Opinion piece by Eamon O Reilly - Read time 4-5 mins

It has been 3 years since I last wrote on the subject of hip injuries in GAA athletes. Over the past couple of weeks I have had more time for reading research articles and it got me thinking back to that original piece. For those of you who haven’t seen that article you can read it here. So where are we now with hip injuries in GAA? Is it still a problem? Are we doing enough about? What else can we do?

Where are we now?

Its very apparent that the problem has not gone away. This year alone there have been a number of high profile cases within GAA circles. Elite athletes who are still young men are getting hip replacements (mostly hip resurfacing- a type of replacement where the ball and socket of the hip is replaced). The higher the intensity in terms of load and competition, the more at risk one is. Some do so, clinging onto whatever game time they can get out of it, other simply so they can walk with their dog or play with their kids. This is a recently new phenomena in terms of the sheer number of high profile cases where we see this happening. Hip resurfacing is a big deal, and for young men to require this surgery is potentially life altering.

Players know that they have to push harder to reach their goal of success. They are willing to push their bodies to achieve this. Training load remains the biggest external risk factor. This hasn’t changed, and arguably this has worsened. There is still a major road block every year from December onwards. Developmental athletes are serving multiple masters. The college athletes in particular are at huge risk of overload at this time. Pre season training with intercounty coupled with Sigerson/Fitzgibbon matches. Everyone wants their piece. From my own experience, these guys are currently training with inter-county teams and only playing Fitz/Sigerson games in the majority. There just isn’t room to do much more. However these guys will still come under pressure to play pre season competitions. The start of the league overlaps with latter rounds of the university competitions. Players train, hit the gym and play multiple games per week.

Recovery between sessions does not happen and suddenly hips and groins are getting sore. At first its only after games or training. A little stiffness getting out of bed or the car. Eventually its pre training, taking a little bit of time to warm into a session. By the time it reaches mid-late February, its stiffening during the game, and by the end of the league its time to address it… but then there is club month and an upcoming intercounty championship campaign so really its never right. Oh, and you still have to keep hammering the gym, dont forget to do that! So this continues on through out the season. Down time just doesn’t happen, the more elite you get. Its not that dissimilar for club teams, with schedules to be adhered to, and each match as important as the next. The athletes body is simply not recovering.

GAA athletes are multidirectional field sport athletes, and hence train like so. From a coaching perspective, training has switched to a more small sided games (SSG) type of coaching which often involves decreasing space to increase intensity. This in turn increases the change of direction, accelerations and decelerations an athlete undertakes leading to increased load through joints. Shuttle running, consecutive day training, long journeys to a training and even surface type can exacerbate this even further.

So what about the gym? The gym plays a huge role in athletic development and as per my previous article , can contribute to differing loading patterns on an athletes hips, especially a developmental (young/ adolescent) athlete. Strength training plays a huge role in preparing athletes for battle and also in terms of injury prevention. But I do think there are changes needed here also which you will see below.

Are hip injuries still a problem?

Hip injuries are certainly still a problem. We can see from the above, our GAA schedule and training methods are still a major player in what happens these athletes. In fact how we treat them is an even bigger problem!! I read a study recently which investigated hip injuries in the US military. 60% didn’t even have a physiotherapy assessment prior to their surgery, and those that had, only had a median of two sessions.

Does this happen in Ireland. I know it does. I have had athletes tell me about consultations with surgeons where they go in with one sore hip, only to be told that their hip that isn’t sore also requires surgery! This is based entirely on imaging and not the person sitting on front of the surgeon. Its absolutely crazy in my opinion. We don’t treat scans, we treat people.

What we are seeing now?

I would be very interested to take a look at the number of guys who have gone for hip resurfacing. My hunch is, that the vast majority of athletes who have to go down this route have had at least one hip scope prior to this surgery and that this is a causative factor in the need for athletes to require hip resurfacing surgery.

Why? In order to undergo any hip surgery you cut through your dynamic stabilisers (the muscles that stabilise your hip). In my experience, these very muscles are the very muscles that are the root cause of most hip issues. I don’t deny that imaging may show a cam/pincer (different types of hip shapes), but in my experience it is almost ALWAYS a hip control issue in addition to excessive training load that leads to pain.

Post hip scope surgery, not only have you very poor dynamic stabilisers, but now your static stabilisation system (ligaments and capsule) have also been affected, so both systems are now hugely reduced. While guys may get some short term relief from surgery, over time I think their hip is deteriorating quicker as they continue to play. This is due to the affects of destabilising both of these systems through surgery. I would love to see an independent long term study in field sports athletes when they have hip pain (pre surgery) and compare the guys who go down the rehab route and those who go down the surgical route 5-10 years down the line. I am convinced that those who go for surgery will be those who are more likely to have progressed to a hip replacement.

There are studies like the Kemp et al study below which show the prevalence of hip arthritis in those patients who undergo hip scope surgery to be as high as 37%. The question therefore is, what happens the athletes who rehab instead of surgery and continue to play? This is less clear. The clear answer to either scenario- > stop athletes getting to this point in the first place.

Note: There are guys reading this, who went for surgery and are doing really well since. That’s absolutely fantastic, I really hope it continues that way. I am writing this article with an overall view on what I see in GAA rather than on an individual basis. I think those with issues will massively outnumber those who don’t.

So why do athletes go for surgery? Alot of the time imaging is the determining factor. Athletes are told, if you don’t go for this, you will need a hip replacement within x number of years etc. I don’t buy this, as I see these guys too and I also see their scans that lead to a surgical decision. More often than not, they can be rehabbed. A study I was involved in from SSC in 2018 tells me they can! Research also tells us that postoperatively there is also a high chance of osteoarthritis post surgery - most likely due to the systems failure mentioned above. A study by Rhon et al(2019) last year told us they saw this after just two years post surgery.

Failed physiotherapy is another reason why these athletes end up in front of a surgeon. There is no doubt that those of us treating hip/groin patients through rehabilitation also need to look in the mirror. Far too often I meet patients who have been ‘rehabbing’ and the sole rehab modality has been a ‘rest it & cardio on the bike type’ approach. This is simply not going to work with an issue like this. You need to address the full range of deficits an athlete has, to fix this issue (strength, control, mechanics etc). The ‘rest’ approach is not physiotherapy so if this is all you have done, you haven’t failed physiotherapy, you have failed rest!

There is another approach that athletes need to be wary of. This is the guru!! The guru claims to have all the answers, and guess what - He can do it in a session or two max or just by looking at you squat! Chronic groin/hip pain does not go away in a 45-60 minute session. These guys really irk me, especially as its a quick sell/fix type approach, playing on an athlete’s emotion and desire to return to play in order to further themselves. That is not why we get into this profession…It will take a lot of work by the athlete and it will also take discipline on return to play, with load modification a must.

What else can we do?

The answer for me lies in education - Coaches, parents and players.

Coaches

1. Limit or spread out the amount of small sided training games you do (tackle box type drills) and avoid shuttle running.

2. . This is especially important on astro or hard pitches in the summer.

3. Appropriate recovery between sessions. If you have athletes who have played the day before (school/college etc) - limit their session. If they have played that day - they should not be training - Look after your athletes.

4. If your player is injured - do not expect them to play through it. This is especially important with developmental athletes.

Parent & Athletes

1. Its important you know what load management looks like- how many sessions is appropriate in a week? Is there adequate recovery?

2. Take ownership of what you take part in and what you miss on a given week.

Strength Coaches - From a hip point of view, there are a number of factors that could (should) be implemented to decrease hip injury risk.

1. Squatting - I know there will be those that disagree with me here, but I simply do not see the risk-reward advantages of anyone back squatting (loaded) below parallel. The weight going through the hip joints are going to contribute to morphological changes (studies show us this in a range of sports) and cause heavy loads through the joint over time. There are better ways to achieve this, namely a hex bar deadlift.

2. Single leg control - This is paramount

3. Specific Hip control exercise - Both pre training and pre gym

4. Coaching running mechanics - straight and multidirectional is especially important with younger athletes.

5. Look at the system as a whole, identify deficits and deal with them- Lumbopelvic control, calf strength, ankle stiffness etc

The GAA is a complex organisation in terms of player demands and the calendar represents one way administrators can impact positively on this. This is one of the biggest changes players need to alleviate load management issues. This is certainly something I would love to see happen over the coming years so as many people get to play the sport for as long as they want to play.

I really hope I am writing about this topic again in another 3 years, in a much more positive light.

About the author:

Eamon currently has worked as an intercounty physiotherapist for 10 years. He is also a current serving member on the GAA’s national medical, scientific and welfare committee. He also serves on the sports science expert group for the GAA. Prior to founding SPARC, he worked in the Sports Surgery clinic. He was clinical lead for Hip/Groin, dealing with a range of complex chronic athletic injuries around the hip including recurrent hamstring issues, lower back, abdominal and hip/groin issues.

If you would like more information from current research please take a look at the below papers on which my opinion is based.

Agricola R, Weinans H. Femoroacetabular impingement: what is its link with osteoarthritis? British journal of sports medicine 2015.

Bardakos NV, Villar RN. Predictors of progression of osteoarthritis in femoroacetabular impingement: a radiological study with a minimum of ten years follow-up. The Journal of bone and joint surgery British volume 2009;91(2):162-9.

Reiman MP, Thorborg K. Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? British journal of sports medicine 2015;49(12):782-4.

Collins JA, Ward JP, Youm T. Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review. Am J Sports Med 2014;42: 3009–15

Farrell G, McGrath F, Hogan B et al (2016) 95% prevalence of abnormality on hip MRI in elite academy level rugby union: A clinical and imaging study of hip disorders. J Sci Med Sport. 2016 Nov;19(11):893-897

Gallo RA, Silvis ML, Smetana B, et al. Asymptomatic hip/groin pathology identified on magnetic resonance imaging of professional hockey players: outcomes and playing status at 4 years' follow-up. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2014;30(10):1222-8.

Tak I, Weir A, Langhout R, et al. The relationship between the frequency of football practice during skeletal growth and the presence of a cam deformity in adult elite football players. British journal of sports medicine 2015;49(9):630-4.

Register B, Pennock AT, Ho CP, et al. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. The American journal of sports medicine 2012;40(12):2720-4.

Ross JR, Nepple JJ, Philippon MJ, et al. Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. The American journal of sports medicine 2014;42(10):2402-9.

Griffin DR, Dickenson EJ, O’Donnell J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome):
an international consensus statement. Br J Sports Med 2016;50:1169–1176. 

Reiman, M. P., Agricola, R., Kemp, J. L., Heerey, J. J., Weir, A., Van Klij, P., Kassarjian, A., Mosler, A. B., Ageberg, E., Hölmich, P., Warholm, K. M., Griffin, D., Mayes, S., Khan, K. M., Crossley, K. M., Bizzini, M., Bloom, N., Casartelli, N. C., Diamond, L. E., ... Dijkstra, H. P. (Accepted/In press). Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018. British journal of sports medicine, [101453]. https://doi.org/10.1136/bjsports-2019-101453

Joanne L. Kemp, PT, PhD,corresponding author Kay M. Crossley, PT, PhD, Rintje Agricola, MD, PhD, Fenna Geuskens,2 and Marienke van Middelkoop, (2018) RADIOGRAPHIC HIP OSTEOARTHRITIS IS PREVALENT, AND IS RELATED TO CAM DEFORMITY 12-24 MONTHS POST-HIP ARTHROSCOPY PhD2Int J Sports Phys Ther. 2018 Apr; 13(2): 177–184.

Enda King,1,2 Andrew Franklyn-Miller,1,3 Chris Richter,1 Eamon O’Reilly,1 Mark Doolan,1 Kieran Moran,4,5 Siobhan Strike,2 Éanna Falvey1,6 Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients -Br J Sports Med 2018;52:1054–1062.