Hip and Groin Injuries in Professional Basketball Players: Impact on Playing Career and Quality of Life After Retirement

Abstract

Background:

Professional basketball players are at increased risk of hip and groin pain. Epidemiologic data exist on the prevalence of hip and groin issues among players in the National Basketball Association (NBA), but little is known about how these injuries affect athletes after retirement.

Hypothesis:

A high proportion of retired NBA athletes would have hip and/or groin pain.

Study Design:

Cross-sectional survey.

Level of Evidence:

Level 4.

Methods:

A survey was developed through an interdisciplinary focus group. The survey was developed to capture data regarding demographics, collegiate and professional athletic injuries, and current quality of life and musculoskeletal health. The questionnaire was electronically distributed to all members of the National Basketball Players Association using SurveyMonkey (N = 900).

Results:

A total of 108 (12%) retired NBA players completed the survey. More than one-third (36.3%) of athletes report currently experiencing hip and/or groin pain, and 17.6% had received injections for hip or groin conditions since retiring from the NBA. Since retiring, 14.7% of respondents had undergone total hip arthroplasty. The median Tegner activity level scale was 3 out of 10. Nearly one-third (32.4%) of athletes report moderate to severe problems with mobility, and close to half (48%) had moderate to extreme pain/discomfort.

Conclusion:

Hip and groin injuries are common among NBA athletes, affecting players throughout their careers and into retirement. A subset of athletes may exist in whom intra-articular hip pathology is not appropriately identified and treated while playing in the NBA.

Clinical Relevance:

Retired NBA athletes are at high risk of hip and groin pain after retirement and are more likely to require total hip arthroplasty compared with the general population.

Lower extremity injuries are the most common type of injuries sustained by professional basketball players, accounting for nearly two-thirds (62%) of all injuries.⁶ This is likely related to the significant volume and intensity of activity, including jumping, running, and pivoting movements, professional basketball players perform throughout their careers. In a 17-year study by Drakos et al,⁶ the overall incidence of injury was 19.1 per 1000 athlete-exposures in the National Basketball Association (NBA), with the majority involving the lower extremities. In addition to acute injuries, professional basketball players are also at risk of repetitive stress injuries, which, though less common, have the potential to be career-ending.¹²

Basketball is not traditionally thought of as a sport that is high risk for hip or groin injuries, compared with hockey or soccer. One study found that hip injuries only accounted for 6.2% of all injuries sustained by NBA players, while knee and ankle injuries were much more common.⁶ A similar study specifically evaluating hip and groin injuries in the NBA over a 24-year period identified an injury rate of 3.26 per 1000 athlete-exposures, resulting in a mean number of 6.3 ± 10 days missed per injury.¹⁰ In that study, the vast majority of injuries were related to the musculature around the hip, with the quadriceps most commonly involved (25% of all hip/groin injuries), and only 1.6% of all injuries were attributed to intra-articular etiology.¹⁰

Nonetheless, there has been an evolving understanding of intra-articular hip pathology, particularly in the young athlete population.¹⁰ Conditions such as femoroacetabular impingement,² extra-articular impingement,⁵ and inguinal disruption (ie, “sports hernia”)⁹ have become much more well understood over the past 2 decades. As well, with the advent of more advanced imaging¹⁵ and the increased utilization of hip arthroscopy, diagnosis of intra- and extra-articular hip and groin conditions has become more precise.¹⁴ In addition, prior studies have found retired professional athletes to be at an increased risk of both knee^1,17 and hip osteoarthritis,¹⁷ though these studies did not include basketball players.

Overall, scant literature exists about how hip injuries and hip pain affect NBA players after retirement and whether these conditions affect health-related quality of life (HRQoL). Thus, the objectives of this survey project were to (1) characterize the epidemiology of hip and groin injuries during the playing careers of NBA athletes and (2) assess the impact of hip and groin pathology on postretirement activity level, HRQoL, and overall health status.

Methods

Survey Development

The survey development process commenced with the formation of a focus group consisting of orthopaedic sports medicine physicians and a statistician, who determined the key areas of focus for the survey. Athletic trainers who had worked with NBA athletes were consulted to ensure items generated were comprehensive and appropriate. Four main categories of questions were developed: demographics, pre-NBA injuries, NBA-career injuries, and postretirement health status. A “sample to redundancy” technique was then employed: New surgeons and athletic trainers were surveyed until no new survey questions emerged. After completion of a first draft of the survey, 2 independent orthopaedic surgeons and a former professional basketball player were involved to assess face validity—that is, whether the survey appropriately covered relevant injuries and their impact on NBA players. Orthopaedic surgeons specializing in treating elite basketball players assessed the survey for content validity. The focus of the survey was tailored toward the hip, knee, and shoulder. Feedback was also elicited in the domains of user-friendliness, time to completion, and clarity. The survey was refined until a final, 61-item questionnaire was developed, consisting of dichotomous, ordinal, nominal, and open field scales. The survey included the Tegner activity level scale, which is a validated instrument for measuring overall activity level on a scale from 0 to 10 with brief descriptors.⁴ In addition, the EuroQol-5D (EQ-5D) instrument was included, which measures 5 quality of life domains on 5-point scales, as well as overall health status on a 0- to 100-point visual analog scale (VAS).¹¹ The survey was determined to be exempt from ethics board review by the University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board. See Appendix 1 (available in the online version of this article) for a complete version of the survey.

Survey Distribution

The survey was distributed using the SurveyMonkey electronic survey platform. It was delivered by email to all retired members of the National Basketball Players Association (NBPA). The survey was available for completion between April 1, 2017, and June 26, 2017, and was only open to NBPA members who had at one point played in the NBA and were retired at the time of survey distribution. Electronic restrictions ensured only 1 response per individual was possible. The NBPA sent out 3 reminder emails to all members to maximize player response rate. The survey was distributed to a total of 900 former NBA players.

Statistical Analysis

Data were exported from SurveyMonkey into a Microsoft Excel (v16.15; Microsoft) spreadsheet. All statistical analysis was performed using SPSS Statistics (v25; IBM Corp). Descriptive statistics were reported using mean or median as appropriate, as well as the corresponding measure of variance (ie, SD, range, etc).

Continuous variables were compared using the Student t test. Dichotomous variables were presented as proportions and compared using the chi-square test. Nonparametric data were compared using the Mann-Whitney U test. A P value <0.05 was established a priori as the threshold for statistical significance. Multiple regression analysis was performed to determine relationships between playing-career hip injury and postretirement HRQoL, activity level, and overall health.

Results

Demographics

A total of 108 retired NBA athletes responded to the survey (response rate, 12%). Not all respondents answered every single question, and there was no way to assess why questions may have been skipped. All data is reported with a denominator of 108 unless otherwise specified. The majority of respondents (N = 78, 72.2%) were older than 55 years. Sixty-eight percent of all respondents (N = 73) spent 5 to 14 years in the NBA. Center was the most commonly reported primary playing position (N = 31, 28.7%), and shooting guard was the least commonly reported (N = 15, 13.9%). All 5 positions were represented in the sample. Table 1 details the demographic characteristics of the respondents.

Table 1.

Demographic characteristics of respondents

Characteristic	Number (N = 108)	%
Age, y
35-44	10	9.3
45-54	20	18.5
55+	78	72.2
Years in NBA
0-4	27	25.0
5-9	34	31.5
10-14	39	36.1
15-19	8	7.4
Primary playing position
Point guard	18	16.7
Shooting guard	15	13.9
Small forward	19	17.6
Power forward	25	23.1
Center	31	28.7

NBA, National Basketball Association.

Injuries Prior to NBA Career

Nearly one-third of all respondents (N = 35, 32.4%) had sustained a significant orthopaedic injury prior to starting their NBA career. Only 4 (3.7%) athletes reported having sustained a hip injury prior to starting their NBA career.

Hip and Groin Injuries During NBA Career

Forty-one out of 105 (39.0%) respondents sustained hip and/or groin injuries while playing in the NBA. Among those, “groin pull/sports hernia” was the most common (N = 35/41, 85.4%), followed by labral tears (N = 5/41, 12.2%) and dislocation (N = 1/41, 2.45%). Of these 41 athletes, 14 (34.1%) reported having received an injection in their hip or groin while playing in the NBA. Only 3 of these 41 athletes (2.8%) required arthroscopic hip surgery while they were playing in the NBA. In addition, 4 athletes reported having had “sports hernia or core muscle” surgery while playing in the NBA, including 1 athlete who had also undergone arthroscopy (Table 2).

Table 2.

Hip and groin injuries while playing in the NBA ^a

	N (%)
Any hip injury	41/105 (39.0)
Type of hip injury b
Groin pull/sports hernia	35 (85.4)
Labral tear	5 (12.2)
Dislocation	1 (2.45)
Steroid injections	14 (34.1)
Surgery
Any surgery b	6 (14.6)
Hip arthroscopy	3 (7.3)
Sports hernia/core muscle surgery	4 (9.8)

NBA, National Basketball Association.

^aN = 41 unless otherwise specified.

^bRespondents can select more than 1 response.

Hip and Groin Pain After Retirement

More than one-third of all retired NBA players stated that they currently have hip and/or groin pain (N = 37/102, 36.3%). Eighteen athletes (N = 18/102, 17.6%) reported having received a hip or groin injection since retiring from the NBA. Fifteen respondents (N = 15/102, 14.7%) had undergone a total hip arthroplasty (THA); 1 of these patients had also undergone hip arthroscopy. Nearly half of these athletes (N = 7) had undergone more than 1 hip surgery since retirement. Only 60% of athletes (N = 9/15) who eventually underwent THA identified a specific hip or groin injury during their NBA career, the majority of whom described it as a “groin pull/sports hernia” (N = 6/9, 66.7%).

Retired NBA players who had sustained a hip or groin injury during their playing career were significantly more likely to require a hip or groin injection after retirement (30.0% vs 9.7%; χ² = 6.8; P = 0.009). Athletes who had sustained a hip or groin injury while in the NBA were also more likely to have current hip pain (45.0% vs 30.6%; χ² = 2.2; P = 0.14) and to undergo hip surgery (22.5% vs 9.7%; χ² = 3.1; P = 0.08) than those who did not sustain a hip or groin injury while in the NBA. These differences were not statistically significant.

Health-Related Quality of Life After Retirement

Overall, the median Tegner activity level score was 3 (light labor). On the EuroQol-5D questionnaire (EQ-5D), more than half of retired NBA athletes reported that they had at least some “problems in walking about” (N = 54/99, 54.0%). The majority of athletes had no problems with self-care activities (N = 88/100, 88.0%). More than half of respondents had slight or more significant problems doing their usual activities (N = 51/99, 51.5%). The majority of athletes had some pain or discomfort (N = 88/100, 88.0%), with nearly half (N = 48/100, 48.0%) rating it between “moderate” and “extreme.” Nearly half of all retired NBA players in the survey reported experiencing some level of anxiety or depression (N = 44/100, 44.0%). Overall, athletes rated their current health at a mean of 74.1 ± 17.1 on the EQ-5D VAS scale.

Those respondents who reported experiencing hip or groin pain after retirement had significantly lower Tegner activity levels compared with those who did not (median, 2.5 vs 4.0; Z = 2.4; P = 0.017). Those with hip pain also had significantly lower scores on the EQ-5D pain/discomfort domain (median, 3 vs 4; Z = 3.6; P < 0.001) (Table 3). Athletes with postretirement hip pain rated their overall health at a mean of 68.8 ± 19.3, which was significantly lower than those without hip pain (mean, 77.2 ± 15.1; P = 0.009). When adjusted for age and ethnicity, having sustained a hip injury during NBA career had a significant impact on current overall health (P = 0.015).

Table 3.

Results of Mann-Whitney U test comparing EQ-5D subscales between athletes with postretirement hip pain and those without

EQ-5D Subscale	Postretirement Hip Pain, Median	No Postretirement Hip Pain, Median	Z	P
Mobility	4	4.5	1.8	0.07
Self-care	5	5	1.4	0.17
Usual activities	4	5	1.7	0.10
Pain/discomfort	3	4	3.6	<0.001 a
Anxiety/depression	5	5	0.5	0.59

EQ-5D, EuroQol-5D questionnaire.

^aStatistically significant difference.

Discussion

The key findings of this survey study are that groin pulls and sports hernias are the most common hip and groin injuries sustained by NBA players, and the majority do not require operative treatment while in the NBA. After retirement, however, more than one-third of NBA athletes experience hip and/or groin pain, and nearly 1 in 6 undergo THA. Thus, despite what appears to be a small minority of NBA athletes who have intra-articular hip pathology while playing professional basketball, a much larger group goes on to have hip pain and require operative management after retirement.

The high percentage of retired NBA players undergoing THA is an interesting finding. The rate found in this survey (15%), is certainly much higher than the population norm for adults older than 50 years living in the United States (2.3%).¹³ Not only is this an unexpectedly high absolute rate of THA, but it was also high relative to the rate of total knee arthroplasty (TKA) among respondents, which was 9%. Previous epidemiologic studies have found that in the North American population, TKAs are roughly 1.5 to 2 times as common as THAs.^3,13 Interestingly, a previous study of retired professional athletes (not including basketball players) did find that while the rates of knee osteoarthritis were higher than the rates of hip osteoarthritis, a greater percentage of retired professional athletes underwent THA compared with TKA (8.3% vs 3.6%).¹⁷ The findings of the current study are consistent with that study and extend the finding to retired basketball players, where THA was found to be 1.6 times as prevalent as TKA in this study.

Four of 10 athletes reported that they had sustained a hip and/or groin injury while playing in the NBA. The vast majority of these injuries were classified as sports hernias or groin pulls, with very few athletes reporting intra-articular pathologies. This pattern, combined with the aforementioned high rate of THA after retirement, suggests a disconnect between the perceived hip health of NBA athletes while they are in the NBA compared with after retirement. There are a number of possible explanations for this. First, given that most of the respondents were older than 55 years, their NBA careers would have taken place 30+ years ago, when intra-articular hip pathology in young athletes was much less well understood than it is today. Thus, truly intra-articular pathologies may have been attributed to extra-articular etiologies such as inguinal disruption. Misdiagnosis of intra-articular hip pathology is common and well documented due to the complex anatomy and the common presence of concomitant diagnoses.^7,16 Alternatively, it is possible that the demands of professional basketball truly result in relatively few acute or repetitive intra-articular hip injuries but may nonetheless predispose athletes to hip osteoarthritis after retirement.

An important finding of this survey was that retired NBA athletes who sustained a hip or groin injury during their NBA career had a significantly lower overall quality of health after retirement. Thus, patient education and early identification of hip pathology is an important facet of caring for retired NBA athletes. Previous literature has revealed mixed evidence with regard to quality of life among retired professional athletes. A qualitative study of retired professional cricketers found that while most athletes reported pain or joint difficulties, 94% were satisfied with their quality of life.⁸ On the other hand, a controlled cross-sectional study of retired professional soccer players found that they had a lower quality of life compared with age-matched, nonprofessional athlete controls.¹ Overall, postretirement health and quality of life among professional athletes are important but often overlooked aspects of sports medicine.

The strengths of this study stem from its thorough methodology. The inclusion of a diverse focus and the use of the sample to redundancy method helped to ensure face and content validity. As well, multiple reminder emails and a 3-month window for survey completion helped maximize participation.

The limitations of the survey include the relatively small sample size, though the target population is unique and limited by nature. As well, a more detailed age breakdown would have allowed more specific analysis of the chronology of hip pathology in the retired professional basketball player. Furthermore, generalizability is somewhat limited given the very specific population chosen for study in this survey. Finally, the response rate is relatively low; however, this study concerns a specific group of athletes with limited previous literature available and thus nonetheless represents novel and valuable data.