Femoroacetabular Impingement in the Throwing Athlete Michael Banffy, MD Sports Medicine, Hip Preservation Kerlan Jobe Institute
Disclosures None
Baseball Hip Injuries - Background Abdominal/groin injuries Three season data (2011-2013) 5% of all injuries; 94% extra articular Non contact mechanism during defensive fielding (32%) Infielders experienced most hip and groin injuries Non-op treatment (12 days missed) Operative treatment (97 days missed) Coleman et al 2015 (AJSM in press)
Increased Prevalence? Incidence? Understanding of hip anatomy has improved Recognition of hip pathology has improved Understanding of soft tissue abnormalities associated with bony morphologies Pathologic coping mechanisms can lead to further injuries
Hip Anatomy
Root of the Problem 90% of patients with labral pathology have associated bony abnormalities Trousdale et al. CORR 2004 Alterations in Joint mechanics Undercoverge Dysplasia Overcoverage Femoroacetabularimpingement (FAI) The two most common causes of osteoarthritis in the hips
Muscle Injury in Athletes 94% of all hip related injuries in baseball are extra-articular Coleman et al. 2015 71% Incidence of Cam Morphology in Baseball Uquillas et al. 2017 in press
Compensatory Injury Patterns with FAI Anterior enthesopathy Hip flexor strains Psoas impingement Subspine impingement Medial enthesopathy Athletic pubalgia Adductor tendinopathy Rectus abdominustendinopathy Osteitis Pubis
Compensatory Injury Patterns with FAI Posterior Compensatory Injury Proximal hamstring strain Deep gluteal syndrome SI Joint dysfunction Lateral enthesopathies Abductor injury ITB Syndrome
Muscle Injury in Athletes Cam avoidance Gait adopted by athletes with symptomatic FAI Increased stress on adductors Chronic microtraumaand injury Schilders et al JBJS 2009 Schilders et al JBJS 2007 Sports Hip Triad Labral tear, adductor strain, and a rectus strain Feeley et al AJSM 2008
Journal of Athletic Training 2010;45(2):191 197 g by the National Athletic Trainers Association, Inc www.nata.org/jat original research Associations Among Hip and Shoulder Range of Motion and Shoulder Injury in Professional Baseball Players Steve Scher, MSPT, ATC, CSCS, PES*; Kyle Anderson, MDÀ; Nick Weber, PT, ATC, CSCS, PES`; Jeff Bajorek, ATC, PES`; Kevin Rand, ATC, CSCS ; Michael J. Bey, PhDI *Team Rehabilitation, Royal Oak, MI; 3Sports Medicine, William Beaumont Hospital, Royal Oak, MI; 4Department of Orthopaedics, Henry Ford Hospital, Detroit, MI; 1Detroit Tigers Baseball, Inc, Detroit, MI; IBone and Joint Center, Henry Ford Hospital, Detroit, MI Cross sectional study Decreased non dominant Hip IR in non-pitchers with a h/o shoulder injury (p=0.05) Increased dominant hip EXT associated with shoulder injury in both pitchers and non-pitchers Decreased dominant shoulder ER in pitchers Decreased dominant shoulder ER in non-pitchers
Femoroacetabular Impingement Pathologic hip structure effects the loading characteristics of the hip Loss of femoral head-offset (cam type lesion) Focal or global acetabular overcoverage (pincer type lesion) Combined impingement
Pincer Lesions Abnormal contact between acetabular rim and femur Acetabular Overcoverage Cephalad Retroversion Focal Rim Lesion Total Acetabular Retroversion Global Overcoverage Profunda and Protrusio Labral degeneration and posteroinferior countrecoup pattern
Cam Lesions Loss of femoral head and neck offset Bump on the femur Increased radius Cam Type lesions lead to shear forces against the acetabulum Chondral delamination and labral detachment
Presentation of FAI Decreased Range of Motion Groin Pain Mechanical symptoms, stiffness, weakness, instability History of recurrent adductor strains/groin pulls History of Hip Flexor/Hamstring Strains/Athletic Pubalgia 65% present with insidious onset of symptoms with no inciting event or trauma 30% present with symptoms after acute injury
Presentation of FAI Decreased Range of Motion Groin Pain Mechanical symptoms, stiffness, weakness, instability History of recurrent adductor strains/groin pulls History of Hip Flexor/Hamstring Strains/Athletic Pubalgia 65% present with insidious onset of symptoms with no inciting event or trauma 30% present with symptoms after acute injury
Player Evaluation Physical Exam Log Roll Suggests intra-articular pathology C-sign Hand cupped above greater trochanter gripping into the groin Suggest intra-articular pathology Anterior Impingement Test Flexion with internal rotation FABER Anterior pain tight anterior capsule/psoas impingment/interal snapping Compare to contralateral side.
Xrays AP Pelvis Acetabular Charateristics Center edge angle Normal >25 o Acetabular inclination Acetabular version Crossover sign Femoral Characteristics Head sphericity Head neck offset Neck shaft angle Trochanteric height
Xrays Modified Dunn Lateral Hip Flexed to 45 o and 20 o abduction Evaluates CAM lesion in area of impingement Assess alpha angle Normal <50 o
MRI Arthrogram MRI vs. MRA sensitivity for acetabular labral tears 66% vs. 79% Diagnostic Injections
Nonoperative Treatment Activity Modification Anti-Inflammatory Medications Anesthetic/Corticosteroid/Biologic Injections Diagnostic? Therapeutic? Abductor strengthening Hip-motion excercises Physical Therapy Improve soft tissue mobility Restore strength of abductors and peri-articular musculature Improve neuromuscular control and postural balance AVOID IMPINGEMENT TYPE STRECHES WHILE TRYING TO OBTAIN GREATER ROM
Operative Treamtment Address all contributory mechanical factors causing impingement Secondarily address intra-articular pathology Labral Tear Chondral delamination Open surgical dislocation Requires trochanteric osteotomy Ganz et al JBJS Br. 2001 Hip Arthroscopy Techniques have evolved to allow for effective and comprehensive treatment of various impingement patterns
Arthroscopy
Outcomes Good to excellent outcomes 70 90% 87% - 93% of athletes return to sports 82% return to same level of sport Bizzini et al. Br J Sports Med 2015 Pillippon et al. Knee Surg Sports Traum Arthros 2007
Hip Arthroscopy in High-Level Baseball Players J.W. Thomas Byrd, M.D., and Kay S. Jones, M.S.N., R.N. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2015: pp 1-4 44 Hips in 41 Athletes (college and professional) Pitchers push leg involved in 12, stride leg in 6 Position Players batting front leg in 8, back leg in 12, both in 2 mhhs: 81 pre op to 94 post op (o<.001) 42/44 returned to baseball (95%) at mean 4.3 months (3-8mo) 90% returned to previous level of competition
Conclusions Hip pathology is prevalent in athletes of all sports including baseball Kinetic Linkage Increased prevalence of FAI in athletes Majority of hip pathology in baseball presents as extra-articular soft tissue injuries Femoroacetabular Impingement likely predisposes athletes to both intra-articular as well as extra-articular injuries Cam Avoidance If required, operative treatment is highly successful in pain relief and return to sport
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