Nonoperative Treatment of Psoas Tendon Avulsion in a Professional Athlete: A Case Report and Evidence Based Review.

CASE: A 36-year-old male professional soccer player sustained an acute left hip injury during a tournament game while defending the goal. Magnetic resonance imaging demonstrated a complete avulsion of the iliopsoas tendon from the left trochanter. The patient was treated nonoperatively, and after 10 weeks, he was able to return to full activity. After 1 year of follow-up, the patient was completely asymptomatic, and was still playing professional soccer without flexion strength deficit. CONCLUSION: In this professional soccer athlete, nonoperative treatment of complete psoas avulsion resulted in a good functional outcome and successful return to play.

Iliopsoas the Hidden Muscle: Anatomy, Diagnosis, and Treatment.

The iliopsoas is a deep muscle group which anatomically connects the spine to the lower limbs. It is composed of the iliacus, psoas major, and psoas minor muscles. The iliopsoas functions as the primary hip flexor. Because the iliopsoas is important for daily activities, including sports, impairments and pathology associated with this muscle group can cause significant limitations. Evaluating pathology associated with the iliopsoas muscle group can be challenging because the patient's complaints are often vague and difficult to discern from other hip problems. This article will review relevant anatomy, discuss common pathologies, present clinical based examination methods, and outline conservative treatment interventions focusing on manual therapy and active exercises.

Hip Flexion Weakness following Transpsoas Interbody Fusion

Objective The present work evaluated the motor deficit resulting from the psoas muscle access through the extreme lateral interbody fusion (XLIF) approach. Methods This was a prospective, non-randomized, controlled, single-center study with 60 patients, with a mean age of 61.8 years old. All of the subjects underwent a lateral transpsoas retroperitoneal approach for lumbar interbody fusion with electroneuromyographic guidance and accessing 1 to 3 lumbar levels (mean level, 1.4; 63% cases in only 1 level; 68% cases included L4-L5). The isometric hip flexion strength in the sitting position was determined bilaterally with a handheld dynamometer (Lafayette Instrument, Lafayette, IN, USA). Themean value of three peak forcemeasurements (N) was calculated. Standardized isometric strength tests were performed before the procedure and at 10 days, 6 weeks, 3 months and 6 months postsurgery. Results Ipsilateral hip flexion was diminished (p < 0.001) at the early postoperative period, but reached preoperative values at 6 weeks (p > 0.12). The mean hip flexion measures before the procedure and at 10 days, 6 weeks, 3 months and 6 months after surgery were the following, respectively: 13 N; 9.7 N; 13.7 N; 14.4 N; and 16 N (ipsilateral); 13.3 N; 13.4 N; 15.3 N; 15.9 N; and 16.1 N (contralateral). Neither the level nor the number of treated levels had a clear association with thigh symptoms, but hip flexion weakness was the most common symptom. Conclusions Patients in the early postoperative period of transpsoas access presented hip flexion weakness. However, this weakness was transient, and electroneuromyography use is still imperative in transpsoas access. In addition, patients must be thoroughly educated about hip flexion weakness to prevent falls in the immediate postoperative period.

non-arthroplasty iliopsoas impingement in athletes: a narrative literature review.

INTRODUCTION: Iliopsoas impingement occurs secondary to a tight iliopsoas tendon that causes impingement during movement. This review presents current aspects regarding the diagnosis of iliopsoas impingement and also exposes the readers to the possible anatomic and clinical variations together with the available treatment options. METHODS: We conducted a narrative literature review with regard to non-arthroplasty iliopsoas impingement. RESULTS: Iliopsoas impingement is characterised by a distinct pattern of labral pathology, with anteriorly localised labral damage, that does not extend to the anterosuperior portion of the acetabulum. Anterior groin pain and intermittent catching, snapping or popping of the hip are common symptoms. Non-specific focal tenderness is often found over the iliopsoas tendon at the level of the anterior aspect of the joint. The 'C-sign' and Impingment test are usually positive. Dynamic ultrasonography is also useful for confirming the diagnosis. Initial management of painful iliopsoas impingement should be conservative. When patients continue to have pain, an ultrasound-guided injection can provide relief and predict the response to the surgical release. For patients who have recurrent pain after local injection of steroids, arthroscopic release has shown to achieve effective results. CONCLUSIONS: Although different treatment options for iliopsoas impingement are emerging, the current standard of therapy is conservative followed by an arthroscopic tenotomy if necessary. Young adult hip surgeons should always keep this differential in mind in a patient presenting with groin pain and mechanical symptoms.

Femoral nerve paralysis complicating a post-traumatic iliopsoas haematoma.

Paralysis of the femoral nerve secondary to iliopsoas haematoma is a rare post-traumatic complication. Because of the large differential diagnosis, a high level of suspicion is required for its early recognition. Treatment modalities are controversial due to the rarity of this entity. An 18-year-old student presented with complete paralysis of the knee extensors and a sensory deficit on the anterior side of the thigh 5 weeks after a sport accident. MRI of the lesser pelvis showed an iliopsoas haematoma. Surgical decompression was performed and recovery was complete at 6 months of follow-up.

Characteristics of acute groin injuries in the hip flexor muscles - a detailed MRI study in athletes.

Hip flexor injuries account for one-third of acute groin injuries; however, little is known about specific injury characteristics. The aims of this study were to describe acute hip flexor injuries using magnetic resonance imaging (MRI) in athletes with acute groin pain and to compare specific muscle injuries with reported injury situations. Male athletes with acute groin pain were prospectively and consecutively included during three sports seasons. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. All athletes with an MRI confirmed acute hip flexor muscle injury were included. A total of 156 athletes presented with acute groin pain of which 33 athletes were included, median age 26 years (range 18-35). There were 16 rectus femoris, 12 iliacus, 7 psoas major, 4 sartorius, and 1 tensor fascia latae injury. Rectus femoris injuries primarily occurred during kicking (10) and sprinting (4), whereas iliacus injuries most frequently occurred during change of direction (5). In 10 (63%) rectus femoris injuries, tendinous injury was observed. The iliacus and psoas major injuries were mainly observed at the musculotendinous junction (MTJ), and two included tendinous injury. We have illustrated specific injury locations within these muscles, which may be relevant for the clinical diagnosis and prognosis of these injuries. Most proximal rectus femoris injuries included tendinous injury. In contrast, distinct acute iliacus and psoas injuries predominantly occurred at the MTJ. Only the iliacus or psoas major were injured during change of direction, whereas rectus femoris injuries occurred primarily during kicking and sprinting.

Adductor Muscle Tear? Ultrasonographic Imaging of Avulsion Injury of the Iliopsoas Tendon.

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Navigation is Equal to Estimation by Eye and Palpation in Preventing Psoas Impingement in THA.

BACKGROUND: Iliopsoas tendon impingement is one possible reason for persistent groin pain and diminished functional outcome after THA. So far, estimation by eye and palpation is the standard procedure to intraoperatively assess the distance of the cup to the anterior rim. However, novel technologies such as imageless navigation enable intraoperative measurements of the cup in relation to the psoas tendon and bony landmarks. QUESTIONS/PURPOSES: We asked whether psoas impingement (1) can be reduced using imageless navigation compared with the standard technique and (2) is associated with specific patient characteristics. Furthermore, we investigated (3) if anterior cup protrusion (overhang) is associated with lower outcome scores for pain and function. METHODS: The current study is a reanalysis of data from a randomized controlled trial evaluating navigation for THA; 135 patients were randomized for surgery with or without the use of imageless navigation. The risk for anterior protrusion of the cup above the acetabular rim and thus potential psoas impingement, defined as an overhang of the cup above the anterior acetabular rim as measured on postoperative CT, was either controlled with the help of navigation or standard control by eye and palpation intraoperatively. Postoperatively, the anterior protrusion of the cup above the acetabular rim was measured on three-dimensional (3-D) CT by a blinded, external institute. In addition to patient-related outcome measures, the Harris hip score, Hip disability and Osteoarthritis Outcome Score, and EuroQol were obtained 1 year postoperatively. Altogether 123 data sets were available for primary analysis and 115 were available for 1-year followup. RESULTS: There was no difference, with the numbers available, between the navigated and the control groups in terms of the mean distance of the cup below the anterosuperior acetabular rim (3.9 mm; -5.3 to 12.6 mm versus 4.4 mm; -7.9 to 13.7 mm; p = 0.72) or the anteroinferior acetabular rim (4.7 mm; -6.2 to 14.8 mm versus 4.2 mm; -7.1 to 16.3 mm; p = 0.29). There was no difference, with the numbers available, in terms of the proportion of cups with anterior overhang (7%, four of 57 versus, 15%, 10 of 66; p = 0.16), respectively. After controlling for potential confounding variables such as cup inclination, cup size, patient age, BMI, stage of arthritis, and length of skin incision, we found cup anteversion (hazard ratio [HR], 0.87; 95% CI, 0.81-0.93; p < 0.001) and female sex (HR, 3.88; 95% CI, 1.01-14.93; p = 0.049) were associated with a propensity to potential psoas impingement. With the numbers available, there were no differences observed in clinical scores between groups with and without anterior cup protrusion. CONCLUSIONS: We found no differences between imageless navigation and estimation by eye and palpation in preventing potential psoas impingement. Despite the comparable clinical outcome for patients with and without cup protrusion, the orthopaedic surgeon should be especially aware of propensity for psoas impingement in women. LEVEL OF EVIDENCE: Level II, therapeutic study.

Novel presentation of a cricket ball-related intra-abdominal injury: genitofemoral nerve referred pain.

Serious intra-abdominal injuries are very uncommon in cricket; traumatic cricket injuries are traditionally musculoskeletal, soft tissue or maxillofacial in origin. The cause of such cricket injuries can be broadly divided into collision type injuries (a result of direct contact with the ball or bat, another player, the ground or boundary) or overuse injuries (due to running, throwing, batting, bowling, repetitive movements and overexertion). This case report describes a rare cause of small bowel perforation and suspected genitofemoral nerve injury secondary to the direct impact of a cricket ball, and includes a brief review of blunt abdominal injuries resulting in isolated small bowel perforations.

Outcomes of Endoscopic Gluteus Medius Repair: Study of Thirty-four Patients with Minimum Two-Year Follow-up.

BACKGROUND: Surgical intervention for partial and full-thickness gluteus medius tears is often recommended for patients who have persistent pain despite nonoperative treatment. Traditionally, the surgical intervention has been carried out through open techniques with good results; however, advantages of endoscopic techniques include less tissue dissection, improved tendon mobilization, and the benefit of arthroscopic correction of intra-articular pathological conditions. The purpose of this report is to provide an update on a previously published study of patients with a gluteus medius tear, with inclusion of additional patients followed for a minimum of two years. METHODS: The study included thirty-four patients who had undergone an endoscopic gluteus medius repair with correction of intra-articular pathological conditions between April 2009 and April 2012 and had been followed for a minimum of two years. Patient-reported outcome measures included the modified Harris hip score, Nonarthritic Hip Score, and Hip Outcome Score-Activities of Daily Living and Sport-Specific Subscale. A visual analog scale (VAS) pain score and a patient satisfaction score were also recorded. RESULTS: The cohort consisted of two men and thirty-two women with a mean age of fifty-seven years (range, twenty to seventy-nine years). Ten patients had a full-thickness tear, and twenty-four patients had a partial-thickness tear. Seventeen patients were treated with a suture bridge technique, after completion of the tear if it was not already complete, and seventeen patients were treated with the transtendinous technique. All patients had surgical correction of intra-articular pathological conditions. There was a significant improvement in all four patient-reported outcomes at three specified time-points. The mean VAS pain score decreased from 6.6 preoperatively to 2.4 at the time of the two-year follow-up (p < 0.001). The mean satisfaction score was 8.5 at two years postoperatively. Of twenty-six patients who had a gait deviation preoperatively, fifteen (58%) regained a completely normal gait. There was no significant difference in patient-reported outcome measures between the two surgical techniques. Four patients required total hip replacement at eleven to sixteen months postoperatively. CONCLUSIONS: After a minimum of two years of follow-up, endoscopic surgical repair with correction of intra-articular pathological conditions was found to be an effective treatment for patients with a gluteus medius tear.

Complete paralysis of the quadriceps secondary to post-traumatic iliopsoas hematoma: a systematic review.

PURPOSE: Paralysis of the femoral nerve secondary to compression by a hematoma of the iliopsoas is rarely post-traumatic. The acute surgical removal of hematoma seems the treatment of choice. The main objective of this systematic review was to determine the optimal delay between the trauma and surgery, to obtain a total functional recovery. METHODS: A search was performed via PubMed. The inclusion criteria were the studies in English language, reporting the results of the treatment of femoral nerve palsy secondary to compression by a post-traumatic hematoma of the iliopsoas. The primary evaluation criterion was the clinical recovery of femoral nerve function. The secondary criteria were the delay of recovery and the delay between the trauma and surgery. RESULTS: Thirteen studies were identified, only case reports. Sixteen patients were included, mean age 16.6 ± 3.4 years, 11 men and 5 women. The injury was associated with the sports practice in 12/16 (75 %) cases. Neurological symptoms developed about 5 days after injury. Femoral palsy was complete in 8 patients and partial in 8 patients. The mean delay between the injury and the diagnosis was 7.3 (2-25) days in conservative group and 17.8 (4-45) days in surgical group. Seven patients were managed conservatively, 6 partial paralysis and 1 total paralysis, and 9 surgically, 7 total paralysis and 2 partial paralysis. The recovery was total in 13/14 patients (seven surgical treatment and six conservative management) and partial in one patient who was managed conservatively despite a total paralysis. The delay of total recovery varied from 1 month to 6 weeks in conservative group and 3 months to 2 years in surgical group. CONCLUSION: This systematic review seems to indicate that whatever the delay, surgery is necessary in case of complete paralysis of the femoral nerve secondary to compression from a post-traumatic hematoma of the iliopsoas muscle.

Safety and efficacy of a new procedure for treating traumatic iliopsoas hematoma: a retroperitoneoscopic approach.

BACKGROUND: Surgical treatment is often recommended for traumatic iliopsoas hematoma. Open surgeries lead to severe surgical trauma, and minimally invasive surgeries cannot completely remove the hematoma. A new treatment protocol for traumatic iliopsoas hematoma by retroperitoneoscopic approach has been introduced. The goal of this study was to determine the safety and efficacy of retroperitoneoscopic approach used to remove iliopsoas hematoma. METHODS: Between January 2009 and July 2012, 13 patients were diagnosed of traumatic iliopsoas hematoma. Retroperitoneoscopic surgeries were performed on all patients to remove the hematomas after admission. The size of hematoma, VASA score and neurologic status were dynamic evaluated before and after surgery. Soft tissue damage and complications caused by retroperitoneoscopic approach also were recorded and evaluated. RESULTS: We performed retroperitoneoscopic surgery to remove traumatic iliopsoas hematoma successfully on 13 patients without complications. The mean procedure time was 52.5 ± 13.4 min, and mean blood loss was 30.7 ± 9.2 ml. Hematoma was completely removed confirmed by ultrasound after surgery. Pain in the affected lower abdominal and thigh immediately was relieved totally for ten patients and partly for three patients after surgery. Quadriceps strength was restored to grade 5 and pain completely disappeared 2 months postoperatively on all patients. Numbness along the femoral nerve distribution disappeared for 11 patients and improved for 2 patients until the last follow-up. None of 13 patients suffered from infection or a new hematoma during follow-up. CONCLUSIONS: Retroperitoneoscopic approach is a safe and effective procedure alternative to conventional surgical approach for treating traumatic iliopsoas hematoma in terms of complete removal of hematoma, minimal invasiveness, absence of radiation, and rapid recovery.

Excision of a permanent inferior vena cava filter with multiple vena caval perforations.

Perforation of an inferior vena cava filter by one the filter device hooks is a recognized possible complication of this device. We describe a case of surgical excision of a permanent inferior vena cava filter associated with multiple perforations of surrounding structures by each of the 6 hooks of the device. Structures affected include the third lumbar vertebral body, transverse mesocolon, the infrarenal aorta, the duodenum, and the psoas muscle. A thorough understanding of the filter design and adequate preoperative imaging were vital in planning the safe surgical excision of this device.

Imaging assessment of groin pain.

Groin pain is a common condition in athletes, especially those who play certain sports, for instance soccer, ice hockey, fencing which request rapid acceleration and frequent changes of movement. This condition represents a diagnostic difficulty for the radiologist due to either the anatomical pubic region complexity than the many causes that can be a source of pain, because the groin pain can be determined by conditions affecting the bony structures, cartilage and muscle tendons that are part of the proper pubis but also from those involving the hip. The approach to the groin through diagnostic imaging is multidisciplinary: The study of the patient is performed by traditional radiographs, ultrasound examination, magnetic resonance imaging or computed tomography, based on clinical suspicion, and each of these methods provides different results depending on the disease in question. The purpose of this article is to examine what are the optimal imaging techniques to investigate the various diseases affecting the patient with groin pain.

Incidentalomas revealed by abdominopelvic computed tomography scans performed in body packers.

BACKGROUND: Body packing is the transport of internally concealed narcotic substances. These may take the form of pellets or sachets, ingested or inserted per anus or per vagina. In France, abdominopelvic scanning without contrast-medium injection is used to check the complete evacuation of ingested narcotics. This sometimes leads to the discovery of incident pathologies, also known as "incidentalomas." OBJECTIVE: Our study described incidentaloma detected by abdominopelvic computed tomography (CT) scanning in body packers. This monocentric prospective study concerned 100 CT scan images from body packers managed in our secure medical unit between September 2009 and April 2010. RESULTS: Thirty-one incidentalomas were discovered on 18 abdominopelvic CT scans, including 2 women. Ten CT scan examinations revealed 1 suspect image, 5 scans included 5 suspect images, 2 scans included 3 suspect images, and 1 scan included 5 suspects images. Once the complete evacuation of all foreign bodies is confirmed, and in the absence of any surgical or medical emergency, incidentaloma management is entrusted to the prison doctors.

Evaluation of hip flexion strength following lateral lumbar interbody fusion.

BACKGROUND CONTEXT: Lateral interbody fusion (LIF) is a minimally invasive procedure that is designed to achieve a solid interbody fusion while minimizing the damage to the surrounding soft tissue. Although short-term results have been promising, few data have been published to date regarding its risks and complication rate. PURPOSE: The aim was to evaluate the extent of injury to the psoas muscle after the LIF procedure by measuring hip flexion strength. STUDY DESIGN: A prospective case series was used in the study. METHOD: Hip flexion strength was measured using a handheld digital dynamometer while the patient was seated on a chair; the examiner held the device against the patient's attempt to flex the hip. Both sides were measured to compare the operated and nonoperated psoas muscles. Each side was measured three times and the average amount (in pounds) was recorded. Measurements were done before and after surgery on Day 2-3, at 2 weeks, 6 weeks, and at 3 and 6 months. RESULTS: Thirty-three patients were recruited for this study. Mean preoperative hip flexion strength values were 20.7±3.47 lb and 21.3±4.31 lb for operated and nonoperated legs, respectively, with no significant difference (p=.85). With a mean of 11.2±2.24 lb postoperative measurements on Day 2, the operated side showed statistically significant reduction of strength (p=.0001). The nonoperated side was also weaker postoperatively, but not significantly (mean=19.12±1.74 lb; p=.097). From the first follow-up visit at 2 weeks, the values on the operated leg had returned to baseline values (20.6, p=.97) and were not significantly different from preoperative values on either side. DISCUSSION: Hip flexion was weakened immediately after the LIF procedure, which may be attributed to psoas muscle injury during the procedure. However, this damage was temporary, with almost complete return to baseline values by 2 weeks.