This case is a 28-year-old left-hand dominant professional ice hockey player. He had deep posterolateral right hip pain for about a week. It was acute and onset. It happened with one particular slap shot in the first period of an NHL game. He tried to play through it for the rest of the game, and he was able to do so, but the next morning, his hip was much more stiff and sore than it was during the game or right after. He had pain crouching, pain getting in and out of the car, and pain pivoting, and pain flexing his hip and going upstairs. He was seen by the team trainer. They gave him some non-steroidals, did some modalities and other treatment, and he didn't really find much benefit, and it just had been going on for a week. He had no prior hip pain, never had any hip surgery. He does have a history of having an ACL reconstruction done on that side six years prior. This was 30 games into the NHL season, just to kind of give a context of timing, so kind of right there. On exam, his Trendelenburg was actually positive on that side, so he had some weakness of the glute med. His strength, actually, his iliopsoas strength was five minus out of five on that side, not associated with any pain, actually a little bit weaker on the contralateral side. Had similar hip flexion, but with some discomfort on the symptomatic hip. His external rotation was 40 degrees on that side versus 60 on the other. His internal rotation was 30 bilaterally, but had pain on the symptomatic side. His impingement and labral stress tests were both positive. Had no tenderness over the glute tendons, no tenderness over the piriformis. His IT band was not particularly tight. These are his x-rays. You can see center jangle is 25. His alpha angle was 65, so he has a CAM lesion. He had a crossing sign, as you can see here, kind of just for better visualization. His AIIS might be a little bit on the low side as well. So what you got is a 20-year-old NHL player, third of the way into the season, essentially, non-dominant leg, acute pain, and has anatomy of FAI. So why don't we have you talk amongst your tables as to what you would do, how you'd approach this in individuals, first time he's had pain, and it's, again, a month and a half or so into the season. Okie doke. So looks like there's a lot of good discussion out there. We'll start off with Dr. Aoki. What did your table, what did you guys decide that you wanted to do there? Can we turn on the microphones for the, yeah, thank you. Can we get the, oh, there we go. So, I know no antecedent pain, an injury in a game, acute symptoms for a month. We'd probably want more information. We would like to have an MR to look at, but if we're looking at just what we have provided with the radiographs and the story, you know, it seems like maybe two things going on. It sounds like something intra-articular, but also, you know, the Trendelenburg gait maybe makes us think that there might be something else going on, that soft tissue. So that's kind of our thoughts as far as where we're at. We were talking a little bit about, you know, getting an MR at the time, or next to, to look for, you know, soft tissue versus intra-articular pathology. And the discussion came up about doing a steroid injection at that time. And I've gotten a little bit gun-shy of doing steroid injections in some of these athletes, partly because, you know, there was that article that came out in JBJS about rapid progression of arthritis after steroid injections. And I didn't think that that correlated with what we saw. And then we just recently had someone on our football team that has a terrible hip now after a steroid injection. So I would lean more towards doing like a PRP or something if we had to go that direction. But anyway, that, those are our kind of initial thoughts. Well, actually, while we got, has anybody here seen rapid destruction of the joint from a single injection of corticosteroid? I've had players complain that they wanted to have rapid progression of osteoarthritis because of steroid injections. Okay. So I've seen it a lot. I've not seen it, but it doesn't mean anything. That doesn't happen? No, absolutely. But there's a lot of experience here. Yeah, John? I mean, there's rarely that you inject an asymptomatic cable of course. So the challenge is when it's gotten to you for that decision clinically, who knows what the right thing is. It used to be arthroscopy. Did arthroscopy cause rapid progression or not? So I think that's a challenge. Yeah. Was it on the way downhill? I know, I remember Dr. Bird presenting a case where somebody came in with hip pain and he opted to treat them nonoperatively. And three months later when they came back to see you, the joint was all destroyed. And fortunately, you... Sometimes it may well be the natural course of the disease. But then you're sort of hung out there to get a steroid injection. But I think in general, trying to... And there's purpose to it. Even if you're convinced they need surgery, this guy's got a lot of secondary things going on with where he's weak. He'd like to get those things in better shape. And I think the potential upside for the masses far outweighs the anecdotal case where somebody thinks maybe it did cause some harm. I think that the general course of the treatment strategy... And like anything, used improperly can be harmful. Namely, you're just putting a shot in there to get it back on the ice. But doing it to facilitate getting his rehab going, put him in a better position for surgery. Again, I think on average... I've never seen rapid chondrosis after an intra-articular steroid injection. And I would say that, you know, even in our collegiate athletes, we use injections pretty often, I mean, to get patients through the season. Sometimes I find people will get that one injection and never come back again. Not very often, but rarely. So you might be able to get somebody out of having surgery and resolve their pain with an injection. I have seen one case of avascular necrosis where a patient had an intra-articular steroid injection from an outside physician, a second one within three months. So I typically like to space them out at least six months. I'd be interested in hearing what other people's takes on how frequent you would give somebody a steroid injection. I like to say minimum of six months. And then I usually cap people at about three total in their lifetime based on the arthroplasty literature that says there's increased risk of infection and problems with a total joint later in life if they've had more than three injections. That's a discussion. So if somebody, you know, has a terrible hip and they're young and they want more injections, I'll go further. Again, I'd love to hear everybody else's comments on frequency of injections, how many injections. And then the last question is how long you wait after an injection before you would perform a hip arthroscopy. I typically wait about six weeks before doing a surgery after an injection. But I would say that one case of AVN, I truly believe that that was probably a hip that was avascular necrosis. They didn't, you know, didn't see it initially, but I think that's where it was headed and she just happened to get an injection. Because it starts with the pain before you see those findings. The other part of it, I think, is that, you know, was it really the corticosteroid that caused it? Was it the natural course? Or again, we know that anesthetic, particularly with epinephrine, is chondrotoxic, right? And so was it the, you know, they blame the cortisone, but maybe it was the, you know, if they use something like lidocaine with epinephrine, that we know is more chondrotoxic than the corticosteroid might be. So if you use like rapivacaine, which is safer for the articular cartilage. From my standpoint, I, you know, I'll give one injection to get somebody through a season, two if they need, but that's kind of it. And I, certainly not sooner than six weeks apart, but usually three months. And I'll give, I tell the patients no more than three in a one year's period of time. But if they don't get really significant benefit with two, I don't know that there's much more benefit to three. But is anybody doing anything differently from a corticosteroid perspective? Thomas? We've done about 15,000, I mean I have, my nurse practitioner has, with no infections. And if all of a sudden you say, oh, well you can't do surgery within three months, I think we all know that oftentimes the diagnostic injection is a very important part of our work on these patients. Not for everybody, but oftentimes they've got other things going on like this guy. And all of a sudden if you've got literature that says you can't do surgery for three months if you do a diagnostic injection, all of a sudden what's going to happen? That diagnostic injection is going out the window and now you're starting to base your treatment on less useful information. So we look at that and there's no increased risk of infection with it, really at all. But typically you're going to wait, as Andrea said, six weeks, because it takes that long if you're using steroids, it takes about that long to figure out whether or not it's a good effect. Thomas, that study came out and I immediately called the authors, because those authors trained me and they practiced with waiting six weeks after the injection. So that was a Pearl Diver study. We know the faults of Pearl Diver. And so I called them and I said, oh, did you change your practice based on this paper? And they said, no, we still only wait six weeks. And you published a paper on that, so, yeah. We had a lot more numbers, but hopefully we discounted that. Because again, as Andrea said, it was a Pearl Diver study. It wasn't their own data, it was what they found in the literature. But like I said, there was a 1% infection rate when people did have the injection. And you don't really know. Anybody said about a 1% infection rate? Yeah, and all my patients get a diagnostic injection ahead of time and some will do the surgery within a couple days and some, most of the time it takes longer than that to get on the schedule, but never, knock on wood, an infection. But so, but- And to make sure, we're sort of mixing two things. We're talking about diagnostic injections and anesthetic versus steroid injections. But really, either one, in our experience, because that study said any injection requires, again, for the diagnostic injections, which we don't wait any timeout amount of time. If we're using steroids, it takes a while to figure out whether or not it's an infection. So this guy, again, he's in season. We couldn't get him an MRI in the next 48 hours and they were going to be going on the road. So we decided we'd give him an intra-articular injection to confirm that the pain was coming from intra-articular as well as to help him rehab. So it was a rapivacaine, a corticosteroid injection. He got 100% pain relief. The plan then was he was going to get an MRA at the end of the season. I tried to do my diagnostic injection with the MRI and use the diagnostic injection as the contrast, if you will, so they only get one shot. And basically, he had 100% pain relief with the injection. He had no pain the rest of the season. He ended up playing six more years in the NHL, never needing another injection or having surgery on his hip. So, you know, you can treat these people conservatively. And in fact, there's a paper that just came out from Fitzgerald in the AJSM where he, with a good structured PT program and corticosteroid injection with several-year follow-up. I don't remember exactly how many years. I think it was five-year. But only one-third of the patients ultimately came to surgery. So not everybody who has anatomy of FAI needs to have surgery. This guy played in the NHL for several years before he ended up having any symptoms. So this was just potentially he just may have pinched some tissue, if you will, and got him flared up. And once you got him calmed down, he was able to get back. So any comments on that? So we'll move on to the next case.

ice hockey player

hip pain

NHL game

conservative treatment

corticosteroid injections