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A vast body of evidence exists advocating the many benefits of daily physical activity from an early age, from reducing cardiovascular disease and the risks associated with obesity, to enhancing metabolic fitness and promoting a healthy state of wellbeing. While there is a growing interest in enhancing the health and fitness of children and adolescents, the associated increased incidence of musculoskeletal injuries as a by-product is often overlooked; the distinction between competitive and recreational involvement in physical activities such as sports best highlights this.
The desire to achieve and be ‘the best’ is an innate quality and the potential rewards can often be a catalyst for the increased intensity of sporting involvement for the passionate athlete. With the increased profile of professional sports, involvement typically begins at an early age and young athletes are socialised to focus exclusively on their sporting success. With this sport-centred identity manifesting, it leads to an increase in competition, whether this is competing for a league title, scholarship for university or to emulate a sporting hero.
This high expectation for success can only be accomplished with an increase in the intensity of training, which can often result in misapplication of valid training sessions. The goal of many coaches and sports trainers to maximise the development of young athletes, with the aim of achieving athletic success at an adult age, is also a contributing factor. While it has been shown to take 10 years, or 10,000 hours of deliberate practice, to develop one’s talent and become an ‘expert’, it is hard to imagine this comes without a physiological cost to the athlete.
In the past number of years, the incidence of sports-related hip injury and subsequent surgery have risen, owing in part to the increased intensity with which our young athletes are training and competing and from an improved awareness of the symptoms and signs of progressive hip injury.
The young musculoskeletal system is a dynamic structure, highly influenced by and responsive to environmental and external cues. Repetitive and high-impact forces associated with running, cutting, rotational and kicking movements makes the hip joint and open growth plates vulnerable to overuse injury at the critical developmental stages.
A mechanical obstruction
Femoro-acetabular impingement (FAI) is the most commonly recognised hip pathology in athletes, leading to chronic hip and groin pain. FAI develops when regular abnormal contact between the acetabular rim and the femoral head or neck results in progressive damage to the soft tissues of the hip joint, including the acetabular labrum (seal) and the articular cartilage. When these structures are compromised, patients will predominantly experience pain and stiffness, usually in the groin but which can also be localised to the front, side or the back of the hip.
Two morphological abnormalities of the hip joint have been identified as causal factors of FAI: a ‘cam’ deformity results from the progressive loss of femoral head sphericity; and a ‘pincer’ deformity exists with global or focal over-coverage of the femoral head by the acetabulum. In the majority of cases, both cam and pincer abnormalities co-exist as a ‘mixed’ impingement.
Signs and symptoms
The development of symptoms associated with hip impingement (FAI) is insidious, often progressing for many years undiagnosed. This is representative among the excess of 1,460 athletes who have undergone surgery for hip impingement at The Hip and Groin Clinic, Whitfield Clinic, Waterford. Over three-quarters (78 per cent) of athletes described the onset of their symptoms as gradual and present in excess of six months to more than five years before an accurate diagnosis was confirmed. Athletes’ complaints of activity-related hip and groin stiffness, loss of speed and agility, persistent hamstring tightness and lower back discomfort are often put down to a heavy training session and are initially managed with regular physiotherapy, including stretching programmes, gluteal activation and core strengthening exercises.
When rudimentary movements such as starting/stopping, squatting, twisting, sprinting, or kicking a ball become limited and/or associated with pain, for some athletes this may begin to signal the presence of underlying hip impingement (FAI). For others, it is not until the severity of the symptoms force a withdrawal from sports altogether that the diagnosis is eventually considered.
While there is the obvious drawback of FAI impacting on performance, there is also the additional psychological impact that this reduced performance, limited involvement or subsequent withdrawal from their chosen sport has on the passionate athlete. High-performing GAA players, from senior club through to county level and athletes regularly competing at national level, appear particularly prone to symptoms of FAI; frustration and low mood is a common finding among such athletes referred for intervention.
The average age of athletes undergoing surgery for FAI at our clinic is 27.5 years; seven-in-10 are competitively involved in one or more sporting types, with an average commencement of sport at eight years of age. At time of presentation, 80 per cent of athletes have previously attended two or more healthcare practitioners (including physiotherapists, GPs, chiropractors and sports doctors) for assessment and/or treatment.
Unfortunately, for the majority of these athletes the presence of the underlying hip impingement has either been misdiagnosed or greatly underestimated. By the time these athletes attend our clinic, 95 per cent have significant labral tearing, with the overwhelming majority having irreversible cartilage damage to the joint surface as a direct consequence of continued engagement in their chosen sports in the presence of symptomatic FAI. (The relative risk of significant articular cartilage damage approximately doubles in the presence of a labral lesion.) Early detection of symptomatic FAI and subsequent referral for definitive surgical treatment for deformity correction and labral repair is important for a successful return to sports and to delay, or possibly prevent, early hip joint degeneration.
Clinical examination classically reveals a reduction in the range of hip movement, with flexion, adduction and internal rotation most significantly reduced. A positive impingement test, as assessed by the reproduction of pain as the hip joint is moved through flexion, adduction and internal rotation (FADIR), is a highly sensitive physical examination test for FAI and is positive in more than 70 per cent of cases presenting at the clinic. Pain may also be experienced in 52 per cent of cases utilising the FABER test, where the hip is moved through flexion, abduction and external rotation.
Plain radiography and MR arthrogram are utilised to establish the nature and extent of bony impingement and confirm the presence of labral and articular cartilage pathology. Pincer deformity (over-coverage of the femoral head) is almost universally present and is the primary cause for hip impingement in all athletes treated, with a CAM deformity present in 62 per cent of cases (Figure 1). Labral tearing and articular cartilage damage is almost invariably evident at time of surgery (Figure 2).
As an initial intervention, conservative measures can be applied to help address the associated pain. Activity modification to reduce weight-bearing forces and reduction or cessation in intensity or frequency of high-impact sporting activities, as well as core strengthening and use of non-steroidal anti-inflammatory drugs (NSAIDs), are the mainstays of non-surgical treatment. While this measure may serve as a temporary relief, the success of conservative care for FAI is largely dependent on the patient’s willingness to modify their sporting activity, ultimately becoming less active in impact sports. Where a morphological abnormality is present and is contributing to adverse symptoms, conservative measures do not alter the bony changes or rectify the pre-existing impingement. Structural bony deformities, as is the case with FAI, require a structural solution. Any significant delay in the surgical treatment of symptomatic FAI, either from misdiagnosis or as a result of lengthy conservative therapy, results in irreversible damage to the labrum and articular cartilage of the hip joint. This is associated with a poorer outcome from surgery, inability to return to competitive sports and the development of early osteoarthritis of the hip, eventually requiring hip replacement.
The success of surgery from an athlete’s perspective is the ability to return to competitive sports without stiffness or pain; significant improvements in range of hip movements and enhanced athletic performance can be expected with meticulous surgical technique, removing all bony deformities with a repair of the labrum and the hip capsule. Over the past 10 years, our surgery has continued to evolve, culminating in the development of the ‘Sports Hip Repair’ technique, utilised specifically for the treatment of athletes with symptoms of FAI. Post-operative results from this unique procedure demonstrate clinically and statistically significant improvement in associated pain, function, physical activity level and quality of life, permitting early resumption of competitive sports.
With a 93 per cent success rate, this minimally-invasive technique permits accurate restoration of the hip anatomy and anatomical repair of injured intra-articular soft tissues. A structured and proactive postoperative rehabilitation programme is a requisite to achieve optimal outcome and a rapid return to sports.
Figure 1: (a) Pre-operative x-ray of a 30-year-old professional athlete with significant pincer and cam deformities consistent with FAI; (b) post-operative x-ray following resection of bony abnoralities
Figure 2: (a) labral tear; (b) labral repair
Early and accurate recognition
Athletes with early stages of FAI are more likely to have a better outcome than those with more extensive articular cartilage delamination or exposed bone. Our results clearly indicate that athletes who present with symptoms of FAI for longer than two years (although still expecting significant improvement in pain and function) will have a statistically significant decrease in overall success compared to those treated with symptoms for less than two years; a worrying statistic which is supported by other international researchers. This reinforces the importance of early diagnosis and appropriate surgical correction to avoid poorer outcome and irreversible damage, leading to osteoarthritis and total hip replacement.
Healthcare professionals, including GPs and physiotherapists, are becoming more familiar with the classical signs and symptoms of underlying hip pathology, leading to earlier diagnosis and intervention, with better outcomes for the athlete. With an increased awareness of typical warning signs and the acceptance that ongoing hip pain and stiffness are not normal by-products of a good training session, further injury, misdiagnosis and the potential for further degeneration can be avoided with the underlying problem surgically corrected.
The age-old, misleading ‘no pain, no gain’ ethos held by many budding young athletes needs to be re-evaluated. Training and coaching should be orientated to maintain player welfare, both psychosocial and physical, with holistic training regimes in place to prevent injury risk factors. The expectations of and training regimes executed at a senior level should not be transferred among younger emerging athletes. While there is an increased emphasis on competitive success in our young athletes, the associated high-intensity training to achieve and maintain this ‘winning status’ often compromises the very same.
The participation in high-level competitive impact sports is commonly associated with an increased risk of future osteoarthritis; the classic symptoms and clinical signs of FAI not only act as an important ‘early warning’ sign, but present an opportunity to surgically correct the deformities and repair damage structures to delay or prevent further deterioration and the requirement of premature hip replacement.
References available on request