A few years back, an athletic woman was referred to me
because of symptomatic
femoroacetabular impingement (FAI) in both hips and central
groin pain from refractory osteitis pubis that began during her first
pregnancy. She underwent an endoscopic pubic
symphysectomy/curettage as part of a comprehensive single-stage minimally
invasive surgery that also included bilateral arthroscopic surgeries for FAI
61013). Since then, Ive been hearing more about
athletic pubalgia and, no doubt because of increasing
awareness, Im seeing this condition in my practice with commensurately
increasing frequency. Often this is in patients with FAI.
In hopes of expanding our understanding, Ive
invited some clinical thought-leaders to this months Round Table
for an open discussion of an arguably timely topic.
Dean K. Matsuda, MD
|Round Table Participants
Dean K. Matsuda, MD
Kaiser West Los
Angeles Medical Center
Los Angeles, Calif.
Christopher M. Larson, MD
Orthopedic Sports Medicine Institute
Eden Prairie, Minn.
William C. Meyers, MD
Adam Zoga, MD
Associate Professor of Radiology
Director of Musculoskeletal MRI and Ambulatory Imaging Centers
Jefferson University Hospital
Dean K. Matsuda, MD: I have heard athletic
pubalgia (AP) termed a wastebasket diagnosis encompassing many
diverse conditions. Im not saying I agree with that, but what exactly is
William C. Meyers, MD: Athletic pubalgia is an
umbrella term for career ending, or quality-of-life-threatening,
musculoskeletal injuries involving attachments and/or soft tissue support
structures of the pubis. Terms such as
sportsmans hernia mislead the lay and
medical communities into thinking these problems are occult hernias. I see many
patients each week who have had unsuccessful hernia surgery for these injuries.
We discourage that term since it leads to difficulty in accurately diagnosing
and successfully treating the injuries.
These are real injuries within complex anatomy. There
are more muscles, ligaments, bones and other soft tissues in the pelvis than
anywhere else. There are a lot of systems to consider including gynecologic,
genitourinary, gastrointestinal and neurologic. Nerves and soft tissues are
packed in close proximity, and there is a prevalence of referred pain that
makes diagnoses particularly difficult. Plus, the hip is imbedded as the
deepest joint in the body. One should think in terms of the pubic bone as
another joint (the pubic joint) with many attachments and that the hip and
pubic joints work closely together in maintaining pelvic stability.
If you dissect a fresh cadaver and cut the
rectus abdominis attachment to the pubis, you get profound
changes in pressure in the adductor region. These changes are what led us to
look at this anatomy more closely. One way to simplify the functional anatomy
in this region is to compare the pubic joint to the knee: the
central attachments (eg, rectus abdominis and three adductors for the pubis;
cruciate ligaments for the knee) are most important for stability. The more
lateral structures crossing the joint (eg,
rectus femoris, sartorius for the pubis; collateral ligaments
for the knee) provide important support, but are not as important for stability
and heal quicker often without surgery. This analogy grossly simplifies
the pathophysiology but can help visualize these injuries. The symphyses
symphyseal joint do get involved, but rarely as the primary
problem. They get involved usually in a reactive way (ie, a
secondary osteitis pubis) possibly from cartilage plate tears and
tiny avulsion fractures rubbing the wrong way.
True hernias, of course, do occur in this relatively
young population, and it is really important to emphasize that they are almost
always coincidental and do not cause the exertional pain experienced by the
Matsuda: With so many different conditions, is
there anything besides anatomic region that ties these together?
Meyers: Function and pathophysiology tie the
anatomy and the AP conditions together. Here are several factors:
- These conditions involve the same anatomic region and many structures
are actually attached to each other, such as the rectus abdominis and the three
most important adductors: pectineus, adductor longus and brevis.
- The forces often compete and involve several opposing directions:
side-to-side, superior-inferior, anterior-posterior, and obliquely or in
- The patients usually complain of pain in several different locations
and involving different soft tissue or skeletal structures.
- The hip and soft tissue structures outside the hip are intimately
related not only in proximity, but also in terms of overlapping pathology and
pain referral patterns. One injury can lead to another. In fact, about 10 to
15% of the time (the percentage varies according to sport, gender and several
other factors), the patients come in with simultaneous hip and AP problems.
- The concept of the pubic joint described previously ties
the aforementioned observations together.
- Often, the patients wont get better unless the multiple sites
of pain are addressed surgically.
- I spend a great deal of each week re-operating on patients who have
had unsuccessful or transiently successful hernia operations for their pains.
- One needs to keep in mind that persistent or recurrent pain after a
hernia (or other) operation can also come from other sources such as the hip,
non-musculoskeletal causes or synthetic mesh.
Matsuda: Were hearing a lot about
athletes with FAI. How common is AP seen in these athletes and is there some
Christopher M. Larson, MD: The true prevalence or
incidence of associated FAI and AP in athletes is not well defined at this
point. We are, however, seeing an increase in the number of athletes with this
association. Several recent studies also support this observation. Feeley and
coworkers found an association between
hip labral tears, rectus abdominis tears, and adductor strains
in NFL players and coined this the Sports Hip Triad. Verrall and
coworkers published two compelling articles that show a strong association
between hip joint range of motion limitations and the development of chronic
groin pain and osteitis pubis in Australian League Football Players. Another
article by Weir and colleagues found that 94% of athletes who presented with
long-standing proximal adductor pain had radiographic evidence for FAI. It is
clear that both hip joint disorders and AP often present independent of each
other in athletes. I believe, however, that when athletes present with both FAI
and AP, there is a biomechanical basis behind this association. FAI typically
presents with limitations in hip range of motion which can lead to increased
stresses and subsequent compensatory patterns involving the abdominal obliques,
distal rectus abdominis, pubic symphysis, and adductor musculature during
athletic activity. I think it is these compensatory patterns that can lead to
athletic pubalgia and other extra-articular hip related symptoms in this
pelvis of a collegiate soccer player with FAI and athletic pubalgia reveals
bilateral cam impingement (dashed arrow), bilateral acetabular retroversion
(line drawing), and osteitis pubis (solid arrow).
Image: Larson CM
Associated AP with rectus abdominis involvement, as
mentioned by Dr. Meyers, can lead to a relative anterior pelvic tilt/
instability which can further aggravate the intra-articular hip symptoms.
Matsuda: With so many separate, albeit related
conditions, how does one perform a physical examination for AP?
Meyers: It is important to consider both history
and physical examination. Histories should be conducted with careful attention
to three sets of diagnoses: AP; hip; and other causes. Because AP results
primarily from muscular disruption, the pain of AP is primarily exertional in
nature and predictable with initiation of forceful activities such as sprinting
and changes of direction. The pain may also affect normal activities such as
coughing, sneezing or rolling over in bed at night. The pain may vary from side
to side, depending on patterns of compensation, and involve multiple sites of
soft tissue attachments such as the rectus abdominis and specific adductor
muscles. The inflammatory response associated with the osteitis pubis that
sometimes accompanies AP may cause tenderness and pain particularly after
cessation of activities.
In contrast, patients with hip problems usually describe
pain with or after minimal activity such as prolonged standing, walking or
jogging, or with certain postures such as prolonged sitting, or going up and
down stairs or lunging. The pain is often more sporadic and less predictable.
Pain from other causes often has historical clues such as genitourinary,
gastrointestinal, back, gynecological symptoms or past problems, or continuous
or sporadic pain totally unrelated to physical activity. Some patients who have
other causes also may have benign musculoskeletal injuries at the same time,
sometimes making accurate diagnosis perilous.
Physical examinations should be conducted with careful
attention to the same three categories of diagnoses. For AP, we have developed
resistance tests for each of the muscles attaching to or crossing the pubic
symphysis or joint (see Table). These tests involve resistance against the
primary action of each muscle. Interpretation of each test involves three
considerations: Does the test cause pain? Does the resultant pain correlate to
the muscle being tested? and Does the resultant pain re-create the pain causing
the athletes disability? For the hip problems, the examination involves
primarily range-of-motion tests without interference from contraction of
muscles. These include the standard
FABER (flexion, abduction, external rotation) and
FADIR (hip flexion, adduction, internal rotation) tests, plus
numerous other rotational or hyperflexion or hyperextension tests that could
isolate anterior, posterior or lateral impingements or other pathology.
Localized tenderness, of course, is sometimes helpful for specific diagnoses,
although the tenderness associated with various types of bony or soft tissue
inflammation also can be confusing. Extreme pain with light touch may also be a
clue to the existence of CRPS (chronic regional pain syndrome)/RSD (reflex sympathetic dystrophy). Comprehensive physical
examinations, sometimes with internal pelvic or rectal examinations, may be
extremely important to detect the non-musculoskeletal diagnoses.
Larson: I agree that a thorough physical
examination is required to accurately diagnose athletes with athletic related
groin pain. It is imperative to have an understanding and ability to perform a
physical examination for both intra-articular and extra-articular causes for
athletic-related groin pain (Table). Dr Meyers nicely outlined the examination
for AP. Because of the association between AP and FAI in some athletes, it is
critical to evaluate for any underlying hip joint related pain. Although
multiple tests are described and useful, I find that groin or deep lateral hip
pain elicited with the FADIR test, FABER test, Butterfly test (flexion,
abduction, internal rotation) and lateral impingement test (abduction,
extension, internal rotation) indicate possible underlying hip joint pathology.
In addition, limitations in hip forward flexion, internal rotation, and
abduction range of motion may be indicative of underlying FAI. I also rely
heavily on diagnostic injections to try and piece the overall picture together.
Relief, or lack thereof, with an anesthetic injection followed by an
examination and or exercise challenge helps to rule in or out the potential
pain generators. I often use pubic symphyseal or pubic cleft, adductor
peritendinous, psoas bursal, and intra-articular hip anesthetic injections to
confirm the respective areas contributing to the overall picture.
Matsuda: So now that weve narrowed down
the diagnosis, what imaging studies for which conditions make the most sense?
Coronal oblique T2-weighted fat
suppressed MR image in an 18-year-old collegiate soccer player with chronic,
refractory bilateral groin pain shows severe osteitis pubis manifesting as bone
marrow edema spanning the pubic symphysis (arrows). Note the skeletally
immature and edematous pubic apophysis on the left (arrowhead).
Image: Zoga A
Adam Zoga, MD: Musculoskeletal lesions at or near
the pubic symphysis and internal derangements of the hip are the two most
common lesions encountered by a musculoskeletal radiologist in the assessment
of groin pain in the active patient. When either of these is suspected, an MRI
with a protocol tailored to the particular lesion is the imaging study of
choice. However, at my institution, the first three sequences acquired with
either a noncontrast AP MR protocol or a direct
MR arthrogram of the hip are identical, covering the entire
musculoskeletal pelvis. Therefore, targeting either of these lesions with a
dedicated MRI does not necessarily mean that the other will be entirely
overlooked. Often, subchondral changes at the acetabulum are observed on a
dedicated AP MRI, indicating cartilage loss and likely a labral tear at the
hip. Similarly, bone marrow edema at the pubic symphysis is encountered with
some frequency on direct MR arthrographic hip studies, indicating an AP lesion
that may be the source of groin pain, or may coincide with a concomitant hip
Allowing for this, a noncontrast MRI utilizing a
dedicated AP protocol is indicated with suspected osteitis pubis, rectus
abdominis or adductor tendon lesion, and even in the setting of a true groin
hernia. This protocol does not require any specialized MR equipment or
excessive time, but effective imaging plane and sequence selection is
essential. In 2011, a dedicated AP protocol should be available at most quality
imaging centers with 1.5 or 3 Tesla MR scanners. Unfortunately, the level of
quality at privately owned MRI centers still varies considerably, so it is best
to insure that your radiologist and/or technologist are at least aware of a
such a dedicated AP protocol before finalizing the referral.
Optimal imaging of internal derangements of the hip is a
bit more difficult and labor intensive, as noncontrast hip protocols,
regardless of the equipment, are relatively insensitive for acetabular labrum
tears and articular cartilage lesions. The study of choice is a direct MR
arthrogram, where high-resolution arthrographic sequences dedicated to the hip
are acquired after a fluoroscopy- or ultrasound-guided intra-articular
injection of gadolinium-based contrast material diluted in saline. In
conjunction with the contrast injection, we place anesthetic into the hip joint
and we compare patient symptoms during provocative maneuvers both before and
after the procedure. If the groin pain resolves on similar maneuvers post
procedure, in intra-articular source for pain is confirmed.
oblique T2-weighted fat suppressed MR image from an athletic pubalgia MRI on a
27-year-old NFL player with an acute left-sided groin injury that occurred with
running while rotated at the waist shows a very large rectus abdominis/adductor
aponeurosis tear, or the lesion sometimes called sports hernia.
There is a large gap between the torn rectus abdominis attachment and adductor
tendon origins (arrows) with retraction of the adductor longus (curved arrow)
and mild capsular hypertrophy at the pubic symphysis (arrowhead) indicating
chronic osteitis pubis. Note the normal rectus abdominis/adductor aponeurosis
on the right (serpentine arrow).
T2-weighted fat suppressed MR image from a 20-year-old lacrosse player with
acute on chronic groin pain shows a more subtle athletic pubalgia lesion. At
midline, there is a plate like disruption of the caudal rectus abdominis
attachment from the pubic bone (arrowheads), sometimes referred to as a rectus
abdominis/adductor aponeurotic plate disruption. The more cephalad rectus
abdominis muscle is denoted by R.A.
Images: Zoga A
Matsuda: What types of conservative treatments
seem effective in the management of AP? What is a typical timeframe of
Meyers: The answer to most of what you are asking
is: it depends. Keep in mind there are about 18 different distinct categories
of AP. In a recent paper we described 26 different distinct anatomic regions
and 121 different combinations of procedures that we performed. Plus, there is
definitely a role for nonoperative treatment for a number of the different
problems. On the other hand, surgery is usually required for the severe central
injury in the high performance athlete. For example, if the injury involves
partial avulsion of the rectus abdominis and all three central adductors, early
surgery may be best and completely correct the problem. Often, the athletes
return to full play within a relatively short time frame. Timing of surgery
involves multiple factors: how well the athlete presently performs, the
specific injury, severity of the injury, how early it is in the season, etc.
There is no typical time frame of nonoperative management and
often, the conservative thing to do for many of these problems is surgery. For
some problems, nonoperative therapy is much less predictable in terms of
success. Properly administered steroid injections have about an 80% chance of
temporizing the problem and enabling return to play in selected cases.
We have not had good success with platelet-rich plasma
(PRP) as yet for insertional pathology. Prolotherapy in general has not been
helpful but has not really hurt. If it comes down to injection, one should
inject into the region of pain and be cognizant of the number of anatomic
considerations there. Symphyseal joint injections are very painful and rarely
helpful. Osteitis pubis usually has a muscular disruption associated with it
and should not be considered a separate problem in most athletes. Of course,
there is another entity we call it primary osteitis which is not
associated with disrupted attachments or joint instability. That entity usually
does not affect athletes and may be difficult to treat. The symphyseal joint
disruption of pregnancy is another problem.
Larson: I believe that in most cases conservative
treatment is employed first. The success of conservative treatment is often
dictated by the degree of disability, injury pattern and chronicity of the
symptoms. I stress to in-season athletes avoidance of pain-generating
activities in the weight room such as deep hip flexion, low repetition, heavy
weight cleans, squats, and lunges. A core stabilization program that focuses on
lower abdominal (if tolerated) and posterior gluteal strengthening can be
helpful in order to restore pelvic mechanics. I think in-season therapeutic
injections of corticosteroids can occasionally be considered in higher-level
athletes. I will typically allow one intra-articular hip injection, and
occasional symphyseal, pubic cleft, and psoas bursal corticosteroid injections
depending on the regions affected in order to finish a season or augment
improvement with physical therapy. Although PRP and other injections
(prolotherapy) into the rectus abdominis, adductors, or even the pubic
symphysis may be considered in some cases, there is minimal-to-no scientific
literature supporting or refuting these injections in this setting. There is
limited data reporting the success rate of various conservative measures, but I
like to see at least 3 months of conservative management without improvements
prior to considering surgical treatment options for most athletes.
Matsuda: So for an athlete that has undergone
a prolonged course of nonsurgical treatment, when do you offer surgery?
Larson: I consider nonsurgical measures to have
failed when the athlete is no longer making progress and has pain that limits
his or her ability to compete. I consider surgery in the off-season when the
athlete is able to complete the season but is still limited. I consider surgery
in-season when the athlete is not able to participate secondary to continued
disability. I will rarely consider earlier surgical intervention for
elite-athletes with large symptomatic cam lesions, significant limitations, and
only 4 to 6 months prior to a major sporting event or season. This may allow
for enough time to recover from surgery prior to a season or event, and avoids
having to consider surgery just prior to or during the season which can lead to
significant time lost from athletics. I still believe that all athletes,
regardless of the level, should have a course of conservative care prior to
consideration of surgery for athletic related groin pain. The exceptions to
this might include associated loose bodies in the hip with associated
mechanical symptoms, or non-concentric reductions or loose bodies after hip
subluxations which are rare. The diagnosis in most of these cases of AP and
FAI, however, can be quite elusive and I typically dont see these
athletes until they have had disability for several months or longer.
Meyers: Aggressive symphyseal joint surgery
should be reserved for those patients with primary osteitis. One does not
usually need to address the osteitis of AP directly.
Matsuda: What surgical procedures are
typically employed and how successful are they?
Meyers: The way to think about the specific
surgery is to consider three main things: the precise anatomic structures
involved; whether or not each involved structure is primary or secondary, ie,
compensatory; and whether one needs to tighten or loosen the involved
structures, or leave them alone. Mesh or biologic material should be avoided
because it is usually unnecessary, and when unsuccessful it can create immense
difficulty in determining whether the pain is due to missed pathology, mesh,
hip or a combination of the above. Intense scarring from the mesh may also
prevent return to previous levels of play.
Return to full play also depends on multiple factors.
The factors overlap with the ones mentioned above about decision and timing of
operations. From the standpoint of the injury itself, the player may return to
100% play within 3 weeks of the injury for some injuries and 6 to 7 weeks for
others. The extent of adductor involvement often plays a role in timing.
Existence of a concomitant hip problem may play a huge role. One addresses the
patient with both hip and AP involvement according to several factors: which is
more severe or more severely limiting from a playing standpoint, anticipated
durations of rehabilitation, current level of performance, and practical
Matsuda: If you have an athlete sidelined for
months with refractory AP and FAI, which condition do you address first?
Larson: Athletes who present with both FAI and AP
present a difficult treatment dilemma. This is an entity that currently
requires a close working relationship between hip, sports medicine, orthopedic,
and general surgeons. We have presented and submitted for publication a study
looking at 37 hips in elite athletes (32 current or former professional and
collegiate athletes) who presented with symptomatic intra-articular hip
pathology and concomitant AP. We found that if the AP component was addressed
alone, only 25% of athletes returned to sports without limitations. If only the
intra-articular pathology was addressed 50% returned to sports without
limitations. When both intra-articular and AP pathology was surgically
addressed concurrently or at separate settings, 89% of athletes returned to
sports without limitations. A general surgeon specializing in sports hip
disorders and I have now performed over 20 concurrent AP and arthroscopic hip
(FAI) procedures in elite athletes. This is done on an outpatient basis and we
feel that this can significantly reduce time lost from athletics in this unique
patient population. I recognize that many areas do not have general surgeons
and orthopedic surgeons that specialize in sports hip disorders and work at the
same institutions allowing for universal use of this surgical approach. Our
study, however, showed that if the both disorders were addressed at separate
settings, results were equivalent to concomitant surgery.
Cadaveric image demonstrating some of
the major anatomic structures involved in athletic pubalgia.
Image: Zoga A
It should be noted that we only used this approach to
treat symptomatic pathology not to treat abnormal imaging studies that were
asymptomatic on physical examination. If the ROM limitations secondary to FAI
lead to a compensatory development of AP, it may also be reasonable to consider
treating the hip joint pathology first and later addressing the AP symptoms if
they fail to resolve after FAI corrective surgery.
Matsuda: Were hearing about dGEMRIC
(delayed gadolinium-enhanced MRI of cartilage), T2 mapping and other
cartilage-specific MRI innovations in the context of preoperative biochemical
assessment of articular cartilage in conditions such as dysplasia and FAI. Are
there specific new imaging technologies that may play a future role in the
diagnosis of AP?
Zoga: Musculoskeletal ultrasound is used
internationally with more prevalence than it is in the United States. A focused
ultrasound can be useful for many AP lesions, offering supreme resolution of
soft tissue structures as well as the ability of image during dynamic maneuvers
such as valsalva or active thigh adduction. However, underlying osseous (bone
marrow) edema is an important finding on MRI that will be occult to ultrasound,
and ultrasound fails as a larger field of view screening modality for more
distant sources of groin pain such as internal derangements of the hip. CT and
nuclear medicine exams play little role in the assessment of AP.
As for MRI, there is always a tradeoff between
maximizing image contrast or resolution and imaging time. A noncontrast AP
protocol should include small field of view sequences dedicated to the pubic
symphysis region in a plane prescribed along the arcuate line of the pelvis,
maximizing sensitivity for small rectus abdominis and adductor lesions.
Intravenous contrast protocols will show enhancement at the site of most AP
lesions, but generally yield the same differential considerations with similar
sensitivities as would a noncontrast protocol. An exception to this would be
unexpected postoperative groin pain, where contrast enhanced protocols can
maximize sensitivity for infection and hematoma formation. A direct MR
arthrogram of the pubic symphysis can be performed, but there has been no
investigation as to whether this would increase sensitivities or specificities
for injury, and a pubic symphysis injection can be somewhat unpleasant, and
seems excessive for the purposes of imaging. Very high resolution spoiled
gradient echo cartilage sequences can be performed at the pubic symphysis, and
these have been shown to be useful in assessing maturation of apophyseal
cartilage in the young pubalgia patient, but it is unclear if this information
will alter a treatment algorithm.
For suspected inguinal hernia, patients can be placed
prone on the MR table and ultrafast imaging sequences can be acquired during
valsalva in an effort to show visceral structures sliding into the inguinal
canal, but these sequences lack the resolution necessary for the diagnosis of
early rectus abdominis lesions and the contrast necessary for identification of
mild bone marrow edema.
Matsuda: Regarding the surgical management of
AP, should these procedures be performed by general and/or orthopedic surgeons?
Do you envision orthopedic surgeons performing some of these surgical
procedures? And if so, which ones?
Meyers: Surgeons need to learn the anatomy and
understand the various conditions that can affect this area. This means an
experience with not only the different soft tissue injuries that affect this
area, but also with general orthopedics, subtle hip injuries and various other
conditions that can occur in this area: gynocologic, GI, urologic, neurologic,
etc. We should not be thinking in terms of which existent specialty has
provided the best training to date to deal with these problems. We need people
who are truly interested and understand the anatomy and likely
pathophysiologies; and we need to think out of the box. Up to now, few people
have been interested in these injuries. We need people thoroughly versed in the
anatomy, the various pathophysiologies, soft tissue and hip problems, as well
as the other causes of pelvic pain in this area. We need contributors to
perform research in this new field. We will find ways to incorporate the
various disciplines into this fertile area of knowledge growth.
View from anterior pubic portal of
ossified pubic symphysis prior to endoscopic pubic symphysectomy performed as
single-stage surgery with bilateral arthroscopic surgeries for FAI. The pubic
symphysis (black arrow) is outlined with black lines. Heterotopic ossification
(red arrow) was also resected with this procedure.
Image: Matsuda DK
Larson: I think that AP surgery should be
performed by a surgeon with specialized training in the procedure and knowledge
of the pertinent anatomy. I am not sure it is reasonable for an orthopedic
surgeon without a general surgery background to surgically treat AP unless they
are capable of managing the potential complications or associated findings that
might be encountered in some cases, perhaps the presence of occult hernia. I do
think that associated adductor, pectineus, or gracilis releases could be
performed by the orthopedic surgeon and I, in fact, perform this part of the
procedure in our concomitant surgeries. Again, if a general surgeon with this
specialty is not residing in their community, the orthopedic surgeon could
perform the hip joint surgery and refer the athlete to a specialist elsewhere
to have the AP surgery done in the following weeks.
Matsuda: What do you envision for the future
treatment of AP?
Meyers: This is a ripe field for contributions.
The anatomy is complex and physiology even more so. Understanding the
pathophysiology is a key to success. The musculoskeletal aspects of the pelvis
have been a no-mans land for a long time despite it containing the most
soft tissues and largest muscle bulk in the body. Medical schools are not
teaching students much about this anatomy. We memorized some muscles that
reside in this region and then forgot most of them. Orthopedists rarely go into
this area except for radical removal of tumors. Gynecologists think of this
area as the uterus, tubes, and ovaries. Urologists think of the ureter and
bladder, and general surgeons think of the colon, rectum, and inguinal hernias.
Truly interested people need to focus on basic anatomy and biomechanical
interrelationships between the different structures.
Larson: This topic is going to require further
prospective evaluation in order to better define the optimal treatment in these
athletes. I would argue that general surgeons and orthopedic surgeons should
use the same outcomes scoring in order to directly compare their clinical
results. We need to better define when hip joint surgery and/or AP surgery are
required. Several unanswered questions remain:
- When do we perform myotendinous repairs and releases?
- Can PRP injections be used to treat athletic related groin symptoms
in some cases?
- What is the role for open vs. mini open vs endoscopic repairs of AP?
- What is the role for mesh reinforcement?
- Is osteitis pubis a primary pathology, a secondary reactive change,
and should it be addressed surgical with open or endoscopic procedures?
Even if the surgical procedures remain within their
respective specialties (general and orthopedic surgery), it is imperative that
orthopedic and general surgeons are competent in performing physical
examinations for both intra-articular hip pathology and AP. In the end, this
increasingly recognized association between FAI and AP underscores the
importance of orthopedic and general surgeons working closely together in order
to optimize outcomes in this athletic population.
- Feeley BT, et al. Hip injuries and labral tears in the national
football league. Am J Sports Med. 2008;36(11):2187-2195.
- Larson CM, et al. Association between athletic pubalgia/sports
hernia and intra-articular pathology: a case series. Presented American
Orthopaedic Society for Sports Medicine Specialty Day 2010, March 13, 2010.
Submitted to Arthroscopy, 2010.
- Matsuda DK. Endoscopic Pubic Symphysectomy for Reclacitrant
Osteitis Pubis Associated With Bilateral Femoroacetabular Impingement.
Orthopedics. 2010;33(3):199. ORTHOSuperSite search:
- Meyers WC, et al. Experience with sports hernia
spanning two decades. Ann Surg. 2008; 248(4):656-665.
- Verrall GM, et al. 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.
- Verrall GM, et al. Hip joint range of motion restriction precedes
athletic chronic groin injury. J Sci Med Sport.
- Weir A, et al. Prevalence of radiological signs of femoroacetabular
impingement in patients presenting with long standing adductor-related groin
pain. Br J Sports Med. 2010, Jun.
- Christopher M. Larson, MD, can be reached at 775 Prairie Center
Drive, suite 250, Eden Prairie, MN 55344; 952-944-2519; e-mail:
- Dean K. Matsuda, MD, can be reached at Southern California
Permanente Medical Group, Kaiser West Los Angeles Medical Center, 6041 Cadillac
Ave., Los Angeles, CA; 323-857-4477; e-mail:
- William C. Meyers, MD, can be reached at Core Performance
Physicians Inc., 4623 S. Broad St., Quarters M-1, Philadelphia, PA 19112;
215-334-1274; e-mail: wmeyers@CorePerformancePhysicians.com.
- Adam C. Zoga, MD, can be reached at 132 South 10th St., Room 1083A,
Philadelphia, PA 19107; 215-955-6226; e-mail: