Do Football Players Have a Greater Risk of Developing a Hip Impingement?

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1 Do Football Players Have a Greater Risk of Developing a Hip Impingement? Madeline Kay Johnson and Robert Stow, PhD Department of Kinesiology, University of Wisconsin-Eau Claire, Eau Claire, WI Acknowledgements We would like to thank Dr. Matt Evans and the Blugold Fellowship program for making this project possible. We would also like to thank Drs. Nathaniel Stewart and Karl Stein for their contributions towards this project as well as the senior athletic training students and staff for their assistance with data collection. We would also like to thank Dr. Jeff Goodman for his assistance with the statistical analysis, and Robert Stow for his work that made this project possible. Abstract The intent of this study was to investigate the hip characteristics of collegiate level football players in relation to the characteristics of patients suffering from femoroacetabular impingement. In addition, examination of football playing position was analyzed to see if differences arose. Femoroacetabular impingement (FAI) is caused when the neck of the femur, due to limited internal rotation, biomechanically contacts the pelvis in an atypical manner. Data was collected from participants from the University of Wisconsin- Eau Claire football program including measurements of hip range of motion and a hip impingement test. Results showed that 5.9% of football players tested positive for hip impingement, compared to 2.3% of the other sports. Football also showed a significantly (p<0.05) higher rate for clinical positives in decreased hip internal rotation and flexion. In regards to football playing positions, offensive and defensive line positions were significantly more likely to have decreased hip flexion. Clinically the use of decreased hip flexion, internal rotation, and/or discomfort with the hip impingement test has been used to diagnosis FAI. Our results suggest that playing football, especially at the offensive or defensive line, linebacker, or safety positions may predispose an individual to developing clinical symptoms of FAI. Key Words: Femoroacetabular Impingement: pathological condition involving femoral neck Osteoarthritis: joint disorder due to aging, wearing, or tearing of joint Hip Range of Motion: distance the hip joint can move between the flexed and extended position Hip Flexion: Forward movement of the lower leg in the coronal plane that decreases the hip angle Hip Internal Rotation: Rotational movement along the longitudinal axis of the hip joint towards the midline of the body Volume 1 Number 1 June 2013 Journal of Athletic Medicine Page 78

2 INTRODUCTION Osteoarthritis in the hip has been known to develop in older populations, resulting in open surgeries to repair damaged bone and cartilage and in many cases a total hip replacement is the end result (Ganz, Leunig, Leunig-Ganz, & Harris, 2008). Recently, a new mechanism has appeared in the literature that has been thought to be a leading cause of osteoarthritis in patients later in life. It has been proposed that femoroacetabular impingement (FAI) may be a factor involved in the development of osteoarthritis (Philippon, Stubbs, Schenker, Maxwell, Ganz, & Leunig, 2007). In fact, a retrospective study of Caucasian cases in the United States suggested 79% of the cases of adult osteoarthritis were associated with FAI (Ganz, Parvizi, Beck, Leunig, Nötzli, & Siebenrock, 2003). Femoroacetabular impingement results from an abnormal contact between the neck of the femur and pelvis. Due to this impingement, the individual experiences changes or pathological conditions in the femoral neck, labrum, and/or acetabulum, resulting in groin pain and decreased range of motion in the hip (Lavigne, Parvizi, Beck, Siebenrock, Ganz, &Leunig, 2004). There are two main deformities associated with FAI. The Cam form involves the femoral head and neck not being perfectly round and having a much larger radius then usual (Figure 1). Figure 1. Types of FAI pathologies. This results in abnormal contact between the rim of the socket and the femoral head. The Cam form has been mostly found in young athletic males. The Pincer form is another deformity that is associated with FAI differing from the Cam by the acetabulum over-covering the head of the femur creating a pinching effect (Figure 1). This form is found more frequently in middleaged women involved in athletic activities. It is more common that these two forms are both found or mixed in an impingement with Cam predominance (Corten, Ganz, Chosa, & Leunig, 2011). Currently found in the literature, the largest group of individuals diagnosed with FAI is young (average age of 30), physically active adults (Kaplan, Shah, & Youm, 2010). Many patients who are diagnosed with FAI have histories of participating in athletics that promote certain movements, especially movements that exaggerate hip internal rotation such as a goalkeeper s stance in ice hockey. FAI has been prevalent in sports that have sharp cutting and sprinting movements, especially common in ice hockey, tennis, martial arts, and soccer (Keogh & Batt, 2008) due to having movements involving a consistent internal rotation and flexion of the hip. These movements promote impinging of the femoral neck against the acetabular labrum (Keogh & Batt, 2008). In many cases, the onset of FAI begins with groin pain due to overuse or injuries to the hip. The common thought at this point is that the physically active individual often thinks they Volume 1 Number 1 June 2013 Journal of Athletic Medicine Page 79

3 have pulled a muscle, backs off of activity for a few days and continues on with life. After consulting a physician for the groin pain, FAI is often misdiagnosed as a groin strain, knee or lumbar spine pathology, ovarian cysts, trochanteric bursitis, and/or abdominal region hernias (Philippon, Maxwell, Johnston, Schenker, & Briggs, 2007). In many cases this may lead to weeks or months of incorrect treatment and/or unnecessary and costly surgeries in some cases (Keogh & Batt, 2008). It was the intent of this study to investigate the characteristics of the college age (18-23 years of age) intercollegiate athlete and their predisposition to having a deformity (FAI). Due to their long standing as a physically active individual and playing sport at a competitive level (collegiate athletics), we hope to gain a better understanding of what type of individual exhibits clinical signs and symptoms associated with FAI. Thus posing the question, does playing in competitive athletics potentially contribute to the development or exacerbation of FAI? METHODS The Institutional Review Board at UW- Eau Claire provided approval for this study. Participants were recruited from the University of Wisconsin- Eau Claire s Intercollegiate Athletic program and were currently eligible to participate in football. The participants were contacted through the medical services area in the Department of Intercollegiate Athletics and asked to participate in this study. 108 male collegiate football players (19.8±1.5 years, 182.4±18.6 cm height, 97.6±21.1 kg weight) participated in this study. During the athletes preseason football physical, at the athletic training center on UW Eau Claire s campus, participants were asked to read and sign an informed consent document if they wished to participate in the study. They then were directed to complete a survey that gathered basic demographic information, a brief medical history that was relevant to prior hip injuries, and prior sport/activity participation. Research assistants reviewed the survey for completeness before allowing the participants to proceed. After completing the survey, the research assistants, senior athletic training students and athletic training staff members, administered the physical assessment tests. These students and staff were specifically trained for these tests and practiced the measurement methods prior to administering the tests. The researchers took participants height and weight in addition to administering range of motion tests in teams of two to provide a more accurate administration of the tests. A goniometer was used to measure hip internal rotation by having the patient in a supine position, flexing the hip and knee to 90, and rotating the hip inwards passively to the endpoint of rotation (Ganz et al., 2003). Data was gathered on both hips, regardless of the participant s prior health history. Hip flexion range of motion was also tested with a goniometer with the patient in a supine position and flexing the hip passively to its maximum end range of motion (Ganz, et al., 2003). Figure 2 displays the layout of the hip internal rotation test. The hip flexion range of motion test is displayed in Figure 3. Volume 1 Number 1 June 2013 Journal of Athletic Medicine Page 80

4 Figure 2. Hip Internal Rotation Test. Figure 3. Hip Flexion Test. These specific tests were measured in passive range of motion. Finally, the research assistants directed participants in completing a hip impingement and Trendelenburg sign tests (Nunley, Prather, Hunt, Schoenecker, & Clohisy, 2011). If participant s test met specific criteria (< 115 hip flexion, < 15 internal rotation, or pain with internal rotation) (Ganz et al., 2008) they were recorded as positive for exhibiting the clinical symptoms of FAI. RESULTS Descriptive statistics were used to report the characteristics of the population as well as chi-square analysis to test the proportionality of pathological symptoms and functioning. Statistical significance was set at p<0.05. Statistical analyses were performed using SPSS version 18.0 (SPSS Inc.). As shown in Table 1, only the hip flexion and internal rotation measurements were found to be significant in relation to having clinical signs for FAI. Table 1. Football players results broken down by criteria tested. p<0.05 Volume 1 Number 1 June 2013 Journal of Athletic Medicine Page 81

5 Approximately half of the participants (42.6%) tested positive in the hip flexion tests. While not as many participants tested positive in regards to hip internal rotation (5.6%), the findings were found to be significant. Table 2 breaks down the data collected by football playing position specifically. Table 2. Results by football playing position. N= 108 Two positions were found to have a high number of positive cases. Out of 17 offensive linemen participants, 82.4% met the criteria for the hip flexion test and 17.6% for the hip internal rotation range of motion. These were the highest percentages found between the nine different playing positions. Defensive linebackers had the second highest percentages with hip flexion and hip internal rotation at 81.3% and 12.5% respectively. Our study provides data that suggests that participating in certain football positions may present a greater risk of developing the clinical signs of FAI. No significant difference was found when comparing various other sports included in the data collection (i.e., Woman s volleyball, soccer, ice hockey, gymnastics, Men s ice hockey) to the development of clinical signs of FAI. Our results suggest that playing the football positions of offensive or defensive line, linebacker, or safety positions may predispose an individual to developing clinical symptoms of FAI. 11.8% of defensive linebackers reported having hip pain with the hip impingement test, which was a much larger percentage when compared to percentages of other positions, though this statistic was not found to be significant. DISCUSSION The principal finding in this study is that clinical FAI symptoms are significantly found in a population of collegiate football players. Could certain athletic activities be indicators for populations that have a higher chance of developing clinical symptoms of FAI? This study partially supports the initial question that participating in football may lead to a higher incidence of developing FAI. Alongside football, other sports such as hockey and soccer have seen high Volume 1 Number 1 June 2013 Journal of Athletic Medicine Page 82

6 percentages of FAI cases among players, as seen in the literature of surgical case studies (Keogh & Batt, 2008). These sports involve a lot of cutting and sprinting so is it plausible that these movements specifically attribute to the development of FAI (Kaplan, Shah, & Youm, 2010). These questions will remain unanswered until more research has been completed in regards to the characteristics of FAI. Our findings and other studies completed on populations affected by FAI, can influence the way physicians think about diagnosis and treatment of patients complaining of hip/groin discomfort. One possible stride that could be made in the diagnosis of FAI is early screenings. Since a correlation has been reported between athletes involved in certain sports, such as football, pre-screening individuals involved in these sports could identify FAI at an earlier stage and a younger age. Another finding in this study is that certain football playing positions are more susceptible to having FAI symptoms, especially the offensive and defensive line. This could be another factor that could come into question when pre-screening individuals for FAI characteristics. Certain sports should not only be singled out for pre-screenings, but special attention should also be paid to specific playing positions. More research focusing on playing positions most affected by FAI, could assist in developing specific criteria that can be established for precisely which sports and positions could be more prone to this pathology. If FAI is not caught early enough, there is a higher probability that the individual affected could be faced with having osteoarthritis and possibly needing a total hip replacement later in life, potentially by years of age. This open surgery is highly invasive and has many physical costs such as loss of movement and in many cases loss of activity (Philippon, Schenker, Briggs, & Kuppersmith, 2007). Instead, it may benefit the active lifestyle of a younger athlete to be prescreened for FAI and then have corrections through arthroscopic surgery. This surgery is minor compared to a total hip replacement that may be needed down the road for the athlete (Bedi et al., 2011). This type of surgery will allow competitive level athletes to return to a high level of performance in a minimal amount of time (Philippon, Schenker, Briggs, & Kuppersmith, 2007). This study had various limitations. First, the population was limited to one university and sport season. It would be beneficial to obtain a larger sample size with a varied demographic. This would allow data to be more accurate to the actual population of collegiate football players. Another limitation was that we only had a few positive cases of FAI related symptoms. This is also due to the low number of participants in the study. This could have affected results because the ratio of positive cases to negative FAI cases may not be accurately represented in a sample population of this size. It would be beneficial for future studies on FAI to include a larger sample population focusing on other sports as well. The more information gained by studies such as this one, the greater the chance of FAI symptoms being recognized at a younger age. This can hopefully save patients some money that would have been used for total hip replacements down the road and can let them continue their active lifestyles for a much longer period of time. REFERENCES Bedi, A., Dolan, M., Hetsroni, I., Magennis, E., Lipman, J., Buly, R., & Kelly, B. T. (2011). Surgical treatment of femoroacetabular impingement improves hip kinematics. Am J Sports Med., 39, 43. Corten, K., Ganz, R., Chosa, E., & Leunig, M. (2011). Bone apposition of the acetabular rim in deep hips. J Bone Joint Surg Am., 93, Volume 1 Number 1 June 2013 Journal of Athletic Medicine Page 83

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