Hip Pain in the Young Athlete and Active Patient on Orlando Medical News

Hip Pain in the Young Athlete and Active Patient

By: JUAN AGUDELO, MD

Posted: Monday, October 10, 2011 3:43 pm

Hip Pain in the Young Athlete and Active Patient

Physicians must continue to work together with parents, coaches and allied health practitioners to reinforce the importance of early detection of hip joint pain. Sports like soccer, hockey, ballet, martial arts, cycling and other activities that require deep squatting motions, may predispose patients to Femoroacetabular Impingement (FAI) and early hip osteoarthritis.

Our understanding of hip osteoarthritis has increased tremendously in the last decade. Osteoarthritis has always been characterized as “idiopathic,” but current research shows up to 80 percent of cases have a predisposing factor that can be identified. Subtle developmental abnormalities of the hip previously seen as “normal” by radiologists and orthopaedic surgeons are now proven to result in hip impingement (FAI) and osteoarthritis.

Acute onset groin pain during strenuous physical activity cannot be ignored. Groin pain after a long car trip or sitting for a long period of time should be considered red flags. The typical symptoms of groin pain in young, active patients are occasional catching or clicking. Groin pain was previously treated as a hip pointer or as strain or overuse syndromes, where the patient was sent to physical therapy along with a short period of rest.

Now, we have to think twice. Are we facing a patient with an initial labral tear? Is the hip morphology “normal” or did we find a malformation predisposing the patient to FAI? Does the patient have a mild, subclinical sliding of the capital femoral ephyphises (SCFE) and now shows a case of hip impingement? These questions must be asked when evaluating a patient with anterior hip pain.

Hip muscular sprains, contusions, tendonitis or bursitis should improve quickly over a 1-2 week period of conservative measures. If symptoms persist beyond this point we must take further action.

To solve this difficult problem, however, we have outstanding tools starting with careful clinical evaluations, including gait, symmetry of the lower extremities, range of motion of the lower back and hip joint and also specific clinical tests to screen for labral tears and FAI. Specific tests include flexion of the hip to 90 degrees with the patient supine, slight abduction with internal rotation and abduction with external rotation. These maneuvers will elicit pain or ache in the groin region and/or anterior hip.

Plain radiographs would be the next step of treatment. Non-sphericity of the femoral head (Cam lesion) or a deep acetabulum (pincer) are the classical findings of FAI, which often times are present in the same patient, to some extent. Cam impingements impose increased pressure in the labrum and detach the periphery of the acetabular cartilage from the subjacent bone (cartilage delamination) and pincer impingements result in increased contact pressure on the labrum (labral tears) and femoral head cartilage, both leading to the onset of early osteoarthtitis. An MRI arthrogram is the best tool to evaluate the femoral head, acetabular morphology, cartilage delamination and to diagnose a tear of the hip labum.

There are specific measurements used by radiologists and orthopaedic surgeons to evaluate the hip. One of the commonly used tests is the Alpha angle. The Alpha angle measures the arc of the femoral head, which is perfectly round. An increased alpha angle means that less of the femoral head circumference is able to clear or rotate under the acetabulum, initially “impinging” upon contact with the labrum and then shearing the acetabular cartilage during hip flexion (cartilage delamination).

Treatment alternatives include hip arthroscopy, hip arthroscopy and minimally invasive arthrotomy or surgical hip dislocation. The goal is to restore the hip anatomy by shaving the extra bone off the femoral head and acetabulum and repairing the labrum. About 75-80 percent of patients will return to previous competitive levels and remain symptom free after two years.

We currently need additional research to determine if early diagnosis and treatment of FAI will prevent future hip osteoarthritis.

Juan Agudelo, MD, is an orthopaedic surgeon specializing in reconstructive and total joint repair and replacements for knees and hips. Dr. Agudelo earned his medical degree from the Health Sciences Institute in Medellín, Colombia.

In 2010, Dr. Agudelo was accepted as a fellow for adult reconstruction at the University of Colorado’s Department of Orthopaedic Surgery. Prior to joining Florida Hospital East Orlando, Dr. Agudelo held the position of orthopaedic trauma research fellow in the Department of Orthopaedics at Denver Health Medical Center, and was also an assistant professor in the Department of Orthopaedic Surgery at Universidad Pontificia Bolivariana as well as the Health Sciences Institute.

Dr. Agudelo has authored more than 20 publications, and has been on the review board of the Journal of Orthopaedic Trauma since 2008.

El es colombiano y le da la bienvenida a pacientes que hablan español.