In order to obtain AMA PRA Category 1 Credit™, participants are required to:

1. Review the CME information along with the learning objectives at the beginning of the CME article. Determine if these objectives match your individual learning needs. If so, read the article carefully.

2. The post-test questions have been designed to provide a useful link between the CME article and your everyday practice. Read each question, choose the correct answer and record your answers on the registration form.

3. Complete the evaluation portion of the Registration and Evaluation Form. Forms and tests cannot be processed if the evaluation section is incomplete.

4. Send the Registration and Evaluation Form to: MDAdvisor CME Dept c/o MDAdvantage Insurance Company 100 Franklin Corner Rd Lawrenceville, NJ 08648 Or complete online at www.surveymonkey.com/r/Summer2018CME

Or fax to: 978-367-9148

5. Retain a copy of your test answers. Your answer sheet will be graded, and if a passing score of 70% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and take the test again.

6. Mail the Registration and Evaluation Form on or before the deadline, which is August 1, 2019. Forms received after that date will not be processed.

Tendinous Conditions of the Hip and PelvisBy Jennifer Kurowicki, MD, John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, and Anthony J. Scillia, MD

Authors: Jennifer Kurowicki, MD (orthopaedic surgery research fellow with St. Joseph’s Healthcare System in affiliation with Seton Hall University-School of Health and Medical Sciences, Orthopaedic Surgery Residency Program); John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, and Anthony J. Scillia, MD (New Jersey Orthopaedic Institute (Wayne, NJ) and St. Joseph’s Healthcare System (Paterson, NJ).Accreditation Statement: HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Society of New Jersey (MSNJ) and through the Joint Providership of Health Research Education and Trust of New Jersey (HRET) and MDAdvantage. HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.AMA Credit Designation Statement: HRET designates this enduring activity for 1.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, there are no relevant financial relationships to disclose. No commercial funding has been accepted for the activity.

CME

11MDADVISOR

LEARNING OBJECTIVESAt the conclusion of this activity, participants will be able to:

1 Identify intra-articular and extra-articular causes of hip pain.

2 Understand the anatomy and associated physical exam findings in evaluation of hip pathology.

3 Describe the utility of diagnostic imaging.

4 Discuss the operative and non-operative management of these disorders.

INTRODUCTION Hip pain is among the most common complaints seen in an orthopedist’s office. Historically, hip pain has been attributed to osteoarthritis and treated conservatively with physical therapy and corticosteroid injections until definitive treatment with hip arthroplasty was indicated. However, technological innovations, including arthros-copy and ortho-biologics, combined with improved con-ceptual understanding of hip pathology, have improved a physician’s ability to diagnosis and treat a plethora of complex hip pathologies. Thus, a non-specific com-plaint such as hip pain has an ever-evolving differential diagnosis and requires physicians to have a firm grasp of possible sources.

Obtaining a comprehensive history, physical exam and appropriate imagining studies can help categorize hip pain into its two major causes: intra-articular or extra-ar-ticular pathologies. Intra-articular hip pain typically pres-ents with pain that radiates anteriorly to the groin and is associated with mechanical symptoms, such as clicking or catching.1 Common intra-articular producers of pain can include osteoarthritis, labral tear, femoroacetabular-impingement (FAI) or loose bodies.1–3

Conversely, extra-articular pathologies may mimic hip pain but are associated with the surrounding muscles, tendons, bursae, bones or nerves. Core muscle injury, also known as sports hernia, is a common mimicker of anterior groin pain seen in high-level athletes and should be differentiated from labral tears, FAI or osteoarthritis. Patients with lateral hip pain should be evaluated for greater trochanteric pain syndrome, which encompasses the trifecta of trochanteric bursitis, external snapping hip (coxa saltans) and abductor tendinopathy.2, 4, 5 Last, the main etiologies of posterior hip pain are extra-articular, including piriformis syndrome or a tear of the proximal hamstring.3, 6, 7

This article provides a general overview of the anatomy, diagnostic testing and treatment strategies for the man-agement of the most common cause of anterior/groin, lateral and posterior hip pain.

Anterior/Groin PainAnterior/groin pain may be the result of core muscle injury, femoroacetabular impingement or osteoarthritis.

Core Muscle Injury. The abdominal conjoined tendon is formed from the fibers of the internal oblique and transver-sus abdominis as the tendon inserts on the pubic tubercle. This tendon merges with fibers of the rectus abdominis and external oblique to form the pubic aponeurosis and meets at the origin of the adductor longus and gracilis muscles on the pubic symphysis. Core muscle injury, com-monly referred to as “sports hernia,” occurs when shearing forces are applied across the pubis during simultaneous trunk hyperextension and thigh hyperabduction resulting in a tear of the conjoined tendon insertion of the adductor longus and rectus abdominis on the pubis.3, 8-11

This injury is commonly seen in male athletes, particu-larly in sports with an abundance of kicking and twisting, such as soccer, hockey or rugby.12, 13 Typically, there is an insidious onset of symptoms that are relieved with rest and aggravated by sneezing, coughing or activity.11, 14 Physical exam will be devoid of true hernia and demon-strate tenderness to palpation of the adductor insertion on the pubis. Pain can also be elicited with resisted sit-up or resisted hip adduction.

Plain radiographs can demonstrate bone resorption and widening of the pubic symphysis (indicative of osteitis pubis) as well as rule out possible fractures or avulsions.1 Magnetic resonance imaging (MRI) of the pelvis demon-strating increased signal at the pubis and high-intensity signal at the groin muscles is considered the gold standard for diagnosis15 (see Figure 1).

Conservative management with activity modification and rest for 6 to 12 weeks, cryotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy aimed at core and adductor strengthening are the first line of treatment.16 For patients who fail a minimum of three months of non-operative therapy, surgical inter-vention using a mini-open approach to repair the rectus abdominis to the periosteum of the pubis and adductor lengthening has been described.17 Operative management in athletes has demonstrated a full return to play in up to 97 percent of patients.11

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Femoroacetabular Impingement (FAI). Femoroacetabular impinge-ment (FAI) is a result of abnormal articulation between the acetabu-lum and the proximal femur due to abnormal variants in anatomy. Pincer impingement occurs due to acetab-ular overcoverage of the proximal femur, while cam impingement is a result of an aspherical femoral head-neck junction.1 As a result, impinge-ment can cause decreased range of motion, pain, labral tears and an increased incidence of osteoarthri-

tis.18, 19 Commonly seen in hockey, golf, dance, soccer and football, patients complain of pain with prolonged sitting, rising from a seated position or lateral, cutting-type action.20 The flexion-abduction-external rotation (FABER) maneuver is considered positive for FAI if the maneuver elicits pain.

Plain anterior-posterior (A/P) and cross-table pelvic radio-graphs can be utilized to evaluate acetabular overhang and head-neck femoral anatomic variants, respectively. MR arthrog-raphy can evaluate for concomitant labral pathology in which an increased signal within the labrum and extension of contrast into the labrum indicates tearing21 (see Figure 2).

Conservative man-agement with NSAIDs, physical therapy and intra-articular cortisone injections is the primary treatment. Hip arthros-copy including femoro-plasty for cam lesions, acetabuloplasty for pin-cer lesions and labral repair have demon-

strated excellent results and high rates of return to play.22 Osteoarthritis. Hip osteoarthritis (OA) is a degenerative

disease causing progressive loss of cartilage and joint space, resulting in pain, stiffness and mechanical symptoms, such as catching or locking. In patients 30 years and older, the prev-alence of symptomatic hip OA is 3 percent with prevalence increasing with age, female gender and obesity.23 A physical exam is significant for decreased hip flexion and extension with limited internal rotation. Standing AP pelvic or AP/lateral hip radiographs demonstrate joint space narrowing, osteophytes, subchondral sclerosis and cysts.

First-line treatment for all patients is NSAIDs, weight loss (particularly in patients with BMI >40 kg/m2) and intra-ar-ticular hip injections. Corticosteroids, hyaluronic acid and

platelet-rich plasma (PRP) injections have all demonstrated functional improvement and pain reduction similar to one another.24, 25 In patients refractory to conservative treatment, total hip arthroplasty (THA) may be considered. The direct anterior approach has recently been popularized utilizing an internervous, intermuscular plane at the interval between the tensor fasciae latae and the sartorius muscle.26 This approach has been linked to less muscle damage and pain, quicker hospi-tal discharge and better functioning at short-term follow-up.27-30

LATERAL HIP PAIN CAUSED BY GREATER TROCHANTERIC PAIN SYNDROMEGreater trochanteric pain syndrome (GTPS) is a common cause of lateral hip pain due to inflammation of the trochanteric bur-sae, external snapping of the hip and tendinopathy of the glu-teus medius and minimus.31 While all three of these pathologies may be seen individually, it is common to see these diagnoses concomitantly. There are three bursae in the peritrochanteric space that aid in the smooth motion of the gluteus tendons, iliotibial band (ITB) and tensor fascia lata (TFL); these bursae often become inflamed, inciting lateral hip pain.

External snapping hip is the audible snapping sensation caused by a tight or thickened ITB as it slides over the greater trochanter during hip flexion and extension.32, 33 This is com-monly seen in middle-aged women and is often asymptomatic; however, in the setting of trochanteric bursitis, patients report lateral pain.1 Snapping is often reproducible on exam, and a positive Ober test indicates ITB tightness.

Conservative management with rest, core and abductor strengthening and stretching, NSAIDs and ultrasound-guided injections should be trialed initially. In external snapping hip refractory to non-operative management, surgical techniques, including open lengthening or release of the ITB, versus arthroscopic techniques may be explored. Regardless of open or arthroscopic technique, 98 percent of patients in pooled data were able to return to pre-activity levels.5

Abductor tendon tears of the gluteus medius and/or minimus present as lateral hip pain that is worsened by climbing stairs and a positive Trendelenburg gait.34 Pain on physical exam is exacerbated by resisted hip external rotation or abduction.34

MRI demonstrates a 73 percent sensitivity and a 95 percent specificity for hip abductor pathology, with high signal intensity superior or lateral to the greater trochanter, gluteus medius tendon elongation and tendon discontinuity, all correlated to a tear of the hip abductor.36

Use of steroid injections guided via ultrasound, fluoros-copy or palpation has been shown to provide equivocal pain relief.37-40 Surgical management is reserved for patients who fail three months of conservative treatment. Operative techniques continue to evolve from open to arthroscopic, demonstrating satisfactory outcomes regardless of technique.

Anthony J. Scillia, Copyright 2018. Reprinted with permission.

Anthony J. Scillia, Copyright 2018. Reprinted with permission.

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Posterior/ Gluteal PainPosterior/gluteal pain is often caused by piriformis syndrome or proximal hamstring tear.

Piriformis Syndrome. The piriformis muscle courses in close proximity, just superior to, the sciatic nerve. Anatomic variations in the muscle or nerve, muscular hypertrophy or trauma may result in irritation and compression of the sciatic nerve and result in posterior hip and gluteal pain.41 Patients typically describe pain that radiates from the hip down to the ankle and is worsened by sitting for long periods.42 A physical exam will demonstrate pain on palpation of the greater tro-chanter, a negative straight leg test and reproducible pain on resisted abduction of flexed, internally rotated hip.41 There is MRI utility in ruling out possible lumbar disk herniations and demonstrating piriformis hypertrophy.

Physical therapy should be aimed at stretching the piriformis, stabilizing the lumbosacral joint and strengthening the hip abductor through exercise. Injections under fluoroscopic guid-ance should be targeted to the origin of the piriformis muscle and have demonstrated therapeutic relief.43 If a patient fails to improve following six months of conservative therapy, surgical intervention by open or arthroscopic technique is indicated. In a case series of 60 arthroscopic piriformis releases with a two-year follow-up, there was significant improvement in pain and function.44

Proximal Hamstring Tear. Injury to the proximal hamstring usually occurs during eccentric lengthening, resulting in a par-tial tear to complete avulsion of the hamstring from its origin on the ischial tuberosity. On a physical exam, posterior thigh ecchymosis is typically present when a complete proximal hamstring rupture has occurred. Additionally, tenderness to palpation of the ischial tuberosity, pain with knee flexion at 45 degrees hip flexion, hamstring weakness and a palpable defect may be present on physical exam. MRI can be used to detect tears in the bone-tendon interface. However, studies have demonstrated correlation between asymptomatic ham-string tendinopathy and increasing age; thus, care must be taken to differentiate acute versus chronic injury.45

Non-operative treatment with rest, ice, compression and elevation or ultrasound-guided injections may be indicated for patients with partial tears of one or two tendons. Patients

with greater than 2 cm retraction, involvement of semimem-branous, semitendinous and biceps femoris tendons or failed conservative management may benefit from surgical repair (see Figure 3).46 Repair of proximal hamstring ruptures has demonstrated high rates of return to play, greater restoration of hamstring strength and higher patient satisfaction compared to those treated non-operatively.47, 48 The evolution of surgical techniques to arthroscopic has begun to gain popularity and has demonstrated satisfactory mid-term results.49

CONCLUSIONAs our knowledge of the anatomy surrounding the hip con-tinues to develop, paralleled with the introduction of innova-tive diagnostic and surgical techniques, physicians can readily manage a multitude of hip pathologies. Conservative manage-ment with ultrasound-guided injections and physical therapy remain the first-line treatment options; however, in the event of refractory pain, minimally-invasive arthroscopic surgical options are available demonstrating excellent outcomes.

Jennifer Kurowicki, MD, is an orthopaedic surgery research fellow with St. Joseph’s Healthcare System in affiliation with Seton Hall University-School of Health and Medical Sciences, Orthopaedic Surgery Residency Program. John J. Callaghan, MD, Craig Wright, MD, Anthony Festa, MD, Vincent K. McInerney, MD, and Anthony J. Scillia, MD, practice at New Jersey Orthopaedic Institute (Wayne, NJ) and are affiliated with St. Joseph’s Healthcare System (Paterson, NJ).

1. Karrasch, C., & Lynch, S. (2014). Practical approach to hip pain. Medical Clinics of North America, 98, 737–754, xi.

2. Redmond, J. M., Chen, A. W., & Domb, B. G. (2016). Greater trochanteric pain syndrome. Journal of the American Academy of Orthopaedic Surgeons, 24, 231–240.

3. Tibor, L. M., & Sekiya, J. K. (2008). Differential diagnosis of pain around the hip joint. Arthroscopy, 24, 1407–1421.

4. Pierce, T. P., Issa, K., Kurowicki, J., Festa, A., McInerney, V. K., & Scillia, A. J. (2018). Abductor tendon tears of the hip. Journal of Bone and Joint Surgery Reviews, 6, e6.

5. Pierce, T. P., Kurowicki, J., Issa, K., Festa, A., Scillia, A. J., & McInerney, V. K. (2018, June). External snapping hip: A systematic review of outcomes following surgical intervention. Hip International. [Epub ahead of print.] www.ncbi.nlm.nih.gov/pubmed/29902932.

6. Scillia, A., Choo, A., Milman, E., McInerney, V., & Festa, A. (2011). Snapping of the proximal hamstring origin: A rare cause of coxa saltans: A case report. American Journal of Bone and Joint Surgery, 93, e1251–1253.

7. Jankovic, D., Peng, P., & van Zundert, A. (2013). Brief review: Piriformis syndrome: Etiology, diagnosis, and management. Canadian Journal of Anesthesia, 60, 1003–1012.

8. Akita, K., Niga, S., Yamato, Y., Muneta, T., & Sato, T. (1999). Anatomic basis of chronic groin pain with special reference to sports hernia. Surgical and Radiologic Anatomy, 21, 1–5.

9. Joesting, D. R. (2002). Diagnosis and treatment of sportsman’s hernia. Current Sports Medicine Reports, 1, 121–124.

10. Meyers, W. C., McKechnie, A., Philippon, M. J., Horner, M. A., Zoga, A. C., & Devon, O. N. (2008). Experience with “sports hernia” spanning two decades. Annals of Surgery, 248, 656–665.

Anthony J. Scillia, Copyright 2018. Reprinted with permission.

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11. Meyers, W. C., Foley, D. P., Garrett, W. E., Lohnes, J. H., & Mandlebaum, B. R. (2000). Management of severe lower abdominal or inguinal pain in high-performance athletes. American Journal of Sports Medicine, 28, 2–8.

12. Santilli, O. L., Nardelli, N., Santilli, H. A., & Tripoloni, D. E. (2016). Sports hernias: Experience in a sports medicine center. Hernia, 20, 77–84.

13. Ahumada, L. A., Ashruf, S., Espinosa-de-los-Monteros, A., Long, L. N., de la Torre, J. I., Garth, W. P., & Vasconez, L. O. (2005). Athletic pubalgia: Definition and surgical treatment. Annals of Plastic Surgery, 55, 393–396.

14. van Veen, R. N., de Baat, P., Heijboer, M. P., Kazemier, G., Punt, B. J., Dwarksing, R. S., … van Eijcket, C. H. J. (2007). Successful endoscopic treatment of chronic groin pain in athletes. Surgical Endoscopy, 21, 189–193.

15. Albers, S. L., Spritzer, C. E., Garrett, W. E., & Meyers, W. C. (2001). MR findings in athletes with pubalgia. Skeletal Radiology, 30, 270–277.

16. Larson, C. M. (2014). Sports hernia/athletic pubalgia: Evaluation and management. Sports Health, 6, 139–144.

17. Scillia, A. J., Pierce, T. P., Simone, E., Novak, R. C., & Emblom, B. A. (2017). Mini-open incision sports hernia repair: A surgical technique for core muscle injury. Arthroscopy Techniques, 6, e1281–e1284.

18. Beck, M., Kalhor, M., Leunig, M., & Ganz, R. (2005). Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. British Journal of Bone and Joint Surgery, 87, 1012–1018.

19. Ganz, R., Parvizi, J., Beck, M., Leunig, M., Notzli, H., & Siebenrock, K. A. (2003). Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research. www.ncbi.nlm.nih.gov/pubmed/14646708.

20. Philippon, M., Schenker, M., Briggs, K., & Kuppersmith, D. (2007). Femoroacetabular impingement in 45 professional athletes: Associated pathologies and return to sport following arthroscopic decompression. Knee Surgery, Sports Traumatology, Arthroscopy, 15, 908–914.

21. Czerny, C., Hofmann, S., Neuhold, A., Tschauner, C., Engel, A., Recht, M. P., & Kramer, J. (1996). Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging. Radiology, 200, 225–230.

22. Schallmo, M. S., Fitzpatrick, T. H., Yancey, H. B., Marquez-Lara, A., Luo, T. D., & Stubbs, A. J. (2018). Return-to-play and performance outcomes of professional athletes in North America after hip arthroscopy from 1999 to 2016. The American Journal of Sports Medicine. http://journals.sagepub.com/doi/abs/10.1177/0363546518773080.

23. Nho, S. J., Kymes, S. M., Callaghan, J. J., & Felson, D. T. (2013). The burden of hip osteoarthritis in the United States: Epidemiologic and economic considerations. Journal of the American Academy of Orthopaedic Surgeons, 21, S1–6.

24. Battaglia, M., Guaraldi, F., Vannini, F., Rossi, G., Timoncini, A., Buda, R., & Giannini, S. (2013). Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus hyaluronic acid for hip osteoarthritis. Orthopedics, 36, e1501–1508.

25. Levine, M. E., Nace, J., Kapadia, B. H., Issa, K., Banerjee, S., Cherian, J., & Mont, M. (2013). Treatment of primary hip osteoarthritis for the primary care physician and the indications for total hip arthroplasty. Journal of Long-Term Effects of Medical Implants, 23, 323–330.

26. Post, Z. D., Orozco, F., Diaz-Ledezma, C., Hozack, W. J., & Ong, A. (2014). Direct anterior approach for total hip arthroplasty: Indications, technique, and results. Journal of the American Academy of Orthopaedic Surgeons, 22, 595–603.

27. Martin, C. T., Pugely, A. J., Gao, Y., & Clark, C. R. (2013). A comparison of hospital length of stay and short-term morbidity between the anterior and the posterior approaches to total hip arthroplasty. Journal of Arthroplasty, 28, 849–854.

28. Bremer, A. K., Kalberer, F., Pfirrmann, C. W., & Dora, C. (2011). Soft-tissue changes in hip abductor muscles and tendons after total hip replacement: Comparison between the direct anterior and the transgluteal approaches. British Journal of Bone and Joint Surgery, 93, 886–889.

29. Meneghini, R. M., Pagnano, M. W., Trousdale, R. T., & Hozack, W. J. (2006). Muscle damage during MIS total hip arthroplasty: Smith-Petersen versus posterior approach. Clinical Orthopaedics and Related Research, 453, 293–298.

30. Barrett, W. P., Turner, S. E., & Leopold, J. P. (2013). Prospective randomized study of direct anterior vs postero-lateral approach for total hip arthroplasty. Journal of Arthroplasty, 28, 1634–1638.

31. Strauss, E. J., Nho, S. J., & Kelly, B. T. (2010). Greater trochanteric pain syndrome. Sports Medicine and Arthroscopy Review, 18, 113–119.

32. Allen, W. C., & Cope, R. (1995). Coxa Saltans: The snapping hip revisited. Journal of the American Academy of Orthopaedic Surgeons, 3, 303–308.

33. Brignall, C. G., & Stainsby, G. D. (1991). The snapping hip: Treatment by Z-plasty. British Journal of Bone and Joint Surgery, 73, 253–254.

34. Twair, A., Ryan, M., O’Connell, M., Powell, T., O’Byrne, J., & Eustace, S. (2003). MRI of failed total hip replacement caused by abductor muscle avulsion. American Journal of Roentgenology, 181, 1547–1550.

35. Domb, B. G., Nasser, R. M., & Botser, I. B. (2010). Partial-thickness tears of the gluteus medius: Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy, 26, 1697–1705.

36. Cvitanic, O., Henzie, G., Skezas, N., Lyons, J., & Minter, J. (2004). MRI diagnosis of tears of the hip abductor tendons (gluteus medius and gluteus minimus). American Journal of Roentgenology, 182, 137–143.

37. Cohen, S. P., Strassels, S. A., Foster, L., Marvel, J., Williams, K., Crooks, M., … Williams, N. (2009). Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanteric pain syndrome: Multicentre randomised controlled trial. BMJ. www.bmj.com/content/338/bmj.b1088.

38. McEvoy, J. R., Lee, K. S., Blankenbaker, D. G., del Rio, A. M., & Keene, J. S. (2013). Ultrasound-guided corticosteroid injections for treatment of greater trochanteric pain syndrome: Greater trochanter bursa versus subgluteus medius bursa. American Journal of Roentgenology, 201, W313–317.

39. Brinks, A., van Rijn, R. M., Willemsen, S. P., Bohnen, A. M., Nerhaar, J. A., Koes, B. W., & Bierma-Zeinstra, S. M. (2011). Corticosteroid injections for greater trochanteric pain syndrome: A randomized controlled trial in primary care. Annals of Family Medicine, 9, 226–234.

40. Labrosse, J. M., Cardinal, E., Leduc, B. E., Duranceau, J., Remillard, J., Bureau, N. J., … Brassard, P. (2010). Effectiveness of ultrasound-guided corticosteroid injection for the treatment of gluteus medius tendinopathy. American Journal of Roentgenology, 194, 202–206.

41. Windisch, G., Braun, E. M., & Anderhuber, F. (2007). Piriformis muscle: Clinical anatomy and consideration of the piriformis syndrome. Surgical and Radiologic Anatomy, 29, 37–45.

42. Reus, M., de Dios Berna, J., Vazquez, V., Redondo, M. V., & Alonso, J. (2008). Piriformis syndrome: A simple technique for US-guided infiltration of the perisciatic nerve. Preliminary results. European Radiology, 18, 616–620.

43. Byeon, G. J., & Kim, K. H. (2011). Piriformis syndrome in knee osteoarthritis patients after wearing rocker bottom shoes. Korean Journal of Pain, 24, 93–99.

44. Park, M. S., Yoon, S. J., Jung, S. Y., & Kim, S. H. (2016). Clinical results of endoscopic sciatic nerve decompression for deep gluteal syndrome: Mean 2-year follow-up. BMC Musculoskeletal Disorders, 17, 218.

45. De Smet, A. A., Blankenbaker, D. G., Alsheik, N. H., & Lindstrom, M. J. (2012). MRI appearance of the proximal hamstring tendons in patients with and without symptomatic proximal hamstring tendinopathy. American Journal of Roentgenology, 198, 418–422.

46. De Smet, A. A., & Best, T. M. (2000). MR imaging of the distribution and location of acute hamstring injuries in athletes. American Journal of Roentgenology, 174, 393–399.

47. Bodendorfer, B. M., Curley, A. J., Kotler, J. A., Ryan, J. M., Jejurikar, N. S., Kumar, A., & Postma, W. F. (2017). Outcomes after operative and nonoperative treatment of proximal hamstring avulsions: A systematic review and meta-analysis. American Journal of Sports Medicine. www.ncbi.nlm.nih.gov/pubmed/29016194363546517732526.

48. Shambaugh, B. C., Olsen, J. R., Lacerte, E., Kellum, E., & Miller, S. L. (2017). A comparison of nonoperative and operative treatment of complete proximal hamstring ruptures. Orthopaedic Journal of Sports Medicine. http://journals.sagepub.com/doi/full/10.1177/2325967117738551.

49. Lindner, D., Trenga, A. P., Stake, C. E., Jackson, T. J., El Bitar, Y. F., & Domb, B. G. (2014). Endoscopic repair of a chronic incomplete proximal hamstring avulsion in a cheerleader. Clinical Journal of Sport Medicine, 24, 83–86.

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TENDINOUS CONDITIONS OF THE HIP AND PELVIS

CME QUESTIONSDeadline for Response: August 1, 2019

1 All patients with hip pain should be managed conservatively until definitive treatment with total hip arthroplasty is indicated.a. Trueb. False

2 In a patient with suspected diagnosis of core muscle injury (sports hernia), which of the following is considered the gold standard for confirming diagnosis?

a. Plain radiographs b. Magnetic resonance imaging (MRI) of the pelvisc. Computed tomography (CT) scan of the pelvisd. Ultrasound

3 Which of the following is the best physical exam maneuver to evaluate femoroacetabular impingement (FAI)?a. Resisted sit-up b. Ober’s test c. Flexion-abduction-external rotation (FABER) maneuverd. Trendelenburg sign

4 Patients with intra-articular hip pathology are more likely to present with mechanical symptoms, such as clicking, catching or locking.

a. True b. False

5 Which of the following is true regarding the direct anterior approach for total hip arthroplasty?a. Recommended for obese patients (BMI >40 kg/m2) b. Requires longer hospital length of stayc. Incurs less muscle damage d. Increases time under anesthesia

6 Which of the following diagnoses should be considered in a patient with lateral side hip pain?a. Greater trochanteric pain syndromeb. Hip osteoarthritisc. Piriformis syndrome d. Core muscle injury

7 External snapping hip refractory to conservative treatment can be treated surgically with iliotibial band lengthening or release.a. Trueb. False

8 Which of the following is an indication for surgical repair of a proximal hamstring tear?a. <2 cm of retractionb. Involvement of semimembranous and semitendinous femoris only c. Involvement of semimembranous and biceps femoris onlyd. Involvement of semimembranous, semitendinous and biceps femoris

9 Compared to conservative treatment, patients managed surgically for proximal hamstring tears demonstrate: a. Decreased hamstring strengthb. Higher rates of return to playc. Decreased range of motiond. Higher rate of recurrence

10 Which of the following is not a component of greater trochanteric pain syndrome?a. Gluteus medius tendonb. Gluteus minimus tendonc. Gluteus maximus tendond. Tensor fascia lata

This post-test may also be completed online at www.surveymonkey.com/r/Summer2018CME

MDADVISOR | Summer 201816CME

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5. Will the knowledge learned today affect your practice? Very Much Moderately Minimally None

6. Based on your participation in the CME activity, describe ways in which you will change the way you practice medicine.Yes Describe

No Why not?

N/A Were you the wrong audience for this activity?

7. Did this CME activity change what you know about:• Intra-articular and extra-articular causes of hip pain. Yes No• The anatomy and associated physical exam findings in evaluation of hip pathology. Yes No• The utility of diagnostic imaging. Yes No• The operative and non-operative management of these disorders. Yes No

8. Based on your participation today, what barriers to the implementation of the strategies or skills taught today have you identified?

Suggested topics for future programs:

TENDINOUS CONDITIONS OF THE HIP AND PELVIS

REGISTRATION AND EVALUATION FORM(Must be completed in order for your CME Quiz to be scored)

Deadline for Response: August 1, 2019