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Hip Instability in the Athlete

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Hip and Groin Pain in the Athlete

Abstract

Symptomatic hip microinstability is an emerging concept with growing supportive basic science, biomechanical, and clinical literature. Despite the lack of a clear definition or standardized evaluative criteria, it is now well generally recognized as a potential cause of hip pain in young, athletic patients. Pathologic hip instability is a result of underlying bony and soft-tissue abnormalities or dysfunction, but often the exact etiology remains unclear. Non-operative treatment is focused on activity modification and strengthening of the periarticular hip musculature, while surgical intervention is focused on identifying and treating the underlying cause as well as any associated intra-articular pathology. In many cases, patterns of microinstability associated with normal bony anatomy are treated with arthroscopic hip capsular plication. The purpose of this chapter is to review the anatomy and pathomechanics associated with hip microinstability and discuss diagnostic strategies and options for treatment.

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References

  1. Shu B, Safran MR. Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability. Clin Sports Med. 2011;30(2):349–67. https://doi.org/10.1016/j.csm.2010.12.008.

    Article  PubMed  Google Scholar 

  2. Boykin RE, Anz AW, Bushnell BD, Kocher MS, Stubbs AJ, Philippon MJ. Hip instability. J Am Acad Orthop Surg. 2011;19(6):340–9.

    Article  PubMed  Google Scholar 

  3. Dy CJ, Thompson MT, Crawford MJ, Alexander JW, McCarthy JC, Noble PC. Tensile strain in the anterior part of the acetabular labrum during provocative maneuvering of the normal hip. J Bone Joint Surg Am. 2008;90(7):1464–72. https://doi.org/10.2106/JBJS.G.00467.

    Article  PubMed  Google Scholar 

  4. Safran MR, Lopomo N, Zaffagnini S, Signorelli C, Vaughn ZD, Lindsey DP, et al. In vitro analysis of peri-articular soft tissues passive constraining effect on hip kinematics and joint stability. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1655–63. https://doi.org/10.1007/s00167-012-2091-6.

    Article  PubMed  Google Scholar 

  5. Gilles B, Christophe FK, Magnenat-Thalmann N, Becker CD, Duc SR, Menetrey J, et al. MRI-based assessment of hip joint translations. J Biomech. 2009;42(9):1201–5. https://doi.org/10.1016/j.jbiomech.2009.03.033.

    Article  PubMed  Google Scholar 

  6. Charbonnier C, Kolo FC, Duthon VB, Magnenat-Thalmann N, Becker CD, Hoffmeyer P, et al. Assessment of congruence and impingement of the hip joint in professional ballet dancers: a motion capture study. Am J Sports Med. 2011;39(3):557–66. https://doi.org/10.1177/0363546510386002.

    Article  PubMed  Google Scholar 

  7. Philippon MJ. The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med. 2001;20(4):817–29.

    Article  CAS  PubMed  Google Scholar 

  8. Kohnlein W, Ganz R, Impellizzeri FM, Leunig M. Acetabular morphology: implications for joint-preserving surgery. Clin Orthop Relat Res. 2009;467(3):682–91. https://doi.org/10.1007/s11999-008-0682-9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Shindle MK, Ranawat AS, Kelly BT. Diagnosis and management of traumatic and atraumatic hip instability in the athletic patient. Clin Sports Med. 2006;25(2):309–26, ix-x. https://doi.org/10.1016/j.csm.2005.12.003.

    Article  PubMed  Google Scholar 

  10. Domb BG, Martin DE, Botser IB. Risk factors for ligamentum teres tears. Arthroscopy. 2013;29(1):64–73. https://doi.org/10.1016/j.arthro.2012.07.009.

    Article  PubMed  Google Scholar 

  11. Byrd JW, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy. 2004;20(4):385–91. https://doi.org/10.1016/j.arthro.2004.01.025.

    Article  PubMed  Google Scholar 

  12. Byrd JW. Labral lesions: an elusive source of hip pain case reports and literature review. Arthroscopy. 1996;12(5):603–12.

    Article  CAS  PubMed  Google Scholar 

  13. Larson CM, Giveans MR, Stone RM. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: mean 3.5-year follow-up. Am J Sports Med. 2012;40(5):1015–21. https://doi.org/10.1177/0363546511434578.

    Article  PubMed  Google Scholar 

  14. Ayeni OR, Adamich J, Farrokhyar F, Simunovic N, Crouch S, Philippon MJ, et al. Surgical management of labral tears during femoroacetabular impingement surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):756–62. https://doi.org/10.1007/s00167-014-2886-8.

    Article  CAS  PubMed  Google Scholar 

  15. Philippon MJ, Arnoczky SP, Torrie A. Arthroscopic repair of the acetabular labrum: a histologic assessment of healing in an ovine model. Arthroscopy. 2007;23(4):376–80. https://doi.org/10.1016/j.arthro.2007.01.017.

    Article  PubMed  Google Scholar 

  16. Crawford MJ, Dy CJ, Alexander JW, Thompson M, Schroder SJ, Vega CE, et al. The 2007 Frank Stinchfield Award. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res. 2007;465:16–22. https://doi.org/10.1097/BLO.0b013e31815b181f.

    Article  PubMed  Google Scholar 

  17. Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech. 2003;36(2):171–8.

    Article  CAS  PubMed  Google Scholar 

  18. Safran MR. The acetabular labrum: anatomic and functional characteristics and rationale for surgical intervention. J Am Acad Orthop Surg. 2010;18(6):338–45.

    Article  PubMed  Google Scholar 

  19. Signorelli C, Bonanzinga T, Lopomo N, Zaffagnini S, Marcacci M, Safran M. Evaluation of the sealing function of the acetabular labrum: an in vitro biomechanical study. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):62–71. https://doi.org/10.1007/s00167-015-3851-x.

    Article  CAS  PubMed  Google Scholar 

  20. Nepple JJ, Philippon MJ, Campbell KJ, Dornan GJ, Jansson KS, LaPrade RF, et al. The hip fluid seal—part II: the effect of an acetabular labral tear, repair, resection, and reconstruction on hip stability to distraction. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):730–6. https://doi.org/10.1007/s00167-014-2875-y.

    Article  PubMed  Google Scholar 

  21. Telleria JJ, Lindsey DP, Giori NJ, Safran MR. An anatomic arthroscopic description of the hip capsular ligaments for the hip arthroscopist. Arthroscopy. 2011;27(5):628–36. https://doi.org/10.1016/j.arthro.2011.01.007.

    Article  PubMed  Google Scholar 

  22. Ito H, Song Y, Lindsey DP, Safran MR, Giori NJ. The proximal hip joint capsule and the zona orbicularis contribute to hip joint stability in distraction. J Orthop Res. 2009;27(8):989–95. https://doi.org/10.1002/jor.20852.

    Article  PubMed  Google Scholar 

  23. van Arkel RJ, Amis AA, Jeffers JR. The envelope of passive motion allowed by the capsular ligaments of the hip. J Biomech. 2015;48(14):3803–9. https://doi.org/10.1016/j.jbiomech.2015.09.002.

    Article  PubMed  PubMed Central  Google Scholar 

  24. van Arkel RJ, Amis AA, Cobb JP, Jeffers JR. The capsular ligaments provide more hip rotational restraint than the acetabular labrum and the ligamentum teres: an experimental study. Bone Joint J. 2015;97-B(4):484–91. https://doi.org/10.1302/0301-620X.97B4.34638.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Myers CA, Register BC, Lertwanich P, Ejnisman L, Pennington WW, Giphart JE, et al. Role of the acetabular labrum and the iliofemoral ligament in hip stability: an in vitro biplane fluoroscopy study. Am J Sports Med. 2011;39(Suppl):85S–91S. https://doi.org/10.1177/0363546511412161.

    Article  PubMed  Google Scholar 

  26. Guille JT, Pizzutillo PD, MacEwen GD. Development dysplasia of the hip from birth to six months. J Am Acad Orthop Surg. 2000;8(4):232–42.

    Article  CAS  PubMed  Google Scholar 

  27. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;(417):112–20. https://doi.org/10.1097/01.blo.0000096804.78689.c2.

  28. Canham CD, Yen YM, Giordano BD. Does femoroacetabular impingement cause hip instability? A systematic review. Arthroscopy. 2016;32(1):203–8. https://doi.org/10.1016/j.arthro.2015.07.021.

    Article  PubMed  Google Scholar 

  29. Moorman CT 3rd, Warren RF, Hershman EB, Crowe JF, Potter HG, Barnes R, et al. Traumatic posterior hip subluxation in American football. J Bone Joint Surg Am. 2003;85-A(7):1190–6.

    Article  Google Scholar 

  30. Duthon VB, Charbonnier C, Kolo FC, Magnenat-Thalmann N, Becker CD, Bouvet C, et al. Correlation of clinical and magnetic resonance imaging findings in hips of elite female ballet dancers. Arthroscopy. 2013;29(3):411–9. https://doi.org/10.1016/j.arthro.2012.10.012.

    Article  PubMed  Google Scholar 

  31. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy. 2009;25(4):400–4. https://doi.org/10.1016/j.arthro.2008.12.011.

    Article  PubMed  Google Scholar 

  32. Ranawat AS, McClincy M, Sekiya JK. Anterior dislocation of the hip after arthroscopy in a patient with capsular laxity of the hip. A case report. J Bone Joint Surg Am. 2009;91(1):192–7. https://doi.org/10.2106/JBJS.G.01367.

    Article  PubMed  Google Scholar 

  33. Sansone M, Ahlden M, Jonasson P, Sward L, Eriksson T, Karlsson J. Total dislocation of the hip joint after arthroscopy and ileopsoas tenotomy. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):420–3. https://doi.org/10.1007/s00167-012-2300-3.

    Article  PubMed  Google Scholar 

  34. Mei-Dan O, McConkey MO, Brick M. Catastrophic failure of hip arthroscopy due to iatrogenic instability: can partial division of the ligamentum teres and iliofemoral ligament cause subluxation? Arthroscopy. 2012;28(3):440–5. https://doi.org/10.1016/j.arthro.2011.12.005.

    Article  PubMed  Google Scholar 

  35. Wuerz TH, Song SH, Grzybowski JS, Martin HD, Mather RC 3rd, Salata MJ, et al. Capsulotomy size affects hip joint kinematic stability. Arthroscopy. 2016;32(8):1571–80. https://doi.org/10.1016/j.arthro.2016.01.049.

    Article  PubMed  Google Scholar 

  36. Abrams GD, Hart MA, Takami K, Bayne CO, Kelly BT, Espinoza Orias AA, et al. Biomechanical evaluation of capsulotomy, capsulectomy, and capsular repair on hip rotation. Arthroscopy. 2015;31(8):1511–7. https://doi.org/10.1016/j.arthro.2015.02.031.

    Article  PubMed  Google Scholar 

  37. Khair MM, Grzybowski JS, Kuhns BD, Wuerz TH, Shewman E, Nho SJ. The effect of capsulotomy and capsular repair on hip distraction: a cadaveric investigation. Arthroscopy. 2017;33(3):559–65. https://doi.org/10.1016/j.arthro.2016.09.019.

    Article  PubMed  Google Scholar 

  38. Frank RM, Lee S, Bush-Joseph CA, Kelly BT, Salata MJ, Nho SJ. Improved outcomes after hip arthroscopic surgery in patients undergoing T-capsulotomy with complete repair versus partial repair for femoroacetabular impingement: a comparative matched-pair analysis. Am J Sports Med. 2014;42(11):2634–42. https://doi.org/10.1177/0363546514548017.

    Article  PubMed  Google Scholar 

  39. McCormick F, Slikker W 3rd, Harris JD, Gupta AK, Abrams GD, Frank J, et al. Evidence of capsular defect following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):902–5. https://doi.org/10.1007/s00167-013-2591-z.

    Article  PubMed  Google Scholar 

  40. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Revision hip arthroscopy. Am J Sports Med. 2007;35(11):1918–21. https://doi.org/10.1177/0363546507305097.

    Article  PubMed  Google Scholar 

  41. Hoppe DJ, Truntzer JN, Shapiro LM, Abrams GD, Safran MR. Diagnostic accuracy of 3 physical examination tests in the assessment of hip microinstability. Orthop J Sports Med. 2017;5(11):2325967117740121. https://doi.org/10.1177/2325967117740121.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Welton KL, Jesse MK, Kraeutler MJ, Garabekyan T, Mei-Dan O. The anteroposterior pelvic radiograph: acetabular and femoral measurements and relation to hip pathologies. J Bone Joint Surg Am. 2018;100(1):76–85. https://doi.org/10.2106/JBJS.17.00500.

    Article  PubMed  Google Scholar 

  43. Dandachli W, Ul Islam S, Tippett R, Hall-Craggs MA, Witt JD. Analysis of acetabular version in the native hip: comparison between 2D axial CT and 3D CT measurements. Skelet Radiol. 2011;40(7):877–83. https://doi.org/10.1007/s00256-010-1065-3.

    Article  Google Scholar 

  44. Tannast M, Fritsch S, Zheng G, Siebenrock KA, Steppacher SD. Which radiographic hip parameters do not have to be corrected for pelvic rotation and tilt? Clin Orthop Relat Res. 2015;473(4):1255–66. https://doi.org/10.1007/s11999-014-3936-8.

    Article  PubMed  Google Scholar 

  45. Jamali AA, Mladenov K, Meyer DC, Martinez A, Beck M, Ganz R, et al. Anteroposterior pelvic radiographs to assess acetabular retroversion: high validity of the “cross-over-sign”. J Orthop Res. 2007;25(6):758–65. https://doi.org/10.1002/jor.20380.

    Article  PubMed  Google Scholar 

  46. Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br. 1999;81(2):281–8.

    Article  CAS  PubMed  Google Scholar 

  47. Werner CM, Copeland CE, Ruckstuhl T, Stromberg J, Turen CH, Kalberer F, et al. Radiographic markers of acetabular retroversion: correlation of the cross-over sign, ischial spine sign and posterior wall sign. Acta Orthop Belg. 2010;76(2):166–73.

    PubMed  Google Scholar 

  48. Kalberer F, Sierra RJ, Madan SS, Ganz R, Leunig M. Ischial spine projection into the pelvis: a new sign for acetabular retroversion. Clin Orthop Relat Res. 2008;466(3):677–83. https://doi.org/10.1007/s11999-007-0058-6.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Kakaty DK, Fischer AF, Hosalkar HS, Siebenrock KA, Tannast M. The ischial spine sign: does pelvic tilt and rotation matter? Clin Orthop Relat Res. 2010;468(3):769–74. https://doi.org/10.1007/s11999-009-1021-5.

    Article  PubMed  Google Scholar 

  50. Wyatt M, Weidner J, Pfluger D, Beck M. The Femoro-Epiphyseal Acetabular Roof (FEAR) index: a new measurement associated with instability in borderline hip dysplasia? Clin Orthop Relat Res. 2017;475(3):861–9. https://doi.org/10.1007/s11999-016-5137-0.

    Article  PubMed  Google Scholar 

  51. Magerkurth O, Jacobson JA, Morag Y, Caoili E, Fessell D, Sekiya JK. Capsular laxity of the hip: findings at magnetic resonance arthrography. Arthroscopy. 2013;29(10):1615–22. https://doi.org/10.1016/j.arthro.2013.07.261.

    Article  PubMed  Google Scholar 

  52. Shibata KR, Matsuda S, Safran MR. Is there a distinct pattern to the acetabular labrum and articular cartilage damage in the non-dysplastic hip with instability? Knee Surg Sports Traumatol Arthrosc. 2017;25(1):84–93. https://doi.org/10.1007/s00167-016-4342-4.

    Article  PubMed  Google Scholar 

  53. Lieberman JR, Altchek DW, Salvati EA. Recurrent dislocation of a hip with a labral lesion: treatment with a modified Bankart-type repair. Case report. J Bone Joint Surg Am. 1993;75(10):1524–7.

    Article  CAS  PubMed  Google Scholar 

  54. Dall D, Macnab I, Gross A. Recurrent anterior dislocation of the hip. J Bone Joint Surg Am. 1970;52(3):574–6.

    Article  CAS  PubMed  Google Scholar 

  55. Rashleigh-Belcher HJ, Cannon SR. Recurrent dislocation of the hip with a “Bankart-type” lesion. J Bone Joint Surg Br. 1986;68(3):398–9.

    Article  CAS  PubMed  Google Scholar 

  56. Philippon MJ, Trindade CAC, Goldsmith MT, Rasmussen MT, Saroki AJ, Loken S, et al. Biomechanical assessment of hip capsular repair and reconstruction procedures using a 6 degrees of freedom robotic system. Am J Sports Med. 2017;45(8):1745–54. https://doi.org/10.1177/0363546517697956.

    Article  PubMed  Google Scholar 

  57. Larson CM, Stone RM, Grossi EF, Giveans MR, Cornelsen GD. Ehlers-Danlos syndrome: arthroscopic management for extreme soft-tissue hip instability. Arthroscopy. 2015;31(12):2287–94. https://doi.org/10.1016/j.arthro.2015.06.005.

    Article  PubMed  Google Scholar 

  58. Domb BG, Stake CE, Lindner D, El-Bitar Y, Jackson TJ. Arthroscopic capsular plication and labral preservation in borderline hip dysplasia: two-year clinical outcomes of a surgical approach to a challenging problem. Am J Sports Med. 2013;41(11):2591–8. https://doi.org/10.1177/0363546513499154.

    Article  PubMed  Google Scholar 

  59. Kalisvaart MM, Safran MR. Microinstability of the hip-it does exist: etiology, diagnosis and treatment. J Hip Preserv Surg. 2015;2(2):123–35. https://doi.org/10.1093/jhps/hnv017.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA

    Amit Nathani & Marc Safran

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  1. Amit Nathani
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  2. Marc Safran
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Correspondence to Marc Safran .

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Editors and Affiliations

  1. Orthopaedic Surgery, Stanford University, Redwood City, CA, USA

    Marc Safran

  2. Department of Orthopaedics, Acibadem University, Istanbul, Turkey

    Mustafa Karahan

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Nathani, A., Safran, M. (2019). Hip Instability in the Athlete. In: Safran, M., Karahan, M. (eds) Hip and Groin Pain in the Athlete . Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-58699-0_10

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  • DOI: https://doi.org/10.1007/978-3-662-58699-0_10

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