So I'm going to take us on a tour of the hip here. I'm a sports medicine trained hip arthroscopy, hip preservation physician. So this is something we all see, but there's not much guidance out there or history with the hips. So hopefully, we'll take a little bit of a whirlwind tour here around the hips. So why is this important? This study out of AJSM in 2020 shows us the injury burden of these hip and groin and thigh injuries. The thigh being the hamstring, we all know the burden that these hamstring injuries have. But the hip and groin is not insignificant. So it's important to keep in mind and be comfortable managing these players. The interesting thing about the hip, and we had a conference at our institution last year about this, is it's starting to think about the hip in your athletes, that the hip takes very different forms depending on the athlete and the injury patterns. And the pathology is different based on what your player is doing. So we have one of my senior partners coined the term hockey player's hip. Hockey players have these impingement, these FAI hips. It's very different than the gymnast who has an unstable hip and is lax as compared to the baseball player who's 5 million times over a lifetime been turning in one direction on a hip. You're going to have different pathology based on their sport. So just keep this in mind that all hips aren't the same. What are we seeing in the athlete? I break this down into very simplistic forms in muscular injuries, articular injuries, groin injuries, which have a vague combination of terms characterizing them. I've called this instability, but kind of the fracture subluxation dislocations that we see around the hip. So, and I'm going to have a little bit more of a focus on football, given that that's the sport I take care of primarily, but really can apply this to any of the sports we've talked about. So we see a lot of muscular injuries around the hip. We have the benefit, like Drew mentioned, of having immediate imaging of all of our injuries and follow-up imaging. So we use MRI quite a bit in understanding these soft tissue injuries around the hip and core. And I think they're very valuable. The take home with this is I would say, work with your radiologist just to make sure you're getting a good MRI sequence, whether it's an MRI of the pelvis that you want or a non kind of arthrogram unilateral hip imaging. I don't use really arthrogram around the hip at all because I like these edema patterns around the hip. Looking for soft tissue injury, looking for articular injury, looking for an effusion. You know, if the player had an injury, I would recommend not kind of loading them up with arthrogram material. You're not going to see an effusion. So I really, take home here is get a good imaging sequence with your radiologist so you have, you're looking for the right things. What do we do? Well, typical rehab for these soft tissue injuries around the hip and core is typical stuff that you're working with your athletic trainers. It's rest period of maintaining cardiovascular fitness. It's not being too concerned that the radiologist said, there's a labral tear. It's working on modalities. We use, I'll talk a little bit later about injections. We do use injections around the hip and core. It's strengthening and then it's returned to sport. And we've taken a lot from the hamstring. We really use GPS monitoring and workload progression and accelerations to monitor our progression with any of these injuries back to sport. And I frankly have also taken a lot from kind of return to sport, ACL, return to sport to the hip and core and just making sure they've got a balanced workload and can progress back into more dynamic activities before we let them back. The couple of surgical parts of this are what are we doing with these hamstring injuries? And typically we've taken the approach of fixing the acute hamstring avulsions mostly because we know that there's a subset of patients that do okay with non-surgical treatment, but if they don't, then they're in a tough spot because chronic repair doesn't do well and patients with chronic symptoms oftentimes don't have a good outcome. So we've generally taken literature supports doing an acute repair of a proximal hamstring avulsion in an athletic hip. What about the adductor? And we'll maybe talk a little bit later about the adductor. Classically, these have been almost all treated, particularly, certainly the muscle injuries, but even the avulsions off the pubic bone, there's support to treat these non-surgically. We've taken the approach and other institutions have kind of taken the approach to possibly treat these more like hamstrings where you have an acute injury that involves the periosteum and all that collagen that's come off the pubic bone there. Serena Barnum in New York and others, Mike Gerhart in LA have published their outcomes with repairing these adductors. And we've taken the same approach at our institution. If we have a big adductor avulsion, we've had soccer players, we've had football players, we've gone to start to repair these more often currently. So what about the joint itself, the articular injury that we're all very concerned about and its possible progression into arthritis of the hip? So what is FAI? Are those terms thrown around? Is it a radiographic finding? Is it a combination of symptoms? But most basically, this is a group of hip disorders that are related to the structure of the hip joint and then the loads that are put on the hip and then the symptoms that result as a result. So it's a common mechanism. We have some abnormal morphology that leads to premature contact between the femur and the socket. So what does that lead to? It's really, it's not a radiographic diagnosis. We know from many studies that 30, 40, 50% of patients, players, and particularly in twisting sports have these features on their radiographs. So the radiographs don't worry us. It's when the patients develop this syndrome. So this has been described now more accurately as an FAI syndrome, which is a combination of these radiographic features, clinical signs, i.e. physical exam maneuvers that reproduce these symptoms, positive impingement test, positive fader sign, and then clinical symptoms that the patient reports, typical for this. So when we have these features, then we make this diagnosis of FAI syndrome. And it doesn't necessarily involve an MRI showing that there's a labral tear or not. Really, the MRI is probably the least important part of this fulfilling the picture. So typically these players, these patients that come to see you in your general office, sometimes they're high-level players. Oftentimes they're weekend people that just sit at their desk and then they play soccer with their kids and now their hip hurts and they're 30 years old. And they come in and they say, I'm having a hard time getting in and out of the car. I can't exercise with my kids. I have groin pain. I have some C-shaped pain. What are we gonna do? Oftentimes also they may have some compensatory problems. So they may also come in with some pubalgia symptoms, some low back pain, some radiating pain. But really think about the hip as the kind of core of this. And then a lot of these other problems can be secondary, particularly the back with these older athletes and kind of the years of abnormal mechanics from their hip. So what do we do? First, we oftentimes talk them off the ledge that their radiologist told them they have a labral tear. Not the end of the world. I talked to them about being a symptom of the problem. It's not the problem. Most patients with FAI can be treated initially, particularly the athlete in season. We try to give them a period of non-operative treatment. It's rest, it's shutting them down. It's NSAIDs, it's good PT to work on their core. Much of the same stuff that Drew talked about. We do use some injections, particularly for diagnosis I use them. I use most commonly, I'll use just local anesthetic for diagnosis. I'll put it in somebody's hip joint. Do you get better? Okay, this is a symptomatic hip joint. I don't typically use steroid in the joint in general, but in select cases, particularly in the athletes here, we commonly in season, we'll use things like VSCO, PRP with a professional team. We have the benefit of having a stock room of Euflexa or other VSCO. And so even though it's not indicated through insurance companies, we've had good success using VSCO in the hip for a symptomatic FAI. And you can get it actually. If you have a patient that's responded real well on their knee and you wanna do VSCO in their hip, they can order it from Canada or other online places. And it's a very good application. PT, what are we gonna do? Much of the same stuff. It's core stability. It's lumbopelvic stability. It's discouraging their therapist from doing active hip flexion exercises, which aggravate their iliopsoas. It's getting their pelvic tilt back. It's working on a gradual progression back to sport. And oftentimes, these patients with a symptomatic FAI joint can return to sport. When do we think about surgery for this? Well, it's really when we have this syndrome, we have this clear diagnosis. Sometimes we need a diagnostic local anesthetic injections. They have a relatively healthy joint. They've failed to respond to non-surgical care. And then we think about an arthroscopic procedure. And this is the common finding intraoperatively. You see you've got a big labral tear. You've already got chondral injury. So there are some groups of patients, and we'll talk about a little bit further, that were a little more aggressive with surgery just based on their age and their morphology of their hip. But the common endpoint is this damage to the end of the S-tabular rim. So how do these players do? Brian Kelly's group published in 2017 a report of FAI in the NFL, and they're good outcomes. I mean, these players get back to play. Mean outcome is six months. I tell my patients it's usually about five to six months to get back to sports. And they have a similar career to their peers. So if it comes to surgery, this is a good operation, particularly for football players. And a lot of the FAI surgery, less reproducible, I would say, in the more unstable hip or the dancer or the gymnast. But that's where the difference in sport comes in. So what are these? We've used the term groin pain syndrome. And so this syndrome is a clinical symptom in the inguinal pubic adductor area affecting sports. This came out of the Italian Consensus Group in 2016. But we've all heard these terms, right? Sports hernia, pubalgia, sportsman's hernia, adductor strain. And so they all kind of fall into this group of problems around the hip and core that aren't necessarily hip FAI or hip labral tears. The group with the Doha Agreement in 2015, this group sought to try to define this a little bit better, because this has been a bit of a black box for all of us for years, where it was characterized once upon a time as a sports hernia. It's not really a hernia. And it's been kind of a nebulous kind of group of terms since then. So I think of a good way of thinking about this is really like we do in other areas of the body, where is the pain and kind of what's driving it? What's the pathophysiology here? So these players can come in with more adductor-based problems. They can have iliopsoas, kind of hip flexor problems. They can have inguinal pain. They can have very commonly pubic bone pain, which we'll go through a little bit. Then we have this kind of combination of where the hip fits into this. And so start thinking about these problems based on the pathophysiology. Most commonly, this is a result of this third joint around the hip, the pubic joint, where the rectus comes down and attaches into this aponeurosis where the adductor comes up and they kind of form this thick band of collagen over the pubic bone here. And there are a lot of little sensory nerves. There's your inguinal canal right there. And this is where these symptoms arise from. How does this fit in with hip and FAI? This is from Brian Kelly and Patrick Birmingham's group that we think the abnormal mechanics and stresses from the hip joint also probably drive some of this where the hip repeatedly goes into these deep flexion positions. It affects their SI joint, affects their pubic bone. We get osteitis pubis, or we get this inflammation around the pubic bone. Probably it's more likely the result of mechanical issues than any other inflammatory or other cause that people have in the past have thought about osteitis pubis. Most commonly, we see these problems either, when you see these patients, push on them, see where they hurt. If they hurt right on the pubic bone or right on the adductor at its attachment, this is really a problem with this part of the pubic joint. Other times, they'll hurt more laterally. This very commonly can be seen with kind of some weakening of the inguinal floor. It's not truly a direct hernia. This is a intraoperative view of kind of the weakening of that floor that one of my general surgery colleagues who I work with is kind of demonstrating here. But this can oftentimes lead to irritation of some of these little sensory nerves. And they'll have a little more laterally based pain and probably no radiographic findings. So there's really no specific radiographic finding for particularly this pattern. Well, we wrote about this a few years ago, Brian Zuccarone and I, one of the general surgeons at our institution. And we tried to review some of the techniques that are out there for this. So you may hear your general surgery colleagues talking about repair of this area. So what are they typically doing? They're taking an approach that either involves repairing the inguinal floor, like we see in B, releasing the adductor or lengthening the adductor, doing some combination. Oshuak is the surgeon in Munich that takes care of a lot of the soccer players over there, where it's a combination of repair of the inguinal floor, extending onto the lateral rectus, or the classic Myers repair from Philadelphia, which is kind of reinforcement of this lateral border of the rectus to the periosteum. And then oftentimes lengthening of the adductor tendon sheath. So it's not such a black box out there. It's anatomy like we all deal with in other parts of the body. The issue here is this takes, at least in our hands, a combination of orthopedic surgeon and a general surgeon to kind of work through this and understand, is this a hip, is this a core? When do we operate on this, and who operates on it, or both of us operate on it? So how do we do this? Chris Larson presented this, and I'm grateful to him for sharing some of his slides. At 2019 at the NFL Physician Society, the question was, when do we operate on the hip, when do we operate on the core, and what are the dilemmas here? So what, as I mentioned earlier, what we know is that most of these patients have some sort of documented labral abnormality on their hip MRI, if you get them, and they all have FAI. They have x-rays that show a little CAM lesion or a little reactive change of their acetabulum. So what do we do with them? A third of them will have some evidence of pubalgia, some bone marrow edema, some change in the rectus or the adductor. How do we confirm where the problem's coming from? So it's, again, back to history, physical, and these diagnostic injections are really helpful in my hands, particularly local anesthetic injections. The problem is that the core injury surgery is a much faster return to play. So if you have just a core problem, probably wanna just take care of the core. FAI, it's a good surgery with hip arthroscopy, but it takes longer, and you don't wanna violate the hip joint if you don't have to. So when do we do both? When do we do one, when do we do the other? Can fixing the hip lead to resolution of the core? These are all the things that we kind of struggle with in our players. So I use these injections, a little diagram, you know, particularly the local anesthetic. I think if you put steroid in there, they get relief of, you know, everything feels better with a steroid. Their back feels better, their hip feels better. So I really value those first couple hours after the local anesthetic injection. I re-examine them in my office. I see, I push on them again. I put their hip into these end range positions, and, you know, does their hip get better? Does it all get better? Does their core get better? And that really helps to guide some of our decision-making. You know, the thing to talk about with the surgical timing is when do we do this? You know, most of these hip FAI problems, if they can manage it during the season, we can fix it after the season. And the other thing to keep in mind, the pain that does not recreate the symptoms, you put anybody's hip into a deep end range position, usually it hurts. But if that's not what they're coming in for, then, you know, you have to take that with a grain of salt. You know, the end range deep fader position hurts not all of us. The last piece I mentioned earlier is some of these young kids with significant morphologic changes, big CAM lesions, they're already breaking down their cartilage. These are the kids we probably should be a little more aggressive with surgery to try to protect their hip in the long run. Last piece I wanted to hit on is hip instability. I've grouped these all together. What does this encompass? Well, we see these. We see these in our football players, hip dislocations, acetabular fractures, opostatus post-ORF, we see instability, posterior subluxations, where you have loose bodies. I would start to think about the hip a little bit more like the shoulder, you know, and just be aware when somebody comes in three weeks after what seemingly was a benign injury and they still can't put weight down, they may have subluxed their hip and just kind of, you know, keep your antennas up for these types of instability events. So the current things we're thinking about is how does morphology lead to some of these events? What's the role for arthroscopy? When can we let these players back to play? And do we need follow-up imaging? So Brian Giordano and their group out of Rochester published this concept that CAM morphology may lead to some predisposition to some of these instability events based on the morphology. There's still more work to be done here, but this is the kind of concept that some of these morphologic structures may lead to some of these posterior instability events in these athletes. So keep your antennas up. Hip arthroscopy, when is it used? We typically will use this for persistent pain as Mark Philippon and the group described several years ago. You know, just because someone has a subluxation event doesn't necessarily mean they all have to be rushed off for surgery if they have a labral tear or even a small loose body. So you can rehab these players, you can treat them like a shoulder subluxation, but if it persists or if the loose body is really big, that's when I start thinking about hip arthroscopy surgery. Mark Price and the group out of Boston published this report from the NFL data, you know, showing kind of the, at least the publicly reported data on hip instability events and time lost. And we have an example kind of on the right of the Washington quarterback being, you know, all normal play, but just falling onto that flex knee, hips driven posteriorly, subluxation event, time lost, and oftentimes it's similar whether you have surgery or not. When do we need MRI follow-up? So if the MRI changes during the, MRI changes in the femoral head are pretty common in the first three weeks. I, yeah, if the MRI is normal at four to six weeks, we don't get follow-up imaging. Abnormal signal, then you follow it up to look for ABN, because that's kind of what we're all trying to watch out for in the future. Return to play, Mark Safran's group reported that players can get back really only about an 86 to 87% successful return to play. So there is a real issue here with potential for osteonecrosis and kind of sport changing injury. All right, thanks very much.

hip injuries

rehabilitation

diagnosis

treatment

hip arthroscopy