The subject of this case is a 22-year-old NCAA Division I football defensive back who experienced extreme left hip pain following contact with another player with his hip flexed during an early season game. The subject was informed that data collected regarding the case would be submitted for publication.
The on-field medical team transported the subject to a nearby emergency room where plain film radiographs revealed a posterior left hip dislocation (Figures 1A-B), negative for fracture, along with mild pre-existing femoral head CAM deformities bilaterally, thus, the diagnosis was consistent with a type 1 dislocation.
The left hip was reduced (Figures 2A-B) and the subject was instructed to be non-weight-bearing on the left lower extremity with bilateral axillary crutches for two weeks, followed by adding 25% weightbearing each week thereafter to weight bearing as tolerated while maintaining standard posterior hip precautions (no hip flexion greater than 90 , no hip adduction, no hip internal rotation) for a total of six weeks. Magnetic resonance imaging was also performed of the left knee and findings indicated a "low grade" left medial collateral ligament sprain.
Three weeks after injury the subject had a chief complaint of ongoing limited function and left hip, knee, and posterior thigh pain. Primary personal goals were full return to sport without fear of repeated dislocation.
The subject presented to the clinic approximately three weeks after the injury ambulating with bilateral axillary crutches and apparently weight-bearing at approximately 75% on the left lower extremity (LLE), although he had been instructed to be no greater than 25% weight-bearing at that time. He reported 2/10 on the numeric pain rating scale (NPRS) at rest, located in the anterior left hip region, and 5/10 at worst with mild rotational movements in the left hip, knee, and posterior thigh. The subject demonstrated limited left lower extremity range of motion (ROM) and motor performance detailed in Tables 1 & 2.
The subject reported medial left knee pain with active end range left knee flexion, and had an empty endfeel secondary to pain with gentle left hip internal rotation, flexion, and extension. The subject presented with positive grade 1 left knee valgus stress test (mild pain, no gapping apparent), and tenderness to palpation in the left psoas, distal biceps femoris, and medial collateral ligament. Resisted left knee flexion reproduced the subject's posterior mid-thigh complaint. The subject's static right lower extremity balance was within normal limits, however the left was not tested in consideration of precautions. He presented with a positive trace left knee effusion as assessed by sweep test and recorded a 51/80 on the Lower Extremity Functional Scale. Dermatomal light touch was intact and deep tendon reflexes were 1+ throughout bilateral lower extremities.
The subject presented with impaired left lower extremity motor performance, range of motion deficits, pain, and diminished function and weight-bearing ability consistent with status post traumatic posterior dislocation of the left hip, with secondary soft tissue injury around the hip joint, a grade 1 left MCL sprain, and a grade 1 hamstring strain.
The subject was progressed through a phased formal physical therapy program, averaging two visits per week over 14 weeks with multi-modal care including weekly consults with the team physician and the athletic department. Following the 14 weeks, full return to sport was facilitated by the athletic program's athletic training and strength and conditioning staff. Loading of the left hip and lower extremity was carefully controlled throughout the course of care utilizing rating of perceived exertion, percentage of pre-injury 1-repetition-maximum (1RM), and a rolling 1.1-1.2 acute to chronic workload ratio (ACWR) for prescribed resistance exercise, return to run, and plyometric activities.
This phase emphasized pain reduction, appropriate healing of affected tissues, strengthening of LLE in protected ranges, and re-introduction of weight-bearing (WB) activity with normalization of gait. The subject was instructed by his physician to be non-weightbearing (NWB) on the LLE until two weeks post-reduction, and then to progress to weightbearing as tolerated (WBAT) at six weeks. The subject demonstrated poor adherence to WB precautions in non-clinical areas and was educated at evaluation and thereafter about appropriate percentage of WB. Posterior hip precautions were placed until six weeks post-reduction. Initial treatment included instrument-assisted soft tissue mobilization (IASTM) to the left hamstrings and medial knee region, and manual techniques to reduce left psoas spasm. Progressive resistance exercise (PRE) was prescribed in NWB positions emphasizing left hip external rotators and extensors while avoiding hip ROM precautions, and eccentric training of left knee flexor musculature. As precautions allowed, the subject was encouraged to begin WB with lateral shifting in standing and protected leg press activity, progressing to partial squatting on stable and unstable surfaces. Gait training was performed to normalize gait and progress from bilateral axillary crutch use to single crutch, and then no assistive device. Aerobic and upper extremity conditioning were achieved with progressive moderate intensity upright cycling and seated UE resistance exercise supervised by strength and conditioning staff. After six weeks the subject demonstrated normalized gait, normalized left hip ROM (hip flexion 0-115 , IR 30  at 90  flexion), reported minimal pain at rest and with prescribed activities, and demonstrated improved left hip motor performance, exhibited by hand-held dynamometer and manual muscle tests.
This phase emphasized progressive loading of the left lower extremity and reintroduction of non-contact impact activity. The subject performed progressive unilateral leg press beginning at 50% pre-injury 1-repetition-max (1RM), elevated conventional barbell deadlift of 50% pre-injury 1RM, and kettlebell goblet squats beginning at 20lb progressing up to 100lb by 10 weeks post-injury. He was prescribed progressive elliptical and pool running aerobic activity for two weeks, followed by initiation of a gradual return to run program beginning with two bouts of 2 minutes of running on the treadmill. Core and hip strengthening interventions included various planks, bridging with physioball, half-kneeling cable column chops, and sidestepping and kickbacks with elastic bands at the ankles. Gentle stretching was prescribed for the left hip flexors and knee flexors. Balance training was performed with single leg stance on unstable surfaces and multi-directional rebounder ball toss on stable surfaces. The subject was barred from performing plyometrics, Olympic lifts, and any agility activities. After 10 weeks the subject was able to asymptomatically perform multiple bouts of five minutes of easy pace running on treadmill and artificial turf, 60% preinjury 1RM elevated conventional deadlift and left single leg press, and single leg stance on stable surfaces with external perturbation.
This phase emphasized return to plyometric impact activity, agilities, and non-contact sport-specific movement. The subject was prescribed low-intensity single plane agilities without cutting movements, progressing to multiplanar tasks with greater intensity, such as T- and pro-agility style drills with integration of non-contact sport-specific movements. Low-intensity double leg plyometrics were initiated progressing to single leg plyometrics with an emphasis on left hip external rotation control. He initiated a progressive sprinting program during this phase, and performed varied single leg static balance exercises on unstable surfaces with external perturbations. At the end of this phase the subject was able to asymptomatically perform lateral single leg jumps into alternate direction sprint starts, 36-inch double leg box jumps, single leg stance on unstable surfaces with perturbation, 70% of pre-injury 1RM resistance exercise on all non-Olympic lifts (e.g., trap-bar deadlift, elevated conventional deadlift, barbell squat, kettlebell squat), sets of 8 x 40 yard sprints, and all non-contact drills prescribed.
The subject completed the return to sport phase with the athletic training and strength and conditioning staff. Formal physical therapy care was ended since he had asymptomatically performed the majority of non-contact sport activity and his athletic program staff provided extensive monitoring and care to continue guiding his return to full participation. He successfully returned to a normal training schedule without restrictions for that point in the off-season.
Three months following initial injury the subject was asymptomatically performing the majority of non-contact sport activity and training. He was restricted from contact, >80%1RM lower extremity PRE, and Olympic lifts (e.g., clean variations, snatch, jerk). Following a one to two week visit to home the subject returned and continued care with athletic training and strength and conditioning staff. He reintegrated into typical defensive back off-season training approximately four to five months post injury without restrictions.
At seven months post injury, the subject returned to his team physician with report of "pinching" in his anterior left hip with rotational agilities and movements. The physician noted normal strength and range of motion of the left hip, but positive clinical tests for acetabular or labral involvement. A magnetic resonance arthrogram was ordered, which revealed an osteochondral lesion of the superomedial femoral head with underlying intense subchondral marrow signal abnormality and overlying near-full to full thickness cartilage defect of 12x5 mm. There was additional full thickness cartilage delamination with chondral flap posterior and inferior to the osteochondral lesion of 6x6 mm along with a partial thickness, non-detached tear of the anterior labrum, which extended superiorly to the anterosuperior labrum (Figures 3A-B). Mild incipient subclinical avascular necrosis was identified in weightbearing regions of the femoral head.
In consideration of imaging results the subject was recommended the options of a trial of intra-articular corticosteroid injection with prescribed rest or surgical intervention including cartilaginous debridement. The subject selected the surgical option and underwent the surgical procedure almost immediately, which consisted of 10 to 2 o'clock left labral repair with cam osteoplasty and acetabular chondroplasty including; femoral head chondral debridement, iliofemoral capsular thermal plication, loose body removal with anterior inferior iliac spine decompression, and injection of plasma rich platelets and Supartz  (synthetic joint lubrication).
The subject successfully completed the initial post-surgical protocol at a third-party facility, passed the Vail Hip Sports Test, completed a transitional period of physical therapy at the collegiate facility, and was cleared for reintegration into sport approximately four months post operatively. He was able to return to full play in the following football season. Figure 4 details the full course from injury to return to sport the next season.