Thank you for the introduction, and I want to thank Anna for allowing me to present today. There's a list of disclosures. So sports hernia, it's really a non-anatomic, non-diagnostic term that's been attributed many different causes of groin pain. The definition really is just pain in the lower abdomen or proximal adductor related to athletic injury. This confluence of the rectus abdominis and the adductor tendon has a significant amount of strain there, so micro tears can turn into full thickness tears with the particular activity being athletically related. Again, non-specific terms have been thrown around. Googling hockey groin on the bottom right, this is what comes up, which is actually a spear to the groin of a hockey player. This is not what hockey groin was meant to be in the literature. And so clearly if there's a miscommunication with the type of nomenclature, it's better for us to figure things out. So at the first World Conference of Groin Pain and Athletes in Doha in 2014, a Delphi process was instituted. And during this process, they categorized the groin injuries in four subcategories. So in the adductor region, if there's adductor pain and pain with resisted adduction, that was in that category. Similarly with the iliopsoas, if there is tenderness along the iliopsoas tendon and pain with a resisted hip flexion or pain with passive extension, that was diagnostic in that category. And in the inguinal region, if you had pain with tenderness to palpation there with a lack of a true inguinal hernia and pain with resisted abdominal crunch, that was diagnostic. Now the core muscle injuries that we treat in this talk are going to be in this particular category. And the final category is the pubic-related groin pain, which is truly just tenderness to palpation because there's no particular resisted musculature that you can test. So in this anatomy, the pubic epineurosis really is a confluence of the rectus abdominis, the conjoined tendon, the external oblique, and the adductor origins. It's a small amount of space with the potential for a large amount of pathology. And of course, you always have the potential for indirect and direct hernias within this region. So epidemiology of core muscle injuries, typically young males in hockey, football, rugby, contact sports, because men do things like this, unfortunately. And it's hard to know what kind of injuries they're going to come out with. But in the female patient, the schematic to the right, the female patient has a wider set pelvis and it's actually protective because it takes away some of the adductor vector force is applied. So pathophysiology, the rectus abdominis and adductor longus are really at this fulcrum here. They're pulling opposite directions. And unfortunately, the pectineus and the gracilis actually add to that inferior direction. So there's a push-pull technique going on and unfortunately, the inferior direction often wins. So chief complaint, groin pain. The biggest thing you need to do when patients come to the office is determine if there's a true inguinal hernia or not. If there is not, then you can proceed with the workup. But if there is, it has to be treated. Of the line of questions that are presented to the right, I think the most important to ask first and foremost are when and where. It can lead the clinician to figure out the particular injury that the patient suffered, what position the extremity was in to determine which subcategory the muscle was in. It's a very uniquely challenging physical exam when we talk about core muscle injuries. So we'll get into the differential diagnosis here. So core muscle injuries. You've got to palpate. You've got to use your resisted adduction, resisted hemicrunch test, resisted hip flexion. You've got to figure out what's going on and put your hands on the patient. You can't forget about the back, SI joint, radiculopathies. You can't forget about the hip because FAI can cause decreased range of motion of the hip which can increase extra articular strain. And you can't forget about the abdomen either. So imaging. Top left, normal MRI. Bottom left, osteitis pubis. You can see that on the axial MRI with the bony edema. Middle two images. This is a crossing the midline rectus abdominis injury, fairly large. On the right, increasing severity of order from the top right. This is an adductor longus injury along the symphysis pubis. And you can see in the bottom right, full thickness retracted tear. So imaging. We still want to make sure we treat FAI pathology because Dr. Larson actually talked us in 2011 in arthroscopy that patients that received FAI management concurrently with sports hernia management had approximately 90% return to play versus 25% or 50% if they were treated individually for sports hernias or FAI. Similarly label management. We saw some of these earlier in Dr. Dohm's talk. But if you're performing anatomic label repair or knotless circumferential label reconstruction, this needs to be addressed potentially during the same or staged procedure with the core muscle injury. So surgical procedures for core muscle injuries, limited outcomes, lack of consensus. Many different techniques. Open, mini open, laparoscopic, endoscopic. The bottom line is you've got to be able to prepare and treat whatever you see. So mesh repairs for the posterior inguinal canal, repair external oblique aponeurosis, repairing the external inguinal ring, the transverse fascia, or a true hernia repair. You've got to be prepared to decompress genitofemoral or ilioinguinal nerves. In our hands, the rectus abdominis is often repaired with a potential partial adductor release or adductor repair if you had a full thickness rupture with retraction as we saw in that last photo. FAI correction needs to be done with label repair. And a pubic symphysectomy needs to be done if the patient has osteitis pubis. And we published on this technique, prefer to do it endoscopically with good results. So management options in the literature. Again there's not much consensus, there's lots of variability. Take home point from this talk is do what you're comfortable with but be prepared because you can encounter multiple different pathologies during a single procedure. Sports hernia is becoming increasingly recognized yet needs more clinical studies. Little consensus upon optimal timing and optimal surgical measures but you've got to be prepared for anything. Thank you.

sports hernias

groin injuries

nomenclature of groin injuries

core muscle injuries

diagnosis and treatment options