A Guide To Hip Injuries And Lower Extremity Ramifications In Female Athletes

John F. Connors, DPM, and Ana J. Sanz, DPM

   Many runners will consult a sports podiatrist for their lower extremity injuries. It is very important to have an understanding of lower extremity biomechanics and the mechanism behind running injuries. Surrounding yourself with other sports medicine specialists is very important in facilitating appropriate referrals and the best multidisciplinary care.

   Accordingly, let us take a closer look at some of the more common hip injuries in the female athlete and how they may contribute to lower extremity issues.

   Although hip injuries can occur in any sport, runners and soccer players are at increased risk. The complexity in and around the pelvis and hip often makes a diagnosis difficult.

   There are distinct differences between the male and female pelvis. Females generally have a lower body mass and their pelvic anatomy reflects these features. The female bones and joints are smaller, and the markings for ligament and tendon attachments are less pronounced. The pelvis in the female is larger than in the male. The amount of femoral anteversion is higher in females. Also the pubic symphysis in the female has a wider fibrocartilage disc. Females tend to have more ligamentous laxity and overpronation.

   These anatomical differences reflect the functional differences between the male and female, and may contribute to the increase in lower extremity injuries in the female athlete.

   Muscle and tendon injuries are common around the hip and pelvis of the female athlete. Muscle strains and pulls about the pelvis comprise most of these injuries. In the skeletally immature patient, one must consider an apophyseal injury at the bony origin. The muscles that are typically involved include the iliopsoas, adductors, gluteals, sartorius and rectus femoris muscles. Pain with isolated testing of the injured muscle will help clarify the diagnosis.

Pertinent Pointers On Common Hip Injuries

   Bursitis. This injury consists of a viscous fluid sac located in areas that produce friction over bony prominences and between tendons. The most commonly inflamed bursae are the trochanteric, iliopectineal and ischial bursae (the trochanteric bursae being the most commonly affected). Athletes may describe a snapping sensation at the greater trochanter, which is a result of the iliotibial band passing over the greater trochanter.

   Iliopsoas muscle strain. The major actions of these muscles are to provide hip flexion. Anterior tilting in the sagittal plane causes a contraction of the hip flexors. The symptoms most often reported are pain in the groin area and lower back pain when the patient is running or walking. Tenderness may be present along the course of the tendon and at the insertion.

   Piriformis syndrome. The major action of the piriformis is external rotation of the hip. Common complaints here include “pain in the buttocks.” This often can be confused with sciatica. The sciatic nerve passes immediately below the piriformis muscle and, in some people, the sciatic nerve can actually travel through the piriformis muscle.

   Hip labral tear. The socket of the hip joint is lined by cartilage called the labrum. This cartilage provides stability and cushioning for the hip joint. These tears can result from injury or repetitive movements that cause wear and tear on the hip joint. In many cases, a hip labral tear causes no signs or symptoms, and does not require treatment. Occasionally, a hip labral tear may cause pain or a “catching” sensation in the hip joint. Oftentimes, the athlete does not recall a particular incident, which triggered the pain.

   Iliotibial band syndrome. This is a fascia strip that passes down the lateral aspect of the thigh from the crest of the ilium and inserts into the lateral tibial condyle. As the knee flexes and extends during running, this band repeatedly rubs over the lateral femoral condyle. This causes inflammation and pain. There is direct correlation between hip abductor (gluteus medius) weakness and iliotibial band syndrome.

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