Lower Extremity Injuries & Bursitis

Lower Extremity Soft Tissue Injuries

• Objective is to describe the mechanism of injury, symptoms, and signs of groin, hamstring, and adductor injuries.
• Objective is to design a plan of care to address the typical impairments, functional limitations, and disability caused by these injuries.

Iliopectineal and Iliopsoas Bursitis

• Both types of bursitis present with pain in the groin and anterior thigh, sometimes down to the knee.

Iliopectineal Bursitis

• The bursa is located between the iliopsoas muscle and the hip joint over the capsule of the hip.
• Palpate near the head of the femur, around one to two cm below the middle third of the inguinal ligament, halfway between the pubic tubercle and the greater trochanter.

Iliopsoas Bursitis

• The bursa is found medially near the insertion of the iliopsoas in the femoral triangle.
• Tenderness can be found by palpating over the lesser trochanter, just below the inguinal ligament.
• Palpate while the patient is supine, hip flexed to 90 degrees, and passively abducting the hip.
• Pain occurs with passive and resisted hip flexion, and possibly with passive hip extension.

Ischial Bursitis

• Located over the ischial tuberosity, which may irritate the sciatic nerve.
• Cause acute and very intense pain
• Sitting aggravates the condition.
• Palpation of the ischial tuberosity reveals tenderness, and possibly a "doughy" texture of the bursa.

Hernias: Occult hernia

• Types include: Inguinal, Incisional, Epigastric, Umbilical, Femoral, Spigelian, and Diastasis Recti (not).

Inguinal Hernias

• Intra-abdominal fat or small intestine bulges through a weak area in the lower abdominal muscles at the inguinal ring.
• Appears as a bulge on one or both sides of the groin.
• Can occur at any time from infancy to adulthood.
• Indirect hernias are congenital, and occur in males and premature infants.
• Direct hernias result from connective tissue degeneration of abdominal muscles, and occur only in males through straining, coughing, twisting, etc

Inguinal Hernias: Symptoms

• Small bulge may be present.
• Bulge may disappear while lying down
• Males can present as a swollen or enlarged scrotum
• Cause Discomfort or sharp pain with lifting or straining
• Feeling of weakness or pressure in the groin
• Burning, gurgling, or an aching feeling at the bulge

Athletic Pubalgia/Sports Hernia

• Weakening of the posterior inguinal wall causes occult direct or indirect hernia.
• Tear in one of the lower abdominal muscles in either the inguinal canal or connective tissues.
• Diagnosis via exclusion
• Location of the pain is more laterally and proximally than in groin disruption.

Athletic Pubalgia/Sports Hernia: Characteristics

• "Hidden" hernia presents without visible bumps or lumps.
• Symptoms: lower abdomen, groin, pubic, and adductor pain.
• Insidious onset, gradually worsening, diffuse, deep groin pain.
• Pain in the lower abdomen and pubic region.
• Activities that increase abdominal pressure, such as twisting, running, and cutting, usually cause pain.
• Radiation of pain to the testicles is present in ~30% of cases.

Athletic Pubalgia/Sports Hernia: Diagnosis and Treatment

• Radiographs, isotope bone scans, and MRI may help to exclude other causes of groin pain.
• Non-operative treatment is rarely successful.
• Often tried, conservative treatment can be effective if symptoms persist, surgical exploration is warranted.
• Prevention: Core stability exercises provide the same success rate if you wait to have surgery.

Osteitis Pubis

• Characterized by pubic symphysis pain and joint disruption.
• Results from repetitive stress from increased shearing forces on the joint, or traction from the pelvic musculature, limited IR, or fixation of the SIJ.
• Symptoms: exercise-induced pain, gradual onset of pain in the lower abdomen and pubic area.

Osteitis Pubis: Diagnosis and Treatment

• Lack of tenderness excludes diagnosis
• Radiographs: may be normal or show widening, irregular contour of articular surface, or periarticular sclerosis.
• Isotope bone scan: may show increased uptake.
• MRI: marrow edema early in course.
• Treatment: Condition is self-limiting, but can take up to one year to heal.
• Pain free Rx: stretching, strengthening, biomechanical abnormality assessment etc.
• May refer pain to the groin.

Tendinopathies and Muscle Strains

• Adductor strain most commonly involves the adductor longus
• Hamstring strain can occur at the attachment to the ischial tuberosity or within the midbellies.
• Assess: Stretch, resist, and palpate.

Groin Injury (Adductor Tendinopathy/Strain)

• Rapid acceleration and deceleration due to sudden changes in direction and kicking can occur.
• Sports with high incidence include soccer, rugby, Australian Rules Football, ice hockey, Gaelic football, and cricket.
  • 10% of all injuries in elite Swedish ice hockey players
  • 43% of all muscle strains in elite Finnish ice hockey players
  • 3.2 strains/1000 player-game exposure in NHL
  • 10-18 injuries/100 soccer players
  • 24% of all LE strains in NFL.

Tissue Capacity/Load

• The EMG activity of hip adductors is highest during the eccentric phase of high-speed soccer kicking.
• Skating, during the lateral skating push, also causes increase.
• Loading substantially increases as kicking or skating velocity increases and when sudden, unplanned movements occur.

Risk Factors

• Previous groin injury
• Higher level of play
• Reduced hip adductor strength
  • Eccentric hip-adductor to -abductor strength ratio of <0.8 associated with an increased risk for acute adductor strains in mens ice hockey.
• Lower levels of sport-specific training

Assessment

• PROMS
  • Copenhagen Hip and Groin Outcome Score (HAGOS)
• Impairments
  • Strength
    • Large eccentric abdominal deficits (37% deficit)
  • ROM
    • Severe restrictions in passive ROM are related to early impairment and muscle guarding immediately after serious muscle-tendon rupture or avulsion and intra-articular hip conditions

Management

• Most resolve within 1-3 weeks.
• If prolonged, may be due to pubic syphysis or bone reaction.
• If not managed appropriately, can take > 6 months to resolve.

Rehabilitation

• Phase-specific exercises for adductor, gluteal and trunk work in order to improve balance, coordination and plyometric ability
• Clinical milestones met prior to return:
  • No or minimal pain (0-2/10) during or after the following:

1. Clinical examination including adductor palpation, stretching, and squeeze
2. Adductor strength training at heavy loads (10-repetition maximum)and 10 repetitions of Copenhagen adductor exercises
3. Sport-specific training including maximal actions of running, sprinting, change of direction, skating, and kicking, depending on sporting relevance for the individual athlete

Hamstring Strain

• Sports that involve sprinting or extreme hamstring stretching have high incidence including: - Track - American/Australian Football - Soccer - Rugby - Dancers
• Incidence
  • NFL: second to knee sprains
  • Days lost: 8-25 days
  • 1/3 of injuries recur within 2 weeks of return to sport
• Incidence
  • Muscle head involved - Biceps femoris (70%) - Semitendinosus (15%) - Other (15%) - Tissue involved - Myotendinous junction (52%) - Location - Proximal (34%)
    • Central (33.4%)
      • Distal (32.6%)

Hamstring Strain: Risk factors

• Non modifiable
  • Previous HIS (risk for reinjury)
  • Age > 23 years
  • ACL injuries
  • Calf strains
  • Other knee and ankle ligament injuries
• Modifiable
  • Hamstring fascicle length
  • Hamstring stiffness
• Possible
  • High-speed running demands with abnormal trunk and pelvic posture and motor control

Hamstring Strain: Management

• Acute strains treated with PEACE and LOVE, anti-inflammatories, physical modalities like ice and pulsed ultrasound and isometric exercise.
• Begin gentle warmup, stretching, resistive exercise, gradual resumption of activity in the subacute phase which lasts 2 or 3 weeks.
• At four weeks, introduce resistive exercise emphasizing the injured region of the muscle and eccentrics.

Hamstring Strain: Return to Play

• Clinicians should use caution in RTP decisions for individuals who did not complete an appropriately progressed, comprehensive impairment-based functional exercise program that specifically included eccentric training (B)
• Clinicians should use:
  • hamstring strength -pain level at the time of injury
  • number of days from injury to pain-free walking and area of tenderness measured at initial evaluation to estimate RTP. (B)