Catching Hip Injuries

Recent advances in arthroscopic surgery have sent an increasing number of athletic trainers into the previously unexplored world of hip rehab.

By R.J. Anderson

R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at rja@MomentumMedia.com.

Training & Conditioning, 15.4, May/June 2005, http://www.momentummedia.com/articles/tc/tc1504/hipinjuries.htm

In early March 2004, University of Virginia catcher Scott Headd began complaining of tightness in his right hip. Over the next week, the tightness evolved into a snapping and popping sensation accompanied by sharp, shooting pain when Headd maneuvered to block wayward pitches or exploded out of his crouch to throw out base runners.

Brian McGuire, PT, ATC, Assistant Athletic Trainer at Virginia, says that after a round of X-rays showed the bone structure in the hip to be normal, the initial diagnosis was an extra-articular snapping of the hip tendon. The physician surmised that the iliopsoas tendon was catching part of the pelvis, causing a snap when Headd’s hip was flexed.

Of all the body parts athletic trainers treat, the one they tend to have the least experience with is the hip. And surgical options, especially for athletes, are just now starting to catch up with procedures for the knee and shoulder. In this article, we’ll discuss the current trends in treating hip labral tears, while detailing Headd’s specific case.

ASSESSING THE DAMAGE
When an athlete has significant hip pain and a clean X-ray, most athletic trainers suggest assessing the area one step at a time. “We start with modalities to decrease the pain, and if after a few weeks the athlete fails to progress, we give them a cortisone injection and have them rest for a week,” says Bernie DePalma, MEd, PT, ATC, Head Athletic Trainer/Physical Therapist at Cornell University, adding that 60 percent of the time the injection clears up an athlete’s hip pain.

“Then we start rehabbing them again,” DePalma continues. “It usually takes four weeks, and if the pain comes back within those four weeks, we begin looking into other things.”

Pete Draovitch, ATC, PT, CSCS, Physical Therapy and Rehabilitation Specialist at the University of Pittsburgh Medical Center, recommends that clinicians also look for other sources of pain. “We try to first rule out a back or foot injury,” says Draovitch, who, like DePalma, recommends doing very light rehab and basic treatment with an athlete for six to eight weeks in order to rule out a muscle pull or strain.

“Most good therapists and athletic trainers can get people back from a pulled muscle in the pelvic region in less than two months,” says Draovitch. “Once that time passes and you’ve ruled out that type of injury as the problem, you need to re-examine and determine whether the injury is extra-articular (outside the joint) or inter-articular (inside the joint).

“If it’s outside the joint, you probably need to set up a different rehab program,” Draovitch continues. “If it’s inter-articular, then you probably have to examine it diagnostically and clinically and decide whether it warrants having surgery.”

Draovitch, who estimates that he’s worked on about 3,000 hip injuries in the last five years, says he uses a technique called Russian Stimulation as part of a hip assessment. “It’s a technique where we contract their gluteus medius muscle or their adductors as much as we can for a 10-second period—we’ll do 10 reps, with 10 seconds on and 50 seconds off,” he explains. “If I see that the muscles aren’t firing sufficiently to counteract the force that I’m applying, I’ll usually say, ‘This isn’t working. Let’s get you in with an orthopedic surgeon.’”

At Virginia, McGuire followed a similar path. To start, Headd was given a fluoroscopic-guided corticosteroid injection. “We hoped that the injection would decrease the inflammation in his hip,” says McGuire, “and also rule out a labral tear.”

After receiving the injection, Headd took four days off, missing a game and several practices. Despite the treatment and time off, Headd’s symptoms remained. “After the injection didn’t work, there wasn’t a whole lot else to think other than it was the labrum,” says McGuire. “At that point, we were in the middle of our season and there were three choices: Stop all activity and rest, have season-ending surgery if a tear was detected by an arthrogram MRI, or play through it as long as he could.”

While the pain was there, so was the remainder of an exciting season. Headd was in his junior year and an integral part of the team. “It was painful, but he could play with it, and we felt he wouldn’t do any further damage” says McGuire. “He was able and willing to play through the pain, so we let him.”

Throughout the season, McGuire and the coaching staff helped Headd manage the injury with anti-inflammatories and ice, keeping him out of drills and weight-lifting activities that bothered his hip. They also monitored his pain levels. “If it had gotten bad enough, then we would have drawn the line and not allowed him to continue,” says McGuire.

Headd didn’t miss a game for the rest of the season. His handling of pitchers, timely hitting, and penchant for throwing out would-be base stealers contributed to the Cavaliers school-record-tying win total. His efforts helped catapult Virginia into the 2004 NCAA Division I Tournament, where Headd was named to the regional All-Tournament team.

Upon completion of the season, Headd had an arthrogram MRI performed on his hip. And just as McGuire and the rest of the medical staff had suspected, Headd had a torn labrum.

McGuire surmises that it was probably a chronic, progressive injury that at one point triggered a tear. “It’s kind of like an injury to a pitcher’s elbow,” says McGuire. “Certainly those injuries happen acutely and they come on quickly, but they’re really a result of wear and tear over time, and eventually there’s a straw that breaks the camel’s back. For Scott, it was probably slowly building to that point over the last several years.”

The next decision was whether to try surgery. Rehabbing from a hip arthroscopy can take three to six months and the surgery is relatively new. So even when the season was over and an MRI revealed a tear, McGuire and Headd approached the procedure as a last resort. “You’re never 100-percent certain that surgery is the answer,” says McGuire. “So we gave him four weeks of downtime and took some conservative measures by treating him with anti-inflammatories and ice just to see how the hip reacted.

“We thought that maybe by acting conservatively and giving him a month off it might give the injury an opportunity to quiet down,” says McGuire. “But that didn’t help, so the doctor and Scott decided that it was time for surgery.”

SURGERY & REHAB
An emerging surgical trend, hip arthroscopy is becoming more common, especially among athletes. The application of this minimally invasive technique, combined with advances in MRI, is considered a medical leap in treating many forms of chronic hip injuries.

One of the most common of these procedures is for the treatment of labral tears. Athletes such as NHL Hall of Famer Mario Lemieux, Priest Holmes of the Kansas City Chiefs, the Denver Nuggets’ Marcus Camby, 1998 Olympic figure skating gold medalist Tara Lipinsky, and three-time French Open tennis champion Gustavo Kuerten have all successfully undergone the procedure.

Headd had surgery in late August at Johns Hopkins Hospital in Baltimore. Frank Ebert, MD, an Orthopaedic Surgeon affiliated with Orthopaedic Associates, LLC, in Baltimore, performed an arthroscopic procedure to repair the tear.

Because it is a relatively new technique that has experienced significant growth within the last five years, the rehab that follows hip arthroscopy is unfamiliar to many athletic trainers and physical therapists. That was the case for McGuire, who before working with Headd, hadn’t encountered the injury.

To overcome this, McGuire says that communication was a key element. “I spoke with Dr. Ebert every four weeks and relayed where Scott was, and he would give me goals and guidelines for each four-week period,” says McGuire. “Then after I spoke with Dr. Ebert, Scott and I sat down and mapped out what it would take to reach those goals. Sometimes we switched things around within a four-week period based on how he was feeling.”

Having Headd involved with the design of his rehab program helped in several ways, McGuire says. “It helped me to see Scott’s perspective and what his expectations and anxieties were,” says McGuire. “And it helped him because he knew exactly what to do—he knew the boundaries he couldn’t go over during each period. It also helped provide motivation in reaching short-term goals over each four-week period.

“Once Scott and I solidified each four-week program, I sent a copy to Dr. Ebert and let him review it to make sure they were still safe within his protocol,” continues McGuire. “Then we just went at it, always letting symptoms be the guide.”

SLOW & STEADY
When it comes to rehabbing from hip arthroscopy, DePalma suggests taking it slow. “I think you can overdo the rehab and cause delay of healing and possibly even affect the repaired area,” he says. “My main advice is not to be overly aggressive. I think the biggest mistake people make is confusing rehab time with healing time. It’s tempting to want to do a lot, but you’ve got to go easy and let the tissue heal.”

For McGuire, the overall goal was to get Headd ready to be on the field for the team’s first spring practice, four months post-surgery. But they took each phase one step at a time. Headd eased into his rehab supported by two crutches with partial weight bearing as tolerated for the first two weeks. Then, he switched to one crutch for one week, until he regained his normal gait. During the second week he also started some easy pool walking and stationary biking without resistance.

By the three-week mark, Headd was off the crutches, but he still didn’t do very much in the way of activity. His pool walking was increased to 30 minutes and light resistance was added to his stationary biking, which he also did for 30 minutes. During this time, Headd also began easy hip-active range-of-motion exercises.

“I was hesitant to have him do any ground-based long-distance walking because of the potential for damage to the hip capsule and labrum,” says McGuire. “He walked to class, of course, but any of his long walking for the first couple of weeks was done in the pool.”

The first six weeks of his rehab, Headd met with McGuire twice a day, seven days a week, for about an hour each session. “The first four to six weeks we just wanted to go easy to avoid a synovitis or overstretch,” says McGuire.

At four weeks, Headd began doing light hip isotonics and more weight-bearing exercises such as bridges and single-leg bridges. “We started working the hip extensors, abductors, and external rotators really hard, and we also started light stretching for his hamstrings, hip flexors, quads, and IT bands,” says McGuire. “The things we were really cautious with at that point were the hip rotary motions. He always had close to full external rotation, but internal rotation was about 25-30 percent of his maximum before he had pain. His hip abduction was about 50 percent, so we were also cautious with that.

“For the most part, there were three motions that slowly worked their way back: hip internal rotation, abduction, and flexion,” continues McGuire. “And Scott knew not to push once something started to bother him. The hardest thing was not knowing the exact time when all his hip motions were going to return.”

At six weeks, Headd began light internal-external hip rotation stretching, which marked the first time he even attempted anything beyond his active ROM. He also began upper-body weightlifting workouts with his teammates.

Eight weeks post-op, Headd got his first taste of lower-extremity strength work, which included squats, Romanian dead lifts, four-way hip exercises, lunges, and lateral step work. The lifting program emphasized lighter weights and higher reps and was designed to build his endurance and keep him out of positions that could potentially aggravate his hip or cause a setback. He also began a progressive 12-step walk-jog program as well as interval hitting and throwing programs with the team.

“With squats, Scott started off with about 95 pounds, doing three to five sets of 15-20 reps,” says McGuire. “He wasn’t able to go to parallel yet. If he squatted below 60 degrees he would feel a little anterior pinch so we kept him out of that range.”

Even as the season progressed, Headd only slightly increased the amount of weight he lifted with his legs. Squats, for example, didn’t go more than 135-150 pounds.

At 11 weeks, McGuire added rotary strength work into the mix and Headd completed all of his interval programs. It was at this point that Headd grabbed his mitt and eased into catching drills.

BEHIND THE PLATE
Consistent with the overall pace of Headd’s rehab protocol, the catching drills phase was entered cautiously and monitored closely. For the first week, he positioned himself in the deep squat and caught balls delivered by a pitching machine. Once he was comfortable in his squat, Headd began shifting his weight from side-to-side in order to handle inside and outside pitches. At about the 13-week mark post-op, he started moving around to block wayward pitches.

At 15 weeks, Headd began the tough task of coming out of the deep crouch to throw. “That was the most difficult thing and the last thing he accomplished,” says McGuire. “He had to explode up and open his hips all in one motion. With the injury being in his right hip and Scott being a right-handed thrower, the hardest motion was locking down his hip while throwing to second.”

It took Headd a couple weeks to get comfortable with the explosive maneuver, and he was experiencing some discomfort, which McGuire kept a close eye on. “He was a little sore, but it was tolerable,” says McGuire. “I checked his ROM before each practice, and he never lost ROM or strength during that time. If he had lost ROM from the previous day, then we would have backed him down and kept him out of the catching drills.”

At this point it was December, and with practices set to begin mid-January, Headd knew that he was very close to being ready. “Our goal all along was to make sure that he was 100 percent by mid-January,” says McGuire. “There never was a time crunch. And the coaches were very good about not pushing the rehab process.”

From mid-December until mid-January, Headd went home to Maryland for winter break. During that time he continued doing his weight-training and flexibility programs as well as some additional hip stabilization exercises.

When the team returned for practices in January, Headd again took it slow, and for the first few days he caught only two or three innings during the team’s intrasquad scrimmages. By the end of the month, he was up to six innings.

“Once we got back in January, we had a month before the season started to build up his catching tolerance,” says McGuire. “So if the team had a long, hard practice, we didn’t hesitate to give him the next day off to see how his hip responded and to see what his recovery time would be—if he needed any at all.”

The only setback took place at the end of January. “During a hitting drill he opened his hips too much and felt a little capsulitis,” says McGuire. “But that fully resolved in 10 days, and he never missed any practice time. We just backed him down on his hitting and catching drills for three or four days.”

A HAPPY ENDING
Opening day for the Cavaliers was Feb. 11, and Headd was in the starting lineup. He played nine pain-free innings behind the plate. Deep into the 2005 season Virginia is in the midst of another successful year, and Headd is still pain-free. He continues to lift twice a week as part of the team program, and he does some additional hip stabilization exercises as well as a hip-stretching routine before every practice and game.

So what were the keys to bringing an elite-level athlete back from a hip injury to play such a demanding position? “The biggest thing was that Scott and I were always on the same page,” says McGuire. “Sometimes I think we as athletic trainers make these protocols that are one thing in our minds, but are perceived differently by the athlete.

“But all along, Scott knew his hip, knew what bothered him, and knew what he could progress with,” continues McGuire. “Making sure he and I were working toward the same goal each week was very important. It avoided a lot of potential frustration and anxiety for both of us.”



SIDEBAR:
Hip Prehab
As research on the hip and pelvic region begins to catch up with other areas of the anatomy, many athletic trainers are seeing the benefits of prehabbing that region to ward off potential injury. At Cornell University, Bernie DePalma, MEd, PT, ATC, Head Athletic Trainer/Physical Therapist, says that he is constantly talking to the program’s strength coaches about hip strength and flexibility.

“With the athletes playing ground-based sports, it’s important that you work them with their feet on the ground as much as you can,” says DePalma. “We try to do a lot of closed-chain exercises and alternate them with open-chain exercises.

“We do different kinds of squats and side lunges, work on the slide board, and have them do ballistic movements in between stretches,” he adds. “We also do a lot of core strengthening with those athletes.”

Pete Draovitch, ATC, PT, CSCS, Physical Therapy and Rehabilitation Specialist at the University of Pittsburgh Medical Center, believes in going through a proper warm-up before working the hip area. “Years ago, to prehab rotator cuffs, when athletes were benching extremely heavy weight, I’d start everybody off with a set of rotator cuff exercises just to activate the muscle,” says Draovitch. “Now, it’s not uncommon for me to do something similar for hips. I’ll often have the athlete do a closed-chain exercise before I have them squat or do lunges or something similar.”

Draovitch also has his athletes do a lot of sideways walking with resistance bands placed around their thighs and ankles. “I also use four-way hip machines and Pilates in standing positions to work the hip abductors,” he says. “We just try to create a good balance between hip abduction, adduction, flexion, and extension, and both rotational movements.”