Advertisement

Editorial Commentary: Hip Femoroacetabular Impingement Emotional Impact and Mental Health: An Arthroscope Can’t Fix Everything

      Abstract

      Arthroscopic treatment of femoroacetabular impingement is increasingly common with established clinical success. As with other chronic injuries, there is an emotional impact that can affect recovery, particularly in competitive athletes. As this emotional aspect of injury is more recognized, it will be important to determine comprehensive means of treating both an athlete’s physical and mental health. It is important to establish preoperative expectations. For certain patients, psychological evaluation and treatment is indicated early in the diagnosis and recovery to ensure mental fitness, and this may be especially true for adolescents. A comprehensive and personalized approach to injury recovery is optimal.
      As orthopaedic surgeons, we focus on restoring function and returning patients to their desired activity. We’re trained to diagnose and treat mechanical pathologies—but injuries do not just cause physical damage, as David Filan and Patrick Carton acknowledge in “Chronic Hip Injury Has a Negative Emotional Impact on the Male Athlete With Femoroacetabular Impingement.”
      • Filen D.
      • Carton P.
      Chronic hip injury has a negative emotional impact on the male athlete with femoroacetabular impingement.
      In their recent study, Filen and Carton studied 486 cases of femoroacetabular Impingement (FAI) in male Irish athletes. They noted significant improvement in the physical component summary scores of the SF-36, from 69.4 preoperatively to 91.9 at 2 years postsurgery. However, the mental component summary (MCS) scores improved in many but remained unchanged after arthroscopic treatment. While there is limited literature on the emotional aspects of FAI, Flores et al.
      • Flores S.E.
      • Sheridan J.R.
      • Borak K.R.
      • Zhang A.L.
      When do patients improve after hip arthroscopy for femoroacetabular impingement? A prospective cohort analysis.
      similarly noted no significant change in mental scores in his study of 122 patients.
      We know that mental health plays an important role in athletic performance and recovery from injury.
      • Covassin T.
      • Beidler E.
      • Ostrowski J.
      • Wallace J.
      Psychosocial aspects of rehabilitation in sports.
      • Fischerauer S.F.
      • Talaei-Khoei M.
      • Bexkens R.
      • Ring D.C.
      • Oh L.S.
      • Vranceanu A.-M.
      What is the relationship of fear avoidance to physical function and pain intensity in injured athletes?.
      • Reardon C.L.
      • Hainline B.
      • Aron C.M.
      • et al.
      Mental health in elite athletes: International Olympic Committee consensus statement (2019).
      Injury not only limits a patient’s physical function but also their social and emotional well-being. The injured athlete is no longer practicing and competing with teammates. For many, their sport is directly tied to their identity and may be their livelihood. Therefore, it is not surprising that injured athletes would be emotionally affected. What we would hope, however, is that a surgical treatment that is effective in treating a mechanical problem would also lead to improvements in a patient’s mental health. It is worth noting that in Filan and Carton’s study, the average preoperative MCS was high, which could have limited the room for improvement following arthroscopic treatment of FAI. To account for this, the authors used a novel method called the percentage of possible improvement, or POPI, to limit ceiling effect of a high MCS.
      There are limitations to Filen and Carton’s study,
      • Filen D.
      • Carton P.
      Chronic hip injury has a negative emotional impact on the male athlete with femoroacetabular impingement.
      as they note. The patient population may not yield generalizable results, as it only includes male patients. The most common sporting activities of study participants were hurling and Gaelic football, which are not as prevalent outside the Emerald Isle. While the study included cases from 2008 to 2016, the authors note that a capsular repair was not routinely done until 2013, leaving variability in surgical technique within the studied cases. Another important consideration is that patients were not screened, nor results stratified, based on pre-existing mental health conditions like depression. A recent systematic review of patients with FAI and preoperative mental health disorders found inferior outcomes at medium-term outcomes.
      • Dick A.G.
      • Smith C.
      • Bankes M.J.K.
      • George M.
      The impact of mental health disorders on outcomes following hip arthroscopy for femoroacetabular impingement syndrome: A systematic review.
      Arthroscopy is an effective way to treat pain and restore function in FAI. However, pre- and postoperative care may be just as critical to optimize outcomes. It is important to establish and meet preoperative expectations.
      • Mannion A.
      • Impellizzeri F.
      • Naal F.
      • Leunig M.
      Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement.
      For certain patients, psychological evaluation and treatment is an additional component to care, and this may be especially true for adolescents.
      • Richard H.M.
      • Cerza S.P.
      • Rocha A.D.L.
      • Podeszwa D.A.
      Preoperative mental health status is a significant predictor of postoperative outcomes in adolescents treated with hip preservation surgery.
      For many of our athletes, being out of their sport for 6 to 9 months can have a deleterious effect on their psychological well-being and their sense of self. We often intervene with sports psychology early in the diagnosis and recovery to ensure mental fitness. A comprehensive and personalized approach to injury recovery is optimal.
      In summary, as we continue to strive to provide our patients with the best possible outcomes, it is important to address both physical and emotional aspects of an injury. There is more to learn regarding not only the role of mental health in FAI but how to best address it as a cooperative part of injury recovery. We can restore physical function with an arthroscope, but we need to continue to seek out the best methods of treating the emotional aspects of injury as well.

      Supplementary Data

      References

        • Filen D.
        • Carton P.
        Chronic hip injury has a negative emotional impact on the male athlete with femoroacetabular impingement.
        Arthroscopy. 2021; 37: 577-578
        • Flores S.E.
        • Sheridan J.R.
        • Borak K.R.
        • Zhang A.L.
        When do patients improve after hip arthroscopy for femoroacetabular impingement? A prospective cohort analysis.
        Am J Sports Med. 2018; 46: 3111-3118
        • Covassin T.
        • Beidler E.
        • Ostrowski J.
        • Wallace J.
        Psychosocial aspects of rehabilitation in sports.
        Clin Sports Med. 2015; 34: 199-212
        • Fischerauer S.F.
        • Talaei-Khoei M.
        • Bexkens R.
        • Ring D.C.
        • Oh L.S.
        • Vranceanu A.-M.
        What is the relationship of fear avoidance to physical function and pain intensity in injured athletes?.
        Clin Orthop Rel Res. 2018; 476: 754-763
        • Reardon C.L.
        • Hainline B.
        • Aron C.M.
        • et al.
        Mental health in elite athletes: International Olympic Committee consensus statement (2019).
        Br J Sports Med. 2019; 53: 667-699
        • Dick A.G.
        • Smith C.
        • Bankes M.J.K.
        • George M.
        The impact of mental health disorders on outcomes following hip arthroscopy for femoroacetabular impingement syndrome: A systematic review.
        J Hip Preserv Surg. 2020; 7: 195-204
        • Mannion A.
        • Impellizzeri F.
        • Naal F.
        • Leunig M.
        Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement.
        Osteoarthritis Cartilage. 2013; 21: 44-50
        • Richard H.M.
        • Cerza S.P.
        • Rocha A.D.L.
        • Podeszwa D.A.
        Preoperative mental health status is a significant predictor of postoperative outcomes in adolescents treated with hip preservation surgery.
        J Child Orthop. 2020; 14: 259-265