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Lower hip ROM found in soccer players with previous hip, groin injuries
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Although results from a cross-sectional study of professional soccer players indicated decreased hip range of motion correlated with more hip- and groin-related symptoms and previous injuries, decreased motion did not significantly correlate with the presence of cam deformities.
Researchers examined 60 adult professional soccer players from two Dutch premier professional leagues with hip and groin symptoms. Investigators obtained player characteristics, hip range of motion (ROM) measurements, radiographs and questionnaires. The club medical staff had all players complete the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire. Two physical therapists, who were blinded as to whether players had cam deformities, conducted either the bent knee fall out test or the rotational hip ROM test on the players.
The presence of cam deformity was identified with alpha angle measurements. A multivariable regression model was used to determine correlations between hip ROM and hip and groin symptoms.
Results showed current hip and groin pain did not correlate with hip ROM. Although investigators noted players with lower HAGOS showed less internal rotation and total rotation than players with higher scores, this finding was not statistically significant. There were no significant differences between players with pain and those without regarding the bent knee fall out test. Hips with previous hip- and groin-related time-loss injuries compared to those without demonstrated less internal rotation and total rotation.
According to researchers, hips with cam deformity vs. hips without had less internal rotation and total rotation with higher bent knee fall out test scores; however, these findings were not significant. ‒ by Monica Jaramillo
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Shital N. Parikh, MD, FACS
Tak and colleagues performed a cross-sectional study of 60 professional soccer players to study the relationship between hip and groin symptoms, hip range of motion (HROM) and radiographic cam deformity. Though it is known that hip and groin injuries are common in elite soccer players, it is difficult to quantify or estimate the prevalence, duration and severity of these symptoms.
The authors used three different methods to measure these symptoms and the results of the study differed for each measurement. Seventy-three percent of participants responded “yes” to a single question, “Do you have any hip or groin pain?” – a surprisingly high prevalence, but there was no difference in HROM between those who reported pain and those who did not. When measured using the self-reported Copenhagen Hip and Groin Outcome Score, 20% (12 of 60 players) who were most affected and had the least scores showed some decrease in HROM (internal and total rotation), but this decrease was not significant. Fifteen percent (nine of 60 players) reported a time-loss injury, which was defined as missing at least one practice or match in the previous season due to hip- and groin-related symptoms. These patients demonstrated a significant decrease in HROM (internal and total rotation).
These findings represent the importance and effect of how a variable (hip and groin symptoms for the current study) is measured in a study. While a simple dichotomous question inquiring about presence of hip and groin pain is likely to yield more positive response, the time-loss injury would be at the most severe end of injury spectrum. The use of a validated patient-reported outcome score most likely reflects the true measure of symptoms.
The authors then studied the interaction effects of cam deformity, the three varied methods to measure hip and groin symptoms, and HROM. The cam deformity was diagnosed on screening radiographs using an alpha angle value of greater than 60°. The hips with cam deformity (60 of 120 hips) did not show significant decrease in HROM, though this may be related to the study being underpowered. There were no interaction effects of cam deformity and two measurements of symptoms (outcome score or time-loss injury), but there was significant interaction effect of cam deformity on the third measure, i.e., presence of hip and groin pain. These findings emphasize the importance of correlation of cam deformity with patient symptoms and physical findings, since cam deformity has shown to present in 54.8% of asymptomatic athletes.
Demographic data, including age, body mass index and leg dominance, were recorded in this study, but were not analyzed as risk factors or contributing factors for either hip and groin symptoms or decreased HROM. Since the age of the players in the study ranged from 18 years to 38 years, it is possible that increased age may be an independent risk factor based on increased exposure and injuries. Similarly, BMI (range, 19 to 28) and leg dominance may be independent risk factors for increased symptoms and decreased HROM.
The authors concluded that lower outcome scores (more symptomatic) and previous time-loss injuries were associated with decreased HROM, independent of the presence of a cam deformity. The current study, based on its retrospective design, cannot establish a causal relationship between hip and groin symptoms and decreased HROM.
In the future, if prospective studies could help to define this relationship better, then the findings of this study could have implications in the management and prevention of hip and groin injuries in athletes. This would be similar to the lessons learned from the well-studied shoulder pathology in symptomatic baseball pitchers who exhibit internal impingement and glenohumeral internal rotation deficits. Physical therapy and stretching to increase shoulder internal rotation has shown to alleviate symptoms in these overhead athletes and a similar case could be made for soccer players with decreased hip motion.
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Prather H, et al. Knee Surg Sports Traumatol Arthrosc. 2015;doi:10.1007/s00167-013-2713-7.
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