Hip pain is a very topical issue within GAA players at the moment. In the past year there has been some high profile articles within the media, with often misleading information and scaremongering being circulated, confusing the patients that we see in our clinic.
So what is it?
For years there has been a poor establishment of diagnostic criteria and management of this injury, however the Warwick Agreement on Femoroacetabular Impingement Syndrome has outlined the consensus of world experts. Femoroacetabular 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. The main symptoms that people present with in the clinic is hip or groin pain during certain movements or positions e.g. changing direction or cutting during training/match. Pain may also be felt in the buttock and thigh.
Patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way.
In clinic, GAA players often report an increase in training load, playing with multiple teams and multiple age groups, general increase in stiffness in the hips and groin over a sustained period.
Diagnosis of FAI syndrome does not depend on a single clinical sign. Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used test, flexion adduction internal rotation (FADIR), is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion. There will be strength deficits around the joint on testing, especially in Hip Abduction and Hip Flexion. Hip flexion deficits were associated with a decrease in function as shown by the association with the greater loss in range of motion and patient reported outcomes. It is well established that large strength deficits are found in people who have chronic hip pain, leading to weakness of the hip rotators and hip abductors. There is suggestion of impairments in hip frontal, sagittal and transverse plane ROM during gait, squatting and stair climbing. A recent research paper showed that during a squat movement, participants with FAI had decreased hip internal rotation and increased anterior pelvic tilt compared to a normal group. The study also showed the FAI group had decreased gluteal and hamstring strength compared to the normal group. In theory, decreased activation of the gluteus maximus and/or hamstring muscles may contribute to the lack of posterior pelvis tilt. Hypothetically, relative posterior tilt of the pelvis during this phase of squatting would limit the potential for impingement in the presence of cam morphology.
The average age of symptomatic hip pain in this group is about 28 years, with nearly a 50/50 split in male and females, however this is a North American population,
with very little research been done in GAA. Studies of adolescents have made it apparent that the development of FAI may also be due to developmental adaptations during skeletal maturation as a result of activities that involve repetitive hip motion, such as field based sports. Recent research demonstrates an increased prevalence of FAI type-deformities in elite adolescent athletes compared to their age-matched non-athletic controls.
This suggests that the morphological changes of FAI may be a response to repetitive stress at the hip joint secondary to sporting activity during periods of skeletal growth.
Research has shown that in particular, adolescent males who participate in ice-hockey, basketball and to a lesser extent soccer, whilst performing a minimum of three training sessions and games per week are currently at greatest risk of developing a boney deformity in the hip and potentially progressing to symptomatic hip impingement. So from a practical point of view, parents and coaches need to be aware of the amount of training load that young adolescents are participating in, especially during times of growth spurts. While physical activity is hugely important, a 15 year old boy playing three different sports up to 9 or 10 times a week while going through a growth spurt needs to be properly managed.
Rehabilitation aims to reduce patients’ symptoms by improving hip stability, neuromuscular control and movement patterns. However, for optimal results in returning the player to pain free play it is important that all confounding variables are explored.
- Activity Modifications to reduce pain
- Training Load education
- Range of Motion deficits
- Especially Internal Rotation
- Strength deficits
- Sagittal plane
- Frontal plane
- Transverse plane
- Movement patterns
- eg. modifying squat and deadlift mechanics to prevent pain and increase glute/hamstring strength
- Correct poor mechanic mechanics
- Change of Direction
One of the most important things that patients need to understand is there is no one size fits all to these problems. Each case has different challenges and rehabilitation needs to target the presenting persons deficits so a suitable tailored programme can be prescribed.
Thomas Divilly MSc MISCP
Griffin et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. (2016). 50
Hayes et al. Persons With Chronic Hip Joint Pain Exhibit Reduced Hip Muscle Strength. Journal of Orthopaedic & Sports Physical Therapy. (2014). 44 (11).
Nepple, J.J. et al. Hip Strength Deficits in Patients With Symptomatic Femoroacetabular Impingement and Labral Tears. Arthroscopy: The Journal of Arthroscopic and Related Surgery. (2015). Vol 31, No 11 ,
Diamond et al. Isometric and Isokinetic hip strength and agonist/antagonist ratios in symptomatic femoroacetabular impingement. Journal of Science and Medicine in Sport. (2016) 696-701.
Bagwell et al. Hip kinematics and kinetics in persons with and without cam femoroacetabular impingement during a deep squat task. Clinical Biomechanics. (2016). 87-92.
de Silva et al. Does high level youth sports participation increase the risk of femoroacetabular impingement? A review of the current literature. Pediatric Rheumatology. (2016). 14:16