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FAI – An Avoidable Overuse

Injury ??

23/5 2013

Leif Swärd

Growth

One of natures mysteries!

How does it work?

Opinion

Experience

Science

Opinion

Experience

Science

Hopefully can more research on ”the mystery of growth” give us a

more scientific ground for our recommendations on optimal training

for growing individuals1

UnstableStable

• Load is required for normal growth (Malina1969).

• Wolff´s lag: Mucles and bone adapts to load by

succesive adaptation to the load. (Wolff 1892)

• Unclear what effect extreme training programs

during growth have – are the strength of the tissue

including the growth plates exceeded?

Knowledge we have and haven´t!

The growth plates are affected by

So how does load influence growth ?

• Compression forces reduces growth

• Traction forces increases growth

• Torsion forces ?

• Shear forces??

• Combination of foces???

Physiotherapi to correct Scoliosis

>100 years ago in London

Compression and traction was used to correct growth

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2013

• Today there are indications that growing individuals

are loading their bodies to much or unbalanced in

some activities, resulting in growth disturbances.

• The interest for the effect of load during growth has

therefore increased!

• Many thoughts!

• Many opinions!

• Lack of science?!

Influence on the hip?

Growth velosity is greatest at birth and

decreases until complete growth at 20 years of

age except the growth spurt at puberty when it

increases during a limited period.

Pubertal growth spurt is individual

1985 Yelverton Tegner

”Hockey hip”

2013-06-12 10

What do you see?

Growth!

Discuss with yor neighbour for 1 min:

What is:

Epiphysis

Physis

Metaphysis

Diaphysis

Apophysis

The growing

cortical bone

• Epifysis

• Physis

• Metafysis

• Diafysis

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Physis

Physis One model of explanation

how overload (stress) can

affect growth.

Microfraktures disturbing the

circulation i the metaphyses

Ossification is disturbed

The growth is disturbed

Explanation to the abnormal growth zone

”gymnasts wrist”

Examples in sports

• Compression! Fotboll players – varus knees

• Traction! Tennis player – long dominant arm

• Rotatory! Tennis player shoulder, Ballet danser hip

• Shear! Fotboll, Ishockey etc hips

Growth plate

of the head of the femur

Epiphysis

Physis

Metaphysis

Physis

Is the Cam deformity a stress related

growth adaptation?

4

Pistol grip deformity

(lokalized laterally)

Normal hip

Tror att pistol grip och Cam förändring har samma genes

Pistol grip!

Cam!

Same same but different?

Cam?

Cam deformity is identifierad in Lauenstein/Billing projektion

(20° flexion + external rotation � the ventro lateral profile)

Tror att pistol grip och Cam förändring har samma genes?!

Cam deformity is identifierad in Lauenstein/Billing projektion

(20° flexion + external rotation � the ventro lateral profile)

Pistol grip!

Cam!

Not same but different!

Cam!

AP X-ray Lauenstein

Abnormal contour of the femoral head!

http://commons.wikimedia.org/w/index.php?titl

e=File%3AFAI.theora.ogvhttp://www.ncbi.nlm.

nih.gov/pmc/articles/PMC3626254/figure/f3/

To make it more difficult! Differences in growth plates!

The Pincer is formed by a prominent

ventro-cranial acetabular rim

Traction apophysitis?

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What is it and why are there

apophysis?

Apophysitis? – do they result in growth disturbance?

The Rectus Femoris has 2 insertions on the Pelvi side

Spina iliaca anterior inferior (SIAI) and limbus acetabuli.

So, is it a traction apophysitis that cause the Pincer?

SIAI taktion

apophysitis

CAM

FAI =Femuro-Acetabulär

Impingement

(kollision mellan

caput och acetabulum)

Repetition

6

Possible etiologi to CAM and PINCER??

CAM: overload of the growth plate?

PINCER: traktions-apophysit?

StretchingROM limitation is not always due to short muscles

CAM

Pincer

Is the Cam deformity a stress related

growth adaptation?

I am convinced it is a YES !

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What do we see?

What is the cause?

What will it mean for the future?

39

• Studies on athletes and physical active growing

individials has been and are ongoing;

• Abnormalities has been identified in the spine

of athletes, in the discs, end-plates and in the

ring apophses. (Ghelman 1976; Alexander 1977; Hellström 1990; Goldstein 1991,

Swärd 1991; Halvorsen 1996, Lundin 2001, Baranto 2005).

• Shape changes of the hip joint has been

idetified in young elite athletes (Siebenrock 2011)

• Growth plate alteration procedes Cam-type

deformity in elite basketball players. (Siebenrock

2012)

What do we know?

Thank you!