The groin/hip enigma in sports

The hip in athletic groin pain Onur Tetik MD

Professor in Orthopedics and Traumatology

KOC University School of Medicine & American Hospital

Istanbul

IOC ADVANCED TEAM PHYSICIAN COURSE ANTALYA, TURKEY

27-29 NOVEMBER 2017

IntroductionGroin: name

Inguinal: adjective

Junction between abdomen and leg

Acute vs Chronic

Trauma vs Overuse

Intraarticular vs Extraarticular

Orthopedic vs Nonorthopedic

AGEChild

AdolescentAdult (W/M)

Old

Difficulties1. Complex local anatomy with large soft tissue sleeve

2. Complex biomechanics

1. Biggest joint,

2. Carry the body weight,

3. 2nd biggest ROM

3. Wide differential diagnosis

4. Often diffuse, insidious symptoms with nonspecific

presentation

5. Often multiple diagnoses 27-90% (one triggers the other

SIEVING

Conservative Surgery

TEAM APPROACH !

Incidence

• Sports injuries: 2.5-5 % groin related

• High school athletes 5-9 % USA

• Any sports

Sudden: Acceleration Deceleration, Hip Abd-Add, Rotational

• Soccer, Rugby, Skiing, Skating, Horse riding

• Ice hockey 10 %

• Football 5 %

• Muscle strain the most common

• “Sports hip triad” labral tear, adductor strain, rectus

abdominus strain

Hip pathology ??

Think twice

THINK LATERAL!• Inflammatory arthropathy

• Infection,

• Tumour

• Lumbar spine

• Metabolic bone disease

• Nerve entrapment syndromes

• Referred pain

– Abdomen / Spine / Pelvic viscera etc etc…......

48y, W TennisPain for 2 mos

A) EXTRA ARTICULAR

B) PERIARTICULAR (BONY)

C) INTRA ARTICULAR

D) NON-ORTHOPEDIC /

REFERRED

Classification

D) NON-ORTHOPEDIC

(REFERRED/MEDICAL)

• Lumbar / Sacral pathology

• Gynecologic

• Urologic

• Testicular neoplasm,

• Ureteral colic,

• Prostatitis,

• Epidydimitis,

• Urethritis,

• Hydro/Varicocele

• GI

• Hernia, (Inguinal, Femoral, Peritoneal)

• Inflammatory bowel D

• Aneurysm

• Appendicitis

• Neoplasms

Diagnostics

• Radiography

– Osteitis pubis

– Stress fractures

– Osteomiyelitis

– SFCE

– OA

• Bone scan

– Osteitis pubis

– Stress fractures

– Osteomiyelitis

– SI

– Tenoperiosteal lesions

•US injections

–Muscle tears

–Hematoma

–Inguinal hernia

–Bursitis

•Nerve conduction

–Neuropathies

•Peritonel radyography

•Herniography

•CT

•Bony pathologies

•Surgical planning

•MRI*

Bone & soft tissue

–AVN

–Disc hernia

–Ostetis pubis

A) Extraarticular1. Muscle tendon unit strains* / “Pulled Groin”

2. Athletic Pubalgia / Osteitis Pubis

3. Snapping Hip

4. Nerve entrapment syndromes

5. Avulsion and apophyseal injuries

6. Piriformis syndrome

7. Ischiofemoral impingement syndrome

8. Bursitis

9. Trochanteric

10.Hip and thigh contusions

11.Limb length discrepancies

12.Lymphatic problems

Muscle tendon unit problems

Groin Pull = Strain

• Adductor strain – Pectineus

– Adductor brevis & Adductor longus

– Gracilis & Adductor magnus

• Iliopsoas insertion

• Rectus femoris origin (ASİS)

• Rectus abdominis

• Sartorius

Adductors*• Soccer 10-18%

– Abductor ROM limitation+ Adductor weakness

– Lower extremity biomechanical problems

– Hip musculature weakness

• Adductor longus & gracilis MT junction

• Preseason camps x 20 > Season

• US + MRI

16y boy, weightlifter

Tx

• Chronic: ~6 mos +

Active muscle strengthening better > Passive PT

• Painless full ROM + 70% of strength = return to Sport

• Early return to sport recurrence + other pathologies

• Prevention !!! (Adds = Min 80% of Abds)

Iliopsoas

• Hip flex or hyperextension sports

• Diagnosis 32-41 mos.!

• Exam(extension test, supine 15o heel rise test)

• Surgery rare

– success 12/16

High hamstring strain

Ischial tuberosity avulsion

Conservative

No surgery except

Displacement>2cm ~Surgery

Sartorius & Rectus femoris strains

Tx Conservative

Scar tissue excision ? (after complete tears and painful scar formation)

Avulsion and Apophyseal injuries17y, M Soccer 16y, M, Weight lifting

SİAS 21-25y Ossification late Tuber ischii 20-30 y

!

Adolescent (14-17y)Hard training

14-40% Avulsion fracture

Athletic Pubalgia / Osteitis Pubis

• Over trained adolescent and prepubescent

• Repetitive adductor pull shearing forces

• Symptoms

– Adductor pain occurred 80%

– Pain around the pubic symphysis 40%

– Lower abdominal pain 30%

– Hip pain 12%

– Referred scrotal pain 8%

Widening Narrowing, OA

Osteitis Pubis Tx

• Usually self-limited !

• Xray (+) Asymptomatic soccer player 76%

• Acute PT + Medical (Oral Cs?)+ Manipulation

• Injection? Acute period ~– When?: Immediately vs 1.week

– No sport for 1 week

– ~Repeat: 2-3 weeks

Recurrence rate 25%

• More than a year to resolve

(mean 9.6 mos)

• Surgery:

– Vertical instability

– No response to conservativeTx

‘Snapping Hip’ Syndrome

INTERNAL

• Labral tear

• Loose bodies

• Synovial chondramatosis

• Osteochondramatosis

• Hip subluxation

EXTERNAL• Iliotibial band

tensor fascia lata,

gluteus medius tendon

(external)

• Psoas tendon – Ilio-pectineal eminentia

– Anterior hip

(internal)

Not a diagnosis, Symptom 70% painless

Snapping iliotibial band

• Repetitive activities

• Iatrogenic

• Prominent trochanter

• Coxa vara

• Reduced bi-iliac width

• Tight IT band

Snapping iliopsoas tendon

• 5-10% asymptomatic

• Hip Flex+Abd+ER neutral

Surgery if neededAnterior / Inferior / Proximal/ Arthroscopic

•MRI

•Iliopsoas bursography

•US

Nerve entrapment syndromes

Reasons

1. Post surgical

1. Appendectomy,

2. Hernia repair

3. Pfannen Steil incision: scar tissue or

deep fascia impingement

2. Blunt trauma

3. Overstretching

4. Compression

• Nerve block: Dx & Tx

• Plexitis, Neuritis

Piriformis syndrome

• Never radiates down

• Anatomic variations !

• Hard to show

• Stretching

• Very rarely surgery

Ischiofemoral impingement syndrome

• Lately popularized

• Conservative Tx

• Surgery underlying causes

Bursitis

• Overuse or Trauma

• Conservative

• Aspiration and injection (Serial)

• Rarely surgery

Hip pointer hip bruise

Iliac crest or Trochanter major

and soft tissue contusions

TxConservative

Hematoma

! Myositis ossificans!

Chronic bursitis

Lymphatic problemsDrains

• skin of the lower limb,

• lower abdominal wall,

• scrotum,

• labia,

• vagina,

• anal canal

*Posterior abdominal wall abnormalities

Sports hernias

Groin disruptions

Sports hernia

• Insidious-onset, gradually worsening, deep

chronic groin pain

• 1/3 trauma history (+)

• No true hernia

• Coughing and bearing down increases 10%

• Post exercise and next morning pain

• Resisted adduction 65% painful

Causes

• Muscle imbalance with relatively strong adductors

• Weak lower abdominal musculature

• Increased shearing forces across the hemipelvis

• Overuse

• Genetically weakened inguinal wall

Sports hernia

• Surgery for groin pain 30% documented sports hernias

• PE hernia ~

• Radiating pain 30%

Inguinal ligament, perineum, rectus muscles

• Imaging: MRI?

• Nonoperative treatment unsuccessful

• Surgery 90% success

Groin Disruption

Pathology

• Tears of

– Transversalis fascia,

– External oblique,

– Conjoined tendon

– Avulsion of fibers of the internal

oblique at the pubic tubercle

• Abnormalities of the insertion of the

rectus abdominus

Groin Disruption

• Conservative treatment not good

• Surgical repair 87-95%

• Exploration:

– external oblique aponeurosis

repair (mesh)

– superficial inguinal ring

reconstruction

– conjoined tendon repair

– transversalis fasicia plication

– Inguinal canal posterior wall

repair (mesh)

– Nerve release

B) Periarticular

• Hip fractures and dislocations

• Stress fractures*

• Femoral head AVN

• Slipped femoral capital epiphysis

• Capsular (Ligamentous) lesions

Hip fractures and dislocations

Stress fracturesFemoral neck or Ischium pubis

General risks:1. History of prior stress fracture

2. Low level of physical fitness, non-athlete

3. Increasing volume and intensity

4. Female Gender

5. Menstrual irregularity

6. Diet poor in calcium

7. Poor bone health

8. Poor biomechanics

IR, Hop test

X-ray: 2-4w, 50% (-)Bone scan: 72sa 32% false (-)MRI !

Tx4-6 w rest3-5 mos for back to sport

21y, F 1500m RunnerIncreasing pain for 2 mos

Femoral neck

✔

Femoral head AVN• Systemic corticosteroid use or heavy alcohol consumption

• Anabolic steroids

• 10% to 20% no clearly identifiable risk factor

• 40% to 80% of patients have bilateral involvement

• Conservative or surgical

Slipped femoral capital epiphysis

AdolescentsMay need surgery

C) Intraarticular

• Hip joint problems

• Femoroacetabular impingement

• Labral tears

• Chondral problems (Loose bodies)

• Synovial diseases

• Infection

• Ligamentum teres

• Osteochondritis dissecans

• Degenerative arthritis

Hip arthroscopy

Indications

• Labral tears

• Loose body

• O.A.

• Chondral lesions

• Synovial pathologies

• AVN

• SA

• Lig. teres tears

Labral tears

Chronic groin pain 22%

• Usually in the anterior/superior aspect

• Diffuse poorly localized groin pain and mechanical

symptoms in the hip/groin area

• Association with adjacent articular cartilage damage

• PE 75 - 88%

• MRI arthrography + Local anesthetics

• Conservative at least 6 weeks

• Arthroscopic debridement / repair / reconstruction

Arthroscopic treatment results

Stage Labrum Femoral

chodropathy

Acetabular

chodropathy

Arthrosis

1 Tear - - -

2 Tear + - -

3 Tear +/- + -

4 - - + +

80-90%

17-40%

22%

Loose body, OA, Synovial pathologies

FAI

• CAM Impingement

• Pincer Impingement

Thank You

Hip = Teamwork