Return to Professional Ice Hockey After Hip Surgery

American Journal of Sports
Medicine
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Femoroacetabular 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

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Femoroacetabular Impingement in
Professional Ice Hockey Players
A Case Series of 5 Athletes After Open Surgical
Decompression of the Hip
Mario 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, Switzerland

Background: 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 in
athletes after this procedure are unknown.
Purpose: To describe the functional and sport-related outcome 2 years after open surgical hip decompression in a group of
young 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 femoroacetabular
impingement were treated with open surgical decompression of the hip. The operation was performed by the same surgeon, and
all athletes followed the same rehabilitation guidelines. Mean follow-up time was 2.7 years. Outcome measures were recorded
as time to regain symmetrical hip rotation, regain preoperative core/hip muscle strength, return to team practice, and play at
competitive level.
Results: Hip rotation range of motion was regained by a mean 10.3 weeks. Core and hip strength values reached preoperative
levels 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 again
at 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 play

Femoroacetabular 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 and
range of motion (ROM), and decreased performance in the internal rotation (end of range).25,27 The association of
athlete.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 potentially
gery 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 in
player), 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, open
Research 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 functional
The American Journal of Sports Medicine, Vol. 35, No. 11 and sport-related outcome 2 years after open surgical
DOI: 10.1177/0363546507304141 decompression of cam FAI in a group of young professional
© 2007 American Orthopaedic Society for Sports Medicine ice hockey players.

1955

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 2006

1 21 Forward Yes (Junior) Left 10 44
2 22 Goaltender Yes (1st team) Right 18 36
3c 22 Forward Yes (Junior) Right 9 33
Left 16 26
4 22 Forward Yes (1st team) Right 13 32
5 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 hip
Patient Population joint, which can be examined for an intra-articular bony
impingement. If necessary, the ligamentum teres is cut to
This 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 femoral
ice 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 are
were playing for the same team in the professional ice hockey completely detached from the acetabular rim, and the excess
league 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 therefore
main national team). The athletes were suffering from unspe- areas uncovered by cartilage may remain (here microfracture
cific 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 subsequential
conservative treatment; massage and gentle traction of the osteotomies under careful protection of vessels responsible for
hip joint were helpful in a momentary reduction of the symp- the femoral head perfusion (medial femoral circumflex
toms, while forceful stretching and ROM exercises exacer- artery11,21). After reduction of the hip joint, the mobility is
bated 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 does
limiting 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 osteotomized
the 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 consisted
tion showed a painful hip joint with reduced ROM in of removing the nonspherical portion of the femoral head
internal 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 intertrochanteric
sive 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 resection
arthrography (with gadolinium contrast)14,17,18 and plain arthroplasty of the excessive anterior rim) with anchored
radiography (2 planes: anteroposterior and crosstable lat- sutures was performed first (Figure 1 C and D). None of the
eral views)7 before surgery. In all cases, cam FAIs (reduced hips had articular cartilage lesions requiring debridement
femoral head and neck offset) with associated labral or microfracture. The operations were performed by the
lesions19 (located primarily anterosuperior) were diag- same orthopaedic surgeon.
nosed, and surgical treatment was planned. The operations
were performed between 2003 and 2005.
Rehabilitation

Surgical Technique The 5 athletes followed the same rehabilitation guidelines
and were supervised by the same physical therapist. The
The athletes underwent a surgical open hip dislocation; rehabilitation was divided into 5 phases. Phases II to IV
this technique is described in detail elsewhere.9,16 In sum- were not strictly time-based but rather dependent on the
mary, the patient is placed in a stable lateral decubitus individual progress of the patient during training. The
position. 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

Vol. 35, No. 11, 2007 Femoroacetabular Impingement in Professional Ice Hockey Players 1957

Figure 1. Intraoperative photographs of the right hip joint of patient number 2. The femoral head (FH) and neck junction (NJ) are
shown 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 phase
In this phase, the patient was allowed to ambulate toe- included the unrestricted return to practice with the ice
touch 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 passive
flexion 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/external
crutches, 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 the
begun. Sensorimotor exercises2 to promote neuromuscular hip in neutral rotation.5 Range of motion measurements
control of the pelvis and lower extremity were emphasized, were performed using a goniometer.13
and 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. The
The goal of this phase was to improve the neuromuscular tests for the ventral, lateral (Figure 2), and dorsal core/hip
stabilization and to begin the sport-specific strength and muscle chains were proven to be valid and reliable.4,26
endurance 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 and
endurance. 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

1958 Bizzini et al The American Journal of Sports Medicine

TABLE 2
Postoperative Clinical and Functional Outcomesa

Patient

1 2 3b 4 5

Time to symmetrical ROM (rotation), wk 8 11 10, 11 9 13
Time to regain preoperative core/hip muscle strength, mo 5.5 6.5 6, 9.5 7.5 12
Time to unrestricted ice training with team, mo 5.5 6 6.5 6 9.5
Time to first competitive game with team, mo 7 9 10 8 14
Playing with team at FU (Y/N) Y Y N Y N
Return 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 first
and 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 were
cle strength. The subject, in a side-lying position, moves the found in patients with early degenerative changes not
pelvis up and down between the mat and the bar in a defined exceeding grade I osteoarthrosis of the hip joint. The Merle
rhythm. The bar’s height is adjusted individually. The number of d’Aubigné and Postel Hip Score were used as outcome
repetitions 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 of
moving 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 the
petitive 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 crucial
Committee 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 months
RESULTS 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 than
sented in Table 1, while the clinical functional outcomes a field player’s, but in this small group, the goaltender was
are 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, this
weeks (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 these
toms (pain score = 0) to unrestricted team practice on the ice structures needs time. These considerations may explain
at a mean of 6.7 months (range, 5.5-9.5) postoperatively. The why the athletes needed several months (more than 6 on
players 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.

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 patients
arthroscopic 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, Schenker
and 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 a
dures, stated that “typically, athletes can return to a com-
technique with full access to the femoral head and acetabulum without
petitive 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 Joint
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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. Reliability
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only the Swiss professional league, but also the Swiss patients with osteoarthritis. Physiother Res Int. 2000;5:241-248.
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in second division, but their performance level was not impingement and the cam effect: an MRI-based quantitative anatom-
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Anterior femoroacetabular impingement: part I. Techniques of joint-
decompression of the hip. Taking the unrestricted full
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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 risk
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