Disclosures. The $100,000,000 Questions? UNDERSTANDING & PREVENTING? ATHLETIC HIP INJURY. Arthrex, Inc. Breg, Inc. Employed physician

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1 UNDERSTANDING & PREVENTING? ATHLETIC HIP INJURY John J Christoforetti, MD Disclosures Arthrex, Inc Paid consultant, royalty Breg, Inc Paid consultant, royalty Employed physician Allegheny Health Network The $100,000,000 Questions? What is wrong with my hip? Can you fix my hip so I can play sports again? What can I do: To exercise? To prepare for sports? To LIVE the way I want? Should I invest in this athlete? Scholarship? Contract?

2 Classification of Athletic Hip Injury By damaged tissue Intraarticular versus Extraarticular Abdominal versus Hip Joint versus Periarticular By symptom onset Acute versus Chronic By injury mechanism Traumatic versus Atraumatic (overuse) Combination of factors common Conceptual Understanding of Athletic Hip Injury Functional Demand Mechanical Structure Genetic/Biomaterial Practical Implications: A, B, C s Understand A: training and competitive demands of specific sport activity for specific patients Understand B: the available skeletal functional range of motion Understand C: that athletes will achieve A despite B at the expense of terminal bone/soft tissue/chondral structures

3 Parallel Diagnostic Pathways Search for Pain Generator Today Physical exam elements Passive ROM/ tenderness on palpation/ inspection for deformity Imaging elements Plain radiographs (early and appropriately) MRI or MRA (appropriately and sometimes early) Search for Conflict in A,B,C s that lead to today and will shape tomorrow! Physical Exam Elements Sports training regimen and performance mechanics General laxity exam Impingement exams Imaging Elements: Specialized and standard plain xrays MRI/MRA CT scan

4 Radiographs: Standard Series AP Pelvis Centered at symphysis pubis Dunn/Cross Table or Frog Lateral Special Views False Profile Anterior wall coverage Weight Bearing views Severe Arthritis: Tonnis 3

5 Normal: Tonnis 0 Mild Arthritis: Tonnis 1 Moderate Arthritis: Tonnis 2

6 Why order an MRI Scan? Rules OUT pathology Stress fracture Neoplasia Effusion Myotendinous injury Pelvic or abdominal visceral injury Arthrogram Historically used for detection of labrum tears IS SUPERIOR to nonarthrogram at identifying chondral surface injury False positive and false negative rates 1-2% are likely underestimated MRI Diagnosis: Stress fracture MRI diagnosis: Avascular necrosis

7 Deciding for MRI/MRA: (most important in revision cases) Functional Understanding of Hip Anterior Athletic Hip Pain Loose Hip Increased ROTATORY motion at 90 degrees flexion Frequent alternate joint laxity Female gender Snaps, pops, clicks May complain of feeling stiff or tight with findings above Psoas and other lateral achy pain common as muscles work to dynamically stabilize the joint! Tight Hip Decreased rotatory motion at 90 degrees flexion May have muscular stiffness as well, but not always Multiple aches/soreness in lumbar spine/pubic bone due to compensatory motion and often degenerative changes Internal Snapping Hip Snap of tendons crossing the joint capsule Typically the iliopsoas muscle crossing at the anterior pubic bone RARELY can bruise labrum below (psoas impingement) Described by Domb, Kelly Occurs when patient moves from flexion abduction external rotation to extension internal rotation 30-40% of hips will experience this on occasion

8 ABC s: Snapping hip and CIFI Sport demands generate force that exceeds inherent concentric reduction of hip joint Muscles and lumbopelvic bones MUST dynamically realign to generate macro-stability Contractures (dynamic or fixed) or simply new pathways of deep tissue motion result Our thought for why some patients struggle with modern trend to mix static progressive deep joint mobilization with impact sport Practical Information Typically associated with weak core muscles and poor trunk/proximal limb control Weak gluteus maximus musculature Therapy to correct is typically effective Patients need counseling and reassurance When sub-psoas bursitis causes painful snap, ultrasound guided corticosteroid and physical therapy are the best first line of action

9 Basic Science of the Capsule The Function of the Hip Capsular Ligaments: Traditional cadaver A Quantitative descriptive Report studies Origin/insertion descriptive (Martin et al) Sectioning studies (Safran, Sekiya) Premise: Douglas ligaments P. Beall, function M.D., and as Bryan check Kelly, M.D. reign stabilizers under tensile force at length endpoints Hal D. Martin, D.O., Adam Savage, B.S., Brett A. Braly, B.S., Ian J. Palmer, Ph.D., Purpose: Our purpose was to analyze the anatomy and quantitative contributions of the hip capsular ligaments. Methods: The stabilizing roles of the medial and lateral arms of the iliofemoral ligament, pubofemoral ligament, and ischiofemoral ligament were examined in 12 matched pairs of fresh-frozen cadaveric hips (6 male and 6 female hips). The motion at the hip joint was measured in internal and external rotation through ranges of motion from 30 flexion to 10 extension along a neutral swing path. The motionwas standardized byuseofframe stabilization andmotiontracking. Results: There isaclear and consistent ligamentous pattern within the hipcorresponding toadistinct function and contribution to internalandexternalrotation. Onreleasingtheischiofemoral ligament, thegreatestgaininrangeofmotion was that of internal rotation. The largest increase of motion by releasing the pubofemoral ligament was observed in external rotation, especially during extension. The release of the medial and lateral arms of theiliofemoral ligament eachgavethegreatest increaseofmotioninexternal rotation, withthelateral arm release providing more range of motion in flexion and in a neutral position. The lateral arm release also showed a significant motion increase in internal rotation, primarily in extension. Conclusions: The ischiofemoral ligament controls internal rotation in flexion and extension. The lateral armof the iliofemoral ligament has dual control of external rotation in flexion and both internal and external rotation in extension. The pubofemoral ligament controls external rotation in extension with contributions from the medial and lateral arms of the iliofemoral ligament. Together, these findings can have significant clinical applications. Clinical Relevance: When abnormal muscular and osseous pathology can be eliminated as acauseofinstabilityorrestrictiverangeofmotion,theunderstandingoftheindependentfunctionsofthe hip ligaments will aid in defining accurate assessment and nonsurgical and arthroscopic treatment techniques. Key Words: Hip Ligaments Flexion Extension Internal rotation External rotation. T Hip Ligaments (Martin et al.) he hip is a unique joint that possesses both mobility and stability because of its anatomic configuration. 1 A portion of the hip s stability may be attributed to the strong, dense articular capsule of the Iliofemoral Ligament: Lateral arm: From Oklahoma Sports Science &Orthopaedics ER in flexion (H.D.M., I.J.P.) and College of Medicine, University of Oklahoma (A.S., B.A.B., FUNCTION OF HIP ER CAPSULAR and IR LIGAMENTS in extension D.P.B.), Oklahoma City, Oklahoma; Department of Radiology Services, Clinical Radiology of Oklahoma (D.P.B.), Eugene, Oklahoma; and Hospital for Special Surgery (B.K.), New York, New York, U.S.A. The FIGURE authors 2. (A) Line report drawing ofno left hip conflict anterior of interest. ligaments. (A, intertrochanteric knob, insertion of Address iliofemoral ligament correspondence medial arm; B, intertrochanteric crest, insertion of iliofemoral ligament lateral and reprint requests to Hal D. Martin, D.O., arm; Oklahoma C, iliopectineal eminence, Sports medial Science to inser-tion of pubofemoral ligament; small black arrows, Orthopaedics, 6205 N. Santa Fe #200, orbicular Oklahoma ligament.) (B) City, Line drawing OK of 73118, left hip U.S.A. haldavidmartin@ posterior ligaments. (A, insertion of superior band yahoo.com of ischiofemoral ligament, which is anterior to mid 2008 axis ofby greater the trochanter; Arthroscopy B, inferior band of Association of North America ischiofemoral ligament; C, point at which zona /08/ $34.00/0 orbicularis blends with ischiofemoral ligament; D, origin of lateral arm of iliofemoral ligament; black doi: /j.arthro arrow, sling of pubofemoral ligament and inferior orbicular ligament.) hip. The capsule has a cylindrical sleeve-like shape and proximally inserts both anteriorly and posteriorly along the periphery of the acetabulum outside the labrum. Distally, the capsule attaches to the femur anteriorly along the intertrochanteric line, but posteriorly, it has an Ischiofemoral arched free border that only partially covers the femoral ligament: neck. Most of the fibers are longitudinally oriented, IR in except flexion forand the circular fibers of the 191 zona orbicularis extension located posteriorly and inferiorly. 2,3 Together, these osseous and ligamentous structures and the musculotendinous components help to characterize and Pubofemoral constrain the Ligament: dynamic movements of the hip. 4 It is known that ER peak in extension contact forces are 2 to 3 times the body weight in level walking, well over 7 times during stair climbing, and over 8 times during stumbling. 5,6 The hip is, therefore, not only important in the transfer of weight and energy between the 188 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 2 (February), 2008: pp the iliofemoral ligament inserts on the anterior greater trochanteric crest (Fig 2A). The pubofemoral ligament was noted to resemble a sling, running inferior to the medial arm of the iliofemoral ligament, medial and inferior to the iliopectineal eminence, originating at the pubic portion of the acetabular rim and the obturator crest of the pubic bone and attaching distally to the femoral neck. Fibers from the pubofemoral ligament blend with the medial arm of the iliofemoral ligament. The sling of the pubofemoral ligament was also noted to wrap inferiorly around the neck of the femur and insert inferior to the ischiofemoral ligament along the posterior intertrochanteric crest. The ischiofemoral ligament originates at the ischial portion of the acetabular rim and crosses the hip capsule in 2 horizontal bands. The superior band spirals superolaterally, arching across the femoral neck to blend with the zona orbicularis fibers, and inserts medial to the anterosuperior base of the greater trochanter. The inferior band inserts more posteriorly, medial to the base of the greater trochanter along the posterior intertrochanteric crest (Fig 2B). When the hip was in internal rotation (Tables 1 and 2, Fig 3) and the medial arm of the iliofemoral ligament was severed, no notable change was observed. However, when the lateral arm of the iliofemoral was cut, an increase of 5 was seen in all positions except 30 flexion. Similar to the medial arm, when the pubofemoral ligament was resected, no significant change was noted. When the ischiofemoral ligament was cut, the amount of internal rotation allowed doubled throughout the entire swing path of the femur. Therefore, the TABLE 1. Mean Internal and External Rotation After Release of Corresponding Ligament Flexion 15 Flexion 0 Neutral Extension IR ER IR ER IR ER IR ER All intact Med Ilio Lat Ilio Pubo Ischio Zona Orbicularis NOTE. Figures 3 and 4 are visual representations of Table 1. Abbreviations: IR, internal rotation; ER, external rotation; Med Ilio, medial arm of iliofemoral ligament; LatIlio, lateral arm of iliofemoral ligament; Pubo, pubofemoral ligament; Ischio, ischiofemoral ligament. Thick constriction point of hip capsule located at the femoral head/neck juncture Point of volumetric entrapment of proximal femur Mosier, Maynard et al. (pending publication)

10 Potential Explanation for Poor Outcomes in Surgery: Capsule None Z T Interportal Capsulectomy Laxity Correction: A rare option Iliopsoas Impingement Domb et al. 3 o clock labrum tear Associated with tight psoas and repetitive painful snap Transcapsular release and labrum repair shown to be effective OPINION: rare.

11 Cautionary Case This is a 22 year old female Division I rower, who presented to us with persistent right hip for two years following arthroscopic labral repair and transcapsular psoas release at an outside center. She had been unable to return to her pre-operative level of activity due to the pain. On physical exam, she had pain with flexion and a feeling of weakness in the operative side. MRI arthrogram Arthroscopy

12 Acetabular Labrum Fibrocartilage Extension of acetabular rim Suction-seal Load bearing in dysplasia Segmental loss OVER 2cm results in instability Vascular supply is from the capsular side Labrum Tear Seldes Classification Tight Hips: OA or FAI? Femoroacetabular Impingement The repetitive abutment between the femoral neck and the acetabular rim that occurs within the normal range of motion This group needs more motion than their bone structure permits, resulting in a conflict Excess sheer and compressive loads result at the hip bearing surfaces And adjacent areas (SI joint, spine, pubis!)

13 Two Types of FAI CAM impingement Pincer impingement Mixed type most common! Functional Classification of Labrum Tear: Looks for a SOURCE Traumatic Rare Likely FAI or dysplasia associated Atraumatic Attritional separation of articular cartilage from labrum base (FAI or dysplasia) Case (Courtesy of Dr Bojan Zoric, Massachusetts) A 21 year-old male collegiate golfer presents to the office with increasing pain in the groin and inability to perform over a semester of conservative care. Physical exam is significant for limited internal rotation at 90 degrees hip flexion and reproduction of his pain with passive flexion, adduction and internal rotation of the hip.

14 Radiographs MRI-arthrogram Treatment

15 Functional Understanding of Lateral Hip Pain in Athletes Primary lateral pathology Typically traumatic diagnosis or reactive to underlying degenerative process More common in master s athletes UNCOMMONLY a major issue in first 3 decades Referred Lateral Pain Typically a fatigue or neuromuscular balance issue that may be very treatable conservative Lumbar spine history Cleared lumbar spine does not equal normal lumbar spine May be referred from hip joint itself Coxa Saltans (snapping hip syndrome) Clinical descriptive term for feeling or hearing audible pop upon hip motion Remnant of prepreservation surgery literature Still exists as a presenting symptom for many patients/athletes Coxa Saltans Externa Iliotibial band and tensor muscle complex interacting with lateral greater trochanter Patients will have history of a trick hip or hip popping out Demonstrated easily in the office Often created by classic hip therapy isokinetic exercises

16 Patient Image with Permission Gluteus Medius Tears Master s Athletes 40 s to 80 s True prevalence unknown Many case series of open repair in the literature Few arthroscopic repair series No quality conservative care series MUST RULE OUT SPINE PATHOLOGY Functional Understanding of Posterior Hip Pain Primary pathology Most typical in master s athletes Hamstrings tendinopathy Ischiofemoral impingement Must always be skeptical if no reproducible exam finding exists Referred Pain Typical reason for posterior pain is in this category Spine, spine, spine Osteoarthritis SI joint, hip joint, spine Rarely, Ligamentum Teres can refer pain posteriorly in nonarthritic hips Typically associated with instability

17 Muscle Tears: Hamstring Origin Increasingly reported Avulsion of common origin of biceps, semimembranosus from ischial tuberosity Retraction greater than 2cm of all three tendons or greater than 3 cm retraction of 2 tendons surgical care recommended Partial tears at origin (tendinopathy) Common in middle aged endurance athlete PRP rarely effective Ischial bursa injection can be effective Rest/avoid eccentric or plyometrics Surgery last option for 6 months or greater of symptoms Arthroscopic and open can be effective Surgical Care: Proximal Hamstrings Several reported series in the literature Cohen and Bradley Larson CL. Long term risks of nonoperative care (Hoffmann KJ et al. JBJS. Jun 2014.) Poor function Sciatic symptoms Sitting pain Reduced effectiveness of surgical care Subbu et al. AJSM. Nov Suture anchor repair of tendon to bone followed by rehabiliation and return to sport at 3-4 months Recent systematic review: Van der Made et al. AJSM Ligamentum Teres LT is an end range stabilizer to hip rotation at 90 degrees flexion Martin HD, Hatem MA, Kivlan BR, Martin RL. Arthroscopy Diagnosing Tears: Deep or even posterior pain Common in FAI & Dysplasia MRI-Arthrogram is helpful Arthroscopy is gold standard Treatment is conservative If failure, then debridement (arthroscopic) and reconstruction have been described

18 Frontiers: External Hip Impingement Conflicting trochantericpelvic interaction that leads to soft tissue damage or pain Ischiofemoral impingement Deep gluteal syndrome Sub-spine impingement AIIS to distal neck impingement Trochanteric-pelvic impingement Ischiofemoral impingement Hal Martin, DO Contact between lesser trochanter of femur and the ischium of the pelvis Sciatic compression, sitting pain NOT a reasonable line of query in obese, nonathlete Prevention Strategy Theoretical exceeds proven scientific evidence Logic guided with and OPEN mind for creativity Imaging (plain radiographs) after identification of functional range conflict Limited rotatory motion in sport that requires more Excessive rotatory motion in sport that demands load or plyometric explosive force Preseason/preparticipation questions designed to identify hip structural copers

19 AHN:Center for Athletic Hip Injury Research Co-investigators with U of Rochester Identifying a set of return to sport parameters following hip arthroscopy for athletes Trialing specialized bicycle pedal at CMU lab funded by Disney Animation Tracking outcomes with Duquesne University PhD candidates MASH study group (multicenter outcomes group) More to come! Conceptual Understanding of Athletic Hip Injury Functional Demand Mechanical Structure Genetic/Biomaterial Conclusions Understanding athletic hip pathology requires a dual search for today s pain generator and global sport/structure mismatch We are at the beginning of an exciting journey that hopes to unite core/kinetic chain concepts with prevention and treatment of end-tissue damage Correct diagnosis prior to surgical care is increasingly essential as we learn!

20 THANK YOU! John J Christoforetti, MD