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Orthopedists discuss management of athletic hip injuries, part 2

Issue: February 2017

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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 injuries 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 an athlete to prematurely retire from a sport 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 get the athlete back on the field.

This is part 2 of the Orthopedics Today Round Table discussion on 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. Click here to read part 1.

T. Sean Lynch, MD
Moderator

T. Sean Lynch, MD: Do injections play a role in your treatment algorithm? What are your specific injection protocols and who performs these?

Christopher M. Larson, MD: Generally, we use injections for diagnostic purposes. Occasionally it can be challenging to sort out the proportion of intra-articular pain vs. extra-articular pain. We will often use intra-articular injections followed by examination or an exercise challenge in order to confirm the presence or absence of one or both disorders. If there is excellent relief of anterior hip-related pain but persistent lower abdominal/proximal adductor-related pain, a concurrent or staged procedure is typically recommended for elite athletes. Less commonly corticosteroid, platelet-rich plasma (PRP) or stem cell injections might be considered for elite athletes, although evidence is lacking regarding efficacy. Depending on the pain generators, hip joint, pubic symphyseal, psoas bursal, adductor cleft and trigger point, injections can be considered in season.

Shane J. Nho, MD, MS: Yes, I have a low threshold for performing intra-articular injections. If there are comorbitities (lumbar spine, sacroiliac joint dysfunction, pelvic floor dysfunction or greater trochanteric pain syndrome), then an intra-articular injection may help to determine how much pain is originating from the hip joint. If there are atypical presentations of hip pain (lateral buttock or medial), then an intra-articular injection will help to determine if the pain is coming from the hip vs. neuromuscular dysfunction. Injections may help patients understand how much pain is coming from the hip or what percent of pain is improved when the hip is anesthetized.

Lynch: How do seasonal and career factors affect your treatment?

Larson: When surgery is indicated, we typically wait until immediately after the season to perform the surgery. Athletes will typically get back to sport-specific activity 6 weeks to 3 months after core muscle procedures and 5 months to 7 months after femoroacetabular impingement (FAI) corrective procedures. In-season surgery is generally only considered for athletes with disabilities, resulting in their inability to participate effectively in their sport. Occasionally, we will consider injections to allow continued participation until the end of the season for high-level athletes.

Marc Safran, MD: Recovery from hip arthroscopy to water sports — like water polo — may take 3 months to 4 months to return to competition, while land-based sports — like soccer, basketball and football — take 5 months to 8 months to return to competitive levels of athletics. Further, athletes with FAI generally have had the bony dysmorphology years before developing symptoms. Thus, if a player can make it through the season, then surgery is postponed until the end of the season. If the pain affects the ability of the athlete to play with normal mechanics, then an attempt of image-guided intra-articular corticosteroid or hyaluronic acid injection may allow the athlete to complete the season with pain relief. However, discussion with the athlete about the potential consequences of delaying surgery should be undertaken, as a few recent studies have shown that athletes with symptoms of more than 1 year were less likely to return to high-level sports than those whose symptoms were less than 1 year. For an athlete who is near the end of their career, particularly if pain is only with athletic participation and not affecting participation level and mechanics, then surgery may not necessarily be recommended.

Lynch: In your experience, how successful is nonoperative treatment? Are there specific types of patients who will not respond to this management?

Nho: Nonoperative treatment can be successful for some athletes with neuromuscular dysfunction due to FAI. Active-release therapy or manual techniques may be a useful adjunct to help treat hip flexor tendonitis, adductor tendonitis or gluteal weakness. Some of our physical therapists will use dry needling to help with muscular spasticity.

Safran: In a study we performed in Stanford University’s varsity athletes for 2 years, 40 athletes were diagnosed with FAI. Of the 40 athletes with FAI at more than 2-years follow-up, only 57% ultimately came to surgery. This was a surprise, as this is a bony problem that was treated conservatively with physical therapy and only four of the 17 who did not have surgery required a corticosteroid injection. Of the 43% who were successfully treated nonoperatively, one patient gave up sports due to hip and other injuries. Of those who had surgery, one patient gave up sports due to a cardiac issue.

No one factor was identified to predict success with nonoperative treatment. However, in those with more severe and/or constant pain, only short-term relief with corticosteroid injection and sports that required hard cutting and/or squatting seem to fail nonoperative management.

Lynch: Do you believe symptomatic labral injuries can be prevented in athletes?

Asheesh Bedi, MD: This is a great question and one we will look to research to answer. I do not think we know at this time. If the etiology of hip impingement is related to the joint reactive forces in the maturing skeleton and is influenced by the compliance of the periarticular soft tissues and musculature, it is possible that modification of activity, loads and stretching/physical therapy could have a preventative role.

Safran: Asymptomatic labral tears are common. Labral tears as a result of FAI may be preventable by avoiding deep flexion, particularly with weight training doing squats and deadlifts and maintaining good gluteal strength. The key is identification of FAI on pre-participation examination. Those who may be at higher risk have hip internal rotation of less than 20°, while hip flexion and hip external rotation are normal.

Maintaining good hip and core strength may help reduce the risk of symptomatic labral pathology in athletes with hip laxity or hip microinstability.

Lynch: Do you perform single-stage/bilateral hip arthroscopy in athletes with symptomatic bilateral FAI/labral injuries? If yes, please share your pearls for success. If no, what are the reasons why?

Bedi: Single-stage surgery for bilaterally symptomatic hips is possible in adept hands, as long as traction times can be kept to a minimum. The potential advantage is a single anesthetic and minimizing rehabilitation time if there is a pressing need for return to play. That being said, I have favored a staged approach of 4 weeks to 6 weeks between hips. This allows the patient to weight-bear right away after both surgeries and recover from the first surgery to have a “trusted” limb. This also offers insights from the first surgery to guide the patient on the desire to pursue the contralateral hip.

Larson: I have performed bilateral, single-stage hip arthroscopy, but do not recommend that to my athletic population. I prefer to perform the procedures 4 weeks to 6 weeks apart to allow for more focused aggressive rehabilitation and protected weight-bearing as larger femoral resections are often needed in the young male athletic population. I do not believe a return to athletics is significantly different with a 4 week or so delay between surgeries in my hands. If a microfracture is more likely on one side, then I will do that side second. This allows for the athlete to come off crutches more quickly after the first surgery in preparation for the contralateral side.

Lynch: Do you see a role for addressing both hips with arthroscopy when only one side is symptomatic in a high-level athlete?

Nho: No. If only one side is symptomatic, then I would recommend treatment for the symptomatic side only. I would counsel the athlete to be aware of the possibility of the opposite hip becoming symptomatic. If the opposite hip becomes symptomatic, then treatment is appropriate.

Safran: Around 80% to 85% of patients have similar anatomy of both hips. Thus, it is common to see athletes with bilateral hip FAI anatomy be symptomatic in one hip. Some patients develop hip pain later in the contralateral hip, while some present with bilateral hip pain. However, only 15% of my recreational athletes eventually require surgery in both hips. My elite (collegiate, professional and Olympic) athletes ultimately require hip arthroscopy of both hips about 25% of the time.

When performed staged or at the same time, rehabilitation of both hips would shorten an athlete’s total rehabilitation and time away from sports compared with having surgery on one hip after return to sport and developing pain of the contralateral hip. However, 75% of athletes do not develop contralateral hip pain and, thus, surgery may have been unnecessary. Further, rehabilitation of both hips, whether performed staged or at the same time, usually prolongs rehabilitation compared with unilateral hip arthroscopy. Taking into consideration that hip arthroscopy is not without risk and complications, it does not seem to be reasonable to prophylactically operate on a contralateral asymptomatic hip with FAI anatomy.

Lynch: What is on the horizon in the management and treatment of these conditions?

Bedi: Hip preservation is exciting because the unknown is far greater than the known. The role for individualized surgical corrections, surgical navigation, biomarkers, adjunct chondral preservation procedures and preventative interventions are a few areas that remain to be explored and may have a dramatic influence on our clinical practices.

Nho: Hip arthroscopy for the treatment of chondrolabral injury and correction of FAI is technically demanding and the surgical techniques are still evolving. Capsular management is an area that continues to be challenging and proper management will allow more reproducible outcomes. Computer modeling and robotic technology are other modalities that might be on the horizon.

Lynch: Describe your approach to athletic pubalgia surgery? When and how do you address the adductor muscle?

Ulrike Muschaweck, MD: To understand the surgical procedure of the athletic pubalgia, understanding its definition is most important. Athletic pubalgia is the description of all symptoms in the groin/pubic area caused by the so-called sportsman’s groin, sports hernia, inguinal-related groin pain or Gilmore’s groin. In the case of all these diagnoses, we have to expect the following symptoms: groin pain and sharp pulling and radiating to the inner upper thigh, testicle, pubic bone and back. At times, there is a feeling of electricity.

The radiation in all these areas and the feeling of electricity are typical for a nerve irritation, which is caused by a nerve compression. Nerve compression is caused by a bulge in the area of the posterior wall of the groin canal, which can develop due to a circumscribed weakness. Due to this weakness, the groin canal becomes wider, which leads to a retraction of the rectus muscle to the medial cranial part. Therefore, there is an increasing tension at the pubic bone, causing pubic pain.

The Minimal Repair Technique or Muschaweck Repair addresses all these points: reinforcement of the posterior wall of the groin canal; mesh-free stabilization of the posterior wall with an overlapping suture in the area of the posterior wall; release of the nerve (genital branch of the genitofemoral nerve); and re-fixation of the rectus muscle to the right position at the pubic bone, which is reduces the increased tension immediately.

The adductor tendons are not addressed because the nerve release (genital branch) removes the adductor pain. This nerve is responsible for the adductor pain and, additionally, the release removes the adductor pain.

Lynch : Do you stage or perform simultaneous hip arthroscopy?

Images: Lynch S

Muschaweck: No. I perform my clinics in close cooperation with experienced hip arthroscopy surgeons, Damian Griffin, MD, and Earnest Schilders, MD, in my centers in the United Kingdom. We always try to decide on the lead symptom, whether it is a groin or hip pathology, and start therapy there.

Lynch: How would you address this athlete’s hip (Figure 1)?

A) Athletic pubalgia procedure only.
B) AP procedure with simultaneous bilateral hip arthroscopy.
C) AP procedure with simultaneous left hip arthroscopy and staging of right hip arthroscopy.
D) AP procedure with stage left hip arthroscopy.
E) AP procedure and assess hip symptoms during therapy for need for any hip procedure.

Bedi: E.

Larson: E. There are a number of factors to consider here. I would definitely recommend an AP procedure. I am concerned about the large cam deformity, as this is associated with a significant risk for chondral delamination with time. If there were no symptoms with sports activity and only mild pain on exam, I would lean toward AP surgery only. If there were symptoms with participation, I would recommend FAI correction as well on the symptomatic left side only. This will likely lead to improved range of motion, which might protect the AP procedure from recurrent injury. If it is unclear with regard to the left hip symptoms, I would consider an intra-articular anesthetic injection followed by an exercise challenge to determine the level of symptoms and potential need for FAI surgery. I do not recommend surgery for truly asymptomatic FAI.

Safran: A or E if the therapy is after he has recovered from the surgery. This is not an uncommon scenario in football, as well as many other sports, including ice hockey, soccer and tennis. The MRI demonstrates a moderate cam lesion and labral tear, but only physiologic fluid. The key is determining the degree of intra-articular hip pain. In reality, the athletic pubalgia surgery has a recovery/return to sport of less than 6 weeks. There is a risk the patient will eventually become more symptomatic in the hip and possibly even the core muscle injury with repeated abutment as a result of the FAI, but hip arthroscopy will also prolong recovery on the order of several months, which may affect his/her draft status. Additionally, the patient may not have been able to give a full effort of core rehabilitation with his core muscle/athletic pubalgia injury.

Lynch: How would you address this athlete (Figure 2)?

A) Continue physical therapy.
B) Ultrasound-guided corticosteroid injection with continued physical therapy.
C) Ultrasound-guided PRP with continued physical therapy.
D) Open repair of abductor.
E) Arthroscopic repair of abductor.

Bedi: Based on the severity of the partial tear, I would favor C or D.

Larson: C. This is a challenging dilemma with a partial abductor tear in a highly active endurance athlete. If this was a larger full-thickness tear with associated weakness, I would recommend either an open or endoscopic abductor repair. In this case, if there is only partial tearing and primarily pain rather than profound weakness, I would still exhaust further non-surgical treatment. Therefore, I would consider either a stem cell or PRP injection prior to consideration for abductor repair.

Safran: A, B or E. Partial hip abductor injury is not uncommon and usually responds to physical therapy. Four weeks is not a full course of physical therapy. However, if he or she sees no improvement and is anxious about it, then I would be inclined to start with a single, image-guided corticosteroid injection and then more physical therapy. If this fails, I would consider PRP to facilitated a healing response and more physical therapy. As a last resort and after failed injections, I would consider an arthroscopic abductor repair.

• For more information:
• Asheesh Bedi, MD, is the team physician for the Detroit Lions and the service chief for sports medicine, associate professor of orthopedic surgery, head orthopedic team physician at the University of Michigan. He can be reached at 500 S. State St. Ann Arbor, MI 48109; email: abedi@med.umich.edu.
• Christopher M. Larson, MD, is the head team physician for the Minnesota Vikings. He can be reached at Twin Cities Orthopedics, 4010 W. 65th St., Edina, MN 55435; email: chrislarson@tcomn.com.
• T. Sean Lynch, MD, is the team physician for Fordham University, the hip injury consultant for Columbia University Athletics and an assistant professor of orthopedic surgery at Columbia University Medical Center. He can be reached at 622 W. 168 St., PH-11, New York, NY 10032; email: tsl2120@columbia.edu.
• Ulrike Muschaweck, MD, is the surgical chief at the Hernia Center. He can be reached at Arabella St. 17, 81925 Munich, Germany; email: um@hernien.de.
• Shane J. Nho, MD, MS, is the director of the Hip Preservation Center and assistant professor of orthopedic surgery at Rush University. He can be reached at Midwest Orthopaedics at Rush, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: shane.nho@rushortho.com.
• Marc Safran, MD, is a professor of orthopedic surgery, chief of sports medicine at Stanford University and team physician at Stanford University. He is the past president of the International Society of Hip Arthroscopy and vice president of the International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. He can be reached at Stanford University, 450 Broadway St., Pavilion A, Redwood City, CA 94063; email: msafran@stanford.edu.

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.