Abstract
Background:
Arthroscopic hip surgery for femoroacetabular impingement syndrome (FAIS) has high rates of return to sport; however, patient return to long-distance running is unclear.
Hypotheses:
(1) Long-distance runners undergoing arthroscopic hip surgery for FAIS are a distinctive subgroup in terms of demographics, hip injury characteristics, and running metrics. (2) Most patients will return to general running but a lower proportion return to long-distance running after arthroscopic hip surgery.
Study Design:
Case series.
Level of Evidence:
Level 4.
Methods:
An institutional hip preservation registry was reviewed retrospectively for long-distance runners (half marathons, marathons) who underwent primary hip arthroscopies for FAIS between March 2008 and January 2018. Patient demographics, injury characteristics, and clinical and radiographic findings were recorded. Multivariable logistic regression analysis identified potential risk factors for not returning to long-distance running.
Results:
Sixty-eight (78 hips) long-distance runners (mean patient age, 37.8 ± 8.9 years; 38 (56%) female; mean weekly running mileage before injury, 34.5 ± 16.9 miles) were included. Overall, 50 runners (74%) returned to any running, of which 25 (50%) returned to long-distance running, completing half/full marathons races after surgery. Most common reasons for not returning to running were pain or discomfort (50%) followed by fear of reinjury (22%), and additional different injuries (22%). Multivariable logistic regression analysis revealed female runners (odds ratio, 0.2; CI, 0.0-0.9; P = 0.03) were less likely to return to long-distance running.
Conclusions:
Most (74%) long distance runners returned to running after hip arthroscopic treatment for FAIS; however, only 37% returned to long-distance running. Satisfaction from surgery was not necessarily associated with return to running. Female long-distance runners were less likely to return to long-distance running after surgery.
Clinical Relevance:
Study findings provide helpful context for clinicians counseling patients with symptomatic FAIS who are considering hip arthroscopy and are concerned about return to long-distance running.
Keywords: femoroacetabular impingement, hip arthroscopy, return to run, return to sport, running
Hip arthroscopy for symptomatic femoroacetabular impingement syndrome (FAIS) has shown favorable outcomes in various patient populations and high rates of return to various sports.1,3,5,7,10,11,14,20 Among all sports, running is among the most popular training activities19,21; however, only a few studies specifically investigated and reported on return to running after a hip arthroscopy for FAIS. These studies reported 79% to 94% return to running rates, and 50% to 100% return to same level of run rates in recreational and competitive runners.4,9
The wide range of reported return to running rates after hip arthroscopy for FAIS may be attributed to the varying methodologies used to evaluate return to running in different studies. Moreover, running is a spectrum of activities with diverse characteristics, including duration, distance, and speed, which can contribute to these observed differences. Distance, particularly, plays a major role in the overall demand from the human body. Running - a high impact sport - increases loads on the hip joint by >5 times the bodyweight. When considering a marathon run of approximately 42 kilometers, a 70-kg runner sustains an average vertical force of 2800 tons acting on the hip, knee, and ankle joints.6,8,23 This is one of the reasons why return to long-distance running should be evaluated and reported on separately. Other reasons are related to the demographic and psychological characteristics of this unique population of runners,15,18,19 as well as their specific hip injury characteristics.
Therefore, the aims of this study were to report on (1) demographics and hip injury characteristics, (2) rates of return to long-distance running and running performance, and (3) factors associated with return to running, among long-distance runners who underwent hip arthroscopic treatment for FAIS.
The hypotheses of this study were that (1) long-distance runners undergoing arthroscopic hip surgery for FAIS are a distinctive subgroup of runners in terms of demographics, hip injury characteristics, and running metrics; and (2) the majority of long-distance runners will return to general running, with a lower proportion returning to long-distance running after surgery.
Methods
Cohort Identification
This study was approved by the Hospital for Special Surgery institutional review board (2018-0171). Patients undergoing arthroscopic treatment for FAIS at this institution are enrolled prospectively in a Hip Preservation Registry. Patient demographics, physical examination findings, radiographic measurements, intraoperative surgical data, postoperative complications, and any subsequent hip surgeries are recorded for each patient. In the case of bilateral hip arthroscopy, staged or simultaneous, the aforementioned data is entered per hip. Registry data entry utilizes standardized patient and clinician forms for uniformity across the participating surgeons. Preoperatively, patients had indicated their primary sport of interest and corresponding level of play from recreational to professional. Our hip registry database was reviewed retrospectively to identify a cohort of self-identified long-distance runners (half-marathon and marathon distances) who underwent primary hip arthroscopic treatment for FAIS between 2008 and 2018.
Surgical Indications and Interventions
Indication for hip arthroscopy is warranted if there are clinical and radiographic findings suggesting impingement and/or labral tearing, and if the patient has failed nonsurgical treatment for ≥3 months, including activity modification, nonsteroidal anti-inflammatory drugs, hip injections, and physical therapy. Clinical physical examination evidence includes limited range of motion (flexion, internal rotation at 90° flexion, and external rotation at 90° flexion), positive pain and impingement tests, and self-reported symptoms affecting the patient’s activities of daily living and/or ability to participate in sports. Upon imaging, Coronal center edge angle (CEA) >25°, Tönnis grade <2, an alpha angle >50° on computed tomography scans and magnetic resonance imaging evaluation of labral pathology were used as surgical indicators.
Specific diagnoses, surgical procedures performed, and intraoperative findings are entered into the registry by the designated surgeon immediately after each case using a standardized clinician intraoperative form.
Rehabilitation
Patients followed a postoperative course that involved a flat-foot partial weightbearing limit for 2 weeks with the aid of crutches. Demanding labor and high impact activities were limited through the first 12 weeks. Implementation of physical therapy began immediately postoperatively with passive range of motion of the hip joint. The typical rehabilitation program involves gradual development of muscle strengthening, endurance, functional training, and agility. Exact guidelines depended on the specific procedures performed during the hip arthroscopy as well as the patient-specific sport. Running may be resumed around 6 to 8 months after surgery.
Return to Run
A focused questionnaire (Appendix 1, available in the online version of this article), administered by telephone or email, was used to assess qualities of patients’ running performance before the onset of hip symptoms, after the onset of symptoms, and after surgery, as well as the timing and level of return to running postoperatively. The primary criteria used to define a long-distance runner was having completed ≥1 marathon or half-marathon before undergoing hip surgery. Patients who denied this were excluded from analysis. No race finish time parameters were used for exclusion. Additional questions to further verify long-distance running characteristics of study participant included: weekly running time, weekly distance ran, and frequency of participation in running races, including half/full marathons and other races, during their healthiest presurgery state. Included runners were also asked to self-identify as a recreational or competitive runners. Those who returned to running provided information about timing of return and their postsurgery level of running and estimated how this compared with their preinjury running period. Those that did not return to running specified their reasons for why not. Return to long-distance running was considered as a completion of a half or full marathon race. All participants were asked about satisfaction with the results of their hip surgery.
Statistical Analysis
SPSS software Version 25 (IBM) was used to perform the statistical analyses. Descriptive statistics were reported as means with standard deviations for continuous variables and frequencies with percentages for categorical variables. For patients with bilateral hips, mean time between both surgeries was calculated. Univariate comparisons were analyzed with the χ2 test for categorical variables and with the Mann-Whitney U test for continuous variables. The pre and postoperative running routines of patients (miles and hours per week; marathons, half marathons, and other races per year) were compared using the Wilcoxon Ranks Test. Significance levels were set at P < 0.05. Multivariate analyses using backward stepwise competing logistic regression models were performed to examine potential predictors for returning to any running and returning to long-distance running. The backward variable retention criterion was set at a liberal P value of <0.1. Patient-based and hip-based data were evaluated separately using univariate and multivariate analyses. Bilateral hips were excluded from the hip-based analyses, as it was unknown whether one or both hips influenced return to running.
Results
Demographic, Radiographic, and Intraoperative Findings
A total of 111 patients were identified as self-reported long-distance runners and were contacted, of whom 27 denied completing a half or full distance marathon before surgery and were excluded. Of the remaining confirmed 84 long-distance runners, 16 did not complete the return to run questionnaire and were excluded. Our study cohort consisted of a total of 68 long-distance runners, of whom 10 underwent bilateral hip arthroscopy, for a total of 78 hips (female, n = 43, 55.1%). Mean age at surgery was 37.8 ± 8.9 years. Mean follow-up time was 6 ± 2.3 years. Additional demographics, history of hip pain characteristics, and physical examination findings are detailed in Table 1.
Table 1.
Demographics, history, physical examination, and radiographic findings for the cohort of 78 hips
| Hips (N = 78) | |
|---|---|
| Sex | |
| Female | 43 (55.1) |
| Male | 35 (44.9) |
| Age at surgery, years | 37.8 ± 8.9 |
| Body mass index, a kg/m2 | 23.8 ± 3.3 |
| Surgical side | |
| Left | 39 (50.0) |
| Right | 39 (50.0) |
| Bilateral | 20 (25.6) |
| Level of competition | |
| Competitive | 13 (16.7) |
| Recreational | 65 (83.3) |
| Mechanism of injury | |
| Acute, nontraumatic | 6 (7.7) |
| Acute, traumatic | 1 (1.3) |
| Chronic | 42 (53.8) |
| Missing | 29 (37.2) |
| Hip range of motion, deg | |
| Internal b | 12.3 ± 9.0 |
| External b | 45.3 ± 12.1 |
| Flexion b | 103.8 ± 11.6 |
| Preoperative imaging measures | |
| Alpha angle, c deg | 64.9 ± 12.1 |
| Coronal CEA, d deg | 32.5 ± 5.4 |
| Femoral version, e deg | 13.6 ± 9.1 |
| Acetabular version, deg | |
| 1 o’clock f | 1.5 ± 8.2 |
| 2 o’clock c | 10.1 ± 9.2 |
| 3 o’clock c | 16.0 ± 4.6 |
Values are presented as mean ± SD or N (%). CEA, center edge angle.
Data available for 73 hips (93.6%).
Data available for 51 hips (65.4%).
Data available for 52 hips (66.7%).
Data available for 59 hips (75.6%).
Data available for 56 hips (71.8%).
Data available for 51 hips (65.4%).
Evaluation of preoperative radiographs and CT scans revealed a cohort mean alpha angle of 64.9 ± 12.1 degrees and mean femoral version of +13.6 ± 9.1 degrees. Additional measurements are detailed in Table 1. All hips underwent primary hip arthroscopy. During hip arthroscopy, the majority of the cohort underwent labral repair (n = 59 hips, 75.6%) and cam decompression (n = 65 hips, 83.3%). Surgeries in the bilateral cases were performed an average of 66.4 weeks apart. Additional radiographic and intraoperative findings are detailed in Table 2.
Table 2.
Intraoperative findings and procedures
| Hips (N = 78) | |
|---|---|
| Labral tear present | |
| No | 3 (3.8) |
| Yes | 73 (93.6) |
| Missing | 2 (2.6) |
| Femoral chondral defects | |
| No | 76 (97.4) |
| Yes | 0 (0.0) |
| Missing | 2 (2.6) |
| Acetabular articular chondral defects | |
| No | 76 (97.4) |
| Yes | 0 (0.0) |
| Missing | 2 (2.6) |
| AIIS decompression | |
| No | 31 (39.7) |
| Yes | 45 (57.7) |
| Missing | 2 (2.6) |
| Cam decompression | |
| No | 11 (14.1) |
| Yes | 65 (83.3) |
| Missing | 2 (2.6) |
| Rim decompression | |
| No | 50 (64.1) |
| Yes | 26 (33.3) |
| Missing | 2 (2.6) |
| Cam + Rim + AIIS decompression | |
| No | 64 (82.1) |
| Yes | 12 (15.4) |
| Missing | 2 (2.6) |
| No. of sutures for capsular closure | |
| 0 | 1 (1.3) |
| 2 | 4 (5.1) |
| 3 | 9 (11.5) |
| 4 | 32 (41.0) |
| 5 | 24 (30.8) |
| 6 | 3 (3.8) |
| Missing | 5 (6.4) |
| Labrum tear treatment | |
| Repair only | 59 (75.6) |
| Debridement only | 15 (19.2) |
| Both | 0 (0.0) |
| Missing | 2 (2.6) |
Values are presented as No. (%). AIIS, anterior inferior iliac spine; RIM, acetabular rim.
Preinjury and Presurgery Running Data
Included runners (68 patients) reported running a mean of 34.5 miles/week (SD, 16.9), 6.2 hours/week (SD, 2.3), participating in a total mean number of 3.7 marathon races (range, 0-15; median, 2), 1 (SD, 0.8) marathon per year, 2.2 (SD, 1.7) half marathons per year, and 5.8 (SD, 4.8) other races per year. Runners reported a mean of 77.3 weeks (range, 1-780) of hip symptoms before seeking medical care. The majority of runners had to modify (21 runners, 30.9%) or stop (38 runners, 55.9%) their running activity after hip symptoms started for a mean duration of 43.3 ± 4.5 weeks before surgery.
Return to Running
Overall, 50 runners (73.5%) reported returning to any running after their hip arthroscopy, of which half (37% of total cohort) returned to long-distance running specifically, completing half or full marathon races. The mean time until return to running with minimal pain was 30.1 (SD, 15.8) weeks, and the mean time until return to run half or full marathons was 65.5 (SD, 34.3) weeks. Of those who returned to any running, 35 runners (70%) reported they returned to the same preinjury level of run or better (Figure 1); 46 runners (92%) reported satisfaction from the surgery. Additional return to running data is detailed in Table 3.
Figure 1.
Postsurgery level of running as reported by 50 runners who returned to any running after surgery, compared with (a) preinjury running level and (b) presurgery with hip symptoms running level.
Table 3.
Return to running data among long-distance runners who returned to any running
| Runners (N = 50) | |
|---|---|
| Returned to long-distance running | |
| Yes, marathons | 3 (6.0) |
| Yes, half-marathons | 13 (26.0) |
| Yes, both | 9 (18.0) |
| No | 25 (50.0) |
| Time to return to half/full marathon, weeks | 65.5 ± 34.3 |
| Time to return to running with minimal pain, weeks | 30.1 ± 15.8 |
| Level of running compared with preinjury | |
| Better | 7 (14.0) |
| Same | 28 (56.0) |
| Worse | 13 (26.0) |
| Missing | 2 (4.0) |
| Level of running compared with right before surgery | |
| Better | 37 (74.0) |
| Same | 7 (14.0) |
| Worse | 5 (10.0) |
| Missing | 1 (2.0) |
| Reason(s) if decreased volume/intensity of running during follow-up (multiselect): | |
| Pain or discomfort | 15 (30.0) |
| Fear of reinjury | 15 (30.0) |
| Loss of interest | 5 (10.0) |
| Other physical limitation (injury) | 15 (30.0) |
| Life circumstances | 18 (36.0) |
| Poor performance | 4 (8.0) |
| Other | 11 (22.0) |
| Satisfaction | |
| Very satisfied | 34 (68.0) |
| Somewhat satisfied | 12 (24.0) |
| Neither satisfied nor dissatisfied | 3 (6.0) |
| Somewhat dissatisfied | 1 (2.0) |
| Very dissatisfied | 0 (0.0) |
| Would choose to repeat surgery | |
| Yes | 44 (88.0) |
| No | 5 (10.0) |
| Unsure | 1 (2.0) |
Values are presented as mean ± SD or No. (%).
A total of 18 runners (26.5%) did not return to any running after surgery. Reasons for not returning to running (running could choose >1 reason) included: hip pain or discomfort (9 runners, 50%), fear of reinjury (4 runners, 22%), other physical limitations (4 runners, 22%), loss of interest (3 runners, 17%), and life circumstances (3 runners, 17%). Among the 18 runners who did not return to any running, two-thirds (12 runners, 67%) still reported postoperative satisfaction.
Comparative analyses of hip-based data for runners after unilateral surgery (N = 58) using multivariable logistic regression analyses of hip-based demographics, history data, clinical findings, and radiographic measurements, between runners who returned to long-distance running and those who did not return to long-distance running, revealed that female runners (odds ratio [OR], 0.2; 95% CI, 0-0.9; P = 0.03) were less likely to return to long-distance running. There were no statistically significant differences for hip-based data between those who returned to any running after surgery and those who did not return to run.
Preinjury and Postsurgery Running Metrics
Preinjury (presymptomatic) versus postsurgery running metrics analyses of all runners who returned to long-distance running (n = 25) and to any running (n = 50) is shown in Table 4.
Table 4.
Preinjury vs postsurgery comparison of running metrics for runners who returned to running
| Preinjury | Postsurgery | P value | |||
|---|---|---|---|---|---|
| Runners who returned to long-distance running (N = 25) | |||||
| Mean | SD | Mean | SD | Wilcoxon Ranks Test | |
| Miles/week | 36.8 | 17.1 | 23.7 | 13.3 | 0.001 |
| Hours/week | 6.5 | 2.2 | 5.3 | 3.3 | 0.07 |
| Marathons/year | 1.3 | 0.9 | 0.7 | 1.0 | <0.001 |
| Half marathons/year | 2.4 | 2.3 | 1.6 | 2.1 | 0.15 |
| Other races/year | 7.7 | 5.5 | 4.7 | 5.3 | 0.01 |
| Runners who returned to any running (N = 50) | |||||
| Miles/week | 33.2 | 15.7 | 15.0 | 12.8 | <0.001 |
| Hours/week | 6.1 | 2.2 | 3.4 | 3.0 | <0.001 |
| Marathons/year | 1.1 | 0.8 | 0.4 | 0.8 | <0.001 |
| Half marathons/year | 2.2 | 1.9 | 0.8 | 1.7 | <0.001 |
| Other races/year | 6.5 | 5.2 | 3.1 | 4.5 | <0.001 |
Complications and Additional Surgeries
Of 68 patients included in this study, 9 (13%) underwent an additional ipsilateral surgery during the follow-up period: 4 patients underwent conversion to total hip replacement and 1 patient underwent hip resurfacing, at a mean time of 5 years from the index arthroscopic surgery. Two patients underwent revision hip arthroscopy at 9 months and 4.3 years after index arthroscopic surgery. One patient underwent periacetabular osteotomy at 21 months after index arthroscopic surgery, and 1 patient underwent open surgical hip dislocation at 2 years after index arthroscopic surgery. No other complications were recorded.
Discussion
The most important finding of the present study was that, despite a majority of long-distance runners returning to any running (73.5%), only one-third returned to long-distance running completing ≥1 long-distance race after their hip arthroscopy surgery for FAIS. This study’s hypothesis was consistent with the reported findings. Furthermore, female long-distance runners were less likely to return to long-distance running after surgery.
This study confirms that long-distance runners represent a distinct cohort of runners. Compared with previously reported cohorts of runners undergoing hip arthroscopy for FAIS, the long-distance runners in this study were older (mean age, 37.8 ± 8.9 years vs 26.3 ± 7.8 and 32.4 ± 12.4 years).4,9 They also experienced increased loads on their hip joints due to the high running volumes and intensities during training and racing (mean weekly mileage before injury was 34.5 ± 16.9 vs 9.6 ± 6.5 miles). 9 Although these runners are known to exhibit resilience and motivation, 15 which are generally positive traits, these characteristics may also contribute to delayed presentation for medical care (mean time from injury to seeking care, 19 months). Finally, and importantly, for this population, returning to sport and running means training for, and participating in, long-distance races, rather than just casual running. These factors highlight the unique challenges in optimally managing injuries in this athletic cohort.
This study reports on lower rates of return to any running after hip arthroscopy among recreational and professional runners (73.5%), compared with previous reports (79%, 94%).4,9 Several reasons may explain these differences in return to running rates across studies. First, as shown above, long-distance runners have unique characteristics that may influence return to running rates. Second, there are differences in methodologies used to evaluate return to running across studies. To provide as accurate as possible return to running data, we utilized a designated sport-specific and population-specific return to running questionnaire and included only confirmed active long-distance runners who completed ≥1 long-distance race before their hip surgery. In addition, preinjury running metrics were collected to verify inclusion of long-distance runners only. In their study reporting on return to running after hip arthroscopy, Chen et al 4 chose to include runners running >1 mile per day and excluded runners who reported they did not intend to return to running after surgery. In addition, data on the methodology used to evaluate return to running was not provided and running metrics were not reported in their study.
The importance of accurate data on return to sport after surgical treatment of sports injuries is well recognized. However, a notable lack of standardization and validation in the methods used to determine return-to-sport data is evident in the published literature.13,17 The methodologies employed in studies reporting on return-to-sport can significantly impact the results and may introduce substantial biases. As suggested previously, 13 it is crucial that published papers clearly outline the specific methodology utilized in determining return-to-sport data. This clarity is essential to enable readers to fully understand the process of data collection and analysis, thereby enhancing the interpretation and application of the reported results.
Most long-distance runners who returned to any running (70%) reported that they were able to return to the same or better level of running compared with their preinjury status. This is an encouraging finding, especially when considering that nearly 9 out of 10 runners had reported having to modify or stop running altogether due to their hip-related symptoms before undergoing surgery. However, the data also showed that, as a collective group, their running performance metrics, such as weekly mileage, training hours, and number of races per year, decreased after surgery when compared with their preinjury running performance. Similar findings were described by Levy et al 9 in their study reporting on a high rate of return to running among professional and recreation runners after hip arthroscopy for FAIS. This study shed some light on possible reasons for this decrease. Whereas hip pain or discomfort was a factor cited by 30% of the runners who returned to running, other factors were equally prevalent, including life circumstances (36%), other physical limitations (30%), fear of reinjury (30%), and other reasons (Table 3). The wide range of reasons highlights the complex nature of return-to-sport evaluation after surgery in any sport.
This study reports on a mean time of 16.4 months to return to long-distance running. A comprehensive systematic review and meta-analysis reported on a mean time of 5.4 to 8.5 months to return to various sports after hip arthroscopy for FAIS. 3 Evaluating runners specifically, Levy et al 9 reported a mean of 8.5 months to return to running after hip arthroscopy for FAIS. Reasons for the extended period of return to participation in long-distance running events reported in this study may include the fact that a typical marathon training program is 16 to 20 weeks long and requires a certain baseline level of running fitness before starting the program. Another potential contributing factor to this longer recovery timeline could be the availability and scheduling limitations for long-distance running events.
Female long-distance runners are 5 times less likely to return to long-distance running after arthroscopic FAIS surgery when compared with male runners. Similarly, lower likelihood of return to sport was reported for female competitive soccer players, when compared with male players. 12 A recently published systematic review found that almost one-third of FAIS literature reporting on outcomes after arthroscopic treatment determined that female sex was a negative predictor of postoperative outcomes, while most studies found no difference or conclusive evidence when comparing sex-based outcomes after hip arthroscopy for FAIS. 16 Although reasons for possible sex-based outcome differences are unclear, there is a need for further research evaluating potential sex-based differences in outcomes after hip arthroscopy for FAIS. This research must also focus specifically on the athletic population and return-to-sport outcomes.
Return to any sport after an injury, and particularly after a surgery, is a complex process influenced by many factors.2,22 Although return to sport is an important goal to many athletes, others may be happy and satisfied with their outcome without going back to their sport. 12 This study found that most runners who did not return to any running were still satisfied with their surgery (67%). As previously suggested, athletes who are aware of the implications of their injury may decide not to return to their sport or modify their physical activity with the aim to maintain their hip health and general wellbeing.12,24 -26 This study reports on overall high rates of satisfaction from surgery: 85% for the whole cohort and 92% for those who returned to any running after surgery.
There are several limitations to this study. The return to running questionnaire used was specifically designed for this study; however, it is not a validated questionnaire. There is a lack of validated tools evaluating return-to-sport data, and reporting bias is a limitation we acknowledge as well. This study does not report on additional outcomes besides return to running, since these data were not available. This study also did not evaluate psychological readiness of runners to return to run after surgery, as these data were not available. A total of 16 runners were excluded for not completing the return to run questionnaire, and their data were not available. Finally, this was a retrospective, registry-based study, which carries its inherent risk of errors and biases, such as patients’ recall of their experiences.
Strengths of this study include evaluating and reporting on a unique group of athletes, long-distance runners, and the likelihood they will return to long-distance running after hip arthroscopy for FAIS, as well as presurgery and postsurgery quantitative running performance variables. The data reported were based on a population and sport-specific questionnaire and a systematic selection process confirming only long-distance runners were included.
Conclusion
This study found that arthroscopic management of symptomatic FAIS in long-distance runners enabled most (7 out of 10) of them to return to any running after surgery, whereas before surgery nearly 9 out of 10 runners had to modify or stop running due to hip symptoms. However, return to long-distance running, (completing half/full marathons) was accomplished only by one-third of runners after surgery. Satisfaction from surgery was not necessarily related to return to running, as most runners who did not return to running were nevertheless satisfied with their outcome. The finding that female long-distance runners were less likely to return to long-distance running after surgery is a direction for future research investigating risk factors in this unique population of athletes. This study can provide helpful context for clinicians when counseling patients with symptomatic FAIS who are considering hip arthroscopy and are concerned about return to long-distance running.
Supplemental Material
Supplemental material, sj-pdf-1-sph-10.1177_19417381251340072 for Return to Long-Distance Running After Hip Arthroscopy for Femoroacetabular Impingement by Niv Marom, Reena J. Olsen, Joost Burger, Matthew S. Dooley, Anil H. Ranawat, Bryan T. Kelly and Danyal H. Nawabi in Sports Health
Footnotes
The following authors declared potential conflicts of interest: N.M. has received education payments from Smith & Nephew. A.R. has received consulting fees from Arthrex, Anika, Bodycad, ConforMIS, Enhatch, Heron Therapeutics, Marrow Cellulation, NewClip, Stryker, Smith & Nephew, Xiros, CeramTec, and Convatec, royalties from Depuy Senthes, ConforMIS, and Stryker, and Research Support from CeramTec. D.N. has received consulting fees from ConMed and Newclip USA, education payments from Arthrex and Gothom Surgical Solutions, acquisitions payments from Smith & Nephew, and hospitality from Linvatec and Stryker. B.K. has received consulting fees from Arthrex, Organicell, and Smith & Nephew, royalties from Arthrex, hospitality from Stryker, and ownership interest from Organicell, Relief Labs, and Vincera Institute.
ORCID iDs: Niv Marom 
https://orcid.org/0000-0001-5393-6134
Reena J. Olsen
https://orcid.org/0000-0002-0012-1481
Anil H. Ranawat
https://orcid.org/0000-0002-3634-4871
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Supplementary Materials
Supplemental material, sj-pdf-1-sph-10.1177_19417381251340072 for Return to Long-Distance Running After Hip Arthroscopy for Femoroacetabular Impingement by Niv Marom, Reena J. Olsen, Joost Burger, Matthew S. Dooley, Anil H. Ranawat, Bryan T. Kelly and Danyal H. Nawabi in Sports Health