Sportspecific Mechanisms Of Hip Injuries In The Athlete

As arthroscopic treatments of the hip continue to evolve, there is an increasing need to understand the basic performance biomechanics of the hip joint. This information is important, as it can provide the foundation by which joint function, pathology, and therapeutic modalities can be evaluated. There are a number of recent studies that have applied different approaches to study the hip biomechanics, particularity in THR. However, there is clearly a void in the amount of literature related to the function, and pathology of the normal or injured, nonarthritic hip. Thus, the remainder of this article will offer our understanding as to how these injuries result in athletes. It is important to keep in mind that a majority of athletes undergoing hip arthroscopy have a complex injury pattern, with damage to the acetabular labrum, capsular structure, and cartilage surfaces. To ascertain the specific injury sequence and pattern(s) of cause and effect, significant research still needs to be performed.


During the downswing of a right-handed golfer, the right hip is forced into external rotation during axial loading. This movement tends to push the femoral head anteriorly, and over time may lead to focal anterior capsular laxity and stretching of the iliofemoral ligament [72,73]. Subsequent joint instability may result leading to increased translation of the ball in the socket. Labral tears, particularly in the anterosuperior weight-bearing region of the acetabulum, may follow. The labrum has been shown to function as a physiologic seal, stabilizing the femoral head in the acetabulum [74,75]. In a further propagation of the injury, labral tear leads to reduction in seal function; increased translation of the femoral head may result. In addition, an unpublished report by Bharam et al (70th Annual Meeting of the American Academy of Orthopaedic Surgeons) showed that chondral delamination in the area adjacent to the labral tear is a frequent finding in golfers.


In martial arts, particularly taekwondo, a good kick can be performed well above an athlete's head. The proper positioning for a taekwondo side kick places the stance leg in 90° of external rotation. The stance leg must then sustain significant loads while the opposite leg performs the kick. Similar to the mechanism in golfers, the forced external rotation and axial loading in the stance leg (not the kicking leg) may cause anterior capsular laxity and elongation of the iliofemoral ligament. As a result of the increased translation of the femoral head with respect to the acetabulum, labral and chondral injuries may follow.

Ballet/Figure Skating

Elite ballet dancers and figure skaters perform the extremes of rotational movement during their routines. Flexibility of the lower extremities is crucial for success. Some athletes excel at these sports due to their generalized ligamentous laxity; yet, despite this apparent advantage, they may also suffer from symptoms of hip instability. Other ballet dancers and figure skaters may suffer from instability secondary to repeated hip rotation and focal capsular laxity. Hip laxity has been reported in a ballet dancer to be the cause of atraumatic dislocation of the hip [76]. A very common finding in ballet dancers and figure skaters undergoing hip arthroscopic surgery is capsular laxity with associated labral tear

Injuries to the ligamentum teres are also common in ballet dancers and figure skaters. This ligament connects the margins of the acetabular notch and transverse ligament to the fovea capitus on the femoral head. It is thought to function as a secondary stabilizer to external hip rotation [77]. In athletes with hip instability, the ligamentum teres is under increased stress to help stabilize the joint. Tears to the ligament often result.

Ice Hockey

Hockey players may suffer from traumatic hip injuries after direct blows to the greater trochanter. Isolated labral tears and chondral injuries from simple mechanical shearing are commonly found in these patients [78]. In addition to trauma, hockey players can suffer from overuse-type hip injuries. While skating, significant flexion, abduction, and slight external rotation forces are present at the hip. As a goalie, the hip sustains significant flexion and internal rotation forces. In flexion and abduction or flexion and internal rotation, any morphologic abnormality at the femoral head-neck junction would hit the antero-superior labrum and the acetabular rim. This abnormality is found in patients with cam-type femoroacetabular impingement [1,2,79] and is a very common finding in elite hockey players undergoing hip arthroscopy. Whether this is a subtle developmental deformity exacerbated by sport or whether there is a unique mechanism for the development of cam-type impingement in athletes is still not known.


Although most cases of hip instability are present in athletes whose sports demand excessive rotational movements, runners may also present with subtle anterior hip instability [80]. In the stride phase of high-level extensive running, repeated hip hyperextension may stretch the anterior capsule and iliofemoral ligament. The resulting microinstability may subtly increase femoral head translation, and with repeated insults, cause labral tear and chondral injury.

During running, when the foot contacts the ground the femur is in an abducted position in relation to the pelvis. Thus, the gluteus medius and tensor fascia latae are eccentrically loaded. As the running support phase progresses, these muscles must then contract as abduction occurs at the hip. Thus, it is believed that gluteus medius weakness may lead to decreased thigh control manifesting in increased thigh adduction and internal femoral rotation. These changes may predispose the runner to several pathologic conditions including iliotibial band syndrome at the knee [81].


[1] Lavigne M, Parvizi J, Beck M, et al. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop 2004;418:61-6.

[2] Ito K, Minka 2nd MA, Leunig M, et al. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br 2001;83(2):171-6.

[3] Notzli HP, Wyss TF, Stoecklin CH, et al. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br 2002;84(4):556-60.

[4] Crowninshield RD, Maloney WJ, Wentz DH, et al. Biomechanics of large femoral heads: what they do and don't do. Clin Orthop 2004;429:102-7.

[5] Nordin M, Frankel V. Biomechanics of the hip. Philadelphia (PA): Lea & Febiger; 1970.

[6] Anda S, Svenningsen S, Dale LG, et al. The acetabular sector angle of the adult hip determined by computed tomography. Acta Radiol Diagn (Stockh) 1986;27(4): 443-7.

[7] Reikeras O, Bjerkreim I, Kolbenstvedt A. Anteversion of the acetabulum and femoral neck in normals and in patients with osteoarthritis of the hip. Acta Orthop Scand 1983;54(1): 18-23.

[8] Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am 2003;85-A(2):278-86.

[9] Tonnis D, Heinecke A. Decreased acetabular anteversion and femur neck antetorsion cause pain and arthrosis. 1: statistics and clinical sequelae. Z Orthop Ihre Grenzgeb 1999; 137(2):153-9.

[10] Felson D. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev 1988;10:1-28.

[11] McCarthy JC, Noble PC, Schuck MR, et al. The Otto E. Aufranc Award: the role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393: 25-37.

[12] Reijman M, Hazes JM, Pols HA, et al. Acetabular dysplasia predicts incident osteoarthritis of the hip: the Rotterdam study. Arthritis Rheum 2005;52(3):787-93.

[13] Lievense AM, Bierma-Zeinstra SM, Verhagen AP, et al. Influence of hip dysplasia on the development of osteoarthritis of the hip. Ann Rheum Dis 2004;63(6):621-6.

[14] Fabry G. Normal and abnormal torsional development of the lower extremities. Acta Orthop Belg 1997;63(4):229-32.

[15] Kaltsas DS. Comparative study of the properties of the shoulder joint capsule with those of other joint capsules. Clin Orthop 1983;173:20-6.

[16] Barkow H. Syndesmologie oder die Lehre vond den Bandern, durch welche die Knochen des menschlichen Korpers zum Gerippe vereint warden. Beslau: Aderholz; 1841.

[17] Fuss FK, Bacher A. New aspects of the morphology and function of the human hip joint ligaments. Am J Anat 1991;192(1):1-13.

[18] Wasielewski R. The hip. Philadelphia (PA): Lipponcott-Raven; 1998.

[19] Murray M, Drought A, Kory R. Walking patterns of normal men. J Bone Joint Surg 1964; 46-A:335-60.

[20] Howse AJ. Orthopaedists aid ballet. Clin Orthop 1972;89:52-63.

[21] Offierski CM. Traumatic dislocation of the hip in children. J Bone Joint Surg Br 1981; 63-B(2):194-7.

[22] O'Leary C, Doyle J, Fenelon G, et al. Traumatic dislocation of the hip in Rugby Union football. Ir Med J 1987;80(10):291-2.

[23] Hoffer JA, O'Donovan MJ, Pratt CA, et al. Discharge patterns of hindlimb motoneurons during normal cat locomotion. Science 1981;213(4506):466-7.

[24] Moritani T, deVries HA. Neural factors versus hypertrophy in the time course of muscle strength gain. Am J Phys Med 1979;58(3):115-30.

[25] Gordon AM, Huxley AF, Julian FJ. The variation in isometric tension with sarcomere length in vertebrate muscle fibres. J Physiol 1966;184(1):170-92.

[26] Hill AV. First and last experiments in skeletal muscle mechanics. London: Cambridge University Press; 1970.

[27] Horowits R, Podolsky RJ. The positional stability of thick filaments in activated skeletal muscle depends on sarcomere length: evidence for the role of titin filaments. J Cell Biol 1987;105(5):2217-23.

[28] Lieber RL, Brown CC. Quantitative method for comparison of skeletal muscle architectural properties. J Biomech 1992;25(5):557-60.

[29] Gans C. Fiber architecture and muscle function. Exerc Sport Sci Rev 1982;10:160-207.

[30] Zajac FE. How musculotendon architecture and joint geometry affect the capacity of muscles to move and exert force on objects: a review with application to arm and forearm tendon transfer design. J Hand Surg [Am] 1992;17(5):799-804.

[31] Arnold AS, Salinas S, Asakawa DJ, et al. Accuracy of muscle moment arms estimated from MRI-based musculoskeletal models of the lower extremity. Comput Aided Surg 2000; 5(2):108-19.

[32] Blemker SS, Delp SL. Three-dimensional representation of complex muscle architectures and geometries. Ann Biomed Eng 2005;33(5):661-73.

[33] Dostal WF, Soderberg GL, Andrews JG. Actions of hip muscles. Phys Ther 1986;66(3): 351-61.

[34] Delp SL, Loan JP, Hoy MG, et al. An interactive graphics-based model of the lower extremity to study orthopaedic surgical procedures. IEEE Trans Biomed Eng 1990;37(8): 757-67.

[35] Brand R, Crowninshield RD, Wittstock C, et al. A model of lower extremity muscle anatomy. J Biomech Eng 1982;104(4):304-10.

[36] Herzog W, ter Keurs HE. Force-length relation of in-vivo human rectus femoris muscles. Pflugers Arch 1988;411 (6):642-7.

[37] Arnold AS, Delp SL. Rotational moment arms of the medial hamstrings and adductors vary with femoral geometry and limb position: implications for the treatment of internally rotated gait. J Biomech 2001;34(4):437-47.

[38] Anderson FC, Pandy MG. Individual muscle contributions to support in normal walking. Gait Posture 2003;17(2):159-69.

[39] Van Den B, Anton J, Read L, et al. An analysis of hip joint loading during walking, running, and skiing. Med Sci Sports Exerc 1999;31(1):131-42.

[40] Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities. J Biomech 2001;34(7):859-71.

[41] Paul JP. Biomechanics. The biomechanics of the hip-joint and its clinical relevance. Proc R Soc Med 1966;59(10):943-8.

[42] Pedersen D, Brand R, Cheng C, et al. Direct comparison of muscle force predictions using linear and nonlinear programming. J Biomech Eng 1987;109:192-9.

[43] Scopp JM, Moorman 3rd CT. The assessment of athletic hip injury. Clin Sports Med 2001; 20(4):647-59.

[44] American Orthopaedic Society for Sports Medicine. Injuries to the pelvis, hip, and thigh. Rosemont (IL): American Academy of Orthopaedic Surgeons; 1994.

[45] Bullough P, Goodfellow J, Greenwald AS, et al. Incongruent surfaces in the human hip joint. Nature 1968;217(135):1290.

[46] Johnston RC, Smidt GL. Measurement of hip-joint motion during walking. Evaluation of an electrogoniometric method. J Bone Joint Surg Am 1969;51(6):1082-94.

[47] Palastanga N, Field D, Soames R. Anatomy and human movement. 4th ed. Oxford: Butterworth-Heinemann; 2002.

[48] Ward F. Outlines of human osteology. London: Renshaw; 1838.

[49] Pauwels F. Biomechanics of the normal and diseased hip. Berlin: Springer-Verlag; 1973.

[50] Woodburne R. Essentials of human anatomy. 3rd ed. New York: Oxford University Press; 1965.

[51] Wells W. Kinesiology. 4th ed. Philadelphia (PA): WB Saunders; 1969.

[52] Goss C. Gray's anatomy of the human body. 28th ed. Philadelphia: Lea & Febiger; 1969.

[53] Lust G, Craig PH, Ross Jr GE, et al. Studies on pectineus muscles in canine hip dysplasia. Cornell Vet 1972;62(4):628-45.

[54] Lamb DW, Pollock GA. Hip deformities in cerebral palsy and their treatment. Dev Med Child Neurol 1962;4:488-98.

[55] Takebe K, Vitti M, Basmajian JV. Electromyography of pectineus muscle. Anat Rec 1974; 180(2):281 -3.

[56] Basmajian JV, Greenlaw RK. Electromyography of iliacus and psoas with inserted fine-wire electrodes (abstract). Anat Rec 1968;160:130.

[57] Andersson E, Oddsson L, Grundstrom H, et al. The role of the psoas and iliacus muscles for stability and movement of the lumbar spine, pelvis and hip. Scand J Med Sci Sports 1995;5(1):10-6.

[58] LaBan MM, Raptou AD, Johnson EW. Electromyographic study of function of iliopsoas muscle. Arch Phys Med Rehabil 1965;46(10):676-9.

[59] Nachemson A. Electromyographic studies on the vertebral portion of the psoas muscle; with special reference to its stabilizing function of the lumbar spine. Acta Orthop Scand 1966;37(2):177-90.

[60] Karlsson E, Jonsson B. Function of the gluteus maximus muscle. An electromyographic study. Acta Morphol Neerl Scand 1965;34:161-9.

[61] Joseph J, Williams PL. Electromyography of certain hip muscles. J Anat 1957;91(2):286-94.

[62] Greenlaw RK. Function of muscles about the hip during normal level walking [PhD Thesis]. Canada: Queen's University; 1973.

[63] Houtz SJ, Fischer FJ. An analysis of muscle action and joint excursion during exercise on a stationary bicycle. J Bone Joint Surg Am 1959;41-A(1):123-31.

[64] Goto Y, Kumamoto M, Okamoto T. Electromographis study of the function of the muscles participating in thigh elevation in various planes. Res J Phys Ed 1974;18:269-76.

[65] Wheatley MD, Jahnke WD. Electromyographic study of the superficial thigh and hip muscles in normal individuals. Arch Phys Med Rehabil 1951;32(8):508-15.

[66] Carlsoo S, Fohlin L. The mechanics of the two-joint muscles rectus femoris, sartorius and tensor fasciae latae in relation to their activity. Scand J Rehabil Med 1969;1(3):107-11.

[67] Carvalho CAFGO, Vitti M, Berzin F. Electromyographic study of tensor fascia latae and sortorius. Electromyogr Clin Neuirophysiol 1972;12:387-400.

[68] Duchenne G. Physiology of movement. Philedelphia (PA): WB Saunders; 1949 [original; reissued in 1959].

[69] Janda VVF. Polyelectromyographic study of muscle testing with special reference to fatigue. Copenhagen: IX World Rehabilitation Congress; 1963. p. 80-4.

[70] Janda VSV. The role of the thigh adductors in movement of the hip and knee joint. Courrier 1965;15:1-3.

[71] de Sousa OMVM. Estudio electromiografico de los musculos adductores largo y mayor. Arch Mex Anat 1965;7:50-3.

[72] Philippon MJ. The role of arthroscopic thermal capsulorraphy in the hip. Clin Sports Med 2001;20(4):817-29.

[73] Philippon MJ. Arthroscopy of the hip in the management of the athlete. In: McGinty JB, editor. Operative arthroscopy. 3rd ed. Philadelphia (PA): Lippincott-Williams & Wilkins; 2003. p. 879-83.

[74] Ferguson SJ, Bryant JT, Ganz R, et al. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech 2003;36(2):171-8.

[75] Ferguson SJ, Bryant JT, Ganz R, et al. The acetabular labrum seal: a poroelastic finite element model. Clin Biomech (Bristol, Avon) 2000;15(6):463-8.

[76] Stein DA, Polatsch DB, Gidumal R, et al. Low-energy anterior hip dislocation in a dancer. Am J Orthop 2002;31(10):591-4.

[77] Gray AJ, Villar RN. The ligamentum teres of the hip: an arthroscopic classification of its pathology. Arthroscopy 1997;13(5):575-8.

[78] Byrd JW. Lateral impact injury. A source of occult hip pathology. Clin Sports Med 2001; 20(4):801 -15.

[79] Siebenrock KA, Wahab KH, Werlen S, et al. Abnormal extension of the femoral head epiphysis as a cause of cam impingement. Clin Orthop 2004;418:54-60.

[80] Guanche CA, Sikka RS. Acetabular labral tears with underlying chondromalacia: a possible association with high-level running. Arthroscopy 2005;21(5):580-5.

[81] Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000;10(3):169-75.

[82] Veeger HE, Yu B, An KN, et al. Parameters for modeling the upper extremity. J Biomech 1997;30(6):647-52.

Clin Sports Med 25 (2006) 199-210

Perfecting Your Golf Swing

Perfecting Your Golf Swing

So you have seen Tiger elegantly making that last hole down the course and from that scene you realize one thing: you want to learn how to play this game.

Get My Free Ebook

Post a comment