Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

femoral neck stress fracture

1st line – immediate internal fixation

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ACUTE
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femoral neck stress fracture
|
superior femoral neck stress fracture (tension-side fracture)
1st line – 

immediate internal fixation

Superior femoral neck fractures (tension-side) must be identified and treated promptly with internal fixation to prevent complications of fracture propagation and displacement including osteonecrosis, nonunion, malunion, and post-traumatic arthritis.

Displacement of a femoral neck stress fracture is fortunately rare with timely recognition. Among stress fractures that do displace, rates of osteonecrosis have been reported to be between 24% and 33%.[26][27]

1st line – cessation of high-impact activities and protected weight-bearing for 6 to 8 weeks

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ACUTE
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femoral neck stress fracture
|
inferior femoral neck stress fracture (compression-side fracture)
1st line – 

cessation of high-impact activities and protected weight-bearing for 6 to 8 weeks

Inferior femoral neck stress fractures are mechanically stable and can be treated nonoperatively with excellent healing rates in compliant patients.

The mainstay of successful treatment is immediate cessation of high-impact activities and protected weight-bearing (using a cane or crutches) for 6 to 8 weeks.

Follow-up imaging to ensure proper healing is advisable.

traumatic or overuse injury: initial presentation

1st line – conservative management

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ACUTE
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traumatic or overuse injury: initial presentation
1st line – 

conservative management

Appropriate initial management includes rest, activity modification, ice or heat, and protected weight-bearing (using a cane or crutches).

Physical therapy with a gradual return to activities should be commenced once symptoms have abated, usually within 4 to 6 weeks of initiating treatment.

Addressing the specific structure (often muscle/tendon) that is injured with specific exercise is very important, but the delicate balance that exists around the pelvis involving balance, coordination, and strength should also be restored before return to sports.

Consider – nonsteroidal anti-inflammatory drugs (NSAIDs)

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ACUTE
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traumatic or overuse injury: initial presentation
Consider – 

nonsteroidal anti-inflammatory drugs (NSAIDs)

Treatment recommended for SOME patients in selected patient group

NSAIDs can be used judiciously for pain relief.

Primary options

diclofenac potassium: 100-150 mg/day orally (immediate-release) given in divided doses every 8-12 hours when required

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

ONGOING

traumatic or overuse injury: not responding to initial management

1st line – advanced imaging studies ± orthopedic referral

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ONGOING
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traumatic or overuse injury: not responding to initial management
1st line – 

advanced imaging studies ± orthopedic referral

In patients who do not respond to initial conservative management, ultrasound or MRI imaging studies are helpful for arriving at a more definitive diagnosis.

In some cases, referral to an orthopedic surgeon may be warranted.

In all cases, patient compliance with initial conservative management should be checked.

Plus – functional physical therapy and strengthening

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ONGOING
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traumatic or overuse injury: not responding to initial management
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longstanding adductor-related groin pain
Plus – 

functional physical therapy and strengthening

Treatment recommended for ALL patients in selected patient group

For patients with longstanding adductor-related groin pain, a specific exercise therapy program aimed at improving strength and coordination of the muscles acting on the pelvis is significantly better than a conventional physical therapy program. In one prospective, randomized trial, 79% of patients involved in an active sports training program for 8 to 12 weeks returned to their previous level of activity with no residual pain, compared with 14% of patients in the conventional therapy group.[22]

Cessation of aggravating exercises/sports activity is a mainstay in treatment. Return to sports may take up to 6 months for chronic adductor strains.[4]

Consider – adductor longus tenotomy

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ONGOING
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traumatic or overuse injury: not responding to initial management
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longstanding adductor-related groin pain
Consider – 

adductor longus tenotomy

Treatment recommended for SOME patients in selected patient group

Adductor longus tenotomy may be performed in cases of chronic, debilitating groin pain due to adductor injury that has failed to respond after 6 months of nonoperative treatment, but should be used with great care.[23]

Good long-term results can be achieved, with 75% of patients returning to their previous sport within 3 to 4 months of surgery. About one third of patients may perform at a reduced level. A decrease in muscle strength is commonly observed but does not seem to influence sports participation.[28]

Plus – physical therapy

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ONGOING
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traumatic or overuse injury: not responding to initial management
|
osteitis pubis
Plus – 

physical therapy

Treatment recommended for ALL patients in selected patient group

Osteitis pubis is probably a reflection of other entities and should in most cases be treated along the lines of adductor-related groin pain.

Plus – functional physical therapy and strengthening

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ONGOING
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traumatic or overuse injury: not responding to initial management
|
inguinal-related groin pain
Plus – 

functional physical therapy and strengthening

Treatment recommended for ALL patients in selected patient group

Therapy aimed at improving strength and coordination of pelvic and, particularly, abdominal muscles should be started and continued for at least 8 to 10 weeks before surgery is considered.

Consider – surgical exploration and repair

Back
ONGOING
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traumatic or overuse injury: not responding to initial management
|
inguinal-related groin pain
Consider – 

surgical exploration and repair

Treatment recommended for SOME patients in selected patient group

Patients who do not respond to physical therapy may need to be considered for operative repair.

Plus – strengthening exercises + pelvic muscle coordination program

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ONGOING
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traumatic or overuse injury: not responding to initial management
|
iliopsoas-related groin pain
Plus – 

strengthening exercises + pelvic muscle coordination program

Treatment recommended for ALL patients in selected patient group

Exercises to strengthen the iliopsoas muscle should be tried, especially if the muscle is tight.

If doing the exercise therapy is too painful, ultrasound-guided corticosteroid injections can be helpful in order to lower the pain and enable the exercises to continue.

A pelvic muscle coordination program should accompany the exercise therapy.

Plus – arthroscopic surgery

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ONGOING
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traumatic or overuse injury: not responding to initial management
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labral tears
Plus – 

arthroscopic surgery

Treatment recommended for ALL patients in selected patient group

Arthroscopic surgery of the hip joint with debridement or labral refixation.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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