Hip Injuries and Conditions in the Endurance Athlete

Evaluation and management of the endurance athlete with hip pain requires a thorough knowledge of the layered structure of normal anatomy and pathoanatomy in (intra-articular) and around (extra-articular) the hip joint. The subjective history and objective physical examination must be combined with imaging to properly “treat the athlete and not the MRI.” Patients with intra-articular pathology like FAIS (Femoroacetabular Impingement Syndrome) typically report deep groin pain, worse with the offending sporting activity, deep flexion, and rotational maneuvers, like squats or lunges. Patients with acetabular dysplasia also report deep pain, but usually lateral or posterolateral, worse with weight-bearing exercise, like running. In FAIS, physical examination typically reveals a loss of hip flexion and internal rotation with positive impingement findings. In dysplasia, supraphysiologic motion is common, with hypermobility signs, like elevated Beighton scores, frequently present. Risk factors for proximal femoral stress-related bone injury must be sought, evaluated, and promptly managed. Plain radiographs are very useful in endurance athletes with hip pain. However, advanced imaging with MRI and CT has a distinct and often necessary role. Sources of pain around the hip joint frequently coexist and the clinician must systematically assess all potential diagnoses, as they are not mutually exclusive.