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Hip injuries on the rise around MLB

Hip injuries on the rise around MLB

PHILADELPHIA -- Mike Lowell followed the Marlins' strength and conditioning programs religiously.

He worked out properly.

He stretched properly.

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But late in the season he felt tightness in his right groin. Nobody could figure out why exactly because he had completed every program asked of him. But regardless of how hard he worked, the groin always tightened.

Lowell, who played for the Marlins from 1999-2005 before he joined the Red Sox in 2006, learned later he had a torn labrum in his hip and required surgery.

He is not alone. Hip injuries have been diagnosed more frequently in Major League Baseball. Lowell, who had successful surgery to repair the labrum Oct. 20, 2008, is one of several notable players who have had hip surgeries in recent months. Others include Yankees third baseman Alex Rodriguez, Phillies second baseman Chase Utley, Mets first baseman Carlos Delgado and Royals third baseman Alex Gordon. Phillies pitcher Brett Myers had successful hip surgery Thursday.

"You know, Tommy John got a surgery named after him. I think they should name this one after me," Lowell joked.

But why all the hip injuries all of a sudden?

"I think the main reason is improved recognition of the pathology," said orthopedic surgeon and hip specialist Bryan T. Kelly, who peformed Myers' surgery at the Hospital for Special Surgery in New York. "They were treated with rest and anti-inflammatories, and they would get persistent problems with it. Now we're beginning to recognize that a lot of problems that seem to be muscle strains or muscle pulls are ending up these [hip] problems."

"Are these injuries occurring more frequently or are we just more aware of them and more precise at diagnosing them and treating them?" said Phillies team physician Michael Ciccotti, who is intimately familiar with hip injuries because of Utley and Myers. "It could be a combination of both of those. To answer that question, you really need to have an understanding of the injury."

WHAT IS IT?

The hip joint is a ball in a socket. The socket has a fibrous rim called the labrum. The labrum is like an inner tube on a bike wheel.

"It's soft, kind of firm, rubbery," Ciccotti said.

There are ligaments that stabilize the hip and a thin membrane called the capsule, which sheathes the entire joint. Then there are the massive muscles that motor the leg and stabilize the body.

Elite athletes put tremendous force through their hip joint, which is why injuries can occur. The hip can become injured when the labrum becomes frayed, torn or detached; when the smooth cartilage coating inside the joint becomes damaged; or when bony spurs develop on the ball or the socket.

"There may also be some bony alterations," Ciccotti said.

That is called femoroacetabular impingement, which means there is a slight change in the bony form of the hip joint.

"Some of these elite-level athletes might have some sudden event, they might twist or fall abruptly, but they might also have this femoroacetabular impingement that might predispose them to it," Ciccotti said.

Athletes often complain of anterior hip pain or groin pain. They will mention locking or clicking or catching or giving out, which is what Myers described before he learned he needed surgery.

Gordon said his injury came up gradually.

"I kept trying to play and it just got worse and worse," he said. "I could have played with it. I was playing with it. But just every play, everything I did was painful. So the games were not fun. When I'd go in the dugout, I'd try to go in and fix it -- I wasn't even in the dugout. So I thought to myself, 'Can I do this for 162 games? Is it worth it? Or should I try to get it fixed and come back healthy?'"

Gordon, like the others, chose to get it fixed.

THE SURGERY

Gordon might not have been so lucky had he played 20 years ago.

"Accessing the hip joint to treat some of these bone spurs was too dangerous because the surgery was worse than the disease," Kelly said. "Over the last 10 years arthroscopic approaches to this have become more accessible. More training is being done. We have better tools and instrumentations that are allowing us into the joint, so a lot of these procedures that weren't done at all because they were too dangerous or done only by a few people because the surgeries were too big and people didn't want to do it, are being done with more frequency and more safely."

The gains in these surgeries have proven to be remarkably effective in the short-term.

"We have short-term results that are very promising," Ciccotti said. "You just have to go to Citizens Bank Park to see Chase back on the field. He had his surgery in November. You have Mike Lowell back. You have A-Rod. The long-term results, meaning two years, five years, 10 years down the road, they're not available yet. We have to see what happens. We're returning these athletes to the same high-level forces that actually cause the injury. We're making them whole again to do the activity that probably led to the injury in some degree."

But right now, like Ciccotti said, the short-term results are promising. Players know it, too.

"I talked to both of those guys [Lowell and Utley] prior to making the decision of doing this intermediate surgery," Rodriguez said last month. "I've been following them closely and it seems like both of those guys have been doing very well. I've been staying in touch with Utley a little bit, so I'm encouraged."

PREVENTION

Nobody really is certain why these injuries happen, but there are theories.

It could be changes in technique. Athletes could be doing something differently than in the past, although baseball hasn't changed dramatically over the last 20 years.

It could be equipment. The mound. Shoes. Field surface. But again, those things have not changed dramatically over the years.

It could be training techniques.

"Some physicians have suggested that it's because we've focused on other areas," Ciccotti said. "So much was focused on the ACL that we've come up with techniques to strengthen quads and hamstrings and calf muscles. May we be doing that in such a way that it predisposes the joint next door, which is the hip joint? That's possible. But there's not a seemingly clear anatomic relation to that. It doesn't necessarily make clear medical sense that would be the case."

Perhaps the most interesting reason these injuries maybe be occurring more regularly is that elite athletes start playing at an earlier age and they specialize in a sport at an early age. Decades ago athletes might shift from one sport to another -- football in the fall, basketball in the winter, baseball in the spring, for example. If a particular activity put a tremendous amount of torque on the hip joint and that athlete did it a couple months out of the year instead of year-round, it stands to reason that the one who did it for a longer period of time might be more likely to develop an injury.

"The way that a bone grows -- there's something called the growth plate," Kelly said. "The growth plate fuses somewhere between the ages, say, of 11 to 15, depending if you're male or female and how mature you are. If you subject your hip to a lot of repetitive rotational forces, there is some thought this may result in abnormal remodeling of the hip."

Kelly said one should be aware that "repetitive rotational loads" may not be as benign as previously thought when considering hip development, although he pointed out there has not been enough research to make a recommendation. But just like coaches are told to watch the adolescent elbow, they might want to have similar concerns about the hip.

"Unfortunately it's a mismatch between what your functional requirements are in your sport and your physiological capacity in your hip joint," Kelly said. "If there's a mismatch you can try to do things ... but those things are things that athletes probably aren't going to want to do because it will affect their performance. I think it's identifying the problem and treating it before there's any permanent damage."

Major League Baseball players might be more likely to have increased incidents of hip injuries for that reason. Fortunately, the technology is improving and getting them back on the field.

"Hip injuries sound scary because we've come accustomed to knees, shoulders and elbows, just take them through the meat market," Lowell said. "The hip sounds a lot more complex but I really don't think it is. It's something you can definitely come back from. From a flexibility standpoint and all that, when I stretch, I don't feel anything holding me back."

Todd Zolecki is a reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.

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