Femoroacetabular Impingement: Morphology Does Not Equal Pathology

Femoroacetabular Impingement Syndrome (FAIS) was described as early as 19361 and has been drastically increasing in popularity over the past two decades2. As this condition has become more respected amongst the medical community, the number of patients identified with FAIS was significantly increased3. With this increased recognition, there has also been a markedly rising number of hip arthroscopy surgeries being performed. Literature has demonstrated an 18-fold increase from 1999 to 20094 and a 25-fold increase between 2006 and 20135. With regards to indication for surgery, Peters and colleagues performed a scoping review to identify what factors surgeons use to make this decision6. This study found the below criteria used by surgeons for surgical intervention in the literature…

Criteria Studies reporting criteria
Alpha angle > 60°, CE angle > 40°, or presence of acetabular retroversion 72 (67%)
No clinical evidence of inflammatory arthritis changes 69 (64%)
Diagnostric injection or MRI indicating presence of intra-articular pathology or labral damage 66 (61%)
Acetabular retroversion (Crossover sign) 62 (57%)
Failed non-surgical treatment 47 (44%)
Anterior Impingement Test 39 (36%)
Positive FADDIR or Anterior Impingement Test 38 (35%)
Hip pain > 3 months 26 (24%)
Failed formal Physical Therapy-led program 19 (18%)
Lateral centre edge angle > 20° 18 (17%)
Flexion and IR decreased 12 (11%)
CE angle > 40° 8 (7%)
IR decreased 7 (6%)
Hip IR < 20° in 90° hip flexion 6 (6%)
Alpha angle > 60° 2 (2%)

As you can see from the data obtained from their study, the vast majority of the information used to determine surgery in this patient population is related to radiological findings and extent of morphological changes. Most surprisingly, failure of conservative management and especially failure of formal physical therapy was not included in the vast majority of published studies.

With this information, it appears we may be getting ahead of ourselves…

What is FAIS?

The femoroacetabular joint refers to the articulation between the proximal femur and the acetabulum of the pelvis. In FAIS, altered boney morphology of the femoral neck (Cam Morphology) or of the Acetabular rim (Pincer Morphology) leads to premature contact of the two osseous structures. Based on the orientation of the joint, this premature contact typically occurs during hip flexion and/or internal rotation7,8. This abnormal contact has also been blamed for additional pathological conditions such as acetabular labral tears, chondral lesions, and osteoarthritis.

Altered Morphology Does Not ALWAYS Matter

As with most morphological abnormalities, these factors do not always lead to pain and are fairly common in the general and athletic populations. A systematic review conducted by Frank and colleagues9 of 2,114 asymptomatic hips found a very high prevalence of altered morphology. They found that 67% of subjects had radiologically confirmed pincer morphology, whereas 37-55% of athletes and 23% of the general population demonstrated cam morphology. To further evaluate the association of morphology in symptomatic patients, athletes, and asymptomatic individuals, Mascarenhas and colleagues performed a systematic review of 60 studies10. This study found that cam morphology was significantly more common in athletes versus asymptomatic subjects but not compared to symptomatic patients, significantly more common in symptomatic versus asymptomatic cases. Whereas, no significant differences were found between pincer morphology prevalence when comparing athletes to symptomatic patients. However, mixed-type FAI was significantly more common in athletes versus asymptomatic subjects and in asymptomatic versus symptomatic subjects.

Additionally, when looking at those pathologies that are said to be caused by altered morphology, the prevalence is also very high among asymptomatic individuals. The presence of acetabular labral tears and chondral lesions were found in asymptomatic individuals with a prevalence of 44-69% and 20-24%, respectively11,12.

In fact, the level of morphological abnormality often does not coincide with severity of symptoms. A study of 616 adults with hip pain found no association between radiographic signs of FAIS or a positive Flexion Adduction Internal Rotation (FADDIR) test with degree of hip pain13. More recently, Jacobs and colleagues investigated the relationship of preoperative symptom severity and magnitude of boney morphology14. This study of 64 patients prior to arthroscopic hip surgery found no correlation between symptom severity and degree of acetabular labral tear or femoroacetabular boney morphology. There was however a significant influence of depressive symptoms (as determined by the Mental Component Score) and severity of hip-related symptoms, which gives further credence to the link between psychosocial factors and symptom severity irregardless of morphological or pathological changes.

When Does Altered Morphology Matter?

Previous diagnostic criteria for femoroacetabular impingement relied heavily upon the level of morphological changes. Ganz et al. and Sankar et al. determined that the diagnosis of FAIS was appropriate if (1) there was abnormal morphology of the femur and/or acetabulum, (2) if there was abnormal contact between these two structures, (3) if the patient participated in activities that resulted in supraphysiologic motion that results in such abnormal contact and collision, (4) repetitive motion resulting in the continuous insult, (5) presence of soft-tissue damage15,16. Once again, these criteria are not sufficient to accurately diagnose a patient with FAIS because there is no weight put on clinical signs or symptoms.

More recently, Griffin and colleagues attempted to better define appropriate terminology, diagnosis, treatment, and prognosis for FAIS17. At this consensus meeting, they agreed that accurate diagnosis depended upon clinical signs, symptoms, and diagnostic criteria. They therefore defined FAIS as:

“Femoroacetabular impingement syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum.”

— 2016 Warwick Agreement on Femoroacetabular Impingement Syndrome (Griffin et al., 2016)

The key differentiating factors between this and previous descriptions are the additional criteria of ‘symptomatic’ and the emphasis on symptoms and clinical signs in addition to diagnostic criteria. This definition was met with a 9.8/10 agreement and allows for the entire patient presentation to be taken into consideration, not just the underlying morphological changes. To expand upon this agreement, Reiman and colleagues performed an international and multi-disciplinary Delphi survey to identify pertinent aspects of the subjective history, clinical examination, and radiological examination18. This survey found agreement on the following aspects in patients presenting with FAIS…

Subjective Examination
Descriptor Consensus Support
Deep anterior groin pain, especially worse with activities such as prolonged sitting, squatting, car transfers, and dressing 98.4%
Pain with hip flexion or rotational activities 96.7%
Pinching or aching in the hip/groin associated with activitity 96.7%
Deep groin pain with twisting or turning or pivoting 95.1%
Intermittent sharp deep groin pain 95.1%

Subjective self report should be the cornerstone of the examination of any injury and FAIS is no exception. Patients often present with reports of deep anterior groin pain that is exacerbated with activities involving deep flexion, rotational activities, and squatting. The subjective attributes agreed upon for individuals presenting with FAIS closely coincides with a diagnostic study performed by Clohisy and colleagues19 who looked at 51 patients with confirmed, symptomatic FAIS. This study showed that 88% of patients had pain localized to the groin region and aggravating factors included general activity-related (71%), running (69%), sitting (65%), and pivoting (63%).

Physical Examination
Descriptor Consensus Support
Limited IR with hip flexion with pain 96.7%
Limited IR with pain 91.8%
Limited and painful hip flexion 83.6%
Special Testing
Descriptor Consensus Support
Positive FADDIR/Anterior Impingement Test 91.8%
No special tests are diagnostic of FAIS; Only valuable as screening tool 82.0%

A systematic review of 16 studies related to physical impairments in individuals with FAIS demonstrates similar findings as the Delphi survey. This study agreed that the available literature currently demonstrates that individuals with FAIS have decreased hip ROM into impingement (flexion/internal rotation in 90° flexion), which is often limited by pain20.

When looking at the included criteria for special testing in FAIS, the two agreed upon findings seem contradictory. On one end, a positive FADDIR test is beneficial, however on the other end, it is also noted that no special tests are diagnostic for FAIS. According to the literature in reference to special testing for FAIS, there has been no test that can be seen as confirmatory of the diagnosis due to very low positive likelihood ratios and specificity values21-23. That being said, the use of the FADDIR test does offer benefit due to the very high sensitivity and low negative likelihood ratios reported in the literature (Sn= 0.94-0.99, -LR= 0.14-0.45)22, however its capacity as a screening method has recently come into question24. A cross-sectional study of 74 ice hockey players (average age of 16 years old) contradicted the current literature with regards to the FADDIR test’s screening capacity. This unique study questions its capacity to screen for pure cam, pincer, or combined morphology (Sn= 0.41, -LR= 1.24) and pure cam or combined morphology (Sn= 0.60, -LR= 0.78). As we continue to evaluate the capacity to screen for FAIS, there will be more consensus, but as of now the FADDIR can be used as a screening tool with caution and with taking into consideration the patient’s additional clinical signs and subjective complaints.

Understanding that FAIS is far more than morphological changes to the proximal femur or acetabulum will allow us as clinicians and researchers to move forward in the evaluation, treatment, and return to sport of this patient population. By evaluating the ability of conservative management to return athletes to their prior level of function, this drastic spike in surgical procedures may start to stabilize. Boney morphology is a well-known contributor to FAIS, but it only tells one portion of the story, we need to dig deeper in order to successfully manage this patient population.

References:

1. Smith-Petersen M. Treatment of malum coxae senilis, old slipped upper femoral epiphysis, intrapelvic protrusion of the acetabulum, and coxa plana by means of acetabuloplasty. J Bone Joint Surg Am. 1936; 18: 869–80.
2. Khan M, Oduwole KO, Razdan P, et al. Sources and quality of literature addressing femoroacetabular impingement: a scoping review 2011-2015. Curr Rev Musculoskelet Med. 2016. doi:10.1007/s12178-016-9364-5.
3. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013; 29: 661–5.
4. Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am. 2012; 94: e23. dos:10.2106/JBJS.J.01886
5. Cvetanovich GL, Chalmers PN, Levy DM, et al. Hip arthroscopy surgical volume trends and 30-day postoperative complications. Arthroscopy. 2016; 32: 1286–92.
6. Peters S, Laing A, Emerson C, et al. Surgical criteria for femoroacetabular impingement syndrome: a scoping review. British Journal of Sports Medicine. February 2017. doi:10.1136/bjsports-2016-096936.
7. Fernquest S, Arnold C, Palmer A, et al. Osseous impingement occurs early in flexion in cam-type femoroacetabular impingement: a 4D CT model. The Bone & Joint Journal. 2017;99-B(4 Supple B):41-48. doi:10.1302/0301-620X.99B4.BJJ-2016-1274.R1.
8. Kobayashi N, Inaba Y, Kubota S, et al. The Distribution of Impingement Region in Cam-Type Femoroacetabular Impingement and Borderline Dysplasia of the Hip With or Without Cam Deformity: A Computer Simulation Study. Arthroscopy. November 2016. doi:10.1016/j.arthro.2016.08.018.
9. Frank JM, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy. 2015 Jun;31(6):1199-204. doi: 10.1016/j.arthro.2014.11.042.
10. Mascarenhas VV, Rego P, Dantas P, et al. Imaging prevalence of femoroacetabular impingement in symptomatic patients, athletes, and asymptomatic individuals: A systematic review. European Journal of Radiology. 2016;85(1):73-95. doi:10.1016/j.ejrad.2015.10.016.
11. Register B, et al. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med. 2012 Dec;40(12):2720-4. doi: 10.1177/0363546512462124.
12. Tresch F, Dietrich TJ, Pfirrmann CWA, Sutter R. Hip MRI: Prevalence of articular cartilage defects and labral tears in asymptomatic volunteers. A comparison with a matched population of patients with femoroacetabular impingement. J Magn Reson Imaging. December 2016:1-12. doi:10.1002/jmri.25565.
13. Yamauchi R, Inoue R, Chiba D, et al. Association of clinical and radiographic signs of femoroacetabular impingement in the general population. J Orthop Sci. November 2016. doi:10.1016/j.jos.2016.09.014.
14. Jacobs CA, Burnham JM, Jochimsen KN, Molina D, Hamilton DA, Duncan ST. Preoperative Symptoms in Femoroacetabular Impingement Patients Are More Related to Mental Health Scores Than the Severity of Labral Tear or Magnitude of Bony Deformity. The Journal of Arthroplasty. July 2017. doi:10.1016/j.arth.2017.06.053.
15. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003; 417: 112–20.
16. Sankar WN, Nevitt M, Parvizi J, et al. Femoroacetabular impingement: defining the condition and its role in the pathophysiology of osteoarthritis. J Am Acad Ortho Surg. 2013; 21(Suppl 1) :S7–S15.
17. Griffin DR, Dickenson EJ, O’Donnell J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine. 2016; 50(19): 1169-1176. doi:10.1136/bjsports-2016-096743.
18. Reiman MP, Thorborg K, Covington K, Cook CE, Holmich P. Important clinical descriptors to include in the examination and assessment of patients with femoroacetabular impingement syndrome: an international and multi-disciplinary Delphi survey. Knee Surg Sports Traumatol Arthrosc. 2017;22(4):806. doi:10.1007/s00167-017-4484-z.
19. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clinical Orthopaedics and Related Research. 2009;467(3):638-644. doi:10.1007/s11999-008-0680-y.
20. Diamond LE, Dobson FL, Bennell KL, Wrigley TV, Hodges PW, Hinman RS. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. British Journal of Sports Medicine. 2015;49(4):230-242. doi:10.1136/bjsports-2013-093340.
21. Pacheco-Carrillo A, Medina-Porqueres I. Physical examination tests for the diagnosis of femoroacetabular impingement. A systematic review. Phys Ther Sport. 2016;21:87-93. doi:10.1016/j.ptsp.2016.01.002.
22. Reiman MP, Goode AP, Cook CE, Holmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. British Journal of Sports Medicine. 2015;49(12):811-811. doi:10.1136/bjsports-2014-094302.
23. Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. British Journal of Sports Medicine. 2013;47(14):893-902. doi:10.1136/bjsports-2012-091035.
24. Casartelli NC, Brunner R, Maffiuletti NA, et al. The FADIR test accuracy for screening cam and pincer morphology in youth ice hockey players. J Sci Med Sport. June 2017. doi:10.1016/j.jsams.2017.06.011.

The Athlete’s Hip: Simplifying Evaluation, Treatment, and Return to Sport

The Athlete’s Hip can be a complicated issue for sports medicine professionals and athletes alike… Do you want to learn how to accurately and efficiently evaluate and treat this population?

Currently scheduling for 2018/19, see below for information regarding the course and learn if you want to host a course!

Description:

Hip pathology is an often under-appreciated and misunderstood problem for clinicians and athletes alike. As intra-articular and extra-articular hip pain has become more prominent, surgical procedures have increased exponentially, but examination and conservative management have unfortunately lagged behind.

This two-day course will delve into evidence-based evaluation, conservative management, and return to sport of athletes presenting with hip pain. Through lecture and lab sessions, you will learn how to evaluate and treat athletes presenting with intra-articular (femoroacetabular impingement syndrome, acetabular labral pathology, and ligamentum teres pathology) and extra-articular pathology (sacroiliac joint, extra-articular impingement, athletic pubalgia, piriformis syndrome, proximal hamstring pathology, and greater trochanteric pain syndrome).

By simplifying the evaluation and management of these conditions, at the conclusion of this course, clinician will be more confident in determining underlying pathology, appropriate management, need for surgical consult, and safe return to sport.

Presenter:

John Snyder, PT, DPT, OCS, CSCS

Objectives:

Upon completion of this course, participants will be able to:

  • Understand the complexity of pain and its impact on hip pathology
  • Understand the impact of femoroacetabular biomechanics on hip and concomitant LE pathology and injury risk
  • Be able to accurately assess for red flags (avascular necrosis, femoral stress fracture, and inguinal hernia) and referral from proximal regions
  • Be able to accurately and efficiently evaluate extra-articular and intra-articular hip pathology
  • Be able to screen for and determine the need for surgical intervention
  • Understand pathology dependent and region dependent manual therapy and exercise progression for hip pathology
  • Progression of LE exercise and end-stage rehabilitation principles
  • Be able to determine psychosocial, functional testing, and pathology specific factors to determine safe and efficient return to sport

Schedule

Day 1

09:00 – 09:30 Introduction & Pain Science
09:30 – 10:15 Impact of hip pathology and biomechanics on movement
10:15 – 11:00 Screening of Pelvic/Hip Region (Lab/Lecture)
11:00 – 11:15 Break
11:15 – 12:15 Examination of Intra-articular Pathology (Lecture)
12:30 – 13:30 Lunch
13:30 – 14:30 Examination of Intra-articular Pathology (Lab)
14:30 – 15:15 Examination of Extra-articular Pathology (Lecture)
15:15 – 15:30 Break
15:30 – 16:00 Examination of Extra-articular Pathology (Lab)
16:00 – 17:00 Where does surgery fit in?

Day 2

09:00 – 10:00 Epidemiology of Conservative and Surgical Interventions
10:00 – 10:45 Treatment of Intra-articular hip pathology (Lab/Lecture)
10:45 – 11:00 Break
11:00 – 12:00 Treatment of Extra-articular hip pathology (Lab/Lecture)
12:00 – 13:00 Lunch
13:00 – 14:00 End-stage Rehabilitation Considerations
14:00 – 15:30 Return to Sport Determination (Lecture/Lab)
15:30 – 15:45 Final Comments/Conclusion

Scheduled Dates

I am currently scheduling for 2018-2019. Please contact me if you are interested in hosting The Athlete’s Hip or Management of the Ice Hockey Athlete at your facility.

Lateral Hip Pain? Time to Stop Blaming the Poor Bursa…

Lateral hip pain is a very common occurrence amongst the general population and even more-so for middle-aged women, who demonstrate a 4x higher prevalence then men. In fact, literature has found that 23.5% of women over the age of 50 indicate having persistent lateral hip pain (15% unilateral and 8.5% bilateral)1.

Pain in this region can be caused by various anatomical and neurovascular structures, from the sacroiliac joint to referral from the lumbar spine. However, among these potential structures, the greater trochanteric bursa has historically been to blame2,3 and is likely the most common source…

Or is it?

The beginning of the end for Trochanteric Bursitis started with a study conducted by Bird and colleagues in 20014. With the hypothesis that gluteus medius tendinopathy was the prevailing underlying pathology in lateral hip pain, they evaluated 24 patients via magnetic resonance imaging. The results very much fell in line with their hypothesis as 45.8% had a gluteus medius tear, 62.5% had gluteus medius tendinopathy, and only 8.3% presented with trochanteric bursal distension.

A 2007 study conducted by Silva and colleagues5 set out to further understand whether this persistent lateral hip pain can actually be blamed on an inflamed trochanteric bursa. This prospective, case-controlled, blinded study attempted to determine the histopathologic features of patients with greater trochanteric bursitis versus asymptomatic control subjects. Bursal specimens were obtained following each subject undergoing total hip arthroplasty on the involved hip. Two different blinded surgical pathologists evaluated the samples and found no signs of acute or chronic inflammation in the control or greater trochanteric bursitis groups. Unfortunately, this study had a few significant limitations. One being that it was an extremely small sample size (6 subjects) and the other being that all subjects were undergoing a THA on the involved hip.

Similar to the original article in 2007, Board and colleagues also compared pathohistolgical composition of the trochanteric bursa in individuals undergoing ipsilateral THA. However, this study was performed on a much larger scale with 100 subjects included (50 with greater trochanteric pain and 50 without pain in this region). Once again, this study found no evidence of acute or chronic inflammation in the 100 included subjects, however 20% of subjects in the ‘trochanteric bursitis’ group demonstrated thinning of the gluteus medius tendon6.

This led the authors to conclude…

It is perhaps best to view any involvement of the trochanteric bursae within Greater Trochanteric Pain Syndrome as a secondary event with the inciting initial pathology stemming from either involvement of the ilio-tibial band or from the ‘abductor cuff’ of the hip that is the gluteus medius and minimus tendons — Board et al., 2014

And to continue beating a dead horse, another study demonstrated more confirmatory findings. Long and colleagues7 more recently published a much larger study trying to answer the same question. This retrospective review of musculoskeletal sonographic findings of 877 patients with greater trochanteric pain demonstrated very similar results. Of the included subjects, 700 (79.8%) did not have trochanteric bursitis on ultrasound. The most commonly involved pathological conditions were gluteal tendinosis (438; 49.9%) and a thickened iliotibial band (250; 28.5%).

What’s in a name?

Lateral hip pain… Trochanteric Bursitis… Greater Trochanteric Pain Syndrome (GTPS).

Why does it matter what we call pain localized to the greater trochanteric region? When we think “-itis”, understandably we jump to the conclusion that this an inflammatory disorder and more specifically an inflammatory condition of the bursa in the case of trochanteric bursitis. This then leads to interventions that act to decrease inflammation of the involved structures. These conservative interventions likely start at NSAIDs and end at cortisone injections prior to the eventual progression to surgical interventions. When we look at the interventions studied in the case of GTPS, there is an overwhelming predominance of anti-inflammatory procedures. A systematic review of conservative treatment for GTPS included 8 studies (696 patients). Of these 8 studies, 6 investigated cortisone injections, 2 on extracorpal shockwave therapy, 1 on orthotics, and 1 on ‘home training’8.

That is right, there has yet to be a study looking at activity modification or physical therapy in the treatment of greater trochanteric pain syndrome (however there are two large studies currently underway). And the one study looking at ‘home training’ left A LOT to be desired. This lack of understanding related to the underlying pathology in GTPS has led to an over-reliance on anti-inflammatory interventions in the literature and in clinical practice.

Now that we have all but eliminated trochanteric bursitis from contention, maybe we can finally determine the best way to treat this complex condition…

References:

1. Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Arch Phys Med Rehabil. 2007; 88(8): 988-992. doi:10.1016/j.apmr.2007.04.014.
2. Stegemann H. Die chirurgische Bedeutung paraartikularer Kalka-blagerungen. Arch Klin Chir. 1923; 125: 718-738.
3. Ege Rasmussen KJ, Fano N. Trochanteric bursitis: treatment by corticosteroid injection. Scand J Rheumatol. 1985;14:417–420.
4. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis & Rheumatism. 2001;44(9):2138-2145. doi:10.1002/1529-0131(200109)44:9<2138::AID-ART367>3.0.CO;2-M.
5. Silva F, Adams T, Feinstein J, Arroyo RA. Trochanteric bursitis: refuting the myth of inflammation. J Clin Rheumatol. 2008; 14(2): 82-86. doi:10.1097/RHU.0b013e31816b4471.
6. Board TN, Hughes SJ, Freemont AJ. Trochanteric bursitis: the last great misnomer. Hip Int. 2014; 24(6): 610-615. doi:10.5301/hipint.5000154.
7. Long SS, Surrey DE, Nazarian LN. Sonography of Greater Trochanteric Pain Syndrome and the Rarity of Primary Bursitis. American Journal of Roentgenology. 2013; 201(5): 1083-1086. doi:10.2214/AJR.12.10038.
8. Barratt PA, Brookes N, Newson A. Conservative treatments for greater trochanteric pain syndrome: a systematic review. British Journal of Sports Medicine. 2016. doi:10.1136/bjsports-2015-095858.

Early Sport Specialization…

Growing up and playing competitive hockey, my goal was always to obtain a college scholarship and maybe, just maybe make it to that next level. So, I did what any other talented young athlete would do, listen to well-meaning coaches and scouts and focus all of my energy on MY sport at a young age. I thoroughly enjoyed playing hockey and was happy to play 2 hours, 5 times a week year-round…

My story of early specialization is all too common in competitive athletics. A recent study by Post and colleagues found that the vast majority of division 1 athletes that specialize early do so because…

The most common reason cited by athletes for choosing to specialize in their college sport was enjoying that sport the most. The second and third most frequent selections were having an opportunity to earn a scholarship to play in college and being the best at that sport, respectively. Only 9.9% (n = 34) of athletes cited parental influence as the most important factor in their decision to specialize in their college sport. — Post et al., 2017

All of these reasons make perfect sense, but do athletes who specialize early actually have more success than multi-sport athletes?

According to the same study, the prevalence of highly specialized athletes (year round training of > 8 months per year, chose a single main sport, and quit all sports to focus on a single sport) increased significantly from freshman (16.9%) to senior year (41.1%) of high school. In a separate study, amongst high school athletes, 29.5% classified themselves as one-sport athletes and 36.4% were considered highly specialized in their chosen sport. Based on this information, there does not seem to be a significant difference between division 1 athletes and the general high school athlete population with regards to specialization.

Furthermore, approximately 90% of 2016 and 2017 NFL draft picks played multiple sports during high school. In agreement with this trend, 100% of 2016 national college football award winners, including all 5 Heisman Trophy finalists, were not highly specialized or single-sport athletes in high school. And looking closer at the two teams who played in Super Bowl LI, approximately 87% of the players on both teams were multi-sport athletes in high school. The current evidence does not necessarily look favorable for the highly specialized athlete.

More importantly, how does early specialization impact risk of injury?

In order to be successful, you need to be healthy and the literature once again does not give favor to specialization. Athletes with high competition volume, who participated in a club sport, or who were highly specialized had 2.08 times greater odds of reporting a previous lower extremity injury than those with low competition volume, 1.50 times greater odds than no club sport participation, and 2.58 times greater odds in comparison to low specialization. Building upon this information, another study found that highly specialized athletes were more likely to report a previous injury of any kind or an overuse injury in the previous year compared with athletes in the low specialization group. Athletes who played their primary sport more than 8 months of the year were 1.68 times more likely to report an upper extremity overuse injury or 1.66 times more likely to sustain a lower extremity overuse injury. When looking at serious overuse injuries, highly specialized athletes were 2.38 times more likely than multi-sport athletes.

When looking closer at ice hockey, one of the most common areas of injury tends to revolve around the hip/pelvic region. Being that highly specialized athletes are 2.74 times more likely to sustain an overuse injury to this region, this should be an area of specific concern… 

Femoroacetabular Impingement Syndrome (FAIS) is an abnormal growth of bone localized to the femoral neck and/or acetabular rim. In the case of Cam morphology (increased bone growth on femoral neck), the prevalence significantly increases in ice hockey players as they age. Even when compared to a similar group of athletes (skiers), the ice hockey group showed a consistent increase in prevalence as age increases. While this altered morphology may not result in a painful condition, as a recent study showed prevalence of FAIS in 68% of ice hockey players with only 22% demonstrating symptoms. This increased prevalence of altered hip/pelvic morphology speaks to the repetitive nature of the sport (especially among goaltenders) and may predispose them to hip/groin pathology as their career progresses.

Moving to the psychological impact of sport specialization, there is also evidence to support increased levels of drop out in those highly specialized athletes.

Among ice hockey players, those who began off-ice training earlier and those that invested a larger number of hours training at a younger age were more likely to drop-out of their sport. This study showed that hockey players started playing at 5 years old and the athletes that ended up dropping out began off-ice training at 11.75 years old in comparison to 13.8 years old in those who continued playing. Additionally, those that continued playing their sport invested an average of 6.8 hours to off-ice training versus 107 hours per year in the drop out group.

Dropout can occur for any number of reasons spanning from psychological to physical factors. Studies looking into reasoning behind burnout in competitive tennis players found burned-out players had less input into training and sport-related decisions and practiced fewer days with decreased motivation. While sport specialization has not necessarily been linked to burnout, the underlying stressors related to the early and highly specialized athlete mimic those reasons for dropout.

Knowing the negative impact of early and high specialization in one sport, what can we as athletes, coaches, parents, and healthcare providers do? 

  1. Take a break. Actually take the off-season off and find another sport or passion during this time.
  2. Develop overall athleticism. There is a reason multi-sport athletes are generally more successful at higher levels. They have been exposed to different movements and stresses that their primary sport does not provide them.
  3. Listen to your body and your mind. Are you feeling burnt out or are you suffering from a nagging injury? Take the time to have these factors addressed… See a physical therapist, see a sports psychologist, or see the appropriate medical professional.
  4. HAVE FUN. Sports are meant to be a positive influence on your life, not a drain on you physically and mentally.

We as a culture need to make a change in how youth and competitive sports are positioned. The highly specialized athlete is not necessarily more successful, is more likely to sustain an overuse or serious injury, and demonstrates the psychological profile of those that drop-out of their sport. We need to embrace the need for varying experiences and movement activities. The literature is fairly definitive and we need to push our children, athletes, and coaches to focus on the enjoying their athletic career and on developing overall athleticism during this timeframe.

References:

1. Bell DR, Post EG, Trigsted SM, Hetzel S, McGuine TA, Brooks MA. Prevalence of Sport Specialization in High School Athletics: A 1-Year Observational Study. Am J Sports Med. 2016;44(6):1469-1474. doi:10.1177/0363546516629943.
2. Brunner R, Maffiuletti NA, Casartelli NC, et al. Prevalence and Functional Consequences of Femoroacetabular Impingement in Young Male Ice Hockey Players. Am J Sports Med. 2015;44(1):46-53. doi:10.1177/0363546515607000.
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9. Myer GD, Jayanthi N, Difiori JP, et al. Sport Specialization, Part I: Does Early Sports Specialization Increase Negative Outcomes and Reduce the Opportunity for Success in Young Athletes? Sports Health: A Multidisciplinary Approach. 2015;7(5):437-442. doi:10.1177/1941738115598747.
10. Myer GD, Jayanthi N, Difiori JP, et al. Sports Specialization, Part II: Alternative Solutions to Early Sport Specialization in Youth Athletes. Sports Health: A Multidisciplinary Approach. 2016;8(1):65-73. doi:10.1177/1941738115614811.
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Review: MedBridgeGO Patient HEP app

Patient compliance is an integral piece of the rehabilitation puzzle. Patients being consistent with their prescribed home exercise program depends on several factors, however there are two aspects that stand out beyond the rest.

  1. Forming a Therapeutic Alliance with the patient and getting buy-in that their program will help them achieve THEIR goals
  2. Providing a thorough, efficient, and easy to use resource so that they can feel confident in the performance of their program.

While the first aspect of the puzzle relies on the clinician and their ability to educate and coach their patient, the second aspect can be accomplished with the correct technology. Recently, Medbridge came out with their MedBridgeGO app to compliment their growing Home Exercise Program. I have been using both the HEP and app for the past month and below are my thoughts…

How it Works:

1. You use MedBridge’s VERY easy to use home exercise program

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2. The patient downloads and accesses MedbridgeGO, then inputs their access code (provided by their PT)

3. Their session begins…

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Additional Features:

1. Patient education resources that are modifiable are also available to be accessed via the MedbridgeGO application. This allows the patient easy access to information regarding their condition.

2. The ability to set a reminder in order to improve patient compliance.

This feature gives your patients the ability to set an alarm that will automatically sync with their phone’s alarm system. This allows for the patient to have continual reminders that they need to do their homework. In theory, this eliminates the, “I forgot” excuse.

1. Ease of Use

The program is very easy to use and I have been able to utilize it with patients in their teens (much more successfully) and my geriatric population (with a bit more coaching). There will always be patients that prefer a paper home exercise program whether because they prefer that medium or they do not feel comfortable with the technology. All menus and screens spell out what needs to be done and it is presented in a very clear, simple manner.

2. Accuracy of Program

With over 4,000 exercises and 150 patient education resources, there is ample to choose from when making your patient’s home exercise program. That being said, if something has not found its way into their database yet, you do have the ability to add your own exercises/patient education or modify existing content. All exercises chosen in the HEP transferred seamlessly to the MedbrdgeGO app throughout my use to this point.

3. Patient Compliance

The added benefit in this system is being able to see when patients actually performed their HEP… Some patients can be a but ‘misleading’ in their responses. Outside of this additional checks and balances, I have found that giving my patients an easy to perform and easy to access home exercise program has led to increased compliance and accuracy of exercise performance throughout my time using the program.

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4. Overall

This program gives the therapist all of the tools needed to provide a simple, effective home exercise program. The program itself is not for everyone because it does require a requisite comfort level with technology, however this has been a much smaller population than I had expected.

As great as the program is, there are a few areas that do need addressed moving forward. The exercise program is based on a timer that is calculated based on the sets and reps chosen by the therapist. However, as we know, patients perform movements with varying levels of ease and speed. This can make some patients feel as though they are lagging behind throughout the program. Additionally, this issue especially comes through when giving patients a hold time during their exercise (i.e. hold a bridge for 5 seconds or long duration isometrics for 30 seconds) since the current time calculation does not account for this. By having the patient ‘pause’ their program, this issue can be worked around.

The MedbridgeGO app gives the clinician and patient the ability to ensure that they are 100% on the same page with regards to exercise performance and frequency of performance. It has a few small areas that need addressed (and I am sure they will be), but overall adding this program has been incredibly beneficial to my patient care and I will continue to utilize it moving forward.

Updated Clinical Prediction Rule Resource (Again)

Clinical Prediction Rules (CPRs) are an interesting, complicated, and often misunderstood area of rehabilitation research.

To say all CPRs are not created equal would be a significant understatement.

In this most recent rehaul of the CPR Resource, I focused on not just adding to the quantity of rules included, but I spent the vast majority of time adding adequate information in order to allow the reader to discern the value of each specific rule.

From rules that have been invalidated under further investigation (Stabilization for low back pain) to those that have contradictory findings (Spinal manipulation for low back pain), enough information is available to allow the reader to make the most logical decision based on the evidence available.

In addition to the added thoroughness of the information provided, I have also added several rules that were left off the original list. See below for the additional rules provided…

Diagnostic:

Ankylosing Spondylitis (Berlin Criteria)
Ankylosing Spondylitis (IBP Criteria)

Interventional:

Exercise for Ankylosing Spondylitis
Manual Therapy and Exercise for Acute Lateral Ankle Sprain
Mobilization with Movement for Lateral Epicondyalgia

Finally, make the best clinical judgment of each rule based on your patient population, the stage of CPR development (derivation –> validation –> impact analysis –> implementation), and the literature supporting or refuting its value.

Welcome to the New Site!

This site was created to act as a resource to rehabilitation professionals, students, and patients alike…

Having spent nearly 5 years blogging, I have amassed a large amount of content and I have been able to see how my thought processes and beliefs have evolved over this timeframe. In doing so, I have recognized areas that needed to be updated in order to keep up with the current literature.

I have recently updated my Clinical Prediction Rule and Functional Testing resources to include updated information and to more accurately present the strength of each rule/test. This allows for the information to be more easily and accurately used in clinical practice.

I will be posting several articles detailing the improvement to my website and how each area has been updated.

Additionally, I am happy to announce that I am offering two Live courses and am in the process of scheduling for 2018-2019. If you are interested in hosting The Athlete’s Hip: Simplifying Examination, Treatment, and Return to Sport or Evaluation & Management of the Ice Hockey Athlete, feel free to Contact Me.

Thanks again for reading and for all the support you have given me and my content over the last 5+ years!

– John Snyder, PT, DPT, OCS, CSCS