#453 Sports Injuries Part 1: Concussion and Hip Pain

September 16, 2024 | By Matthew Watto, MD

Audio

Video

Transcript available via YouTube

Concussion Concepts and Impingement Instruction! 

Follow along as the great Dr. Senter guides us through the diagnosis, workup, and treatment of an all-star lineup of sport injuries. Part 1 covers concussions, femoroacetabular  impingement (FAI), and the ongoing quest to diagnose Paul’s mysterious hip injury. 

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Show Segments

00:00 Introduction 

08:43 Case 1 – Concussion 

9:39 Approach and Workup of Concussions 

18:08 Treatment of Concussions (Return to Activity) 

24:10 Consideration of Head Imaging 

33:20 Case 2 – Hip Pain (FAI) 

34:15 Hip Anatomy and Differential Diagnosis 

38:41 Hip Physical Exam 

45:41 Hip Imaging 

47:28 Treatment of FAI

Outro & Take Home Points 

Concussion Pearls

1. Consider using a comprehensive assessment tool such as the SCOAT6 to identify and quantify your patient’s symptoms. Clinicians can choose which components to use based on the patient’s presentation.
2. It can be helpful to target whichever “bucket” your patient’s symptoms seem to fall in: headache, sleep, emotional, cognitive. 
3. Graded return to activity is the mainstay of treatment. You can use frameworks such as those provided in CDC Concussion Resources, or California Interscholastic Federation, or the bottom of the SCOAT6. 
4.  Patients can guide their progress with the “two point rule” (if an activity worsens a symptom by 2 on a scale 0-10, it’s time to step back). 
5. In the absence of red flag symptoms, it is generally accepted that there is no need to force a patient to remain awake after a concussion! 

Femoroacetabular Impingement Pearls 

1. A hip exam including FABER and FADIR can help differentiate intra articular pain (localizing to the anterior hip crease) from other sources including sacroiliac joint pain.
2. Femoroacetabular impingement is caused by the pinching between bony enlargement of the femoral head-neck junction (cam type) or increased overhang of the acetabular socket (pincer type), or both.
3. The recommended imaging for FAI consists of a 2 view x-ray (AP and Dunn lateral). If the patient is not improving after a few months of physical therapy, MRI can be considered to evaluate alternative diagnoses or plan surgery. 
4. Patients often do well with physical therapy and activity modification, however surgery may have to be considered if they are not improving.

Sports Injuries Part 1 – Show Notes 

Concussion

Evaluation

Mild traumatic brain injuries, commonly known as concussions, can present with a variety of symptoms. They are diagnosed clinically based on a compatible history of head injury and symptoms including headache, dizziness, sadness, anxiety, fogginess, etc. They may or may not have the classical associated period of short-lived neurological impairment including loss of memory or consciousness. There are currently no established definitive diagnostic lab or imaging findings (Giza 2013), (McCrory 2013).

The Sport Concussion Office Assessment Tool, 6th edition (SCOAT6) can guide the evaluation of concussions and their associated symptoms. It is quite comprehensive; clinicians may select which components to use based on the patient’s presentation.

Dr. Senter finds that these symptoms tend to fall into four buckets: headache, sleep, cognitive, and emotional. This categorization can make them easier to follow over time.

Dr. Senter uses cross sectional imaging only in certain circumstances. In the acute setting, red flags or tools such as the NEXUS or Canadian Head CT Rule can determine the need for CT imaging (Valente 2023). MRI may be considered for persistent symptoms around the 6-8 week mark, however Dr. Senter notes this is an “evidence free zone.”

Treatment

Recovery involves a graded return to activity after a period of rest for 24-48 hours (McCrory 2013), and yes activity takes a central role in this! As long as the patient takes care to avoid further head injuries, they should get plenty of rest and begin a slow graded return to cognitive and physical activity. Dr. Senter recommends several options of structured programs: 

• CDC
• California Interscholastic Federation
• The bottom of the SCOAT6 
• Buffalo Concussion Treadmill Test

As a simple tool to guide patient activity, Dr. Senter recommends the “two point rule:” when a given activity worsens a symptom by 2 on scale of 0-10, it is time to dial back and take a break. This rule is even used as part of the recommendations of the SCOAT6! 

Symptoms generally improve over time, and should be monitored in frequent follow up. Dr. Senter notes this commonly takes around 4 weeks, and will see patients on a weekly basis when they are early in their course. 

Pharmacologic management tends to revolve around symptomatic management, and is also an area of very little formal evidence or recommendations. Most expert opinion will prescribe symptomatically, e.g. NSAIDs and acetaminophen for headaches, and Dr. Senter notes she may occasionally SSRIs for persistent mood symptoms. 

The CDC provides excellent resources both for patients and clinicians.

Femoroacetabular Impingement (FAI)

Anatomy & Pathology

The hip joint is a ball-and-socket joint, where the “socket” is a region of the pelvis called the acetabulum, and the “ball” is the head of the femur, connected to the rest of the bone by the femoral neck. The labrum is a fibrocartilaginous structure along the inside of the acetabulum. 

FAI pathology can consist of pincer type, cam type, or a combination of both. Pincer morphology involves increased overhang of the rim of the acetabulum (i.e. a sharper socket), while cam type involves bony enlargement of the femoral head-neck junction (a misshapen ball). This mismatch causes a “grinding and pinching” that generates intraarticular pain during what would otherwise be normal range of motion (Ganz 2003). 

Differential Diagnosis

The initial evaluation of hip pain involves diligent localization. Classically, intraarticular hip pain will localize to the anterior hip crease, although tendonitis of hip flexor muscles (e.g. iliopsoas) may also localize here. Patients may also endorse “hip pain” that actually localizes to the greater trochanter, low back, thigh, etc. 

The differential diagnosis of intraarticular hip pain in athletes is broad and can include:

• FAI
• Labral tears
• Femoral stress fractures
• Osteoarthritis 

These can be difficult to differentiate, and should take historical factors into account (history of heavy repetitive exercise in the case of stress fractures, older age in the case of OA). 

Physical Exam

Dr. Senter recommends watching USCF Ortho’s Youtube channel for tips on the hip and other MSK physical exams. 

Her general hip exam includes:

• Evaluation of the low back (e.g. assess if leaning forward or extending back reproduces symptoms), 
• Palpation of bony structures including the anterior superior iliac crest, palpate the inguinal crease (which may be tender in iliopsoas tendonitis), and palpating laterally to assess for trochanteric pain. If the pain is posterior, palpation of the lumbar spine, the area of the sacroiliac joints, as well as the sciatic notch or piriformis area and ischial tuberosity is helpful.
• Range of motion (starting with the unaffected side first) through flexion/ internal rotation/ external rotation. 
• FADIR is a special exam maneuver of the hip, and is preferred in the diagnosis of FAI. Its name is actually an acronym for how to perform it. It is done by having a patient lie down, Flex the hip fully or to 90 degrees (with knee flexed), ADduct the leg towards the midline, and Internally Rotate the leg (i.e. rotate the foot away from midline). This pinches the joint and will often reproduce pain in FAI. 
• The counterpart of FADIR is FABER. In similar fashion, it involves Flexion of the hip, ABduction of the leg away from midline, and External Rotation, essentially having them lie their ipsilateral foot above or below the contralateral knee. Pressing downward on the ipsilateral knee while stabilizing the contralateral hip can reproduce intraarticular hip pain in the anterior hip crease, or SI joint pain in the back.  
• As an additional maneuver, Dr. Senter recommends having certain patients (if they are able!) hop on one foot, as this will exacerbate symptoms in femoral stress fractures. 

Tendonitis may be identified if pain is elicited by providing downward resistance on the raised leg of a supine patient. Unfortunately this may be exacerbated by intraarticular pathology as well. 

FABER and FADIR are commonly used for the evaluation of FAI and labral tears, and are thought to have fairly high sensitivity but low specificity. These values range widely across different studies (Tijssen 2012)

Imaging

Imaging for suspected FAI should include x-rays, generally consisting of 2 views: AP and Dunn lateral. The Dunn lateral is taken while the patient’s hip is flexed and slightly abducted. 

Further imaging is generally not recommended if the diagnosis has confidently been reached, however MRI may be performed if the diagnosis is uncertain or if planning for surgery (see below “Treatment”). 

Treatment

Treatment of FAI generally consists of activity modification and physical therapy. These should focus on strengthening the core and hip muscles. Fortunately, these measures will help relieve symptoms from hip labral tears as well (Kemp 2020, Pennock 2018).    

If patients do not have access to physical therapy, Dr. Senter recommends using UCSF’s Sports Medicine Rehab Resources, which include instructional videos on hip and many other joint rehabilitation protocols. 

Dr. Senter considers corticosteroid injections as a diagnostic tool to confirm that she’s dealing with an intraarticular issue. 

When patients are not improving with around 3 months of conservative management, Dr. Senter considers MRI and/or Orthopedic referral. 

Links

1. The Crosstown Trail (San Francisco hiking trail)
2. SCOAT6 (concussion evaluation system)
3. NEXUS or Canadian Head CT Rule (acute head CT decision making tools)
4. Buffalo Concussion Treadmill Test (concussion activity guideline)
5. California Interscholastic Federation (concussion activity guideline)
6. CDC Concussion Resources (various patient and clinician resources)
7. UCSF’s Sports Medicine Rehab Resources (instructional videos on joint strengthening)
8. UCSF Ortho’s Youtube page (detailed videos on physical exam maneuver)

Goal

Listeners will develop a framework to work up sport-related injuries including concussions and femoral acetabular impingement. 

Learning objectives

After listening to this episode listeners will…  

1. Know how to use clinical tools to assess concussions.
2. Know several published frameworks for return to activity guidance for concussions. 
3. Be able to perform a targeted physical exam for suspected femoroacetabular impingement. 
4. Be familiar with the recommended imaging and treatment for FAI. 

Disclosures

Dr. Senter reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Jyang E, Wikoff P, Senter C, Williams PN, Watto MF. “#453 Sports Injuries with Dr. Carlin Senter – Part 1”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date September 16, 2024.