Athletic Pubalgia / Sports Hernia & Proximal Hamstring Injuries: Making the Diagnosis and What to do?? Christopher M. Larson MD

Disclosures • Consultant: – Smith & Nephew – A3 surgical

• Stockholder: – A3 surgical

Groin, Hip, & Abdominal Injuries are increasingly recognized in Athletes

Cause of GROIN pain Typically 4 Categories • 1. Adductor Dysfunction • 2. Osteitis Pubis • 3. Hip Joint / Intra-articular Pathology • 4. Sports Hernia / Athletic Pubalgia

Geographical Differences Under / Over-Diagnose Sports Hernia / AP

• European Soccer / Football Players with Groin pain: – More often diagnosed with “Sports Hernia”

Sports Hernia / Athletic Pubalgia “Definition” • Exertional lower abdominal pain and sometimes adductor related pain in athletes • Source of significant disability and time lost from athletic activity

• Australian Rules Football Players with Groin pain – More often diagnosed with “Osteitis Pubis”

• Better with Rest & Worsens with Athletics • Evolving concept with varying presentations in athletes

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Structures Involved??? – Distal rectus Abd / TTP pubic tubercle

Neural Entrapment • Ilioinguinal = sensory to the groin

• Genitofemoral = sensory to scrotum and labia

– Adductor / pectineus / gracilis origin – Internal / external oblique / transversus abdominus

• Iliohypogastric = sensory to the lower abdomen

– Posterior inguinal floor / transversalis fascia and dilated external inguinal ring

Sports Hernia / Athletic Pubalgia

“Clinical Presentation” • Acute = • Trunk hyperextension, Hip abduction – Acute rectus abdominus tear / Adductor injury

• Insidious = • Increasing lower abdominal & adductor related pain

Hip and Pelvis Disorders are Intertwined / Puzzle

• Radiographic FAI seen in 86% of patients undergoing “Sports Hernia” repair (84% Cam-type Fai) • Economopoulos et al., Sports Health 2014

Physical Examination • Palpate: – Obliques / Transversus – Rectus Abdominus / conjoined tendon – Pubic symphysis / tubercle – Adductors / Pectineus / Gracilis

• Resisted: – Adduction – Sit-ups

Cam Induced Symphyseal Motion • Cadaveric study • Increased Symphyseal motion secondary to Cam-type FAI

• Significant overlap and Compensatory issues

• May lead to pubalgia type symptoms

Courtesy of P. Birmingham MD

• Birmingham et al., AJSM 2012

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Physical Examination

Imaging Clues

Intra-articular Pathology

Findings in Asymptomatic Athletes • 39 professional and collegiate hockey players (all Asymptomatic)

FAI Prevalence in NFL Prospects • 239 hips with radiographs at NFL combine – 2009-2010

• 90% with at least one finding c/w FAI

• 3T MRI scans • 36% pathology adductor-rectus abd aponeurosis

• 68 players symptomatic • 57 players asymptomatic

– Athletic pubalgia / Sports Hernia / Core Muscle Injury

• 64% hip joint pathology – 56% labral tears – 39% cam impingement (FAI) • Silvis et al., AJSM 2011

• Increasing alpha angle (Larger Cam Morphology) was most predictive of symptoms • Large Cam-type FAI (Limited IR) may be the at risk athletes – Larson et al., Arthroscopy 2012

Differential Dx

Diagnostic Injections Help solve the Puzzle • Intra-articular Hip

• Sports Hernia / Athletic pubalgia / Core Muscle Injury • Osteitis Pubis

– P.E. or exercise challenge • Intra-articular hip pathology (FAI)

• Symphyseal – Dye tracking up rectus or down the adductors

• Adductor / pubic cleft / Rectus Abd

• Beware of symptoms in the perineum / testicular / scrotal / vulvar / anal / sitting Medial Ischial pain – Pudendal nerve neuralgia / Sciatic nerve entrapment

• Various GI and GU disorders

• Psoas bursal injections

– Multidisciplinary approach

• ATHLETIC not Sedentary / Work Comp PUBALGIA!!!!

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Non-surgical Treatment – Period of Rest – Core stabilization / functional rehab – Avoidance of heavy weight, deep hip flexion weight training (Cleans, Lunges, Deep squats) – Hurt yourself doing what you do / Not in the weight room

Non-surgical Outcomes • Prospective, Randomized = Laparoscopic Surgery (Mesh) to Non-surgical treatment for Athletic Pubalgia in Athletes = 30 patients surgery & 30 patients PT – 3-6 months of symptoms prior to enrolling (all athletes) – PT = 8 weeks of 3 x wk core stability exercises for 90 minutes per session

• Full RT sports 1 & 3 months= – 67% & 90% in Surgical Group – 20% & 27% in Non-surgical Group

• At 1 year = – Occasionally symphyseal / adductor cleft / rectus abd corticosteroid / PRP (high level athlete)

– SURGICAL treatment = 29/30 (97%) full RT sport & No pain – NON-Surgical = 15/30 (50%) full RT sport • 7 of those (23%) had surgery for continued pain • Paajanen et al., Surgery 2011

Surgical Rx for Athletic Pubalgia • Mesh Repairs • •

Open Laparoscopic

Outcomes After Surgery for Athletic Pubalgia / Sports Hernia

• Broad pelvic floor repairs • Minimal-open repairs • +- Adductor / Pectineus / Gracilis releases • Neurectomy / Decompression • Ilioinguinal • Iliohypogastric • Genitofemoral

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Original Description: “Gilmore’s Groin” Mr Jerry Gilmore – London, England

Results of Sports Hernia “Experts” • Pelvic Floor Repair “No Mesh” (Meyers) – 5460 operations, 95% RT Sport, Mean = 3 months

• 1980 = 3 professional Soccer players • “Minimal Repair” “No Mesh” (Muschaweck) • “Severe Groin Injury” • TRIAD – External oblique tear – Avulsion of conjoint tendon from pubic tubercle – Dehiscence of conjoint tendon from inguinal ligament

– 129 operations, 84% RT Sport, Mean = 14 days

• Open “Mesh Repair” (Brown, Brunt) – 98 & 100 operations, 90-97% RT Sport, Mean 6-8 weeks

• Laparoscopic “Mesh Repair” (Paajanen) – Later Reported = 10 years experience with a 97% RT sport rate in 360 patients by 10 weeks post op (Non Mesh Repair +- adductor release)

– 30 operations, 90% RT sport, Mean 4wks to 3 months

• Gilmore 1980,1991,1998

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Comparative / Controlled Studies Surgical Techniques for Sports Hernia • Prospective, Randomized study = • Laparoscopic (Mesh) vs Open (Mesh and Non-Mesh) – Laparoscopic = 92% training at 4 weeks – Open = 64% training at 4 weeks – Only difference between groups = Time to RT Sports • Ingoldby, Br J Surg 1997

• Open (No Mesh) vs “Minimal Repair” – 14 athletes open Bassini type repair • RT Sports 6 months (9/14 RT prior level) – 14 athletes “Minimal Repair” • RT Sports 5.6 weeks (13 / 14 RT prior level) • Economopoulos et al (Hanks) Sports Health 2013

Be Comprehensive with Your Evaluation & Treatment!!

Sustained RT to Play Data after Sports Hernia / AP Surgery • 43 NHL players with Sports Hernia surgery – 2001-2008

• 80% returned to play for 2 or more seasons • Veteran players have sig drops in production after sports hernia surgery c/w Younger players & control NHL Players • More predictable in Younger players – Jakoi et al., AJSM 2013

Association between FAI / Chronic Adductor Pain / Osteitis Pubis / Athletic Pubalgia / Sports Hernia • FAI = decreased Hip ROM • Limited ROM = increased stress on extra-articular structures

But Don’t OVERTREAT or Treat ASYMPTOMATIC Imaging Findings!!!

Treatment of Athletes with Symptomatic Intra-articular Hip Pathology and Athletic Pubalgia / Sports Hernia: A Case Series

• Increase Stress on Abdominal / Adductors / Symphysis = – Athletic Pubalgia / Sports Hernia – Osteitis Pubis – ? Other extra-articular myotendinous compensatory disorders

Athletic Pubalgia and FAI • 37 hips, mean age 25 years, Majority professional or D1 athletes • SYMPTOMATIC Athletic pubalgia and FAI / labral tear • When both are SYMPTOMATIC!!!!!:

Larson et al., Arthroscopy 2011

Sports Hernia Surgery alone =

25% RT sports

Arthroscopic FAI correction alone =

50% RT sports

Both at same or subsequent setting = 89% RT sports MHHS pre 75, post 96 (mean improvement = 21 pts) Larson et al., Arthroscopy 2011

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Athletic Pubalgia and FAI • 38 professional Athletes, mean age 31 years

Proximal Hamstring Ruptures

– AP surgery alone = 0% RTP – FAI surgery alone = 39% RTP – FAI and AP surgery = 95% RTP

• Mean time RTP = 5.9 months • Hammoud et al., Arthroscopy 2012

Proximal Hamstring Ruptures • < 1% of all hamstring injuries • > 50% result of water skiing injuries • Forceful hip flexion / knee extension injury – – – – –

Water Skiing Slip and fall “Splits Position” Sliding into a base Eccentric Firing of partially torn tendon

• If proximal “pop” & bruising posterior thigh = get MRI

Case # 1: Acute Proximal Hamstring Rupture

Surgical Decision Making? • Decreased Tension in Medial and Lateral hamstrings compared to contra-lateral leg!!!! – Popliteal Angle Test

• Medical Comorbidities / Sedentary = Non-surgical • 1-2 cm retraction, 2-3 tendon tear, active individuals, Poor medial / lateral hamstring tension = Surgical repair ideally within 2-4 weeks

Video = The Injury

• 43 y/o female injured her proximal / posterior thigh showing her dog. Fell down and unable to continue. • MRI showed complete proximal hamstring rupture • Wants to remain active showing her dog and running • Significantly decreased medial and lateral hamstring tension

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Surgical Treatment • Prefer Longitudinal incision beginning at the gluteal crease

Case # 2: Chronic Proximal Hamstring Rupture • 45 year old female, former Olympic team handball player had a water-skiing injury 5 years prior

• Retract the Gluteus Maximus proximally

• MRI showed complete Left proximal hamstring rupture and treated non-surgically

• Repair the tendon with 2 to 3 double armed suture anchors

• Continued weakness and “Give Way” / knee hyperextension, inability to run

• Acute cases stay medial to tendon / palpate & protect sciatic nerve (No Neurolysis)

Original Injury MRI Now 8 cm retracted

Surgical Treatment • Prone with two large rolls (4 blankets ) one under chest and one under pelvis or spine table • Hip Flexion 30-40 degrees and Knees flexed 45 degrees (Feet resting on 3 to 4 pillows) • General Anesthesia / NO PARALYSIS

SciaticHamstring

Expose / mobilize Hamstrings

8mm Bone Plug

Prepare Achilles Graft

Achilles

Incision

Sciatic Nerve Neurolysis

Guide Pin Placed IT

Secured with 7mm Screw

Post-op Protocol Sciatic nerve

• Hinged knee brace for 4 – 6 weeks • Minimal Tension after repair = 4 weeks in brace – 60 degree Extension stop for 2 weeks – 30 degree for 2 weeks

Hamstring Construct

• Chronic or > Retraction / Tension = 6 weeks in brace – 90 degree Extension stop 2 weeks – 60 degree for 2weeks – 30 degree for 2 weeks

Completed Reconstruction #5 non-absorbable sutures

Post-op Radiograph

• PT core stability 6-8 weeks • Resisted Hamstring Strengthening 10 – 12 weeks • RT Sports 5-7 months

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Proximal Hamstring Ruptures: Systematic Review 2008 • 18 studies • 286 surgical cases vs 14 non-surgical cases • 95 acute surgery vs 191 chronic surgery (> 4wks) • Greater RT sports for surgical (82%) vs non-surgical (14%) • Greater RT sports for acute (96%) vs chronic (75%) – Harris et al., Int J Sports Med 2011 – Murray et al., KSSTA 2009, Larson Op Tech Sports Med 2009, Folsom and Larson AJSM 2008

Our Recent Study 2014 (AJSM) • Acute vs Chronic Surgery for Hamstring Ruptures • 72 patients (All 2 or 3 tendon ruptures): – 51 Acute surgery • Mean time to surgery = 18 days

– 21 Chronic surgery (14 Allograft reconstructions) • Mean time to surgery = 441 days

• SANE ADL and Sports Scores, SF-12, VAS, Patient Satisfaction • Larson et al., AJSM 2014

Our Recent Study 2014 (AJSM) • No statistically significant differences for RT ADL’s between Acute (93%) vs Chronic (87%)

Return to Sports after Proximal Hamstring Rupture and Repair?? • 79% RT sports same level @ 6m

• Acute repairs had > RT Sports compared to Chronic surgery (80% vs 70%) p=0.026 • There were no differences for SF-12 scores, VAS scores, or patient satisfaction (85% overall) • > 5-6cm retraction = predictive of need for ALLOGRAFT • If Active recommend surgical repair acutely • If Sedentary or Comorbidities = Non-surgical treatment and delayed chronic repair / reconstruction if continued issues with ADL’s (Giving way / Knee Hyperextension)

“Sports Hernia” Conclusions • Sports Hernia / Athletic Pubalgia can lead to significant disability in athletes • Various Structures are implicated and the pattern of presentation is variable • Surgical Management results in a return to preinjury athletic performance in > 80 to 90% regardless of the specific surgical technique • Better outcomes measures and sustained return to play data is needed moving forward rather than simply return to play (??1 game / match)

• Lefevre et al., KSSTA 2013

• NFL study, 10 players – 90% RT to NFL – Only 50% played more than 1 game • Mansour et al., AJO 2013

• Our study – SANE Sports Score (0-100%) – 51 acute (80% RT sports) – 21 chronic (70% RT sports) • Rust, Larson et al., AJSM 2104

“Sports Hernia” Conclusions • There is an association between intra-articular hip pathology (FAI) and extra-articular sports pubalgia disorders in a subset of patients • Management of both SYMPTOMATIC intraarticular and sports hernia / pubalgia pathology improved overall outcomes in Elite Athletes • Further studies, however, are necessary in order to evaluate the relationship between ROM deficits (FAI), hip joint pathology, and extra-articular hip compensatory patterns and injuries up and down the kinetic chain

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Proximal Hamstring Conclusions

Thank You!

• Complete proximal Hamstring ruptures in active individuals are best treated surgically in order to maximize RT sporting activities • Late repair / reconstruction can restore ADL function but has inferior return to sports outcomes compared to acute repair • More than 5 - 6cm retraction in chronic cases increases the probability that an allograft will be required • Prognosis for sustained return to Elite / Professional level sports after proximal hamstring repair appears to be gaurded

Twin Cities Orthopedics MOSMI Edina, Minnesota

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