Right Lateral Hip Injury - Squash

Abstract

HISTORY: 55 year old elite male squash player felt a sudden onset of hip pain mid match. As he lunged to his left to return a ball, his left leg was in the stance phase and his right leg was in the swing phase, crossing over his body towards his left side. While mid-swing of the right leg, he heard a pop in his right hip and could not bear weight on his right leg. The next day, he began to ambulate with a hiking stick for assistance. He reported to the outpatient sports medicine clinic 10 days after the injury presenting with lateral hip pain described as focal, dull and rated 1/10. PHYSICAL EXAMINATION: 5/5 strength in hip flexors, knee flexors and extensors. Tenderness to palpation of the anterior rim of the right iliac crest. No tenderness to palpation of the right PSIS, buttock, or greater trochanter. No pain with passive hip flexion, internal or external rotation. Pain with hip abduction in the side-lying position on the right, worse with the hip extended and with clamshells. Pain with single leg hop on the right. No sign of an antalgic gait. DIFFERENTIAL DIAGNOSIS: Hip osteoarthritis Iliopsoas tendonitis Trochanter bursitis Tear of gluteus medius muscle Lumbar paraspinal muscle sprain TESTS AND RESULTS: Right hip radiographs: No acute fracture, mal-alignment or osseous findings. Mild degenerative disease of the visualized lower lumbar space. Ultrasound focused on the right lateral hip at the iliac crest: Appeared to be a 2 cm x 2 cm partial tear of the right gluteus medius muscle off of the iliac crest. FINAL WORKING DIAGNOSIS: Right gluteus medius partial muscle tear at the attachment to the iliac crest TREATMENT AND OUTCOMES: A non-load bearing mechanism of injury is unusual in this case, which could mean the patient had underlying degenerative changes to the gluteus medius prior to the injury. Physical Therapy (weeks 1-2 after evaluation) - progressive strengthening of hip girdle muscles with no direct gluteus medius muscle activation. Repeat focused ultrasound at week 4 showed healing of the partial gluteus medius muscle tear. Physical Therapy (weeks 4-8) - progressive strengthening exercises focusing on dynamic movements of the lower musculoskeletal extremity with a low-intensity return to squash program. Return to squash matches starting at week 8 and painless hip abduction, extension and dynamic movements required for competitive squash.