Hip Injuries in Hockey: “Coach- my hip hurts!”

Hip Injuries in Hockey: “Coach- my hip hurts!”

Created on: Friday, April 13, 2018
Author: Dr. Ryan Fader

 As Minnesota hockey season winds down and professional hockey playoffs get started , we took a little time to review common hip issues in hockey players with Dr. Ryan Fader. He shares details on common hockey hip issues below.

If you are a hockey player, parent, or coach, the terms “groin strain” or “hip flexor strain” are likely familiar to your ears.  But what does this mean, and why are these hip injuries so common throughout Minnesota’s most popular sport?  As the game continues to evolve with increasingly specialized and highly skilled sport-specific training occurring at younger and younger ages, it is important to explore this broad diagnosis further.

Ice hockey, and other dynamic sports involving high hip flexion and a low-squatting position, place significant demands on the body, particularly the hip joint and it’s surrounding muscular envelope.  The hip is the deepest and most protected joint in the body with 17 different muscles surrounding it that are important for its function.  The famous quote “the legs feed the wolf” holds true in hockey, and at the center of this is the hip joint.  Therefore, it is no wonder this area can be under significant demand and strain during skating.  Do strains of the “hip flexor” occur in hockey players?  Simply put: yes.  But looking further in to the broad category and etiology of hip pain in the adolescent and adult athlete alike is worthwhile.
Although there are many reasons for hip pain in the hockey athlete, I would like to focus attention on the three most common:  hip impingement/labral tear, sports hernia and groin strains, and avulsion injuries. In this post, we’ll focus on the hip impingement/labral tear and soft tissue strains in the hockey athlete. In part 2 of the Sports & Orthopedic Specialists, part of Allina Health Hip Preservation blog, we will  expand on the other causes of hip pain. 
Hip Impingement (FAI) and Labral Tears
Rampant among hockey players is the diagnosis of Femoroacetabular Impingement (FAI), or simply “Hip Impingement”.  This is a bony abnormality of the hip in which there is excess bone, making an incongruent hip joint.  This is often associated with a tear in the hip labrum, a cartilaginous structure at the rim of the socket portion of the joint and serves a variety of functions including acting as a bumper, helps deepened the hip socket, and provides a suction seal for normal mechanics.  When youth and adult athletes complain of hip pain, this is always considered a possible cause.1,2, 3 Often times this anatomy is present without symptoms, but repetitive hip flexion activities, such as skating, can precipitate symptoms.  The patient may experience this as groin pain, pinching in the hip, muscular strain, pain on the outside the hip, limited motion, or pain in the low back.  In fact, the symptoms experienced are so broad that a recent study found patients with this condition were on average misdiagnosed for 21 months, and seen by 3.3 health care providers prior to the diagnosis of labral tear from hip impingement.4.Literature also suggests that butterfly goalies are at particular risk, and this is thought to be due to the position of the hip that is required to achieve this technique.5,6 The long-term risk of this condition is lifestyle limitation or disability in the short term, and advanced arthritis in the long term.
Diagnosis is made by listening to the patient about their symptoms and provocative activities, standard radiographs, and often times MRI imaging.  Once diagnosed, treatment of hip Impingement and labral tears is targeted at reducing inflammation and symptoms, and each treatment plan is tailored to the individual patient’s needs, factoring in not only the symptoms and limitation, but also their level of sport, timing with season, etc.  Traditionally, a trial of conservative management is trialed, aiming to reduce inflammation, improve motion, and strengthen the hip’s surrounding musculature.  This is accomplished with an anti-inflammatory medication, advanced hip-centric physical therapy with a skilled therapist, often times an injection if needed to help allow an athlete to finish a season.  If these are ineffective for a lasting period of time, minimally invasive arthroscopic hip surgery has demonstrated excellent results not only in improving symptoms and correcting the anatomy, but also with return to sport.7,8  
Soft tissue strains
Bony hip impingement aside, true muscular tears are common.  Given the dynamic nature of skating, all 17 hip muscles are working in some way shape or form, and with the onset of either early skating prior to stretch, for growing fatigue as a game or practice ensues, it is possible to pull any of these muscles. An important distinction from hip impingement pain is that muscular strains will typically be sudden in onset, and they tend to improve with a short period of rest, anti-inflammatory meds, and stretching, over a 7-10 day period. Most common muscle groups affected are:
Hip flexors
Adductor or “groin” muscles
Gluteal or “butt” muscles
Abdominal muscles 
These injuries can be true muscular strains that are short-lived, or can be repetitive if not given enough time to calm down.
Growing attention has been paid to a subset of patients with muscular strains, now broadly classified as “core muscle injuries” or “sports hernia”, in which there is a tug-o-war between the rectus abdominal muscle and the adductor muscles.  This can result in abdominal, pubic, groin, or inner thigh pain.  Presently, the majority of these injuries are treated with a short period of rest, anti-inflammatories, and physical therapy.  The role of injections remains to be defined.  Rarely are they treated surgical.  Despite this, there is a growing body of literature supporting the association of these “sports hernias” with hip impingement, and surgical management of both the abnormal hip anatomy and the muscle itself, in combination, is becoming more common.9,11
1. Röling MA, Mathijssen NM, Bloem RM. Incidence of symptomatic femoroacetabular impingement in the general population: a prospective registration study. J Hip Preserv Surg.  2016 Mar 25;3(3):203-7. 
2. Lerch TD, Todorski IAS, Steppacher SD, Schmaranzer F, Werlen SF, Siebenrock KA, Tannast M1. Prevalence of Femoral and Acetabular Version Abnormalities in Patients With Symptomatic Hip Disease: A Controlled Study of 538 Hips. Am J Sports Med. 2018 Jan;46(1):122-134. 
3. Larson CM, Safran MR, Brcka DA, Vaughn ZD, Giveans MR, Stone RM. Predictors of Clinically Suspected Intra-articular Hip Symptoms and Prevalence of Hip Pathomorphologies Presenting to Sports Medicine and Hip Preservation Orthopaedic Surgeons. Arthroscopy. 2018 Mar;34(3):825-831. 
4. Burnett RS, Della Rocca GJ, Prather H, Curry M, Maloney WJ, Clohisy JC.  Clinical presentation of patients with tears of the acetabular labrum.  J Bone Joint Surg Am.  2006 Jul; 88(7): 1448-57.
5. Whiteside D, Deneweth JM, Bedi A, Zernicke RF, Goulet GC. Femoroacetabular Impingement in Elite Ice Hockey Goaltenders: Etiological Implications of On-Ice Hip Mechanics. Am J Sports Med. 2015 Jul;43(7):1689-97. 
6. Ross JR, Bedi A, Stone RM, Sibilsky Enselman E, Kelly BT, Larson CM. Characterization of symptomatic hip impingement in butterfly ice hockey goalies. Arthroscopy. 2015 Apr;31(4):635-42. 
7. Menge TJ, Briggs KK, Philippon MJ.  Predictors of Length of Career After Hip Arthroscopy for Femoroacetabular Impingement in Professional Hockey Players. Am J Sports Med. 2016 Sep;44(9):2286-91. 
8. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: a systematic review. Br J Sports Med. 2015 Jun;49(12):819-24.
9. Strosberg DS, Ellis TJ, Renton DB.  The role of femoroacetabular impingement in core muscle injury/athletic pubalgia:  diagnosis and management.  Front Surg. 2016; 3:6.
10. Munegato D, Bigoni M, Gridavilla G, Olmi S, Cesena G, Zatti G.  Sports hernia and femoroacetabular impingement in athletes: a systematic review. World J Clin Cases. 2015 Sep 16; 3(9): 823-830.
11. Larson CM.  Sports hernia/athletic pubalgia. Sports Health. 2014 Mar; 6(2): 139-144.



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