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The authors are from Houston Methodist Orthopedics and Sports Medicine, Houston, Texas.
Dr Harris, Mr Gerrie, and Dr Lintner have no relevant financial relationships to disclose. Dr Varner is a paid consultant for and receives royalties from Solana and holds stock in Wright Medical. Dr McCulloch receives research support from Arthrex, DePuy, and Zimmer and is on the speaker's bureau of Genyme.
The patient had symptoms for more than 18 months. Initially, dancing was the only instigating activity, especially with the splits position, during "turnout," with deep hip flexion and rotation, and with extension and external rotation. Physical examination showed 9 of 9 Beighton criteria and symmetric range of motion in both hips, with 150° flexion, 155° hip abduction, and 20° internal and 70° external rotation (at 90° flexion). On hip abduction to a firm endpoint, the extremity was internally rotated and exacerbation of pain was noted (trochanteric-pelvic impingement test). Importantly, these signs on physical examination were the same symptoms that the patient experienced while dancing. Over 6 months, the pain progressed and the patient became weaker and was unable to perform a single-leg stance without a pelvic dip (Trendelenburg) or a single-leg squat. Radiographs showed Tonnis grade 0, normal lateral and anterior-center edge and Tonnis angles, and normal alpha angles (Dunn 45° and 90°). However, the tip of the greater trochanter was above the center of the femoral head, and there was coxa profunda, a type 2 anterior inferior iliac spine, and evidence of head-neck junction cortical sclerosis and distal anterolateral neck impingement cyst formation. Splits radiograph showed a vacuum sign and trochanteric-pelvic extra-articular impingement. Magnetic resonance imaging showed no labral injury. The findings of evaluation strongly suggested intra-articular pathology. A preliminary diagnosis of hip microinstability was made, with soft tissue (elevated Beighton) and osseous (trochanteric-pelvic impingement, subspine impingement, acetabular rim impingement [pincer]) contributions. Ultrasound-guided diagnostic and therapeutic bilateral intra-articular injections of local anesthetic and corticosteroid were performed, with complete resolution of pain 5 minutes after injection. The patient began a core, hips, and pelvis strengthening protocol to focus on dynamic stabilization of microinstability. Within 6 weeks, the patient had returned to dancing 5 days per week without symptoms. One year after injection, the patient was continuing a strengthening program in addition to dancing,...