Journal of Bodywork & Movement Therapies 37 (2024) 344–349

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

A rare soccer-related injury: Traumatic posterior hip fracture-dislocation –

Case series and overview of the literature
Stefan F. van Wonderen a, *, Bouke W. Hepkema b, Leo M.G. Geeraedts Jr. a
a
Amsterdam UMC location VUmc, Department of Surgery, Section Trauma Surgery, De Boelelaan 1117, Amsterdam, the Netherlands
b
Amsterdam UMC location VUmc, Department of Physical Medicine and Rehabilitation, De Boelelaan 1117, Amsterdam, the Netherlands

A R T I C L E I N F O A B S T R A C T

Handling Editor: Dr Jerrilyn Cambron Background: Soccer is one of the most popular sports with millions of active professional and non-professional
players worldwide. Traumatic hip dislocations are rare in soccer but can lead to major sequelae both physi­
Keywords: cally and psychologically. The aim of this review was to obtain insight into the outcomes after surgerically
Hip dislocation repaired hip fracture-dislocation in soccer players as well as rehabilitation and prevention.
Fracture-dislocation
Methods: Two cases of a posterior hip fracture-dislocation that occurred during an amateur soccer match are
Soccer
presented and mechanism of injury, complications and rehabilitation were analysed. Follow-up of both patients
Quality of life
was at least one year after surgery. Questionnaires and physical examinations were obtained to quantify and
qualify outcome.
Results: In both cases the hip-dislocations were reduced within 3 h after injury. Semi-elective open reduction and
internal fixation was performed within seven days. In one case, there was a concomitant Pipkin fracture and
sciatic nerve neuropathy. There were no postoperative complications. Follow-up showed full of range of motion
and normal hip functionality in both cases. However, both patients indicated a reduced quality of life and anxiety
related to the accident.
Conclusion: Traumatic hip fracture-dislocations during soccer practice are extremely rare. Despite uncomplicated
fracture healing after surgery and return of hip function, both patients still suffer from psychological problems
resulting in a decreased quality of life. Further research is required to enhance psychological outcomes, as well as
to facilitate return to pre-injury levels of participation and engagement in sports following traumatic hip fracture-
dislocations related to soccer.

1. Background
Soccer is one of the most popular sports with millions of active
professional and non-professional players worldwide. The overall inci­
dence of soccer injuries in adult male amateur players ranges from 4.3 to
29.6 injuries per 1000 soccer hours (Gatterer et al., 2012; Hagglund
et al., 2007; Kordi et al., 2011). The most frequent soccer injuries are
contusions, sprains and strains in the lower extremities (Nielsen and
Yde, 1989; van Beijsterveldt et al., 2014; Gebert et al., 2018). In
contrast, fractures are quite rare whereas hip fracture-dislocations dur­
ing soccer practice are extremely rare (Nielsen and Yde, 1989; van
Beijsterveldt et al., 2014; Gebert et al., 2018). In addition, traumatic hip
fracture-dislocations in sports represents 1.4–3.2% of all traumatic hip
dislocations (Sahin et al., 2003; Pascarella et al., 2019).
Hip dislocations can be anterior or posterior and are associated with
femoral head-, neck and/or acetabular fractures. Anterior hip disloca­
tions represent 10% of all traumatic hip dislocations whereas posterior
hip dislocations represent 90% (Clegg et al., 2010). Mechanism of injury
associated with posterior hip dislocation is forced adduction, internal
rotation and flexion of the hip. Typically, 70–100% of traumatic hip
fracture-dislocations occur as a consequence of motor vehicle accidents
(MVA), where the patient’s bent knee makes contact with the dashboard
upon impact (Clegg et al., 2010; Cooper et al., 2018). Posterior hip
dislocations are associated with sciatic nerve injury, osteoarthritis,
avascular necrosis and heterotopic ossification (HO) (Pascarella et al.,
2019; Clegg et al., 2010).
The objective of this review was to gain a comprehensive under­
standing of the outcomes, encompassing both physical and

* Corresponding author. Department of Surgery, Section Trauma Surgery , Amsterdam UMC, location VUmc , De Boelelaan 1117, PO Box 7057, 1007 MB,
Amsterdam, the Netherlands.
E-mail address: s.vanwonderen@amsterdamumc.nl (S.F. van Wonderen).

https://doi.org/10.1016/j.jbmt.2023.11.037
Received 9 December 2022; Received in revised form 5 September 2023; Accepted 24 November 2023
Available online 9 December 2023
1360-8592/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S.F. van Wonderen et al. Journal of Bodywork & Movement Therapies 37 (2024) 344–349

psychological aspects, following surgical repair of hip fracture-
dislocations in soccer players. Additionally, the review aimed to
explore aspects of rehabilitation and injury prevention. In this review,
two cases of amateur soccer players with traumatic posterior hip
fracture-dislocations and an overview of the literature will be presented.
2. Method
Two cases of non-professional soccer players with traumatic hip
dislocation-fracture were prospectively reviewed up to two years after
hospital discharge. The Copenhagen Hip and Groin Outcome Score
(HAGOS-NL) was obtained as a patient reported outcome questionnaire
for pain, symptoms, physical function in daily living, physical function
in sports, participation in physical activities as well as hip and/or groin
related quality of life (QoL) (Giezen et al., 2017; de Groot et al., 2009;
Binkley et al., 1999). The EuroQol Five Dimensions Health Questionnaire
with five-level scale (EQ-5D-5L) was used as measurement of generic
health (Herdman et al., 2011). With regard to physical examination,
cluster of hop tests from Gustavsson were obtained after a minimum of
one year after surgery to monitor limb symmetry (Davies et al., 2020). A
search strategy was developed to search PubMed, Embase and Google
Scholar for the prevalence of hip-fracture dislocation after soccer related
injury. Search terms were posterior hip-fracture dislocation, soccer or
football player and similar terms. The search strategy in PubMed can be
found in Appendix 1. Studies that reported hip-fracture dislocations
after soccer related injury (not American Football) were included. A
language restriction was applied: English, German and Dutch articles
were included. In addition, reference lists of articles were examined to
identify additional studies. Written consent for participation and pub­
lication of this study was obtained from both individuals. This report
followed the CARE guidelines.
3. Results/description of cases
3.1. Literature overview
Thirty-three articles were screened. In total, eight cases of traumatic
hip dislocations in soccer have been reported (Bakalakos et al., 2019;
Lax-Perez et al., 2012; Liska et al., 2011; Yasin and Singh, 2009; Schuh
et al., 2009; Giza et al., 2004). Five patients were injured during outdoor
soccer (Bakalakos et al., 2019; Lax-Perez et al., 2012; Liska et al., 2011;
Schuh et al., 2009; Giza et al., 2004) and 3 patients from indoor soccer
(Yasin and Singh, 2009; Giza et al., 2004). Studies were described in
Table 1 including patient information, treatment and outcomes.
3.2. Case presentation I
A young adult male was presented at the Emergency Department
(ED) with a soccer related injury of his left hip. History taking revealed
that the patient fell on his knee while his hip was in end range of internal
rotation and adduction. On observation the injured extremity was
internally rotated and adducted. Plain radiographs of the proximal
femur and pelvic confirmed a posterior hip dislocation associated with a
posterior acetabular wall fracture (Fig. 1A). The dislocation was reduced
within 3 hours after trauma under general analgesia in the operation
room. Post reduction computer tomography (CT) confirmed correct
reduction associated with an ipsilateral posterior wall fracture and an
intra-articular fragment (Fig. 1C). Seven days after injury, elective open
reduction and internal fixation (ORIF) was performed (Fig. 1B). The
intra-articular bone fragment was removed and fixation was obtained by
two interfragmentary lag screws and a buttress plate. Thromboprophy­
laxis consisted of subcutaneous (s.c.) low-molecular-weight heparin
(LMWH) for six weeks and to reduce HO, indomethacin was adminis­
tered for two weeks post-surgery. Post-operative treatment consisted of
partial weight bearing (10%) for six weeks. The patient was discharged
four days after surgery without postoperative complications and
referred to a primary care physical therapist according to the transmural
trauma care model (TTCM) (Wiertsema et al., 2019). On the 6-month
and 12-month follow-up, the patient had full range of motion (FROM)
of the hip when compared to the non-injured site and was free of pain.
Plain radiographic images during follow-up showed a progressive
consolidation and no signs of avascular necrosis. Parameter outcomes
after two years are described in Table 2. With regard to questionnaires
outcomes, both HAGOS-NL and EQ-5D-5L showed a reduced value of
QoL, potentially as a result of anxiety after trauma. In contrast, physical
examination showed a normal hip symmetry of movement without
limitations.

Table 1
Overview of case reports of soccer-related traumatic hip-fracture dislocations.
Author Patient information Treatment Follow-up

Bakalakos et al., 2018 ( 33-years, male ORIF: two lag screws. 12-month follow-up: FROM and free of pain.
Bakalakos et al., 2019) Posterior hip-fracture Kocher-Langenbeck approach
dislocation
Lax-Perez et al., 2012 ( 28-years, male ORIF: two compression screws and an eight-hole 18 months follow-up: slight lack of flexion and internal rotation
Lax-Perez et al., 2012) Posterior hip-fracture plate. and a Harris Hip Score of 97.87.
dislocation Kocher-Langenbeck approach.
Liska et al., 2010 (Liska 36-years, male ORIF: Decompression of the femoral head and an 3 months follow-up: removal of the screw because of persisting
et al., 2011) Avascular necrosis electromagnetic-inducing screw was implanted. pain and severe posttraumatic osteoarthritis.
following hip fracture-
dislocation
Yasin and Singh, 2009 ( 50-years, male ORIF: two lag screws. 24-months follow up: asymptomatic.
Yasin and Singh, 2009) Posterior hip fracture- Kocher-Langenbeck approach
dislocation
22-years, male ORIF: lag screw. 24-months follow up: asymptomatic.
Posterior hip fracture- Posterior approach.
dislocation
Schuh et al., 2009 (Schuh 38-years, male Closed reduction within 2h using general 6-months follow-up: FROM
et al., 2009) Anterior hip dislocation anesthetic.
Giza et al., 2004 (Giza 28-years, male ORIF: Reconstruction plate 12-months follow-up: free of pain and a short musculoskeletal
et al., 2004) Posterior hip fracture- Kocher-Langenbeck approach function assessment (SMFA) score of 5.43 (best score = 0, worst
dislocation score = 100).
41-years, female ORIF: Reconstruction plate 12-months follow-up: free of pain and a SMFA score of 9.78. 5◦
Posterior hip-fracture Kocher-Langenbeck approach deficit passive internal rotation.
dislocation

345
S.F. van Wonderen et al.
Fig. 1. (A) Antero-posterior hip X-ray: posterior fracture-dislocation of the left hip of case I. (B) CT scan axial view of case I: after hip reduction showing dislocation
of the dorsal acetabular fracture fragment (dorsal/cranial dislocation) as well as an intra-articular bone fragment. (C) Iliac wing view x-ray postoperative of case I:
restoration of posterior wall using two interfragmentary compression screws and a buttress plate.
3.3. Case presentation II
Another young adult male was presented at the ED after making a
misstep during a physical soccer duel while his knee was in full exten­
sion and a flexed hip resulting in severe pain and immediate inability to
walk or move his right foot. On observation the injured extremity was
internally rotated and adducted and neurological examination showed
paresis of the tibialis anterior muscle, extensor digitorum longus muscle,
extensor hallucis longus muscle and peroneus longus muscle. In addi­
tion, the patient had decreased sensitivity at the dorsolateral side below
his right ankle. Plain radiographs showed a posterior hip dislocation
associated with an acetabular fracture (Fig. 2A). The dislocation was
reduced with procedural sedation and analgesia in the ED. Plain radio­
graphs and CT-scan confirmed adequate reduction and the association
with a fracture of the posterior wall of the acetabulum and femoral head
(Fig. 2B and C). Five days after admission ORIF was performed using the
Kocher-Langenbeck approach with trochanter osteotomy introducing
two lag screws in the femoral head fracture after reduction, two lag
screws in the posterior wall fracture and a ten-hole buttress plate. The
sciatic nerve was macroscopically intact. Postoperative radiographs
showed a good reduction of the fragments (Fig. 2D). After surgery, the
inability to dorsiflex his right foot was maintained. Plantar flexion
showed no limitations regarding strength and ROM. The patient was
discharged six days after surgery without postoperative complications
and was also referred to a primary care physical therapist according to
the TTCM. Patient II also received thromboprophylaxis for 6 weeks as
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Journal of Bodywork & Movement Therapies 37 (2024) 344–349
well as indomethacin for two weeks post-surgery and post-operative
treatment consists partial weight bearing for 6 weeks. On the 3-month
and 6-month follow-up, the patient had FROM of the hip when
compared to the non-injured site and was free of pain but still had a
remaining foot drop. Electromyography was performed to confirm
neuropathy of the sciatic nerve most likely as the result of axonotmesis.
Plain radiographic images during follow-up showed a progressive
consolidation and no signs of avascular necrosis. As the results of sciatic
nerve branch neuropathy, the patient started using an ankle foot
orthosis (AFO) for outdoor performance. Outcome parameters after one
year of follow up are described in Table 2. Both HAGOS-NL and EQ-5D-
5L showed a reduced QoL, especially without using an AFO. Without
AFO, a reduced mobility in physical activities was seen as well as in­
crease in anxiety for injuries. In contrast, physical examination showed a
normal hip symmetry regarding strength and ROM without limitations
in mobilization while using an AFO.
4. Discussion
In this study, both patients reported a limited QoL after the accident
in follow-up questionnaires. Patient I showed a reduced QoL, even after
surgical reconstruction of the acetabulum without complications. The
patient was free of pain and had FROM. However, anxiety for sustaining
new injuries and depressed feelings dominated his post-accident life
resulting in a diminished QoL. Even after one year of follow-up, Patient
II continued to experience neuropathy in the sciatic nerve bundle,
S.F. van Wonderen et al. Journal of Bodywork & Movement Therapies 37 (2024) 344–349

Table 2
Parameter outcomes of patient I and II. HAGOS, The Copenhagen Hip and Groin Outcome Score; EQ-5D-5L, EuroQol Five Dimensions Health Questionnaire with five-
level scale; ADL, activities of daily living; PA, physical activities.
Patient HAGOS-NL EQ-5D-5L Hop test

I Pain 75 Mobility 1 Vertical jump 86%

Symptoms 71,4 Self-care 1 Hop for distance 92%
ADL 70 Usual activities 1 Side to side 94%
Sport 50 Pain/discomfort 1
PA 25 Anxiety/depression 5
QOL 10

II Pain 100 Mobility 1a/4b Vertical jump 86%a

Symptoms 92,86 Self-care 1a/1b Hop for distance 92%a
ADL 100a/90b Usual activities 1a/4b Side to side 94%a
Sport 65,62 Pain/discomfort 1a/2b
PA 25 Anxiety/depression 1a/4b
QOL 65
a
With ankle foot orthosis (AFO).
b
Without AFO.

leading to a diminished quality of life and limitations in physical ac­
tivities and sports performance. On the contrary, the surgical treatment
was performed without complications. Similar results were observed in
the study conducted by Borg et al., which found that patients who un­
derwent surgical treatment for displaced acetabular fractures exhibited
a decreased QoL score when compared to the general population after a
two-year follow-up period. Additionally, the authors showed that
anatomic reduction resulted in higher QoL scores in most dimensions
compared to complications (Borg et al., 2012).
In similar case reports of traumatic hip dislocation in soccer players,
adequate surgical treatment is commonly described, yet there is often an
absence of quantified data concerning physical and psychological
outcome parameters. Only Giza et al. reported a short musculoskeletal
function assessment (SMFA) outcome score in two patients after operative
treatment. In the majority of case reports, all patients regained their
FROM and were pain-free in the subsequent months following operative
reduction. Nevertheless, Liska et al. documented posttraumatic
avascular necrosis and osteoarthritis during the follow-up period
(Bakalakos et al., 2019; Lax-Perez et al., 2012; Liska et al., 2011; Yasin
and Singh, 2009; Schuh et al., 2009; Giza et al., 2004). Cases of posterior
hip fracture-dislocations were also noted in rugby, gymnastics, and
basketball (Peter et al., 2003). However, it’s worth noting that sciatic
nerve injury was only documented in a single case report (Tennent et al.,
1998).
Traumatic hip fracture-dislocations in sports represents 1.4–3.2% of
all traumatic hip dislocations (Sahin et al., 2003; Pascarella et al., 2019)
and only eight cases have been reported in non-professional soccer
players (Bakalakos et al., 2019; Lax-Perez et al., 2012; Liska et al., 2011;
Yasin and Singh, 2009; Schuh et al., 2009; Giza et al., 2004). A posterior
hip dislocation is associated with a flexed, internally rotated, adducted
and shortened leg. In addition, a neurovascular exam should be per­
formed prior to reduction (Brooks and Ribbans, 2000). The hip dislo­
cation can be recognized on a radiographic anteroposterior view of the
pelvic (Tornetta and Mostafavi, 1997). After reduction, radiographs and

Fig. 2. (A) Antero-posterior hip X-ray: posterior fracture-dislocation of the right hip of case II. (B) Computed tomography of the pelvic in coronal view of case II:
fracture of the right femoral head. (C) Computed tomography of the pelvic in sagittal view of case II: cranioposterior rim fragment of the acetabulum. (D) Antero-
posterior hip X-ray postoperative: restoration of the acetabulum performing trochanter osteotomy and insertion of two interfragmentary lag screws in the femoral
head fracture. Two interfragmentary lag screws were inserted in the posterior wall fracture and a ten-hole buttress plate was used to stabilize the fragments.

347
S.F. van Wonderen et al.
radiographic CT imaging should be performed to reveal occult fractures
or intra-articular bodies (Brooks and Ribbans, 2000). Surgical inter­
vention is necessary when there are concomitant fractures involving the
femoral head, neck, or acetabulum, or when the hip joint is deemed
unstable (Pascarella et al., 2019). Posterior hip dislocations are often
linked to potential complications, including sciatic nerve injury, osteo­
arthritis, avascular necrosis, and the formation of HO (Pascarella et al.,
2019; Clegg et al., 2010). Previous studies suggest that hip reduction
should ideally be carried out within 6–8 hours after the traumatic event
to minimize the risk of avascular necrosis (Sahin et al., 2003; Pascarella
et al., 2019). In our cases, Patient I underwent hip reduction within 3
hours after the injury, while Patient II’s hip was reduced within 1 hour
following the trauma.
Regarding patient outcomes, this is the first reported case of sciatic
nerve injury related a traumatic hip fracture-dislocation in soccer. Ac­
cording to Cornwell and Radomisli, the incidence of nerve injury after
traumatic hip fracture-dislocation ranges from 0 to 20% in adults
(Cornwall and Radomisli, 2000). In these cases, the peroneal bundle of
the sciatic nerve is most often injured as a result of acute laceration,
stretching, compression or encased in HO (Cornwall and Radomisli,
2000). Partial recovery occurred in 60–70% of the patients without
correlation to trauma mechanism or treatment (Cornwall and Radomisli,
2000). However, in our case the peroneal axonotmesis did not recover
and the patient required an AFO for outdoor performance.
While there is a lack of specific studies on the prevention of hip
fracture-dislocations, it is worth noting that professional soccer players
and other athletes engaged in high-performance activities recognize the
significance of rigorous and appropriate warm-up techniques. These
techniques have been shown to enhance performance and reduce the
occurrence of sports-related injuries (Fradkin et al., 2010). Since all
soccer injuries contain a high percentage of sport related injuries, the
International Federation of Association Football (FIFA) introduced the
FIFA 11+ prevention programme (Bizzini et al., 2013). This programme
include specific strengthening, balancing, jumping and landing exercises
and should be included during a structured warm-up session which
result to injury reduction and so, may reduce traumatic hip
fracture-dislocations (Bizzini et al., 2013). In a systematic review and
meta-analysis, it was shown that the FIFA 11+ prevention program re­
sults in a substantial injury-preventing effect of 39% by reducing soccer
injuries in recreational and sub elite soccer players (Thorborg et al.,
2017). Furthermore, there have been no reported cases of professional
soccer players experiencing hip fracture-dislocations, possibly attribut­
able to their rigorous training and warm-up routines. Nevertheless,
given the rarity of such injuries in soccer, we can only speculate that
implementing appropriate warm-up techniques may contribute to
reducing the occurrence of this specific type of injury.
Throughout the follow-up period, neither of the patients resumed
their participation in sports following the injury, primarily due to psy­
chological factors. Psychological factors have been demonstrated to play
a crucial role in the recovery and rehabilitation period after sports in­
juries. A systematic review revealed that autonomy, competence, and
relatedness were linked to the likelihood of athletes returning to sports
following an injury (Ardern et al., 2013). Positive psychological re­
sponses such as motivation, confidence and lower levels of anxiety were
associated with returning to the preinjury level of participation and
returning to sport more quickly. Anxiety was a prominent emotional
response at the time of returning to sport despite the fact that overall
emotions became more positive as recovery and rehabilitation pro­
gressed. The authors recommend that clinicians should prioritize
addressing anxiety and also emphasize psychological factors related to
autonomy and competence during rehabilitation (Ardern et al., 2013).
Utilizing confidence-boosting strategies like goal setting can be partic­
ularly effective in this regard (Ardern et al., 2013).
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Journal of Bodywork & Movement Therapies 37 (2024) 344–349
5. Conclusion
Traumatic hip fracture-dislocations during soccer practice are
extremely rare but can have significant and potentially severe sequelae.
Despite uncomplicated fracture healing after surgery and attaining
FROM and weight bearing, both patients still suffer from anxiety,
depression or the consequences of peroneal nerve bundle neuropathy
resulting in a decreased QoL. Positive psychological reactions, along
with factors like autonomy, competence, and connectedness, appear to
play a significant role during rehabilitation when individuals are pre­
paring to return to sports. Further research is required to enhance psy­
chological outcomes, as well as to facilitate return to pre-injury levels of
participation and engagement in sports following traumatic hip fracture-
dislocations related to soccer.
Ethical approval
Written consent for participation and publication of this study was
obtained from both individuals. No traceable patient information is
contained within this manuscript.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Stefan F. van Wonderen: Writing – original draft. Bouke W. Hep­
kema: Investigation, Writing – review & editing. Leo M.G. Geeraedts:
Conceptualization, Investigation, Supervision, Writing – review &
editing.
Declaration of competing interest
There are no known conflicts of interest associated with this paper.
Acknowledgments
Not applicable.
Appendices.
Appendix 1
Search: (hip fracture-dislocation[Title/Abstract] OR hip fracture
[Title/Abstract] OR hip dislocation[Title/Abstract] OR collum fracture-
dislocation[Title/Abstract] OR collum fracture[Title/Abstract] OR col­
lum dislocation[Title/Abstract]) AND (Soccer[Title/Abstract] OR foot­
ball[Title/Abstract] OR futsal[Title/Abstract]) = 33 hits.
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