Radiographic evidence of femoroacetabular impingement in athletes with athletic pubalgia

Associations Between Hip Pathology, Hip and Groin Pain, and Injuries in Hockey Athletes: A Clinical Commentary

Femoroacetabular impingement (FAI), particularly cam morphology, is highly prevalent among elite hockey athletes. Moreover, hip and groin pain has become a common issue in hockey, with approximately 50% of European professional athletes reported to experience a hip or groin problem during a season. While most athletes will not miss training or competition due to this, restricted competitive performance and increased risk of reduced physical and psychological well-being are likely. Recent research suggests that the development of cam morphology is related to the repetitive shear stresses experienced at the hip joint during adolescence from skating. This condition likely increases the potential for intra-articular and extra-articular injuries in these athletes later in their careers. Research also indicates that the hip joint mechanics during forward skating substantially increase the possibility of sustaining a labral tear compared to other sports. Such an injury can increase femoral head movement within the joint, potentially causing secondary damage to the iliofemoral ligament, ligamentum teres and joint capsule. These injuries and the high density of nociceptors in the affected structures may explain the high prevalence of hip and groin pain in hockey athletes. Compensatory adaptations, such as reduced hip strength, stability, and range-of-motion (ROM) likely increase the opportunity for core muscle injuries and hip flexor and adductor injuries. Specifically, the limited hip ROM associated with cam morphology appears to exacerbate the risk of these injuries as there will be an increase in pubic symphysis stress and transverse strain during rotational movements. It is hoped that this article will assist practitioners currently working with hockey athletes to develop evidence-informed monitoring strategies and training interventions, aimed at reducing the incidence and severity of hip and groin problems, ultimately enhancing athlete performance and well-being. Therefore, the purpose of this clinical commentary was to examine current evidence on common hip pathologies in hockey athletes, exploring potential associations between hip and groin pain and the biomechanics of hockey activities.

Level of Evidence

5.

Outcomes and Proportions of Subsequent Contralateral Sports Hernia Repair Following Primary Unilateral Repair

BACKGROUND

In the event that nonoperative treatment for sports hernia fails, surgical repair may be warranted. Bilateral repair can occur in up to 45% of surgically treated patients.

PURPOSE

To investigate the clinical outcomes of athletes who underwent unilateral sports hernia repair and determine the proportion of patients who required contralateral sports hernia repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We identified patients at our institution who underwent primary unilateral sports hernia repair (rectus abdominis-adductor longus aponeurotic plate repair and adductor lengthening) with a single surgeon between 2015 and 2020. We assessed patient-reported outcomes using the Hip Outcome Score-Sport (HOS-Sport), the Numeric Pain Rating Scale, and an internally developed return-to-play questionnaire. We further collected data regarding subsequent sports hernia procedures on the ipsilateral or contralateral side. We calculated summary statistics for outcomes and examined the association between preinjury patient characteristics and the HOS-Sport score at follow-up or successful return to preinjury sport using linear and logistic regression, respectively.

RESULTS

A total of 104 of 128 (81.3%) eligible patients (mean age at surgery, 23.0 ± 6.2 years; 94.2% male; 51.9% American football athletes) completed follow-up at a mean time of 4.4 ± 1.5 years. Overall, 79.8% of athletes (n = 83) were able to return to their preinjury sport/activity, but 90.2% (83/92) who attempted to return were able to do so. When examining reasons for not returning to preinjury sport, only 9 patients reported not returning to preinjury sport because of limitations or persistent symptoms from their original injury. Only 4 patients underwent subsequent sports hernia procedures (3 contralateral, 1 ipsilateral revision) after their index unilateral sports hernia repair. At follow-up, the mean HOS-Sport score was high (94.0 ± 10.8), and the mean Numeric Pain Rating Scale score was low (0.31 ± 1.26). There were no preinjury patient characteristics associated with either the HOS-Sport score at follow-up or the successful return to preinjury sport.

CONCLUSION

Patients with unilateral sports hernia symptoms can undergo repair and return to sport at the preinjury level with little concern for injuries to the contralateral groin. In our cohort, patient-reported hip function and pain outcomes at follow-up were excellent.

Relationship between Femoroacetabular Impingement and Pubalgia in Professional Soccer Players

Objective  To analyze the relationship between pubalgia and femoroacetabular impingement (FAI) in professional athletes of a soccer club, defining the prevalence of these conditions in the sample studied. Methods  It is an epidemiological, cross-sectional, and analytical study including 90 professional soccer players active from 2019 to 2021. We accessed the medical records of the subjects to retrieve information from the modified Pre-Competition Medical Assessment (PCMA) protocol, orthopedic physical examination, and anteroposterior pelvic radiographs to assess pubalgia and FAI, respectively. Inclusion criteria were athletes playing in the professional soccer club in the 2019 to 2021 season, who underwent a modified PCMA upon admission, and who signed an informed consent form. Results  FAI was highly prevalent (85.6%) in the sample. This prevalence may occur because, in Brazil, people start playing sports early, not always in suitable fields, or with no proper equipment and supervision. In addition, the CAM-type impingement was the most frequent (62.2%). These injuries are related to high-intensity movements, including those associated with soccer. Furthermore, there is no dependency correlation between pubalgia and FAI. FAI was present in only 20% of athletes with pubalgia complaints. Conclusion  There was a high prevalence of FAI in professional soccer players in the studied population (85.6%) but with no relationship between FAI and pubalgia.

Criteria for Return to Play After Hip Arthroscopy in the Treatment of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is a common pathology in athletes that often requires operative management in the form of hip arthroscopy.

PURPOSE

To systematically review the rates and level of return to play (RTP) and the criteria used for RTP after hip arthroscopy for FAI in athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature, based on the PRISMA guidelines, was performed using PubMed, Embase, and Scopus databases. Studies reporting outcomes after the use of hip arthroscopy for FAI were included. Outcomes analyzed were RTP rate, RTP level, and criteria used for RTP. Statistical analysis was performed using SPSS software.

RESULTS

Our review found 130 studies, which included 14,069 patients (14,517 hips) and had a mean methodological quality of evidence (MQOE) of 40.4 (range, 5-67). The majority of patients were female (53.7%), the mean patient age was 30.4 years (range, 15-47 years), and the mean follow-up was 29.7 months (range, 6-75 months). A total of 81 studies reported RTP rates, with an overall RTP rate of 85.4% over a mean period of 6.6 months. Additionally, 49 studies reported the rate of RTP at preinjury level as 72.6%. Specific RTP criteria were reported in 97 studies (77.2%), with time being the most commonly reported item, which was reported in 80 studies (69.2%). A total of 45 studies (57.9%) advised RTP at 3 to 6 months after hip arthroscopy.

CONCLUSION

The overall rate of reported RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who returned to sports did not return at their preinjury level. Development of validated rehabilitation criteria for safe return to sports after hip arthroscopy for FAI could potentially improve clinical outcomes while also increasing rates of RTP at preinjury levels.

[Arthroscopically assisted minimally invasive symphysioplasty for the treatment of pubic related groin pain]

OBJECTIVE

Therapy of pubic related groin pain via minimally invasive symphysioplasty.

INDICATIONS

Therapy of refractory pubic related groin pain based on osteitis pubis.

CONTRAINDICATIONS

Groin pain from causes other than pubic related groin pain.

SURGICAL TECHNIQUE

After a minimally invasive approach, an incision in the anterior capsule is made while protecting the dorsal capsule parts and the arcuate pubic ligament. The symphysis end plates are remodeled arthroscopically assisted using a surgical burr. The newly created pubic symphysis joint is filled with autogenous fibrin to support the formation of a new discus interpubicus.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing for 4 weeks with 20 kg using crutches is recommended. During the first 4 weeks the range of motion should be restricted.

RESULTS

Since 2010, 10 athletes (7 men, 3 women; average age 34.1 ± 7.8 (23-47) years) have undergone arthroscopically assisted minimally invasive symphysioplasty and treatment of femoroacetabular impingement syndrome. The average follow-up time was 5.1 (2-9) years. All patients returned to their sport level. The mean preoperative Nonarthritic Hip Score (NAHS) of 64.4 ± 15.1 (32.1-86.5) points improved to a mean postoperative NAHS of 91.4 ± 9.8 (62.4-98.75) points (p < 0.0001). The average patient satisfaction (scale 0 to 10; 10 highest satisfaction) was 9.8 ± 0.4 (9-10).

Femoroacetabular impingement: correlation between imaging parameters, sport activity, and chondral damage

BACKGROUND

Femoroacetabular impingement is characterised by an abnormal contact between the acetabulum and the femoral head-neck junction. Femoroacetabular impingement shows three main clinical frameworks: Pincer-FAI, Cam-FAI and Cam-Pincer mixed form. The aim of the study was to investigate the correlation between femoroacetabular impingement, imaging, activity and chondral damages.

METHODS

Forty-one patients, undergoing arthroscopic chondroartroplasty for Cam and Cam-Pincer mixed form were considered. All patients underwent an X-ray hip evaluation (G1 group), while 15 patients also underwent a pelvis MRI evaluation (G2 subgroup). For G1 patients, the superior-inferior offset ratio and alpha angle were calculated from the X-ray examinations. For G2 patients, the antero-posterior offset ratio was also calculated from pelvis MRI. Chondral damage was classified according to the Outerbridge classification.

RESULTS

The superior-inferior offset ratio and the antero-posterior offset ratio were respectively 0.50 ± 0.23 and 0.33 ± 0.19. The α angle predictive for a chondral damage of IV degree was 81.5°.The chondral damage of the patients suffering from Cam-FAI and Cam-Pincer mixed form were respectively 3.53±0.80 and 3.00±1.41.

CONCLUSIONS

From the results was possible to: - Elaborate two tables providing a reliable indirect calculation of the alpha angle. - Establish an alpha angle cut-off value indicative for a IV degree chondral damage. - Show that Pincer-FAI does not represent an aggravating factor for chondral damage - Show that the level of sports activity was related to the severity of chondral damage. - Show that a physically demanding occupation was not an aggravating factor for chondral damage.

Core Muscle and Adductor Injury

Core muscle injury is a common but difficult problem to treat. Although it can affect all individuals, it is most commonly seen in male athletes in cutting, twisting, pivoting, and explosive sports. Owing to the high association of femoroacetabular impingement, we believe these individuals are best treated with a multidisciplinary approach involving both orthopedic and general surgeons. Conservative treatment should be the first step in management. When conservative means are unsuccessful, operative intervention to correct all the pathologic issues around the pubis can have extremely high success rates.

Laparoscopic Approach to Inguinal Disruption in Athletes: a Retrospective 13-Year Analysis of 198 Patients in a Single-Surgeon Setting

Background

Inguinal disruption (ID) is a condition of chronic groin pain affecting mainly athletes. ID cannot be defined as a true hernia. Pathogenesis is multifactorial due to repetitive and excessive forces applied to the inguino-pelvic region. Examination reveals tenderness to palpation of the inguinal region. Differential diagnosis is challenging; imaging is helpful for excluding other pathologies. Surgery is the treatment of choice when conservative treatment fails. Primary aim of the study was to evaluate the time to return to full sport activity after transabdominal preperitoneal patch plasty (TAPP) technique in ID. Secondary aim was to evaluate the postoperative complication rate both in the immediate post-operative time and in 1 year follow-up and to verify the relapse rate after surgery. In this study, we consider time to return to full sport activity as the time needed to return to pre-injury sport activity.

Results

A retrospective study is reported by evaluating 198 cases of ID from a single surgeon experience. All patients failed a previous conservative treatment. All cases were treated with the TAPP approach. Time to return to full sport activity was 4 weeks for 94.4% of patients, with a total of 98.5% of active patients at 9 months. Post-operative inguinal pain was the main complication (9.1%). On 13 years follow-up, we report a recurrence rate of 2.5%.

Conclusions

Current management algorithm for ID, in professional athletes, supports the role of surgery after at least 2 months of conservative treatment. Recently, the role of surgery has been highlighted for a definitive treatment and a faster full recovery to sport activity, especially for elite professional athletes. In our opinion, laparoscopic surgery is the mainstay for non-responsive ID treatment. We present a long-term retrospective evaluation of a wide cohort of professional athletes diagnosed and treated in a systematic way.

Management of osteitis pubis in athletes: rehabilitation and return to training - a review of the most recent literature

Osteitis pubis is a common cause of chronic groin pain, especially in athletes. Although a precise etiology is not defined, it seems to be related to muscular imbalance and pelvic instability. Diagnosis is based on detailed history, clinical evaluation, and imaging, which are crucial for a correct diagnosis and proper management. Many different therapeutic approaches have been proposed for osteitis pubis; conservative treatment represents the first-line approach and provides good results in most patients, especially if based on an individualized multimodal rehabilitative management. Different surgical options have been also described, but they should be reserved to recalcitrant cases. In this review, a critical analysis of the literature about athletic osteitis pubis is performed, especially focusing on its diagnostic and therapeutic management.

Athletic Pubalgia Secondary to Rectus Abdominis-Adductor Longus Aponeurotic Plate Injury: Diagnosis, Management, and Operative Treatment of 100 Competitive Athletes

Background

A rectus abdominis-adductor longus (RA-AL) aponeurotic plate injury, commonly associated with athletic pubalgia, sports hernia, or a core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia abnormalities has led to better management of this debilitating condition.

Hypothesis

Surgical repair of RA-AL aponeurotic plate injuries will result in decreased symptoms and high rates of return to play.

Study Design

Case series; Level of evidence, 4.

Methods

Using our billing and clinical database, patients who underwent RA-AL aponeurotic plate repair by a single surgeon at a single institution were contacted for Hip Outcome Score (HOS) and return-to-play data. Patients with a confirmed diagnosis by history, physical examination, and magnetic resonance imaging who failed 6 to 12 weeks of appropriate conservative treatment were indicated for surgery. Surgical repair involved adductor longus fractional lengthening, limited adductor longus tenotomy, and a turn-up flap of the released adductor tendon and aponeurosis onto the rectus abdominis for imbrication reinforcement.

Results

Of 100 patients who met the inclusion criteria, 85 (85%) were contacted. A total of 82 (96%) patients were able to return to play at a mean of 4.1 months after repair. Hip function was rated as 98% of normal and sports function as 92% of normal. Factors associated with negative outcomes were multiple procedures, prior inguinal hernia repair, and female sex. Negative outcomes were demonstrated by decreased HOS scores and decreased sports function. The overall complication rate was 7%.

Conclusion

RA-AL aponeurotic plate repair by the method of an adductor-to-rectus abdominis turn-up flap is a safe procedure with high return-to-play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic-related surgery and female patients had worse outcomes.

A COMBINED TREATMENT APPROACH EMPHASIZING IMPAIRMENT-BASED MANUAL THERAPY AND EXERCISE FOR HIP-RELATED COMPENSATORY INJURY IN ELITE ATHLETES: A CASE SERIES

BACKGROUND/PURPOSE

Athletes experiencing hip, groin, and low back pain often exhibit similar clinical characteristics. Individuals with hip, groin and low back pain may have the presence of multiple concurrent pathoanatomical diagnoses. Regardless, similar regional characteristics and dysfunction may contribute to the patient's chief complaint, potentially creating a sub-group of individuals that may be defined by lumbopelvic and hip mobility limitations, motor control impairments, and other shared clinical findings. The purpose of this case series is to describe the conservative management of elite athletes, within the identified aforementioned sub-group, that emphasized regional manual therapy interventions, and therapeutic exercise designed to improve lumbopelvic and hip mobility, stability and motor control.

CASE DESCRIPTIONS

Five elite athletes were clinically diagnosed by a physical therapist with primary pathologies including adductor-related groin pain (ARGP), femoral acetabular impingement (FAI) with acetabular labral lesion and acute, mechanical low back pain (LBP). Similar subjective, objective findings and overall clinical profiles were identified among all subjects. Common findings aside from the chief complaint included, but were not limited to, decreased hip range of motion (ROM), impaired lumbopelvic motor control and strength, lumbar hypomobility in at least one segment, and a positive hip flexion-adduction-internal rotation (FADIR) special test. A three-phase impairment-based physical therapy program was implemented to resolve the primary complaints and return the subjects to their desired level of function. Acute phase rehabilitation consisted of manual therapy and fundamental motor control exercises. Progression to the sub-acute and terminal phases was based on improved subjective pain reports and progress with functional impairments. As the subjects progress through the rehabilitation phases, the delivery of physical therapy interventions were defined by decreased manual therapies and an increased emphasis and priority on graded exercise.

OUTCOMES

Significant reductions in reported pain (>2 points Numeric Pain Rating Scale), improved reported function via functional outcome measures (Hip and Groin Outcome Score), and continued participation in sport occurred in all five cases without the need for surgical intervention.

DISCUSSION

The athletes described in this case series make up a common clinical sub-group defined by hip and lumbopelvic mobility restrictions, lumbopelvic and lower extremity motor control impairments and potentially other shared clinical findings. Despite differences in pathoanatomic findings, similar objective findings were identified and similar treatment plans were applied, potentially affecting the movement system as a whole. Subjects were conservatively managed allowing continued participation in sport within their competitive seasons.

CONCLUSION

Comprehensive conservative treatment of the athletes with shared impairments, as described in this case series, may be of clinical importance when managing athletes with hip, groin, and low back pain.

LEVEL OF EVIDENCE

Therapy, Level 4, Case Series.

Cam morphology and inguinal pathologies: is there a possible connection?

Background

To analyse the prevalences of the cam and pincer morphologies in a cohort of patients with groin pain syndrome caused by inguinal pathologies.

Materials and methods

Forty-four patients (40 men and 4 women) who suffered from groin pain syndrome were enrolled in the study. All the patients were radiographically and clinically evaluated following a standardised protocol established by the First Groin Pain Syndrome Italian Consensus Conference on Terminology, Clinical Evaluation and Imaging Assessment in Groin Pain in Athlete. Subsequently, all of the subjects underwent a laparoscopic repair of the posterior inguinal wall.

Results

The study demonstrated an association between the cam morphology and inguinal pathologies in 88.6% of the cases (39 subjects). This relationship may be explained by noting that the cam morphology leads to biomechanical stress at the posterior inguinal wall level.

Conclusions

Athletic subjects who present the cam morphology may be considered a population at risk of developing inguinal pathologies.

Level of evidence

Level IV, Observational cross-sectional study.

Athletic Hip Injuries

Historically, athletic hip injuries have garnered little attention; however, these injuries account for approximately 6% of all sports injuries and their prevalence is increasing. At times, the diagnosis and management of hip injuries can be challenging and elusive for the team physician. Hip injuries are seen in high-level athletes who participate in cutting and pivoting sports that require rapid acceleration and deceleration. Described previously as the "sports hip triad," these injuries consist of adductor strains, osteitis pubis, athletic pubalgia, or core muscle injury, often with underlying range-of-motion limitations secondary to femoroacetabular impingement. These disorders can happen in isolation but frequently occur in combination. To add to the diagnostic challenge, numerous intra-articular disorders and extra-articular soft-tissue restraints about the hip can serve as pain generators, in addition to referred pain from the lumbar spine, bowel, bladder, and reproductive organs. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.

Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete

The nomenclature and the lack of consensus of clinical evaluation and imaging assessment in groin pain generate significant confusion in this field. The Groin Pain Syndrome Italian Consensus Conference has been organised in order to prepare a consensus document regarding taxonomy, clinical evaluation and imaging assessment for groin pain. A 1-day Consensus Conference was organised on 5 February 2016, in Milan (Italy). 41 Italian experts with different backgrounds participated in the discussion. A consensus document previously drafted was discussed, eventually modified, and finally approved by all members of the Consensus Conference. Unanimous consensus was reached concerning: (1) taxonomy (2) clinical evaluation and (3) imaging assessment. The synthesis of these 3 points is included in this paper. The Groin Pain Syndrome Italian Consensus Conference reached a consensus on three main points concerning the groin pain syndrome assessment, in an attempt to clarify this challenging medical problem.

A retrospective analysis on the correlation between hip pain, physical examination findings, and alpha angle on MR images

BACKGROUND

We aimed to search whether alpha angle, a radiological clue used in the diagnosis of femoroacetabular impingement, is correlated with the presence of hip pain, internal rotation angle, and impingement test results on hip impingement patients (CAM type).

METHODS

Medical records of 334 patients (156 women, 178 men) with an average age of 33.8 ± 8.4 (range 20-50) years were retrospectively studied for the alpha angle of the hip measured on magnetic resonance images (MRI). Hip pain and internal rotation angles as well as results of impingement tests were reviewed.

RESULTS

Hip pain was reported more frequently on the right side (n = 35, 10.5%) compared to the left side (n = 22, 6.6%) (p = 0.047). No difference was observed between the right and left sides regarding alpha angles (p = 0.145), internal rotation angles (p = 0.637), or positivity of impingement test (p = 0.210). Internal rotation angles were significantly higher in cases without hip pain (p < 0.001) and in patients with negative impingement test result (p < 0.001). Internal rotation angle correlated positively with age and negatively with the alpha angle. Alpha angle was increased in cases that report pain, those with an internal rotation angle <20°, or cases with positive impingement test. The pain was more common, internal rotation angle was higher, and positivity for impingement was more frequent if the alpha angle was <55°. Patients with hip pain or positive impingement test or internal rotation angle <20° had increased alpha angles (p < 0.001).

CONCLUSIONS

The pain, impingement test results, and internal rotation angle seem to be associated with alpha angle of the hip measured on MRI in hip impingement patients.

The 'Hip Vacuum Sign'-a new radiographic phenomenon in femoro-acetabular impingement

Femoro-acetabular impingement (FAI) is a frequent cause for groin pain in young and active patients. We discovered a so far undescribed radiographic phenomenon only visible in frog-leg lateral radiographs. The aim of this study was to describe this new radiological sign, to determine its prevalence in a symptomatic population and to investigate the correlation to a potential underlying pathology. We retrospectively reviewed all patients, who had been sent to our clinic between 2010 and 2012 for hip complaints. We excluded patients older than 50 years and patients with advanced osteoarthritis. Two independent investigators blinded to clinical data independently examined all images for the presence, location and dimension of a vacuum phenomenon and a potential underlying hip pathology. We included 242 patients. 137 of them showed clinical and radiological signs of FAI. A hip vacuum phenomenon was identified in 20 of 242 patients (8%). Interestingly, all these patients showed distinct signs of femoro-acetabular impingement. In reference to this, the prevalence of the "Hip Vacuum Sign" was 15% (20/137) in symptomatic patients with FAI. There was no correlation with age or gender. We identified a new radiological sign, the "Hip Vacuum Sign", in 15% of symptomatic patients with FAI. It was only visible in frog-leg lateral radiographs. We suggest that it represents a subluxation of the femoral head due to a lever mechanism between the femoral neck and the acetabular rim and is, therefore, a hint for a relevant femoro-acetabular impingement mechanism.

Rehabilitation and Return to Sport Following Surgical Repair of the Rectus Abdominis and Adductor Longus in a Professional Basketball Player: A Case Report

Study Design Case report. Background Acute traumatic avulsion of the rectus abdominis and adductor longus is rare. Chronic groin injuries, often falling under the athletic pubalgia spectrum, have been reported to be more common. There is limited evidence detailing the comprehensive rehabilitation and return to sport of an athlete following surgical or conservative treatment of avulsion injuries of the pubis or other sports-related groin pathologies. Case Description A 29-year-old National Basketball Association player sustained a contact injury during a professional basketball game. This case report describes a unique clinical situation specific to professional sport, in which a surgical repair of an avulsed rectus abdominis and adductor longus was combined with a multimodal impairment- and outcomes-based rehabilitation program. Outcomes The patient returned to in-season competition at 5 weeks postoperation. Objective measures were tracked throughout rehabilitation and compared to baseline assessments. Measures such as the Copenhagen Hip and Groin Outcome Score and numeric pain-rating scale revealed progress beyond the minimal important difference. Discussion This case report details the clinical reasoning and evidence-informed interventions involved in the return to elite sport. Detailed programming and objective assessment may assist in achieving desired outcomes ahead of previously established timelines. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2016;46(8):697-706. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6352.

Etiology of Femoroacetabular Impingement in Athletes: A Review of Recent Findings

The relationship between hip deformities and osteoarthritis has recently received a lot of attention. In particular, it has been shown that both osteoarthritis and its precursors, such as the hip deformities that lead to femoroacetabular impingement (FAI), are more prevalent in elite athletes compared with the general population. However, the etiology of the above-mentioned types of hip deformity is not currently well understood. Many recent studies have attempted to shed light on the etiology of this disease. In this article, the main clinical, radiological, mechanobiological, and biomechanical findings of relevance to understanding the etiology of hip deformities leading to FAI are reviewed. Based on these findings, a consistent biomechanical theory explaining the development of hip deformities in athletes is then presented. According to the presented theory, the repetitive, impact-like musculoskeletal loads that athletes experience, particularly when they undertake extreme ranges of hip motion, cause the development of hip deformities. According to this theory, these musculoskeletal loads trigger abnormal growth patterns during the years of skeletal development and cause the formation of hip deformities. A number of hypotheses based on the proposed theory are then formulated that could be tested in future studies to ascertain whether the proposed theory could sufficiently describe the development of hip deformities in athletes.

The Role of Femoroacetabular Impingement in Core Muscle Injury/Athletic Pubalgia: Diagnosis and Management

Chronic groin pain in athletes represents a major diagnostic and therapeutic challenge in sports medicine. Two recognized causes of inguinal pain in the young adult athlete are core muscle injury/athletic pubalgia (CMI/AP) and femoroacetabular impingement (FAI). CMI/AP and FAI were previously considered to be two distinct entities; however, recent studies have suggested both entities to frequently coincide in the athlete with groin pain. This article briefly discusses the role of FAI in CMI/AP and the diagnosis and management of this complex disease.

MRI for the preoperative evaluation of femoroacetabular impingement

Femoroacetabular impingement (FAI) refers to a condition characterized by impingement of the femoral head–neck junction against the acetabular rim, often due to underlying osseous and/or soft tissue morphological abnormalities. It is a common cause of hip pain and limited range of motion in young and middle-aged adults. Hip preservation surgery aims to correct the morphological variants seen in FAI, thereby relieving pain and improving function, and potentially preventing early osteoarthritis. The purpose of this article is to review the mechanisms of chondral and labral injury in FAI to facilitate an understanding of patterns of chondrolabral injury seen on MRI. Preoperative MRI evaluation of FAI should include assessment of osseous morphologic abnormalities, labral tears, cartilage status, and other associated compensatory injuries of the pelvis. As advanced chondral wear is the major relative contraindication for hip preservation surgery, MRI is useful in the selection of patients likely to benefit from surgery.

Teaching points

• The most common anatomical osseous abnormalities predisposing to FAI include cam and pincer lesions.

• Morphological abnormalities, labral lesions, and cartilage status should be assessed.

• In cam impingement, chondral wear most commonly occurs anterosuperiorly.

• Pre-existing advanced osteoarthritis is the strongest predictor of poor outcomes after FAI surgery.

• Injury to muscles and tendons or other pelvic structures can coexist with FAI.

Sports hernia and femoroacetabular impingement in athletes: A systematic review

AIM: To investigate the association between sports hernias and femoroacetabular impingement (FAI) in athletes.

METHODS: PubMed, MEDLINE, CINAHL, Embase, Cochrane Controlled Trials Register, and Google Scholar databases were electronically searched for articles relating to sports hernia, athletic pubalgia, groin pain, long-standing adductor-related groin pain, Gilmore groin, adductor pain syndrome, and FAI. The initial search identified 196 studies, of which only articles reporting on the association of sports hernia and FAI or laparoscopic treatment of sports hernia were selected for systematic review. Finally, 24 studies were reviewed to evaluate the prevalence of FAI in cases of sports hernia and examine treatment outcomes and evidence for a common underlying pathogenic mechanism.

RESULTS: FAI has been reported in as few as 12% to as high as 94% of patients with sports hernias, athletic pubalgia or adductor-related groin pain. Cam-type impingement is proposed to lead to increased symphyseal motion with overload on the surrounding extra-articular structures and muscle, which can result in the development of sports hernia and athletic pubalgia. Laparoscopic repair of sports hernias, via either the transabdominal preperitoneal or extraperitoneal approach, has a high success rate and earlier recovery of full sports activity compared to open surgery or conservative treatment. For patients with FAI and sports hernia, the surgical management of both pathologies is more effective than sports pubalgia treatment or hip arthroscopy alone (89% vs 33% of cases). As sports hernias and FAI are typically treated by general and orthopedic surgeons, respectively, a multidisciplinary approach for diagnosis and treatment is recommended for optimal treatment of patients with these injuries.

CONCLUSION: The restriction in range of motion due to FAI likely contributes to sports hernias; therefore, surgical treatment of both pathologies represents an optimal therapy.

Sonographic prevalence of groin hernias and adductor tendinopathy in patients with femoroacetabular impingement

BACKGROUND

Femoroacetabular impingement (FAI) is a common debilitating condition that is associated with groin pain and limitation in young and active patients. Besides FAI, various disorders such as hernias, adductor tendinopathy, athletic pubalgia, lumbar spine affections, and others can cause similar symptoms.

PURPOSE

To determine the prevalence of inguinal and/or femoral herniation and adductor insertion tendinopathy using dynamic ultrasound in a cohort of patients with radiographic evidence of FAI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study consisted of 74 patients (36 female and 38 male; mean age, 29 years; 83 symptomatic hips) with groin pain and radiographic evidence of FAI. In addition to the usual diagnostic algorithm, all patients underwent a dynamic ultrasound examination for signs of groin herniation and tendinopathy of the proximal insertion of the adductors.

RESULTS

Evidence of groin herniation was found in 34 hips (41%). There were 27 inguinal (6 female, 21 male) and 10 femoral (9 female, 1 male) hernias. In 3 cases, inguinal and femoral herniation was coexistent. Overall, 5 patients underwent subsequent hernia repair. Patients with groin herniation were significantly older than those without (33 vs 27 years, respectively; P = .01). There were no significant differences for any of the radiographic or clinical parameters. Tendinopathy of the proximal adductor insertion was detected in 19 cases (23%; 11 female, 8 male). Tendinopathy was coexistent with groin herniation in 8 of the 19 cases. There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy. Patients with a negative diagnostic hip injection result were more likely to have a concomitant groin hernia than those with a positive injection result (80% vs 27%, respectively). Overall, 38 hips underwent FAI surgery with satisfactory outcomes in terms of score values and subjective improvement.

CONCLUSION

The results demonstrate that groin herniation and adductor insertion tendinopathy coexist frequently in patients with FAI. Although the clinical effect is yet unclear, 5 patients underwent hernia repair. Dynamic ultrasound is a useful tool to detect such pathological abnormalities. Diagnostic hip injections can be helpful to differentiate between the sources of pain.