After dislocating and fracturing his right hip during training camp in 2013, Dennis Pitta suffered the same injury just 14 months later. At the time, Ravens fans feared that the second injury could be career-ending. With news that Pitta is being placed on injured reserve yet again, it appears this truly may be the end.
Media reports have made it clear that Pitta wants to play again, and he refuses to announce retirement at this moment. However, doctors have advised Pitta not to play, and rightfully so. This article will examine the anatomy and nature of Pitta's injury as well as highlight the risks that he will be taking should he decide to return to the field next season.
ANATOMY OF THE HIP JOINT
The hip is an example of a ball-and-socket joint. The femoral head (top of the thigh bone) is shaped like a ball and articulates with the acetabulum of the pelvis, which serves as the socket.
The hip is, typically, a very stable joint. This is due to the fact that the femoral head sits deep in the socket and the hip joint has such strong ligaments to help keep it in place (see below). In addition, there are also big, strong muscles that surround the hip region and aid in providing further stability.
HOW DO THESE INJURIES OCCUR?
Extremely high forces are typically required in order to cause the hip to dislocate. For that reason, the vast majority of these injuries occur as a result of major automobile accidents. The most common mechanism of injury in these cases is when the person's knee strikes the dashboard, thereby forcing the femoral head to translate posteriorly over the rim of the acetabulum.
It is actually quite rare to experience a single hip dislocation in sports, let alone two. Multiple studies have examined the prevalence of these injuries in athletics and each has found that only 2% to 5% of all hip dislocations occur during participation in sports.
ANALYSIS OF PITTA'S LATEST INJURY
Given all of this information, the most concerning aspect of Pitta's latest injury is how it occurred. For those who do not remember, he was not hit, tackled, or anything. He wasn't even touched. Quite simply, a non-contact injury resulting in a hip dislocation is a major red flag and suggests anatomical dysfunction.
It was reported after his first injury that his hip ligaments were not damaged in the process. However, the mechanism of his most recent injury certainly implies otherwise. In order for his hip to dislocate like it did, the ligaments had to be compromised in some way. This would result in significant instability of the hip and would explain how a dislocation occurred without any contact.
POTENTIAL RISKS OF PLAYING AGAIN
Most fans expected that time and rehabilitation would allow for his hip to fully heal. Athletes get hurt and return to play all the time, right? But it's important to remember that this is not your typical sports injury.
A common argument I hear is that injuries are a part of the game and there are always risks involved. This is certainly true. However, if Pitta chooses to play again he carries a higher risk of injury and is susceptible to a number of complications; some being very serious.
The most obvious risk he takes is dislocating his hip yet again. It's pretty evident that his injuries have caused some laxity to the ligaments that help support his hip. Unfortunately ligament healing is fairly slow and they don't always heal completely. Research has shown that even a year after ligamentous injury a large percentage of patients still demonstrate signs of joint laxity and instability.
Pitta's rehab has likely emphasized strengthening the muscles that surround his hip in an effort to help gain further stability. However, this can only accomplish so much. Without adequate ligamentous support, the hip will be in grave danger of dislocating again. With each dislocation he risks causing further damage to the articular cartilage, ligaments, nerves, and other structures in and around the hip.
One of the most serious complications would be a disruption of the blood supply to the head of his femur. This is termed avascular necrosis and is the same hip condition that ended the playing career of Bo Jackson.
This pathology is essentially defined as a death of bone tissue due to a lack of blood supply. The femoral head relies on blood from the femoral neck (area between femoral head and femoral shaft) in order to survive. When the hip dislocates blood flow to the hip can be disturbed. When this blood supply becomes compromised the bone begins to weaken and, eventually, it dies.
It's plausible that Pitta has some underlying avascular necrosis already. However, the risk of him developing this condition certainly increases should he experience subsequent dislocations of his hip. There's no doubt that we all would love to see Pitta return to play again. But this is a perfect example of when the risks of playing simply outweigh the rewards.
-Dr. Bobby Esbrandt, PT, DPT, PES