So you are an athlete with groin pain? Keyhole hip surgery is one solution

by Richard Villar, BSc MA MS FRCS

Dubai UAE, November 11, 2015: Sometimes I despair. I mean who designed the human hip? From wherever it appeared, the hip joint must surely be one of the most common reasons for athletes to not fulfil their potential.

It starts with the shape of the ball, the hip being what the anatomists describe as a ball-and-socket design. You might imagine that each of us would have a perfectly round ball positioned carefully within a perfectly matching socket. Yet that actually happens infrequently. The round ball is so often shaped like a pear, so when the hip moves, instead of movement being full and unrestricted, the flatter portion of the pear strikes against the edge of the socket. This process is called “impingement” and is enormously common. Actually the correct term is “femoroacetabular impingement”. That is such a mouthful that even the medics cannot say it, so generally this is called FAI. The condition can lead to the tearing of a cartilage-like structure on the edge of the hip socket - the labrum - and from there arthritis is said to develop. No wonder athletes are worried by this diagnosis and no wonder some truly famous names have been forced to give up sport thanks to the effects of FAI.

For those of us who spend our time dealing with the athletes of the world - and I am blessed by such a privilege - it does not take long to realise how inefficient our hips can be. FAI is incredibly common. For many the first sign of hip trouble can be a dull ache in the groin or maybe thigh, not always during exercise but often shortly afterwards. Frequently this will be diagnosed as a groin strain, appropriate treatment administered and yet the wretched thing will simply not go away. Days pass, then weeks, then months, occasionally even years and slowly the once proficient athlete finds their talent steadily slipping away.

Sometime later, into my consulting room they come. If an X-ray has not been taken, we do it then. The same applies to an MRI scan. Both those investigations are very helpful when deciding what to do. The end point is not always surgery, as rehabilitation under the keen eye of an experienced physiotherapist can so often settle a patient’s symptoms. Yet however capable the physiotherapy provision, it is simply not possible by such means to alter the shape of the ball. Consequently, if symptoms have reached a point when sport is being compromised, surgery - keyhole surgery - is sometimes suggested.

Keyhole surgery of the hip may sound simple but sadly it is not. The ability to enter into a hip joint with a small viewing instrument, the same as might be used for the knee or shoulder, can take many years to develop. There are plenty of traps for the unwary, so good training, decent experience, and regular updating are essential. The technique is not available everywhere but specialist units do exist and it is worth hunting those down. Do remember that the athlete with a pear-shaped hip ball does not always require surgery. Conservative therapy is a perfectly reasonable first step. After all, surgery is often followed by a period on crutches anyway, combined with plenty of rehabilitation, and it can be quite some months before full sporting potential can be regained. 

So how long does it take to return to sport after this surgery? Take the Olympic Games as an example. At the last Games there were five patients from one Olympic team on whom we had performed keyhole hip surgery and who subsequently won a medal. We tried not to operate on any athlete for a good year before the event although one did stagger in to my office in the January of that year, utterly unable to run a solitary step. Forced into undertaking surgery despite our worries, the athlete did us proud, and made it to the finals by August. Sadly, a medal was missed by a whisker.

How about the ballerina from a world-renowned ballet company on whom we performed keyhole hip surgery not so long ago? If any career is designed to stress the human hip, ballet must surely be it. In this case it was 22 weeks from surgery to being back on stage. Try watching the performance as the surgeon - I did - and all I could see in my mind were stitches pinging and popping everywhere. Yet I need not have worried. The performance was immaculate, the hip truly astounding, and I realised by the end of the evening that there had been no need to hold my head in my hands throughout.

Yet what both these cases demonstrate is that the decision to operate should not be taken easily and that a patient will be looking towards at least six months before they can return to full potential. They will appear to recover from surgery quite quickly and to the world they will appear fine. However, for a hip to take the thumps and bumps of professional sport it must be truly resilient. That simply takes time. Yet, when sporting prowess begins to fade, a little time is perhaps worth investing. Keyhole hip surgery is there, ready and waiting, and may just be appropriate for you.