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Sporting Hip Pain

13 Apr 2018
Hip pain is a common musculoskeletal complaint among athletes. Athletes may experience hip pain for a variety reasons which can include: - Local muscle strains and tendinopathy (gluteal, hip flexor, proximal quadricep and deep hip stabiliser muscles) - Contusion (bruise, commonly called a ‘’hip pointer”) - Bone fractures (pelvic, femoral) - Hip labral tears - Osteoarthritis

Hip pain can be either acute (i.e., comes on suddenly) or chronic. One cause of chronic hip pain is femoroacetabular impingement (FAI). In simple terms FAI is related to extra bone growth on either the neck of the femur, the acetabulum, or both. This characteristic bone growth can be detected on x-ray or magnetic resonance imaging (MRI). During hip movement, the additional bony mass can restrict hip movement and cause pain.

The Warwick Agreement, an international consensus statement, has defined FAI as “… a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum.”(1) It is important to note that an individual with anatomical changes on x-ray and NO hip pain does not fall under the diagnosis of FAI and clinicians should be questioning a diagnosis of FAI in the absence of pain.

Imaging studies show that anatomical changes to bony morphology on x-ray may be normal in some asymptomatic individuals and more prevalent in some athletic populations e.g. ice hockey and soccer players.(2, 3) Some researchers believe that bony changes around the hip joint, in the absence of pain, may be normal and reflect bone adaption in response to load. This may be particularly true while bony growth plates are still open in the growing athlete. There is also some discussion amongst researchers that FAI may be a precursor to hip osteoarthritis and therefore early effective management of the hip pain, such as improving strength around the hip joint, can have a huge impact on an individual’s future joint health.

In the last decade, arthroscopy (keyhole surgery) has been increasingly used to improve pain and function in athletes with FAI. A systematic review by Kemp and colleagues found that hip arthroscopy can reduce pain and improve function in patients with intra-articular hip pathology, including FAI. (4) While benefits of arthroscopy can last up to 10 years, evidence of surgical benefits beyond 3 years is limited and needs further research.(4) More studies are required on the effectiveness of exercise and education for FAI and the impact of surgery on development of osteoarthritis. These studies are currently underway around the world so expect an increased growth in publications in this area in years to come.

What should clinicians do while we wait for this research to be published? According to the Warrick agreement, a multimodal rehabilitation approach should be used. This multimodal approach could include some form of manual therapy, hip strengthening and functional retraining and include an education component. Of course, clinicians should defend their choice of interventions with the findings of validated patient-reported outcome measures, such as the HAGOS and IHOT (see list below), and functional performance tests such as the single leg rise and hop tests.

Manual therapy can include soft tissue techniques around the hip and pelvis as well as the lumbar spine. Hip strengthening exercises targeting hip extension, abduction and adduction, as well as trunk strength and core stability can help reduce loads on the hip joint e.g. squats and planks. Make sure that exercises are specific, structured and an individual assessed regularly for exercise progression. The ‘good’ side should also be considered. A functional retraining component can include tasks such as single leg squats, steps, and retraining hopping and jumping techniques. Focus with functional retraining should concentrate on technique of performing the exercise/task. Individual feedback can enhance these exercises e.g. verbal feedback together with feedback from a mirror. Patient education should include a component on hip pain. For example pain associated with FAI may not be completely resolve, even with surgery and flare ups can be common. Small increases in pain with exercise and activity can be normal and athletes need to understand this and not be fearful. Education should also address an individual’s expectations and specific goals.

 References

  1. Griffin D, Dickenson E, O'donnell J, Awan T, Beck M, Clohisy J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. 2016;50(19):1169-76.
  2. Mascarenhas VV, Rego P, Dantas P, Morais F, McWilliams J, Collado D, et al. Imaging prevalence of femoroacetabular impingement in symptomatic patients, athletes, and asymptomatic individuals: A systematic review. European Journal of Radiology.85(1):73-95.
  3. Frank JM, Harris JD, Erickson BJ, Slikker W, Bush-Joseph CA, Salata MJ, et al. Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy. 2015;31(6):1199-204.
  4. Kemp JL, Collins NJ, Makdissi M, Schache AG, Machotka Z, Crossley K. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med. 2012;46(9):632-43.



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