People may know Lleyton Hewitt had an injury to the hip joint called femoro-acetabular impingement (FAI), which means the ball of the joint had been knocking up against the wall of the socket. A small bump on the front of the hip bone can develop, either through genetics or activity, which can accentuate the impingement. As the two surfaces bang together it stimulates the hip to lay down more bone, so gradually over many years the impingement will occur more easily as there is less room around the joint to play with. Over time the pain inhibits muscles that control and protect the movement of the joint, further worsening the impingement. This becomes a downward spiral over time, accelerating the wear and tear process.
Around the edge of the socket there is a lip of cartilage called the labrum, which acts like a seal for the joint. Hewitt sustained a tear to his labrum and as a result of the impingement he had also damaged some of the cartilage within his joint. He underwent arthroscopic surgery to repair the labrum and shave away some of the bump of bone on his hip to reduce the risk of the injury recurring and help improve his movement.
Hewitt was advised to consider retirement as the damage to the cartilage in his hip was considerable, and it would be a long road back to rehabilitate the joint to the level required to compete at the top of men's tennis. It is a testimony to Hewitt's dedication that he was able to get back to play Wimbledon six months following his second hip operation. This is no mean feat, as it can take six months for most people just to be running.
Hip injuries in tennis
Any sports or activities that involve twisting and flexing the hip into the end of its range are at an increased risk of developing this injury. Tennis is a great example, as is AFL, soccer, dancing and martial arts. It’s not uncommon for younger tennis players to be affected by hip injuries either. Australian Bernard Tomic was 21 when he had hip surgery. Even though Tomic is younger in age, his body had seen a lot of mileage on a tennis court. Intense training from a young age when the skeleton is maturing can set up this sort of injury.
With advances in medical imaging, more research and greater experience something like FAI can be picked up sooner and then we can make educated judgements on the best action plan. Tomic’s operation should help prolong his career, as it will allow him to improve his movement and slow down the damage to the cartilage in the joint.
The trend of players sliding to return has made hip injuries more prevalent in today’s game. This shot of world No.1 Novak Djokovic is a great example. See how he is lunging to his right, bending over heavily at the trunk and leaning to the right, his right knee is turning inwards significantly. His right hip would be getting massively impinged, but he gets away with it to a degree because he is incredibly flexible.
The recovery from hip injuries is often slow and steady, sometimes taking up to three months to get back to normal daily activity pain free. As surgery involves shaving bone and repairing cartilage, these structures need to be given the time to heal before too much strain can be applied to the joint otherwise there is a risk of annoying the joint and slowing down recovery.
Commonly, athletes have been dealing with their hip pain for many years, as it may have started out as a small twinge and progressed to a disabling pain. Over this time the athlete would have made subtle changes, both consciously and sub-consciously, to their movement to help combat the pain. This leads to imbalances in muscle strength and coordination which can take many months to reverse. The pain will have inhibited many of the little muscles that hold the joint together, not only in the hip but also around the trunk and further down the leg.
Spot the signs
Hip pain often presents as groin pain. If the joint is particularly inflamed then it can be a dull ache at rest, with a sharp pain when the knee is pulled towards the chest or rotated inwards. The pain can wrap around into the buttock and lower back and also be referred down the thigh to the knee. Examples of day-to-day things that can be difficult with a hip injury are putting on socks, sitting on low chairs and going up stairs.
- Keep the muscles around the hip strong. A strength program should include exercises that focus on power and strength but also challenge endurance and co-ordination. The latter is especially true for the deeper muscles that rotate, extend (pull the leg back) and abduct (pull the leg outwards to the side) the hip.
- Mix up playing surfaces, this way leg and hip muscles are used in different ways and can help avoid muscles imbalances that might develop with being on the same surface all the time.
- Good core strength is important too, as the trunk/pelvis houses the socket for the ball to connect with. If there is weakness within the core muscles, then the hip can be affected and contribute to a hip injury.
- Listen to your body, if there is a little niggle that just isn't settling down within 2-3 weeks then get it assessed by a sports medicine professional with experience in hip injuries. A slightly longer period of rest and rehab may be required to resolve the issue, and avoid it coming back to bite you further down the track.
Rob is a Director of the St Kilda Road Sports & Physiotherapy Centre in Melbourne. I’d like to thank Rob for another excellent contribution to our blog.
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