Return to sport following hip arthroscopy for femoroacetabular impingement syndrome: return to sport rates and methodological considerations

Ishøi L
Sports Orthopaedic Research Center, Department of ­Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark

Introduction by the editor Mario Bizzini

Research studies on “Return to sport” (or return to play) have been recently published also in the field of hip arthroscopy for femoroacetabular impingement (FAI) in athletes. While most published papers discuss cases series (low level of evidence), Lasse Ishoi and the group of K. Thorborg and P. Hölmich (Copenhagen, Denmark) conducted one of the first prospective cohort studies on this topic. The paper has already been published in AJSM and the results were presented at the #SportSuisse2018 conference. One of the key methodological points is the definition of “Return to sport” when conducting studies: is it return to any sport at any level, or return to preinjury sport at preinjury level? The post-operative sport performance level of the athletes is also rarely reported. The aim of this study was to investigate the rate of return to preinjury sport at preinjury level in athletes and associated sport performance following hip arthroscopy for FAI syndrome. Ishoi et al found that 57.1% of athletes return to preinjury sport at preinjury level after FAI surgery, and 1/3 of these can expect to reach optimal sport performance (which means approx. 20% of all involved athletes). These figures are clearly less optimistic than the previously published 74–95% return to sport rates, and also show how important is the operational definition of “Return to sport”.

Forschungsstudien zum Thema «Return to sport» (oder return to play) sind kürzlich auch auf dem Gebiet der Hüft­arthroskopie für das femoroacetabuläre Impingement (FAI) bei Sportlern veröffentlicht worden. Während die meisten Publikationen über case series (tiefe Evidenzstufe) berichten, führten Lasse Ishøi und die Gruppe von K. Thorborg und P. Hölmich (Kopenhagen, Dänemark) eine der ersten prospektiven Kohortenstudien zu diesem Thema durch. Das ­Papier wurde bereits im AJSM veröffentlicht und die Ergebnisse wurden an der #SportSuisse2018 Konferenz vorgestellt. Einer der wichtigsten methodischen Punkte (bei der Durchführung von Studien): ist die Definition von «Return to sport»: ist es die Rückkehr zu irgendeinem Sport auf irgend­einer Ebene oder die Rückkehr zum Vorverletzungssport auf Vorverlet­zungsebene? Auch das postoperative sportliche Leistungsniveau der Athleten wird selten dokumentiert. Ziel dieser Studie war es, die Rückkehrrate zum Vorverletzungssport auf Vorverletzungsniveau bei Athleten und die damit verbundene Sportleistung nach der Hüft­arthroskopie beim FAI-Syndrom zu untersuchen. Ishoi et al. fanden heraus, dass 57,1% der Athleten nach einer FAI-Operation in den Vorverletzungssport auf Vorverletzungsniveau zurückkehren und 1/3 von ihnen mit einer optimalen Sportleistung rechnen können (das bedeutet ca. 20% aller beteiligten Athleten). Diese Zahlen sind deutlich weniger optimistisch als die zuvor veröffentlichte 74–95%ige Rückkehr zu den Sportraten und zeigen auch, wie wichtig die operative Definition von «Return to sport» ist.

Introduction

Longstanding groin pain is frequently observed in athletes participating in sports involving explosive activities of change of direction, sprints, and kicking/skating, such as football codes [17,18,24,27,30,34,36], ice hockey [7], basketball [40], and tennis [1]. In recent years, intra-articular hip joint pathology has gained increased recognition as an important differential diagnosis of longstanding groin pain, and is now seen as a common cause of longstanding groin pain in athletes [5,12,35]. In relation to this, the prevalence of injuries caused by intra-articular hip joint pathology in the Australian Football League has increased gradually during a 10-year period (2002–2012) [27]. The most common diagnosis related to intra-articular hip joint pathology is femoroacetabular impingement syndrome (FAIS) defined in the 2016 Warwick Agreement as a motion-related disorder of the hip joint [15]. The diagnosis is based on a combination of symptoms, clinical signs, and radiological findings [15]. FAIS is caused by cam and/or pincer morphology, which may lead to a collision between the femoral head-neck junction and the acetabular rim [14]. Over time this may result in subsequent hip labral pathology and intra-articular cartilage damage [14] increasing the risk of radiographic end-stage osteoarthritis of the hip joint [2, 3].

Surgical treatment

Patients with FAIs often undergo surgical treatment [29] consisting of an arthroscopic procedure in most cases [8]. The purpose of surgical treatment is to correct morphology (cam and/or pincer) associated with FAIS, including treatment of potential co-existing labral and/or cartilage pathology [15]. Several studies have shown promising effect of hip arthroscopy for FAIS regarding self-reported hip and groin function related to pain, quality-of-life, and sport and recreational activities [16,22]. However, despite pre-to-post surgery improvements in self-reported hip and groin function, the majority of patients do not reach normative values in self-reported hip and groin function when compared to a healthy control group without hip and groin pain [33]. Specifically, less than 25% obtain a normal self-reported hip and groin function in relation to sport and recreational activities [33]. Such persistent deficits may likely affect the ability to return to sport following hip arthroscopy for FAIS [9].

Return to sport

For athletes, the ability to return to sport is often the most important parameter when evaluating the effect of a treatment [4]. Return to sport following hip arthroscopy for FAIS has been studied extensively and summarized in several systematic reviews. In a 2015 systematic review based on 18 case-series, 87% returned to sport at a mean follow-up of 2.3 years post-operatively [6]. Such return to sport rate has also been found in subsequent reviews [28].
While these return to sport rates are promising for athletes with intentions to return to sport, the studies included in the systematic reviews contain some methodological limitations, which may limit the interpretation of the return to sport rate.

Methodological considerations on existing return to sport literature
When advising patients with FAIS on the ability to return to sport following hip arthroscopy, it is important to understand if the existing literature can be generalized to hip arthroscopy surgeons and clinics around the world. However, most literature on return to sport following hip arthroscopy for FAIS has been conducted on different high-volume hip arthroscopy centers with single world-renowned surgeons. Consequently, this may likely result in selection bias of surgical candidates and limit the extrapolation of findings to other clinics, hospitals, or surgeons [6].
Another, and very important, limitation is the use of unclear return to sport definitions. As the definition of return to sport determines the treatment outcome as successful or not, a clear definition of return to sport is paramount. In relation to this, the return to sport definition in existing literature range from return to training activities or return to any sport to return to preinjury level. However, for athletes, the most important parameter is often to return to their preinjury sport at preinjury level [4]. Furthermore, a recent consensus statement on return to sport suggested that return to preinjury sport at preinjury level may consists of different phases from restricted participation to optimal performance [4]. Thus, it is possible to return to preinjury sport at preinjury level without performing at an optimal level [4] (Figure 1). However, information on sport performance following hip arthroscopy for FAIS is lacking [28].

Return to sport and performance using consensus-based definitions
Two recent studies from Scandinavia, published after the latest systematic review [28], have investigated return to sport and performance following hip arthroscopy for FAIS using consensus-based definitions of return to sport and performance [19, 39]. In Ishoi et al. [19] 189 athletes (aged 18-30-years old at the time of surgery) included from the Danish Hip Arthroscopy Registry, were surveyed using a return to sport questionnaire investigating previous and present sport activities including associated sport performance. All included athletes had an intention to return to their preinjury sport at preinjury level. The results showed that at a mean follow-up of 33 months, 57% of athletes were engaged in their preinjury sport at preinjury level. However, of those only 1 out of 3 athletes, corresponding to 17% of the total study sample, reported optimal sport performance [19]. Similar results were observed in Wörner et al. [39] in a cohort of 127 patients.
Furthermore, Wörner et al. [39] showed that 89% of patients return to some sort of sport, highlighting the importance of the return to sport definition (eg. return to sport vs. return to preinjury sport at preinjury level).

Factors associated with return to sport
Several contextual factors have been proposed to influence the ability to return to sport following hip arthroscopy for FAIS. In studies where the rate of return to sport has been compared between elite and recreational athletes, there seems to be a clear trend toward a higher return to sport rate in elite athletes [6]. However, Ishoi et al. [19] found no statistically significant difference in the rate of return to preinjury sport at preinjury level. The higher return to sport rate in elite athletes observed in some studies has been suggested to be due to factors associated with the elite sport environment, such as better access to training and treatment facilities, prestige, and economics etc. [6].
Beside the level of play (elite versus recreational) some studies indicate a lower return to sport rate in high-impact sports such as running, football etc. [6,26]. In relation to this, Domb et al. [9] observed that athletes who did not return to sport following hip arthroscopy for FAIS reported problems in high-impact sport activities such running and jumping, indicating that the hip joint may be load compromised in some athletes precluding participation in high-impact sports [32].
Another potential important, but often overlooked, factor is presence of extra-articular problems such as adductor- or inguinal-related groin pain, which is usually not addressed during the hip arthroscopy [23,25,31]. Thus, the clinician should be aware of this, and address these factors, during the post-operative rehabilitation period [37].

Post-operative rehabilitation

Despite lack of level 1 evidence, post-operative rehabilitation is considered important for the ability to cope with sport activities and thus for the ability to return to sport following hip arthroscopy for FAIS [38]. Based on expert opinions [10,11] and studies on physical impairments in FAIS patients [13], the rehabilitation should focus on restoring muscle function around the hip joint as peak muscle strength has been positively correlated to self-reported hip and groin function [20,21]. Furthermore, as the load-bearing capacity of the hip joint seems to be impaired in FAIS patients [32], restoration of force absorption capacity of the hip joint complex should be prioritized to increase the likelihood of returning to sport [9].

Summary

Hip arthroscopy is a widely adopted procedure to treat athletes with femoroacetabular impingement syndrome. Several studies yield beneficial effect on self-reported hip and groin function including the ability to return to sport. However, recent, and more detailed, studies have shown that the majority the patients do not reach normative values of self-reported sport and recreational function 12-months following hip arthroscopy for FAIS. This deficit in self-reported hip and groin function seems to be reflected in the return to sport rates, where around 50–60% of athletes return to their preinjury sport at preinjury level, and around 20% of athletes return to optimal performance.

Corresponding author

Lasse Ishøi
Physiotherapist,
Post Graduate Diploma Sports and Exercise Medicine,
MSc. Sports Science
PhD candidate,
Sports Orthopaedic Research Center – Copenhagen
Department of Orthopaedic Surgery,
Copenhagen University Hospital,
Amager-Hvidovre, Denmark
Hvidovre Hospital
Kettegård Allé 30
DK-2650 Hvidovre, Denmark
lasse.ishoei@regionh.dk

References

1. Abrams GD, Renstrom PA, Safran MR (2012) Epidemiology of musculoskeletal injury in the tennis player. Br J Sports Med 46:492-498.
2. Agricola R, Heijboer MP, Bierma-Zeinstra SM, Verhaar JA, Weinans H, Waarsing JH (2013) Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK). Ann Rheum Dis 72:918-923.
3. Agricola R, Waarsing JH, Arden NK, Carr AJ, Bierma-Zeinstra SM, Thomas GE, et al. (2013) Cam impingement of the hip: a risk factor for hip osteoarthritis. Nat Rev Rheumatol 9:630-634.
4. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, et al. (2016) 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 50:853-864.
5. Bradshaw CJ, Bundy M, Falvey E (2008) The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med 42:851-854.
6. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M (2015) Return to sport after hip surgery for femoroacetabular impingement: a systematic review. Br J Sports Med 49:819-824.
7. Dalton SL, Zupon AB, Gardner EC, Djoko A, Dompier TP, Kerr ZY (2016) The Epidemiology of Hip/Groin Injuries in National Collegiate Athletic Association Men’s and Women’s Ice Hockey: 2009-2010 Through 2014-2015 Academic Years. Orthop J Sports Med 4:2325967116632692.
8. de Sa D, Holmich P, Phillips M, Heaven S, Simunovic N, Philippon MJ, et al. (2016) Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med 50:1181-1186.
9. Domb BG, Dunne KF, Martin TJ, Gui C, Finch NA, Vemula SP, et al. (2016) Patient reported outcomes for patients who returned to sport compared with those who did not after hip arthroscopy: minimum 2-year follow-up. J Hip Preserv Surg 3:124-131.
10. Domb BG, Sgroi TA, VanDevender JC (2016) Physical Therapy Protocol After Hip Arthroscopy: Clinical Guidelines Supported by 2-Year Outcomes. Sports Health 8:347-354.
11. Domb BG, Stake CE, Finch NA, Cramer TL (2014) Return to sport after hip arthroscopy: aggregate recommendations from high-volume hip arthroscopy centers. Orthopedics 37:e902-905.
12. Falvey EC, King E, Kinsella S, Franklyn-Miller A (2016) Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients–clinical findings, MRI findings and patient-reported outcome measures at baseline. Br J Sports Med 50:423-430.
13. Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM (2016) Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. Br J Sports Med 50:1180.
14. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA (2003) Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res;10.1097/01.blo.0000096804.78689.c2112-120.
15. Griffin DR, Dickenson EJ, O’Donnell J, Agricola R, Awan T, Beck M, et al. (2016) The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med 50:1169-1176.
16. Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, et al. (2018) Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 391:2225-2235.
17. Haroy J, Clarsen B, Thorborg K, Holmich P, Bahr R, Andersen TE (2017) Groin Problems in Male Soccer Players Are More Common Than Previously Reported. Am J Sports Med;10.1177/0363546516687539363546516687539
18. Holmich P, Thorborg K, Dehlendorff C, Krogsgaard K, Gluud C (2014) Incidence and clinical presentation of groin injuries in sub-elite male soccer. Br J Sports Med 48:1245-1250.
19. Ishoi L, Thorborg K, Kraemer O, Holmich P (2018) Return to Sport and Performance After Hip Arthroscopy for Femoroacetabular Impingement in 18- to 30-Year-Old Athletes: A Cross-sectional Cohort Study of 189 Athletes. The American journal of sports medicine;10.1177/0363546518789070363546518789070.
20. Kemp JL, Makdissi M, Schache AG, Finch CF, Pritchard MG, Crossley KM (2016) Is quality of life following hip arthroscopy in patients with chondrolabral pathology associated with impairments in hip strength or range of motion? Knee Surg Sports Traumatol Arthrosc 24:3955-3961.
21. Kemp JL, Risberg MA, Schache AG, Makdissi M, Pritchard MG, Crossley KM (2016) Patients With Chondrolabral Pathology Have Bilateral Functional Impairments 12 to 24 Months After Unilateral Hip Arthroscopy: A Cross-sectional Study. J Orthop Sports Phys Ther 46:947-956
22. Kierkegaard S, Langeskov-Christensen M, Lund B, Naal FD, Mechlenburg I, Dalgas U, et al. (2017) Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis. Br J Sports Med 51:572-579.
23. Larson CM, Pierce BR, Giveans MR (2011) Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy 27:768-775.
24. Murphy JC, O’Malley E, Gissane C, Blake C (2012) Incidence of injury in Gaelic football: a 4-year prospective study. Am J Sports Med 40:2113-2120.
25. Naal FD, Dalla Riva F, Wuerz TH, Dubs B, Leunig M (2015) Sonographic prevalence of groin hernias and adductor tendinopathy in patients with femoroacetabular impingement. Am J Sports Med 43:2146-2151.
26. Naal FD, Schar M, Miozzari HH, Notzli HP (2014) Sports and Activity Levels After Open Surgical Treatment of Femoroacetabular Impingement. Am J Sports Med 42:1690-1695.
27. Orchard JW, Seward H, Orchard JJ (2013) Results of 2 decades of injury surveillance and public release of data in the Australian Football League. Am J Sports Med 41:734-741.
28. Reiman MP, Peters S, Sylvain J, Hagymasi S, Mather RC, Goode AP (2018) Femoroacetabular impingement surgery allows 74% of athletes to return to the same competitive level of sports participation but their level of performance remains unreported: a systematic review with meta-analysis. Br J Sports Med;10.1136/bjsports-2017-098696.
29. Reiman MP, Thorborg K, Holmich P (2016) Femoroacetabular Impingement Surgery Is on the Rise-But What Is the Next Step? J Orthop Sports Phys Ther 46:406-408.
30. Roos KG, Wasserman EB, Dalton SL, Gray A, Djoko A, Dompier TP, et al. (2016) Epidemiology of 3825 injuries sustained in six seasons of National Collegiate Athletic Association men’s and women’s soccer (2009/2010-2014/2015). Br J Sports Med;10.1136/bjsports-2015-
    095718.
31. Sansone M, Ahlden M, Jonasson P, Thomee R, Falk A, Sward L, et al. (2014) Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes. Knee Surg Sports Traumatol Arthrosc 22:786-792.
32. Speirs AD, Beaule PE, Huang A, Frei H (2017) Properties of the cartilage layer from the cam-type hip impingement deformity. J Biomech 55:78-84.
33. Thorborg K, Kraemer O, Madsen AD, Holmich P (2018) Patient-Reported Outcomes Within the First Year After Hip Arthroscopy and Rehabilitation for Femoroacetabular Impingement and/or Labral Injury: The Difference Between Getting Better and Getting Back to Normal. Am J Sports Med;10.1177/0363546518786971363546518786971.
34. Thorborg K, Rathleff MS, Petersen P, Branci S, Holmich P (2017) Prevalence and severity of hip and groin pain in sub-elite male football: a cross-sectional cohort study of 695 players. Scand J Med Sci Sports 27:107-114.
35. Tijssen M, van Cingel RE, de Visser E, Holmich P, Nijhuis-van der Sanden MW (2017) Hip joint pathology: relationship between patient history, physical tests, and arthroscopy findings in clinical practice. Scand J Med Sci Sports 27:342-350.
36. Walden M, Hagglund M, Ekstrand J (2015) The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med 49:792-797.
37. Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, et al. (2015) Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 49:768-774.
38. Worner T, Thorborg K, Moksnes H, Eek F (2017) Similar views on rehabilitation following hip arthroscopy among physiotherapists and surgeons in Scandinavia: a specialized care survey. Knee Surg Sports Traumatol Arthrosc;10.1007/s00167-017-4676-6.
39. Worner T, Thorborg K, Stalman A, Webster KE, Momatz Olsson H, Eek F (2018) High or low return to sport rates following hip arthroscopy is a matter of definition? Br J Sports Med;10.1136/bjsports-2018-099154.
40. Zuckerman SL, Wegner AM, Roos KG, Djoko A, Dompier TP, Kerr ZY (2016) Injuries sustained in National Collegiate Athletic Association men’s and women’s basketball, 2009/2010-2014/2015. Br J Sports Med;10.1136/bjsports-2016-096005.