Método de Solución de Problemas y Herramientas de la Calidad

Figure 4 IT band lengthening to treat external snapping hip syndrome arthroscopically. A, Intact IT band. B, Lengthened IT band.

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enlargement or abnormal uptake by the piriformis mus- cle, whereas MRI can be used to confirm an enlarged piriformis muscle.22

Initial treatment of piriformis syndrome includes physical therapy, along with anti-inflammatory medica- tion, analgesics, and muscle relaxants. In addition, ac- tivity modification, massage, heat, and ultrasound treatment may be used to relieve pain.24_{Biomechanical}

abnormalities that impact posture, pelvic obliquities, and leg-length inequalities should be corrected. Physical therapy programs should initially involve stretching ex- ercises, followed by hip abductor strengthening once pain has subsided. If physical therapy is ineffective, lo- cal anesthetic and/or steroid injections can be used.22

Surgery may be indicated for patients unresponsive to nonsurgical treatment or in the presence of anatomic abnormality of the piriformis muscle; this structure may be thinned, divided, or excised.22 _{Surgical treat-}

ment includes release of the piriformis muscle, which has been occasionally reported to cause compression of the sciatic nerve.23

Gluteus Medius Syndrome

Gluteus medius syndrome is normally caused by over- use and characterized as a cause of greater trochanteric pain syndrome. Gluteus medius injury can vary in se- verity and include peritendinitis, tendinosis, and partial or complete tears.25 _{Gluteus medius syndrome occurs}

more commonly in women, particularly those who par- ticipate in running or step aerobics, although it can be the result of a direct blow to the gluteus medius.26 _Pa-

tients may have dull pain in the lateral hip and point tenderness adjacent to the greater trochanter, with ad- ditional weakness with hip abduction.25 _Frequently,

there is pain with attempts to climb or descend stairs. The patient should be tested for pain with resisted ab- duction, as well as with passive hip adduction and in- ternal rotation.27 _{Patients with more severe symptoms}

will have weakness and a positive Trendelenburg ma- neuver with one-legged stance. MRI and ultrasound have been useful for detecting soft-tissue edema, an early sign of gluteus medius syndrome.25,26_Nonsurgical

management includes activity modification, massage, ice, and stretching exercises, in addition to anesthetic or steroid injections to treat associated pain.27_Surgery

may be indicated for recalcitrant symptoms in patients with partial or full tears. If the gluteus medius tendon has a full- or partial-thickness tear, it can be repaired by excision of the degenerative tear tissue, curettage of the bone surface attachment, and then reattachment using bone anchors in combination with direct side-to-side repair of the tendon.26

Summary

The groin and pelvis make up a complex anatomic re- gion that plays a critical role in various athletic activi-

ties and is traversed by forces greater than six to eight times body weight, even with light activity, making this region particularly prone to sports injuries. Because many groin and pelvis injuries have similar presenta- tions and many patients have coexisting injuries, it is imperative that clinicians be knowledgeable of the dif- ferences between the conditions and the treatment op- tions to provide the most effective treatment.

Annotated References

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N Am 2005;13:727-742.

The authors present a review of various conditions that may contribute to sports-related groin pain and the ap- plicable imaging techniques for diagnosing specific con- ditions.

2. Anderson K, Strickland S, Warren R: Hip and groin in- juries in athletes. Am J Sports Med 2001;29:521-533. 3. Morelli V, Espinoza L: Groin injuries and groin pain in

athletes: Part 2. Prim Care Clin Office Pract 2005;32: 185-200.

The authors present part II of a two-part review of com- mon injuries that can cause groin pain in athletes and include a discussion on the presentation of injury, diag- nostic methods, and treatment options.

4. Morelli V, Weaver V: Groin injuries and groin pain in athletes: Part 1. Prim Care Clin Office Pract 2005;32: 163-183.

The authors present part I of a two-part review of com- mon injuries that can cause groin pain in athletes and include a discussion on the presentation of injury, diag- nostic methods, and treatment options.

5. Brittenden J, Robinson P: Imaging of pelvic injuries in athletes. Br J Radiol 2005;78:457-468.

The authors review pelvic injuries in athletes and indi- cated imaging methods for the diagnosis and treatment of such injuries.

6. Flanum ME, Keene JS, Blankenbaker DG, Desmet AA: Arthroscopic treatment of the painful “internal” snap- ping hip: Results of a new endoscopic technique and im- aging protocol. Am J Sports Med 2007;35:770-779. The authors present a cases series assessing an imaging protocol and a new endoscopic technique for the treat- ment of internal snapping hip syndrome. Level of evi- dence: IV.

7. Farber AJ, Wilckens JH: Sports hernia: Diagnosis and therapeutic approach. J Am Acad Orthop Surg 2007; 15:507-514.

The authors present a review of sports hernia, including a description of the condition and the diagnostic and therapeutic approaches used to treat the condition.

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8. Ahumada LA, et al: Athletic pubalgia: Definition and surgical treatment. Ann Plast Surg 2005;55:393-396. The authors present a retrospective review to assess di- agnostic approaches and the use of an open approach using mesh as a surgical treatment of athletic pubalgia. Level of evidence: IV.

9. Lee CH, Huang G, Chao KH, Jean JL, Wu SS: Surgical treatment of displaced stress fractures of the femoral neck in military recruits: A report of 42 cases. Arch Or-

thop Trauma Surg 2003;123:527-533.

The authors present a prospective cohort to assess the efficacy of surgical treatment of stress fractures of the femoral neck in a military population at an average follow-up of 5.6 years. Level of evidence: II.

10. Miller C, Major N, Toth A: Pelvic stress injuries in the athlete: Management and prevention. Sports Med 2003; 33:1003-1012.

The authors present a review of stress fractures of the pelvis, including the mechanism of injury, diagnosis, treatment, and prevention.

11. Mehin R, Meek R, O’Brien P, Blachut P: Surgery for os- teitis pubis. Can J Surg 2006;49:170-176.

The authors present a retrospective review of four sur- gical treatment options for osteitis pubis, and a review of literature pertaining to osteitis pubis. Level of evi- dence: IV.

12. Paajanen H, Heikkinen J, Hermunen H, Airo I: Success- ful treatment of osteitis pubis by using totally extraperi- toneal endoscopic technique. Int J Sports Med 2005;26: 303-306.

The authors present case reports of athletes with osteitis pubis and describe the outcome of surgical treatment us- ing a totally extraperitoneal endoscopic technique. Level of evidence: IV.

13. McCarthy A, Vicenzino B: Treatment of osteitis pubis via the pelvic muscles. Man Ther 2003;8:257-260. The authors present a case report of osteitis pubis and describe an alternative approach for assessment, as well as rehabilitation methods for treating the condition. Level of evidence: IV.

14. Strauss EJ, Campbell K, Bosco JA: Analysis of the cross- sectional area of the adductor longus tendon: A descrip- tive anatomic study. Am J Sports Med 2007;35: 996-999.

The authors present a basic science study of the ana- tomic features of the adductor longus tendon and the re- lationship between the structure’s anatomy and adduc- tor strain.

15. Holmich P: Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” ap- proach: A prospective study of 207 patients. Br J Sports

Med 2007;41:247-252.

The authors present a prospective, case-control study to test the reliability of clinical examination techniques in assessing pathology in the adductors, iliopsoas, and rec-

tus abdominis in a cohort of athletes. Level of evi- dence: IV.

16. Blazina ME: The “hip-pointer,” a term to describe a specific kind of athletic injury. Calif Med 1967; 106:450.

17. Ilizaliturri VM Jr, Villalobos FE, Chaidez PA, Valero FS, Aguilera JM: Internal snapping hip syndrome: Treat- ment by endoscopic release of the iliopsoas tendon. Ar-

throscopy 2005;21:1375-1380.

The authors present a case series to assess the efficacy of treating internal snapping hip syndrome by endoscopic release of the iliopsoas tendon. Level of evidence: IV. 18. Wahl CJ, Warren RF, Adler RS, Hannafin JA, Han-

sen B: Internal coxa saltans (snapping hip) as a result of overtraining: A report of 3 cases in professional athletes with a review of causes and the role of ultrasound in early diagnosis and management. Am J Sports Med 2004;32:1302-1309.

The authors present case reports of patients with inter- nal snapping hip syndrome and the use of ultrasound for early diagnosis and management. Level of evi- dence: IV.

19. Winston P, Awan R, Cassidy JD, Bleakney RK: Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med 2007;35:118-126.

The authors present a cross-sectional study that in- volved a questionnaire completed by elite ballet dancers to establish the prevalence, associated factors, and mechanism of the snapping hip, as well as the efficacy of physical and ultrasound examination methods. Level of evidence: III.

20. Overdeck KH, Palmer WE: Imaging of hip and groin in- juries in athletes. Semin Musculoskelet Radiol 2004;8: 41-55.

The authors present a review of common hip and groin injuries in athletes and the imaging techniques indicated for the various conditions discussed.

21. Ilizaliturri VM Jr, Martinez-Escalante F, Chaidez PA, Camacho-Galindo J: Endoscopic iliotibial band release for external snapping hip syndrome. Arthroscopy 2006; 22:505-510.

The authors present a prospective case series to assess the treatment of external snapping syndrome by endo- scopic iliotibial band release. Level of evidence: IV. 22. Benzon HT, Katz J, Benzon HA, Iqbal MS: Piriformis

syndrome: Anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology 2003;98:1442-1448.

The authors present a basic science study of the pirifor- mis muscle’s anatomic features and a new injection tech- nique. In addition, a retrospective review assessing injec- tion site and depth, as well as patient response, and a literature review are presented.

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23. Windisch G, Braun EM, Anderhuber F: Piriformis mus- cle: Clinical anatomy and consideration of the pirifor- mis syndrome. Surg Radiol Anat 2007;29:37-45. The authors present a basic science study of pertinent anatomic features of the piriformis muscle as well as a review of clinical presentation treatment options for pir- iformis syndrome.

24. Yoon SJ, Ho J, Kang HY, et al: Low-dose botulinum toxin type A for the treatment of refractory piriformis syndrome. Pharmacotherapy 2007;27:657-665. The authors present a prospective, nonrandomized trial testing the efficacy of low-dose botulism toxin type A for the treatment of refractory piriformis syndrome. Level of evidence: II.

25. Kong A, Van der Vliet A, Zadow S: MRI and US of glu- teal tendinopathy in greater trochanteric pain syn- drome. Eur Radiol 2007;17:1772-1783.

The authors present a review of the efficacy of MRI and ultrasound in the diagnosis of gluteal tendinopathy and

describe the anatomic features of the gluteus minimus and medius muscles.

26. Connell DA, Bass C, Sykes CJ, Young D, Edwards E: Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol 2003;13:1339-1347. The authors present a case-control study that tested the efficacy of sonography in patients with gluteus medius and minimus tendinopathy by comparing symptomatic patients to asymptomatic control subjects. Level of evi- dence: III.

27. Hammer WI: The hip and thigh, in Hammer WI (ed):

Functional Soft Tissue Examination and Treatment by Manual Methods, ed 3. Boston, MA, Jones and Bartlett

Publishers, 2007, pp 286-287.

The author reviews pertinent descriptions, diagnostic approaches, and treatment options for various hip and thigh conditions.

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