Debate: Sports Hernia   Friday, October 14, 2011 • 14:45 – 15:05pm  General Session     Sports Hernia: Caused by FAI    Christopher Larson, MD USA    Sports Hernia: Not an FAI Thing   Per Hölmich, MD DENMARK     

Sports Hernia / Athletic Pubalgia: Caused by FAI? Christopher M. Larson MD Director: Arthroscopic Hip Joint Preservation Minnesota Orthopedic Sports Medicine Institute (MOSMI) Twin Cities Orthopedics (TCO) Athletic Pubalgia / Sports Hernia and Associated Intra and Extra-articular Hip Pathology: Piecing the Puzzle Together -

Athletic Pubalgia / Sports Hernia Background and Definition o Exertional Lower abdominal pain in athletes o Source of significant disability and time lost from athletics o Typically insidious onset of symptoms o Historically male predominance o Seeing increasing number of females o Multiple structures implicated and variable presentation  Internal / External oblique / transversalis fascia  Lower Rectus Abdominus / Conjoined tendon  Proximal Adductor longus / Brevis / Magnus, Pectineus, Gracilis  Deficient posterior inguinal floor / dilated superficial inguinal ring

  



Figure 6: Forces at work for Athletic Pubalgia

-

-

-

 Figure 7: External oblique / fascial tears (Sports Hernia)  Physical Examination o TTP over internal / external obliques o TTP over the conjoined tendon / rectus abdominus o TTP pubic symphysis / tubercle o TTP proximal adductors / pectineus / gracilis o Pain resisted hip adduction o Pain resisted sit-ups / crunches o Evaluate for intra-articular hip disorders (ROM / Impingement tests) Diagnostic Injections o Injections followed by P.E. or Exercise Challenge o Symphyseal Injections  Dye tracking up rectus / down the adductors o Intra-articular Injections o Psoas bursal injections o Adductor tendon sheath / pubic cleft injections Imaging clues o Plain Radiographs  Hip pathomorphology (FAI)  Oseitis Pubis (lysis, sclerosis, cystic changes)

   o MRI 

-

Figure 8: Bilateral FAI and Oseitis pubis

Underlying hip pathomorphology  FAI , dysplasia , labrochondral pathology  Rectus abdominus adductor apponeurotic tearing  Adductor tears / tendinopathy  Osteitis pubis  Specific athletic pubalgia MRI protocols  MRI can be unremarkable Conservative Treatement o Variable success in the literature

-

-

o Activity modification (not always practical for elite athletes) o Avoid deep hip flexion / heavy weight squats, cleans, lunges in weight room o Focus on core stability and decreasing anterior pelvic tilt mechanics  Focus on Gluteal muscles initially and later on lower abdominals o Occasionally symphyseal / pubic cleft / psoas bursal corticosteroid injections Surgical Treatment o If unable to participate or compete consider in season surgery o If able to compete but limiting surgery after the season o Multiple surgical procedures described with > 90% return to sports in most  Broad pelvic floor repairs  External oblique / transversalis fascial repairs  Posterior inguinal floor repairs  Mesh repairs  Open / mini open / endoscopic techniques describes  +- concomitant adductor / pectineus releases  +- neurolysis / neurectomy o Outcomes studies with validated measures limited (RT sports) Association of Intra-articular and Extra-articular Pathology Piecing together a Puzzle / Subset of Elite Athletes Intra-articular pathology o NFL study  Association of labral tear, rectus abdominus tear, adductor strain  Sports Hip Triad o Femoroacetabular Impingement (FAI)  Cam and pincer-type  Labral-chondral injury  Disability in athletes  Associated ROM deficits (Flexion / IR / Abduction)  90% of NFL prospects with X-rays had FAI o Osteitis Pubis  Symphyseal lysis / cystic changes / sclerosis

  

Figure 9: MRI reveals increased signal c/w osteitis pubis

 

-

-

> 50% of NFL prospects with X-rays have osteitis pubis Relationship to hip ROM deficits (? FAI)  Australian rules football studies o Chronic Adductor Pain / Pathology  34 athletes with long standing adductor pain  94% had radiographic FAI o Association of FAI and Athletic Pubalgia / Sports Hernia  37 hips in elite athletes (32 current or former professional / national level / collegiate level)  All had athletic pubalgia and symptomatic intra-articular pathology  95% FAI  70% osteitis pubis  Athletic pubalgia repair only = 25% return to sports without limitations  Hip arthroscopy only = 50% return to sports without limitations  Concurrent or eventual surgical management of both Athletic Pubalgia and Intra-articular hip pathology = 89% return to sports without limitations  13 hips same setting hip arthroscopy and Athletic Pubalgia repair Current Theory (Subset of Elite Athletes) o FAI leads to ROM limitations (FF/IR) o ROM limitations lead to increased stress / demand on extra-articular structures o This increased stress on extra-articular structures can lead to:  Athletic pubalgia / Sports Hernia  Proximal Adductor / Pectineus / Gracilis injury  Osteitis pubis Conclusion o Athletic Pubalgia / Sports Hernia is a real entity in Athletes o Can be associated in some cases with intra-articular hip pathology o General Surgeons and Orthopaedic surgeons need to work closely together o Management of hip pathology if present may allow for healing of extraarticular hip pathology o Concurrent or eventual staged management of intra-articular and extraarticular hip pathology when necessary leads to a predictable return to sports in most

Selected References: 1. Meyers WC, Mckechnie A, Philippon MJ, Horner MA, Zoga AC, Devon ON. Experience with “sports hernia” spanning two decades. Ann Surg 2008. 248(4):656-65 2. Brown RA, Mascia A, Kinnear DG, Lacroix V, Feldman L, Mulder DS. An 18 year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment,and results.

3. Feeley BT, Powell JW, Muller MS, Barnes RP, Warren RF, Kelly BT. Hip injuries and labral tears in the national football league. Am J Sports Med 2008. 36(11):2187-95. 4. Verrall GM, Slavotinek JP, Barnes PG, Esterman A, Oakeshott RD, Spriggins AJ. Hip joint range of motion restriction precedes athletic chronic groin injury. J Sci Med Sport 2007. 10(6):463-6 5. Verrall GM, Hamilton IA, Slavotinek JP, Oakeshott RD, Spriggins AJ, Barnes PG, Fon GT. Hip joint range of motion reduction in sports-related chronic groin injury diagnosis as pubic bone stress injury. J sci Med sport 2005. 8(1):77-84 6. Weir A, de Vos RJ, Moen M, Holmich P, Tol J. Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long standing adductor-related groin pain. Br J Sports Med 2010, Jun. 7. Larson CM, Giveans MR, Pierce B. Association between athletic pubalgia / sports hernia and intra-articular pathology: a case series. Arthroscopy 2010, June 27(6):768-75

 

Debate: Sports Hernia - Not an FAI Thing  Per  Hölmich, MD