High Incidence of Athletic Pubalgia Symptoms in Professional Athletes With Symptomatic Femoroacetabular Impingement Sommer Hammoud, M.D., Asheesh Bedi, M.D., Erin Magennis, B.A., William C. Meyers, M.D., and Bryan T. Kelly, M.D. Purpose: The purpose of this study was to identify the incidence of symptoms consistent with athletic pubalgia (AP) in athletes requiring surgical treatment for femoroacetabular impingement (FAI) and the frequency of surgical treatment of both AP and FAI in this group of patients. Methods: Thirty-eight consecutive professional athletes, with a mean age of 31 years, underwent arthroscopic surgery for symptomatic FAI that limited their ability to play competitively. In all cases a cam and/or focal rim osteoplasty with labral refixation or debridement was performed. In 1 case concomitant intramuscular lengthening of the psoas was performed. Retrospective data regarding prior AP surgery and return to play were collected. Results: Thirty-two percent of patients had previously undergone AP surgery, and 1 patient underwent AP surgery concomitantly with surgical treatment of FAI. No patient returned to his previous level of competition after isolated AP surgery. Thirty-nine percent had AP symptoms that resolved with FAI surgery alone. Of the 38 patients, 36 returned to their previous level of play; all 12 patients with combined AP and FAI surgery returned to professional competition. The mean duration before return to play was 5.9 months (range, 3 to 9 months) after arthroscopic surgery. Conclusions: There is a high incidence of symptoms of AP in professional athletes with FAI of the hip. This study draws attention to the overlap of these 2 diagnoses and highlights the importance of exercising caution in diagnosing AP in a patient with FAI. Level of Evidence: Level IV, therapeutic, retrospective case series. emoroacetabular impingement (FAI) describes 2 osteoplasty of proximal femoral and acetabular dys- Fmain variations of morphologic abnormalities of morphology with labral debridement or refixation. the hip and resultant observed patterns of chondral and Both open and arthroscopic approaches have been labral injury: (1) cam impingement resulting from loss reported with favorable clinical outcomes in 75% to of offset of the femoral head-neck junction and (2) 95% of patients, with up to 93% of athletes returning pincer impingement due to focal rim lesions or ceph- to sport.2-9 alad retroversion.1 Current treatment for FAI involves Athletic pubalgia (AP) refers to a syndrome of disabling lower abdominal and inguinal exertional pain with progression to include adductor pain in high-performance athletes.10-12 Symptoms occur with From the Hospital for Special Surgery (S.H., E.M., B.T.K.), New York, New York; MedSport, Section of Sports Medicine and Shoul- resisted hip adduction or with resisted abdominal con- der Surgery, University of Michigan (A.B.), Ann Arbor, Michigan; tractions. The mechanism is postulated to be a com- and Department of Surgery, Drexel University (W.C.M.), Philadel- plex injury to the flexion/adduction apparatus of the phia, Pennsylvania, U.S.A. The authors report that they have no conflicts of interest in the lower abdomen and hip.10 To enhance the comprehen- authorship and publication of this article. sion of the spectrum of injuries observed in AP, the Received April 20, 2011; accepted February 22, 2012. Address correspondence to Asheesh Bedi, M.D., MedSport, Uni- “pubic joint” has been described as the second joint versity of Michigan, 24 Frank Lloyd Wright Dr, Lobby A, Ann within the pelvis, with the hip joint being the first.13 Arbor, MI 48106, U.S.A. E-mail: [email protected] This second joint comprises the entirety of the right © 2012 by the Arthroscopy Association of North America 0749-8063/11247/$36.00 and left pubic symphyses with all of their musculo- doi:10.1016/j.arthro.2012.02.024 tendinous attachments. Asymmetric distribution of ex- 1388 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 10 (October), 2012: pp 1388-1395 AP AND FAI IN PROFESSIONAL ATHLETES 1389 treme forces around this joint, as is most commonly TABLE 1. Preoperative Sporting Activities of 38 seen in the elite athlete, may result in the constellation Professional Athletes 11,13 of abdominal and pelvic injuries found in AP. No. of Patients Undergoing Surgical repair is aimed at the various structures that Sport No. of Patients AP Surgery normally attach to the pubic symphysis and/or selec- tive epimysiotomy or detachment.13-15 An overall suc- Football 13 4 Baseball 9 2 cess rate of greater than 95% in returning patients to Hockey 8 4 their previous level of activity has been reported.13 Soccer 5 2 Both FAI and AP are frequently reported in high- Basketball 2 0 performance athletes, most commonly in soccer, hockey, Skating 1 0 football, and baseball players.7,13,16 When viewed as a Total 38 12 group, such injuries account for a significant proportion of lost playing time and early retirement in profes- sional athletes. Although it has been suggested that and/or AP symptoms, defined as lower abdominal or these should be viewed in concert when examining an adductor pain. Three subsets of patients are described. athlete presenting with groin pain, an association be- The first consists of 12 patients who presented with tween the 2 has not previously been shown. Both both FAI and AP symptoms and required surgical conditions often present with a similar constellation of treatment of both the FAI and AP. Of these, all but 1 clinical symptoms, including groin discomfort and initially presented to a general surgeon specializing in restricted range of motion (ROM). the treatment of AP. The last patient initially pre- The hip is a ball-and-socket type of joint with 3 sented to the senior author’s sports medicine/hip pres- degrees of freedom. Loss of clearance between the ervation practice. Because of a lack of complete ob- femoral neck and acetabular rim may compromise jective data in the records, we cannot report the exact maximum hip excursion in multiple planes.17-19 This time line between AP and FAI surgery for all the abnormal bony contact and resultant restriction in patients. The second subset comprises 15 patients who terminal motion in the high-performance athlete due presented with both FAI and AP symptoms, in whom to FAI may result in compensatory stresses on the both sets of symptoms resolved after surgical treat- lumbar spine, pubic symphysis, sacroiliac joint, and ment of FAI alone. The final subset, consisting of 11 posterior acetabulum. These alterations in hip joint patients, presented with FAI symptoms alone and un- mechanics due to underlying impingement may result derwent surgical treatment. The algorithmic approach in excessive strains and secondary injury to the pos- taken by the senior authors (W.C.M. and B.T.K.) will terior inguinal wall, resulting in symptomatic AP. The be described. purpose of this study was to identify the incidence of For the first subset of patients who presented to a symptoms consistent with AP in athletes requiring general surgeon with both FAI and AP symptoms, surgical treatment for FAI. Our hypothesis was that histories and physical examinations were conducted some athletes may manifest AP symptoms due to with careful attention to 3 sets of diagnoses: AP, hip, compensatory stresses from FAI; moreover, surgical and other causes. Patients with AP pain describe ab- correction of FAI may resolve these symptoms. dominal/adductor pain that is primarily exertional in nature (resisted sit-ups) and often predictable with METHODS initiation of forceful activities such as sprinting and changes of direction.11 The pain may also affect nor- This study was approved by our institutional review mal activities such as coughing, sneezing, or rolling board. From April 2005 to April 2010, 38 consecutive over in bed at night.11 The pain may vary from side to professional athletes underwent arthroscopic surgery side, depending on patterns of compensation, and in- for the treatment of symptomatic FAI that limited their volve multiple sites of soft-tissue attachments, includ- ability to return to competitive play. The group in- ing the rectus abdominis and specific adductor mus- cluded 9 baseball players, 13 football players, 8 cles. Specific resistance tests for each of the muscles hockey players, 5 soccer players, 2 basketball players, attaching to or crossing the pubic symphysis or joint and 1 skater (Table 1). All patients were men, with a were used in assessing the patient with AP symptoms. mean age of 31 years (range, 19 to 35 years). Localized tenderness over the pubic symphysis, distal Throughout our article, we describe patients as hav- rectus abdominis/conjoined tendon, or proximal ad- ing FAI symptoms, defined as hip or groin pain, ductor tendon is also helpful in localization of the 1390 S. HAMMOUD ET AL. pathology.20 Specialized pelvic magnetic resonance imaging (MRI) and magnetic resonance arthrography studies of the hip were performed on all patients to assess for AP and overlapping ball-in-socket hip in- juries. At the time of magnetic resonance arthrogra- phy, the use of dedicated Sensorcaine (AstraZeneca LP, Wilmington, DE) or lidocaine protocols allowed for both diagnostic and therapeutic benefits. Those patients with diagnosed AP but who had relief of concomitant FAI symptoms after intra-articular injec- tion and had findings of a labral tear on clinical examination and MRI were diagnosed with FAI, and surgical treatment of FAI was planned to follow the AP surgery. Surgical treatment of AP varied depend- ing on the precise pathology with both direct repairs of defects and repairs or releases of compensatory inju- ries. The diagnosis of symptomatic FAI was made based on clinical examination and imaging studies per- formed by a sports medicine orthopaedist, specializing in hip preservation (B.T.K.).