Clin Sports Med Volume 25 Issue 2 April 2006 - Hip Injuries, English medicine

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Clin Sports Med 25 (2006) xiii
CLINICS IN SPORTS MEDICINE
FOREWORD
Hip Injuries
Mark D. Miller, MD
Consulting Editor
O
rthopedic sports medicine used to be mostly the knee and shoulder.
OK, throw in an occasional ankle or elbow to spice things up
…
or is it just that our recognition of them has increased dramatically?
Hip arthroscopy, treatment of sports hernias, femoroacetabular impingement,
hip instability, and a variety of other diagnoses and treatment options did not
even exist 10 years ago! So, for those of you who don
—
’
t know what all the fuss is
please read this issue carefully!
Drs. Bharam and Philippon have done an excellent job of pulling this issue
together and have covered the gamut of hip disorders in the athlete. Most of
the topics are arthroscopically related
which is appropriate, because this a new
frontier for most of us. This issue is thorough and comprehensive
—
—
please enjoy!
Mark D. Miller, MD
Professor, Division of Sports Medicine
Department of Orthopaedic Surgery
University of Virginia Health System
P.O. Box 800159
Charlottesville, VA 22903-0753, USA
E-mail address:
0278-5919/06/$
–
see front matter
© 2006 Elsevier Inc. All rights reserved.
doi:
but
the hip? Interestingly, hip injuries have increased dramatically in
recent years
about
—
xvi
CLINICS IN SPORTS MEDICINE
–
PREFACE
Hip Injuries
Srino Bharam, MD, Marc J. Philippon, MD
Guest Editors
8% during athletic
activity and may place the athlete at risk of injury during athletic participation.
Hip pain in the recreational to elite athlete in both men and women can result
from either acute injury or repetitive hip-demanding activity, affecting athletic
participation. These sports-specific injuries are seen in multiple sports, including
cutting activities (football, soccer), repetitive rotational activities (golfers, martial
artists), dancers, and skaters.
Evaluation of hip pain in the athlete can be challenging to the sports medicine
practitioner. This requires a detailed history and hip exam and appropriate
imaging studies. Communication with trainers and physical therapists is also
essential in the evaluation process.
Recent advancements in hip arthroscopy have expanded our knowledge of
the management of athletes with hip injury. Adaptations to arthroscopic instru-
mentation have been established to overcome the constrained hip joint and dense
muscular envelope. Flexible instrumentation has also been developed for im-
proving access to the hip joint in both the central and peripheral compartments.
Refined arthroscopic techniques have improved our ability to manage labral
tears, chondral injuries, capsular laxity, impingement, loose bodies, ligamentum
teres tears, and snapping hip syndrome. Structural abnormalities predisposing
athletes to intra-articular hip injury can also be addressed with arthro-
scopic intervention.
–
0278-5919/06/$
–
see front matter
© 2006 Elsevier Inc. All rights reserved.
doi:
Clin Sports Med 25 (2006) xv
hip injuries in athletes for the sports medicine practitioner. Five to six
percent of all adult athletic injuries and 24% of pediatric athletic inju-
ries are hip-related injuries. Hip loading increases up to 5%
T
he recent popularity of hip arthroscopy has led to a new focus on
xvi
PREFACE
Managing athletic hip injuries with hip arthroscopy and a well-defined
rehabilitation protocol can safely return athletes back to competition.
We would like to thank our authors for their dedication in providing us their
expertise and update on this subspecialty field of sports medicine.
s Medical Center
Lenox Hill Hospital
36 7th Avenue, Suite #502
New York, NY 10011, USA
E-mail address:
’
Marc J. Philippon, MD
Steadman-Hawkins Clinic
181 West Meadow Drive, Suite 1000
Vail, CO 81657, USA
E-mail address:
Srino Bharam, MD
St. Vincent
197
CLINICS IN SPORTS MEDICINE
–
Neuromuscular Hip Biomechanics and
Pathology in the Athlete
Michael R. Torry, PhD
a,
*
, Mara L. Schenker, BS
a
,
Hal D. Martin, DO
b
, Doug Hogoboom, BS
a
,
Marc J. Philippon, MD
a
a
Biomechanics Research Laboratory, Steadman-Hawkins Research Foundation, 181 West Meadow Drive,
Suite 1000, Vail, CO 81657, USA
b
Oklahoma Sports Science and Orthopedics, 6205 N. Santa Fe, Suite 200, Oklahoma City, OK 73118, USA
constrained by the anatomy of the region, including osseous, ligamen-
tous, and musculotendonous structures. The majority of patients who
require hip arthroscopy are young, active individuals with a history of hip or
groin pain. In some athletes, the onset of hip pain may be due to a traumatic
event such as a fall, tackle, or collision. However, in many sports, athletes suffer
a minor hip injury or perform repetitive motions that exacerbate a chronic
pathologic or congenital hip condition that leads to increased capsular laxity
and labral tears over time. One of the obvious benefits of arthroscopic hip
surgery in this population is that it allows the surgeon to perform procedures
within the hip joint with a minimal amount of postoperative morbidity, allowing
for a return to sporting activities in a shorter time period. This type of surgery
is relatively new, with only a few experts advancing in the field worldwide.
However, this surgery is gaining popularity among sports medicine/orthopedic
surgeons, and is being performed more and more on all levels of athletes and in
the nonarthritic, hip-injured population alike.
Although joint mechanics for total hip joint replacements (THR) are well
described, little is known with regard to hip joint mechanics in injuries such as
hip labral tears that are observed in younger athletes; and although hip arthro-
scopic techniques have been developed and evolved over the last 5 years, the
mechanisms of these injuries across various sports are not well understood.
Moreover, rehabilitation protocols associated with hip arthroscopy remain
rooted in THR theories and paradigms. It is evident from the literature that
rehabilitation after hip arthroscopic surgery requires a mechanical foundation
for its implementation during initial, intermediate, and return to sport/agility
protocols. Without such a scientific foundation, the risk of an unsuccessful
surgery or reinjury is greatly enhanced.
*
Corresponding author. E-mail address:
(M.R. Torry).
0278-5919/06/$
–
see front matter
© 2006 Elsevier Inc. All rights reserved.
doi:
Clin Sports Med 25 (2006) 179
D
ynamic movement occurs at the hip joint and is characterized and
180
TORRY, SCHENKER, MARTIN, ET AL
The purpose of this article is to review the literature related to the osseous,
ligamentous support as well as the neuromuscular control strategies associated
with hip joint mechanics. The neuromuscular contributions to hip stability and
mobility with respect to gait will be provided because the data related to gait
represents the largest body of knowledge regarding hip function. Further, this
article will describe the probable mechanisms of injury in sporting activities most
often associated with hip injury in the young athlete.
neck offset, ace-
tabular anteversion, and acetabular coverage of the femoral head. Proper func-
tion of the hip joint necessitates that the amount of offset from the femoral head
to the femoral neck be enough to allow a full range of motion without impinging
upon the acetabular labrum. A lack of offset from the femoral head to the
femoral neck has been described as a cause for femoroacetabular impingement
[1]
. Flexion at the hip may cause the osseous femoral head
–
neck junction to
come into contact with the acetabular labrum, resulting in impingement
[1
–
–
3]
.A
large femoral head can compensate for a flat head
–
neck junction by simulating
offset and adding stability to the joint
[4]
.
Large variations exist in the rotational axis that characterizes the relationship
between the acetabular and femoral osseous structures. The range of acetabular
anteversion to femoral anteversion affects the rotation of the extremity and
changes from the time of birth and through mature skeletal development. The
transfer of dynamic and static load to the ligamentous and osseous structures is
dependent on this relationship. Abnormal distribution of force or pressure in an
incongruent joint precipitates chronic or acute injury. Normal adult acetabular
positioning intersects the sagittal plane at 40° and the transverse plane at 60°,
opening anteriorly and laterally
[5]
. The acetabulum is positioned approximately
45° caudally and 15° anteriorly
[6,7]
. Normal anteversion of the acetabulum
is essential to maintaining a normal relationship with the femoral head and is
critical in avoidance of impingement
[8]
. Normal range of acetabular anteversion
as defined by Tonnis and Heinecke
[9]
is 15° to 20°, decreased anteversion is 10°
to 14°, and increased anteversion is 21° to 25°. An increase in external rotation
is commonly found with decreased acetabular anteversion.
In addition to recognizing acetabular anteversion, it is also important to ap-
preciate the degree of femoral head coverage provided by the acetabulum. This
can be measured radiographically as the central edge angle of Wiberg, which is
defined as the angle between the horizontal line through the center of the femoral
head and a line tangent to the superior and inferior acetabular rims. The normal
center edge angle is 30° and a decrease in this angle (dysplasia) has been as-
sociated with rapid onset of osteoarthritis
[10
–
13]
. Center edge angles of less
OSSEOUS STRUCTURES CONTRIBUTING TO HIP STABILIZATION
The adult hip is a multiaxial ball-and-socket synovial joint composed of two
bony structures: the femur and the acetabulum. This bony architecture provides
the hip with inherent stability. Three biomechanical and anatomic geometries
of the femur and acetabulum are significant to joint stability and preservation of
the labrum and articular cartilage: appropriate femoral head
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Clin Sports Med Volume 25 Issue 2 April 2006 - Hip Injuries, English medicine

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