 I'm really honored to have the orthopedic surgeon and managing partner of the Steadman Clinic, the co-chairman and co-director of Sports Medicine Fellowship with the Steadman Philippone Research Institute in Vale, Colorado, the supporter and leader of this fourth injury symposium. Mark is known as one of the world's leading, I'm going to change that, I have editorial control, is known as the world's leading orthopedic hip surgeon. Used by his peers in U.S. history and news and world report for being one of the top one percent the nation is in in in his specialty, I just want to drop the mic on that one alone. As mentioned he and his wife's name are trustees with the U.S. Olympic and Paralympic Foundation and launched the Sports Medicine Fund with the foundation that allows us to strategically identify opportunities to advance sports medicine for Olympic and Paralympic hopefuls. My honor to introduce to you and kick off the next session, Dr. Mark Philippone. Hi, this is Mark Philippone. My assignment is to talk to you about hip screening to identify the hip at risk. These are my disclosures. Now and later, hip injuries in the athlete. There's been a trend in hypotroscopy procedures over the past few years. They have increased drastically over the past 20 years. Femoral acetabular impingement, coming known as FAI, describe a anatomical bony abnormality of the femur or the acetabulum creating a conflict, especially with motion. While the prevalence of FAI varies widely throughout the literature, 5 to 75%, other athletes are more likely to develop deformities. Condition predisposed individuals to both acute and chronic injuries, pain and labor ulterior tear in the short term, conical defects and osteotritis in the long term. FAI can be isolated as a cam impingement, a pincer impingement or a mix impingement. The cam refers to the head and neck junction deformity, the pincer over the acetabular deformity and most of our patients usually are mixed type of deformity. You can see in this video what happens when you have a cam impingement. The convexity at the head and neck junction causes excessive pressure at the convalable junction causing a separation. The larger the cam, the more stress at the convalable junction. And over time, the cartilage really starts delaminating and that can lead to great fallusion. The red zone shows you the area of stress in a cam impingement deformity. Pincer impingement refers to the impingement on the acetabular. As you can see, the premature conflict occurs where the neck pinches the labrum and often the stress induced by repetitive motion can cause pressure also in the posterior and inferior portion of the acetabulum as you can see here and that can lead to what we call a contracoolusion. The type of injury to the cartilage is different in a pincer type. It's more rim-condrosis and you can see here in this picture the red zone shows the posterior infirellusion that's related to the contracoolusion. So the etiology of the FAI are not truly well understood, making primary prevention difficult. Cam develop in skeletally immature patients, possibly due to extreme stress on the growth plate. Longer courses that have suggested that certain movements contribute to the development of FAI deformity. There's also an association between training intensity in FAI and further research is certainly needed in primary prevention, pathogenetic disease and methods of preventing deformity. So this is a paper published in AJSM where we looked at prevalence of increased alpha angle in yet youth ice hockey player and we found that there was an increased risk of FAI in hockey players compared to skiers and also what we found is that the prevalence of hockey players' cam deformity appears to be increasing with age. I-risk motion, if we look at these videos here you can see a baseball player in rotation, bigger skater and obviously trauma. All these can lead to serious damage to the hip if there's an underlying bony impingement. So the research is focusing on sooner prevention, determining at risk population, identifying at risk hips and managing at risk hips. So it's common in many sports. Common sports has certainly more hip injuries or are what we call hip at risk. Ice hockey, golf, ballet, baseball, martial arts and many others. You can see here a person who is a Taekwondo athlete. You can see on the modeling there how much load there is in high prepduction and rotation in that sport. If we look at the hip moment in various sport, walking Taekwondo, football player quarterback, baseball player batter, PJ golfer, you can see that as I just showed that Taekwondo appears to have higher hip moment forces. Also if we look at lateral to medial forces you can see the same pattern. So what are the criteria for screening? This is from the criteria from the World Health Organization. The condition being screened isn't a point health problem. And we know that hip injuries, untreated, inactive people with motion at risk can certainly lead to damage to the cartilage. So hip arthroscopy increased eightfold between 99 and 2009. 60% of the athlete in cutting through in sports developed hip osteoarthritis. There's certainly a detectable early stage and silent FAI can lead to damage. So it's very important to have some type of screening process especially in sports at risk like ice hockey. So early treatment is certainly better than later treatment and it's suitable test to detect at an early age. These are criteria that meets the World Health Organization. So for us we like to use the favorite distance test, the impingement test enter and posterior, and the rotation range of motion measurement usually in FAI will have decrease into rotation. These are example of enter and posterior impingement test, how it is performed. The favorite distance, you can see here it's positive on the left on this patient. And we consider it positive if there's a difference in the distance of created force and immunity between the affected and the unaffected leg. Now sometime you'll have patient about issues, this will be taken into consideration. Femal torsion also has to be taken into consideration for this test. So hip range of motion, supine flexion, abduction, abduction, prone extension to the rotation, hip strain, leg roll test, pelvic tilt observation, and trend number gain assessment. This is an example of the leg roll test before surgery and then you'll see the next movement there after correction with capsule placation. Each sports is different and I think it's important to understand the motion at risk. MRI screening, oblique axial view, data collected that we like is the alpha angle, labopathology and femal version. We're trying to make the screening process portable. So ultrasound is a good tool also to use for screening. For pre-participation screening in youth tennis players, we work in Spain with the Fondation Rafa Nadal and Clinic Maffrey with Dr. Cotoro and we really looked at that sport specifically in Barcelona as a great academy to follow that and what we found is that we looked at 148 tennis players from that tennis academy. There was no difference in the age tournament play per year or weeks when comparing with players with hip at risk to no at risk and subject with hip at risk at play tennis longer than nine and a half years compared to those without risk. The pre-participation screening also in weightlifter, 85 elite weightlifter we looked at. The average year of competition was 10.6, 70% of the athletes at FAI labopathology, athletes with CAM were older and femal weightlifter were more likely to have a CAM, different in the other sports and a weightlifter with CAM were 9.5 times more likely to have a labotare. So ACET and X screening certainly contribute to our understanding of the pathogens of FAI. We have to identify the risk factors. We want to detect the disease, individual without symptom of that disease. We're not predicting injury, we're identifying at risk hip. Through education and change in training we can manage the at risk hip and delay improvement for the damage. It's important to understand the importance of secondary prevention, duration of symptom, predict the outcome, pain less than two years versus pain greater than two years as you can see here, the difference in the outcome. Return to play and carrying the link in hockey, we look at return to play 28 males. What we found in that study at JSM is that the longer they played with their symptoms, the more damage they had to their cartilage. Also return to play was longer for those who had symptoms longer period of time. We also look at carry a link, we look at 60 male professional hockey players. We found that those who had duration of symptoms between players that played great in five years and those who did not, 9.3 months versus 20.2 months. Sports test is also a test we like to use before returning the patient to training. The new research on injury prevention and healing, we look at personalized LT aging program for our surgery and biological treatment such as synodic agents, clinical trials with FISA and LASARTEN to improve bone marrow aspirate concentrate, we will get funding from NIH. Then we are looking at phase one, two clinical trial randomized to buy two-figural design and what's important also is the FDA has approved the investigation of the new drug application for FISA. So this is a very exciting project and we're hoping to improve our hypothesis. In conclusion, studies are currently on their way to provide a better understanding of the etiology of FAI. It's necessary to improve primary prevention. Different sports or different factors for FAI can identify that risk population and risk individual using epidemiological studies and proper management of that risk individual can improve outcome and increase care eligibility. I think it's important to identify these patient at risk and modify their training if indicated and really provide them with an option of early intervention if indicated to prevent college damage that often can lead to great four lesions. Thank you very much and thank you for your attention.