by Steve Mora MD, Orange County Hip Arthroscopy Specialist
Hip pain in Mixed Martial Arts (MMA) fighters is common. There is a lack of medical information regarding this unique problem in this unique population. Mixed Martial Arts combat athletes are unique in that their sport requires mastering various techniques which in turn predisposes them to various types of injury mechanisms. The successful MMA athlete has to practice boxing, Jiu Jitsu, Muay Thai, wrestling, judo, kick boxing, and ground and pound. High level MMA fighters train hard and are exposed to both acute trauma and cumulative training related trauma. These athletes get kicked, punched and thrown. They may also get injured blocking kicks, punches and guarding. They often train through pain and injuries. Professional MMA fighters are prone to various types of hip injuries.
Hip injury mechanism can therefore be caused by a multitude of situations including acute impact trauma, repetitive pivoting on leg during a kick, hyperflexion/rotation while guarding on ones back, direct groin/thigh impact from a kick, and lateral hip impactions injury from falling onto side.
Nailing the correct diagnosis is key, especially in cases of hip pain. Diagnosing the cause of hip pain is not always ,straightforward. This is due in part to the complex anatomy around the hip. The underlying pain can be originating from the joint cartilage, abnormal mechanics of the joint, the surrounding muscles and tissue, nerve entrapment, referred pain from the spine or deep gluteal region and tendon tears or degeneration. Pain can be deferred from the spine, pelvis or abdominal musculature.
Therefore evaluation of these athletes requires a solid understanding of the anatomy, mechanism and a detailed history and examination. The evaluation requires not only a good detailed history and exam but also good multi view plain radiographs. Approximately half of the conditions can be diagnosed with a basic evaluation. The plain X-Rays can pick up fractures of the greater trochanter (due to landing on side), heterotopic ossification (due to direct kick/impact), signs of early hip joint degeneration, tendon calcifications (associated with avulsions) and signs of impingement.
In some cases an MRI will be necessary to evaluate for stress fractures due to overtraining or from a fall. An MRI/Arthrogram is done to look for labral tears from acute injuries or from repetitive trauma. The arthrogram is an injection of dye just before the actual MRI scan. When done together it is called MR/Arthrogram. The injected dye or contrast moving through the joint helps to improve the sensitivity of the MR images especially when a labral tear or cartilage damage is being considered. A CT scan is done in some cases prior to arthroscopic surgery for impingement. A CT scan can help to define the size and location of “cam type” impingement bone spurs. The CT scan is excellent for looking at bony anatomy but not soft tissue.
In some cases the cause of the groin pain is not due to a problem within the ball and socket joint but rather a above near the pubic symphysis or anterior pelvic wall. If the injury involves the inguinal area, it might be a soft tissue injury of the abdominal or pelvic muscles and tendons. Doctors refer to this condition as pubalgia. Pubalgia usually occurs from repetitive kicking. The kicking leg will experience pain in the groin area. The pain is often attributed to a “occult” hernia. The work up might be a little more involved and might include a single evaluation by a general surgeon to rule out traditional hernia. An MRI might be done. The diagnosis is usually confirmed once the history and examination are carried out. If pubalgia is suspected a referral to a knowledgeable general surgeon is necessary.
Heterotopic Ossification, a.k.a. as H.O., is an unusual condition following a hematoma or severe deep bruise usually due to a kick. For uncertain reasons the collection of blood becomes calcified or ossified. It’s a rare condition in the general population but tends to be seen in situations where direct trauma is frequently encountered. The pain usually follows a known single traumatic event. It tends to worsen with time. The H.O. will cause blocks in motion, especially, if it involves the anterior groin musculature or inside the hip joint. In some cases the hard calcification can be felt deep in the muscle. This condition is very difficult to treat. The large ossification can be surgically excised however there is no guarantee that it will not recur. Surgical excision depends on the “maturity” of the calcium deposit and the safety of the surgical exposure. Some surgeons will not attempt surgical removal until they confirm that the calcification is no longer growing or inflamed. A bone scan prior to surgery can assist with this determination.
Fractures, contusions, and hematomas are treated with activity modification, anti-inflammatories, steroid injections and rest. Fractures will usually heal when the aggravating mechanism is stopped. If the fracture occurred from a fall, rest will usually lead to complete recovery. A short period of physiotherapy will help reduce the likelihood of late effects such as stiffness, fibrosis, and weakness. Bursitis following a fall will be successfully treated with rest, a steroid injection and a short course of anti-inflammatory medication. Treatment for contusions, strains, hematomas is usually successful without surgery. Time off training might be 3-6 weeks.
Fractures around the hip joint can be problematic. In some cases fractures around the hip will require an extended period of rest with crutch use. Surgery will often be recommended if a crack develops in the femoral neck such as pictured below. In some cases the fracture will be fixed surgically by passing 3 screws across the crack to close it down. Healing time 3-6 months.
Labral tears and or impingement of the hip is a condition which is due to abnormal gliding of the ball and socket mechanism of the hip joint. Adaptive pathological changes occur around the hip joint which leads to pain. Hip impingement is thought to be an early harbinger of arthritis however this has not been firmly established. Hip impingement has been seen in athletes such as hockey player goal keepers and kicking athletes. Mixed Martial Arts fighters are also susceptible to these conditions due to repetitive flexion and outward motion of the leg. The symptoms of impingement are stiffness in the groin or front of the thigh and/or a loss of motion. In cases of an unstable labral tear there will be catching and painful movements.
The athlete will have pain when he or she flexes and rotates the hip especially while guarding or checking a kick. The pain is located over the front of the hip or the groin area. Treatment depends on various factors including the level and the findings of the imaging studies. Patients are usually treated without surgery. Non operative treatment can be successful if done right. It usually requires appropriate therapy, soft tissue mobilization, stretching and fluoroscopically guided intra-articular injections. Platelet rich plasma might help in some cases but it is not supported by scientific studies. Therapy is focused on strengthening the core musculature, range of motion of the spine, pelvis, abdominals and hip. An MRI and sometimes a CT scan is done to confirm and or prepare for surgery. If surgery is necessary it is arthroscopic, outpatient and done under general anesthesia. Hip impingement surgery is challenging and should be done by a sports medicine trained orthopedic surgeon. The surgery usually requires shaving down bony spurs and reattaching or trimming labral tears.Crutches are used for 3-6 weeks. If the labral tear is “repaired” the recovery period before a patient is allowed to start camp might be 4-6 months. As mentioned above, hip impingement might be an early presentation of arthritis therefore proper treatment might slow down the progress. Healing time for labral tear treated without surgery 4-8 weeks, after labral trimming 6-8 weeks, and after labral repair 3-6 months.
Hip pain in MMA athletes is common. The causes are multifactorial; sometimes it’s from an acute injury and other times it’s from over-training. The diagnosis depends on a detailed evaluation by a doctor who understands the mechanics of mixed martial arts. A good history, examination and quality X-Rays will often times lead to the correct diagnosis. Sometimes an MR Arthrogram is necessary to confirm the diagnosis of a labral tear or a stress fracture. A delay in the diagnosis might lead to the wrong treatment and a longer period of recovery and time off training. Treatment may require referrals to high level physical therapists and or chiropractic specialist.
Red flags which require an immediate evaluation by a doctor
- Inability to apply weight to leg after a lateral fall (fracture or bone bruise)
- Extremely painful catching or clicking with rotation (labral tear)
- Pain that does not improve after a few days
- Pain that does not allow training
Mixed Martial Arts athletes with hip pain can benefit from an evaluation by orthopedic doctor with knowledge of the unique mechanism associated with the sport. The doctor should also have an understanding of the high demands of the MMA fighter so that a patient and sports specific treatment plan can be carried out. Hip pain can be successfully treated once the diagnosis is nailed and appropriate treatment started.
About Steve A. Mora MD:
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He received his medical education at UC Irvine College of Medicine where he finished in the top of his class earning the coveted AOA Medical Society honors. He completed his Orthopedic Surgery training LAC+USC Medical Center and then did a additional Sports Medicine Fellowship at the Santa Monica Orthopaedic and Sports Medicine Group where focused on sports medicine, shoulder, knee, hip arthroscopy. He has published numerous book chapters on the topics of ACL injuries in soccer players, cartilage restoration, and athletic hip injuries. He is currently practicing Orthopedic Surgery in the City of Orange Orange County. He is a founding partner at Restore Orthopedics and Spine Center (www.restoreorthopedics.com). Dr. Mora’s practice focus is on sports related trauma, MMA injury treatment, arthroscopy of the shoulder, hip, knee and elbow, and partial and total knee replacement. He sees athletes of all levels including professional soccer and UFC/MMA patients. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
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Restore Orthopedics and Spine Center
112o W. La Veta Ave, Third Floor
Orange, CA 92868
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