Hip impingement


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nice article on the "in" diagnosis in the active athlete

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Hip impingement

  1. 1. American Journal of Sports Medicine http://ajs.sagepub.comFemoroacetabular Impingement in Professional Ice Hockey Players: A Case Series of 5 Athletes After Open Surgical Decompression of the Hip Mario Bizzini, Hubert P. Notzli and Nicola A. Maffiuletti Am. J. Sports Med. 2007; 35; 1955 originally published online Jul 3, 2007; DOI: 10.1177/0363546507304141 The online version of this article can be found at: http://ajs.sagepub.com/cgi/content/abstract/35/11/1955 Published by: http://www.sagepublications.com On behalf of: American Orthopaedic Society for Sports Medicine Additional services and information for American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Downloaded from http://ajs.sagepub.com by ANDREW CANNON on January 17, 2008 © 2007 American Orthopaedic Society for Sports Medicine. All rights reserved. Not for commercial use or unauthorized distribution.
  2. 2. Femoroacetabular Impingement inProfessional Ice Hockey PlayersA Case Series of 5 Athletes After Open SurgicalDecompression of the HipMario Bizzini,*† MSc, PT, Hubert P. Notzli,‡ MD, and Nicola A. Maffiuletti,† PhD †From the Neuromuscular Research Laboratory, Schulthess Clinic, Zurich, Switzerland, ‡and the Orthopaedic Department, Ziegler Hospital, Bern, SwitzerlandBackground: Femoroacetabular impingement of the hip joint has been identified as a major cause for hip pain in athletes.Surgical open decompression of the hip has historically been proposed as the first treatment of choice. Functional outcomes inathletes after this procedure are unknown.Purpose: To describe the functional and sport-related outcome 2 years after open surgical hip decompression in a group ofyoung professional ice hockey players suffering from cam femoroacetabular impingement.Study Design: Case series; Level of evidence, 4.Methods: Five young professional ice hockey players (mean age, 21.4 y at follow-up) who suffered from cam femoroacetabularimpingement were treated with open surgical decompression of the hip. The operation was performed by the same surgeon, andall athletes followed the same rehabilitation guidelines. Mean follow-up time was 2.7 years. Outcome measures were recordedas time to regain symmetrical hip rotation, regain preoperative core/hip muscle strength, return to team practice, and play atcompetitive level.Results: Hip rotation range of motion was regained by a mean 10.3 weeks. Core and hip strength values reached preoperativelevels by a mean 7.8 months. Return to unrestricted team practice with the ice hockey team was achieved by a mean 6.7 months,and athletes were able to play their first competitive game after a mean 9.6 months. Three athletes were able to perform againat the highest level and in international competitions. Two athletes had to return to minor league ice hockey.Conclusion: Return to high-level ice hockey after open surgical decompression of the hip was possible in this series of 5 con-secutive cases.Keywords: femoroacetabular impingement; surgical open decompression; ice hockey; rehabilitation; return to playFemoroacetabular impingement (FAI) of the hip joint has external rotation. For the goaltender (often using the but-been identified as a major cause for hip pain, reduced terfly technique), the hip joint is stressed in flexion andrange of motion (ROM), and decreased performance in the internal rotation (end of range).25,27 The association ofathlete.23 Philippon and Schenker23 reported that 57 of 157 these combined movements and the presence of any abnor-professional athletes who underwent hip arthroscopic sur- mality of the femoral head-neck junction are potentiallygery required decompression for FAI. detrimental for the labrum and the acetabular rim. In ice hockey, the players may suffer from traumatic and Although very little is known of the cause,22,24 the cam-overuse type of hip injuries. During skating (as a field type FAI14,16 is currently more frequently diagnosed inplayer), the hip is mainly loaded in flexion, abduction, and young elite ice hockey players (M. Bizzini et al, unpub- lished data, 2006).23 *Address correspondence to Mario Bizzini, MSc, PT, Neuromuscular Because of the severe hindrance to sports performance, openResearch Laboratory, Schulthess Clinic, Lengghalde 2, 8008 Zurich, surgical dislocation procedures have historically been pro-Switzerland (e-mail: mario.bizzini@kws.ch). posed as the first treatment option for FAI decompression.9,10 No potential conflict of interest declared. The aim of this case series was to describe the functionalThe American Journal of Sports Medicine, Vol. 35, No. 11 and sport-related outcome 2 years after open surgicalDOI: 10.1177/0363546507304141 decompression of cam FAI in a group of young professional© 2007 American Orthopaedic Society for Sports Medicine ice hockey players. 1955 Downloaded from http://ajs.sagepub.com by ANDREW CANNON on January 17, 2008 © 2007 American Orthopaedic Society for Sports Medicine. All rights reserved. Not for commercial use or unauthorized distribution.
  3. 3. 1956 Bizzini et al The American Journal of Sports Medicine TABLE 1 Characteristics of the 5 Athletesa Duration Age at National Involved of Symptomsb FU Time (Mo)Patient FU, y Position Team Hip (mo) at December 20061 21 Forward Yes (Junior) Left 10 442 22 Goaltender Yes (1st team) Right 18 363c 22 Forward Yes (Junior) Right 9 33 Left 16 264 22 Forward Yes (1st team) Right 13 325 20 Defender Yes (Junior) Right 12 20 a FU, follow-up. b Duration of symptoms from onset to surgery. c Bilateral hip surgery (with a 7-month delay between the 2 interventions).MATERIALS AND METHODS including the piriformis. The gluteus minimus is dissected from the capsule. A Z-shaped capsulotomy exposes the hipPatient Population joint, which can be examined for an intra-articular bony impingement. If necessary, the ligamentum teres is cut toThis prospective case series included 5 young players allow the complete dislocation of the femoral head and to(mean age, 21.4 y; range, 20-22 y) of a Swiss professional expose the cartilage of the acetabulum and the femoralice hockey team with diagnosed cam FAI.16 head itself. In cases with a labral lesion, the revision of the These athletes (1 goaltender, 1 defender, and 3 forwards) labrum is done first. The damaged areas of the labrum arewere playing for the same team in the professional ice hockey completely detached from the acetabular rim, and the excessleague in Switzerland. The 5 players were regularly selected bone is, if possible, trimmed back to the level of stable carti-for the Swiss national teams (first junior selections, then lage. Unstable cartilage has to be removed, and thereforemain national team). The athletes were suffering from unspe- areas uncovered by cartilage may remain (here microfracturecific hip/groin pain for an average time of 13 months (range, may be indicated to stimulate cartilage repair). Finally, a nor-9-18 mo) from onset to surgery (Table 1). They all had failed mal concave neck contour is re-created by subsequentialconservative treatment; massage and gentle traction of the osteotomies under careful protection of vessels responsible forhip joint were helpful in a momentary reduction of the symp- the femoral head perfusion (medial femoral circumflextoms, while forceful stretching and ROM exercises exacer- artery11,21). After reduction of the hip joint, the mobility isbated the symptoms. The loss of ROM in hip rotation tested, especially in the combined flexion/ adduction/internal(especially internal rotation) was the main performance- rotation position, to confirm that the bony impingement doeslimiting factor. The FAI was first misdiagnosed, and the not exist anymore. Then the capsular flaps are loosely reap-signs and symptoms were classified under “groin pain.” By proximated with an absorbable suture, and the osteotomizedthe time the athletes were finally looked at by a hip spe- greater trochanter is fixed with two 3.5-mm cortical screws.cialist, they were no longer able to play. Clinical examina- In the 5 athletes (6 hips), the surgical treatment consistedtion showed a painful hip joint with reduced ROM in of removing the nonspherical portion of the femoral headinternal rotation29 and a positive impingement test result and creating a normal waist at the femoral head-neck junc-(symptom reproduction with a combined maneuver of pas- tion by reducing the bone as far as the intertrochantericsive flexion, adduction, and internal rotation).15,19 All ath- region (Figure 1 A and B). In all cases, an additional refixa-letes underwent conventional magnetic resonance (MR) tion of the labrum to the acetabular rim (after resectionarthrography (with gadolinium contrast)14,17,18 and plain arthroplasty of the excessive anterior rim) with anchoredradiography (2 planes: anteroposterior and crosstable lat- sutures was performed first (Figure 1 C and D). None of theeral views)7 before surgery. In all cases, cam FAIs (reduced hips had articular cartilage lesions requiring debridementfemoral head and neck offset) with associated labral or microfracture. The operations were performed by thelesions19 (located primarily anterosuperior) were diag- same orthopaedic surgeon.nosed, and surgical treatment was planned. The operationswere performed between 2003 and 2005. RehabilitationSurgical Technique The 5 athletes followed the same rehabilitation guidelines and were supervised by the same physical therapist. TheThe athletes underwent a surgical open hip dislocation; rehabilitation was divided into 5 phases. Phases II to IVthis technique is described in detail elsewhere.9,16 In sum- were not strictly time-based but rather dependent on themary, the patient is placed in a stable lateral decubitus individual progress of the patient during training. Theposition. The trochanteric osteotomy approach allows for return to sport (phase V) was allowed only if important cri-exposure of the hip capsule while respecting the integrity teria (ROM, strength, sport-specific neuromuscular control)of the gluteus medius and the external rotator muscles, were met (M. Bizzini et al, unpublished data, 2006).3,12 Downloaded from http://ajs.sagepub.com by ANDREW CANNON on January 17, 2008 © 2007 American Orthopaedic Society for Sports Medicine. All rights reserved. Not for commercial use or unauthorized distribution.
  4. 4. Vol. 35, No. 11, 2007 Femoroacetabular Impingement in Professional Ice Hockey Players 1957Figure 1. Intraoperative photographs of the right hip joint of patient number 2. The femoral head (FH) and neck junction (NJ) areshown before (A) and after (B) the resection osteoplasty. Before this intervention, the damaged labrum (L) was repaired and refix-ated (C-D). Phase I or “Maximal Protection Phase” (0 to 6-8 Weeks). Phase V or “Return to Sport” (From Week 25). This phaseIn this phase, the patient was allowed to ambulate toe- included the unrestricted return to practice with the icetouch weightbearing. The goals were optimal healing of the hockey team and later the full return to the game or play-trochanter osteotomy and healing of the labrum and of the ing a competitive ice hockey match.soft tissues.16 Active ROM exercises were not performed, and passiveflexion was limited to 70°. In the first postoperative week Outcome Measures(hospital stay), a passive motion device was used.16 Phase II or “Controlled Ambulation Phase” (9-12 Weeks). The athletes were followed for an average of 2.7 years post-The phase lasted until the patient could walk without operatively (range, 1.8-3.8). Hip ROM for internal/externalcrutches, with minimal symptoms, and minimal limping. rotation was examined with the subject in a prone position Passive and active ROM exercises (without forcing) were on a padded table with the test knee flexed to 90° and thebegun. Sensorimotor exercises2 to promote neuromuscular hip in neutral rotation.5 Range of motion measurementscontrol of the pelvis and lower extremity were emphasized, were performed using a goniometer.13and strengthening exercises for the abductors were initiated. Core and hip muscle strength was documented with a test Phase III or “Controlled Progression Phase” (13-18 Weeks). battery adopted by the Swiss Olympic Medical Centers. TheThe goal of this phase was to improve the neuromuscular tests for the ventral, lateral (Figure 2), and dorsal core/hipstabilization and to begin the sport-specific strength and muscle chains were proven to be valid and reliable.4,26endurance training. Abductor muscle strengthening was The exact times to regain hip ROM, to match the preop-also intensified, and weight training was started. erative core/hip muscle strength, to unrestricted team Phase IV or “Intensive Training Phase” (19-24 Weeks). training on the ice, and to the first appearance in a com-This phase included an intensive training of the different petitive game were recorded by the sport physical thera-parameters: flexibility, coordination, agility, strength, and pist supervising the postoperative rehabilitation andendurance. The athlete was allowed to follow an individual training of the athletes.program on the ice, where the basic skating moves were An oral numeric 0-to-10 rating scale28 was used through-trained.27 out the rehabilitation process to document pain. The athletes Downloaded from http://ajs.sagepub.com by ANDREW CANNON on January 17, 2008 © 2007 American Orthopaedic Society for Sports Medicine. All rights reserved. Not for commercial use or unauthorized distribution.
  5. 5. 1958 Bizzini et al The American Journal of Sports Medicine TABLE 2 Postoperative Clinical and Functional Outcomesa Patient 1 2 3b 4 5Time to symmetrical ROM (rotation), wk 8 11 10, 11 9 13Time to regain preoperative core/hip muscle strength, mo 5.5 6.5 6, 9.5 7.5 12Time to unrestricted ice training with team, mo 5.5 6 6.5 6 9.5Time to first competitive game with team, mo 7 9 10 8 14Playing with team at FU (Y/N) Y Y N Y NReturn to national team (Y/N) Y (Jr WC ′05, ′06) Y N Y (WC ′05) N a ROM, range of motion; FU, follow-up; WC, World Championship of the International Ice Hockey Federation; Y, yes; N, no. b Bilateral hip surgery (with a 7-month delay between the 2 interventions). There were no intensive training or games between the firstand second surgery. At the time of follow-up (mean, 2.7 y), 3 patients were fully reintegrated in the team and playing in the Swiss ice hockey professional league. These 3 players were selected again for the Swiss national teams. The other 2 players (1 of them had surgery on both hips), also pain- and symptom-free, were not able to reach their preoperative level of performance and were sent to the farm team (minor league ice hockey). DISCUSSION Few studies1,20 have analyzed the outcomes in individual patients after surgical open decompression for FAI treat- ment. Beck et al1 presented a retrospective case series of 19 FAI patients treated with the open bony resection pro- cedure (follow-up, 4.0-5.2 y). Murphy et al20 reported the results of 23 FAI patients treated with open bony debride-Figure 2. Test settings for the lateral core (trunk) and hip mus- ment (follow-up, 2-12 y). In these studies, good results werecle strength. The subject, in a side-lying position, moves the found in patients with early degenerative changes notpelvis up and down between the mat and the bar in a defined exceeding grade I osteoarthrosis of the hip joint. The Merlerhythm. The bar’s height is adjusted individually. The number of d’Aubigné and Postel Hip Score were used as outcomerepetitions and the time are monitored by the examiner. The measures (typically used in total hip arthroplasty follow-test is stopped when the subject loses his body control while ups), and no details concerning the (sports) activity level ofmoving or when he is no longer able to touch the bar. these patients (average age, 35-36 y) were given. There are no published studies on the functional out- come after FAI treated with open surgery in athletes.were allowed to return to team training and to full com- When dealing with high-level athletes, not only is thepetitive game only if they were pain-free. “return to play” important, but even more so, the return The present study was approved by the local Ethics to unrestricted training and competitive sport are crucialCommittee for Human Subjects Research. (M. Bizzini et al, unpublished data, 2006).3 In this case series, the 5 ice hockey players were able to return to high-level sports, on average, more than 9 monthsRESULTS after surgery. Interestingly, there was no difference concerning outcomes between the goaltender and the other 4 field players.The demographic characteristics of the athletes are pre- A goaltender’s hip is usually significantly more stressed thansented in Table 1, while the clinical functional outcomes a field player’s, but in this small group, the goaltender wasare listed in Table 2. among those able to return to play at the highest level. Return to preoperative ROM (internal and external rota- Although Ganz et al9,10 showed that the surgical disloca-tion) of the involved hip joint was achieved at a mean of 10.3 tion of the hip with proper technique is a safe procedure, thisweeks (range, 8-13) after surgery. The patients reached their represents a major operation. Bone (trochanter osteotomy)preoperative core/hip strength level by a mean of 7.8 months and soft tissue (dissection of the gluteus minimus, capsulo-(range, 5.5-12). The athletes were able to return without symp- tomy) interventions are relevant, and the healing of thesetoms (pain score = 0) to unrestricted team practice on the ice structures needs time. These considerations may explainat a mean of 6.7 months (range, 5.5-9.5) postoperatively. The why the athletes needed several months (more than 6 onplayers could participate in their first competitive game average) before regaining their preoperative core/hip mus-after a mean of 9.6 months (range, 7-14). cle strength. Downloaded from http://ajs.sagepub.com by ANDREW CANNON on January 17, 2008 © 2007 American Orthopaedic Society for Sports Medicine. All rights reserved. Not for commercial use or unauthorized distribution.
  6. 6. Vol. 35, No. 11, 2007 Femoroacetabular Impingement in Professional Ice Hockey Players 1959 Philippon and Schenker23 suggested that the operative 6. Byrd JW. The role of hip arthroscopy in the athletic hip. Clin Sports Med. 2006;25:255-278.trauma sustained during the open procedure might make 7. Eijer H, Leunig M, Mahomed MN, Ganz R. Cross-table lateral radi-it difficult for high-level athletes to return to play. The ographs for screening of anterior femoral head-neck offset in patientsarthroscopic surgical approach seems to reduce postopera- with femoroacetabular impingement. Hip Int. 2001;11:37-41.tive morbidity and provide a shorter rehabilitation time 8. Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenkerand quicker return to play for athletes.6,23 Enseki et al,8 in ML. The hip joint: arthroscopic procedures and postoperative rehabil-discussing the rehabilitation after hip arthroscopic proce- itation. J Orthop Sports Phys Ther. 2006;36:516-525. 9. Ganz R, Gill TJ, Gautier E, et al. Surgical dislocation of the adult hip adures, stated that “typically, athletes can return to a com- technique with full access to the femoral head and acetabulum withoutpetitive environment in 10 to 32 weeks.” However, there is the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119-1124.so far no publication on the outcomes in athletes after 10. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA.arthroscopic surgery for FAI decompression. Femoroacetabular impingement: a cause for early osteoarthritis of the In this case series, the athletes were able to return to hip. Clin Orthop. 2003;417:112-120.competitive ice hockey. But the necessary amount of reha- 11. Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Jointbilitation and sport-specific training was considerable, and Surg Br. 2000;82:679-683.not every athlete could reach his preoperative playing skill 12. Griffin KM. Rehabilitation of the hip. Clin Sports Med. 2001;20:837-847.and performance. Two field players and the goaltender did 13. Holm I, Bolstad B, Lutken T, Ervik A, Rokkum M, Steen H. Reliabilityreturn to high-level ice hockey performance (including not of goniometric measurements and visual estimates of hip ROM inonly the Swiss professional league, but also the Swiss patients with osteoarthritis. Physiother Res Int. 2000;5:241-248.National Team). The 2 other athletes were able to compete 14. Ito K, Minka MA 2nd, Leunig M, Werlen S, Ganz R. Femoroacetabularin second division, but their performance level was not impingement and the cam effect: an MRI-based quantitative anatom- ical study of the femoral head-neck offset. J Bone Joint Surg Br.enough for the professional league. 2001;83:171-176. 15. Klaue K, Durnin CW, Ganz R. The acetabular rim syndrome: a clinicalCONCLUSION presentation of dysplasia of the hip. J Bone Joint Surg Br. 1991;73:423-429.Historically, treatment for FAI consists of an open surgical 16. Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement: part I. Techniques of joint-decompression of the hip. Taking the unrestricted full preserving surgery. Clin Orthop. 2004;418:61-66.return to competitive sports as a criterion, this type of sur- 17. Leunig M, Werlen S, Ungersbock A, Ito K, Ganz R. Evaluation of thegery, combined with an intensive rehabilitation program, acetabular labrum by MR arthrography. J Bone Joint Surgwas successful in 3 out of 5 ice hockey players suffering Br.1997;79:230-234.from cam FAI. The other 2 were not able to reach their 18. Locher S, Werlen S, Leunig M, Ganz R. MR arthrography with radialprevious playing level. The return to play at competitive sequences for visualization of early hip pathology not visible on plainlevel was reached after 9.6 months. The hip musculature radiographs. Z Orthop Ihre Grenzb. 2002;140:52-57. 19. Martin RL, Enseki KR, Draovitch P, Trapuzzano T, Philippon MJ.strength needed several months before reaching preopera- Acetabular labral tears of the hip: examination and diagnostic chal-tive levels, and this was certainly a reason for the length of lenges. J Orthop Sports Phys Ther. 2006;36:503-515.rehabilitation and a concern for professional athletes. 20. Murphy S, Tannast M, Kim YJ, Buly R, Millis MB. Debridement of the adultLonger-term outcomes for open surgical decompression of hip for femoroacetabular impingement. Clin Orthop. 2004;429:178-181.the hip in high-level athletes are still unknown. 21. Notzli H, Siebenrock KA, Hempfing A, Ramseier LE, Ganz R. Perfusion of the femoral head during surgical dislocation of the hip. Monitoring by laser Doppler flowmetry. J Bone Joint Surg Br. 2002;84:300-304.ACKNOWLEDGMENT 22. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The contour of the femoral head-neck junction as a predictor of riskThe authors gratefully acknowledge Dr U. Brunner of anterior impingment. J Bone Joint Surg Br. 2002;84:556-560.(Kloten, Switzerland) for his cooperation throughout the 23. Philippon MJ, Schenker ML. Arthroscopy for the treatment ofstudy, and Mr C. McCammon (Research Department, femoroacetabular impingement in the athlete. Clin Sports Med. 2006;Schulthess Clinic, Zurich, Switzerland) for the English 25:299-308. 24. Siebenrock KA, Wahab KH, Werlen S, Kalhor M, Leunig M, Ganz R.revision of the article. Abnormal extension of the femoral head ephiphysis as a cause of cam impingement. Clin Orthop. 2004;418:54-60.REFERENCES 25. Torry MR, Schenker ML, Martin HD, Hogoboom D, Philippon MJ. Neuromuscular hip biomechanics and pathology in the athlete. Clin 1. 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