Deep Groin Pain in a Masters Athlete With Borderline Acetabular Dysplasia
A 32-year-old woman who plays competitive masters field hockey presents with 18 months of right deep groin pain. The pain is sharp with hip flexion and pivoting, worse after sitting, and occasionally catches. She runs 25 miles per week. NSAIDs and six months of physical therapy have failed. Examination shows painful FADIR and FABER tests, internal rotation of 5°, flexion of 105°, and abduction of 25°. Radiographs show a lateral center-edge angle of 19°, Tönnis grade 0, alpha angle of 63°, and acetabular index of 12°. MRI shows an anterosuperior labral tear without full-thickness cartilage loss. She asks whether an arthroscopy can simply 'clean up the tear' so she can play next season.
1. Why is arthroscopic labral treatment alone likely to fail here, and which findings would change your recommendation?
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The centerpiece is the lateral center-edge angle of 19°, which places her in borderline-to-frank dysplasia territory. In a dysplastic hip the labrum is loaded as a secondary stabilizer; repairing or debriding it without addressing the shallow acetabulum leaves the same edge loading and shear, and published series show high rates of failure, progressive osteoarthritis, and even instability after arthroscopy in this group. The alpha angle of 63° and the cam morphology are real but secondary, because resecting cam in an undercovered hip can further destabilize it. Findings that would make arthroscopy reasonable include a center-edge angle above 25°, preserved joint space (Tönnis 0–1), no acetabular rim overload, and a labral tear with clear mechanical symptoms; a false-profile view and functional assessment of anterior coverage refine that judgment. Given her age, Tönnis 0, and failure of six months of therapy, the discussion should center on periacetabular osteotomy with or without concomitant arthroscopy rather than arthroscopic labral surgery alone. I would obtain a false-profile radiograph and a CT for planning.
2. Construct a management plan and explain how you would counsel her about returning to field hockey.
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There are three options. First, continued nonoperative care with activity modification: gluteal and deep hip rotator strengthening, avoiding end-range flexion and pivoting, and a trial of an intra-articular corticosteroid injection for a flare. This may permit recreational play but does not change the underlying coverage, and her 18-month history suggests it is unlikely to be definitive. Second, periacetabular osteotomy: recovery takes 6–12 months, protected weight bearing for 6–8 weeks, and return to impact sport typically at 9–12 months, with good but not guaranteed outcomes and risks including nonunion, nerve injury, and thromboembolism. Third, hip arthroscopy, which I would advise against as a stand-alone procedure and would explain why. I would frame the shared decision around her goals: if she wants to keep playing masters hockey at a high level for years, osteotomy offers the more durable solution; if she wants to avoid a major osteotomy, she is choosing symptom control rather than correction. Document the discussion and involve a hip preservation colleague.