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.

Golf

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 In addition, an unpublished report by Bharam et al (70th Annual Meeting of the American Academy of Orthopaedic Surgeons) showed that chondral delamination in the area adjacent to the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.

Taekwondo

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.

Running

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].

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