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Hip and Core Muscle Injuries in Soccer

October 11, 2018 | Surgery
Benjamin Sherman, DO ; Jorge Chahla, MD, PhD ; William Hutchinson, MD ; Michael Gerhardt, MD
Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Gerhardt reports that he is a consultant for Arthrex, Ferring Pharmaceuticals, Stryker, and Medacta. The other authors report no actual or potential conflict of interest in relation to this article.

Dr. Sherman is a Resident Physician, Riverside University Health System, Moreno Valley, California. Dr. Chahla is a Sports Medicine Fellow, Cedars-Sinai Kerlan-Jobe Institute, Santa Monica, California. Dr. Hutchinson is a Medical Director, Pacific Coast Hernia Center, Santa Monica, California. Dr. Gerhardt is a Sports Medicine Co-Fellowship Director, Cedars-Sinai Kerlan-Jobe Institute; and Team Physician, US Soccer and Major League Soccer, FIFA Medical Center of Excellence, Santa Monica, California.

Address correspondence to: Benjamin Sherman, DO, Riverside University Health System, 26520 Cactus Ave., Moreno Valley, CA 92555 (tel, 951-486-4698; email, Sherms04@gmail.com).

Benjamin Sherman, DO Jorge Chahla, MD, PhD William Hutchinson, MD Michael Gerhardt, MD . Hip and Core Muscle Injuries in Soccer. Am J Orthop.

October 11, 2018

TAKE-HOME POINTS

  • Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need surgical intervention.
  • Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain.
  • Acute groin pain in soccer players is most commonly caused by muscle strain involving the adductor longus, the iliopsoas or the rectus femoris.
  • Inguinal-related groin pain is a common cause of chronic groin pain and typically is the most challenging to treat with a complex pathophysiology and a high association with femoroacetabular impingement.
  • Hip-related groin pain (femoroacetabular impingement, labral tears, and chondral injuries) usually respond well to surgical intervention and has high rates of return to sport.

HIP-RELATED GROIN PAIN IN SOCCER ATHLETES

Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.44 FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.45,46

FEMOROACETABULAR IMPINGEMENT

FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.47 During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.25 Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.25 Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.48

We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues49 documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.50

Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues51 measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.51 A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.51 Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.52 While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.6 Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).33 Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.

Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.53 In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.54 Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.54

Continue to: LABRAL TEARS...

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