

2 The musculotendinous junction is thought to be the most common site

of injury in a muscle strain. the sarcomeres near the junction are less
elastic than those found at the central portion of the muscle. The
musculotendinous junction is likely to be vulnerable to indirect muscle
injury that results from excessive force.
ÿortality/ÿorbidity
2 Improper management of acute adductor strains or returning to play before
pain-free sport-specific activities can be performed may lead to chronic injury.

2 Chronic adductor strain:

± Generally, symptoms are more diffuse with typical complaints of pain and stiffness in
the groin region in the morning and at the beginning of athletic activity. Pain and
stiffness often resolve after a period of warming up but often recur after athletic
activity.
± Typical findings include tenderness at the origin of the adductor longus and/or the
gracilis located at the inferior pubic ramus and pain with resisted adduction.
2 Improper management of acute adductor strains:
± According to a study by Renstrom and Peterson, 42% of athletes with groin muscle-
tendon injuries could not return to physical activity after more than 20 weeks following
the initial injury.
± This prolonged length of time seems to indicate the importance of proper
management of these injuries in the acute stage.
History
2 Groin pain can represent a number of different diagnoses, and all differential
diagnoses should be kept in mind when assessing the patient. Obtain
information about the mechanism of injury and loss of function, as well as about
the location, quality, duration, and severity of pain. The aggravating and
alleviating factors also should be noted.
2 Location - Usually, pain is described at the site of the adductor longus tendon
proximally, especially with rapid adduction of the thigh. As the injury becomes
more chronic, pain may radiate distally along the medial aspect of the thigh
and/or proximally toward the rectus abdominis.
± Exercise-induced medial thigh pain over the area of the adductors, especially after
kicking and twisting, may indicate obturator neuropathy.
± Pain at the symphysis pubis or scrotum may be more consistent with osteitis pubis.
± Conjoined tendon lesions present as pain that radiates upward into the rectus
abdominis or laterally along the inguinal ligament. Exquisite tenderness is present at
the site of the injury.
History
2 Quality - Acute injuries are described as a sudden ripping or stabbing
pain in the groin. Chronic injuries are described as a diffuse dull ache.
2 Duration - Initial intense pain lasts less than a second. This initial pain
is soon replaced with an intense dull ache.
2 Severity of pain - Pain severity can vary with different patients.
2 Loss of function - True loss of function is not observed unless a grade
3 tear is present. In the case of a severe tear, loss of hip adduction
occurs. Loss of function also should alert the physician to possible
nerve involvement (obturator nerve entrapment).
2 ÿechanism of injury - Rapid adduction of the hip against an abduction
force (eg, changing direction suddenly in tennis), acute forced
abduction that puts an unusual stretch on the tendon (eg, a rugby
tackle), and a sudden acceleration in sprinting are the most common
mechanisms of injury.
Physical
2 Tenderness, swelling, and ecchymosis can be observed at the superior medial
thigh. Sometimes, a defect in the muscle can be palpated.
2 Pain is noted with resisted adduction and full passive abduction of the hip.
2 A pure hip adductor strain can be distinguished from combination injuries
involving the hip flexors (ie, iliopsoas, rectus femoris) by having the patient lie in
the supine position. If more discomfort is reproduced with resistive adduction
when the knee and hip are extended than if the hip and knee are flexed, a pure
hip adductor strain can be assumed.
2 Physical findings can help distinguish adductor strains from other causes of
groin pain such as the following:
± Iliopsoas strain - Hip flexion against resistance is painful. Tenderness is difficult to
localize because the insertion of the iliopsoas is deep.
± Osteitis pubis - Tenderness of the symphysis pubis and possible loss of full rotation of
one or both hip joints are noted.
± Conjoined tendon lesions (ie, sportsman's hernia) - Exquisite tenderness upon
palpation at the inguinal canal. Having the patient cough reproduces pain.
± Obturator neuropathy - Adductor muscle weakness, muscle spasm, and paresthesia
over the medial aspect of the distal thigh may be present. Loss of adductor tendon
reflex with preservation of other muscle stretch reflexes often is observed. A positive
Howship-Romberg sign (medial knee pain induced by forced hip abduction, extension,
and internal rotation) sometimes is observed.
ÿ



2 ÿedical: The goals of pharmacotherapy in adductor strain are

to reduce morbidity and prevent complications.
± NSAIDS
± ÿuscle relaxants
2 Surgical: Surgery is indicated in acute strains only when there
is rupture and in select chronic strains refractory to
conservative treatment.
± A tenotomy for adductor longus is performed. A compression
bandage then is applied for 24 hours. The patient may walk after 2
days and may resume running within pain limits 5 weeks
postoperatively. The usual time period to return to unrestricted
sports activities is 10-12 weeks.
r


2 The initial management of an adductor injury should include protection, rest,
ice, compression, and elevation (PRICE). Painful activities should be avoided.
The use of crutches during the first few days may be indicated to relieve pain.
2 Some authorities believe that stretching in the acute phase may aggravate the
condition and lead to a chronic lesion. Control of muscle spasms is important
for rehabilitation. Spasms may be alleviated with medication and/or modalities
(eg, ice, electrical muscle stimulation). Passive range-of-motion (PROÿ)
exercises are initiated when they patient can perform them without pain. Active
muscle exercises can be advanced slowly from isometric contractions without
resistance to isometrics with resistance, progressing eventually to dynamic
exercises when tolerated with little or no pain.
2 Strengthening abdominal and hip flexor muscles is an essential part of
rehabilitation of groin injuries. Coactivation of the abdominal muscles and the
adductor muscles is a useful and functional exercise. Completing many
repetitions increases the endurance of the adductor muscles. A fatigued
muscle/tendon complex is more vulnerable to injury. The patient should aim to
progress gradually to 30-40 repetitions. Proprioceptive exercises are
recommended, along with stretching, as well as an aquatic training program if
accessible. After several days, heat and support bandages are recommended.
Grade I strain

2 ÿodalities and pain-free hip stretching exercises can begin

immediately.
2 Pain-free progressive strengthening exercises also can be
initiated immediately and can progress to include hip flexion
(with knee straight and bent) and adduction.
2 Therapy may be advanced to include the slide board,
plyometrics (lateral sliding, lateral lunges and X lunges )and,
finally, sport-specific functional drills.
2 The athlete may not be required to miss competition time,
depending on the severity of the injury.
Grade II strain

2 Therapy should begin immediately with gentle pain-free active

range of motion (AROÿ) exercises of the hip.
2 Isometric exercises should be initiated as soon as the patient
can perform them without pain.
2 After 1 week, pain-free slide board exercises and plyometrics
can be initiated.
2 Soon after the first week, sport-specific functional drills can
begin.
2 An athlete with a grade II strain may miss 3-14 days of
competition, depending on the severity of the injury.
Grade III strain (nonsurgical)
2 PRICE plus a non ± weight-bearing restriction for acute strains
2 Rest for 1-3 days with continuous compression is appropriate.
2 If surgery is not indicated, pain-free isometric exercises and slow,
pain-free AROÿ exercises can be started between days 3 and 5.
2 The athlete should continue to use crutches until normal pain-free
ambulation is possible.
2 Initiate pain-free stretching exercises, progressive resistive
strengthening exercises (without pain), and proprioceptive
neuromuscular facilitation (PNF) between days 7 and 10.
2 Usually within 10 days after starting progressive resistive
strengthening exercises, the patient should be able to perform pain-
free slide board exercises and plyometrics and eventually advance to
sport-specific
Chronic strain

2 In the treatment of long-standing groin pain, rest, ice, massage, and therapeutic
ultrasound have been recommended. Nonsteroidal anti-inflammatory drugs
(NSAIDs) and steroid injections have been suggested, but no controlled trials
have been published on the subject. Forceful adductor stretch under general
anesthetic has been recommended. A careful monitored program with a total
cessation of the sports activity is necessary for the chronic adductor injury to
heal and become pain-free.
2 This program should consist of isometric exercises, strengthening of the hip-
and pelvis-stabilizing muscles, and proprioceptive training.
± No increase in pain should be experienced during or after the exercises.
± The load of the exercises gradually is increased. Specific strengthening of the
adductor muscles then is implemented.
± Cycling can be used to maintain general conditioning. Running can begin only after
the patient can perform these exercises at high intensity without pain. Sprinting and
cutting activities then may follow.
± Sport-specific training is the final step before full return to sport. This part of the
rehabilitation program may take 3-6 months.



2 Hamstring injuries are common problems
that may result in significant loss of on-field
time for many athletes because these injuries
tend to heal slowly. Once injury occurs, the
patient is at high risk for recurrence without
proper rest and rehabilitation.
2 While hamstring injuries can occur in people
of any age, incidence increases with age.
  

2 ÿany different causative factors can contribute to hamstring

injuries. The most significant causes include the following:
± Inadequate flexibility of the hamstrings can result in injury. This
may be related to the patient having no or a poor stretching
routine.
± Inadequate strength or endurance of the hamstrings with either a
side-to-side weakness or an imbalance between the hamstrings
and the knee extensors can lead to injury.
± ÿuscle fatigue can lead to dyssynergia of muscle contraction.
± Insufficient warm-up time may be involved.
± Poor running technique may play a role.
± Return to activity before complete healing has occurred can lead
to recurrence.
  
2 Hamstring strain is a noncontact injury and usually occurs with either acute or
insidious onset. Strain injuries frequently are seen in athletes who run, jump, and
kick. Avulsion injuries are seen in patients who participate in water-skiing, dancing,
weight lifting, and ice-skating. The avulsion injury usually follows a burst of speed,
and the patient may report a popping or tearing sensation. The most commonly
affected muscle area in the hamstring complex is the short head of the biceps
femoris, possibly because of its innervation.
2 As with most strain injuries, the injury can occur at the following 4 places:
± Origin of the muscle
± ÿusculotendinous junction
± ÿuscle belly
± Insertion of the muscle
2 Injury is most likely to occur while the musculotendinous junction undergoes
maximum strain during eccentric contraction of the hamstrings.
2 The American ÿedical Association (AÿA) has described 3 grades of severity of
hamstring injuries.
± First-degree strain is the result of stretching of the musculotendinous unit and involves
tearing of only a few muscle or tendon fibers.
± Second-degree injury refers to a more severe muscle tear without complete disruption of
the musculotendinous unit.
± Third-degree injury refers to a complete tear of the musculotendinous unit.
Physical
2 In addition to pain in the posterior thigh, the physical examination may
reveal any of the following signs or symptoms:
± Tenderness over the site of injury
± Ecchymosis
± Palpable mass
2 A palpable defect may be felt with severe strains, but swelling and the deep
location of the muscle may obscure this finding in the acute stage.
2 Palpate the muscle for a defect with the patient in a prone position and the knee
flexed to 90°. This position relaxes the muscle and decreases cramping and
pain. Palpate while maintaining slight tension on the muscle.
± Pain with passive extension of the knee and the hip flexed at 90°, as
compared with the noninjured side, which stretches the muscle
± Pain with resisted knee flexion, which activates the muscle
d


2 The diagnosis is typically clinical, but some imaging studies may helpful if the
clinical picture is unclear.
2 Radiographs can rule out an avulsion injury from the ischial tuberosity or other
fractures, but they generally are not otherwise of significant help.
2 Ultrasonographic studies may aid the physician when confirming the diagnosis
of hamstring strain, but they do not always indicate definitive results. The
quality of the study is related to the expertise of the technician and the
cooperation of the patient.
2 When a confirmation or grading of a hamstring strain is necessary, magnetic
resonance imaging (ÿRI) is the most sensitive test used when considering the
diagnosis of hamstring strain, but it should be used sparingly because of the
cost and patient discomfort.3 Some data suggest that ÿRI is helpful when
attempting to predict return in a high-performance athlete in combination with
supporting clinical evidence.
2 Studies have shown that more than 6 weeks' delay before return to sport has
been reported with the following:
2 Complete transection
2 Involvement of 50% of cross-sectional muscle
2 Ganglionlike fluid collections
2 Hemorrhagelike signal
2 Distal myotendinous tears
2 Deep muscle tears
ÿ



2 ÿedical management
± The standard choice for medication is nonsteroidal anti-
inflammatory drugs (NSAIDs). These medications not only
provide analgesia but also can decrease some of the
mediators of inflammation.
2 Surgical management
± Need for surgical intervention is extremely rare after a
hamstring injury. Surgery is recommended only in the case
of complete rupture of the proximal or distal attachment of
the myotendinous complex into the bone.
Physical Therapy

2 The key to successful recovery from a hamstring

strain is recognition of the injury and of the severity
of the stain.
2 Physical therapy (PT) is the mainstay of treatment.
The program depends on the severity of the injury
and on the time that has elapsed since the injury.
Very few scientific data are available to determine
specific rehabilitation and treatment protocols for
hamstring injuries.
| 

2 During the acute phase (1-5 d), most of the treatment is geared toward
decreasing the inflammation and maintaining range of motion.
2 PRICE (ie, protection, rest, ice, compression, elevation) is the initial
treatment.
2 When the pain has decreased, the therapist may begin painless
gentle passive range of motion and active-assistive range of motion.
2 The patient also may benefit from a cane or crutches to aid in
ambulation to keep active.
2 Even if a patient with a first-degree injury is feeling better after a few
days and wants to return to participating in his or her sport, it is usually
recommended that he or she complete a rehabilitation program to
avoid chronic injury.
2 ÿuscle strengthening, balance, and stretching should be emphasized
to the patient as a prevention of recurrence.
Ñ | 


2 The subacute phase (5 d to 3 wk) is when the inflammation of

the injury appears to be lessening.
2 The goal of treatment in this stage is to begin some active
range of motion and start strengthening.
2 Aquatic therapy is helpful in encouraging activity with
decreased weight bearing.
2 Pain-free submaximal isometric exercises also are encouraged.
2 TENS
2 Ice is also helpful to decrease pain and inflammation.
2 The patient also should resume cardiovascular training, which
may include swimming with a pull buoy between the legs, and
upper extremity exercises.
r 


2 The remodeling phase (1-6 wk) is when the patient is able to perform isometric
exercises at 100% effort without pain.
2 Prone isotonic hamstring exercises are now added to the transcutaneous
electrical nerve stimulation unit and ice.
2 Begin unilaterally with ankle weights, using low weight and a high number of
repetitions.
2 Slowly increase the weight as tolerated as long as the patient's pain is not
increased afterwards.
2 Importantly, do not increase the weight too rapidly because this could lead to a
chronic injury.
2 Once concentric strengthening is tolerated at a normal level, the patient may
begin eccentric strengthening. Because this exercise puts the most strain on
the muscle, supervised exercising and slow progression of weight is
recommended. In the prone position, the patient performs a unilateral
contraction to 90° of knee flexion and then slowly lowers the weight.If the
patient experiences pain or stiffness, then decrease the weight to a more
tolerable amount. When the affected leg is within 10% of the unaffected leg,
then the patient may advance to a more aggressive therapy program.
2 Continued stretching of the hamstring is essential and should occur prior to
exercise. ÿoist heat prior to exercise may provide improved results. A posterior
pelvic tilt may help eliminate lumbar compensation.
o
|

2 The functional stage is 2 weeks to 6 months.
2 At this point, the patient should have a normal gait pattern and can
begin fast walking. When the patient can ambulate for 20-30 minutes
at a fast speed without pain or stiffness, short periods of jogging can
be added to the fast walking.
2 When the patient can perform a 15- to 30-minute jog, then short
periods of sprinting may be added to the jog. Eventually, more sport-
specific exercises may be added. Have the patient continue with the
hamstring strengthening and stretching throughout this stage.
2 During the later stages of therapy, plyometric exercises may be used
to increase speed and power during training. These exercises consist
of muscle stretching followed by concentric contraction, allowing for a
stronger contraction because of muscle facilitation and decreased
inhibition.
2 Low-level exercises may be used initially (eg, jumping rope), followed
by higher-level exercises as tolerated (eg, side jumping over a low
object, jumping onto and off a box). Because the higher level exercises
are associated with a higher rate of injury, they should be performed
with supervision.
r 
 

2 This can occur anywhere between 3 weeks and 6 months.

2 Isometric strength testing and flexibility testing may be
performed prior to returning to play to ensure that no subtle
deficits are present that may lead to chronic injury.
2 The therapist must impress upon the patient the importance of
stretching and warm-up prior to activities to prevent reinjury.
2 Less than 5 weeks are required before return to play for
patients with (1) superficial muscle injury or (2) muscle injury
that involves a small cross-section of muscle.
2 In patients whose injury was due to poor biomechanics, care
should be taken to correct the underlying cause.
2 The patient should be supervised during stretching and
exercise in order to assess poor technique and correct it.
d 
Ñ
 
2 Iliotibial band syndrome (ITBS) is the result of
inflammation and irritation of the distal portion of
the iliotibial tendon as it rubs against the lateral
femoral condyle, or less commonly, the greater
tuberosity.
2 This overuse injury occurs with repetitive flexion
and extension of the knee. Inflammation and
irritation of the iliotibial band (ITB) also may
occur because of a lack of flexibility of the ITB,
which can result in an increase in tension on the
ITB during the stance phase of running.
 
 
2 liotibial band syndrome (ITBS) typically is due to overuse. The injury is
seen most commonly in runners, although other athletes (eg, cyclists,
tennis players) also may be affected. The usual mechanism is irritation of
the iliotibial tract as it crosses over the lateral femoral condyle and, less
commonly, the greater tuberosity. Increased tension or friction of the ITB in
this area can result in an increase of irritation or inflammation. Abnormal
gait or running biomechanics also have been implicated.
2 Cyclists may experience ITBS due to improper positioning on their bike.
Excessive internal or medial rotation of bike cleats and a bike seat that is
too high are 2 main causes of ITBS among cyclists.
2 Long-distance runners have a higher incidence of ITBS than do short-
distance runners and sprinters. This higher incidence may be due to the
change in the biomechanics of running versus sprinting. Long-distance
runners tend to have a more prominent and extended heel-strike and
stance phase in comparison with sprinters. The ITB is under its greatest
tension during the first third of the stance phase.
2 Weakness of muscle groups in the kinetic chain may also result in the
development of ITBS. Weakness in the hip abductor muscles, such as the
gluteus medius, may result in higher forces on the ITB and the tensor
fascia lata.
Physical
2 The physical examination should include the entire lower
extremity to rule out other causes of lateral knee or hip pain. In
most cases, point tenderness occurs with palpation of the
lateral femoral condyle or lateral tibial condyle, especially when
flexing or extending the knee, as the iliotibial band (ITB) slides
across the lateral femoral condyle. Some patients may have
tenderness over the greater trochanteric region of the hip.
2 Strength testing - Strength testing may reveal knee flexor or
extensor weakness or hip abductor weakness.
2 Tests - Increased or noticeable tightness of the ITB also may
be noted upon examination with the Ober test. A modified
Thomas test can be performed to assess flexibility of the hip
flexors, hamstrings, and ITB.
ÿ



2 ÿ|


± ¦Ñd Ñ
2 Ñ |d



± Reports of surgical intervention exist for recurrent iliotibial
band syndrome (ITBS) that has not been responsive to
previous conservative treatment.
± The operation may involve
2 releasing the posterior portion of the ITB
2 performing an osteotomy of the lateral femoral epicondyle
2 performing a bursectomy.
©
 




2 Treatment for iliotibial band syndrome (ITBS) usually

is conservative.
2 Conservative treatment consists of
± relative rest by decreasing the amount of exercise or
training
± the use of superficial heat and stretching prior to exercise
± the use of ice after the activity.
± Heat should be applied before and during stretching for at
least 5-10 minutes, and ice treatments should be
employed using a cold pack applied to the area for 10-15
minutes or using an ice massage, which involves rubbing
ice over the inflamed region for 3-5 minutes or until the area
is numb.
2 Physical therapy is one of the mainstays of treatment for ITBS,
in addition to reducing the amount of inflammation and irritation.
2 The physical therapist can advise the athlete about ways
to modify his/her training program so that faster results are
seen with therapy.
2 Running and cycling should be decreased or avoided to
prevent further repetitive stress to the ITB.
2 Wearing proper shoes also is very important in individuals with
ITBS.
2 Frequently, patients with ITBS demonstrate excessive
pronation of their feet.
2 The physical therapist should evaluate the patient's
biomechanics during walking and running and should assist
him/her in obtaining custom-made orthotics to correct faulty
mechanics that may be causing the ITBS.
2 Physical therapy treatment in the acute stage may
include modalities such as phonophoresis or
iontophoresis in addition to cryotherapy to decrease
the inflammation
2 Since some cases of ITBS are caused by excessive
tension on the ITB, physical therapy can help
to incorporate proper stretching techniques into the
patient's exercise routine.
2 These exercises concentrate on increasing flexibility
of the ITB and of the gluteus muscles.
2 Other muscles that commonly need attention for
flexibility include the hamstrings, quadriceps,
gastrocnemius, and soleus.
2 {
 

||

 
 

d{{


|  
| 



|




 



 |

d{
{
 

 

 |

 


 

2 Soft-tissue mobilization and massage techniques may be used to
assist with lengthening of the sore ITB.
2 Prior to mobilizing the tissues, the physical therapist may perform an
ultrasonographic treatment over the ITB to increase blood flow to the
area and prepare the tissues to be stretched.
2 ÿassage should generally be performed with the ITB in a lengthened
state.
2 As the patient's symptoms improve, the physical therapy can progress
toward strength development and maintenance.
2 The physical therapist should instruct the patient in a home exercise
program that continues to improve the strength and endurance of the
hip and knee, as well as the back and abdominals.
2 Strengthening of the hip abductors and knee flexors and extensors is
an important component of rehabilitation.
2 Once the patient is able to complete all strengthening exercises
without discomfort, he/she may gradually return to the previous
training regimen.
u 
2 Since 1924, osteitis pubis has been known as a noninfectious inflammation of
the pubis symphysis (also known as the pubic symphysis, symphysis pubis, or
symphysis pubica) causing varying degrees of lower abdominal and pelvic pain.
2 Osteitis pubis was first described in patients who had undergone suprapubic
surgery and remains a well-known complication of invasive procedures about
the pelvis.
2 However, it may occur as an inflammatory process in athletes.
2 The incidence and etiology of osteitis pubis as an inflammatory process versus
an infectious process continues to fuel debate among physicians when
confronted by a patient who presents complaining of abdominal pain or pelvic
pain and overlapping symptoms.
2 Osteitis pubis is thought to result from inflammation of the pubis symphysis
and is characterized by sclerosis and bony changes of the pubis symphysis
2 osteitis pubis is more prevalent in men. However, as women continue to lead
more active lifestyles, and become more involved in sports such as soccer, the
incidence and prevalence of the condition may change.
2 Although osteitis pubis can affect all age groups, it is rarely encountered in the
pediatric population. The disorder occurs most commonly in men aged 30-50
years. Women are more frequently affected in their mid-30s.
  

2 Pregnancy/childbirth
2 Gynecologic surgery
2 Urologic surgery
2 Athletic activities (eg, running, football, soccer, ice
hockey, tennis)
2 ÿajor trauma
2 Repeated minor trauma
2 Rheumatologic disorders
2 Unknown etiology
History

2 Pain generally is localized over the symphysis and may radiate

to the groin, medial thigh, or abdomen.
± Onset can be abrupt or insidious (more than 1 mo).
± Pain is exacerbated by activities such as running, pivoting on 1
leg, and kicking.
± Lying on one's side also may exacerbate the pain.
± Pain can occur with walking, climbing stairs, coughing, or
sneezing.
2 The patient may experience a sensation of clicking or popping
when rising from a seated position, turning over in bed, or
walking on uneven ground.
2 The patient may report weakness and difficulty ambulating.
Physical

2 Tenderness to palpation is noted directly

over the pubis symphysis with bilateral
compression of the greater trochanters.
2 The patient may report weakness, chiefly in
the hip adductors, but there also may be
involvement within the hip flexors.
2 A waddling gait may be observed.
Imaging Studies
2 Plain radiographs
± Plain radiographs demonstrate sclerosis, cystic changes, or rarefaction of the medial
portions of the pubic rami (ie, marginal irregularity).
± Instability is defined as more than 2 mm of cephalad translation of the superior pubic
ramus on each side, with the patient standing on 1 leg in turn.
± Widening of the cleft usually is measured to greater than 10 mm.
± The sacroiliac joints also should be evaluated since laxity of one or both may
contribute to pubis symphysis instability.
± Positive findings usually are not apparent until 4 weeks after the onset of symptoms.
2 Bone scans may be negative but can demonstrate intense signal uptake at the
pubis symphysis.
2 Ultrasonography may show abnormal widening of the cleft.
2 Computed tomography (CT) scanning is also used for evaluation of the pubis
symphysis and the posterior pelvic ring.
2 ÿagnetic resonance imaging (ÿRI) studies may indicate bone marrow edema
at the pubis symphysis, but this finding may also be seen in asymptomatic
individuals.
ÿ



2 ÿedical
± NSAIDS
2 Ñ |d


Different surgical
approaches have been described
± curettage
± arthrodesis
± wedge resection
± wide resection.
©
 




2 Rest and time are the primary healing mechanisms.

2 Physical therapy (PT) may be useful during the
early stage. ÿodalities, such as heat or ice, may
provide symptomatic relief. Progressive ambulation
with the aid of an assistive device (eg, cane,
crutches) and possible orthoses (eg, lumbar/sacral
corset, sacroiliac belt) to unload the pelvis for pain
relief and to maintain correct anatomical alignment
may be necessary.5
2 Avoidance of any therapeutic exercise that may
place stress on the pelvic ring is prudent. A home
exercise program that includes pelvic tilts may be
prescribed. Experienced therapists may
attempt dynamic stabilization techniques
î

î 
2 Coxa vara includes all forms of decrease of the femoral neck shaft angle to less than
120-135°.
2 This condition has many etiologies: congenital, acquired, and developmental.
2 Congenital coxa vara (CCV), also referred to as infantile or cervical coxa vara, is a
condition in which a varus deformity exists that is assumed to be caused by either an
embryonic limb bud abnormality or an intrauterine condition causing significant
proximal femoral varus.
2 CCV is, by definition, present at birth but manifests clinically during early childhood
and commonly follows a clinical course that is progressive with growth.
2 As a specific entity, CCV has characteristic clinical and radiographic features that help
differentiate it from other forms of coxa vara. It is commonly associated with a
significant limb-length discrepancy, segmental shortening of the femur, or other
abnormalities of the bony femur.
2 Acquired forms of coxa vara are varus deformities of the proximal femur that develop
secondary to metabolic, neoplastic, or traumatic conditions. This group
includes ricketic coxa vara, fibrous dysplasia, proximal physeal injury, and premature
closure.
2 Also included in this category are secondary varus changes due to generalized
skeletal conditions or dysplasias
Presentation

2 Patients with congenital coxa vara (CCV) usually present with gait
abnormalities. Affected children generally present between the time they begin
ambulation and age 6 years.
2 In most patients, the gait abnormality is progressive and, notably, pain free.
2 Unilateral involvement with an associated relative limb-length discrepancy and
Trendelenburg limp may be noted. This discrepancy in limb lengths usually is
mild, ranging from 1.5 to 4.0 cm.
2 Patients with bilateral involvement commonly present with a waddling gait
abnormality, similar to that of patients with bilateral DDH. The Trendelenburg
sign is commonly elicited in the affected hip or hips.
2 A tabletop examination may reveal weak abductors, a prominent greater
trochanter, decreased abduction due to a decreased articulo-trochanteric
distance, and coxa vara. A decrease in internal rotation also is often noted,
caused by decreased femoral anteversion or true retroversion associated with
this condition.
d


2 Radiology
± Weinstein et al proposed a
radiological means of
quantifying CCV.
± This measure, the Hilgenreiner
epiphyseal angle (HEA), is the
angle subtended by the
horizontal Hilgenreiner line
through the triradiate cartilages
and an oblique line through the
proximal femoral capital
physes, as seen in the image
below.
± A study of normal values of the
HEA found that the angle in
children younger than 7 years
averages 20°, with a wide
variation of 4-35°. The mean
value for those aged 8 years to î

|  

 



maturity is 23°. 

 











 

| |
 





2 Using this measurement, patients in whom surgery is indicated include
the following:
± A child with a clinical limp and an HEA of more than 60°
± A child with a clinical limp and an HEA of 45-60° with documented
progression of varus deformity
2 If left untreated, CCV historically was believed to be a relentless and
progressive deformity leading to pain and a loss of hip function with
the development of premature degenerative changes,. Some authors
have shown, however, that not all patients with the diagnosis of CCV
necessarily follow this course. On the basis of the HEA, 3 relatively
distinct groups have emerged
± In those with an HEA of less than 45°, the CCV is more commonly found to
halt progression spontaneously and to heal without intervention.
± In patients with an HEA of more than 60°, the CCV follows a more
traditional course of progressive deformity that can be aided only by
surgical intervention.
± An intermediate group with angle measurements of 45-60° represent a so-
called "gray zone"; they require observation for either healing or
progression, the latter of which requires surgical intervention.
2 CT scan, with possible 3-dimensional
reconstructions
± anteversion or retroversion and the amount of bone stock in
the area, which is important information for preoperative
surgical planning.
2 ÿRI
± ÿRI findings include widening of the growth plate with
expansion of cartilage medio-distally between the capital
femoral epiphysis and femoral metaphysis.
± The usefulness of ÿRI as a preoperative imaging modality,
in both diagnosis and surgical planning, is relatively limited.
Contraindications for treatment

2 Treatment of CCV is contraindicated in

children who demonstrate any of the
following:
± Lack of symptoms on clinical assessment
± Radiographs showing an HEA of less than 45°
± Radiographs showing an HEA of 45-60° with no
documented progression
2 In such situations, close clinical and
radiographic follow-up is warranted.
Surgical Therapy
2 As surgical intervention is required in a large percentage of those with
congenital coxa vara (CCV), remembering the indications for surgery
and clearly defining the goals of treatment are important to ensure the
best possible outcome and to minimize the number of surgical
procedures for the patient.
2 The goals of surgical intervention are as follows:

± Correction of the neck shaft angle to a more physiologic angle and HEA to
less than 35-40°
± Correction of femoral anteversion (or retroversion) to more normal values
± Ossification and healing of the defective inferomedial femoral neck
fragment
± Reconstitution of the abductor mechanism through replacement of its
normal length-tension relationship
2 Among the intertrochanteric osteotomies the Pauwels Y-shaped and
Langenskiöld valgus-producing osteotomies have been shown to
provide good results. however, these osteotomies have a somewhat
limited ability to correct the associated femoral neck retroversion.
2 In early cases with mild displacement of
capital epiphysis, the epiphysis is fixed with
ÿoore¶s pins under X-Ray control, without
attempting reduction
2 In cases with displacement slip is reduced by
open reduction or subtrochanteric osteotomy
to change the alignment of the joint by
making epiphysis more horizontal.
©
!
2 Legg-Calve-Perthes disease (LCPD) is avascular necrosis of the proximal
femoral head resulting from compromise of the tenuous blood supply to this
area.
2 LCPD usually occurs in children aged 4-10 years.
2 The disease has an insidious onset and may occur after an injury to the hip.
2 In the vast majority of instances, the disorder is unilateral.
2 Both hips are involved in less than 10% of cases, and the joints are involved
successively, not simultaneously.
2 It occurs more commonly in boys than in girls, with a male-to-female ratio of
4:1.
2 The condition is rare, occurring in approximately 4 of 100,000 children.
2 The cause is not known, but children with Legg-Calvé-Perthes disease (LCPD)
have delayed bone age, disproportionate growth, and a mildly shortened
stature.
2 LCPD may be idiopathic, or it may result from a slipped capital femoral
epiphysis, trauma, steroid use, sickle-cell crisis, toxic synovitis, or congenital
dislocation of the hip.
Pathophysiology

2 Rapid growth occurs in relation to development of the blood

supply of the secondary ossification centers in the epiphyses,
creating an interruption of adequate blood flow and making
these areas prone to avascular necrosis.
2 Interruption of the blood supply to the bone results in necrosis,
removal of the necrotic tissue, and its replacement with new
bone.
2 Bone replacement may be so complete and perfect that
completely normal bone may result.
2 The adequacy of bone replacement depends on the age of the
patient, the presence of associated infection, congruity of the
involved joint, and other mechanical and physiologic factors.
2 Necrosis may occur after trauma or infection, but idiopathic
lesions can develop during periods of rapid growth of the
epiphyses.
Presentation
2 The earliest sign of Legg-Calvé-Perthes disease (LCPD) is an intermittent limp
(abductor lurch), especially after exertion, with mild or intermittent pain in the anterior
part of the thigh.
2 LCPD is the most common cause of a limp in the 4- to 10-year-old age group, and
the classic presentation has been described as a painless limp.
2 The patient may present with limited range of motion of the affected extremity.
2 Hip pain may develop and is a result of necrosis of the involved bone. This pain may
be referred to the medial aspect of the ipsilateral knee or to the lateral thigh.
2 The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip
may develop adduction flexion contracture.
2 The patient may have an antalgic gait with limited hip motion.
2 Pain may be present with passive range of motion and limited hip movement,
especially internal rotation and abduction.
2 Children with LCPD can have a Trendelenburg gait resulting from pain in the
gluteus medius muscle.
2 Laboratory studies and radiography may supplement medical history taking and
physical examination in the assessment of a child with a limp.
d


2 Obtain hip radiographs, including anteroposterior and frog-leg lateral views of the pelvis to
establish the diagnosis.
± Initial radiographs can be normal, but radiographic changes can be divided into 5 distinct stages
representing a continuum of the disease process.
2 Stage 1 reveals cessation of femoral epiphyseal growth.
2 Stage 2 is a subchondral fracture.
2 Stage 3 shows resorption.
2 Stage 4 demonstrates reossification.
2 Stage 5 is the healed or residual stage.
± Early radiographic changes may reveal only a nonspecific effusion of the joint associated with slight
widening of the joint space, metaphyseal demineralization (decreased bone density around the joint), and
periarticular swelling (bulging capsule). This is the acute phase, and it may last 1-2 weeks. Decreasing
bone density in and around the joint is noted after a few weeks.
± With advancement of the disease, the joint space between the ossified head and acetabulum widens as the
necrotic ossification center appears denser than the surrounding structures. Narrowing or collapse of the
femoral head causes it to appear widened and flattened (coxa plana). A varus deformity of the femoral neck
may occur as a result of damage to the femoral head growth center and overgrowth of the greater
trochanteric apophysis.
± Eventually, the disease may progress to collapse of the femoral head, increase in the width of the neck,
and demineralization of the femoral head. The final shape of this area depends on the extent of necrosis
and the degree of collapse. All of the findings are correlated with disease progression and the extent of
necrosis. This is the active phase, and it can last 12-40 months.
2 A bone scan can be used to evaluate the site for avascular necrosis.
{

2 ÿ|{

± Consultation with an orthopedist is recommended.
± Treatment goals include eliminating hip irritability, restoring and
maintaining good range of motion in the hip, preventing femoral epiphyseal
collapse, and attaining a spherical femoral head when the hip heals.
± Initial therapy includes minimal weight bearing and protection of the joint,
which is accomplished by maintaining the femur abducted and internally
rotated so that the femoral head is held well inside the rounded portion of
the acetabulum. Abduction and rotation of the femur is accomplished either
by the use of orthotic devices (bracing) or surgery (osteotomy). The
Scottish Rite brace achieves containment by abduction while allowing free
knee motion.
2 Ñ |{

± Results of surgical containment appear to be better than those of
nonsurgical containment (orthosis). Surgical approaches include either
femoral osteotomy to redirect the involved portion within the acetabulum or
innominate osteotomy. Both procedures produce equal results, but femoral
osteotomy may cause shortening of the limb, leading to a chronic limp
± Surgery does not speed healing of the femoral head, but it does cause the
head to reossify in a more spherical fashion.
2 Irritable hip is immobilised in skin traction
2 As soon as spasm and pain disappear mobilise the
hip
2 Grade I& II no specific treatment is required
2 Grade III& IV when head is not deformed keep the
hip in abduction by splint or surgery (osteotomy)
2 Grade III& IV when head is deformed no treatment is
possible. Eventually early OA will develop which will
be treated eventualy
©
 




2 Regain max possible ROÿ at the affected hip along

with strength to achieve physical independence is
the main aim
± Reduction of muscular spasm
± Isometric painless contractions
± Intermitent contraction of the hip joint
± ÿaintainence of the ROÿ
± Prevention of the contractures
± Increase of the muscular strength
± ambulation
r |
 

2 Primary cause if pain and deformity

2 Cryotherapy
2 ÿoist heat
2 With leg in traction
d |
|
|


2 Hip extensors
2 Abductors
2 quads
d

|
|
 

 


2 Early slow relaxed passive movements

2 Helps in maintaining nutrition
2 Helps in maintaining length of soft tissues
ÿ


| 
ruÿ

2 Full ROÿ of hip

2 Extension, abduction &IR to be carried out at
regular intervals and recorded
2 Splint if resting position is not corrected
©

 
|
| 

2 Flexor tightness and contracture is common

2 Gait affected
2 Gentle extension of affected and stretching of
Normal
2 Wieght can be added to maintain
2 Prone lying
d
| 
 | 


2 After pain and spasm decrease

2 Active assisted, assisted resisted & resisted
2 Terminal ranges of Abduction and extension,
quads&hams and dorsiflexors and
plantarflexors
 

2 POP or abduction splint no wt bearing hence

parallel bar non wt bearing and standing
2 Walker then crutches
©u

2 Scottish rite brace

2 Petrie plaster method/broomstick
2 Hip in 30 abduction and 20 internal rotation
with 15 flexion in knee
2 Active mobilisaton initiated after removal
2 Starting from relaxed passive movements to
resisted
©{

  
 
  
   

2 Limb is immobilized in hip spica for 6wks

2 Toe movements
2 Isometrics for knee and hip inside plaster
2 Resisted movm of contra lateral
2 After removal relaxed passive movements
manually then CPÿ
2 ÿobilisation, strengthening then gait training
| 
| ¦

u
| 
2 Osteonecrosis of the femoral head involves the hip joint, with
osteocytes of the femoral head dying along with the bone marrow;
resorption of the dead tissue by new but weaker osseous tissue can
then lead to subchondral fracture and collapse.
2 There are 2 forms of osteonecrosis:
± traumatic (the most common form)
± atraumatic.
2 Other terms to describe this disorder are avascular necrosis and
ischemic necrosis to denote vascular etiology.
2 The term aseptic necrosis also has been used to indicate that infection
does not play a causative role.
2 Alexander ÿunro first identified the condition in 1738. In the mid
1800s, Cruveilhier was the first to attribute the disorder to an
aberration of circulation in the femoral head. Diagnosis of this disorder
has increased because of improved technology and increased
awareness.
  
2 As the name implies, traumatic osteonecrosis is secondary to
direct injury to the femoral head with resultant damage of the
blood supply. Fracture of the femoral head or neck and hip
dislocation are the primary mechanisms of injury.
2 Atraumatic osteonecrosis has many risk factors. The most
commonly associated problems are corticosteroid use and
alcohol abuse. Other factors includesickle cell anemia, Gaucher
disease, systemic lupus erythematosus, coagulopathies,
hyperlipidemia, organ transplantation, caisson disease, and
thyroid disorders. Genetic factors may also play a role
2 The idiopathic cases make up the third most common category.
2 Hip osteonecrosis resulting from corticosteroid use or alcohol
abuse is associated with the worst prognosis.
2 X
± Anteroposterior (AP) radiographs and frog lateral radiographs of
both hips are the primary diagnostic modalities.
2 ÿRI
± Sensitivity and specificity is greater than 98%, which is higher than
all other modalities.
± This study is ideal if x-ray findings are normal and clinical
suspicion is high. ÿRI should be performed in all patients with
osteonecrosis to assess the extent of the disease. Three-
dimensional ÿRI scanning with image registration may be used to
assess changes in lesion size.
± ÿRI is recommended to identify bilateral disease when 1 hip has
radiographic signs of disease and the other is normal (see image
below).
d


||
  
| 

 
 |
r|

î| 
u "rîu

2 Stage 0 - Bone biopsy results consistent with osteonecrosis; other test results normal
2 Stage I - Positive findings on bone scan, ÿRI, or both
± A - <15% involvement of the femoral head (ÿRI)
± B - 15-30% involvement
± C - >30% involvement
2 Stage II - ÿottled appearance of femoral head, osteosclerosis, cyst formation, and
osteopenia on radiographs; no signs of collapse of femoral head on radiographic or
CT study; positive findings on bone scan and ÿRI; no changes in acetabulum
± A - <15% involvement of the femoral head (ÿRI)
± B - 15-30% involvement
± C - >30% involvement
2 Stage III - Presence of crescent sign lesions classified on basis of appearance on AP
and lateral radiographs
± A - <15% crescent sign or <2-mm depression of femoral head
± B - 15-30% crescent sign or 2- to 4-mm depression
± C - >30% crescent sign or >4-mm depression
2 Stage IV - Articular surface flattened; joint space shows narrowing; changes in
acetabulum with evidence of osteosclerosis, cyst formation, and marginal osteophytes
ÿedical ÿanagement
2 Nonsurgical treatment of osteonecrosis is limited. Observation and
protected weight bearing are options. Certain cases of early-stage
disease can be treated successfully with this option. However, most
studies indicate that the risk of disease progression is greater with
nonsurgical treatment than with surgical intervention.
2 Nonsteroidal anti-inflammatory drugs can be used to reduce pain and
inflammation in patients who cannot have surgery for medical or other
reasons or for patients who are undergoing surgical treatment.
2 Physical therapy can be helpful to restore motion and improve gait.
2 Electrical stimulation has been used in several centers. In some
studies, it has been helpful in treatment prior to femoral head collapse.
Surgical Therapy

2 The mainstay of treatment for osteonecrosis

is surgical. Numerous procedures are
available, indicating that no single procedure
is distinctly advantageous. Preoperative
staging, particularly with collapse of the
femoral head, and acetabular involvement
are the determining factors for choosing a
particular operation.