WHY IS THERE SO MUCH HIP SURGERY IN THE GAA?

Opinion piece by Eamon O'Reilly (Clinical Lead SPARC South Dublin)

(Read time 5-6 mins)

Hip injuries are a hot topic in sports medicine at the moment. The issue around hip injuries and hip surgery has been highlighted especially in gaelic games, in recent years. Almost every week during the winter we hear of players retiring 'due to hip injuries'. Alarmingly, the ages of these athletes are decreasing and questions are being asked.  The question then is, what is happening??

For four years my caseload was almost exclusively hip and groins so it is fair to say I have seen a few of this type of injury. Most of the athletes were chronic cases who had previously tried rehabilitation which did not work out. It is such a frustrating injury with long periods out of play common, and there is so much hard work associated with regaining full fitness. It is multidirectional athletes who most often present with hip injuries. Field sport athletes such as rugby, gaelic games, soccer and hockey represent the majority of these. The forces associated with repetitive cutting and changes of direction aggravate any issue.  Although linear athletes do present in clinic, the type of issue and mechanisms normally differs. Overload injuries such as stress fractures and stress reactions are more common with runners, especially when running volumes increase or surfaces change. 

Symptoms of sporting hip injuries

GAA players in particular seem to be presenting more often. The story is always the same. The athlete plays through the injury at first, at the cost of their on field performance. Over time this changes, the warm up is sore, followed by a period of play and then sore towards the end of the game. As this continues, kicking, changing direction become painful, playing time decreases and frustration begins to grow. Athletes often talk about undertaking periods of rest to no avail and ‘trying’ rehab to no avail. The injury is worsened by training and match overload. Post activity, the pain is particularly bad.

Causes for Hip injuries in GAA

The reasons as to why there is such a high prevalence in GAA players are less well investigated. A variety of factors including pitch type, gym work undertaken (squatting gets an especially bad reputation here), an increase in training load, and an increase in the intensity of sport (especially GAA) have all been put forward as potential reasons for athletes developing hip pain. How athletes train has also changed. The mileage clocked up (especially by those in the middle 8) means there are greater distances being covered on the pitch. Training has changed to allow athletes cover these distances. Over the past 15 years there has been an increase in small sided possession games, with a lot of repetitive tackling and changes of direction. All of this load takes it’s toll, especially when followed up with gym sessions and more training. Plus that might only be the load for one team out of 3-4 teams for the athlete!

“Do I need hip surgery?”

I am often asked this question and in the majority of cases the answer is NO! Over the last number of years the question has become more common. In Ireland, GAA insurance figures show 314 hip arthroscopic surgeries in 2014 compared to 80 in 2007.  This indicates a rise of 392%. The numbers of teenagers being operated on has increased from 10 in 2010 to 77 in 2014. These are huge numbers and it is quite scary to think teenagers are having this type of trouble with their hips.

Before I go any further I am going to declare my bias for rehabilitation based programmes, although I do recognise there are a SMALL number of people that hip surgery may be the best solution for.  I have been lucky enough to have previously worked with some excellent hip surgeons who always looked to protect the player first and certainly did not look at surgery as a first line treatment. 

There is currently all sorts of scaremongering going on. I have heard and read the stories of players being told that they must have surgery or they will need a hip replacement by 30, stories of athletes being told that not only does their painful hip need to be operated on, but we better do the other one too (because the scan looks worse), and the stories where surgery does not go so well and players are told “your hip was too far gone”. In my opinion most of this is absolute rubbish. I have not seen the evidence base to support these arguments. If you hear this, you need to take stock and more importantly an independent second opinion. I just cannot understand how it is acceptable to go into a hip joint for a ‘pre emptive surgery’ when the joint is not giving any problems. In fact, the Collins research paper (2014) listed in the reference section below confirms this view.

The increase in imaging has lead to an increase in the diagnosis of CAM and pincer lesions, labral tears and in FAI (femoral acetabular impingement) and this has also lead to an increase in the number of surgeries! What if I told you that this might not necessarily be the best way of going about sorting out this issue? What if I told you there are some really good studies out there that show that this is actually a normal response to load?

More alarmingly, athletes are looking towards surgery as a quick fix to this type of issue without fully realising the effects surgery have both in the long term and in the short term. What makes this even worse is that the majority of these injuries are due to biomechanical overload and surgery is not fixing the biomechanical reasons for the athletes pain.

The long term outcomes of this type of surgery are not yet known, but we often get athletes returning for recurring hip issues post surgery. In fact, I very often see athletes failing to reach previous levels of activity post this type of surgery, or they do return for a season or two before pain recurs. The underlying biomechanical issues that could not be fixed through surgery is the main reason for this. Recently there have been some great studies showing the prevalence of hip changes on MRI in normal injury free athletes. Labral tears are often evident in asymptomatic hips on MRI but do not cause issues. So is your hip the problem or is it a strength deficit or how you move? Is it an issue that requires surgery or can you rehabilitate this injury? Can you improve your performance by addressing these biomechancial factors?

I am not going to tell you that rehabilitation or surgery routes will lead to arthritis or other issues down the line or that one will work out better than the other (in the short or long term), because we simply do not know. I certainly worry that we prematurely jump into surgery without fully knowing where that path will lead us. And I certainly cannot tolerate players being fed the type of scaremongering rubbish mentioned above. This infuriates me, especially when I know the emotional attachment players have to their sport. This is playing on raw emotion to me and that is not right.  So the advice is that before you go down any surgical route make informed decisions by consulting a number of different types of professionals (consultants, sports medicine physicians and physiotherapists). What I do know is that by specifically targeting rehabilitation around the hip and addressing how people move I have seen some great results in a lot of athletes. 

Thank you for reading.

Eamon

If you would like more information from current research please take a look at the below papers on which my opinion is based.

Agricola R, Weinans H. Femoroacetabular impingement: what is its link with osteoarthritis? British journal of sports medicine 2015.

Bardakos NV, Villar RN. Predictors of progression of osteoarthritis in femoroacetabular impingement: a radiological study with a minimum of ten years follow-up. The Journal of bone and joint surgery British volume 2009;91(2):162-9.

Reiman MP, Thorborg K. Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? British journal of sports medicine 2015;49(12):782-4.

Collins JA, Ward JP, Youm T. Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review. Am J Sports Med 2014;42: 3009–15

Farrell G, McGrath F, Hogan B et al (2016) 95% prevalence of abnormality on hip MRI in elite academy level rugby union: A clinical and imaging study of hip disorders. J Sci Med Sport. 2016 Nov;19(11):893-897

Gallo RA, Silvis ML, Smetana B, et al. Asymptomatic hip/groin pathology identified on magnetic resonance imaging of professional hockey players: outcomes and playing status at 4 years' follow-up. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2014;30(10):1222-8.

Tak I, Weir A, Langhout R, et al. The relationship between the frequency of football practice during skeletal growth and the presence of a cam deformity in adult elite football players. British journal of sports medicine 2015;49(9):630-4.

Register B, Pennock AT, Ho CP, et al. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. The American journal of sports medicine 2012;40(12):2720-4.

Ross JR, Nepple JJ, Philippon MJ, et al. Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. The American journal of sports medicine 2014;42(10):2402-9.

Griffin DR, Dickenson EJ, O’Donnell J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome):
an international consensus statement. Br J Sports Med 2016;50:1169–1176.