Core Injuries: a Sports Hernia Misnomer

Core Injury A SPORTS HERNIA MISNOMER Daniel D. Day DO st May 1 , 2019 1 NO DISCLOSURES

2 AGENDA Define Groin pain Develop Working Dx Advanced Workup Treatment Options A Case Study

3 Terminology

Sports Gilmore’s Athletic hernia Groin Pubalgia

Pubic Bio- Inguinal Mechanical Groin pain syn Overload (PIPS)

4 HPI

• Typically Male • Progressive onset or Acute • Deep seated groin pain. • Relieved with rest • Returns with aggravating activity

5 HPI

• Running, Kicking, Cutting, Twisting, Explosive • Common Sports – Soccer, Hockey, Football, LAX • Exam should be precise and specific • R/O inguinal/femoral hernia

Cohen,B, Kleinhenz, D, et al. Understanding Athletic Pubalgia:A Review. RIMED. 10/2016;31-35. 6 DOHA CONSENSUS

• Groin pain in athletes • Defined entities for Groin pain • Adductor- related • Pubic- related • Iliopsoas -related • Inguinal-related • Hip related groin pain • Other related groin pain

Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015;49:768-774. 7 ADDUCTOR-RELATED

• Adductor tenderness • Pain on resisted adduction • Pain on adductor stretch • Dx • Adductor tendinosis • Adductor injury/tear (partial/complete) • Aponeurosis injury/tear

8 PUBIC-RELATED

• Pubic Rami Tenderness • Pain with adductor squeeze • Causes pain across an unstable pubic joint • Pain on resisted crunch • Dx • Osteitis Pubis (trauma/inflammatory/overuse) • Rectus injury/tear • Aponeurosis injury/tear

9 ILIOPSOAS RELATED

• Hip flexor tenderness • Pain with resisted hip flexion • Pain with hip flexor stretch • Snapping with motion • Dx • Hip flexor tendinitis • Iliopsoas bursitis • Snapping hip

10 INGUINAL RELATED

• Inguinal canal tenderness • No palpable hernia • Pain with Valsalva/cough/sneeze • Dx – • Posterior abdominal wall weakness • Superficial inguinal ring dilatation • Inguinal ligament tear • Conjoined tendon tear

11 HIP RELATED

• Hx – catching, locking • No specific tenderness • Positive FADIR • Positive Dynamic Int Rotation • Positive FABER • Positive Scour • Dx • Femoroacetabular impingement • Labral tear • Stress fracture

Cohen,B, Kleinhenz, D, et al. Understanding Athletic Pubalgia:A Review. RIMED. 10/2016;31-35. 12 OTHER RELATED

• Inguinal/femoral hernia • Posthernioplasty pain • Lumbar Referred • Nerve entrapment • Iliohypogastric • Ilioguinal, • Genitofemoral • Obturator • Apophysitis • ASIS (Sartorius/TFL) • AIIS (Rectus Femoris) • Pubic

13 OTHER RELATED

• Adductor Insertion Avulsion Syn. • Stress Fracture • Femur neck • Pubic • Acetabulum • Hip Joint • OA • SCFE/Perthes • AVN • Intra -abdominal • Gynecological/Urologic • Cancer/tumors

https://www.orthobullets.com/knee-and-sports/3093/osteitis-pubis?expandLeftMenu=true 14 DIAGNOSTICS - US

• US

Morley N, Grant T, et al. Sonographic Evaluation of Athletic Pubalgia. Skeletal Radiol (2016) 45:689–699.

Lee S, Endo Y, et al. Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features. Sports Health 2017;9;5:428-435. 15 DIAGNOTICS - US

16 DIAGNOSTICS - US

Significant tendinosis with small partial detachment Calcific tendinosis

17 DIAGNOSTICS - INJ.

Pubic Intra-articular injection Rectus injection

Lee S, Endo Y, et al. Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging 18 Features. Sports Health 2017;9;5:428-435. DIAGNOSTICS - INJ

Intra-articular hip joint

19 DIAGNOSTICS – INJ

Hip Flexor

20 DIAGNOSTICS – XRAY/MRI

Significant Osteitis Pubis in Marathon Runner

Hegazi, et al. Sports Injuries about the Hip:What a Radiologist should know. Radiographics 2016:36:1717-1745 21 DIAGNOSTICS - MRI

Rectus abdominis–adductor longus attachment injury = Superior Cleft Sign

Bryne C, Bowden D, et al. Sports-Related Groin Pain Secondary to Symphysis Pubis Disorders:Correlation Between MRI Findings and Outcome After Fluoroscopy-Guided Injection of Steroid and Local Anesthetic. AJR:2017; 209:380-388. 22 DIAGNOSTICS - MRI

Short adductor (gracilis, adductor brevis, and pectineus muscles) attachment injury – Secondary Cleft Sign

32 Boxer FAI – Cam/Pincer Deformity - High Grade Partial Thickness Cartilage loss - Labral Tear 24 - Cam osseous changes DIAGNOSTICS - REVIEW

• PEARLS • Need good exam! • Palpation and resistance testing were highest predictive values for MRI findings • X-Ray, US, Diagnostic Injections • Need appropriate MRI!

25 TREATMENT - OMT

• Correct pelvic mechanics • Innominate rotation/flare • Sacral dys • Lumbar dys • Pubic dys • Strain/counterstrain/FDR • Lumbar paraspinals • Piriformis • IT Band • Iliopsoas • Rectus/adductor

26 TREATMENT - PT

• Physical Therapy Focus • Mobility first! • Core strength, endurance, coordination and extensibility deficiencies • I mbalances at the hip and abdominal muscles • Dynamically stabilizing the pelvic ring. • Eccentric Adductor strengthening

27 TREATMENT

Elatter O, Choi H, et al. Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health 28 2016;8;4:313-323 TREATMENT - INJ

• Cortisone injections • Percutaneous tendon needling/debridement • Orthobiologics • Platelet Rich Plasma (PRP) • Bone Marrow Concentrate (BMC)

29 TREATMENT - INJ

• 45 Patients • 80mg Depo • 2cc Marcaine • Fluoro guided symphyseal and site of MRI findings injection • 89% had improvement • 60% of those had sustained improvement at 6 months

30 TREATMENT - SURG

• Surgical • Ope n repair of the rectus abdominus, external oblique, transversus abdominus, or transversalis fascia; • R epairs with mesh reinforcement; • Laparoscopic repairs; • Miniopen repairs; • Broad pelvic floor repairs with or without adductor releases. • Adductor repair/tenotomy • Nerve Entrapment Release/Denervation • Hip labral repair/FAI

31 CASE

• S - 21 YO Male, Div 1 Baseball Player • Injury March 2016 – Progressive L sided groin pain • O – L sided Adductor • MRI – Superior cleft sign on L, Osteitis Pubis • A – L AL tear/L RA tear/Osteitis Pubis • P – • PT and PRP 8/2016 • Played 2017 with improved symptoms/not resolved • Surgery 8/2017 – Repair L AL/L RA • 6-8 Week Recovery and progressed to Full RTP symptom free through 2018 Season!

32 THANK YOU!

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