Good? Must be raining out. Two years in a row we've had a good turnout at the HIP session, so nice work to you guys. All right, so I'm just gonna give a little bit of data, I'm gonna give a little bit of my experience, and just run through this concept. So these are my disclosures, they're in the website and the program. So hip anatomy, pathology, and sports. Just briefly, FAI leads to motion limitations and labral chondral injury and can lead to eventual osteoarthritis. CAM-type FAI might be the most predictive of symptoms, if we look at our studies. Dysplasia can be associated with increased hip range of motion, but can also result in instability and eventual arthritis. And core muscle injuries and exertional lower abdominals, sometimes adductor-related pain that can lead to significant disability in athletes. So does athletic activity predict or contribute to the development of CAM-type FAI? So this study looked at elite male basketball players compared to age-matched non-athletes. All these patients were asymptomatic, and the athletes in the study had 10 times the risk of non-athletes to have a CAM deformity. The proposed concept is that a CAM deformity appears to result in growth plate abnormality secondary to the stress of athletics during your adolescent growth or growth spurts. The systematic review of nine different articles also showed that high-level male athletes have two to eight times more likely to develop a CAM deformity than controls. So what is the concept of sports-specific anatomy? So athletics during adolescence have effects on the developing physis and predisposed FAI. Different sports with varying activity requirements might create different patterns of FAI specific to that sport or even player position. And there might be some additional natural selection anatomy such as dysplasia that allows a greater potential range of motion for particular athletes or positions. So let's look at prevalence of hip disorders in athletes in sports-specific anatomy. So American football is where I'll start. So these are collegiate football players. In this study, 95% had radiographic evidence for CAM or pincer-type FAI. This was a study done at the NFL Combine, and over 90% of these athletes had CAM or pincer-type FAI. And if they had a BMI greater than 35, they were associated with global overcoverage. This is a study that we did back in 2012, also at the NFL Combine. 90% with at least one finding consistent with FAI. 46% of these players are asymptomatic, never had symptoms currently or in the past. And what we found is that a larger CAM-type FAI was an independent predictor for the development of symptoms. Pincer-type FAI was not. So these are really our at-risk athletes, I think, these large CAM deformities. This study with Ashish Bedi and Brian Kelly, we looked at NFL football linemen. They tend to have a CAM deformity that was bigger and more posterior on the femur than the general population. And these are very challenging cases. It's a large CAM deformity, and these are big humans. Football sport-specific anatomy. So what would I take from this? There's a high prevalence of CAM-type FAI, and I think this is athletic-related development. Hip dysplasia is relatively uncommon. In my experience, athletic pubalgia, core muscle injury, is highly prevalent in this sport. And adductor and rectus femoris injuries are also not infrequent, and you tend to see that in your skills players. So what about ice hockey? So we have a lot of this in Minnesota. 59 NHL hockey players, this is a study that we did pre-season, 85 to 90% had CAM-type FAI. I think this is developmental. 21%, however, had acetabular dysplastic features. And the larger CAM correlated with decreased hip range of motion, which makes sense. And interestingly, a decreased total arc of hip range of motion, or decreased external rotation, also correlated with symptoms. And I think that was related to the CAM morphology. We also did a study looking at our ice hockey goalies. 68 hips in ice hockey goalies, compared to a match group of position hockey players, all of them had undergone FAI correction. The CAM deformity was larger in goalies compared to the position players. Again, I think this is developmental. But acetabular dysplasia was more common in your goalies, 29%, and I think this is a bit of natural selection given their range of motion requirements and what they do. And this is an interesting study looking at asymptomatic professional and collegiate hockey players. They had a 3T MRI. Again, they're all asymptomatic. And on these MRIs, over a third had athletic pubalgia or core muscle injury, and 64% had joint pathology. Again, all asymptomatic. And then they followed them up four years later. And interestingly, only 14% ever developed hip or groin pain in the next two years. And only one player actually missed a game secondary to pain over the next four years. So these findings are common on your MRI. So ice hockey sport-specific anatomy for our positional players, they have a developmental CAM deformity, a low-volume acetabulum. I think this might help for abduction extension during skating. Athletic pubalgia and adductor pathology is common. And our goalies, they have high range of motion requirements. They have a larger developmental CAM-type FAI, but a greater prevalence of acetabular dysplasia. And I think this may be compensatory or natural selection or both. So the risk for symptoms are related to decreased total arc and external rotation hip motion. Again, I think this is secondary to the CAM deformity. So what about soccer or football? So we look at this study, 95 elite male and female soccer players. 72% of the males and 50% of the females had radiographic hip FAI, so still pretty prevalent. But adductor injury is the most common groin injury in soccer. And in the NCAA database, 40% of all hip injuries were adductor injuries. But interestingly, on MRI, adductor pathology and parasympathetic edema is actually common regardless of whether these soccer players have symptoms or not. So a soccer sport-specific anatomy would be that FAI is common, but it's less common or less prevalent than in football and hockey. But these are kicking, cutting, and pivoting athletes, so this dominates, and therefore adductor pathology and core muscle injury is extremely common whether they have symptoms or not on an MRI. Basketball, we're starting to see less data that we have on some of these sports. Very little data, limited outcomes, return to play. There is one study that showed higher grades of chondral damage in basketball players compared to other athletes. And this is really consistent with my observations that I think male basketball players tend to have very large cam deformities and mixed type FAI, as you see at the top right image. And these extend posterolaterally. And basketball players in variable say the most difficult for them is getting into defensive positions. So my observations suggest that there's large deformities in particular in the femoral side. I think this is developmental, and I think there are these large growth spurts for these basketball players during their adolescence. I think this might be supported by that study that showed higher degrees of chondral damage compared to other athletes. Again, defensive stance reaction tends to be universally most problematic for basketball players. And these are very challenging deformities. These are large deformities and challenging athletes, six foot five to seven feet tall to manage. So what about baseball? Again, very limited data in baseball. This study showed that hip and groin and core muscle injuries made up a very small proportion of overall injuries in baseball, only 2.2%. But interestingly, the numbers were higher in your pitchers. I think it's also interesting to note that the data suggests that there's a decreased hip range of motion on the plant hip correlated with shoulder and elbow injuries in high school baseball pitchers. So there's clearly a kinetic chain issue going on, but we see hip problems a little bit less in baseball. And lastly, I'm gonna finish up with performing arts, ballet, dance, gymnastic, really are hyper flexible athlete. And this is really a different animal. So dancers have greater hip external rotation and less internal rotation than the general population, which allows for turnout. And this greater hip external rotation might be secondary to capsular adaptations or increased femoral retrotorsion. But there seems to be a critical period between 11 and 14 years old, that may be similar to the proximal humerus in little league throwers. Issue femoral impingement on an MRI shows up 63% of the time in asymptomatic elite gymnasts. So this is really not a cause for alarm. Elite ballet dancers will report a snapping hip 91% of the time. Snapping is the rule rather than the exception. So ignore the snapping in my opinion, don't cut the psoas tendon or you could end their dance career. What about hip anatomy? So this study by Josh Harris here, professional ballet dancers, 32% had cam type morphology, but impressively 89% had dysplastic features. So that really predominates. We did a study looking at competitive and professional dancers and a combination of a labor repair, distal base femoral resection, a sub-spine decompression and capsular placation got them back to dance about 84% of the time, only 63% to their pre-injury level. But again, challenging anatomy, challenging athletes with instability and high range of motion impingement. So sport specific anatomy for them, there's less hip internal rotation and greater external rotation, which allows for turnout. Cam type morphology is less common than in other sports, but still 50% in males. Dysplasia is highly prevalent, upwards of 90% near ballet dancers and snapping hips and issue femoral impingement are the rule, not the exception. These four systematic reviews really show in US sports that generally these athletes do well. NHL seems to do the worst in terms of performance and NFL linemen have the lowest return to play rate. I really don't see that in my practice. And I think if you have a sport specific approach, your results are better. So in conclusion, imaging frequently reveals hip and pelvis pathology in asymptomatic athletes. Athletics during the adolescent growth spurt appears to predispose to cam type FAI. There appears to be a sport specific hip anatomy that results from a combination of activity specific FAI development and natural selection. And a knowledge of this anatomy might lead to a sport specific hip procedure in order to optimize outcomes and return to play in these athletes. Thank you very much. Thank you.

hip anatomy

femoroacetabular impingement

athletic pubalgia

adductor injuries

cam deformities