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48 Disorders of the contractile structures

CHAPTER CONTENTS

Resisted flexion 651

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 651Pain and weakness . . . . . . . . . . . . . . . . . 652Painless weakness . . . . . . . . . . . . . . . . . 653

Resisted extension 653

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 653Painless weakness . . . . . . . . . . . . . . . . . 654

Resisted adduction 654

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 654Resisted abduction 655

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 655Pain and weakness . . . . . . . . . . . . . . . . . 656Painless weakness . . . . . . . . . . . . . . . . . 656

Resisted medial rotation 657

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 657Resisted lateral rotation 657

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 657Resisted extension of the knee 657

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 657Pain and weakness . . . . . . . . . . . . . . . . . 658Painless weakness . . . . . . . . . . . . . . . . . 658

Resisted flexion of the knee 658

Pain . . . . . . . . . . . . . . . . . . . . . . . . . 658Painless weakness . . . . . . . . . . . . . . . . . 659

Pain in the buttock usually results from a lesion of the lumbar spine, the hip joint or the sacroiliac joint. Muscular lesions are very uncommon. Even if resisted movements elicit pain in the buttock, gluteal bursitis is more likely to be the cause, espe-cially if one or more passive movements also elicit the pain.

Pain in the groin more often results from a tendinous or muscular lesion. It is good to remember, however, that groin pain may also result from a lesion of the lumbar spine, the hip joint or, uncommonly, the sacroiliac joint. Also, a number of intra-abdominal pathological conditions, such as appendicitis, gynaecological disorders and inguinal or femoral hernia, may cause groin pain (see online chapter Groin pain).1

Resisted flexion

This test primarily examines the psoas muscle. However, a strain or weakness may be obscured because of active contrac-tion of other synergistic muscles such as the rectus femoris, sartorius, tensor fasciae latae and some of the adductors.

Pain

If resisted flexion is strongly opposed and is painful, the fol-lowing conditions should be considered:

• Tendinitis of the: Psoas Rectus femoris Sartorius

• Obturator hernia.

Tendinitis of the psoasTendinitis of the psoas is rare. It may result from an acute hyperextension of the hip or from an overuse injury.2–6 Iliopsoas impingement is also an uncommon cause of pain after total hip replacement.7 The lesion is always located in the femoral triangle and thus accessible to the palpating finger. It can be identified just below the inguinal ligament between the pulsating femoral artery medially and the sartorius muscle laterally.

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cases, treatment can be started the day after onset. However, really deep friction should not last more than 1 minute and is repeated daily, with a gradual increase in the treatment time. In the second week, treatment is performed on alternate days. It is then carried out deeply throughout and for about 15 minutes. A good result is to be expected in 2 weeks. Chronic strain requires 15 minutes of friction, two or three times weekly, depending on the result of each session. A lesion that has persisted for years will respond to 6–8 sessions of deep transverse friction. Treatment is very painful but, in our opinion, there is no alternative. Finding the exact point is not easy and requires a good understanding of local topographical anatomy.

Tendinitis of the rectus femorisResisted flexion is painful, especially if the test is executed with an extended knee (active straight leg raising). Resisted extension of the knee in prone lying position is also painful. The lesion is discussed in ‘Pain on resisted extension of the knee’ (see Ch. 54).

Lesions of the sartoriusLesions of the sartorius muscle are rare and typically occur in soccer players. Resisted flexion of the hip is painful, especially if some external rotation with a flexed knee is added to the movement. Palpation reveals the localization of the lesion, which is either at the tenoperiosteal insertion or 1 or 2 cm more distal in the tendon. Treatment consists either of deep transverse friction or, if the lesion is tenoperiosteal, of one or two infiltrations with triamcinolone.

In young athletes (aged 15–18) who are skeletally imma-ture, an avulsion fracture of the anterior superior spine of the ilium is more common than a muscle strain or tendinitis (see ‘Pain and weakness’).10

Obturator herniaThis lesion is principally found in thin, elderly women, often with a history of recent weight loss, obstipation or chronic respiratory disease. The patient complains of numbness or pins and needles, which may eventually culminate in intense pain at the anterior and medial side of the thigh down to the knee. These symptoms result from compression of the obturator nerve at the obturator foramen by a prolapsed fold of perito-neum. Absence of the adductor reflex test is a sign of involve-ment of motor conduction of the same nerve.11 Pain on resisted hip flexion is explained by pressure exerted by the psoas on the hernia. The differential diagnosis can be made when resisted flexion becomes negative after the patient has been in the Trendelenburg position for upwards of 2 minutes; the effect of gravity is to reduce the prolapse, which is no longer painfully squeezed during active contraction of the psoas.

Pain and weakness

Pain and weakness on resisted flexion can be present in the following conditions.

TreatmentDeep transverse friction is very effective.8 Sonography-guided iliopsoas peritendinous injections with steroid have also been proposed as a safe and effective method of treatment.9

Deep frictionThe patient sits upright on the couch with the hip joint in 90° of flexion and the knees extended – with the hip extended in the supine position, it is not possible for the finger to penetrate deeply enough because of the taut overlying tissues. The thera-pist sits at the patient’s side facing the thigh, with the index and middle fingers placed at the painful tendon in the femoral triangle, just lateral to the femoral artery and medial to the sartorius muscle. The thumb is placed at the outer part of the hip and used as a fulcrum (Fig. 48.1). The transverse movement of friction is imparted by alternating flexion and extension of the wrist and elbow, together with some adduction–abduction movement at the shoulder. In acute

Fig 48.1 • Deep transverse friction to the psoas tendon.

Sartorius

Psoas tendon Inguinal ligament

Femoral nerve

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In a third lumbar root palsy, it is less obvious and is also accom-panied by weakness of the quadriceps.

PsychoneurosisWeakness of hip flexion is also a common finding in psychoneu-rotic patients complaining of pain in the lower back or thigh. The diagnosis can only be made if this sign is accompanied by other inconsistencies in the history and clinical examination (see online chapter Psychogenic pain).

Serious non-specific disorderBecause discoradicular conflicts at the second lumbar level almost never occur, painless weakness of hip flexion should always arouse suspicion of a serious non-specific disorder (see p. 534), such as inflammatory disease or neoplasm.

Resisted extension

Pain

Pain on resisted extension hardly ever has anything to do with the gluteus maximus, in which a lesion occurs only after a direct blow and recovers spontaneously within a few days. However, a contracting gluteus maximus may compress an inflamed gluteal bursa and thus indirectly provoke pain in an inert structure (transmitted stress). Pain after prolonged con-traction of the gluteal muscles indicates a particular form of intermittent claudication.

If there is hamstring tendinitis or sprain of the sacrotuber-ous ligament, resisted flexion of the knee is then also painful (see ‘Resisted flexion of the knee’, p. 658).

Inflamed gluteal bursaAn inflamed gluteal bursa is a much more frequent cause of pain on resisted extension, especially if one or more passive movements also elicit the pain (see ‘Gluteal bursitis’, p. 646).

Buttock claudicationClaudication is the symptomatic expression of peripheral artery disease in the leg. It is confined as pain (aching, heavi-ness, cramping or burning) that is produced with a similar level of walking, disappears after several minutes of standing and occurs at the same distance once walking has resumed.17 Clas-sically, it appears in the calf and/or thigh, but sometimes is confined to the buttock region only and is then caused by a proximal arterial stenosis (bifurcation of the aorta, common iliac, internal iliac and gluteal arteries).18 The essential history is that of a buttock pain that forces the patient to stop walking, improves in a minute or two and reappears when the patient starts walking again. The routine clinical examination is com-pletely negative. An additional test – active extension of the hip in prone-lying position – may reproduce the buttock pain (see p. 625). The usual reduction in femoral pulse may be absent if the stenosis is located on the hypogastric or gluteal artery and there is no substantial damage to the aorta–iliac

Avulsion fracture of the anterior superior iliac spineAvulsion fractures occur more commonly in skeletally imma-ture athletes than in adults because young patients’ tendons are stronger than their cartilaginous growth centres. The same stress that causes a sartorius tendinitis in an adult can cause an avulsion fracture of the anterior superior iliac spine in an adolescent. The fracture does not become widely displaced because of the surrounding thick periosteum.

The lesion is well known in young sprinters, soccer players and jumpers.12 While running, the subject feels a sudden painful click in the groin and upper part of the thigh. From that moment further activity is impossible and the athlete leaves the track with a limp; even walking is painful.13,14 On examination, resisted flexion and resisted lateral rotation of the hip and resisted flexion of the knee are all painful. Palpation reveals ecchymosis and palpable tenderness at the anterior superior iliac spine where the sartorius muscle is attached. Radiography shows slight separation of the iliac spine. Sponta-neous recovery is the rule and takes 2–3 weeks. During this period, however, total bed rest is not necessary. Movement should be permitted to the limits of pain but return to sports activity should be allowed only from the time that clinical examination becomes fully negative.

Avulsion fracture at the apophysis of the lesser trochanterThis may be seen in schoolboys and young athletes. There is no history of sudden onset because the lesion appears to be caused by overuse.15 The complaint is of groin pain during walking. Clinical examination shows a normal range of passive movement but resisted flexion is weak and provokes pain. This should be reason enough to obtain a radiograph, which shows separation at the lesser trochanter. In most instances 2 or 3 weeks’ bed rest in a half-sitting position will be enough for recovery to take place. Once the patient can walk without pain, standing is allowed.

It is important to remember that avulsion fractures of the lesser trochanter in adults are almost always the result of metastatic bone disease.16

Abdominal neoplasmInfiltration of an abdominal neoplasm into the psoas muscle, although rare, is another cause of considerable weakness of hip flexion and pain in the iliac fossa.

Metastasis in the upper femurWeakness and pain in the thigh will be accompanied by marked articular signs in the hip joint and probably a ‘buttock sign’ (see p. 637).

Painless weakness

Lumbar root palsyPainless weakness is a major sign in the rare condition of a second lumbar root palsy in a second lumbar disc protrusion.

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muscle fibres.29 Imaging procedures are usually unnecessary. However, ultrasound, although operator-dependent, can confirm the diagnosis.30

There are three possible locations of the lesion:

• tenoperiosteal• musculotendinous• proximal extent of the muscle belly.

The exact site of the lesion is found on palpation and is more often musculotendinous, a few centimetres below the pubic bone, than tenoperiosteal. Exceptionally, the uppermost part of the muscle belly itself is at fault.

Differential diagnosisAlthough pain in the groin during resisted adduction usually indicates a lesion of the adductor longus, this is not always so. Strong adduction indirectly pulls on bones and ligaments of the pelvic ring and, if a pathological condition is present in this region, the transmitted stress causes pain. A detailed discussion of pubic lesions can be found in the online chapter, Groin pain. The following three lesions are the most important.

Fracture or neoplasm in the pubic bonePalpation of the adductor muscles reveals nothing, whereas a radiograph establishes the presence of a lesion.31

Osteitis pubis (periostitis at the pubic symphysis)This occurs in soccer players and race walkers as the result of repeated shearing of the pubic bones at the symphysis.32 Palpa-tion of the adductor muscles reveals nothing but the pubic symphysis is very tender (see online chapter Groin pain).33

Lesions of the sacroiliac jointSacroiliitis or sacroiliac strain may also be responsible for painful resisted adduction at the hip, caused by distraction of the ilium from the sacrum. Usually, the pain is felt in the buttock and attention is immediately directed to the sacroiliac joint. However, in some instances, pain is felt in the groin or inguinal region and diagnosis can then be more troublesome.34

TreatmentDeep transverse friction is usually effective in tendinous or musculotendinous lesions, whereas tenoperiosteal lesions can be treated by friction or infiltration with triamcinolone. Mus-cular lesions react well to infiltration with local anaesthetics or to deep friction.

Treatment should always be associated with relative rest to avoid further strain on the involved structure. In persistent cases, surgery is indicated.35,36 The procedure used includes division of the adductor longus tendon close to its origin from the pubis. The results seem to be good and most athletes can return to sports after 8 weeks.

Technique: deep frictionThe patient adopts a half-lying position on the couch, with the affected thigh in slight abduction and lateral rotation. The therapist sits level with the patient’s knees and facing the body. In musculotendinous lesions, the affected area is grasped between the thumb and index and middle fingers (Fig. 48.3). Friction is imparted by a drawing movement of the hand

axis.19 Arterial stenosis is confirmed by Doppler ultrasound or arteriography (Fig. 48.2).20

Painless weakness

Painless weakness on resisted extension is indicative of a first sacral root palsy. In the exceptional instance of an extensive paralysis of the gluteus maximus, an ‘extensor’ or ‘gluteus maximus’ lurch may be found; the patient has to thrust the trunk posteriorly to maintain hip extension during walking.

Resisted adduction

Pain

Adductor longusPain on resisted adduction that is localized to the groin usually points to the adductors. While the adductor longus, adductor magnus, adductor brevis and pectineal muscles are all adduc-tors of the hip, of these the adductor longus is most often injured in sports.2,21–24

The mechanism of an acute injury is usually that of a sharp cutting movement, which causes a forceful eccentric contrac-tion of the muscle. Acute lesions are common in soccer players and often result from a sudden slip on a muddy field, which stretches or tears the muscle or tendon fibres.25 Alternatively, the lesion starts as an overuse phenomenon, such as repetitive abduction and adduction movements of the leg in the skating stride or in defence movements in basketball. It also occurs in high-jumping athletes and ballet dancers26 and has been described in middle-aged cricket bowlers and ice-hockey players.27,28 Lastly, it is a well-known lesion (‘rider’s sprain’) in horse sports.

Pain is provoked mainly on resisted adduction but full passive abduction may also hurt because it stretches the injured

Fig 48.2 • Locations of a proximal arterial stenosis.

Common iliac

Superior gluteal

Inferior gluteal

Internal pudendal

Inferior vesicleObturator

Superior vesicle

External iliac

Middle rectal

Posterior division giving off the iliolumbar and lateral sacral

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syringe is filled with triamcinolone and fitted with a 4 cm needle. The needle is inserted just distal from the palpating finger on the periosteum and directed upwards until it hits bone (Fig. 48.5). Using a series of small withdrawals and rein-sertions at slightly different points, the whole area is infil-trated. Meanwhile, the palpating finger is kept on the spot, to detect where the tiny bulges of drug appear.

Another infiltration may be required when the patient is seen 2 weeks after wards, if the resisted adduction test remains positive.

Resisted abduction

Pain

Lesions of the hip abductors are rare. The diagnosis is often difficult because pain on resisted abduction of the hip is often caused by transmitted stress on inflamed bursae (trochanter and gluteal) or strained sacroiliac ligaments.

Glutei medius and minimus musclesMuscular lesions seem not to occur. Local pain during resisted abduction is far more likely caused by compression of an underlying inflamed bursa, which takes place during con-traction of the gluteal muscles.37 If passive abduction is also painful, bursitis is almost a certainty and results from compres-sion of the bursa between the greater trochanter and the ilium (p. 646).

Lesion of the tensor fasciae lataeThis muscular overuse lesion may occur in dancers and ath-letes. It is often caused by repetitive increased tension on the iliotibial band, which results from pelvic tilt or certain activities such as habitual running on the sides of the road (‘downside leg’). Localized pain is felt between pelvic crest and trochanter. The signs are characteristic: lumbar examination reveals pain

medially. At the end of range, the affected structures have passed beyond the fingers and the movement is then repeated.

In tenoperiosteal lesions, the index finger, reinforced by the middle finger, is placed on the pubic bone (Fig. 48.4) and fric-tion is carried out by alternately flexing and extending the elbow, together with a slight adduction and abduction move-ment at the shoulder.

In the acute stage, treatment should be brief and not vigor-ous, but can be repeated daily for the first few days and on alternate days thereafter.

Long-standing scars that may have formed in the absence of treatment at an early stage are given truly deep friction for as long as possible – say, 20 minutes – twice a week.

The results are good in all recent and most chronic cases. Exertion is best avoided until the patient is symptom-free.

Technique: injectionThe patient adopts a half-lying position on a high couch and puts the thigh into slight abduction. The affected spot is identi-fied at the tenoperiosteal junction on the pubic bone. A 2 mL

Fig 48.3 • Deep transverse friction to the adductor longus muscle (musculotendinous junction).

Fig 48.4 • Deep transverse friction to the adductor longus muscle (tenoperiosteal junction).

Fig 48.5 • Infiltration of the adductor longus (tenoperiosteal junction).

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for 20 minutes and is repeated twice a week. Even in long-standing and neglected cases, it will take no more than 6–8 sessions to achieve a satisfactory result.

Sprain of the iliotibial tractThis lesion is often described as the ‘lateral snapping hip syn-drome’. It is caused by slipping of the iliotibial band over the posterior part of the greater trochanter and is frequent in runners, dancers and basketball players.38,39

In addition to the audible snapping phenomenon, the syn-drome is characterized by pain in the region of the greater trochanter which radiates to the buttocks or thighs. The painful snapping can be observed by placing the palm of the hand on the trochanteric area during walking. Signs on examination of the hip may be identical to those of an inflamed bursa underly-ing the iliotibial tract (see p. 647).

The non-operative treatment of choice is infiltration with triamcinolone. In refractory circumstances, surgical treatment is indicated. The procedure usually consists of excising an ellipsoid-shaped portion of the band overlying the greater trochanter.40

Sacroiliac jointMacNab41 also points to the sacroiliac joint as a possible source of pain. When the gluteus medius contracts to abduct the hip, it pulls the ilium away from the sacrum. In the absence of hip joint disease, pain experienced over the sacroiliac joint on resisted abduction of the leg is then highly suggestive of a lesion of the sacroiliac joint (see p. 600).

Pain and weakness

In adolescents, painful weakness of abduction is indicative of an avulsion fracture of the greater trochanter but iliac apo-physitis can be another possibility. It develops in young long-distance runners as the result of repeated contractions of the gluteus medius and tensor fasciae latae on an immature iliac apophysis (see online chapter Hip disorders in children).42

Painless weakness

Painless weakness usually has a neurological cause – weakness of the gluteus medius in a fifth lumbar root palsy. It is also a common finding in disorders of the hip joint and femoral neck, and leads to a raised greater trochanter – protrusion of the acetabulum, epiphysiolysis, congenital dysplasia and malunion after a fracture of the femoral neck. In these instances, resisted abduction is weak and the pelvic–trochanteric muscles are ineffective in stabilizing the pelvis on the leg during walking. In placing the centre of gravity over the hip joint, the patient forces a lurch towards the involved side. Such a movement is called an ‘abductor’ or a ‘gluteus medius’ lurch. In mild cases, only a Trendelenburg gait is found – characteristic dipping of the pelvis towards the leg that is off the ground.

on side flexion of the trunk towards the painless side, although the other lumbar movements are free. Passive and resisted movements of the hip are normal. Resisted abduction may also be painless, especially in the prone-lying position with the hip extended. When a sprain of the tensor is suspected, resisted abduction should be performed in the side-lying position, with the uppermost hip (test limb) flexed to 45°. Alternatively, an accessory test is performed: in a standing position, the patient crosses the painful leg behind the other and bends sideways towards the painless side, taking all the body weight on the affected limb. Pain – sometimes severe – indicates a lesion of the tensor fasciae latae. Palpation then reveals a painful spot between the iliac crest and the greater trochanter.

TreatmentTreatment of a local lesion of the tensor fasciae latae is by deep transverse friction.

TechniqueThe patient lies on the painless side. The upper leg rests on the couch in an extended and slightly adducted position to stretch the iliotibial tract. The lower leg is flexed to about 45° to stabilize the pelvis. The therapist stands level with the hip and dorsal to the patient. The thumbs are placed on top of each other at the affected area, with the fingers opposite the thumbs for counterpressure. Friction is imparted by moving the thumbs forwards over the iliotibial tract in a transverse direction (Fig. 48.6).

At the same time, the elbows are slightly extended together with a flexion movement at the shoulders. Friction is continued

Fig 48.6 • Deep friction to the tensor fasciae latae.

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Differential diagnosisTendinitis of the rectus femoris should be differentiated from lesions of the second and third lumbar roots, usually the result of a disc lesion. Pain is reported over the anterior aspect of the thigh. Knee flexion with the patient in a prone-lying position may provoke the pain. However, testing the muscle for strength is painless, although there may be some weakness. When there is any doubt, an epidural local anaesthetic can be given and confirms the diagnosis.

TreatmentDeep transverse friction of the tendon or infiltration with triamcinolone is effective.

Technique: deep frictionThe patient sits on the couch, with the hip joint in flexion, in order to make it possible for the therapist’s palpating fingers to reach the overlying tissues. The therapist sits at the patient’s side facing the thigh. The painful tendon is found about 8 cm below the anterior superior iliac spine and in line with it, bor-dered by the sartorius muscle medially and the tensor fasciae latae laterally. Two or three fingers are placed just medial to the tendon, using the thumb at the outer side of the thigh for counterpressure (Fig. 48.7).

Friction is imparted by repetitively pulling the fingers over the tendon in a transverse direction. During this movement, the wrist is extended and the shoulder adducted. In acute cases, treatment is started the day after onset. At this point, deep friction should not last more than 1 minute and is repeated daily, with a slow increase in duration. During the second week, treatment is undertaken on alternate days. In chronic cases, treatment takes about 20 minutes, twice a week. Recovery is achieved in 6–8 sessions. During this period, all activities that are likely to worsen the condition should be avoided.

Technique: infiltrationThe patient adopts a half-lying position on a high couch. The affected spot is identified at the tenoperiosteal junction in the triangle between the muscle bellies of sartorius and tensor fasciae latae. A 2 mL syringe is filled with triamcinolone and

Resisted medial rotation

Pain

Pain produced during this resisted movement is rare and usually attributable to an inflamed gluteal bursa. The muscles (the gluteus medius, the anterior fibres of minimus and the tensor fasciae latae) are involved only following a direct blow that causes bruising.

Resisted lateral rotation

Pain

When pain is produced, the quadratus femoris, gemelli and piriformis are initially suspected of being the site of the lesion43 but, except in a direct injury, they are seldom affected. Pain during resisted lateral rotation of the hip is most often the result of transmitted stress of the contracting muscles acting on an inflamed gluteal or trochanteric bursa (see ‘Gluteal bursitis’, p. 646).

Resisted extension of the knee

Pain

Tendinitis of the rectus femoris presents as pain felt in the groin. It has been found in 12% of all groin injuries.2 It is usually an overuse phenomenon that occurs as a result of prolonged, repetitive strengthening exercise or intensive goal-shooting training in soccer.44 Pain is provoked more on resisted exten-sion of the knee than on resisted flexion of the hip, particularly when the patient lies prone with the hip extended. This finding has already been mentioned and is the result of the constant-length phenomenon. Pain is also felt on full passive flexion of the hip and even more so in a combined movement of flexion and adduction, when the tender part is pinched between the upper femur and the anterior spine of the ilium.45 Additionally, full passive rotation of the hip, done with the hip and knee held in 90° of flexion, can sometimes cause enough localized stretch to be painful.

The lesion is located just below the inferior iliac spine (in the body of the tendon). Alternatively, the tender point lies at the proximal part of the muscle belly.46 Treatment is deep transverse friction or infiltration with triamcinolone.

The same stress that causes a muscle strain in an adult can cause an avulsion fracture in an adolescent. The fracture occurs at the apophysis, which becomes separated from the underly-ing bone. The fracture is never widely displaced because of the surrounding thick periosteum.47 Most patients can be treated non-operatively with 6–10 weeks of relative rest.

Lesions of the muscle bellies of the quadriceps are discussed in the chapter on the knee (Ch. 54). Fig 48.7 • Deep friction to the rectus femoris.

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Palpation reveals tenderness either in the tendon or at the tenoperiosteal insertion. The tendons are usually affected at the upper 5 cm of their extent. In tenoperiosteal lesions, the sprain lies at the tuberosity of the ischium.

Differential diagnosisFirst and second sacral root lesionsTendinitis should be differentiated from these lesions, which are usually the result of disc protrusion at the fifth lumbar level. Pain may be reported in the thigh and there is probably also pain at the end of lumbar flexion or straight leg raising, but testing the muscle for strength is painless. Local tenderness is also absent. In case of doubt, epidural local anaesthetic is given.

Ischial bursitisResisted movements are also painless in ischial bursitis or ‘weaver’s bottom’. Local tenderness is then the only clinical finding and points to involvement of the bursa (see p. 648).

TreatmentIn tendinous lesions, the patient is treated with deep transverse friction or infiltration with triamcinolone. Persistent lesions can be treated surgically.48

Technique: deep frictionThe patient adopts a side-lying position or a supine one with hip and knee flexed to 90° and a chair supporting the lower leg. This position is necessary to move the gluteus maximus upwards, bringing the tuberosity of the ischium directly within reach. It also keeps the tendon fairly stretched; otherwise it lies too lax and deep to be properly subject to friction. The therapist stands on the ipsilateral side, level with the patent’s hip. Friction is imparted by applying two or three fingers at the medial aspect of the affected area and moving across the tendon by alternating adduction–abduction at the shoulder and a slight flexion–extension movement at the wrist. The thumb supplies counterpressure and acts as a fulcrum at the outer aspect of the thigh (Fig. 48.8). Treatment is given for 20 minutes, two or three times a week. Recent-onset cases respond sufficiently in about 2 weeks. In chronic cases, 2 months may

fitted with a 4 cm needle. The needle is inserted just distal to the palpating finger on the periosteum and directed upwards until it hits bone. Using a series of small withdrawals and reinsertions at slightly different points, the whole area is infil-trated. Meanwhile, the palpating finger is kept on the spot, to ascertain where the tiny bulges of drug appear. Another injec-tion may be required if the resisted adduction test remains positive when the patient is seen 2 weeks afterwards.

Pain and weakness

This characterizes a partial muscle rupture.

Painless weakness

Painless weakness of the quadriceps is present in third lumbar nerve root compression (see p. 517). If weakness is bilateral, myopathy or myositis should be suspected.

Resisted flexion of the knee

Pain

Painful resisted flexion of the knee implicates the hamstrings (biceps femoris, semitendinosus and semimembranosus). Lesions of the muscle bellies of the hamstrings are discussed in the chapter on the knee (Ch. 54). Tendinous and tenoperio-steal lesions also occur, cause pain in the gluteal area and posterior aspect of the thigh, and are generally referred to as the ‘hamstrings syndrome’.48,49

Hamstrings syndromeThis lesion is common in hurdlers and ballet dancers and is also found in all athletes who engage in rapid acceleration and short intense sprinting, such as baseball, tennis and soccer players.50 The cause of a hamstring strain is not fully understood but most authors today agree that the basic causative reason for its development is the muscle strength imbalance between the hamstrings muscle group and the quadriceps femoris muscle.51 Clinical features of the hamstrings syndrome include pain in the lower gluteal area which radiates down the posterior thigh to the popliteal area. The pain typically increases during performances that stress the hamstring muscles (sprinting or hurdling). Another characteristic complaint is pain felt while sitting. Driving a car typically provokes the pain because of local pressure on the lesion and the increased tension of the hamstring muscles in that position.

Clinical examination shows painful resisted flexion of the knee and resisted extension of the hip. Straight leg raising is of full range but quite painful at the extreme of range. One common clinical test that may induce the pain is the ‘shoe wiping test’ of Pecina52: it consists of having the patient imitate movements typically used when wiping shoes on a doormat; the hamstrings are stretched and at the same time are contract-ing, which causes the typical pain. Fig 48.8 • Deep transverse friction to the hamstring tendons.

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be required for a response; therefore infiltration with steroid suspension is the preferred treatment.

Technique: infiltrationUnless the hip is slightly flexed, the origin of the hamstrings at the ischium remains covered by the gluteus maximus. In order to render the insertion palpable, the patient must adopt a prone position, the pelvis well supported on a high cushion. The origin of the hamstrings is then palpable just distal to the lower gluteal border.

The physician stands next to the patient’s hip and palpates for the tender spot. A 2 mL syringe is filled with triamcinolone and fitted with a 5 cm needle. The needle is inserted well distally and the tip is moved upwards until it strikes bone. Using a series of small withdrawals and reinsertions at slightly different points, the whole area is infiltrated. Another injection

Table 48.1 Summary of disorders of the contractile structures

Test Pain Painful weakness Painless weakness

Resisted flexion Psoas tendinitis

Rectus femoris tendinitis

Sartorius tendinitis

Obturator hernia

Avulsion fracture anterior superior iliac spine

Avulsion fracture lesser trochanter

Abdominal neoplasm

Metastasis upper femur

2nd (3rd) lumbar root

Psychoneurosis

Serious non-specific disorder

Resisted extension Inflamed gluteal bursa

Intermittent claudication

Hamstrings tendinitis

Sprained sacrotuberous ligament

1st sacral nerve root palsy

Resisted adduction Adductor longus lesion

Fracture/neoplasm pubic bone

Osteitis pubis

Sacroiliac joint lesion

Hip joint lesion

Resisted abduction Inflamed gluteal bursa

Lesion of the tensor fasciae latae

Sacroiliac joint lesion

Sprain of iliotibial tract

Avulsion fracture greater trochanter

Iliac apophysitis

5th lumbar nerve root palsy

Raised greater trochanter

Resisted medial rotation Inflamed gluteal bursa (tensor fasciae latae)

Resisted lateral rotation Quadratus femoris lesion

Inflamed bursa

Gluteus maximus or medius lesion

Resisted extension knee Tendinitis rectus femoris Partial rupture rectus femoris 3rd lumbar nerve root palsy

Myopathy

Myositis

Resisted flexion knee Hamstrings tendinitis Partial rupture hamstrings 1st/2nd sacral nerve root lesion

may be required if the resisted flexion test remains positive when the patient is seen 2 weeks afterwards.

Painless weakness

Painless weakness of knee flexion is typical of a full root syn-drome at S1 and/or S2.

Disorders of the contractile structures of the hip and buttock are summarized in Table 48.1.

Access the complete reference list online at www.orthopaedicmedicineonline.com

C H A P T E R 4 8Disorders of the contractile structures

659.e1

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