So I'm going to talk through in kind of a similar format four different kind of clinical types of hip problems we see and just kind of go through some clinical vignettes that we'll hit some cases later as well, so kind of a general approach for the general team physician here. Here are my disclosures. So why is this important? We see this data and taking care of an NFL team, we're going to see a lot of this in these next couple of weeks. The number of adductor strains, the number of hamstring injuries, the number of hip-related injuries is actually quite high. Norm's going to tell you that the foot and ankle is actually the highest, but this is real time lost in the NFL for a number of these injuries. Although the shoulder instability and the ACLs get a lot of the press, a lot of time is missed by our players with many of these types of injuries. So as shown by the NFL Musculoskeletal Committee here. The interesting thing about the hip is that we've started to learn that not only hip injuries, but also kind of hip morphologies play out differently in patients that kind of gravitate toward different sports. So we're starting to try to understand different patterns of injury that your athletes may see based on their sport. And that not only is just the sport they play, but also the shape of their hip that tends to go into those sports. We know that a dancer's hip is very different than an offensive lineman's hip. And the loads on the hockey player's hip and the injuries that they get are very different than the endurance runner. So it's really important to keep in mind not only just the type of pain, but what morphology of this patient's hip. The hip is really unique in that sense that we see so many different morphologies that develop with these athletes from a young age, and then follow them through their career, but also kind of lead them to certain injury patterns. So I think it's really important to kind of keep in mind these types of categories as we start to think about the hip and the loads and the injuries that our athletes are seeing. So the injuries that I want to talk about most specifically, the muscular injuries, we see a lot of these. They're oftentimes handled by our trainer, but they do lead to a lot of downtime for our athletes. Articular injury, we'll talk about FAI, labral injuries, what we've started to call groin pain syndrome, or otherwise known as a sports hernia, that really is a misnomer in a lot of ways. And then some of the instability patterns with fracture, dislocation, subluxation that actually have gotten a lot of press recently with some high-profile injuries. So what about these muscular injuries, these axial injuries, these deep rotator injuries? These soft tissue injuries around the hip, we do a lot of MRI with the Steelers because it helps us to understand, much like a hamstring injury, the grade of the injury, the location, and how we're going to rehab them. So we see these injuries in the anterior compartment. We see the adductors. We're going to see a ton of adductors in the next couple months, and I wish we could decrease this number, but they're still there. These guys come back, they increase their load in training camp, and there's adductors, there's hamstrings, there's the glutes that will come out. There are a lot of traumatic external rotator injuries like this MRI. And then going up into, kind of as Drew's talked about, up into the spine, we think about the kind of hip and core and spine all being related, as well as some pelvic floor that can be injured with traumatic injuries and overuse type of patterns. So what are we doing for these? Well, we're relying heavily on our athletic trainers for these. It's broken down really into three phases that we all know. This acute management, which we've taken, it's not really just rest. These injuries, especially around the core, they can really compensate for these. So we need to protect them. We need to load them optimally. It's not just kind of sitting out until you feel better. It's typical ice, compression, elevation. But we really want to maintain their cardiovascular fitness with these strains around the core and hip. Oftentimes, they can do a bike, they can do an elliptical. We'd use BFR pretty liberally in our training room. Modalities, these players are getting many different inputs, which are all supported here. We do use PRP pretty liberally for a lot of these soft tissue injuries within the first 48 hours. We've taken this from some of our experience with hamstrings and use that for adductors. We use it for gluteal injuries, hip flexor strains, under ultrasound guidance, usually in the first 48 hours. And we really tell the athlete to minimize stretching and kind of deep tissue work. A lot of our athletes have many different inputs. They've got their chiropractor, they've got their other people kind of supporting them who want to massage and do different manual techniques. And we've taken the approach, especially in the first week or 48 hours especially, just let this thing start to heal and get a little sticky before we start really bringing blood flow and digging into it. We then return to the strengthening phase and return to sport. And for us, it's typical pain-free return of strength and range of motion, able to support themselves, gradual return to play. We've really leaned a lot on this GPS monitoring. Our players have this. You may have this at the college level too. And if their fitness, if their accelerations, if their workload and practice isn't up to their baseline, then they're not ready, even though they may say, I'm fine. It really gives us an objective measure for their return to sport with some of these soft tissue injuries. What about the surgical ones? I'll touch briefly. We hear a lot about proximal hamstrings evulsions. Long story short from a lot of papers that support acute repairs, if you're going to do a repair on a hamstring, tend to do better than a chronic. That cutoff being around six weeks is born out in the literature. And then both tend to, in most studies show, better outcomes overall than non-operatively treated evulsions. So we've taken the approach of generally repairing acute evulsions of the hamstring with the expectation that they're going to have a more reliable return of function and strength. What about the adductor? Classically, these were treated non-surgically. There was some support for this out of some NFL literature years ago for non-surgical treatment. However, there's a subset of patients, as we've learned more about these groin syndromes that go on to have chronic groin pain. So is this something we can treat like a hamstring? Serino Barnum in New York, Mike Gerhardt out of Santa Monica have published on this. And we've taken a similar approach of repairing the adductor with these acute evulsions. I do this alongside my general surgeon, kind of sports hernia partner. And really, it's a really straightforward repair. The literature has borne out these have a successful return. And we've found these lead to a much faster return than hamstring evulsions. So we've been very satisfied with our operative management of adductor evulsions. Not the intramuscular ones, but the true evulsions off the pubic bone. So what about the articular injuries? So just as a brief recap, FAI, I mean, this term is thrown around as a structure to the hip, as a syndrome. Really, this is a syndrome. It's this group of symptomatic hip disorders that are related to underlying structure of the hip and then superimposed loads. So it's a common mechanism. It can be related to many different structures. Typically, as is shown in this x-ray, it's oftentimes a structure of the femur bone that leads to loss of offset at the head-neck junction in our athletes that leads to this collision. When you talk about this, to talk about it as a syndrome, though, it's not just an x-ray feature. A lot of your, and I'm going to talk about it later, a lot of your athletes are going to have this structure. We get into a syndrome when they have symptoms related to this, catching, clicking, pain in their groin, pain in the C-shape fashion, clinical signs on x-ray that support this, positive fader sign, positive loss of motion, positive impingement test, and then these radiographic findings. So it takes us down this diagnosis and management more as a syndrome than truly just a radiographic diagnosis because you're going to get these reports from your radiologist, CAM lesion, and the patient's going to have back pain. So it's important to put all these pieces together when you're giving this diagnosis to an athlete. So how do these present? Typically, it's insidious. Oftentimes the athletes don't have any real history of trauma, unlike a shoulder instability with a labral tear. This is a hip labral tear. Oftentimes this is associated with repetitive motion, as we saw with the different sports. Oftentimes cutting sports can be at high risk. They have pain with sitting. You've seen it, your athletes, your patients in the office, typically groin pain, reduced range of motion. Oftentimes they may present with some compensatory patterns. They've been dealing with this deep-seated hip loss of internal rotation. They start to get motion through their SI joints, through their lumbar spine, through their core, and they may have some excessive load at these other compensatory joints, which brings them into your training room or into your office. Typically we can get these places, we try to get these patients, even with an MRI or x-ray diagnosis of a labral tear and a hip impingement, the initial treatment is non-surgical. You want to shut them down. You want to get them on some NSAIDs. You want to, you know, as Drew said, oftentimes the initial inciting event, it may be a labral tear. It may be a chemical kind of inflammatory reaction, but that doesn't necessarily mean they need to be rushed off for hip arthroscopy surgery. You shut them down. You get them on some rehab. You get them on NSAIDs. We sometimes use therapeutic injections around the hip and core. I tend to stay away from cortisone in the athlete, and especially in the young athlete, into the hip joint. I'll sometimes use local anesthetic, rupivacaine, for a diagnostic test only in the hip joint to try to understand is this a hip joint problem. We'll talk about that a little bit later. I'll use cortisone pretty liberally around the iliopsoas, around the SI joint, sometimes in the pubic symphysis. Into the hip joint, we've really found good value with using VSCO. We have it in our training room for patients with knee problems. So if you get a little early degeneration in the hip, although it's not, it's hard to get for patients in the outpatient office. If you have it in your training room where you can get it, a series of VSCO for the hip is, I use it for FAI, I use PRP sometimes in combination, and I think that's a good cocktail for a symptomatic hip joint to calm down that inflammatory response in season. I typically don't use a cortisone injection in season for a symptomatic hip joint. Rehab principles, we talked a little bit about this. It's really based on your athlete, your type of sport, your type of hip, really. You're going to take a different approach to the dancer with the hypermobility who has a hip problem compared to the offensive lineman who's got a stiff hip and some groin pain. So it's really based on their deficit, and then it's oftentimes based, as Drew mentioned, core strength, lumbopelvic stability. We discourage actively stretching into these deep end range, and it's oftentimes just getting their stability back to their hip and core will calm some of the symptoms down. When do we do surgery? Typically, we want to make this diagnosis of this syndrome. We want to have a clear diagnosis. We want to have minimal degenerative disease. We want to know that the patient's failed in general non-surgical care because sometimes, even with these radiographic findings, the pain can go away, and we typically will monitor them. And oftentimes, this can be done in the early off season or in a recreational athlete. It's not an urgent thing. But you can see, this is the damage that's done. This is the chondrolabral junction in the hip with underlying FAI. And pretty classically, this is a 20-year-old kid with a detached labrum and cartilage that's already delaminating right at that junction. I lost a little bit of that page. That's a paper out of HSS with Brian Kelly, outcomes of football players returning to sport, and it's good. It's overall, you know, this surgery is very successful for the symptomatic hip for getting people back to sport. What about this, what we've termed groin pain syndrome? So this, you know, stems out of the fact that this groin-related problem has been called athletic pubalgia. It's been called sports hernia. It's been called core muscle injury, you know, hip sportsman's hernia. And really, the Italian group initially, and then the Doha group, has tried to define this as any clinical symptom related to inguinal, pubic, adductor-related area affecting sports activities. So this Doha consensus tried to differentiate different patterns of groin pain into adductor pain, iliopsoas pain, hip-related pain, inguinal pain, and to try to give some science and kind of background into what's going on at these different areas. And we've tried to take this approach in our own players rather than just trying to chuck it up as a sports hernia, trying to understand the pattern of injury to their hip and core. So what happens? Typically, this is a problem around the pubic bone and around the pubic joint where there's some abnormal strain at this level, either at the rectus adductor attachment or even a little more laterally at the inguinal floor. And then you can get some compression, some irritation of the sensory nerves at this point. And so sometimes there's some kind of associated neural signs. There is also probably a mechanical component in patients that have FAI where the loads across the hip joint, as I mentioned earlier, may lead to some instability at the pubic symphysis. And my opinion is this likely is what leads to some of this osteitis type of bone marrow edema that we see at the pubic symphysis. So the rectus pathology typically is centered, oftentimes these players will have pain at the pubic bone, at the proximal adductor, into the rectus abdominis. They'll have signs on their MRI, sometimes some partial tearing of that aponeurosis there. Whereas inguinal canal pathology oftentimes will present more laterally. Sometimes this is less visualized on an MRI. This is the typical kind of area where patients will get a direct hernia. This is a kind of example of some attenuation of that inguinal floor in a case I did with one of my colleagues. And so, you know, there's different surgical approaches that can be taken for this. So Brian Zuckerbraun and I wrote this mostly for the general surgery colleagues of his to try to help them understand what is being done in these repairs. So typically this is either, as can be seen in the bottom right, with Bill Myers' typical repair which is a reinforcement at that pubic bone rectus interface there with those green sutures and then oftentimes some lengthening or tenotomy type procedure to the adductor to give some length on that tight. To some of the other techniques which you see, the Mushuak which is oftentimes done in Germany for some of these soccer players with more of the inguinal based pathology where if you don't need to address the adductor you can address this through that. So many different ways of doing this. It's really trying to understand what the pattern of injury is. And that's oftentimes more based on their clinical presentation. And this really requires a multidisciplinary approach. It's involving the physical therapist, the athletic trainer, your general surgeon to try to understand is this the hip, is this the core, and where is this problem coming from, what kind of surgery does it need, what kind of non-surgical care would be best for this player. So this really requires your whole team. One of the things that G asked me to talk about which I think is a really interesting topic is how do we differentiate this from the hip and when do we do surgery on one, when do we do surgery on the other. And Chris Larson really gave a great talk. I took some of his slides. He gave this to us at the NFL Physician Society a few years ago. And I think it's really pertinent for this talk as well. So when do we address the hip, when do we address the core, and what are the dilemmas? So what we know is that about 50% of NFL players will have an MRI documented labral abnormality regardless of symptoms. So if you look at some screening MRIs or if you look at some of the other published literature, it's a very high rate of labral pathology. Same thing goes for imaging evidence of FAI. It's almost ubiquitous. And so what do you do with that information? Now add to that that about a third of the players will have some evidence of athletic pubology regardless of symptoms. Put that all together, how do we know where the problem's coming from? Well, it really goes back to your history, your exam. Some of these diagnostic injections, we tend to use local anesthetic injections if there's, if we need some clarity. And it's really not just based on imaging. So we're not making all our decisions here in the hip and core on the MRI findings. What are the other parts that play into this? Well, getting back after core surgery is a lot faster. You can get back in three months. If you add in hip, it takes longer. It's a five to seven month recovery. It's less predictable maybe for Lyman. So really, when do we do one? Well, we really don't want to overtreat, but we don't want to undertreat. So can fixing one lead to resolution of the other? Well, we use these injections. So again, if you get complete relief of all your hip and core pain with a hip injection only, typically we just take care of the hip and let the core symptoms resolve. If it's a mixed bag, you may want to think about a combined procedure. If it doesn't change things at all when you inject the hip joint, this may just be a core problem. You may want to focus the energy on the core there. So it's really case by case. The other thing you want to consider is if you put the player into a deep hip internal rotation position and they say, yeah, that hurts, but that's really not the problem I'm seeing you for, you may want to reconsider. It's like O'Brien's test for the shoulder. Everything hurts when you put the hip into this deflection position. So just be careful with that. You want to really understand, is that your problem or is this something else? The only ones we really want to be a little bit more cautious with and not blow off are these young kids that come in with these huge CAM lesions. We know this can lead to long-term problems with the cartilage, as I showed in that earlier arthroscopy picture. So just to be cautious with the large CAM lesions in young kids that can lead to degeneration of the hip joint. What about hip instability is the last little talk here. So I think of hip instability as all these kind of fracture, dislocation, instability events. Post your hip dislocations, we see this in football players, post your wall fractures, treated by our trauma colleagues with typical fracture management. Hip subluxation, however, probably goes a little bit under-recognized. We're very comfortable with this idea with the shoulder, but it happens in the hip as well. This is a water skier who had a subluxation event, had a large loose body from, and you can see no fracture would not have been identified on an x-ray, but pretty significant loose body that was as a result of a subluxation event. So what are the current concepts with hip instability? Well, one of the issues, and this stems from, I love this paper from 1991, of course, Dr. Warren teaching us all about hip subluxation and the risk for AVN, you know, 30 years ago. Does FAI morphology lead to these events? What's the role for arthroscopy? What's the return to play? So there's some data just, you know, if you hear it out there, there's some data that impingement morphology may lead to some of these instability events as shown by this little schematic here, where if you have some mismatch in the hip range of motion, you may be predisposed to posterior subluxation event because of the CAM lesion. It's a little bit debatable, but this literature is out there from Brian Giordano from Rochester. What's the role for arthroscopy? Mark Philippon published this in 2009, and there's several other notes since then. We use arthroscopy after instability events mostly for treating some of the after effects of it, labral tears, cartilage lesions, loose bodies, when the patient does not, when the patient has typically persistent pain. It's not usually the first line treatment, and we oftentimes will rehab these, but there's some discussion when you see a loose body whether an arthroscopy is indicated early on. What about return to play? So you know, Mark Price and the group out of Boston just published their series looking at hip instability events, and we had this event shown last year with the Washington quarterback where typically, you know, this can be, as we'll see on kind of the slow motion here, you know, typical hit, but the knee jammed posteriorly. It can be a big issue whether it's non-surgically treated or surgically treated. Time loss from injury from these events is high, and we need to be aware of them as they're out there. So follow up, what do we do with these? Typically if there's MRI changes during the first three weeks, it's nonspecific. A normal MRI at four to six weeks doesn't require further imaging. Normal MRIs, we want to repeat to look for signs of avascular necrosis at three months when that typically will show on MRI. So it is worth following your athlete with a dislocation or subluxation event with a follow up MRI. And return to sport. Mark Safran's group showed successful return to sport, recent publication in AJSM of 87%, but 11% ultimately had radiographic evidence of osteonecrosis. So something to keep in mind and monitor for in your athlete. Thanks very much.

hip problems

muscular injuries

articular injuries

instability patterns

hip morphologies