Endoscopic Repair of Hip Abductor Tendon Tears: A Case Report.

Introduction: Greater trochanteric pain syndrome is a common incapacitating hip condition characterized by chronic lateral hip pain. This condition includes a range of pathologies ranging from trochanteric bursitis, hip abductor pathology involving the gluteus medius and minimum, external coxa saltans (snapping hip syndrome), or combinations of these. Hip abductor tendon tears have gained recognition as a main contributor to this condition. This pathology is often misdiagnosed and left untreated because of the frequency of partial-thickness undersurface tears. Once this challenging diagnosis is confirmed, non-operative treatments are considered the first therapeutic approach. Despite the availability and effectiveness of multiple non-operative therapies, a considerable percentage of patients will present with chronic disabling pain and refractory symptoms. Many health-care providers are unaware of accessible advanced surgical techniques that benefit patients unresponsive to conservative management. Case Report: We present the case of a 51-year-old female patient with chronic lateral hip pain refractory to conservative treatment for more than two years, treated successfully with endoscopic abductor tendon repair. The patient returned to the desired activities six months following surgery without any reported complications. Patient's pre-operative reported outcomes utilizing the MHOT-14 and Vail hip scores improved from 27 to 79 points (on a scale of 0-100) and from 30 to 56 points (on a scale of 0-100), respectively, at eight months follow-up. Conclusion: This case report is illustrative of endoscopic surgical repair of the hip abductor tendons in the setting of a chronic full-thickness abductor tendon tear in a female patient after failure of conservative management. The multiple advantages of the technique include performance in an ambulatory day surgery center, soft-tissue preservation, and fewer complications compared to other open techniques. Knowledge of this pathology and its state-of-the-art available treatments is relevant for orthopedic surgeons and a wide range of health providers who encounter patients with chronic lateral hip pain.

Relationship of Average Outcomes Scores and Change in Status Requires Further Interpretation Between 1 and 2 Years Following Hip Arthroscopy.

BACKGROUND: Previous studies have demonstrated a clinically impactful change in patients between 1 and 2 years after hip arthroscopy. Assessment of differences in patient-specific factors between patients who remain the same and those who change (ie, either improve or decline) could provide valuable outcome information for orthopaedic surgeons treating those patients. PURPOSE: To identify patients who experienced change in functional status between 1 and 2 years after hip arthroscopy for femoroacetabular impingement syndrome and assess differences in patient-specific factors between those who improved, remained the same, or declined in functional status. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Prospectively collected data for patients who underwent hip arthroscopy at 1 of 7 centers were analyzed retrospectively at 1 year and 2 years postoperatively. Patients were categorized as "improved,""remained the same," or "declined" between 1- and 2-year follow-up based on the 12-item International Hip Outcome Tool (iHOT-12) minimal clinically important difference (MCID) value. A 1-way analysis of variance was used to assess differences in iHOT-12 scores, age, body mass index (BMI), alpha angle, and center-edge angle (CEA) between groups. Chi-square analyses were used to assess differences in the proportions of male and female patients in the outcome groups. RESULTS: The study included 753 patients (515 women and 238 men), whose mean ± SD age was 34.7 ± 12 years. Average 1-year (±1 month) and 2-year (±2 months) iHOT-12 scores for all patients were 73.7 and 74.9, respectively. Based on the calculated MCID of ±11.5 points, 162 (21.5%) patients improved, 451 (59.9%) remained the same, and 140 (18.6%) declined in status between 1- and 2-year follow-up. Those who improved between 1 and 2 years had lower 1-year iHOT-12 scores (P < .0005). We found no difference in age, BMI, alpha angle, CEA, or sex between groups (P > .05). CONCLUSION: Between 1- and 2-year follow-up assessments, 21.5% of patients improved and 18.6% declined in self-reported functional status. Those with iHOT-12 scores indicating abnormal function at 1 year improved beyond the MCID at 2 years follow-up. Thus, any decisions about the failure or success of arthroscopic hip procedures should not be made until at least the 2-year follow-up. Failing to thrive at 1-year follow-up may not accurately predict outcomes at year 2 or beyond. This could potentially decrease the perceived need for revision surgery in patients who do not thrive before 2-year follow-up.

Corrigendum to: 'Mini-Max' knotless acetabular labrum repair: repair construct rationale and allocation in a consecutive case series with minimum 1-year clinical outcomes.

[This corrects the article DOI: 10.1093/jhps/hnab061.].

Midseason Screening for Groin Pain, Severity, and Disability in 101 Elite American Youth Soccer Players: A Cross-Sectional Study.

OBJECTIVE: To (1) systematically screen for groin pain and type in young elite soccer players and (2) assess whether hip and groin-related severity and disability differed between players with different levels of groin pain and tenderness. DESIGN: Cross-sectional observational. SETTING: Elite American soccer academy at midseason. PARTICIPANTS: One hundred one academy soccer players (mean age 14.3 ± 1.8 years). INTERVENTION: All players underwent clinical examinations to classify groin pain by the Doha agreement taxonomy. MAIN OUTCOME MEASURES: Tests for groin-related severity and disability included the Copenhagen 5-second squeeze test, Copenhagen Hip and Groin Outcome Score (HAGOS), and Hip Outcome Score (HOS). Players were stratified into 3 groups: those with groin pain, those with tenderness, and those with no groin pain or tenderness. RESULTS: Twenty-two players (22%) reported groin pain. Adductor-related groin pain was the most common (n = 14), followed by iliopsoas-related (n = 3), and pubic-related (n = 2). Multiple locations were present in 3 players. Thirty-nine players (39%) did not have groin pain but were tender to palpation in 1 or more structures related to the Doha agreement taxonomy. Copenhagen 5-second squeeze test differentiated between players with and without groin pain (groin pain vs tenderness group: P = 0.011; groin pain vs no groin pain group P < 0.001). Four HAGOS subscales (pain, symptoms, sport/recreation, and quality of life) differentiated between players with and without groin pain ( P < 0.05). CONCLUSIONS: One in five academy soccer players experiences groin pain with adductor-related most common during a midseason screening. Both Copenhagen 5-second squeeze test and HAGOS subscales can differentiate between players with and without groin pain.

Allocation of Anchors During Labral Repair: A Multicenter Cohort Analysis of Labral Treatment in Hip Arthroscopy.

BACKGROUND: While previous studies have established several techniques for suture anchor repair of the acetabular labrum to bone during arthroscopic surgery, the current literature lacks evidence defining the appropriate number of suture anchors required to effectively restore the function of the labral tissue. PURPOSE/HYPOTHESIS: To define the location and size of labral tears identified during hip arthroscopy for acetabular labral treatment in a large multicenter cohort. The secondary purpose was to differentiate the number of anchors used during arthroscopic labral repair. The hypothesis was that the location and size of the labral tear as well as the number of anchors identified would provide a range of fixation density per acetabular region and fixation method to be used as a guide in performing arthroscopic repair. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We used a multicenter registry of prospectively collected hip arthroscopy cases to find patients who underwent arthroscopic labral repair by 1 of 7 orthopaedic surgeons between January 2015 and January 2017. The tear location and number of anchors used during repair were described using the clockface method, where 3 o'clock denoted the anterior extent of the tear and 9 o'clock the posterior extent, regardless of sidedness (left or right). Tear size was denoted as the number of "hours" spanned per clockface arc. Chi-square and univariate analyses of variance were performed to evaluate the data for both the entire group and among surgical centers. RESULTS: A total of 1978 hips underwent arthroscopic treatment of the acetabular labrum; the most common tear size had a 3-hour span (n = 820; 41.5%). Of these hips, 1645 received labral repair, with most common repair location at the 12- to 3-o'clock position (n = 537; 32.6%). The surgeons varied in number of anchors per repair according to labral size (P < .001 for all), using 1 to 1.6 anchors for 1-hour tears, 1.7 to 2.4 anchors for 2-hour tears, 2.1 to 3.2 anchors for 3-hour tears, and 2.2 to 4.1 for 4-hour tears. CONCLUSION: Variation existed in the number of anchor implants per tear size. When labral repair involved a mean clockface arc >2 hours, at least 2 anchor points were fixated.

'Mini-Max' knotless acetabular labrum repair: repair construct rationale and allocation in a consecutive case series with minimum 1-year clinical outcomes.

To describe the 'mini-Max' approach to labrum repair using non-absorbable 2.4-mm knotless suture anchors and report objective clinical outcomes with a large single-surgeon cohort. Level 3 retrospective case series. A retrospective review was conducted to report the use and allocation of non-absorbable 2.4-mm knotless suture anchors during 'mini-Max' labral repair from 2015 to 2018. Descriptive analysis of the labral damage severity, size and number of anchors used to arthroscopically repair the acetabular labrum was performed. Paired-samples t-tests were performed to evaluate whether preoperative and 1-year follow-up patient-reported outcomes (PROs) were statistically significant. An analysis of variance was performed comparing PROs with categorized number of labral anchors. A total of 390 patients were queried in this study, with 330 (85%) diagnosed intraoperatively with acetabular labral tears. A total of 245 patients (137 females and 108 males) with a mean age of 30.1 ± 11.6 years (mean ± SD) at the time of surgery underwent 'mini-Max' labral refixation. Of the 245 labral tears, 88 (35.9%) were graded as mild, 113 (46.1%) as moderate and 44 (18.0%) as severe. Labral repairs required an average of 2.1 ± 0.67 anchors across all patients included. Forty-one repairs (16.7%) required one anchor, 139 (56.7%) required two anchors, 63 (25.7%) required three anchors and 2 (0.8%) required four anchors. Significant improvements were reported for all PROs (P ≤ .001) at a minimum of 1-year follow-up. Arthroscopic 'mini-Max' labral repair using non-absorbable knotless suture anchors is a safe and effective technique for improving the lives of patients suffering from symptomatic acetabular labrum tears.

Arthroscopic Capsular Management of the Hip: A Comparison of Indications for and Clinical Outcomes of Periportal Versus Interportal Capsulotomy.

PURPOSE: To compare the clinical outcomes of periportal capsulotomy versus interportal capsulotomy with closure using a standard clinical algorithm at a minimum of 2 years after hip arthroscopy. METHODS: A retrospective cohort study of patients treated from July 2015 to October 2017 was conducted to determine the effects of 2 capsular management approaches on clinical outcomes. When patient pathology limited adequate exposure via periportal capsulotomy, an interportal capsulotomy was performed. The capsular management approaches were correlated with the following patient-reported outcomes (PROs) at 2 years: Hip Outcome Score (HOS), 12-item International Hip Outcome Tool, visual analog scale for pain, and patient satisfaction. Preoperative comparisons between the 2 groups were analyzed using t tests or the Fisher exact test, depending on the category of data. Two-tailed independent t tests were performed to evaluate whether preoperative and follow-up outcome scores were significantly different between patients treated with a periportal capsulotomy and those treated with an interportal capsulotomy. RESULTS: Overall, patients in both groups experienced significant improvements in all PROs on postoperative comparisons at 2-year follow-up (P < .001). The mean changes in the PROs were as follows: HOS-Activities of Daily Living, 24.7 in the periportal group and 23.5 in the interportal group (P = .484); HOS-Sport-Specific Subscale, 30.2 and 31.3, respectively (P = .895); 12-item International Hip Outcome Tool score, 41.9 and 40.2, respectively (P = .564); and visual analog scale pain score, -40.9 mm and -34.5 mm, respectively (P = .791). Additionally, no statistically significant difference in patient satisfaction at 2-year follow-up was found between patients who underwent interportal capsulotomy and those who underwent periportal capsulotomy (P = .604). CONCLUSIONS: At 2-year follow-up, patients who underwent a periportal capsulotomy reported statistically and clinically significant improvements in PROs and satisfaction with the surgical intervention. This study confirms that the use of a simple clinical algorithm for selection of periportal capsulotomy or interportal capsulotomy with closure results in acceptable management decisions as defined by 2-year PROs. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Pre-operative comparisons for a return to running protocol in recreational athletes following hip arthroscopy.

The purpose of the current study was to present pre-operative comparisons for recreational athletes attempting a return to running following hip arthroscopy, and the return to running progression protocol used to guide them. A prospective, non-randomized cohort study was conducted to evaluate recreational athletes that returned to running following hip arthroscopy. Return to running was the primary outcome measure and defined as the ability to run at least one mile three times weekly while maintaining patient-reported relief of pre-operative symptoms. Patients included were correlated with the following pre-operative patient-reported outcome measures: hip outcome score (HOS), 12-item international outcome tool (iHOT-12), visual analog scale for pain (VAS) and the Short-Form Health Survey (SF-12). Of the 99 included patients, 94 (95%) returned to running successfully with an average return of 4.8 months. There was no statistical difference in pre-operative comparisons between patients that returned to running and did not return to running (P ≥ 0.154). Evaluation of pre-operative clinical outcomes demonstrated no statistical difference between individuals that returned and did not return to running (P ≥ 0.177), but a large difference between the two groups was identified for HOS-ADL (64.8 versus 53.7, returned versus did not return), iHOT-12 (33.8 versus 25.4) and VAS (58.6 versus 69.3). Patients who returned to running demonstrated similar intraoperative procedures as those that did not return to running (P ≥ 0.214). The current study successfully establishes a management plan and progression protocol for patients identifying a return to recreational running following hip arthroscopy. Level of evidence: 3.

Short and long lever adductor squeeze strength values in 100 elite youth soccer players: Does age and previous groin pain matter?

OBJECTIVE: To examine adductor squeeze strength in elite youth soccer players by investigating the relationship of age and previous one-year groin pain on adductor squeeze force outputs, and to provide reference values for youth players. DESIGN: Cross-sectional study. PARTICIPANTS: Elite youth soccer players (n = 100; age 14.5 ± 1.9 years; height 168.0 ± 10.7 cm; mass 60.7 ± 13.0 kg) participated. MAIN OUTCOME MEASURES: Adductor squeeze tests were captured in short and long lever positions, and groin pain assessed via subjective retrospective questionnaire. Multiple linear regressions were computed to compare the effects of age and previous one-year groin pain on adductor squeeze strength. RESULTS: Raw adductor squeeze force values (N) had a moderate positive relationship with age (short r = 0.517, p < 0.001; long r = 0.457, p < 0.001), but not when force is normalized to body mass (N/kg; short r = 0.014, p = 0.444; long r = -0.173, p = 0.043). Previous groin pain did not have an effect on short or long lever squeeze strength. Reference values for long lever adductor squeeze strength (3.59 ± 0.77 Nm/kg) are provided. CONCLUSION: Age and previous groin pain do not have an effect on adductor squeeze strength values in elite youth soccer players, so comparing values to the present adolescent cohort can be quickly interpreted without adjustment for age or previous injury.

Endoscopic-Assisted Anatomic Reconstruction of Chronic Proximal Hamstring Avulsion With Achilles Allograft.

Hamstring injuries commonly occur at the musculotendinous junction; however, they can occur as proximal avulsion injuries. A lack of recognition can lead to proximal hamstring injuries being frequently misdiagnosed, resulting in delayed treatment. Chronic proximal hamstring tears are often retracted and scarred to the surrounding soft tissues. Owing to the poor quality of tissue at the torn ends of the tendon, an augmented reconstruction using an allograft may be required. In cases with poor visualization of the ischial tuberosity and proximal hamstring footprint, an Achilles tendon allograft can be secured directly to the tuberosity with suture anchors. However, visualization of the footprint can be optimized using an arthroscope. This report describes a technique for endoscopic-assisted anatomic reconstruction using an Achilles allograft with both knotless and knotted suture anchors for chronic complete avulsions of the proximal hamstring.

Risk of intra-articular hip injury in adolescent athletes: a five-year multicentre cohort study.

PURPOSE: The purpose of the current study was to establish a risk stratification for hip injury by presenting the classification of sports among adolescent athletes undergoing hip arthroscopy. METHODS: A multicentre registry was queried to examine the incidence of adolescent athletes undergoing hip arthroscopy. Patients were identified and grouped according to their sport-specific risk classification (level I-III). Chi-square analysis was performed to determine the relationship of classification of sport and gender in adolescent athletes to hip arthroscopy. A second chi-square analysis was performed to determine the relationship of classification of sport and number of sports the adolescent athlete was participating in prior to arthroscopic hip surgery. RESULTS: A total of 297 adolescent athletes were included in the study with 129 (43.4%) participating in level I sports compared with 84 (28.3%) in level II and 84(28.3%) in level III sports. Chi-square testing demonstrated a significant effect on gender and sport classification, X2 (2, N = 297) = 31.18, p < 0.01. There was a greater percentage of athletes participating in a single sport (65.3%) compared with multiple sports (34.6%), but was not statistically significant, X2 (1, N = 297) = 1.88, p = 0.17. CONCLUSION: The current study was successful in stratifying a large, multicentre cohort of adolescent athletes requiring hip arthroscopy based on classification levels of sport. There were more male athletes participating in level I sports, while more female athletes participated in level II and level III sports.

Conservative management acutely improves functional movement and clinical outcomes in patients with pre-arthritic hip pain.

Conservative management for individuals with pre-arthritic hip pain is commonly prescribed prior to consideration of surgical management. The purpose of this study is to determine if patients with pre-arthritic hip pain will improve their functional movement control and clinical outcome measures following the implementation of physical therapy and a home-exercise programme. Information was retrospectively collected on consecutive patients and included: demographics, diagnosis, initial and follow-up evaluation of the single leg squat test (SLST) and step-down test (SDT), and patient-reported outcome measures. An independent t-test and one-way analysis of covariance were performed for continuous patient-reported outcome measures and a Fisher's exact test was performed for patient satisfaction. Forty-six patients (31 female and 15 male) diagnosed with pre-arthritic hip pain were included. A total of 30 patients improved their functional movement control during performance of the SLST, whereas 31 patients improved performance of the SDT. There was a statistically significant difference between patients that improved and did not improve (P ≤ 0.017). Patients with pre-arthritic hip pain who improved their functional movement control following a prescribed rehabilitation intervention are likely to report less pain and greater functional ability in their daily and sports-related activities. This study supports conservative management to acutely improve outcomes for patients with pre-arthritic hip pain.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement.

The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on femoroacetabular impingement syndrome (FAIS) was intended to build an international physiotherapy consensus on the assessment, non-surgical physiotherapy treatment, pre-/post-operative management, and return to sport decisions for those patients with FAIS. The panel consisted of 11 physiotherapists and 8 orthopaedic surgeons. There is limited evidence regarding the use of physiotherapy in the overall management of those with FAIS. Therefore, a group of ISHA member physiotherapists, who treat large numbers of FAIS patients and have extensive experience in this area, constructed a consensus statement to guide physiotherapy-related decisions in the overall management of those with FAIS. The consensus was conducted using a modified Delphi technique. Six major topics were the focus of the consensus statement: (i) hip assessment, (ii) non-surgical physiotherapy management, (iii) pre-habilitation prior to hip arthroscopy, (iv) post-operative physiotherapy rehabilitation, (v) stages of post-operative rehabilitation and (vi) return to sports criteria/guidelines after surgery.

Erratum to: The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement.

[This corrects the article DOI: 10.1093/jhps/hnaa043.].

Evidence for Reliability and Validity of Functional Performance Testing in the Evaluation of Nonarthritic Hip Pain.

CONTEXT: The single-legged-squat test (SLST) and step-down test (SDT) are 2 functional performance tests commonly used to evaluate active people with nonarthritic hip pain and dysfunction. However, evidence to support the use of the SLST and SDT in this population is lacking. OBJECTIVE: To offer evidence of reliability and validity for the SLST and SDT in evaluating patients with nonarthritic hip pain. DESIGN: Cross-sectional study. SETTING: Orthopaedic surgeon's clinical office. PATIENTS OR OTHER PARTICIPANTS: Forty-five patients (27 female and 18 male participants; age = 28.5 ± 10 years, height = 171.6 ± 10.1 cm, weight = 73.9 ± 15.2 kg, and body mass index = 25 ± 4.1) diagnosed with nonarthritic hip pain. MAIN OUTCOME MEASURE(S): Participants performed the SLST and SDT. Interrater reliability and validity of passive internal rotation of the hip, visual analog scale (VAS) scores, and hip outcome scores (HOSs) for limitations in activities of daily living and sport-related activities (SRAs) were collected. RESULTS: Interrater reliability was moderate to excellent for both the SLST (0.603-0.939) and SDT (0.745-0.943). Participants who passed or failed the SLST and SDT differed on the following measures: VAS for the SLST (F1,43 = 16.21, P < .001); VAS for the SDT (F1,43 = 13.41, P = .001); HOS-activities of daily living for the SLST (F1,40 = 5.15, P = .029); HOS-SRAs for the SLST (F1,40 = 7.48, P = .009); and HOS-SRAs for the SDT (F1,40 = 6.42, P = .015). CONCLUSIONS: Our study offers evidence for the use of the SLST and SDT as reliable and valid functional performance tests in the evaluation of physical function for patients with nonarthritic hip pain.

NON-OPERATIVE MANAGEMENT OF INDIVIDUALS WITH NON-ARTHRITIC HIP PAIN: A LITERATURE REVIEW.

BACKGROUND: Non-arthritic hip pain is defined as being related to pathologies of the intra-articular structures of the hip that can be symptomatic. A trial of non-operative management is commonly recommended before consideration of surgery for individuals with non-arthritic hip conditions. There is a need to describe a non-operative or conservative treatment plan for individuals with non-arthritic hip pain. PURPOSE: The purpose of this literature review was to systematically examine the literature in order to identify and provide evidence for non-operative or conservative management of individuals with non-arthritic hip pain. A proposed home exercise program will be provided for individuals with non-arthritic hip pain. STUDY DESIGN: Review of the Literature. MATERIALS/METHODS: A literature search of PubMed, Medline, SPORTSDiscus, and CINAHL was conducted. Keywords included: "hip" AND "femoroacetabular impingement" OR "labral tear." Studies were included if they described non-operative management for individuals with non-arthritic hip pain. Studies were excluded if they recommended a trial of conservative treatment without specific management or interventions and/or activity modification without specific details for intervention. RESULTS: A total of 49 studies met the eligibility criteria and were included in the review. Rehabilitation recommendations were identified from manuscripts including clinical trials, case series, discussion articles, or systematic reviews related to the non-operative or conservative management of non-arthritic hip pain. Rehabilitation interventions focused on patient education, activity modification, limitation of aggravating factors, an individualized physical therapy protocol, and use of a home exercise program. CONCLUSIONS: Rehabilitation should address biomechanical deficiencies with neuromuscular training of the hip and lumbopelvic regions. While the current literature on non-operative management is limited, future randomized control trials will establish the effectiveness of specific physical therapy protocols for individuals with non-arthritic hip pain. LEVEL OF EVIDENCE: 3b.

A MECHANISM FOR LIGAMENTUM TERES INJURIES IN FEMOROACETABULAR IMPINGEMENT: AN ANATOMICAL STUDY.

BACKGROUND: Femoroacetabular impingement can produce abnormal biomechanics that lead to compensatory injuries around the hip and pelvis. Ligamentum teres pathologies are commonly associated with these bony deformities but a mechanism for injury has not been described in the literature. PURPOSE: The purpose of this study was to describe a potential mechanism behind ligamentum teres injury and impingement between the femoral neck and acetabulum. STUDY DESIGN: Laboratory controlled cadaveric study. METHODS: Twenty-six hips from 15 embalmed cadavers (8 male; 7 female) with lifespans between 55-93 years were skeletonized. The hip was placed in 90 ° flexion and 0 ° abduction/adduction and internally rotated until the femoral head neck contacted the acetabulum. This position of impingement with respect to internal rotation was recorded with a goniometer. The hip was then further internally rotated until end range of motion was achieved and again the position of internal rotation recorded with a goniometer. RESULTS: The positions of internal rotation at which impingement occurred (mean 9 °; SD 4.2; Range -2 ° to 15 °) when compared to end range (mean 21 °; SD 5.7; Range 5 ° to 27 °) were significantly different (p<0.005; t = 14.8). In all the hips, after impingement occurred the site of bony contact between the femoral neck and acetabulum acted as a pivot point. The femoral head was levered inferiorly with a loss of the rotational center within the acetabulum, as internal rotation continued. This movement of the femoral head caused the ligamentum teres to tighten and restricted further movement. Movement into internal rotation beyond this end position caused rupture of the ligamentum teres. CONCLUSION: Internal rotation range of motion can occur beyond the position of impingement and resulted in abnormal inferior movement of the femoral head and tightening of the ligament teres. This study provides cadaveric evidence for the mechanism of ligamentum teres injury in those with who engage in activities that required motion beyond the point of impingement.

EVIDENCE-BASED PROCEDURES FOR PERFORMING THE SINGLE LEG SQUAT AND STEP-DOWN TESTS IN EVALUATION OF NON-ARTHRITIC HIP PAIN: A LITERATURE REVIEW.

BACKGROUND: Functional performance tests are commonly utilized in screening for injury prevention, evaluating for athletic injuries, and making return-to-play decisions. Two frequently performed functional performance tests are the single leg squat and step-down tests. PURPOSE: The purpose of this study was to systematically review the available psychometric evidence for use of the single leg squat and step-down tests for evaluating non-arthritic hip conditions and construct an evidence-based protocol for test administration. STUDY DESIGN: Review of the Literature. MATERIALS/METHODS: A search of the PubMed and SPORTSDiscus databases was performed. Psychometric evidence of reliability, validity, and responsiveness to support the use of the both tests were collected. The protocols used for administering these tests were extracted, summarized, and combined. RESULTS: Of the 3,406 articles that were reviewed, 56 total articles met the inclusion criteria and were included in the review. Evidence for reliability and validity was available to support the use of the single leg squat and step-down tests. Both tests assess for neuromuscular control of the hip and surrounding muscular structures. Evaluation of these functional movement patterns enable the clinician to assess for limitations that may cause an increase in hip pain and dysfunction. CONCLUSIONS: The single leg squat and step-down tests can assess for kinematic and biomechanical deficiencies and may be useful in the evaluation process for individuals with non-arthritic hip pain. The authors of this review present a comprehensive evidence-based protocol for standardized performance of these tests. LEVEL OF EVIDENCE: 2b.

Accuracy of 3 Clinical Tests to Diagnose Proximal Hamstrings Tears With and Without Sciatic Nerve Involvement in Patients With Posterior Hip Pain.

PURPOSE: To determine the diagnostic accuracy of the active hamstring test at 30° (A-30) and 90° (A-90) of knee flexion, the long stride heel strike (LSHS) test, and combination of the 3 tests for individuals with hamstring tendon tears, with and without sciatic nerve involvement. METHODS: A retrospective review of 564 consecutive clinical records identified 42 subjects with a mean age of 50.31 ± 15 years who underwent a standard physical examination prior to magnetic resonance imaging (MRI) evaluation and diagnostic injection for posterior hip. The physical examination included the A-30, A-90, and LSHS tests. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were calculated to determine the diagnostic accuracy of these 3 tests. RESULTS: Forty-two subjects (female = 32 and male = 10) with a mean age of 50.31 years (range 15-77, ± SD 14.52) met the inclusion criteria and were included in the review. Based on MRI and/or injection, 64.28% (27/42) of subjects were diagnosed with hamstring tear. Fourteen (51.85%) presented with sciatic nerve involvement. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for each test were as follows: A-30 knee flexion: 0.73, 0.97, 23.43, 0.28, and 84.73; A-90 knee flexion: 0.62, 0.97, 20.00, 0.39, and 51.67; LSHS: 0.55, 0.73, 2.08, 0.61, and 3.44. The most accurate findings were obtained when the results of the A-30 and A-90 were combined, with sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of 0.84, 0.97, 26.86, 0.17, and 161.89, respectively. CONCLUSION: The combination of the active hamstring A-30 and A-90 tests proved to be a highly accurate and valuable tool to diagnose proximal hamstring tendons tears with or without sciatic nerve involvement in subjects presenting with posterior hip pain. LEVEL OF EVIDENCE: Level III, diagnostic study.

LENGTH CHANGE OF THE SHORT EXTERNAL ROTATORS OF THE HIP IN COMMON STRETCH POSITIONS: A CADAVERIC STUDY.

BACKGROUND: Stretching of the deep rotators of the hip is commonly employed in patients with lumbosacral, sacroiliac, posterior hip, and buttock pain. There is limited research demonstrating the effectiveness of common stretching techniques on the short external rotators of the hip. PURPOSE: The objective of this study was to evaluate length change during stretching of the superior and inferior fibers of the piriformis, superior gemellus, obturator internus, and inferior gemellus. STUDY DESIGN: Repeated-measures laboratory controlled cadaveric study. METHODS: Seventeen hip joints from nine embalmed cadavers (5 male; 4 female) with an age between 49-96 years were skeletonized. Polypropylene strings were attached from the origin to insertion sites of the short external rotators. The change of length (mm) noted by excursion of the strings was used as a proxy for change in muscle length, when the hip was moved from the anatomical position to four specific stretch positions: 1) 45 ° internal rotation from hip neutral flexion/extension, 2) 45 ° external rotation from 90 ° hip and knee flexion, 3) 30 ° adduction from 90 ° of hip and knee flexion, and 4) 30 ° of adduction with the hip and knee flexed so the lateral malleolus contacted the lateral femoral epicondyle of the contralateral limb , were recorded. RESULTS: There was a significant effect on string displacement by stretch position, F (15,166) = 14.67, p < .0005; Wilk's L = .097, partial n2 = .540. The greatest displacement of the strings corresponding to the superior piriformis, inferior piriformis, and the superior gemellus occurred in 30 ° adduction from 90 ° of hip and knee flexion. The obturator internus and inferior gemellus had the largest string displacement with 45 ° internal rotation from neutral flexion/extension. CONCLUSIONS: While all stretch positions caused a significant string displacement indicating length changes of the deep rotators of the hip, the three stretch positions that caused the greatest change were: 1) 30 ° adduction from 90 ° of hip and knee flexion, 2) 45 ° internal rotation from neutral flexion/extension, and 3) 45 ° external rotation with 90 ° hip and knee flexion. CLINICAL RELEVANCE: This study has clinical implications for the effectiveness of specific stretching techniques on the short external rotators of the hip with the potential to improve the validity of stretching protocols for patients with posterior hip or buttock pain. The piriformis and superior gemellus had a larger change in length when adducting the hip from 90 ° degrees of hip and knee flexion. The obturator internus and inferior gemellus had a greater length change when internally rotating the hip from neutral flexion/extension. LEVEL OF EVIDENCE: 3.