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WELCOME TO THIS PHD HIP AND GROIN TWITTER THREAD
*PhD of Pim van Klij
*The development of the non-perfect hip in young athletes
*Defense passed at 10th of March 2021
*Promotor & co-promotor: Prof. Dr. @janverhaar & Dr. @RintjeAgricola
#Thread1
*PhD of Pim van Klij
*The development of the non-perfect hip in young athletes
*Defense passed at 10th of March 2021
*Promotor & co-promotor: Prof. Dr. @janverhaar & Dr. @RintjeAgricola
#Thread1
#Thread2
This Twitter thread will summarise main findings of this thesis. Highly appreciated when retweeted, liked or wehen to comment/tag colleagues.
FULL PDF: https://www.orthopeden.org/downloads/866/proefschrift-pim-van-klij.pdf
This Twitter thread will summarise main findings of this thesis. Highly appreciated when retweeted, liked or wehen to comment/tag colleagues.
FULL PDF: https://www.orthopeden.org/downloads/866/proefschrift-pim-van-klij.pdf
#Thread3
INTRODUCTION (1/4)
*Hip and groin: highly complex anatomic area
*Groin: clinical entities according to Doha Agreement
https://bjsm.bmj.com/content/49/12/768
*FAI syndrome: triad of symptoms, clinical signs and radiographic findings (cam or pincer morphology) https://bjsm.bmj.com/content/50/19/1169
INTRODUCTION (1/4)
*Hip and groin: highly complex anatomic area
*Groin: clinical entities according to Doha Agreement
https://bjsm.bmj.com/content/49/12/768
*FAI syndrome: triad of symptoms, clinical signs and radiographic findings (cam or pincer morphology) https://bjsm.bmj.com/content/50/19/1169
#Thread4
INTRODUCTION (2/4)
*Cam morphology: bone anterolateral head-neck junction
- Tilt deformity by Murray (1965)
- Pistol grip deformity by Stulberg (1975)
- Nowadays cam morphology by Griffin (2016)
https://www.birpublications.org/doi/pdf/10.1259/0007-1285-38-455-810
INTRODUCTION (2/4)
*Cam morphology: bone anterolateral head-neck junction
- Tilt deformity by Murray (1965)
- Pistol grip deformity by Stulberg (1975)
- Nowadays cam morphology by Griffin (2016)
https://www.birpublications.org/doi/pdf/10.1259/0007-1285-38-455-810
#Thread5
INTRODUCTION (3/4)
*Cam morphology development from 10 years of age
*First cartilage changes (Palmer et al), from 12 to 14 years osseous changes (Agricola et al)
https://journals.sagepub.com/doi/10.1177/0363546512438381?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed https://bjsm.bmj.com/content/52/9/601.long
INTRODUCTION (3/4)
*Cam morphology development from 10 years of age
*First cartilage changes (Palmer et al), from 12 to 14 years osseous changes (Agricola et al)
https://journals.sagepub.com/doi/10.1177/0363546512438381?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed https://bjsm.bmj.com/content/52/9/601.long
#Thread6
INTRODUCTION (4/4)
*Cam morphology associations:
- With symptoms unclear
- Limited ROM (IR and flexion)?
*Pincer morphology: global or focal
- Several measurements
- Heterogeneous definitions and cut-off values: prevalence unsure
https://www.jospt.org/doi/10.2519/jospt.2018.7816
INTRODUCTION (4/4)
*Cam morphology associations:
- With symptoms unclear
- Limited ROM (IR and flexion)?
*Pincer morphology: global or focal
- Several measurements
- Heterogeneous definitions and cut-off values: prevalence unsure
https://www.jospt.org/doi/10.2519/jospt.2018.7816
#Thread7
CHAPTER 2: CLINICAL FUNCTION AND STRENGTH TESTS IN FOOTBALL (1/2)
*To remember:
1.Normal values ABD (3.45 to 3.28Nm/Kg), ADD strength (3.4Nm/kg), ratio (1.0 to 1.05) & HAGOS stable over season
2.Slight increase HAGOS pain, clinically irrelevant https://www.sciencedirect.com/science/article/pii/S1440244021000839
CHAPTER 2: CLINICAL FUNCTION AND STRENGTH TESTS IN FOOTBALL (1/2)
*To remember:
1.Normal values ABD (3.45 to 3.28Nm/Kg), ADD strength (3.4Nm/kg), ratio (1.0 to 1.05) & HAGOS stable over season
2.Slight increase HAGOS pain, clinically irrelevant https://www.sciencedirect.com/science/article/pii/S1440244021000839
#Thread8
CHAPTER 2: CLINICAL FUNCTION AND STRENGTH TESTS IN FOOTBALL (2/2)
*Key messages:
3.Potential implementation of prevention measures
4.Previous (groin)injury: higher hip and groin related problems now
https://www.sciencedirect.com/science/article/pii/S1440244021000839
CHAPTER 2: CLINICAL FUNCTION AND STRENGTH TESTS IN FOOTBALL (2/2)
*Key messages:
3.Potential implementation of prevention measures
4.Previous (groin)injury: higher hip and groin related problems now
https://www.sciencedirect.com/science/article/pii/S1440244021000839
#Thread9
CHAPTER 3: CLINICAL FUNCTION AND STRENGTH TESTS IN FIELD HOCKEY
*Take home:
1. Normal values ABD 2.6Nm/Kg, ADD 2.8Nm/Kg, ratio 1.1), IR 34°, ER 47°
2. Age, dominance, position, level, non-time loss groin pain: no effect on profiles
https://www.sciencedirect.com/science/article/pii/S1466853X20305216?via%3Dihub
CHAPTER 3: CLINICAL FUNCTION AND STRENGTH TESTS IN FIELD HOCKEY
*Take home:
1. Normal values ABD 2.6Nm/Kg, ADD 2.8Nm/Kg, ratio 1.1), IR 34°, ER 47°
2. Age, dominance, position, level, non-time loss groin pain: no effect on profiles
https://www.sciencedirect.com/science/article/pii/S1466853X20305216?via%3Dihub
#Thread10
Implementation normal values ‘in my opinion’ (1/2)
- Risk calculation by ADD/ABD ratio (<0.8, 17x higher risk) [1]
- Change during season? Attention staff (reduce load OR additional adductor training) [2]
[1] https://journals.sagepub.com/doi/10.1177/03635465010290020301?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
[2] https://bjsm.bmj.com/content/53/3/150.long
Implementation normal values ‘in my opinion’ (1/2)
- Risk calculation by ADD/ABD ratio (<0.8, 17x higher risk) [1]
- Change during season? Attention staff (reduce load OR additional adductor training) [2]
[1] https://journals.sagepub.com/doi/10.1177/03635465010290020301?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
[2] https://bjsm.bmj.com/content/53/3/150.long
#Thread11
Implementation normal values ‘in my opinion’ (2/2)
- Motivates players for extra training adductors
- Monitor progression rehab and treatment effect
- Creates sport-, gender- and level specific values
- RTP values in future?
- However: group-based values, not individual
Implementation normal values ‘in my opinion’ (2/2)
- Motivates players for extra training adductors
- Monitor progression rehab and treatment effect
- Creates sport-, gender- and level specific values
- RTP values in future?
- However: group-based values, not individual
#Thread12
CHAPTER 4: CLASSIFYING CAM MORPHOLOGY (1/2)
*To remember:
- SR with 15 studies about alpha angle (AA) threshold for cam morphology
- AA threshold by ROC curve, bimodal distribution,
% reference interval
SCAN QR FOR PDF!
CHAPTER 4: CLASSIFYING CAM MORPHOLOGY (1/2)
*To remember:
- SR with 15 studies about alpha angle (AA) threshold for cam morphology
- AA threshold by ROC curve, bimodal distribution,
% reference interval SCAN QR FOR PDF!
#Thread13
CHAPTER 4: CLASSIFYING CAM MORPHOLOGY (2/2)
*Take home:
- Thresholds between 58-93° in males, 58-94 in females
- CONCLUSION: non-sex specific AA ≥ 60° most appropriate
https://journals.sagepub.com/doi/pdf/10.1177/2325967120938312 > OPEN!
CHAPTER 4: CLASSIFYING CAM MORPHOLOGY (2/2)
*Take home:
- Thresholds between 58-93° in males, 58-94 in females
- CONCLUSION: non-sex specific AA ≥ 60° most appropriate
https://journals.sagepub.com/doi/pdf/10.1177/2325967120938312 > OPEN!
#Thread14
CHAPTER 5: THE DEVELOPMENT OF CAM MORPHOLOGY DURING GROWTH
*Key messages in professional football players, 5-year-follow-up:
- Cam morphology mostly develops during growth, based on AA and visual score
- Cam morphology prevalence around 80%
https://bjsm.bmj.com/content/53/9/532.long
CHAPTER 5: THE DEVELOPMENT OF CAM MORPHOLOGY DURING GROWTH
*Key messages in professional football players, 5-year-follow-up:
- Cam morphology mostly develops during growth, based on AA and visual score
- Cam morphology prevalence around 80%
https://bjsm.bmj.com/content/53/9/532.long
#Thread15
CHAPTER 6: PARAMETERS ASSOCIATED WITH AND PREDICTIVE FOR CAM
*Take home:
- No radiographic/clinical measure predicted cam
- Coxa vara, higher EE + limited IR simultaneously develops with cam
- Acetabular morphology not associated
https://link.springer.com/content/pdf/10.1007/s00167-020-06282-0.pdf
CHAPTER 6: PARAMETERS ASSOCIATED WITH AND PREDICTIVE FOR CAM
*Take home:
- No radiographic/clinical measure predicted cam
- Coxa vara, higher EE + limited IR simultaneously develops with cam
- Acetabular morphology not associated
https://link.springer.com/content/pdf/10.1007/s00167-020-06282-0.pdf
#Thread16
CHAPTER 7: THE ASSOCIATION BETWEEN CAM AND CLINICAL SIGNS AND SYMPTOMS
*Key messages:
- (Large) cam associated with pain (yes/no), but not with HAGOS: relevant?
- Cam presence, size and duration: limited flexion (6°) and IR (3-6°)
https://onlinelibrary.wiley.com/doi/epdf/10.1111/sms.13660 OPEN!
CHAPTER 7: THE ASSOCIATION BETWEEN CAM AND CLINICAL SIGNS AND SYMPTOMS
*Key messages:
- (Large) cam associated with pain (yes/no), but not with HAGOS: relevant?
- Cam presence, size and duration: limited flexion (6°) and IR (3-6°)
https://onlinelibrary.wiley.com/doi/epdf/10.1111/sms.13660 OPEN!
#Thread17
CHAPTER 8: PREVALENCE OF CAM AND PINCER MORPHOLOGY AND FUTURE HIP OA
To remember:
- Cam & pincer: highly prevalent general population
- Prevalence depends on: age, sex, ethnicity, athletic activity, symptoms
- OA: cam has OR 4-10, pincer not
https://www.jospt.org/doi/10.2519/jospt.2018.7816
CHAPTER 8: PREVALENCE OF CAM AND PINCER MORPHOLOGY AND FUTURE HIP OA
To remember:
- Cam & pincer: highly prevalent general population
- Prevalence depends on: age, sex, ethnicity, athletic activity, symptoms
- OA: cam has OR 4-10, pincer not
https://www.jospt.org/doi/10.2519/jospt.2018.7816
#Thread18
CHAPTER 10: GENERAL DISCUSSION (1/9)
Co-authored consensus papers about hip-related pain, young middle aged active adults:
@MikeReiman: https://bjsm.bmj.com/content/54/11/631.long
@AndreaBMosler: https://bjsm.bmj.com/content/54/12/702.long
CHAPTER 10: GENERAL DISCUSSION (1/9)
Co-authored consensus papers about hip-related pain, young middle aged active adults:
@MikeReiman: https://bjsm.bmj.com/content/54/11/631.long
@AndreaBMosler: https://bjsm.bmj.com/content/54/12/702.long
#Thread19
CHAPTER 10: GENERAL DISCUSSION (2/9)
Co-authored consensus papers about hip-related pain, young middle aged active adults:
Impellizeri: https://bjsm.bmj.com/content/54/14/848.long (sleuteltje dicht)
@JoanneLKemp: https://bjsm.bmj.com/content/54/9/504.long (sleuteltje dicht)
@MikeReiman: scan QR code!
CHAPTER 10: GENERAL DISCUSSION (2/9)
Co-authored consensus papers about hip-related pain, young middle aged active adults:
Impellizeri: https://bjsm.bmj.com/content/54/14/848.long (sleuteltje dicht)
@JoanneLKemp: https://bjsm.bmj.com/content/54/9/504.long (sleuteltje dicht)
@MikeReiman: scan QR code!
#Thread20
*Key message @MikeReiman et al (3/9)
- Negative FADIR rules out hip disease
- Diagnostic utility imaging limited: combine with symptoms and signs
- Categorize pain: FAI syndrome, dysplasia/instability, other
- Report AA and LCEA https://bjsm.bmj.com/content/54/11/631.long
*Key message @MikeReiman et al (3/9)
- Negative FADIR rules out hip disease
- Diagnostic utility imaging limited: combine with symptoms and signs
- Categorize pain: FAI syndrome, dysplasia/instability, other
- Report AA and LCEA https://bjsm.bmj.com/content/54/11/631.long
#Thread21
Wooohoo, you already made it to#Thread21, and you’re still reading!
Awesome. Still some ahead, so please keep it up
Wooohoo, you already made it to#Thread21, and you’re still reading!
Awesome. Still some ahead, so please keep it up
#Thread22
*Take home @AndreaBMosler et al (4/9)
- ROM by gonio- or inclinometer
- Measure hip muscle strength
- Use PROM’s
- Manage expectations
- Examine sport-specific activities for RTS (2016 consensus: https://bjsm.bmj.com/content/50/14/853.long) (sleuteltje dicht) https://bjsm.bmj.com/content/54/12/702.long
*Take home @AndreaBMosler et al (4/9)
- ROM by gonio- or inclinometer
- Measure hip muscle strength
- Use PROM’s
- Manage expectations
- Examine sport-specific activities for RTS (2016 consensus: https://bjsm.bmj.com/content/50/14/853.long) (sleuteltje dicht) https://bjsm.bmj.com/content/54/12/702.long
#Thread23
*Main message Impellizeri et al (5/9)
- Use iHOT-12 or 33 and HAGOS
- Both PROMS designed for surgical context
- Psychological evaluation: EQ-5D or SF-36
- Future: individual measurement error and investigate MCID https://bjsm.bmj.com/content/54/14/848.long
*Main message Impellizeri et al (5/9)
- Use iHOT-12 or 33 and HAGOS
- Both PROMS designed for surgical context
- Psychological evaluation: EQ-5D or SF-36
- Future: individual measurement error and investigate MCID https://bjsm.bmj.com/content/54/14/848.long
#Thread24
*Key messages @JoanneLKemp et al (6/9)
- Exercise-based treatment
- >3 months
- Physiotherapy after surgery
- PROMS + clinical measures + psychosocial factors
- Sport advised (!!!)
- Shared-decision, guide expectations, education
https://bjsm.bmj.com/content/54/9/504.long
*Key messages @JoanneLKemp et al (6/9)
- Exercise-based treatment
- >3 months
- Physiotherapy after surgery
- PROMS + clinical measures + psychosocial factors
- Sport advised (!!!)
- Shared-decision, guide expectations, education
https://bjsm.bmj.com/content/54/9/504.long
#Thread25
CHAPTER 10/11: GENERAL DISCUSSION / PERSPECTIVES (7/9)
*Summarized thoughts on FAI syndrome (1/3):
- We are on track for terminology and classification
- Cam might develop by flexion & ER movements (Agricola/Roels) during growth by high loads https://bjsm.bmj.com/content/50/5/263.long
CHAPTER 10/11: GENERAL DISCUSSION / PERSPECTIVES (7/9)
*Summarized thoughts on FAI syndrome (1/3):
- We are on track for terminology and classification
- Cam might develop by flexion & ER movements (Agricola/Roels) during growth by high loads https://bjsm.bmj.com/content/50/5/263.long
#Thread26
CHAPTER 10/11: GENERAL DISCUSSION / PERSPECTIVES (8/9)
*Summarized thoughts on FAI syndrome (2/3):
-No cam after growth plate closure: preventative strategies?
-FAI syndrome: >3 months of adequate PT (Kemp)
-Is hip arthroscopy superior to PT?
https://journals.sagepub.com/doi/10.1177/0363546520952804?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
CHAPTER 10/11: GENERAL DISCUSSION / PERSPECTIVES (8/9)
*Summarized thoughts on FAI syndrome (2/3):
-No cam after growth plate closure: preventative strategies?
-FAI syndrome: >3 months of adequate PT (Kemp)
-Is hip arthroscopy superior to PT?
https://journals.sagepub.com/doi/10.1177/0363546520952804?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
#Thread27
CHAPTER 10/11: GENERAL DISCUSSION/PERSPECTIVES (9/9)
*Future ideas:
-12.5y follow-up Feyenoord cohort (age 28): expect symptoms/early OA signs?
-Clear terminology + cut-offs pincer
-Diagnostic criteria cam morphology
-Optimalisation conservative/surgical treatment
CHAPTER 10/11: GENERAL DISCUSSION/PERSPECTIVES (9/9)
*Future ideas:
-12.5y follow-up Feyenoord cohort (age 28): expect symptoms/early OA signs?
-Clear terminology + cut-offs pincer
-Diagnostic criteria cam morphology
-Optimalisation conservative/surgical treatment
#Thread28
FINAL CONCLUSION PHD
- Normal values hip muscle strength, ROM, HAGOS stable over season
- Cam develops during growth
- Coxa vara, high EE simultaneously with cam
- Cam: no lower HAGOS, but limited flexion and IR
- Cam: higher risk for hip OA (4-10x)
FINAL CONCLUSION PHD
- Normal values hip muscle strength, ROM, HAGOS stable over season
- Cam develops during growth
- Coxa vara, high EE simultaneously with cam
- Cam: no lower HAGOS, but limited flexion and IR
- Cam: higher risk for hip OA (4-10x)
#Thread29
It took a lot of time, motivation and effort to finalize this PhD. This would not have been possible by the amazing supervising of @RintjeAgricola and @janverhaar. As we all know, @RintjeAgricola is one of the founders of this field of expertise, massive appreciation!
It took a lot of time, motivation and effort to finalize this PhD. This would not have been possible by the amazing supervising of @RintjeAgricola and @janverhaar. As we all know, @RintjeAgricola is one of the founders of this field of expertise, massive appreciation!
#Thread30
Also @AdamWeirSports played a major role in my PhD (groin expert!), thanks a lot! I will certainly forget to mention some, in general I would like to thank our LaTrobe friends ( @JHeerey, @JoanneLKemp, @AndreaBMosler), @igorjrtak and @DrPaulDijkstra for all meetings!
Also @AdamWeirSports played a major role in my PhD (groin expert!), thanks a lot! I will certainly forget to mention some, in general I would like to thank our LaTrobe friends ( @JHeerey, @JoanneLKemp, @AndreaBMosler), @igorjrtak and @DrPaulDijkstra for all meetings!
#Finalthread30
Thank you for reading this thread. If you have any questions or want to follow me on Twitter? Don’t hesitate to send me a private message or follow me @pimvklij. Have a nice day!
Thank you for reading this thread. If you have any questions or want to follow me on Twitter? Don’t hesitate to send me a private message or follow me @pimvklij. Have a nice day!
