Hip Pain In Athletes Research Articles

Hip Pain in the Athlete Part 2: How to Work Up, Diagnosis, and Manage Femoroacetabular Impingement

AbstractFemoroacetabular impingement (FAI) is frequently recognized as a cause of hip pain in athletes. Sports predisposing to the development of FAI often include repetitive hip flexion combined with rotational movements or extreme joint range of motion. Hip symptoms often arise due to multiple structural abnormalities in and around the joint. Conservative management with physical therapy is recommended at the initial manifestation of FAI in athletes, which is followed by hip arthroscopy if no improvement is observed. Physicians must consider the socioeconomic impact of the hip injury on active individuals, especially in athletes who compete at a professional level.

Hip Pain in Athletes: Part 1—How to Work Up, Diagnose, and Manage Core Muscle Injuries (Athletic Pubalgia)

AbstractLower abdominal and groin injuries are among the most common causes of pain in athletes. Those that involve the skeletal muscles of the core, defined as the entire body from the chest to the midthigh, are called core muscle injuries. In this review, the authors will describe the anatomy and pathophysiology of core muscle injuries in detail, as well as the appropriate work-up and management. Special consideration is given to the important interrelationship between core muscle injuries and intrinsic hip pathology, such as femoroacetabular impingement, and to the drawbacks of treating these injuries with platelet-rich plasma.

The Use of Musculoskeletal Ultrasound for the Diagnosis of Groin and Hip Pain in Athletes

Athletes are particularly predisposed to injuries in the groin and pelvic region. Men in particular are predisposed to injuries like hernias in the inguinal region. The increased demands and training load on today's athletes combined with individual factors may create the environment for these injuries. Five areas categorize the pain present from different pathological entities in this region: adductor-related, iliopsoas-related, inguinal-related, pubic-related, and hip-related groin pain. It has been extremely difficult in the past to accurately diagnose what has been previously labeled sports hernia, sportsman's groin, or inguinal disruption. Therefore, this article describes the methods and procedures used for diagnostic ultrasound (US) and differentiation between these entities from one practice based on the most current research in musculoskeletal US.

Prevalence of Cam-Type Morphology in Elite Ice Hockey Players

Background: Femoroacetabular impingement (FAI) has been increasingly recognized as a cause of hip pain in athletes at all levels of competition, specifically ice hockey players. Purpose/Hypothesis: The purpose of this study was to define the prevalence of cam and pincer radiographic deformity in elite ice hockey players. The hypothesis was that elite hockey players will have a higher prevalence of radiographic hip abnormalities compared with the general population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Anteroposterior and frog-leg lateral radiographs on 137 elite ice hockey players were prospectively obtained during the 2014-2015 preseason entrance examinations. Study participants included National Hockey League roster players as well as the respective farm team members. Demographic data were collected, including age, position, shooting side, and any history of hip pain or hip surgery. Patients with a history of hip surgery were excluded from the analysis. A single sports medicine fellowship–trained orthopaedic surgeon used standard radiographic measurements to assess for the radiographic presence of cam or pincer deformity. Radiographs with an alpha angle ≥55° on a frog-leg lateral view were defined as cam-positive. Each participant underwent a preseason physical examination with an assessment of hip range of motion and impingement testing. Results: A total of 130 elite ice hockey players were included in the analysis; 180 (69.4%) hips met radiographic criteria for cam-type deformity. The prevalence in right and left hips was 89 (69.5%) and 91 (70.0%), respectively; 70 (60.8%) players demonstrated bilateral involvement. Hips with cam deformity had a mean alpha angle of 67.7° ± 8.3° on the right and 68.9° ± 9.0° on the left. Of the patients with alpha angles ≥55°, 5.6% (5/89) had a positive anterior impingement test of the right hip, while 11% (10/91) had positive anterior impingement test of the left. Players with radiologic cam deformity had a statistically significant deficit in external rotation of the right hip, as well as in both internal and external rotation of the left hip, compared with those with normal alpha angles. When assessing for crossover sign, 64 of 107 (59.8%) had a positive radiographic finding. Forty-one players (38.3%) had evidence of a crossover sign of the right hip and 42 (39.3%) of the left. When comparing position players, goalies had the highest prevalence of cam-type deformity (93.8%) and the least acetabular coverage. Conclusion: The study data suggest that elite ice hockey players have a significantly higher prevalence of radiographic cam deformity in comparison to what has been reported for the general population.

Utility of Intra-articular Hip Injections for Femoroacetabular Impingement: A Systematic Review.

Background:Femoroacetabular impingement (FAI) is a condition that is becoming increasingly recognized as a common etiology of hip pain in athletes, adolescents, and adults. However, history and clinical examination are often inconclusive in reaching a diagnosis, while imaging often detects asymptomatic abnormalities. Treatment has traditionally been limited to surgery, with the role of conservative management remaining unclear.Purpose:To evaluate the utility of the intra-articular hip injection in the diagnosis and management of FAI.Study Design:Systematic review; Level of evidence, 4.Methods:MEDLINE, EMBASE, and PubMed databases were screened in duplicate for studies published between January 1946 and January 2014. Search terms included femoroacetabular impingement, hip impingement, and intra-articular injection. Quality assessment using the Methodological Index for Non-Randomized Studies (MINORS) scale was completed for all included studies. Data evaluated included study design, study objectives, number of hips, injected product, duration of pain relief, and outcomes measured.Results:Our search yielded 8 studies involving 281 hips. Studies were categorized into diagnostic (4 studies), therapeutic (3 studies), and prognostic (1 study) applications. Patients with FAI and its degenerative sequelae obtained greater relief from diagnostic intra-articular hip injection than those without (P < .05). The diagnostic intra-articular injection performed under ultrasound guidance was better tolerated than injections performed under fluoroscopic guidance (pain rating, 5.6 vs 3.0; P < .1). Intra-articular injection of hyaluronic acid was the most effective at providing pain relief (in 23 patients), with significant improvements of functional outcome measures (Harris Hip Score, visual analog scale) present at 12 months. Pooled results with corticosteroid injection resulted in improvement in only 15% (9/60) of patients at 6 weeks. A negative response to intra-articular hip injection was a strong predictor for poor surgical outcomes.Conclusion:The results of this review suggest that (1) pain relief obtained from an intra-articular hip injection supports a diagnosis of FAI, (2) therapeutic relief at 12 months may be achieved, particularly with hyaluronic acid, and (3) a negative response to preoperative injections may predict poor short-term surgical outcomes. Additional large studies are required to build on the small number of studies included in this review, and further delineate the role of intra-articular hip injection in the management of FAI.

Hip Pain in Athletes - When It is Not the Labrum.

Hip pain is a relatively common complaint in sports. It is tempting to blame the athlete's symptoms on labral pathology. However, there is a high incidence of asymptomatic labral disease. Therefore, even when a labral tear is present, it may not be the underlying cause of the patient's pain. Clinicians should familiarize themselves with the large differential diagnosis for hip and pelvis pain to include nonmusculoskeletal pathology. This article reviews nonlabral causes of hip pain in athletes. For ease of classification, the hip is divided into anterior, lateral, and posterior regions.

Incidence of Femoral Acetabular Impingement Syndrome at One Collegiate Athletics Program: A Two-Year, Single Institution Study

Hip pain in athletes has received significant interest in recent years. The purpose of this investigation was to evaluate the incidence of hip injury, specifically femoral acetabular impingement (FAI), within a collegiate athletic program, as well as evaluate the proportion that require surgical intervention. All varsity athletes of an NCAA collegiate division 1 athletics program with 35 sports supported by 18 athletic trainers have injury evaluations recorded on an electronic medical record. A retrospective review of this prospectively obtained data was performed for all hip injuries sustained between March 2009 and June 2012. Inclusion criteria included any hip injury sustained during an NCAA-sanctioned event (practice, or competition) subsequently managed by a staff athletic trainer, and/or a hip injury that was reported during the study time frame. Relative frequency distributions and sample proportions were calculated for these variables and used as dependent metrics for this investigation. The diagnosis of FAI was confirmed by team physician and imaging. During the study period there were a total of 4319 musculoskeletal (MSK) injuries among 2298 student- athletes. There were 428 (10%) hip injuries and 40 (9.3%) of these were diagnosed with FAI - 27 (68%) occurred in females (F), while 13 (32%) occurred in males (M) (F>M, p=0.05). Of cases observed within gender similar sports (n=27), 16 (59%) of FAI cases occurred in females while 11(41%) were seen in male counterparts (not significantly different). Male Basketball (9%), F Synchronized Swimming (8%), F Soccer (6%), F Lacrosse (5%), and M Diving (5%) displayed the highest rate of symptomatic FAI relative to individual roster size compared with other sports (p<0.05). Twenty-three (58%) of symptomatic cases for FAI were treated with arthroscopic surgery. Ten (43%) athletes waited longer than 150 days to undergo arthroscopy, of which 4 had adjunct treatment with corticosteroid injection and 4 patients required microfracture. One athlete (4%) medically retired after surgery. Seventeen (43%) FAI cases did not require surgery. Within this group, all patients received formal physical therapy (PT). None of these athletes had sports limitations. Three of these cases required at least 1 corticosteroid injection. One athlete opted to retire from sport for FAI and other injuries without surgery. In a large collegiate athletic program the prevalence of hip injuries was 10% of all MSK injuries, and 9% of those were diagnosed with FAI. There was a preponderance of females, and more than half the patient underwent surgery with 96% return to sports at the same or higher level. Half the subjects were treated non-operatively with PT, functional progression, and temporary activity modification and returned to sports at the same level. Two athletes retired from sports, 1 with and 1 without surgery. There was a trend toward more significant chondral damage for those that waited longer for surgery.

Conservative Treatment of Femoroacetabular Impingement

Introduction: Femoroacetabular impingement (FAI) has recently been proposed as a cause of abnormal stress contact in the hip joint and as a major cause of hip pain in athletes from different sports. The main objectives of preoperative physiotherapy (PT) are pain relief, muscle strength gain and improved function.

What are athletes' perceptions of rehabilitation outcome 1 year after hip arthroscopy?

Hip arthroscopy is a minimally invasive surgical procedure. Femoroacetabular impingement (FAI) is being increasingly recognized as a cause of hip pain in athletes and is a growing indication for arthroscopic surgery. Few studies have attempted to address patient views on outcome after arthroscopy, and no qualitative studies have been carried out to date. To explore athletes' perceptions of rehabilitation outcome, the rehabilitative process, and return to sport and to gain insight into factors that affected this process. A retrospective qualitative approach was adopted using semistructured interviews. Eight eligible participants were interviewed. Each had been treated with hip arthroscopy for FAI from September to November 2010. Data were audiotaped, transcribed verbatim, and analyzed using thematic analysis. Three main themes emerged. (1) The ability to participate in sport; athletes were relatively satisfied with outcome despite some limitations in sporting ability. (2) Perceptions of hip problems; there was a lack of understanding and an association of hip problems with older people among the general public. (3) Athletes' perception of rehabilitation; athletes were dissatisfied with the rehabilitation and sought greater physiotherapy input. Overall, athletes were relatively satisfied with their outcome 1 y after hip arthroscopy, despite some having to adapt their sporting activities. Key areas that need to be addressed in future research include factors affecting outcomes of hip arthroscopy, longer-term outcomes, perception of FAI among the public and health practitioners, and the development of a standardized evidence-based rehabilitation protocol.

Femoroacetabular impingement in athletes: A review of the current literature

There are several well-recognized causes of hip and groin pain that commonly affect athletes. Femoroacetabular impingement (FAI), also known as hip impingement, is increasingly recognized as a common; and possibly often overlooked; etiology of hip pain in athletes. FAI is characterized by the abutment of the acetabular rim and the proximal femur, which may occur by two mechanisms known as cam or pincer impingement, although most commonly by a combination of the two. It affects athletes at a young age causing significant pain and disruption to athletic performance and activities of daily living. It injures the labrum and articular cartilage and can lead to early osteoarthritis of the hip if left untreated. Patients often report a groin pain, which is typically reproduced by the use of flexion, adduction and internal rotation of the supine hip. Early diagnosis is crucial in order to avoid the severe secondary damage that can occur. Although, FAI is significant for all patients, in athletic individuals they may bring about the end of their sporting careers. Both open and arthroscopic surgical methods are used, with recent reports in athletes showing excellent results for life-style improvement and frequency of returning to the sport. Whether treatment prevents or delays osteoarthritis of the hip is unknown. This article reviews the latest scientific literature in reference to FAI in athletes. It goes some way to explaining the principles, approach and guidelines for management of FAI in athletes.

Arthroscopic Ligamentum Teres Reconstruction

The ligamentum teres (LT) has been studied since the 19th century, and its anatomy and biomechanical function have been well described. Recent advancements in hip arthroscopy have caused increased awareness of LT pathology. Previous reports have estimated the incidence of LT tears during hip arthroscopy to be 4% to 51%, and LT tears have been estimated to be the third most common reason for hip pain in athletes. Biomechanical studies have shown the LT's role in stability of the hip. Despite the growing body of literature on LT anatomy and function, its role as a causative factor in hip pain and hip instability has yet to be clearly defined, and the treatment of LT tears remains controversial. However, in certain cases where hip subluxation and overt instability are related to a traumatic full-thickness tear of the LT, reconstruction of the ligamentum has been suggested. We describe a technique for arthroscopic LT reconstruction using either a semitendinosus autograft or allograft in the supine position.

Femoroacetabular Impingement in Professional Ice Hockey Players

Background Femoroacetabular impingement of the hip joint has been identified as a major cause for hip pain in athletes. Surgical open decompression of the hip has historically been proposed as the first treatment of choice. Functional outcomes in athletes after this procedure are unknown. Purpose To describe the functional and sport-related outcome 2 years after open surgical hip decompression in a group of young professional ice hockey players suffering from cam femoroacetabular impingement. Study Design Case series; Level of evidence, 4. Methods Five young professional ice hockey players (mean age, 21.4 y at follow-up) who suffered from cam femoroacetabular impingement were treated with open surgical decompression of the hip. The operation was performed by the same surgeon, and all athletes followed the same rehabilitation guidelines. Mean follow-up time was 2.7 years. Outcome measures were recorded as time to regain symmetrical hip rotation, regain preoperative core/hip muscle strength, return to team practice, and play at competitive level. Results Hip rotation range of motion was regained by a mean 10.3 weeks. Core and hip strength values reached preoperative levels by a mean 7.8 months. Return to unrestricted team practice with the ice hockey team was achieved by a mean 6.7 months, and athletes were able to play their first competitive game after a mean 9.6 months. Three athletes were able to perform again at the highest level and in international competitions. Two athletes had to return to minor league ice hockey. Conclusion Return to high-level ice hockey after open surgical decompression of the hip was possible in this series of 5 consecutive cases.

Intra-articular disorders of the hip in athletes

The hip is an integral component in load transference during both upper and lower limb athletic performance. The incidence of hip pain in athletes is low, however, approximately 30% of hip pain remains without a clear pre-operative diagnosis. Intra-articular disorders of the hip in athletes can severely hinder athletic performance. Controversial topics such as acetabular labrum tear, femoroacetabular impingement syndrome, instability, and osteoarthrosis along with possible management strategies are outlined in this paper. The importance of specific differential diagnoses is also highlighted.