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Editorial Commentary: Return to Sport: An Ill-Defined Parameter
Editorial Commentary: Return to Sport: An Ill-Defined Parameter Jonathan Robinson, M.D., Nicola C. Casartelli, Ph.D., and Michael Leunig, M.D.
Abstract: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and dysfunction in athletes, which can impair their ability to perform and compete in sports. Hip arthroscopy has become a popular and successful treatment option for the management of FAIS and the return to sport (RTS) of athletes. The concept of RTS has evolved in the last years. Various different factors need to be considered when evaluating RTS after hip arthroscopy for FAIS, such as (1) the definition of RTS (return to participation, RTS, return to performance), (2) the sport type (high-impact vs lowimpact) and sport level (professional vs recreational), and (3) the time to follow-up evaluation. In addition, return to high-impact sports, such as soccer, might not be the best recommendation for some patients undergoing hip arthroscopy for FAIS, as it may accelerate the degeneration of the hip joint. Future research should consider all these aspects of the RTS outcome after hip arthroscopy for FAIS. Valid RTS rates are of utmost importance to provide adequate expectations to patients and to guide decision-making of hip surgeons.
See related article on page 442
F
emoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and dysfunction in athletes, which can significantly limit their ability to perform and compete in sports. Hip arthroscopy has become a popular and successful treatment option for the management of FAIS in both the general and athletic populations, showing favorable results and greater than 90% survivorship.1 The participation in highimpact sports, with cutting and change of direction, such as soccer, seem to increase the risk of FAIS by predisposing the development of underlying cam morphology through high shear stress applied to the femoral head during skeletal development and also by inducing repetitive rotational loads about the hip joint through sport-specific movements.2-4 A systematic review from our institution published in 2015 reported that 87% of athletes returned to sport after hip arthroscopy for FAIS, with 82% of athletes returning to the same preinjury sport level.5 Nevertheless, the concept of return to sport (RTS) has evolved in the last
New York, New York The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/191228/$36.00 https://doi.org/10.1016/j.arthro.2019.10.012
450
years. Today, we appreciate that various different factors need to be considered when evaluating RTS after hip arthroscopy for FAIS, such as (1) the definition of RTS, 2) the type and level of sport, (3) the time to follow-up evaluation, and (4) psychosocial and socioeconomic issues, including time, motivation, and resources.6,7 The rate of RTS significantly depends on its definition. RTS can be defined as (1) return to participation in any sport, (2) return to the same sport at any level and any performance, (3) return to the same sport level at any performance, and (4) return to same sport level and same performance. Until recently, RTS after hip arthroscopy for FAIS has been mainly evaluated as a binary outcome (returned to sport vs not returned to sport) rather than as a continuum, as suggested by Arden et al. in the “2016 Consensus Statement on Return to Sport.”8 The binary outcome approach generally considered RTS as a return to sport participation, without differentiating between the type of sport, the sport level, and sport performance. This approach probably led to misleading and overoptimistic results, which caused excessively high expectations in athletes before hip surgery for FAIS. The rate of RTS after hip surgery for FAIS also seems to be influenced by the type of sport played by the athletes. Trends of lower RTS rates were observed in athletes participating in contact versus noncontact
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 36, No 2 (February), 2020: pp 450-452
451
EDITORIAL COMMENTARY
sports.7 Interestingly, recreational athletes seem to be willing to modify their sport participation habits following hip surgery. Naal et al.9 reported that recreational athletes with FAIS participating in high-impact sports changed to low-impact sports following hip surgery. Moreover, recreational athletes usually demonstrate a lower RTS rate as compared with professional athletes.10 This is likely explained by the fact that professional athletes have (1) more time to dedicate to the rehabilitation process, (2) direct and indirect financial interests, and (3) social pressure from the team.11-13 In addition, it has been reported that rates of RTS after hip arthroscopy changes over time, with lower rates in the first year after surgery, probably due to the long rehabilitation process, and at follow-up longer than 3 years, likely because of persistent hip pain.7 It was with great interest I read the article entitled “Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up”14 by Ortiz-Declet, Yuen, Schwarzman, Chen, Perets, and Domb. We commend the authors for having investigated RTS in an important group of athletes, who frequently present with FAIS, have to undergo hip surgery, but might not have the time, financial, and social resources to successfully return to play soccer. In this small case series, Ortiz-Declet et al. reported a return to soccer at any level of 79%, and at the same level of 55%.14 These results are comparable with previous works, which also reported rates ranging between 49% and 57% for return to the same preinjury sport and sport level.6,7 However, previous studies indicated that only approximately one fifth (17%-21%) of athletes after hip arthroscopy for FAIS returned to the same sport with optimal performance and full sport participation. Interestingly, a very high proportion of patients in the case series of Ortiz-Declet et al. (78%) reported their athletic ability to be the same or greater than within 1 year before surgery, regardless of the sport and sport level to which they returned. In this context, it is important to consider that within 1 year before hip surgery, most of the patients likely experienced hip symptoms and dysfunction that significantly impaired their athletic ability. As an alternative, the evaluation of sport participation and athletic ability of patients before the onset of hip pain and symptoms related to FAIS appears more adequate. Return to high-impact sports, such as soccer, might, however, not be the best recommendation for some patients who undergo hip-preservation surgery for FAIS. In some young athletes, FAIS already presents with significant hip degenerative damages that cannot be fully addressed with hip arthroscopy. In patients with significant cartilage damage, modifying activity with lower-impact sports would be the best medical advice for the health and survival of the native hip. In these patients, high-impact sports would potentially
accelerate the degeneration of the hip joint. However, in professional athletes changing their activity level can prove difficult, as a change to lower-impact sports and activity level may be associated with the end of their careers. The assessment of RTS after hip surgery for FAIS is fairly complex and should consider different factors that can strongly influence the RTS rates, including the recommendation to not RTS. Therefore, it is important that in future studies the continuum of RTS (return to participation, sport, and performance) will be used, and that the effect of sport type, sport level, and changes in RTS rate over time will be considered. Valid RTS rates are of utmost importance to provide adequate expectations to patients and to guide decision-making of hip surgeons.
References 1. Nwachukwu BU, Rebolledo BJ, McCormick F, Rosas S, Harris JD, Kelly BT. Arthroscopic versus open treatment of femoroacetabular impingement: A systematic review of medium-to long-term outcomes. Am J Sports Med 2016;44: 1062-1068. 2. Agricola R, Bessems JHJM, Ginai AZ, et al. The development of cam-type deformity in adolescent and young male soccer players. Am J Sports Med 2012;40:1099-1106. 3. Agricola R, Heijboer MP, Ginai AZ, et al. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: A prospective study with minimum 2-year follow-up. Am J Sports Med 2014;42:798-806. 4. Nawabi DH, Bedi A, Tibor LM, et al. The demographic characteristics of high-level and recreational athletes undergoing hip arthroscopy for femoroacetabular impingement: A sports-specific analysis. Arthroscopy 2014;30: 398-405. 5. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: A systematic review. Br J Sports Med 2015;49: 819-824. 6. Wörner T, Thorborg K, Stålman A, Webster KE, Momatz Olsson H, Eek F. High or low return to sport rates following hip arthroscopy is a matter of definition? Br J Sports Med 2018;52:1475-1476. 7. Ishoi L, Thorborg K, Kraemer O, et al. Return to sport and performance after hip arthroscopy for femoroacetabular impingement in 18- to 30-year-old athletes: A crosssectional cohort study of 189 athletes. Am J Sports Med 2018;46:2578-2587. 8. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50:853-864. 9. Naal FD, Schär M, Miozzari HH, et al. Sports and activity levels after open surgical treatment of femoroacetabular impingement. Am J Sports Med 2014;42:1690-1695. 10. Malviya A, Paliobeis CP, Villar RN. Do professional athletes perform better than recreational athletes after
452
EDITORIAL COMMENTARY
arthroscopy for femoroacetabular impingement? Clin Orthop Relat Res 2013;471:2477-2483. 11. Reiman MP, Peters S, Sylvain J, Hagymasi S, Mather RC, Goode AP. Femoroacetabular impingement surgery allows 74% of athletes to return to the same competitive level of sports participation but their level of performance remains unreported: A systematic review with metaanalysis. Br J Sports Med 2018;52:972-981. 12. Rosinsky PJ, Chen SL, Domb BG. Editorial Commentary: returning to high-impact sports after hip arthroscopy: Are
we shooting ourselves in the hip? Arthroscopy 2019;35: 1429-1431. 13. Jack RA 2nd, Sochacki KR, Hirase T, Vickery JW, Harris JD. Performance and return to sport after hip arthroscopy for femoroacetabular impingement in professional athletes differs between sports. Arthroscopy 2019;35:1422-1428. 14. Ortiz-Declet V, Yuen LC, Schwarzman G, Chen AW, Perets I, Domb BG. Return to play in amateur soccer players undergoing hip arthroscopy: Short-to mid-term follow-up. Arthroscopy 2020;36:442-449.
Abstract: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and dysfunction in athletes, which can impair their ability to perform and compete in sports. Hip arthroscopy has become a popular and successful treatment option for the management of FAIS and the return to sport (RTS) of athletes. The concept of RTS has evolved in the last years. Various different factors need to be considered when evaluating RTS after hip arthroscopy for FAIS, such as (1) the definition of RTS (return to participation, RTS, return to performance), (2) the sport type (high-impact vs lowimpact) and sport level (professional vs recreational), and (3) the time to follow-up evaluation. In addition, return to high-impact sports, such as soccer, might not be the best recommendation for some patients undergoing hip arthroscopy for FAIS, as it may accelerate the degeneration of the hip joint. Future research should consider all these aspects of the RTS outcome after hip arthroscopy for FAIS. Valid RTS rates are of utmost importance to provide adequate expectations to patients and to guide decision-making of hip surgeons.
See related article on page 442
F
emoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and dysfunction in athletes, which can significantly limit their ability to perform and compete in sports. Hip arthroscopy has become a popular and successful treatment option for the management of FAIS in both the general and athletic populations, showing favorable results and greater than 90% survivorship.1 The participation in highimpact sports, with cutting and change of direction, such as soccer, seem to increase the risk of FAIS by predisposing the development of underlying cam morphology through high shear stress applied to the femoral head during skeletal development and also by inducing repetitive rotational loads about the hip joint through sport-specific movements.2-4 A systematic review from our institution published in 2015 reported that 87% of athletes returned to sport after hip arthroscopy for FAIS, with 82% of athletes returning to the same preinjury sport level.5 Nevertheless, the concept of return to sport (RTS) has evolved in the last
New York, New York The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2019 by the Arthroscopy Association of North America 0749-8063/191228/$36.00 https://doi.org/10.1016/j.arthro.2019.10.012
450
years. Today, we appreciate that various different factors need to be considered when evaluating RTS after hip arthroscopy for FAIS, such as (1) the definition of RTS, 2) the type and level of sport, (3) the time to follow-up evaluation, and (4) psychosocial and socioeconomic issues, including time, motivation, and resources.6,7 The rate of RTS significantly depends on its definition. RTS can be defined as (1) return to participation in any sport, (2) return to the same sport at any level and any performance, (3) return to the same sport level at any performance, and (4) return to same sport level and same performance. Until recently, RTS after hip arthroscopy for FAIS has been mainly evaluated as a binary outcome (returned to sport vs not returned to sport) rather than as a continuum, as suggested by Arden et al. in the “2016 Consensus Statement on Return to Sport.”8 The binary outcome approach generally considered RTS as a return to sport participation, without differentiating between the type of sport, the sport level, and sport performance. This approach probably led to misleading and overoptimistic results, which caused excessively high expectations in athletes before hip surgery for FAIS. The rate of RTS after hip surgery for FAIS also seems to be influenced by the type of sport played by the athletes. Trends of lower RTS rates were observed in athletes participating in contact versus noncontact
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 36, No 2 (February), 2020: pp 450-452
451
EDITORIAL COMMENTARY
sports.7 Interestingly, recreational athletes seem to be willing to modify their sport participation habits following hip surgery. Naal et al.9 reported that recreational athletes with FAIS participating in high-impact sports changed to low-impact sports following hip surgery. Moreover, recreational athletes usually demonstrate a lower RTS rate as compared with professional athletes.10 This is likely explained by the fact that professional athletes have (1) more time to dedicate to the rehabilitation process, (2) direct and indirect financial interests, and (3) social pressure from the team.11-13 In addition, it has been reported that rates of RTS after hip arthroscopy changes over time, with lower rates in the first year after surgery, probably due to the long rehabilitation process, and at follow-up longer than 3 years, likely because of persistent hip pain.7 It was with great interest I read the article entitled “Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up”14 by Ortiz-Declet, Yuen, Schwarzman, Chen, Perets, and Domb. We commend the authors for having investigated RTS in an important group of athletes, who frequently present with FAIS, have to undergo hip surgery, but might not have the time, financial, and social resources to successfully return to play soccer. In this small case series, Ortiz-Declet et al. reported a return to soccer at any level of 79%, and at the same level of 55%.14 These results are comparable with previous works, which also reported rates ranging between 49% and 57% for return to the same preinjury sport and sport level.6,7 However, previous studies indicated that only approximately one fifth (17%-21%) of athletes after hip arthroscopy for FAIS returned to the same sport with optimal performance and full sport participation. Interestingly, a very high proportion of patients in the case series of Ortiz-Declet et al. (78%) reported their athletic ability to be the same or greater than within 1 year before surgery, regardless of the sport and sport level to which they returned. In this context, it is important to consider that within 1 year before hip surgery, most of the patients likely experienced hip symptoms and dysfunction that significantly impaired their athletic ability. As an alternative, the evaluation of sport participation and athletic ability of patients before the onset of hip pain and symptoms related to FAIS appears more adequate. Return to high-impact sports, such as soccer, might, however, not be the best recommendation for some patients who undergo hip-preservation surgery for FAIS. In some young athletes, FAIS already presents with significant hip degenerative damages that cannot be fully addressed with hip arthroscopy. In patients with significant cartilage damage, modifying activity with lower-impact sports would be the best medical advice for the health and survival of the native hip. In these patients, high-impact sports would potentially
accelerate the degeneration of the hip joint. However, in professional athletes changing their activity level can prove difficult, as a change to lower-impact sports and activity level may be associated with the end of their careers. The assessment of RTS after hip surgery for FAIS is fairly complex and should consider different factors that can strongly influence the RTS rates, including the recommendation to not RTS. Therefore, it is important that in future studies the continuum of RTS (return to participation, sport, and performance) will be used, and that the effect of sport type, sport level, and changes in RTS rate over time will be considered. Valid RTS rates are of utmost importance to provide adequate expectations to patients and to guide decision-making of hip surgeons.
References 1. Nwachukwu BU, Rebolledo BJ, McCormick F, Rosas S, Harris JD, Kelly BT. Arthroscopic versus open treatment of femoroacetabular impingement: A systematic review of medium-to long-term outcomes. Am J Sports Med 2016;44: 1062-1068. 2. Agricola R, Bessems JHJM, Ginai AZ, et al. The development of cam-type deformity in adolescent and young male soccer players. Am J Sports Med 2012;40:1099-1106. 3. Agricola R, Heijboer MP, Ginai AZ, et al. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: A prospective study with minimum 2-year follow-up. Am J Sports Med 2014;42:798-806. 4. Nawabi DH, Bedi A, Tibor LM, et al. The demographic characteristics of high-level and recreational athletes undergoing hip arthroscopy for femoroacetabular impingement: A sports-specific analysis. Arthroscopy 2014;30: 398-405. 5. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: A systematic review. Br J Sports Med 2015;49: 819-824. 6. Wörner T, Thorborg K, Stålman A, Webster KE, Momatz Olsson H, Eek F. High or low return to sport rates following hip arthroscopy is a matter of definition? Br J Sports Med 2018;52:1475-1476. 7. Ishoi L, Thorborg K, Kraemer O, et al. Return to sport and performance after hip arthroscopy for femoroacetabular impingement in 18- to 30-year-old athletes: A crosssectional cohort study of 189 athletes. Am J Sports Med 2018;46:2578-2587. 8. Ardern CL, Glasgow P, Schneiders A, Witvrouw E, Clarsen B, Cools A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016;50:853-864. 9. Naal FD, Schär M, Miozzari HH, et al. Sports and activity levels after open surgical treatment of femoroacetabular impingement. Am J Sports Med 2014;42:1690-1695. 10. Malviya A, Paliobeis CP, Villar RN. Do professional athletes perform better than recreational athletes after
452
EDITORIAL COMMENTARY
arthroscopy for femoroacetabular impingement? Clin Orthop Relat Res 2013;471:2477-2483. 11. Reiman MP, Peters S, Sylvain J, Hagymasi S, Mather RC, Goode AP. Femoroacetabular impingement surgery allows 74% of athletes to return to the same competitive level of sports participation but their level of performance remains unreported: A systematic review with metaanalysis. Br J Sports Med 2018;52:972-981. 12. Rosinsky PJ, Chen SL, Domb BG. Editorial Commentary: returning to high-impact sports after hip arthroscopy: Are
we shooting ourselves in the hip? Arthroscopy 2019;35: 1429-1431. 13. Jack RA 2nd, Sochacki KR, Hirase T, Vickery JW, Harris JD. Performance and return to sport after hip arthroscopy for femoroacetabular impingement in professional athletes differs between sports. Arthroscopy 2019;35:1422-1428. 14. Ortiz-Declet V, Yuen LC, Schwarzman G, Chen AW, Perets I, Domb BG. Return to play in amateur soccer players undergoing hip arthroscopy: Short-to mid-term follow-up. Arthroscopy 2020;36:442-449.