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For hip & groin geeks - mini thread 🧵🧵

Elite female sprinter

Worsening medial groin pain radiating into lower abdomen & "womb" - no acute episode, pop or tear

Worst on explosive block drills; sprinting especially when fatiguing & losing form, dropping into hip & lumbar extension; core / abdominal S&C work

Can attain max 65% sprint performance

Exam - pain & weakness on isometric long leg squeeze & resisted crunches

NO pain on palpation through pubic symphysis, tubercle or adductor origin MRI with groin protocol - marked symphysis pubis degenerative & erosive change (seen best on VIBE sequences - image) & pubic bone oedema

Common in athletes especially multi-directional sports

Do we consider injecting symphyseal cleft?🧐

Documented consent for images & data ✅

Thread 🧵

'Deep gluteal syndrome' or piriformis syndrome - a patient's journey

Over-diagnosed & a diagnosis of exclusion really...
the neurogenic thoracic outlet syndrome of the pelvis? 🧐

It does exist though Female ex international handball - now marathon training, HIIT, Cross Fit

Worsening inferior gluteal pain - diagnosed as proximal hamstring tendinopathy, but no improvement with physio input & load management

Stress fractures - a detailed thread 🦴🦴🦴

I thought I'd put together an overview & some clinical nuggets from the 'coal-face'

First up, I prefer to call them 'bone stress injuries' - majority don't have a # line on imaging & the language can be scary / nocebic for some Pathophysiology & risk factors

Stress fractures-
Occur in normal bone that is placed under abnormal / persistent load & strain ('training / sporting error')

Insufficiency fractures-
Occur in bone that is under normal strain but is structurally vulnerable eg metabolic conditions

Thread alert 🚨🚨🚨

Ankle inversion injuries don't just result in lateral ligament sprains....

...there are plenty of other injuries to bear in mind when you assess, both acutely & further down the line 1. Talar dome osteochondral injury

Intermittent catching / locking symptoms, usually deep medial joint line pain

Persistent effusion & loss of dorsiflexion

Consider MRI if not progressing with rehab - CSI & aspiration can help first line

Unstable / large fragment ➡️ortho

I get asked about the utility of hip & groin tests all the time

The short answer is there's a big overlap across clinical tests & key pain drivers - no test is particularly specific; some are sensitive

This is my take based on clinical experience - opinions welcome 1. FADDIR test

Starting point & easy to do - should be your 'go to' test

Negative - its not coming from the hip joint

Positive - could be FAI, labral, OA, AVN ...

(disclaimer - FADDIR can also provoke irritable pubic related groin pain)

Thread alert - posterior ankle & heel pain 🚨🚨🚨

Most cases are ‘common garden’ achilles tendinopathy

However, here is a selection of conditions I've seen over time in clinic which can masquerade & are worth considering if the picture is atypical or patient not progressing 1. Achilles enthesitis
🧐
Insertional heel pain, not mid portion

<45?
Psoriasis or inflam bowel disease?
LSp / gluteal pain?
Early morning stiffness & ‘inflammatory’ pattern?

Think spondyloarthropathy

💊
Trial of NSAIDs may be eye-opening
Early rheumatology referral?

Thread alert 🚨🚨🚨 - Medial knee pain!

What else should we be considering beyond OA & MCL sprains?

Here are some differentials to consider & their clinical presentation 🧐 1. Saphenous Nerve irritation

Direct impact, post surgery (eg scope / TKR)

Dislikes knee flexion, garment compression

Diffuse neuropathic Sx, P&N - medial knee, infrapatella, lower leg

🧐
+ive Tinels at Hunters canal
No motor loss, purely sensory

💉
SN block can diag & Rx

1. Unravelling groin pain - a thread

I love this area, but it can be confusing & seemingly complex - esp as there is significant overlap between groin pathologies re clinical behaviour & presentation - and often concurrent pain drivers ‘muddying the waters’ further 2. FADDIR test (Flexion Adduction Internal Rotation)

My ‘go-to’ test alongside ‘hop’ & should be first test done in supine.

If this is negative, then it’s not the joint driving the pain eg FAI, labral tear, OA, AVN.

NB - can have +ive FADDIR with proximal femur stress #

Thread 🚨🚨🚨

Posterolateral knee pain -

Outside of acute ligamentous trauma its a bit of a 'No Man's Land' pathoanatomically 🤨

In the same vein as 'anterior knee pain', here are some conditions to bear in mind if your patients symptoms are puzzling you Biceps femoris tendinopathy -

Seen in explosive activity - eg sprinters

Reduced sprint performance. Pain on striding out / fast walk & acceleration

Diffuse aching around PL knee & on sitting post activity

Can radiate proximal & distal to fibula head

I was asked to write a parallel thread exploring examination of these conditions, given the majority of 'coalface' clinicians don't have the luxury of POCUS.

So here we are. Hope it's helpful

Don't hassle me about specificity / sensitivity of tests - this is a pragmatic thread

https://twitter.com/DrJN_SportsMed/status/1481969926504161282

Quads tendinopathy -

Pain on deep squat, jump

Focal suprapatella tenderness - assess in different knee flexion angles to expose sore tendon

If condition evolves -diffuse pain in suprapatella pouch ? due to quads fat pad inflammation

At risk - bodybuilders - think anabolic

Thread -🚨🚨🚨

Anterior knee pain is super common - understandably, we tend to think of the patellofemoral joint, Hoffa’s fat pad or proximal patella tendon as the main culprits

But there are other less common causes that might not necessarily be on your clinical radar…. Quadriceps insertional calcific tendinopathy -

Similar symptom provocation patterns to patella tendinopathy

When pain spreads can mimic PFP

Jumping sports but also powerlifting /bodybuilders

Incidental calcific changes found v commonly in active population eg cyclists

Hip & groin pain in sporty adolescents IS NOT NORMAL!
(a thread)

Kids aren't 'little adults' - they have different physiology, immature skeleton, growth plates...

They're susceptible to unique conditions

Yet they are robust - if they're not enjoying sport, pay attention... Apophyses are the 'anchors' for the muscle-tendon unit. They're vulnerable to injury - the physeal cartilage is weaker than tendon & muscle - therefore the 'anchor' fails before the 'rope'. Kids rarely tear muscles or have tendinosis; be wary of applying these diagnostic labels

I use MRI in lower back pain 🤭

I also get asked frequently how I manage the scan follow up consults & handle patient Qs

So here is a mini-thread which gives a little comms synopsis - some may nod sagely, others may roll their eyes - that’s cool - no right or wrong. 1. Normal scan-

“This is great news- there is no evidence of damage or injury …you don’t have a ‘bad back’ - it is just unhappy at the moment. There’s no reason why we shouldn’t be able to help you get back to the sport you love & crack on with work”

“So why am i in pain…?”

With consent

Triathlete struggling to swim crawl. Night pain side lying.

OE - Plenty of ‘subacromial’ signs.

POCUS - huge bursal effusion with hyperechogenic frond-like material throughout sac

Another lipoma arborescens?

#likebuses Treating this as typical RCRP / subacromial pain would be fruitless - the pathology causing space occupying effect and if anything loading would perpetuate the cycle by provoking further bursal inflam fluid. POCUS can and does define treatment strategy & prognosis