Round Tables

Orthopedists discuss management of athletic hip injuries, part 1

Although athletic hip injuries do not get the same attention from the mass media as sports injuries to the knee, shoulder or elbow, these conditions are an ever-increasing problem in this population. These are also some of the most difficult diagnostic and management dilemmas that a sports medicine provider faces with overlapping pathology from several locations. These injuries are concerning to all parties, as an athlete can be out for an extended period of time due to the need for extensive rehabilitation. Previously, these injuries might have caused athletes to prematurely retire from sports because of recalcitrant pain. However, with increasing physician recognition, improved imaging modalities and better treatment options, we are more equipped to manage these disorders and the athletes back on the field.

This two-part Orthopedics TodayRound Table brings together a panel to discuss the awareness of athletic hip injuries, realistic expectations for nonoperative and operative care, management concepts of the elite athlete with overlapping pathology and insight to the future of these issues with the increasing role of technology.

T. Sean Lynch, MD
Moderator

Roundtable Participants

  • T. Sean Lynch
  • Moderator

  • T. Sean Lynch, MD
  • New York City
  • Asheesh Bedi
  • Asheesh Bedi, MD
  • Ann Arbor, Mich.
  • Christopher M. Larson
  • Christopher M. Larson, MD
  • Edina, Minn.
  • Ulrike Muschaweck
  • Ulrike Muschaweck, MD
  • Munich
  • Shane Nho
  • Shane J. Nho, MD, MS
  • Chicago
  • Marc Safran
  • Marc Safran, MD
  • Palo Alto, Calif.

 

T. Sean Lynch, MD: Do you observe specific patterns of injury associated with particular sports?

Asheesh Bedi, MD: We see different hip morphologies and patterns of injury that are reflective of the sport. We have generally grouped these into the contact athlete, pivoting athlete, overhead athlete, endurance athlete and hypermobile athlete. It is important for the treating surgeon to recognize the variable morphologies and sport-specific demands and incorporate these considerations into the treatment plan and expectations of the athlete.

Christopher M. Larson, MD: We are recognizing there are “sport- and position-specific” hip disorders in athletes. Femoroacetabular impingement (FAI) has been reported in up to 90% of elite American football and ice hockey players regardless of symptoms. Cam-type morphology is most prevalent and appears to be related to athletic activity during skeletal development. Although dysplastic features are relatively common in ice hockey players and uncommon in football players, the reason for this finding is unclear. Butterfly ice hockey goalies have a higher reported prevalence of cam-type FAI and dysplasia. However, hyperflexibility athletes and, in particular, elite female ballet dancers have a reported prevalence of dysplasia of up to 90%. This might be natural selection allowing for an extremely high range of motion requirement for these athletes. With regard to soft tissue disorders, athletic pubalgia/core muscle injury is common for cutting and pivoting athletes (American football, soccer, ice hockey), and adductor injuries are common in soccer secondary to repetitive kicking. Snapping hips and ischiofemoral impingement on MRI are reported to be highly prevalent in dancers and gymnasts regardless of symptoms.

Lynch: Why are athletic hip injuries increasing in prevalence?

Bedi: The increased “prevalence” of hip injuries is likely multifactorial. Some data reflect our improved understanding and diagnostic evaluation to recognize these injuries. The increasing participation in competitive sports at a younger age and throughout the year may be contributory.

Shane J. Nho, MD, MS: There does seem to be an increasing prevalence of hip and pelvis injuries. In part, this is related to the year-around, single-sport athlete in adolescent patients. Studies have shown the hip morphology will change in response to vigorous sporting activity (hockey, basketball, soccer and football). In addition, hip and pelvis injuries is better recognized by the medical community, so proper treatment can be administered to allow athletes to remain competitive. Lastly, orthopedic surgeons have improved the surgical technique to provide proper treatment with a high rate of return to sports.

Lynch: What physical exam maneuvers do you find most reliable for detecting symptomatic FAI with labral tears? What are pearls on how to perform these?

Larson: Specific maneuvers can help confirm intra-articular hip joint disorders and in some instances the location of the pathology. Flexion/Adduction/Internal Rotation (FADIR) that recreates typical anterior and groin pain is consistent with anteriorly based FAI and labrochondral injury (Figure 1). Higher degrees of flexion with FADIR testing might be required to elicit pain in high range of motion athletes or patients with hypermobility. Flexion, abduction and extension and abduction testing of the hip that elicits anterior or deep lateral pain might indicate more lateral-based FAI and/or labrochondral pathology. A SCOUR test with circumduction of the hip can be helpful if other testing is negative to more aggressively test the hip. Straight hip flexion pain and tenderness to palpation over the anterior inferior iliac spine (AIIS)avulsion can be consistent with subspine or AIIS impingement in the setting of a prominent AIIS (Figure 2).

Anterior impingement test

Shown is an anterior impingement test performed on a patient.

patient being tested for AIIS impingement

Shown is a patient being tested for AIIS impingement.

Images: Lynch S

Ultimately, it is critical to confirm that any pain elicited with provocative maneuvers recreates the athlete’s presenting complaints. If examination recreates pain, but is not the athlete’s typical pain, alternative sources of hip pain should be sought. Range of motion is also critical to evaluate and can help to differentiate impingement (limited range of motion) from dysplasia and or hypermobility (increased range of motion).

Marc Safran, MD: There is no one test to diagnose FAI. The so-called impingement test — where the hip is flexed to 90°, the hip then adducted and finally internally rotated — is a sensitive, but not specific, test. This test should recreate the patient’s pain. Greater degrees of flexion may be seen in laxity associated impingement. Pain also may be produced in extension and abduction. In addition to assessing range of motion, where internal rotation is limited to less than 20°, while the rest of the range of motion is normal, is another sign consistent with hip impingement. Another important test is the labral stress test, also known as the scour maneuver — this is similar to the McMurray’s of the hip, where the hip is started in flexion, abduction and external rotation and is moved to extension, adduction and internal rotation (Figure 3). Pain with extreme flexion is seen in AIIS subspinous impingement, while passive extension (over the end of the table) is also seen with AIIS subspinous impingement.

labral stress test
An orthopedist is performing the labral stress test, which is also known as the scour maneuver. During this test, the hip is started in flexion, abduction and external rotation (a) and is moved to extension, adduction and internal rotation (b).

Posterior impingement is evaluated with a posterior impingement test. In this scenario, posterior hip pain is recreated with the affected hip hyperextended and the hip externally rotated. The contralateral hip is held in flexion during this maneuver to stabilize the pelvis.

Lynch: What imaging features are most important to detect labral tears?

Bedi: A finding of a labral tear is exceedingly common on an MR arthrogram study. The critical step is to determine which of these are of clinical significance. This requires correlating with osseous pathomorphology of impingement or dysplasia that are mechanistically consistent with the location and nature of the labral injury, together with concordant history and physical exam findings.

Nho: Abnormalities in the hip labrum are common on MR imaging and can best be visualized on any sequence. Sagittal and axial views tend to show the anterior labral tears, while coronal views are more likely to show superior labral tears. Paralabral cysts may be seen adjacent to labral tears. The underlying hip morphology should be identified on plain radiographs as well as on MRI.

Lynch: What are your current thoughts on the relationship of core muscle injuries and FAI?

Larson: There is clearly an association between motion-limiting hip disorders and the development of core muscle injury in particular for elite athletes. When hip range of motion is limited and cutting and pivoting is required for athletes, there is increased compensatory requirements or stress on the adjacent joint (SI and pubic symphysis) and musculature (rectus abdominus, adductors, pectineus, obliques and transversus abdominus). This compensatory stress or increased requirements can lead to chronic injury to core musculature and or the pubic symphysis. My experience is athletes who present with both core muscle injury and FAI concurrently tend to have more severe motion limiting FAI and in particular large cam deformities.

It is important to recognize in some cases where imaging reveals both FAI and core muscle injury, one, both or neither of these disorders can become symptomatic. I typically only recommend treatment of the symptomatic pathology, regardless of the relationship between FAI and core muscle injury.

Ulrike Muschaweck, MD: I define core muscles as the totality of all muscles surrounding the hip, including the quadriceps and the rectus. An injury to any of these muscles can result in a FAI. Excessive flexion of the hip in sequence can result in a lesion of the labrum. The case history is important: Was there pain before? Does the patient describe a single traumatic trigger? If the hip is unstable, an injury to the core muscles can lead to decompensation because the abductors stabilize and center. The most conspicuous symptom is a deep hip and groin pain.

Therefore, differential diagnosis, including a precise history of the injury, is paramount. We can ensure correct diagnosis of a groin-related problem by static and dynamic ultrasound in the first row.

Lynch: What are the biggest risk factors for an athlete to develop athletic hip injuries?

Muschaweck: In my eyes, insufficient warm-up and shortened regeneration are the main causes for hip injury.This holds particularly true for all kinds of sports with high-speed, sudden, abrupt, extreme movements.If the muscle training is not well balanced or some groups of muscles are neglected, then the risk of injury is increased.

Safran: Muscle strength about the hip is an important risk factor for hip pain in athletes, as this has been shown in several NCAA studies in athletes. Particularly hip abductor, as well as external rotator weakness, have been associated with hip and low back pain. Also, periarticular muscular weakness and/or tightness may also predispose to hip pain and injury. In the skeletally immature, tight hip flexors and sudden, explosive activity may result in AIIS avulsion injury.

Loss of hip internal rotation has been associated with osteitis pubis and core muscle injuries. This loss of motion may be capsular contracture, but may alternatively be the result of FAI. FAI is clearly associated with labral and chondral damage in the hip joint, as well as core muscle injury and osteitis pubis.

Hip instability, either the result of microtraumatic instability or congenital laxity, may result in labral tears and/or ligamentum teres tears. These are frequently gymnasts, dancers and synchronized swimmers. Further, iliopsoas tendinitis and/or snapping hip is seen more frequently in athletes with hip instability.

Lynch: Describe your initial treatment program for these injuries. What is the most important aspect of the hip that you want to address first in these athletes?

Larson: When athletes present with both symptomatic FAI and core muscle injury, we prefer to address both entities either concurrently or in a staged manner. Our studies have shown that if you only address the core muscle injury or FAI alone, that the return-to-sport rate is between 25% and 50%. If both are managed concurrently or in a staged manner, the return-to-sport rate increases to around 90%. The FAI corrective procedure generally takes significantly longer to recover from than the pubalgia/core muscle surgery. If there is not a general surgeon available with an expertise in the management of core muscle injuries, then we have not found that it matters whether the FAI or core muscle surgery is done first. We generally recommend 3 weeks between the procedures, if done in a staged manner.

Muschaweck: Initially, I would recommend rest and a break in training. The next step is to diagnostically exclude any injury of the joint; in particular, the cartilage, which would result in an orthopedic surgical procedure. There should be an emphasis on concomitant functional treatment to maintain the range of movement and mobility. Physical therapy plays an important role on eliminating certain groups of muscles from treatment. To prevent further injury, coordination training seems sensible.

A note from the editors

Look for Part 2 of this Round Table discussion in the February issue of Orthopedics Today.

Disclosures: Bedi reports he is a board or committee member for the American Orthopaedic Society for Sports Medicine; is a paid consultant for Arthrex; is on the editorial or governing board for the Journal of Shoulder and Elbow Surgery; and receives publishing royalties, financial or material support from SLACK Incorporated and Springer. Larson reports he is a consultant for Smith & Nephew. Nho reports he receives research support from Allosource, Arthrex, Athletico, DJ Orthopaedics, Linvatec, Miomed, Smith & Nephew and Stryker; receives publishing royalties, financial or material support from Springer; receives IP royalties from Ossur; is a paid consultant for Stryker and Ossur; is on the editorial or governing board for the American Journal of Orthopedics; and is a board or committee member of the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America. Lynch reports he is a paid consultant for Smith & Nephew. Muschaweck reports she has no relevant financial disclosures. Safran reports he has non-paid board memberships with the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine and the International Society for Hip Arthroscopy; is a consultant for Medacta, ConMed, Smith & Nephew and Biomimedica; receives fellowship grants from Smith & Nephew and ConMed Linvatec; receives payment for lectures including service on speakers bureaus for Medacta, Smith & Nephew and ConMed; receives royalties from Lipincott Williams & Wilkins, Howmedica/Styker, Smith & Nephew and DJO Global; and receives payment for development of educational presentations from Smith & Nephew.

Although athletic hip injuries do not get the same attention from the mass media as sports injuries to the knee, shoulder or elbow, these conditions are an ever-increasing problem in this population. These are also some of the most difficult diagnostic and management dilemmas that a sports medicine provider faces with overlapping pathology from several locations. These injuries are concerning to all parties, as an athlete can be out for an extended period of time due to the need for extensive rehabilitation. Previously, these injuries might have caused athletes to prematurely retire from sports because of recalcitrant pain. However, with increasing physician recognition, improved imaging modalities and better treatment options, we are more equipped to manage these disorders and the athletes back on the field.

This two-part Orthopedics TodayRound Table brings together a panel to discuss the awareness of athletic hip injuries, realistic expectations for nonoperative and operative care, management concepts of the elite athlete with overlapping pathology and insight to the future of these issues with the increasing role of technology.

T. Sean Lynch, MD
Moderator

Roundtable Participants

  • T. Sean Lynch
  • Moderator

  • T. Sean Lynch, MD
  • New York City
  • Asheesh Bedi
  • Asheesh Bedi, MD
  • Ann Arbor, Mich.
  • Christopher M. Larson
  • Christopher M. Larson, MD
  • Edina, Minn.
  • Ulrike Muschaweck
  • Ulrike Muschaweck, MD
  • Munich
  • Shane Nho
  • Shane J. Nho, MD, MS
  • Chicago
  • Marc Safran
  • Marc Safran, MD
  • Palo Alto, Calif.

 

T. Sean Lynch, MD: Do you observe specific patterns of injury associated with particular sports?

Asheesh Bedi, MD: We see different hip morphologies and patterns of injury that are reflective of the sport. We have generally grouped these into the contact athlete, pivoting athlete, overhead athlete, endurance athlete and hypermobile athlete. It is important for the treating surgeon to recognize the variable morphologies and sport-specific demands and incorporate these considerations into the treatment plan and expectations of the athlete.

Christopher M. Larson, MD: We are recognizing there are “sport- and position-specific” hip disorders in athletes. Femoroacetabular impingement (FAI) has been reported in up to 90% of elite American football and ice hockey players regardless of symptoms. Cam-type morphology is most prevalent and appears to be related to athletic activity during skeletal development. Although dysplastic features are relatively common in ice hockey players and uncommon in football players, the reason for this finding is unclear. Butterfly ice hockey goalies have a higher reported prevalence of cam-type FAI and dysplasia. However, hyperflexibility athletes and, in particular, elite female ballet dancers have a reported prevalence of dysplasia of up to 90%. This might be natural selection allowing for an extremely high range of motion requirement for these athletes. With regard to soft tissue disorders, athletic pubalgia/core muscle injury is common for cutting and pivoting athletes (American football, soccer, ice hockey), and adductor injuries are common in soccer secondary to repetitive kicking. Snapping hips and ischiofemoral impingement on MRI are reported to be highly prevalent in dancers and gymnasts regardless of symptoms.

Lynch: Why are athletic hip injuries increasing in prevalence?

Bedi: The increased “prevalence” of hip injuries is likely multifactorial. Some data reflect our improved understanding and diagnostic evaluation to recognize these injuries. The increasing participation in competitive sports at a younger age and throughout the year may be contributory.

Shane J. Nho, MD, MS: There does seem to be an increasing prevalence of hip and pelvis injuries. In part, this is related to the year-around, single-sport athlete in adolescent patients. Studies have shown the hip morphology will change in response to vigorous sporting activity (hockey, basketball, soccer and football). In addition, hip and pelvis injuries is better recognized by the medical community, so proper treatment can be administered to allow athletes to remain competitive. Lastly, orthopedic surgeons have improved the surgical technique to provide proper treatment with a high rate of return to sports.

Lynch: What physical exam maneuvers do you find most reliable for detecting symptomatic FAI with labral tears? What are pearls on how to perform these?

PAGE BREAK

Larson: Specific maneuvers can help confirm intra-articular hip joint disorders and in some instances the location of the pathology. Flexion/Adduction/Internal Rotation (FADIR) that recreates typical anterior and groin pain is consistent with anteriorly based FAI and labrochondral injury (Figure 1). Higher degrees of flexion with FADIR testing might be required to elicit pain in high range of motion athletes or patients with hypermobility. Flexion, abduction and extension and abduction testing of the hip that elicits anterior or deep lateral pain might indicate more lateral-based FAI and/or labrochondral pathology. A SCOUR test with circumduction of the hip can be helpful if other testing is negative to more aggressively test the hip. Straight hip flexion pain and tenderness to palpation over the anterior inferior iliac spine (AIIS)avulsion can be consistent with subspine or AIIS impingement in the setting of a prominent AIIS (Figure 2).

Anterior impingement test

Shown is an anterior impingement test performed on a patient.

patient being tested for AIIS impingement

Shown is a patient being tested for AIIS impingement.

Images: Lynch S

Ultimately, it is critical to confirm that any pain elicited with provocative maneuvers recreates the athlete’s presenting complaints. If examination recreates pain, but is not the athlete’s typical pain, alternative sources of hip pain should be sought. Range of motion is also critical to evaluate and can help to differentiate impingement (limited range of motion) from dysplasia and or hypermobility (increased range of motion).

Marc Safran, MD: There is no one test to diagnose FAI. The so-called impingement test — where the hip is flexed to 90°, the hip then adducted and finally internally rotated — is a sensitive, but not specific, test. This test should recreate the patient’s pain. Greater degrees of flexion may be seen in laxity associated impingement. Pain also may be produced in extension and abduction. In addition to assessing range of motion, where internal rotation is limited to less than 20°, while the rest of the range of motion is normal, is another sign consistent with hip impingement. Another important test is the labral stress test, also known as the scour maneuver — this is similar to the McMurray’s of the hip, where the hip is started in flexion, abduction and external rotation and is moved to extension, adduction and internal rotation (Figure 3). Pain with extreme flexion is seen in AIIS subspinous impingement, while passive extension (over the end of the table) is also seen with AIIS subspinous impingement.

labral stress test
An orthopedist is performing the labral stress test, which is also known as the scour maneuver. During this test, the hip is started in flexion, abduction and external rotation (a) and is moved to extension, adduction and internal rotation (b).

Posterior impingement is evaluated with a posterior impingement test. In this scenario, posterior hip pain is recreated with the affected hip hyperextended and the hip externally rotated. The contralateral hip is held in flexion during this maneuver to stabilize the pelvis.

Lynch: What imaging features are most important to detect labral tears?

Bedi: A finding of a labral tear is exceedingly common on an MR arthrogram study. The critical step is to determine which of these are of clinical significance. This requires correlating with osseous pathomorphology of impingement or dysplasia that are mechanistically consistent with the location and nature of the labral injury, together with concordant history and physical exam findings.

Nho: Abnormalities in the hip labrum are common on MR imaging and can best be visualized on any sequence. Sagittal and axial views tend to show the anterior labral tears, while coronal views are more likely to show superior labral tears. Paralabral cysts may be seen adjacent to labral tears. The underlying hip morphology should be identified on plain radiographs as well as on MRI.

Lynch: What are your current thoughts on the relationship of core muscle injuries and FAI?

Larson: There is clearly an association between motion-limiting hip disorders and the development of core muscle injury in particular for elite athletes. When hip range of motion is limited and cutting and pivoting is required for athletes, there is increased compensatory requirements or stress on the adjacent joint (SI and pubic symphysis) and musculature (rectus abdominus, adductors, pectineus, obliques and transversus abdominus). This compensatory stress or increased requirements can lead to chronic injury to core musculature and or the pubic symphysis. My experience is athletes who present with both core muscle injury and FAI concurrently tend to have more severe motion limiting FAI and in particular large cam deformities.

It is important to recognize in some cases where imaging reveals both FAI and core muscle injury, one, both or neither of these disorders can become symptomatic. I typically only recommend treatment of the symptomatic pathology, regardless of the relationship between FAI and core muscle injury.

Ulrike Muschaweck, MD: I define core muscles as the totality of all muscles surrounding the hip, including the quadriceps and the rectus. An injury to any of these muscles can result in a FAI. Excessive flexion of the hip in sequence can result in a lesion of the labrum. The case history is important: Was there pain before? Does the patient describe a single traumatic trigger? If the hip is unstable, an injury to the core muscles can lead to decompensation because the abductors stabilize and center. The most conspicuous symptom is a deep hip and groin pain.

Therefore, differential diagnosis, including a precise history of the injury, is paramount. We can ensure correct diagnosis of a groin-related problem by static and dynamic ultrasound in the first row.

PAGE BREAK

Lynch: What are the biggest risk factors for an athlete to develop athletic hip injuries?

Muschaweck: In my eyes, insufficient warm-up and shortened regeneration are the main causes for hip injury.This holds particularly true for all kinds of sports with high-speed, sudden, abrupt, extreme movements.If the muscle training is not well balanced or some groups of muscles are neglected, then the risk of injury is increased.

Safran: Muscle strength about the hip is an important risk factor for hip pain in athletes, as this has been shown in several NCAA studies in athletes. Particularly hip abductor, as well as external rotator weakness, have been associated with hip and low back pain. Also, periarticular muscular weakness and/or tightness may also predispose to hip pain and injury. In the skeletally immature, tight hip flexors and sudden, explosive activity may result in AIIS avulsion injury.

Loss of hip internal rotation has been associated with osteitis pubis and core muscle injuries. This loss of motion may be capsular contracture, but may alternatively be the result of FAI. FAI is clearly associated with labral and chondral damage in the hip joint, as well as core muscle injury and osteitis pubis.

Hip instability, either the result of microtraumatic instability or congenital laxity, may result in labral tears and/or ligamentum teres tears. These are frequently gymnasts, dancers and synchronized swimmers. Further, iliopsoas tendinitis and/or snapping hip is seen more frequently in athletes with hip instability.

Lynch: Describe your initial treatment program for these injuries. What is the most important aspect of the hip that you want to address first in these athletes?

Larson: When athletes present with both symptomatic FAI and core muscle injury, we prefer to address both entities either concurrently or in a staged manner. Our studies have shown that if you only address the core muscle injury or FAI alone, that the return-to-sport rate is between 25% and 50%. If both are managed concurrently or in a staged manner, the return-to-sport rate increases to around 90%. The FAI corrective procedure generally takes significantly longer to recover from than the pubalgia/core muscle surgery. If there is not a general surgeon available with an expertise in the management of core muscle injuries, then we have not found that it matters whether the FAI or core muscle surgery is done first. We generally recommend 3 weeks between the procedures, if done in a staged manner.

Muschaweck: Initially, I would recommend rest and a break in training. The next step is to diagnostically exclude any injury of the joint; in particular, the cartilage, which would result in an orthopedic surgical procedure. There should be an emphasis on concomitant functional treatment to maintain the range of movement and mobility. Physical therapy plays an important role on eliminating certain groups of muscles from treatment. To prevent further injury, coordination training seems sensible.

A note from the editors

Look for Part 2 of this Round Table discussion in the February issue of Orthopedics Today.

Disclosures: Bedi reports he is a board or committee member for the American Orthopaedic Society for Sports Medicine; is a paid consultant for Arthrex; is on the editorial or governing board for the Journal of Shoulder and Elbow Surgery; and receives publishing royalties, financial or material support from SLACK Incorporated and Springer. Larson reports he is a consultant for Smith & Nephew. Nho reports he receives research support from Allosource, Arthrex, Athletico, DJ Orthopaedics, Linvatec, Miomed, Smith & Nephew and Stryker; receives publishing royalties, financial or material support from Springer; receives IP royalties from Ossur; is a paid consultant for Stryker and Ossur; is on the editorial or governing board for the American Journal of Orthopedics; and is a board or committee member of the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America. Lynch reports he is a paid consultant for Smith & Nephew. Muschaweck reports she has no relevant financial disclosures. Safran reports he has non-paid board memberships with the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine and the International Society for Hip Arthroscopy; is a consultant for Medacta, ConMed, Smith & Nephew and Biomimedica; receives fellowship grants from Smith & Nephew and ConMed Linvatec; receives payment for lectures including service on speakers bureaus for Medacta, Smith & Nephew and ConMed; receives royalties from Lipincott Williams & Wilkins, Howmedica/Styker, Smith & Nephew and DJO Global; and receives payment for development of educational presentations from Smith & Nephew.