So there I was, at the top of the Easy Money trail at Bridger Bowl, on a beautiful, crisp January morning without a cloud in the sky. The sun had just cleared the horizon, and I had a beautiful view of the Castle Mountains in the distance. It was cold but not bitterly so, and I had somehow found the perfect layering of clothes that kept me warm, but not too warm, on the ride up Bridger lift. A storm front had moved through the area overnight and left us with 6 inches of fresh powder. I was feeling good that day, and it was one of those days where you’re reminded that it’s just good to be alive. I had been having some soreness in my right hip that came and went but was never really anything to slow me down. If I had to characterize it, I would say it was primarily positional with more pain in positions of high flexion, like with prolonged sitting and deep squats in the gym. Sometimes, I even had a catching sensation or a popping. “Give it some time,” I thought. “It will go away,” I thought. As I left the top of Easy Money, I will admit things got away from me a bit. We all have that comfort zone heading down the mountain in terms of speed, and when we get out of that comfort zone, that’s when accidents happen. Well, I must have been going light speed that day, and when I tried to slow down, I caught my ski going over a hidden bump. I felt my knees being violently thrust into my chest with my hips in deep flexion. At that moment, I had a sharp pain in my right hip. I managed to make it down the mountain but decided that maybe that would do it for the black diamond skiing for the day. Besides, I rationalized, I should spend more time with my sons who were over on Moose Meadows. After that day, my hip really began to bother me. My symptoms were more consistent and prevented me from doing what I liked to do in life. Finally, I could ignore this no more. I needed some help.
The above description is a common mechanism for a sports hip injury, and an accurate diagnosis might have eluded us 10 or 15 years ago. However, our understanding of sports injuries involving the hip joint has increased exponentially over that time frame. The hip joint is a true ball-in-socket joint that is made of the top of the thigh bone, or femur, and the socket which is part of the pelvis, specifically, the acetabulum. The acetabulum has fibrocartilaginous ring which surrounds it like a gasket called the labrum. The labrum serves to deepen the socket, increase coverage of the femoral head, and create a negative-pressure suction seal that increases stability of the joint. There are ligaments that cross the joint as well that aid in stability.
There is a condition called femoroacetabular impingement, or FAI, that we have only just begun to appreciate. It occurs when the hip joint flexes up, and the femur impinges, or strikes, the lip of the acetabulum. This usually occurs because of a developmental problem resulting in an abnormal shape of the femur or the acetabulum. We think this happens around the age of 12 to 14 years when the growth plate of the femur closes. To keep it simple, imagine having a “bump” of extra bone on the neck of the femur which should not be there. When the hip flexes, this “bump” strikes the labrum and the rim of the acetabulum. There is a physical shape mismatch, like trying to fit a square peg into a round hole. This can cause a labral tear and an injury to the cartilage which lines the acetabulum. The other common scenario occurs when the acetabulum faces slightly backward instead of slightly forward. This makes the front rim of the acetabulum more prominent. This prominence can impinge on the neck of the femur with high degrees of hip flexion. Further, both conditions can often occur simultaneously in FAI. As a result of this abnormal contact, FAI leads to cartilage damage in the joint and subsequently is the most common cause of arthritis in the hip for this very reason.
The treatment for FAI in its early stages in patients who fail non-operative treatment is a surgery to remove the “bump” on the femur, correct any bony issues with the rim of the acetabulum, and repair the labrum. Innovations in surgical equipment and techniques now allow this surgery to be performed via a minimally invasive technique with three small “poke” holes using an arthroscope, a small camera that allows us to see and work inside the joint without a large, open incision. The recovery via this minimally invasive technique is much faster and with much less pain versus open hip surgery. In fact, most patients are off any strong narcotic pain medicine within 3 days of surgery. Patients are usually on crutches for 3 weeks after the surgery with partial weightbearing to protect the repair during the healing phase. There is physical therapy as well, usually once or twice a week for the first few months. Most patients are able to return to sport in 4 – 6 months.
The clinical outcomes of this cutting-edge surgery have been very good when performed for the appropriate indications. All of the current data is short term in nature, because this diagnosis is relatively new and the treatment techniques are being refined. That said, there are multiple studies which show 80% good-to-excellent outcomes with one study specifically on intercollegiate athletes demonstrating a 90% return to sport rate.
As we move into the busy ski season, hip injuries will inevitably occur. Every injury does not require surgery. Most do not. However, the good news is that for those sports hip injuries that do require surgery, there is a minimally invasive hip surgery which has been shown to have high success rates. If you have a hip condition stopping you from ripping it, look for a surgeon with specialty training in hip arthroscopy.