Musculo-skeletal   [back to the Category]

Abarticular pathology of the hip   [read the french version]

Author :   Docteur Anne Thiescé

Tendinitis and tendinobursitis

Tendinitis or tendinobursitis affects the tendons and the serous bursae of the muscles: glutaeus medius, hamstrings, rectus femoris, sartorius and psoas. Tendinitis of the hip appears as often in adult dancers as in children training to be professional dancers.

Tendinitis of the rectus femoris and sartorius:
These are the most frequent forms of tendinitis found in ballet dancers and they represent 50% of tendinitis of the hip in dancers.
Pains are in the upper anterior region of the hip.
Pressure on the anterior iliac spine is painful.
Passive stretching by extension of the thigh from the pelvis is painful.
The thwarted isometric contraction is painful:
- In the case of the rectus femoris: thwarted flexion of the thigh from the pelvis, knee extended (battement à la quatrième),Fig 1.
- In the case of the sartorius: flexion - abduction - external rotation of the thigh from the pelvis, knee flexed (attitude devant). Fig 2.

Tendinobursitis of the psoas
Tendinopathy of the psoas can result from bad landings when jumping or from practising movements such as the arrondis.
Bursitis of the psoas is linked to the inflammation of a serous bursa situated under this muscle on the anterior side of the coxofemoral articulation. In 15% of all cases, this bursa communicates with the articular cavity (Beetham 1965) via a capsular orifice situated in the interval lying between the pubofemoral ligament and the iliofemoral fascicle. The appearance of this bursitis is the result of a sudden contraction of the psoas, or, of practising flexion movements of the thigh from the pelvis.
The pain can be anterior at groin level, or, it can be internal, corresponding with the lower insertion of the iliopsoas on the lesser trochanter. It is sometimes accompanied by a tumefaction that can produce an inflammation in a ganglion, or, a hernial disorder.
Positions such as the "grands pliés" and "développés" à la quatrième and à la seconde cause pain.
Painful passive stretching is carried out by the extension of the hip and by the posterior step.
The painful thwarted isometric contraction is tested in thwarted flexion of the thigh from the pelvis, knee flexed and knee extended (battements à la quatrième and attitude devant).
X-rays, in the case of a disorder of the psoas tendon at its lower insertion, can show a slight demineralisation of the superior pole of the lesser trochanter and/or sometimes a slight calcification of the tendon.

Trochanteric tendinobursitis:
The piriformi and the three gluteal muscles have powerful tendinous structures that have their insertion on the trochanter. The tensor fasciae latae slides over the trochanter. Serous bursae allow these sliding movements. Bursae are located between the glutaeus medius and the bone and between the glutaeus minimus and the glutaeus medius. These bursae can sometimes be the seat of an inflammation and, hence, the bursitis. The frequency of its inflammation is explained by the fact that the main function of the glutaeus medius is that of a pelvis stabilising muscle during walking.

The main problem in ballet stems from the practising of popular Russian dances that are used in romantic ballets. Other reasons are more generalised: a slight acetabulum dysplasia, or even, a coxarthrosis, or, then again, a direct trauma or micro-traumas.

Clinical history:
The beginning can be progressive, with pain on the external side of the thigh opposite the greater trochanter, with sometimes several referred pains lower down. The pain appears in a sudden, explosive manner, making walking almost impossible. Sometimes, there is a local tumefaction. The pain can appear when the patient is going up stairs, in a sitting position with crossed legs, when he puts his limb in an abduction position, or, when he is lying on the affected side. This can provoke nocturnal pains which can be mistaken for inflammatory pain.
Clinical examination reveals:
- Unlimited mobility of the hip which is painless except in maximum external rotation and in maximum flexion - adduction by passive stretching of the peritrochanterian muscles, especially the glutaeus medius.
- Examination of the lumbar region of the spine shows no abnormalities, thus, eliminating truncated sciatica.
- Positive signs:
- Excruciating pain caused by the palpation of the upper part of the external side of the greater trochanter. The examination should be carried out whilst the patient is lying on the unaffected side,
- Pain caused by the resisted contraction of the glutaeus medius: the examination, as always, carried out whilst the patient is lying on the unaffected side, the resistance is printed underneath the painful area, the lower limb having to push in the direction of an abduction - slight extension - external rotation of the lower limb - knee extended, Fig 3.
- Pain caused by passive stretching, in adduction - flexion of the thigh from the pelvis and at the end of an external rotation movement.

Radiography eliminates a coxofemoral affection and, more importantly, a bone disorder of the greater trochanter especially one that is infectious such as tuberculosis. It can show whether former attacks have caused calcifications above or parallel to the trochanterian muscles or an irregular condensation that gives the greater trochanter a spiky appearance.
Evolution is chronic, subacute or will result in relapses after several months or years.
Treatment:
The pain abates in 24 to 48 hours, as a rule, with anti-inflammatory treatment and, above all, the corticosteroids loco-dolenti injection. Re-education helps. It should be based on physiotherapy and, in particular, ultrasound, as well as isometric strengthening and progressive stretching of the hip's abductor muscles. This stretching is especially important in ballet where the hip's abductor muscles are very tonic and, are little subjected to stretching constraints.

Other types of tendinitis or tendinobursitis of the hip are more unusual:

Ischial bursitis is usually associated with a disorder of the tendons of the hamstrings or with an apophyseal avulsion.

Pain is felt in the lower buttock, and can spread to the posterior side of the thigh, resulting in a pseudo sciatica with pain via passive stretching of the hamstrings. This pain can be aggravated by a prolonged period of time in a sitting position.
Palpation of the ischial tuberosity is painful.
Passive stretching, via hip flexion and extension of the knee, is painful: positive Lasègue's sign.
The thwarted isometric contraction, via thwarted flexion of the leg from the thigh is also painful. Fig 4.

Bibliography:

Aubert B: Le médecin et la danse classique professionnelle? Thèse de médecine Necker 11/05/1983.

Badnin, Myronova. Traumatismes et Maladies de l’appareil locomoteur chez les danseurs (Russe); chapitre VII. Moscow Medecine 1976 sous la direction du Pr Volkov.

Rovere GD, Lawrence X., Webb MD., Anthony G., Gristina MD., Judith M., Vogel. Musculo-skeletal injuries in theatrical dance students. Am J of sports medicine Vol. 11 no.4 195-198 July-August 1983.

Sammarco GJ.. The dancer’s hip - Injuries to dancers. Clinics in sports medicine 2 (3) 557-61 Nov. 1983

Thiescé A. - Hanche et Danse professionnelle. Thèse Med., Cochin, 1987

Thomassen E., Diseases and injuries of ballet dancers Universitet folaget I Århus 1982 Denmak

Ziegler G. et Euller-Ziegler L., Rhumatismes ab articulaires (épaule non comprise). Enc Med Chir. (Paris-France). Appareil locomoteur, 14360 A10, 4,1989 10p