Thursday 22 August 2019

Comment - Irish sport's career-ending hip injury crisis needs attention urgently

Darach Honan was forced into early retirement
Darach Honan was forced into early retirement

Patrick Carton

Like most club and inter-county players, former Clare hurler Darach Honan gave everything to succeed at the highest level.

However, the physical burden of years of intensive training and playing comes at a cost and Honan’s recent premature retirement from the game because of a progressive, chronic hip injury no longer comes as a surprise to people. Sadly, it’s an all-too familiar story.

So many athletes have been forced to call time at an early stage of their promising careers because of this injury, when the progressive bony deformation of the hip joint results in the mechanical breakdown of the cartilage, eventually leading to irreversible osteoarthritis.

Questions are being asked. Why do these young athletes develop a problem with their hips? Is the training intensity of modern sports too much? Can this be treated with physiotherapy? Is surgery necessary? What are the likely long-term outcomes?

The condition that affects so many of these athletes is commonly referred to as ‘hip impingement’ or ‘labral tear’ and results from the repetitive abnormal contact between the surfaces of a progressively deformed hip — an over-prominent acetabular rim (socket) known as a pincer deformity, and an aspherical femoral head (ball) known as a cam deformity. These bony deformities develop from the strain that intensive sports repeatedly places on the ligaments of the hip, primarily during the growing, adolescent period (12 to 17).

Progressive damage to the important soft tissues of the hip (labrum and cartilage) results in athletes developing groin pain and post-activity stiffness often lasting a couple of days following training or a game. Athletes will often develop restriction of hip movements, hamstring tightness and a reduction in athletic performance.

Our research at Whitfield Clinic, recently published in the Clinical Journal of Sports Medicine (2017) in association with Waterford Institute of Technology, has demonstrated significantly reduced acceleration and agility in athletes with hip impingement compared with a matched, athletic control group.

Once hip impingement becomes symptomatic, physiotherapy, activity modification and training alterations are unlikely to make significant difference and appropriate surgery is the option most likely to be successful.

At present there are no quality studies showing successful physiotherapy treatment for hip impingement in athletes, yet there is an enormous body of evidence which supports the success of surgery. Two ongoing randomised control trials, considered the gold standard of research quality, have already demonstrated significant benefits of surgery over physiotherapy for symptomatic hip impingement at eight and 12 months into the studies.

The quality of surgery is also improving dramatically. An advanced surgical technique, developed at the Whitfield Clinic and published last week in the peer-reviewed International Journal of Hip Preservation Surgery, has been used to repair the hips of many of our top athletes; this new technique now permits keyhole hip impingement surgery to be performed while fully protecting the labrum and cartilage junction, a vital structure that many other techniques may damage.

Since establishing the ‘Hip and Groin Clinic’, at the Whitfield Clinic, Waterford in 2009, more than 2,000 athletes have undergone keyhole hip surgery in the hope that it will repair the damage to their hips and permit a full return to pain-free competitive sports. Although results for most are excellent, the reality for some of these athletes is very different and the surgery will only buy them time because the underlying, irreversible damage to the hip cartilage will still progress, with arthritic change inevitable.

The key to having successful surgery and returning to symptom-free sports is early diagnosis and surgery before permanent damage to the hip cartilage has occurred. This requires physiotherapists, sports doctors and GPs to have a good understanding of hip impingement as a condition and a high index of suspicion for its presence, which for many athletes may be subtle at the earlier stages.

Approximately 80 per cent of our athletes are GAA players, primarily at senior club and inter-county level. At the time of consultation, players, on average, have had symptoms for two years, have failed conservative treatment (physio, sports doctors) and the majority already have permanent damage to the cartilage of the hip. Often the wrong initial diagnosis, continuation of unproven physiotherapy programmes and the injection of steroids into the hip joint only delay effective treatment for these players and increase their risk of irreversible cartilage damage.

If a player is suspected to have underlying hip impingement (hip/groin related symptoms and a reduction in hip range of movement) we recommend they cease playing and training to allow an appropriate assessment, including a full clinical examination and specialist X-ray analysis to be undertaken. A diagnosis and a recommendation can then be made to the player’s medical team. For players with suspected hip impingement or those returning to sport following surgery, we recommend introducing an individualised reduced-intensity training programme, on a long-term basis. 

The prevalence of hip impingement in the Irish field sports is unknown, however in a screening pilot study of more than 100 asymptomatic senior club and inter-county GAA players, we found significant hip abnormalities present in more than 70 per cent. A thorough hip screening programme should be introduced by the main sporting bodies (GAA, FAI, IRFU) to establish the true prevalence of hip impingement in Irish sports, and a review of training intensity, particularly for the adolescent age groups, should be undertaken.

To prevent the continued exodus of athletes from top-level sports due to progressive hip injuries, a focus on early diagnosis and treatment should be encouraged. However, given that prevention is always better than the cure, a fresh look at training load, individualised training programmes and the introduction of hip screening protocols also needs to be considered.

Patrick Carton is a consultant orthopaedic surgeon and specialist in surgery of the hip and groin at Whitfield Clinic, Waterford

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