Stress Fractures: Groin Pathology Presentation PDF

Stress fractures femoral neck stress fractures pubic ramus fractures.  Femoral neck stress fractures A femoral neck stress fracture is a fracture of the femoral neck secondary to repetitive loading. Femoral neck stress fractures present with groin or anterior thigh p...

Stress fractures femoral neck stress fractures pubic ramus fractures.  Femoral neck stress fractures A femoral neck stress fracture is a fracture of the femoral neck secondary to repetitive loading. Femoral neck stress fractures present with groin or anterior thigh pain that is exacerbated by activity and relieved by rest. Again, the pain is difficult to localize on physical examination, but the diagnosis may be suggested by painful limitation of internal rotation of the hip. repetitive loading that comes in 2 patterns: Biomechanics of femoral neck tension compressi side: on side: superior inferior lateral medial neck with neck with weight weight bearing bearing  Mechanism These are caused by repetitive overuse and overload as seen in distance runners. repetitive loading of femoral neck  Pathophysiology repetitive loading causes microscopic fractures in the femoral neck continued repetitive loading does not allow for healing response and stress fracture occurs Contributing risk factors include relative osteoporosis in young female athletes with nutritional or hormonal imbalances, muscle fatigue (which may reduce shock-absorbing abilities), changes in foot gear or training surface, or sudden increases in the training regimen  Associated conditions "female athlete triad" amenorrhea, eating disorder, and osteoporosis must be considered in any female athlete with stress fracture  Presentation History history of overuse or increase in normal training regimen Symptoms insidious onset of pain improves with cessation of activity high impact activities increase pain anterior thigh or groin pain with weight bearing Physical exam may have tenderness directly over femoral neck region with deep palpation  Imaging If the diagnosis is suspected by history, radiographs may be obtained, keeping in mind that changes (when present) normally lag behind the onset of symptoms by two to four weeks. MRI should be performed to make an early, definitive diagnosis. MRI: modality of choice for stress fractures when radiographs are normal MRI Bone scan  TREATMENT Non operative non-weight bearing, crutches and activity restriction indications : compression side stress fractures with fatigue line 50% femoral neck width progression of compression side stress fractures postoperative weight bearing as tolerated  Runners with stress fractures of the inferior femoral neck (compression side) seen on MRI or CT can be treated conservatively, with good prognosis. Many clinicians recommend follow-up imaging to ensure healing before progression of activity. Return to running usually occurs in two to three months. Superior femoral neck stress fractures (traction/tension) are more worrisome and must be treated with open reduction and internal fixation because the risk of progression to complete fracture, displacement and avascular necrosis is high.  Inferior pubic ramus stress fracture Inferior pubic ramus stress fracture is less worrisome. It usually occurs in female distance runners and military recruits, and is fairly easily diagnosed. On physical examination, pain may be elicited on palpation directly over the pubic ramus. Pain is also elicited by one-legged standing or jumping. gradually worsens over a period of weeks. Other symptoms may include: reduced range of movement swelling/inflammation stiffness weakness Diagnosis bone, CT or MRI scan. The diagnosis can be confirmed by a bone scan.  Mechanism if stress is put on the pubic ramus, areas of the bone can become damaged. The damaged areas of the bone are then replaced with new bone. If the process of forming of new bone is slower than the removal of the old bone, weak areas can develop within the pubic ramus at places where it is put under stress. A weak area in the bone can develop into a stress fracture if the pubic ramus is repeatedly stressed. Due to the forces involved in creating stress fractures of the pubic rami, they are more commonly seen in athletes and individuals that train at high intensities.  Treatment Treatment is conservative and straightforward: four to six weeks of relative rest followed by gradual return to sport. Most athletes show complete healing within three to five months. Fracture Treatment: open or closed reduction Soft Tissue Treatment Core Stability Exercises Hydrotherapy Physiotherapy should start immediately after the fracture has been immobilized. Physiotherapy during fracture healing will concentrate on: Promoting healing Encouraging weight bearing Maintaining strength of weakened muscles Maintaining range of movement of the affected and surrounding joints Reducing pain Reducing swelling After fracture has healed and/or cast has been removed physiotherapy is continued for 3-12 months or until pt. have regained full level of function. The aims of physiotherapy are to: Progress weight bearing activities Return to full function Return strength and full range of movement to muscles / joints Focus on sport-specific rehabilitation Optimize the range of movement at the affected joint  Maintenance of hormonal and nutritional balance, modification of foot gear and training surface, and conscientious review of the athlete's training program should be undertaken. Nerve compression LATERAL FEMORAL CUTANEOUS NERVE OBTURATOR NERVE PUDENDAL NEURALGIA (PN):  LATERAL FEMORAL CUTANEOUS NERVE The LFCN passes under or through the inguinal ligament, where compression can occur. provides sensation to the skin along the outer thigh starting from the inguinal ligament and extending down toward the knee. It has also been seen in rifle team members who were required to sit in this same position for prolonged periods. Treatment is composed of refraining from the offending activity; rarely, surgery is warranted. Meralgia paresthetica occurs when the lateral femoral cutaneous nerve —becomes compressed, or pinched. Compression of this nerve can result in numbness, tingling, pain or a burning sensation felt in the outer thigh. Purely a sensory nerve and doesn't affect ability to use leg muscles. The most common cause of damage to this nerve is entrapment at the level of the inguinal ligament.  Causes Idiopathic (or spontaneous) causes -MECHANICAL FACTORS: obesity but also in other conditions that increase intra- abdominal volume such as tight clothing, pregnancy and ascites, in which the nerve may be compressed by the bulging abdomen as it leaves the pelvis. -METABOLIC FACTORS: diabetes mellitus, alcoholism and lead poisoning. Iatrogenic causes Iatrogenic causes can be due to hip replacement or spine surgery. During back surgery the anterior hip can get compressed from the surgical equipment utilized during surgery when the patient is in prone. Also equipment related incidents in individuals who underwent direct lateral and posterior lumbar spinal surgery can cause MP.  Symptoms Patients may have symptoms like pain, burning, numbness, muscle aches, coldness, lightning on the anterolateral aspect of the thigh. A patient can have light pain with spontaneous resolution or may have more severe pain that limits function. Patients may report pain when standing or walking for a long time. The pain can be reduced in a sitting position, because when sitting, the tension in the inguinal ligament reduces. Each patient will have their own specific clinical presentation and distribution of symptoms.  Diagnosis The diagnosis of MP is usually clinical, based on the symptoms found at the coherent history and physically examination. Nerve conduction test of the LFCN. It is very important to note that MP can sometimes occur in combination with certain red flags. These red flags can be the presence of a tumor or a herniated disc in the described area. MRI or ultrasound examinations are performed when suspecting pelvic tumors.Therefore, they must be recognized during the examination and appropriately treated.  Physical examination During physical examination, palpation on the lateral part of the inguinal ligament — at the point where the nerve crosses the inguinal ligament — is usually painful. Some patients also present with hair loss in the areas of the LFCN because they constantly rub this area.  Additional tests To exclude red flags, pelvic radiography is used to rule out bone tumors. Blood tests are used when a metabolic cause is expected.  Management With the conservative management, the causing factors are identified. This conservative management entails f.e. weight loss, informing and advising the patient (encourage wearing loose clothing and no tight belts). Pain can be reduced by applying cold packs in the painful area.  Medical management corticosteroids and local anesthetic agent will reduce pain and improve mobility in most of the MP patients. Anti-inflammatory medication and pain medication to reduce (inflammatory) pain.  Physical therapy management Transcutaneous electrical nerve stimulation Acupuncture (e.g. needling and cupping) Exercising for 30 minutes a day on at least three or four days a week will help with chronic pain management by increasing: -Muscle Strength -Endurance -Stability in the joints -Flexibility in the muscles and joints  Aerobic Exercise Take a brisk walk (outside or inside on a treadmill) Swim or do water aerobic exercises Stationary bicycle indoors Flexibility Exercise exercising against increasing resistance, use of weights, and isometric exercise. Nerve stretches can reduce the tightness in the nerves and also help relieve pain that is associated with tight nerves.  Weight loss in obese patients Physiotherapists aim to promote successful weight management and improved general health by appropriately increasing patients’ levels of physical activity. Manual therapy Active_Release_Techniques (ART), mobilization/manipulation for the pelvis, transverse friction massage of the inguinal ligament, stretching exercises for the hip and pelvic musculature and pelvic stabilization/abdominal core exercises.  Obturator nerve Obturator nerve entrapment is becoming more widely recognized as a cause of chronic groin pain in athletes. obturator nerve supplies the adductor muscles and has a variable cutaneous distribution to the medial thigh. deep aching centered on the adductor origin at the pubic bone. With exercise, the pain become more severe and radiated down the medial thigh toward the knee. Some of the athletes also experienced exercise-related weakness in the affected leg, especially when attempting to jump. Paresthesias rarely present.  Causes Entrapment can be caused if the nerve becomes adhered to the muscles and tissues of the inner thigh. Adhesions limit the amount of forwards and backwards sliding of nerve during movement of the leg. lack of sliding may overstretch the nerve at the site of the adhesions. The obturator nerve may also become trapped, if the muscles and tissues of the inner thigh are excessively tight. following surgery, hemorrhage, or tumor compression  Symptoms Deep ache felt in the medial thigh at pubic bone or in groin… may extend to knee, usually during exercise. If pt. continues to exercise, the pain worsens and, usually, radiates down the inner thigh. reduced spasm range of movement Numbness/ sensory loss swelling/ in medial inflammatio thigh/ n paresthesia Weakness with leg stiffness adduction  Exacerbation of pain may be caused by maneuvers that stretch the nerve either by extension or lateral leg movement. Sometimes medial thigh wasting can be observed. During ambulation, the hip is abnormally abducted.  Diagnosis Plain radiographic studies are normal in persons exhibiting obturator neuropathy. MRI may detect atrophy of the adductor brevis and longus and gracilis suggestive of denervation and obturator nerve entrapment. Diagnosis can be made by electromyogram (if symptoms are present longer than three months). best test to confirm obturator neuropathy is needle electromyography (EMG)… chronic denervation in the short and long adductor muscles  Treatment Conservative management : rest, modification of the activities that initially caused the event, or substituting them with other activities may offer relief. physical therapy (such as ultrasound and interferential treatment), soft tissue massage, adductor muscle and pelvic strengthening exercises, oral anti- inflammatory therapy, corticosteroid injection, and groin stretches.  Surgery should be considered in those with pain and weakness resistant to conservative therapy and documented EMG changes. A rehabilitation plan of physical therapy with gradual return to activities after surgery should be implemented with expected return to activity at 3–6 weeks. Pudendal neuralgia (PN):  Pudendal neuralgia is used interchangeably with "pudendal nerve entrapment“ It can be unilateral or bilateral. Causes include compression, stretch, direct trauma. Pudendal neuralgia is a functional entrapment where pain occurs during a compression or stretch maneuver. The pudendal nerve is compressed during prolong sitting and cycling. Stretch of the nerve by straining with constipation and childbirth. Fitness exercises, machines, weight lifting with squats, leg presses or karate with kickboxing are all etiologic factors.  Symptoms The primary symptom is pain in the genitals or the anal-rectal area.The pain tends to move around in the pelvic area and can occur on one or both sides of the body. Sufferers describe the pain as burning, knife-like or aching, stabbing, pinching, twisting and even numbness. Clinical characteristics include pelvic pain with sitting which increases throughout the day and decreases with standing or lying down and difficulties with urination and/or defecation Interestingly, patients usually report less pain when sitting on a toilet seat, a phenomenon that is believed to be associated with pressure being applied to the ischial tuberosities rather than to the pelvic floor muscles. The pain usually gets progressively worse through the day.  Pudendal neuralgia can be very difficult to diagnose, as no specific test exists. ……. history and physical examination Diagnostic criteria : pain limited to the territory of innervation of the pudendal nerve pain predominant during sitting pain does not awaken the patient from sleep no objective sensory defects Objectively these criteria determine the baseline function of a patient at the beginning of treatment. Once treatment has commenced, the same instrument can be used to determine progress and treatment efficacy. Physical examination focuses on a simple pudendal neurological evaluation. Hyperalgesia is more common.  MRI allows PN to be classified, based on the entrapment site: Type I, in the sciatic notch Type II, the ischial spine and Sacrosciatic ligament Type IIIa, the obturator internus muscle Type IIIb, the obturator internus and piriformis muscles Type IV, the distal branches of the pudendal nerve  Treatment Muscle Relaxants & Analgesics. Pelvic Floor Relaxation exercises Patient Self-Management: Patient should use a cushion( Doughnut or C-Shaped) that supports the ischial tuberosities to elevate the pelvic floor off the seat. Avoidance of postures or movement which triggers pain. Exercises which relax tensed pudendal nerve and will provide temporary relief are: Wide leg bridges Standing backward leg lifts Side-lying hip abduction and extension Hip extension in the quadruped position Cobra pose Wide leg bridges Standing backward leg lifts Side-lying hip abduction and extension Hip extension in the quadruped position Cobra pose  A patient visits her GP with difficulty walking. After clinical examination, obturator nerve palsy is suspected. Which movement is most likely to be impaired? Hip LR Hip adduction Hip extension Hip flexion Osteitis Pubis  Osteitis pubis is defined as an idiopathic, inflammatory condition of the pubic symphysis and surrounding structures, but it is most likely related to overuse or trauma. It may also occur as an inflammatory process in athletes. painful, chronic syndrome that affects the symphysis pubis, adductor and abdominal muscles, and surrounding fascia. The obturator and femoral nerves with their cutaneous branches have been suggested as etiologic factors in groin pain  the abdominal muscles (rectus abdominis and external and internal oblique muscles) attach distally to the inguinal ligament, conjoined tendon, and pubic symphysis, whereas the adductor muscles (pectineus, adductor longus, adductor brevis, adductor magnus, gracilis) arise from the superior and inferior rami of the pubis. Muscle imbalances between the abdominal and hip adductor muscles have been suggested as an etiologic factor in osteitis pubis  Symptoms Osteitis pubis is a rare cause of groin pain but is more common in the athletic patient, specifically soccer players, runners, and rugby players. Patients often present with anterior and medial groin pain made worse with activity. pain when kicking or advancing the leg forward during the swing phase of gait, localized pain in the symphysis pubis, and pain in the lower portion of the abdominal muscle groups. perineal region, inguinal region can be painful The presentation is typical with varying degrees of pelvic and/or perineal pain, reproduced on hip adduction and flexion  Etiology: pregnancy/childbirth high-level of athletic activity urological or gynaecological surgery trauma ankylosing spondylitis  Diagnosis The adductor muscles are evaluated bilaterally for pain and tenderness and increased muscle guarding in the muscle belly and at the musculotendinous attachments. Standard passive flexibility and resisted muscle tests of the adductor and abdominal muscle groups performed to reproduce the painful symptoms. tenderness on palpation of the symphyseal region is common  Plain radiographs may demonstrate symphyseal bony sclerosis, erosions and widening or narrowing of the joint, especially in the chronic phase, while radiographic changes may be absent in the early or mild forms of the condition  Treatment Conservative management includes rest, limited activity, ice and anti-inflammatory drugs, followed by a rehabilitation program. Conservative management aims to correct muscular imbalance around the pubic symphysis, and it usually consists of a progressive exercise program, involving stretching and pelvic musculature strengthening In rare cases, surgical intervention may be required.