Return To Play | Hip Injuries

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– If you have pain in your hips, whether it’s something you were born with, a sports-related condition, or a traumatic injury, UPMC has the experts to help. Orthopaedic surgeons specializing in the hip are trained to treat active people of all ages with a broad range of hip disorders. And when it comes to athletes, there is no shortage of hip injury. Whether you’re a soccer player cutting and pivoting your way down the field or a gymnast stretching and flying through the air, your hips are key to your performance, and they take a lot of stress. Hi, I’m Charlie Batch. Yes, that Charlie Batch if the name is familiar to you, and I’m here with Dr. Craig Mauro and Dr. Michael McClincy, orthopaedic surgeons specializing in the hip at UPMC. Docs, thank you for joining me today. Dr. McClincy, I hear you’re a pediatric orthopaedic physician. What does that mean?

– As a pediatric orthopaedic surgeon, I see patients at UPMC Children’s Hospital of Pittsburgh. We see kids from birth until the age of 26, and my partners at Children’s all have specialized practices. My practice primarily focuses on teenagers and young athletes. I see patients in middle school, high school, college, and beyond dealing with sports-related injuries.

– And Dr. Mauro, how is your role any different when you’re treating older athletes?

– So, I treat a wide range of patients as well, ranging from high schoolers and adolescents all the way through middle-aged people who come to us with weekend warrior-type injuries or hip pain. So, my practice really runs a spectrum of adulthood.

– Can you tell me about some of the common hip conditions that you may see?

– So, common injuries we see are some sport-related, such as muscle strains and injuries, but a more common problem really stems from some of the bone structures we have, such as with femoroacetabular impingement, or hip impingement, and hip labral tears, which can oftentimes lead to hip pain, not only in the athlete, but in the everyday person going to work and dealing with their day-to-day life.

– Doc, can you explain what hip dysplasia is?

– Sure. Hip dysplasia is where the socket does not cover enough of the ball of the ball-and-socket joint. Hip dysplasia is commonly seen at Children’s Hospital. Typically, we see it in infants and treat it at that time without surgery, but occasionally, this can occur in adolescents and young adults. And that typically happens during the growth process. Because the socket is not covering enough of the ball, it puts excess stress across certain regions of the cartilage in the hip joint. That leads to pain. That leads to early arthritis. At Children’s, we have advanced techniques to change the position of the socket, even whenever you are an adolescent or young adult. And we employ those in those cases. And what it does is it sort of normalizes the stress across the hip joint, improves pain, and negates the risk of dysplasia, or at least limits the risk of osteoarthritis in these patients long-term.

– And the interesting thing about this, Charlie, is that some of these same processes that lead to these problems down the line can actually be adaptive, and some young patients can have excess motion. They’re great at their gymnastics, they’re great at their dance because of their structure of their hip, but it’s a kind of a double-edged sword. And we see down the line, some of the unrecognized problems with some of these structures that we then see kind of catching up with them later in life. So we really want to recognize these early in life if patients are having problems with their hips.

– And Dr. Mauro, how is the groin and core connected to hip injuries?

– That’s a great question, Charlie. We see with a lot of these hip related injuries, it’s not just one specific traumatic injury. It’s more of an overuse, as Dr. McClincy was alluding to. Some of our athletes that specialize at a young age sometimes can get into these movement patterns that cause overload on their joints. So in addition to the cross-training and some of the multi-sport specialization, which we think is important, really focusing on the stability of the hip and core is paramount. So, when we see this break down, sometimes the hip-related problems such as hip impingement can lead to the quote-unquote “core problems,” which are things that people refer to as sports hernias, or other related problems. And they go hand in hand. So, if the mechanics around the hip and pelvis are compromised in some way, sometimes these patients will present with hip-based problems, and sometimes the problems around the core, which as I said can be groin strains, can be sports hernias, and some of these other problems that we see in the core.

– Doc, can you explain what hip impingement is?

– Yeah, Charlie. So hip impingement, or more formally known as femoroacetabular impingement or FAI, is a structural problem or a shape of the hip joint where the ball and socket don’t quite fit together perfectly. This can either come from a proud area of bone on the femur side, on the ball side, or a socket that’s too deep or some combination. So that when the patient, the player tries to take their hip through range of motion, they can’t quite get where they need to be, and they reach some impediment at the end of range of motion. This can cause pain, this can cause damage to their cartilage, to the labrum, and it can cause some long-term osteoarthritis if left unchecked in certain cases. So, oftentimes, the presenting symptoms that patients will come in with are groin pain or hip pain. And we put that together with their physical examination, their x-ray findings, and we come up with a diagnosis of hip impingement based on all these features of their hip joint. And this is something we want to recognize and treat with our entire team, nonoperatively, operatively, that I think we’ll discuss a little bit more here through the show.

– And I think that our understanding of hip impingement, FAI, has evolved over the last five or 10 years. And we’ve recognized that there are certain sources of pain and dysfunction, which are more concerning and have longer-lasting impacts than others. So, Dr. Mauro and I continue to work together to try to sort through that and define the best treatment strategies for these patients.

– Dr. Mauro, what is a sports hernia?

– Yeah, it’s an interesting question, Charlie. We face this a lot from our patients. It’s a term that’s been used for many years, and it’s a bit confusing because it’s not actually a hernia. It falls under this pattern of groin pain syndromes. We’ve used this term more commonly to encompass what are muscular injuries around the groin. Sometimes they involve an area where true hernias can occur. Inguinal hernias, direct and indirect hernias, it’s in the same general area. But unlike a hernia, there’s no outpouching of intestines or other abdominal tissue that can sometimes be seen with a hernia. This is truly a muscular injury. We see it around the pubic bone in the front of the hip, as well as radiating down into the groin. So this term has been used for many years, but more commonly now is being referred to as either a groin pain syndrome or a core muscle injury. And we see it very commonly, not only as an overuse type of problem, but sometimes as a traumatic injury in our athletes, very commonly in twisting sports, in hockey. We see it in runners, we see it in football players. And it truly boils down to kind of a muscular injury, like we see in other parts of our body, but involving the abdominal wall and the groin muscles right on the pelvic bone.

– Now, you mentioned abdominal wall. Most people think of that as back injuries, or back pain at times. How are the psoas related to that?

– That’s a great question. So, the iliopsoas runs right next to the hip joint and is kind of between the abdominal wall and the hip joint. So very commonly, people will come in with pain in the front of their hip joint, which we attribute to the iliopsoas, either a tendonitis or a strain in the iliopsoas. But it’s a great mimicker. Sometimes, it behaves like a hip joint problem. Sometimes, it behaves like a sports hernia. And so we really have our antenna up and monitor for the problems with the iliopsoas quite commonly.

– I think we really rely on our ultrasound specialists to help us delineate those two features. Because, again, they’re so closely related, but with targeted injections and dynamic evaluations, which they can do, it really helps us tease out those two different problems.

– And what type of nonsurgical treatments are used for the hip?

– So, as we discussed, we really believe in preventive maintenance around the core, around the glute muscles, around the hips, that really prevent these problems. Some of it’s modifications to training programs, some of it’s close collaboration with our physical therapists, our athletic trainers that we have at a lot of the schools. And some of it’s really just identifying which movements or which activities are causing the pain and making some adjustments to the player’s training.

– And aside from physical therapy and athletic trainers, I think that collaborating with nonoperative sports specialists, physiatrists, is also really helpful. We have a pretty unique program with in-clinic ultrasounds, which we use not uncommonly in our patients. They can provide targeted injections and other sort of treatments with that minimally invasive technique, which is really helpful for a lot of conditions.

– And is all of that used if you don’t need surgery?

– Correct.

– So I know, Dr. Mauro, I said now, if an athlete does need surgery, what’s all involved with that?

– Yes, so surgery can take many forms, and Dr. McClincy and I both perform arthroscopy of the hip, which is through keyhole incisions on the side of the hip, where we repair cartilage problems, we repair structural problems through the hip. But hip surgery can also involve open surgical procedures that Dr. McClincy can talk about, as well as sometimes in our older athletes, talking to them and counseling them about hip replacement, which some of our other colleagues perform. So, when we talk about surgery on the hip, it’s really identifying if it comes to it, what is the right surgery for this patient, whether it’s an arthroscopic procedure, an open procedure, and then collaborating across teams. And really that’s where our teamwork has really been beneficial for patients, as well as collaborating across to some of our other colleagues in general surgery and adult reconstruction, and some of the other surgical fields that patients may benefit from.

– And as athletes, trust me, I hate surgery. And the reason is because of post-op. Dr. McClincy, can you take me what post-op looks like for an athlete?

– Yeah, recovery is variable, and it depends on the type of surgery that you go through. The keyhole surgery that Dr. Mauro talked about is a little bit of a faster recovery. Some of the larger open procedures that I do take a little bit longer. I think that the right surgery is the best recovery for the patients, even if it takes a little bit longer. All of the surgeries involve sort of a stepwise recovery for patients. We work on restoring motion, followed by strength, and then a functional progression. One thing that’s interesting about our program is that we are starting to do research about how and when these patients can be safely returned to sporting activities because that’s still a little bit of a black box in the world of hip preservation. So I think that the abilities and capabilities of the University of Pittsburgh and the medical center have helped us move along that spectrum.

– What is hip preservation?

– Hip preservation is the concept that the problems that patients typically come in with — hip impingement, hip dysplasia — are really underlying structural problems with the ball-and-socket joint. While they cause pain in the short term, they also cause long-term damage. And we know that certain deformities like hip impingement and dysplasia are linked with things like osteoarthritis and developing that condition earlier in life. So, when we help out these patients, we know that we are both treating their acute symptoms, but also we believe setting them up for success down the road, preventing their joint from progressing to early-stage arthritis, and keeping them active for a long period of time.

– And I would add to that, Charlie, I think one of the big questions people come in and say, “Do I have to have surgery?” There are certain conditions that we say to them, “You know what? This surgery or this treatment is really just for your current symptoms.” Another big part of hip preservation is identifying those features or those conditions where we may say to them, “You know, you really should for the health of your joint in the long run, have this surgical intervention.” Or a contrary is, “You know what? Your joint is healthy, and you don’t need this intervention for the long-term health of your joints.” So it’s an added little piece of the discussion we have with patients, not only just return to play, but also the long-term health of their joint.

– And this question is for either one of you. When do you know an athlete is ready to return to play?

– Yeah, that’s another great question, Charlie. So, you know, along the lines we were talking about for postoperative care, we really rely on this relationship with our physical therapists quite a bit preoperatively, and kind of identifying whether someone maybe has failed nonoperative care and becomes a candidate for surgery. But then we kind of leverage that relationship postoperatively and really commit a lot of communication between the physical therapist, and sometimes if they’re with the team, the athletic trainer and the physician who’s overseeing some of that recovery. We’ve learned a lot about return to sport with other injuries — ACL injury, you know, you hear about in the news all the time where we know at specific timeframes the body is ready for certain movements, and we can think about return to sport at six to 12 months with ACL surgery. Well, we’re learning about some of those same ideas with the hip, that some of it’s the body recovering, and the swelling going down, and the muscles recovering. But a lot of it, frankly, comes down to their functional performance, and their confidence, and their ability to understand how they can safely move in space. And so that takes a team. That takes physical therapists, that takes athletic trainers, that takes us as the physician to get a snapshot in the office. But we really rely on that communication around our system to decide when someone’s ready for sport.

– Yeah, I think it’s important to note that their recovery really only starts at the time of surgery. And it’s months until they’re back into sort of those activities that they want to get back into. And by building teams and safely progressing them through those steps, we ensure them the best chance possible of getting back to the activities that they want to do in the safest and easiest pathway possible.

– And you all are at the top of your game in this industry. What is the most rewarding part of your job?

– I really like the immediacy of results. When you operate on people, if it’s a well-done surgery, they get better. And the benefits in hip preservation, specifically, are that patients get better fairly quickly, and they have long-lasting, sort of durable, results. And you see people at, you know, one, two, five, even 10 years after surgery, and they’re still thankful and functioning at a high level after these procedures.

– Yeah, I think that’s a great point. We all as surgeons love to see the outcomes that patients have with our surgical procedures. I think it’s also satisfying when we give a patient a diagnosis and tell them, “You know what? You may not need surgery for this. I’ve got this physical therapist or this nonoperative specialist that’s really going to help.” And they have a great outcome as well. And, for me, that’s also satisfying. And seeing patients come back — they come in with a problem, we’re hopefully able to help diagnose it and give them management in the right direction, and then they get better and are thankful, for me as well, that’s a very satisfying part about my job.

– And the one thing about it is we always have to remind us, former athletes, ice is your best friend. And most people don’t like it, but trust me, they are. But seriously, docs, I just want to really thank you for joining us today. You gave us a lot of really informative information, and thank you for all that you all do. Athletes are very lucky to have you. And if you want to learn more about common hip injuries and individualized treatment plans at UPMC Sports Medicine, visit

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