Combat Arts Hip Injuries Overview

Overview 

Two different problems get lumped together under this heading. Osteitis pubis is a stress injury of the pubic symphysis: repetitive kicking and twisting in MMA loads the joint unevenly, the balance between the anterior muscles and the adductors is lost, and over time the bone and cartilage at the symphysis take the damage. Athletic pubalgia, often called a sports hernia, is a soft tissue injury of the lower abdominal and groin muscles. Both show up as groin pain that worsens with kicking, and a hernia is often suspected first, which is why pubalgia is not diagnosed immediately.

Symptoms 

Causes

Athletic pubalgia is common among those in the combat arts who kick repeatedly or have lots of kicking maneuvers. This is a soft tissue injury of the abdominal muscles such as the rectus sheath, or pelvic muscles such as the adductors. MMA involves planting the feet and twisting hard through the hips, and that exertion can tear the soft tissue of the lower abdomen or groin.

To learn how Pubalgia is diagnosed Click Here

This usually occurs due to a single traumatic event like a punch or kick to the hip area. A hematoma or a deep bruise ensues. For reasons that are still not well understood, the hematoma calcifies and ossifies. Fighters see it because they take repeated direct trauma to the same area, but direct trauma is not the only route — heterotopic ossification also follows surgery, burns and spinal cord injury.

It usually occurs 3 to 12 weeks after sudden trauma to the hip. However, it can take up to 6 months to present. A sudden kick or punch in the hip area can cause a hematoma to develop. Instead of healing, the hematoma calcifies. This happens frequently in those in the combat arts due to the repetitive injury or kicks in the hip area.

To learn how Heterotopic Ossification are diagnosed Click Here

The jiu-jitsu sage John Danaher who was the architect of UFC champions Georges St-Pierre and Chris Weidman has been plagued by Femoroacetabular Impingement (FAI). He admits the MRI of his hip looks like a car wreck and worse, he feels like he’s 100 with all the pain. The hip pain is secondary to mechanical impingement from an abnormal hip structure involving the femur and acetabulum. When an impingement occurs the femoral cam or bump collides with the acetabular rim. It results in the labrum and cartilage getting pinched. Over time, this causes the cartilage of the labrum to wear. Progressively, it leads to hip osteoarthritis if left untreated with repeated trauma.

As the hip rotates to extreme arcs of motion or if there is repetitive, abnormal contact between the bony prominences of the hip and femur, the soft tissue of the femoroacetabular joint gets damaged. The abnormal pathology includes the cam deformity of the femoral head-neck junction as well as pincer lesions of the acetabulum. They both contribute to impingement and pain. Any labral tears and or impingement of the hip causes abnormal gliding of the ball and socket mechanism of the hip joint. The joint tries to adapt, albeit painfully. Mixed Martial Arts fighters subject themselves to repetitive flexion and outward motion of the leg stressing the joint. They have pain when they flex and rotate the hip especially while guarding or checking a kick, if hip impingement is present.

To learn how Impingement of the hip is diagnosed Click Here

Hip injuries are common among those in the combat arts, from acute trauma and even more from chronic overload. The constant kicking and pivoting, checking, and guarding on one leg stresses the joint. Wear and tear can thin the cartilage until the head of the femur grinds in the socket, and that arthritic contact gets worse over the years. Stress fractures of the femoral neck are a separate injury, caused by repetitive loading of otherwise normal bone rather than by arthritis. An acute injury like a sudden fall can fracture the hip outright. Hip throws are common moves in MMA and are frequently used. At 35 Ben Askren, one of the most successful grapplers to grace martial arts, retired as he needed a complete hip replacement due to years of training.

Hip fractures occur in those in the combat arts who withstand high energy trauma. They could be due to overuse of the hip joint through hip throws and pivoting movements of the hip or they could be due to an acute fall or injury. If the hip fracture also involves the fracture of the femoral neck then it will involve months of crutch use.

To learn how Hip Fractures are diagnosed Click Here

Physical Exam

The doctor will start palpating laterally at the inguinal ligament and work to the pubic tubercle. The pubic symphysis is also checked. Any tenderness at or just above the pubic tubercle is indicative of pubalgia. Pain can also be elicited with resisted sit-up exams and hip flexion. In the resisted sit-up exam, the fighter lies supine with the feet stabilized. The arms are held straight ahead and a sit-up is done, holding for 5 seconds. If there is pain at the rectus sheath, the test is positive.

Valsalva maneuvers can also occasionally reproduce pain. The single or bilateral resisted adduction test is another test for pubalgia. The fighter lies supine and flexes the leg to about 30 degrees. The doctor places a hand against the inner side of the heel and asks the fighter to squeeze inward against it — resisted adduction, since it is the adductors being tested. Pain in the groin or over the pubic bone makes the test positive.

A sensory exam is done as sensory deficits and paresthesia in the lower abdomen, inguinal region, thigh, and genitals suggest entrapment of the iliohypogastric, ilioinguinal, and genitofemoral nerves. 

Both hips are checked for range of motion. To separate intra-articular from extra-articular pathology, doctors use tests such as FADIR, FABER or Patrick Test, Scour, DEXRIT (Dynamic External Rotatory Impingement Test), and DIRIT (Dynamic Internal Rotatory Impingement Test). None of them confirms a diagnosis on its own; they steer the imaging.

Imaging

Radiographic must include a standing anteroposterior (AP) pelvis and lateral hip views. Doctors will look for intra-articular pathologies like arthritis, loose bodies, and acetabular dysplasia. Extra-articular pathology like pelvic avulsion fractures sustained during a fight or workout is also seen. Magnetic resonance imaging (MRI) of the pelvis is done in athletic pubalgia. A dedicated hip MR arthrogram is done if there’s a suspicion of labral tears. Rectus disruptions are seen as a cleft sign and tears are characteristics for pubalgia.

Lab Tests

Blood tests do not help confirm pubalgia. However, diagnostic intra- and extra-articular injections of local anesthetic and/or corticosteroid can also diagnose pubalgia. Doctors do it with a fluoroscope or with an ultrasound. After the injection of the hip joint, a provocation test is done to differentiate hip pain from pelvic pain. Any persistent pain in the adductor regions, despite an intra-articular injection, is diagnostic for pubalgia.

To learn how Pubalgia is treated Click Here

During the physical exam doctors look for local edema, effusion, erythema, warmth, and tenderness either in the tissue or joint. Fighters may also present with a low-grade fever and localized swelling. Muscle guarding and spasm around the hip are common as the joint stiffens and movement is lost. 

Plain film radiographs will reveal circumferential bone formation around or near the affected joint, and that appearance is specific for HO. Plain films do not catch it in the first few weeks, so where HO is suspected early a triple-phase bone scan is preferred, because it turns positive sooner than X-ray does.

CT scan delineates the area of bone formation before surgery. Other imaging like ultrasound and 3-dimensional stereolithography is also done, but not always necessary.

Blood tests support the diagnosis of HO without confirming it. Alkaline phosphatase is the most commonly ordered lab test. It is not always elevated early on as the HO forms, and it can take weeks to rise. It does not indicate the severity of the disease, and it also goes up if the fighter has other long bone injuries — so treat it as a clue, not a number to chase.

Erythrocyte sedimentation rate (ESR) is another inflammatory marker tested in HO. It is not specific, and neither is C-reactive protein, which can be elevated early on. Creatine kinase may be raised where there has been a lot of muscle damage. None of these tests grade the severity of HO or predict which treatment will work.

To learn how Heterotopic Ossification are treated Click Here

Doctors will look for pain radiating to the thigh. They will check for the "C sign." It is formed by the index finger and thumb over the anterolateral area of the hip.

They will observe the gait, hip range of motion, and strength. The Trendelenburg gait or abductor lurch is tested. It indicates abductor muscle weakness. While testing hip range of motion, decreased hip flexion and internal rotation is a sign of impingement. Pain with the hip flexed to 90 degrees, adducted and internally rotated — the FADIR test — is the useful provocation test for impingement and labral injury. FABER, or the Patrick test, is far less specific and can be positive with hip, sacroiliac joint or iliopsoas problems, so it does not confirm a labral tear on its own. They will check for any audible snapping of the hip. Palpable snapping with hip range of motion indicates another syndrome that must be differentiated from FAI.

Evaluation of the hip with plain films is the first step. X-rays must include a standing anterior-posterior (AP) pelvis, AP hip and lateral of the hip. These views assess the pelvis and femur. Standing films are necessary despite the pain as they offer the hip position while it’s at a functional load-bearing position.

It also detects hip dysplasia if present. Cam and pincer lesions can be seen in X-ray views. The lateral center edge angle (LCEA) is measured to assess for hip dysplasia with Xrays. Pincer deformities appear as excess bony growth along the acetabular edge. A cam deformity appears as an excess bony growth along the femoral head-neck junction. The head may not be spherical anymore.

Other views include the false profile and the Dunn views of the hip. Here the fighter stands at an angle of 65 degrees as the X-ray is directed towards the affected hip.
The Dunn view is a lateral view of the affected hip. It is obtained at a 45⁰ angle to the hip. It best assesses the cam deformity. 

Magnetic resonance imaging (MRI), with or without intra-articular contrast injection, also assesses FAI. It is helpful as it is very informative about potential labral or cartilage injury resulting from impingement. The MRI provides 3D images of the bony structure and impingement cysts in the femoral neck if any. It can also identify other sources of hip pain such as avascular necrosis, stress fractures, bursitis, and tendonitis.

Blood tests are not needed to diagnose this injury. However, in preparation for surgery, blood tests are required. This includes a complete blood count, type, and Rh for potential transfusions, PT, PTT, and basic metabolic panel.

To learn how Impingement of the hip is treated Click Here

The physical examination is done to check for pain, mobility through ROM testing, and any potential limb deformity. If the leg is shortened and externally rotated limb then it aids in the diagnosis. This occurs due to the unopposed pull of the iliopsoas muscle. Any pain while palpating the groin, axial loading of the hip and 'pin-rolling' of the leg is suspicious for a hip fracture.

Doctors will perform a full primary trauma and secondary trauma assessment.

Hip fractures are diagnosed on plain film radiographs. An anteroposterior and lateral view of the pelvis is done. A lateral view of the affected hip is also done. MRI can pick up occult hip fractures missed on plain films and, therefore is the gold standard. CT is an alternative when an MRI is not available.

Intracapsular hip fractures are classified with the Pauwel classification. This classification divides fractures into three groups:

Type 1: <30 degree
Type 2: 31-50 degrees
Type 3: >50 degrees

An increased angle is a more unstable fracture. Their healing will take longer.

The Garden classification is used for intracapsular hip fractures. It has four fracture patterns:

Type 1: incomplete fracture and no displacement
Type 2: complete fracture and no displacement
Type 3: complete fracture and partial displacement
Type 4: complete fracture and complete displacement

Extracapsular fractures are divided into trochanteric and subtrochanteric fractures. Extracapsular fractures are divided by the AO classification:

A1: two-part, stable fracture
A2: comminuted, unstable fracture
A3: reverse or transverse, unstable fracture

Different fracture types dictate the surgical treatment a fighter will receive.

Fighters must have blood tests to assess for anemia, renal function, and coagulation profile. A bone screen is done to assess osteoporosis or calcium abnormalities. A cross-match is done as operative management for fractured hips can cause significant blood loss.

To learn how Hip Fractures are treated Click Here

Emergency

For a mild groin or hip strain, 7 to 10 days of relative rest and ice is usually enough to settle things down, and a compression wrap may take the edge off. Get it confirmed by a doctor rather than guessing. Go to an emergency department the same day if you cannot bear weight on the leg, if the leg looks shorter or turned outward, if the hip is obviously deformed after a throw or a fall, or if severe pain comes with numbness or a cold, pale foot.

Medical

Rehabilitation with physical therapy is the best therapy for athletes with athletic pubalgia. However, this treatment is tailored based on the level of the athlete. Physical therapy includes core strengthening and stabilization, restoration of pelvic tilt, and postural training. Avoid overload the hip with an increasing range of motion especially those with hip pathology. Conservative treatment is done for 3 months. If it fails to relieve symptoms, surgery is advised. For those athletes who are training for competitive sports, a trial 4-week period of rest is done. For pain management, nonsteroidal anti-inflammatories and oral steroid tapering treatment are tried.

Selective corticosteroid or platelet-rich plasma injections into the rectus muscle and/or adductor longus muscle is also done. If symptoms ease then, the fighter can return to the sport through a trial period. If pain persists, it is up to the fighter to decide to rest or cross over to surgical treatment.

Surgical treatment includes laparoscopic and open procedures. During these operations, the posterior wall is reinforced and the conjoint tendon or the rectus sheath is fixed. If adductor pain is present, then adductor tenotomy is advised. This is where the tendon is divided. A full return to sport can be made in about 6–8 weeks if it is an isolated athletic pubalgia repair. If another hip pathology exists, then expect healing to take about 4 months.

Home

Stop training, get the weight off the injured hip, and either begin R.I.C.E. treatment if the injury is mild, or find a doctor — or go to the hospital — if the injury is intensely painful or you cannot put weight on the leg. Be straight with yourself about what the add-on therapies can do. Acupuncture may help some kinds of chronic pain when it is done by a licensed practitioner with sterile needles, and massage may ease pain in the short term. CBD oil, stem cell injections, deep tissue laser therapy, Traditional Chinese Medicine and Ayurveda are not proven treatments for a hip injury, and stem cell injection in particular is experimental, expensive and largely unregulated. Gentle movement work like yoga or tai chi can keep you moving while you rehab, but none of it replaces getting the injury diagnosed.

Physical therapy must be started two weeks after sustaining the injury. The focus is on improving strength and flexibility in the abdominal and inner thigh muscles.

Usually, post injury, the development of HO is never suspected. It takes weeks for this injury to develop. However, rest and ice are advised to prevent any further aggravation of the hematoma and to allow its complete healing.

The first step in the treatment of HO is keeping the joint moving, with gentle range of motion work alongside pain management. Early passive range of motion must start once HO is diagnosed, to stop the joint stiffening toward ankylosis. Anti-inflammatory medication is used to damp down the new bone formation, and surgical resection is considered only if the joint stays functionally limited. Which drug, and for how long, is a decision for the treating doctor.

Surgical resection is for heterotopic bone that is genuinely limiting the joint, not for every patch of calcification that shows up on a scan. When it is done, it is done only once the HO has fully matured, which is roughly a year or more after the initial injury.

Anti-inflammatory medication is used to try to arrest new bone formation in HO, and to manage the pain alongside it. These are prescription decisions: the treating doctor weighs the stomach, kidney and heart risks of any NSAID against how long you actually need it. Do not go hunting for a specific drug and dose online and self-medicate off it.

The best therapy for HO is preventative. That means gentle ROM exercises, an anti-inflammatory course, and in high-risk cases external beam radiation. Indomethacin is the NSAID most commonly used for prophylaxis; others in the same class include meloxicam, celecoxib and ibuprofen. Which one, at what dose, and for how long is a call for your doctor, not for a website.

Bisphosphonates were once used to try to prevent this bone formation, mostly in people with spinal cord injuries. Etidronate, the drug used for that, has since been discontinued or withdrawn in most markets and is no longer standard practice — anti-inflammatory prophylaxis and radiation are what is used now.

If an acute injury is present, the first step is still medical treatment. These are tried for a period to allow the injury to heal. Pain management with NSAIDS and steroids are advised.

The treatment for impingement of the hip is both medical and surgical.  Medical alternatives include physical therapy, modifying activity, and pain medication. This is typically done with NSAID’s. Intraarticular injection with local anesthetic and steroid is advised if the pain is unbearable. This is a diagnostic and therapeutic tool. It confirms the location of the pain. If all these measures fail, then surgery is advised.

In surgery, the bony causes of impingement are resected and the soft tissues are repaired. Surgery is done arthroscopically or in an open technique. For cam lesions involving the femoral head-neck junction, a cam resection or femoral osteoplasty is done. Surgeons use a high-speed burr and shave down the excess bone.

Pincer lesions on the acetabulum are repaired by an acetabular osteoplasty. For labral tears, the labrum is repaired or simply debrided. If there is focal cartilage damage, a microfracture is made to stimulate new cartilage growth.

Hip dysplasia, if present, is surgically treated by a pelvic osteotomy. The periacetabular osteotomy is commonly done by reorienting the acetabulum. Osteoplasty of the femur and pelvis can be done through an open surgical dislocation of the hip, but that requires extensive soft tissue dissection and a longer recovery, so hip arthroscopy is preferred where the surgeon can reach the problem that way.

Fighters who undergo surgery for FAI have a rehabilitation protocol.  Avoid weight-bearing status for 2 to 6 weeks. Protected weight bearing is advised to prevent stress on the osteoplasty of the acetabulum and to protect the repaired labrum.

Physical therapy is started early. It begins with a passive range of motion exercises of the hip for the first 3 to 4 weeks. Weight-bearing is advanced. It is followed by an active range of motion four weeks after surgery.

After 4 to 8 weeks, strengthening exercises and gait training can begin. Between 8 to 12 weeks, therapists will stress on the recovery of complete hip strength, core strength, balance, and proprioception. After 12 weeks, they will add flexibility exercises like jogging, jumping, and agility exercises.

In the emergency department, ATLS treatment must begin. A proximal femoral fracture can bleed heavily into the thigh, and because that bleeding is internal it is easy to underestimate. Fluid replacement must start early, and blood is given if the fighter shows signs of significant blood loss.

Avoid long preoperative fasting. Fasting causes hypoglycemia, immunosuppression, and dehydration, and it promotes catabolism. Modern anesthetic practice allows clear fluids until a couple of hours before surgery and food until several hours before it; the anesthetic team sets the exact times for each patient.

Oral or intravenous analgesics are given. If pain control is not achieved, a fascia-iliac nerve block is used. Do not apply limb traction, or attempt to reduce this injury even if the injury or fall was witnessed ringside.

The treatment depends on the location of the fracture. Most fighters are operated within 48 hours.

Intracapsular Fractures can be dangerous since the vessels that supply the joint capsule can be damaged. They result in avascular necrosis of the femoral head.

The arthroplasty preferred for displaced intracapsular hip fractures is a total hip replacement (THR) or a hemiarthroplasty. For younger athletes, open reduction and internal fixation of displaced intracapsular hip fractures are considered.

Undisplaced intracapsular fractures are managed conservatively or surgically. Surgical options include fixation or arthroplasty. Fixation is thought to be preferred to arthroplasty as it preserves the native joint. Mobility and function are better. A sliding hip screw (SHS) or cannulated hip screws (CHS) are two such fixation techniques.

After surgery, protected weight-bearing is allowed to prevent fracture displacement. In arthroplasty, the risk of avascular necrosis is removed. This risk persists in those undergoing fixation.

In extracapsular fractures, fixation is the treatment of choice with intramedullary nails (IMN) and sliding hip screws (SHS).

After surgery, transfusion is considered if the hemoglobin falls far enough, or if there are symptoms of anemia like pallor and breathlessness; the surgical team sets that threshold. It is important to mobilize early. Those fighters undergoing arthroplasty can move immediately without weight restrictions. For those undergoing fixation, protected weight-bearing is advised to prevent any displacement of the fracture.

Regular intensive physiotherapy is advised to restore full mobility. Return to play is debatable and depends on the surgery and the recovery time.