For many athletes following any major endurance event they will return to their houses, to recover, celebrate, reflect and rebuild to their next career step. Some, like the athlete in this case study will need to now focus attention on delayed decisions concerning whether to go under the knife to sort out a chronic injury. El Paso, TX’s Injury scientist, Dr. Alexander Jimenez takes a look at the study.
My client has been competing in triathlon for 10 or more years, although his career has included a range of serious injuries which have kept him from races for months on end. In the previous two to three decades, however, he’s enjoyed a sustained period of injury-free training and racing, and has climbed to the peak of the world rankings. But the emergence of hip pain has seen him once more return to the physio’s table.
The triathlete’s accident history highlights a common pattern among sportspeople: 2 tibial stress fractures, a femoral neck stress fracture and a serious ankle sprain — every one of these on his right side. The significant contributing element to the bone stress injuries is a 1.5cm leg-length gap (his right leg is shorter).
He’d first experienced comparable hip pain in 2004; it kept him from running for three months. At that time, nothing was detected on a bone scan or MRI, or so the pain went paralyzed. An intra-articular cortisone injection (CSI) elicited no improvement. The athlete remembers that he chose to train on his painful hip, never allowing the symptoms to settle. The nearest he ever came into an investigation was a hypothesis that he could have a little, undetected, labral lesion.
The present episode of hip pain began initially at night after a hard three-hour bicycle ride. Earlier this, however, he hadn’t cycled for five times. He described his initial symptom as a profound hip tightness (lateral and lateral), together with slight pain in his groin. He was able to continue to train however, was feeling that the hip tightness and pain following both cycling and running (swimming was symptom-free).
A week later his symptoms dramatically worsened when he flew from Australia to Singapore, on his way to a French high- altitude camp. As he got off the airplane, he felt deep hip pain as well as the tightness. As elite athletes tend to do, he coached anyway, running a tricky track session, which made the hip much worse: he was unable to ride or run without pain. He instantly started a course of anti- inflammatories.
I met him in Singapore and evaluated him in the airport, initially ruling out any prospect of a disease or systemic matter. He explained he had been feeling an ache during the night, lying in bed; on waking, the hip would be OK, but got worse the longer he walked.
On assessment, he had the following physical signs:
• walking with obvious limp
• pain on hopping (6/10)
•painful right hip quadrant/impingement test (full hip flexion/adduction)
• reduced right hip flexion (-10 degrees compared to left)
• reduced right hip internal rotation (-10 degrees compared to left)
• increased tone on palpation of TFL, adductors, hip flexors, gluteal, piriformis and deep rotators
• lumbar spine and SIJ were OK
• femoral shaft bone stress test was OK • leg length discrepancy (right side 1.5cm shorter)
• right innominate (pelvis) anteriorly rotated
• weakness in right hip abductors/extensors
• reduced calf endurance on right side (-5 reps)
• ankle dorsiflexion range of movement was OK
• reduced proprioception on right (single leg stance, eyes closed).
I thought the differential diagnoses were:
• femoral neck stress fracture
• labral tear, possibly with hip synovitis
• FAI (femoro-acetabular impingement), possibly with hip synovitis.
I initially treated the triathlete with soft- tissue techniques to reduce the tone around the hip joint. Trigger-point releases were performed on his TFL, adductors, gluteals, piriformis, deep rotators and iliopsoas. This reduced his jump pain into 3/10. Manual long-leg grip further decreased the strain on hopping (2/10). He still had pain and stiffness on walking but it sensed “simpler. As he prepared to embark on his long run flight to Europe, I counseled him to not sit for too long and maintain his stylish as straight as possible to decrease any potential impingement from hip flexion.
Luckily, the hip didn’t get worse throughout the flight. On arrival at the French high-altitude training centre, we initiated a strategy of two swims and two intensive treatments a day, aiming at reducing muscle tone, restoring his range of hip movement and normal muscle control and stamina. We had been expecting that the problem was not a stress fracture, but just minor hip synovitis that could settle quickly. Following a week of conservative treatment, though, we were just able to keep his hop pain in 2/10, and that he still could not run 20 meters without any pain and limping.
In collaboration with medics, we flew to London to see a sports doctor and get MRI scans. The scans revealed no bone stress reaction, fracture or labral ripping — which was a big relief; however, it did show signs consistent with FAI (femoro-acetabular impingement). He had hip synovitis with a rectal lesion on his femur.
Hip injuries aren’t much reported among triathletes — in fact they are notably absent from reports on Olympic and Ironman triathlons, which mention knee, back, H/ Achilles, lower leg, ankle and shoulder as the most common accidents (1-3).
In this state, when the hip is in maximum flexion and internal rotation, the labrum and cartilage abut and impinge; damage to the articular cartilage and acetabular labrum results from this pathologic bony contact. The contact generally results in a structural abnormality of the femur (“camera impingement”) along with the acetabulum (“pincer impingement”) or a combination of both (“mixed impingement”). Over time, via repetitive micro-trauma, the aggravating motion hurts the hip cartilage or labrum (or both) during normal joint motion. This happens along the anterior femoral neck and the anterior–superior acetabular rim. FAI is a possible trigger of early hip joint degeneration (4).
Arthroscopic surgery is the direction of choice for FAI if symptoms do not settle; however as his next Competition was only three and a half a year off, surgery was not an option. Instead, over a five-day interval, the athlete had two cortisone (CSI) and local anesthetic injections into the hip joint (under ultrasound guidance) to settle the indicators.
Our aim was to grow the hip range of motion and extend the capsule to reduce any additional impingement, slowly returning to regular training. Following the competition, the athlete would then should see a hip arthroscopic surgeon to acquire a surgical opinion to the best option for long-term direction.
After both shots my customer felt sore for five days. The initial CSI settled his pain on hopping to 1/10 and after seven days he managed to operate without symptoms. But minor hip stiffness and aching at the end of the day prevented him from progressing to optimal training, so that he then underwent a second steroid injection. This settled the hop pain into 0/10 and decreased the aching; so after five times he returned to mild cycling and after seven days he started running again, also.
The athlete admitted that, following the first shot, he had done more and gone tougher in training than directed, as he had felt “good. This mistake of “too much too soon — all too common in elite athletes — had led to excessive inflammation and aching in the hip nightly after training. After the next injection he returned to normal intensity slower and more gradually.
My client built his training up to regular levels by four months following the final injection (swimming five times per week, cycling four days and running six to seven days). He began with very easy cycling on a wind trainer for 30 minutes, building slowly to 90 minutes before cycling on the street. He cycled two days on and one day away and avoided hills to the first two weeks. He started jogging on the apartment for 15 minutes and slowly built up to 90 minutes after three weeks. He did not run hills or about the track; and as he ran only on every single day, he would diligently concentrate on technique.
From week six to week 11, my client remained on anti inflammatory medication and underwent two treatments a day.
The hands-on treatment continued to:
• increase hip range of movement
• stretch the hip capsule
• normalise pelvic symmetry and hip muscle tone
• improve muscle control and strength • improve proprioception
• ensure optimal biomechanics via video assessment (cycling and running).
Eleven weeks after he first felt his hip pain, the triathlete returned to racing; however he failed to finish the first race, partially because of minor hip stiffness but mainly due to “fitness. Fortunately there were not any prolonged symptoms after the race and a week after he successfully returned to competition, coming second in a really strong field. His very minor ongoing symptoms were handled with anti-inflammatory drugs and hands-on treatments.
If this athlete wants to pursue a long- term triathlon career up to the London Olympics, then he will now require surgery. The arthroscopic surgical technique initially assesses the cartilage and labral surfaces, debrides any abnormalities of the hip joint cartilage and hip labrum, removes the non-spherical segments of the femoral head and any prominent sections of the anterior femoral neck and bony growths on the acetabular rim that may continue to contribute to hip joint impingement. The alternative is early joint degeneration and onset of osteoarthritis.
1. Wilk B et al: “The incidence of musculoskeletal injuries in an amateur triathlete racing club”. J Orthop Sports Phys
Ther 1995 Sep;22(3):108-12.
2. Collins K et al: “Overuse injuries in triathletes. A study of the 1986 Seafair Triathlon”. Am J Sports Med 1989 SepOct;17(5):675-80.
3. Korkia PK et al: “An epidemiological investigation of training and injury patterns in British triathletes”. Br J Sports Med 1994 Sep;28(3):191-6.
4. Ganz R. et al (2003): “Femoroacetabular impingement: a cause for osteoarthritis of the hip”. Clin Orthop Relat Res. 417:112–120. For more information see: http://www.hipfai.com
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