Hip Blog (III): Hip Injuries in Hockey Goalies

Hip Blog (III): Hip Injuries in Hockey Goalies

Created on: Friday, August 24, 2018
Author: Summer Intern: Lauren Topor (Bethel '19), Ryan Fader, MD

The third installment of the Hip Blog was inspired by one of our 2018 Summer Interns, Lauren Topor (Bethel University '19). As a pre-medical student who also happens to be a goalie with the Bethel University Women's Hockey team, she became the ideal guest contributor to review common hip pathology in goalies. 

In Part 1 and 2 of our hip injury blog, we reviewed common hip injuries in hockey, including hip impingement, muscle strains, avulsion injuries, and subluxations. Now, we will transition into a more specialized view within the sport of hockey, looking at hip injuries common to goalies.

Goaltending has been described as one of the most noble positions in sport, despite being home to some of the craziest athletes.  Yet, some of this craziness is necessary to step in front of frozen discs, possibly moving upwards of 90 mph, while wearing 50 pounds of heavy equipment and moving in positions the body should never be subjected to (example A). These abnormal movements put lots of strain on the body, especially the hip joints.  One of the main techniques in modern day goaltending, the butterfly, involves the athlete dropping to their knees and internally rotating their hips while bringing their leg pads and skates forward to cover the lower half of the net.  The combination of hip flexion and internal rotation creates tension and stress across the joint and may lead to a variety of hip conditions.1  This effect can be seen when comparing the hip and groin injury rates in professional goaltenders (1.84 per 1000 game appearances) and forward/defenseman (0.34-0.47 per 1000 game appearances).2

Hip injuries in goalies have been compared to shoulder injuries in pitchers; some athletes just have better anatomy to handle the continued strain of their position. There can often be bony obstructions or muscle tightness that limit the ability of the hips to reach the optimal angle of internal rotation. These bony obstructions, or femoroacetabular impingement (FAI, discussed in Part 1), can often be found in asymptomatic individuals. One study compiled results from 26 other research articles, finding that 37% of individuals had a cam deformity (or impingement where the ball is not round enough to rotate smoothly in the socket) and 67% had a pincer deformity (where extra bone from the socket extends around the ball, holding it more rigidly).3  As can be inferred from these numbers, this condition affects a large number of individuals without them even realizing it.  And once they strap on the pads as an ice hockey goalie, their anatomy and chosen position can create the perfect storm.
Although FAI is prevalent in the normal population, it has been suggested that it is even more common in athletes, especially those using end-range hip movements, which increase the risk for FAI. Hip positions such as internal rotation during flexion and external rotation during abduction (common skating and butterfly movements) can exacerbate the present FAI, ultimately resulting in a labral tear.5  The labrum, a rubbery cartilage lining the hip socket, acts as a cushion and joint seal.  These tears are another hip condition that are often asymptomatic in hockey players, as one study found 71% of athletes having a labral tear in one or both hips without pain.6
Ultimately, FAI can be extremely detrimental to not only the labral cartilage in the hip, but also the articular cartilage.7  This cartilage is a frictionless coating over the ball and socket bones, allowing smooth movement of the joint without pain.  To compare, this cartilage has been likened to the chocolate casing on the outside of a chocolate-covered pretzel.  When the bones of the hip are impinged, the patient continually breaks down this natural padding.  And since cartilage does not have any nerves, this breakdown or osteoarthritis causes no pain until all the cartilage is gone, leading to bone-on-bone rubbing.
At this stage in the progression, hip pain is inevitable without the only available treatment, a hip replacement.  Although this treatment is common in patients over 60 years, replacement has been seen in hockey goalies as young as 25-years-old.  To prevent this early degeneration in athletes with FAI, some have elected to do surgery that shaves down the deformity causing the impingement. This prevents further cartilage damage from FAI and may lead to a performance benefit by improving joint mobility.  In a study following five professional players, all returned to high levels of hockey post-surgery.8  Another surgery called microfracture is used to repair missing cartilage caused by FAI.  By creating small holes in the bone, blood arranges into a clot, which later becomes organized into fibrocartilage, functioning similarly to the native articular cartilage.  This surgery has been found to return 82% of ice hockey players to their former elite level performance.9
Overall, although copious amounts of stress are placed on the hip joint as a goaltender, the position and sport itself provide a number of health and lifestyle benefits.  It is necessary to be hypervigilant about noticing pain and reporting it to your athletic trainer or physician.  With early detection, further damage and premature hip replacements can be prevented.  Some have even suggested screening goaltenders with X-ray or MRI to find structural abnormalities early.  Although this intervention may not be necessary at this time during the butterfly era of goaltending, it is critical to use pain as your guide to know when to seek medical attention. 

1. Pierce CM, Laprade RF, Wahoff M, O’Brien L, Philippon MJ. Ice Hockey Goaltender Rehabilitation, Including On-Ice Progression, After Arthroscopic Hip Surgery for Femoroacetabular Impingement. Journal of Orthopaedic and Sports Physical Therapy. 2013;43(3):129-141.
2. Epstein DM, McHugh M, Yorio M, Neri B. Intra-articular hip injuries in national hockey league players: a descriptive epidemiological study. American Journal of Sports Medicine. 2013;41(2):343-348.
3. Frank JM, Harris JD, Erickson BJ, Slikker W III, Bush-Joseph CA, Salata MJ, Nho SJ. Prevalence of Femoroacetabular Impingement Imaging Finding in Asymptomatic Volunteers: A Systematic Review. Arthroscopy. 2015;31(6):1199-1204.
4. Whiteside D, Deneweth JM, Bedi A, Zernicke RF, Goulet GC. Femoroacetabular Impingement in Elite Ice Hockey Goaltenders: Etiological Implications of On-Ice Hip Mechanics. American Journal of Sports Medicine. 2015;43(7):1689-1697.
5. Stull JD, Philippon MJ, LaPrade RF. “At-risk” positioning and hip biomechanics of the Peewee ice hockey sprint start. American Journal of Sports Medicine. 2011;39:29S-35S.
6. Gallo RA, Silvis ML, Smetana B, Stuck D, Lynch SA, Mosher TJ, Black KP. Asymptomatic Hip/Groin Pathology Identified on Magnetic Resonance Imaging of Professional Hockey Players: Outcomes and Playing Status at 4 Years’ Follow-up. Arthroscopy. 2014;30(10):1222-1228.
7. Pun S, Kumar D, Lane NE. Femoroacetabular impingement. Arthritis and Rheumatology. 2015;67(1):17–27.
8. Bizzini M, Notzli HP, Maffiuletti MA. Femoroacetbular Impingement in Professional Ice Hockey Players: A Case Series of 5 Athletes After Open Surgical Decompression of the Hip. American Journal of Sports Medicine. 2007;35(11):1955-1959.
9. McDonald JE, Herzog MM, Philippon MJ. Performance outcomes in professional hockey players following arthroscopic treatment of FAI and microfracture of the hip. Knee Surgery, Sports Traumatology, Arthroscopy. 214;22(4):915-919.

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