Good evening, and welcome to the extra-articular portion of this HIP course. I would like to thank the course chairman, Dr. Shane Ngo, the faculty masters, and Anna for allowing me to speak tonight on core muscle injuries. I have nothing pertinent to disclose regarding this talk. Core muscle injuries over the past 20 years have changed names multiple times, and it just goes to show you how confusing this type of injury can be. In general, the majority of these athletes will talk about an exertional pain, and the hallmark of these injuries include injuries to the rectus abdominis, the adductor longus, as well as an injury to the posterior wall of the inguinal canal. Also, will be pain in and around the pubic symphysis. My objectives tonight will help, will hope to help make this a little less confusing for you. Well, as Dr. Lynch talked earlier, it's really important to find out where the location of the patient's pain is, and extra-articular hip disorders can hurt in multiple places, but it's the puzzle that you've got to put together to try to figure out which treatment regime is the one that's going to be most effective for your patients. The differential diagnosis of abdominal pain is quite extensive. However, with some important characteristics, I think we can help you in terms of guiding as to whether or not this is secondary to a patient's core muscles or not. The core muscle injuries are poorly understood, which are secondary to a lack of specific clinical tests, as well as the coexistence of multiple pathologies in and around the pelvis and hip area. Important in the anatomy of core muscle injuries is the posterior wall of the inguinal canal and its direct attachment to the pubic symphysis and the pelvis, as well as I talked about beforehand, the rectus abdominis and the adductor musculature. I wish these patients came into you and gave you the exact mechanism of injury, but it's oftentimes very vague. Hyperextension injury in and around the anterior pelvic and pubic symphysis, probably the most common type of mechanism. Freely et al. in 2008 talked about the interplay between femoral acetabular impingement, compensation patterns, and the pelvis itself, leading to what's called the sports hip triad. It's very difficult sometimes to ascertain which is the one which bothers the patients the most, but it is probably the most important thing you're going to do in terms of treating these patients. Core muscle injuries, for the appropriate diagnosis, are recognized if there are more than three of these five symptoms. Again, this came up from the British Hernia Society meeting, which occurred in 2014. They basically described pinpoint tenderness over the pubic tubercle, palpable tenderness over the deep inguinal ring, pain and or dilation of the external ring without an indirect hernia evident, pain at the origin of the adductor longus tendon, and again, a dull diffuse pain in the groin. So this location of the pain becomes very important, and Tishan went through this very well. Is it the hip joint? Is it above the pubis? Or does it involve the adductor musculature? On physical examination, it's very easy. These patients will have tenderness developation over the peripubic area without a palpable indirect hernia. They will oftentimes have pain with resisted rectus sit-ups, which I'll go over. But it's important to do a full hip examination and a full lumbar examination, as well as making sure that you don't have a nerve entrapment issue. Here are my exams for resisted sit-ups. I do them with the legs straight, with the hip and knee flexed with the feet on the table, the hip and knee flexed with the feet off the table. All of these stimulate and put stress across the pelvis, the attachment of the rectus, attachment of the adductor, and the pubic symphysis. Adductor pain can be elicited by resisted adduction and hyperabduction of the leg. And again, this is a fairly easy diagnosis for orthopedic surgeons. Checking for inguinal hernias are not easy diagnosis and must be done if you're going to be someone who's going to look at these patients in both a supine and standing position. You have to be able to palpate the internal and external rings to make a diagnosis as to whether or not there's a hernia present. Imaging studies. We've talked already a lot about imaging studies and that they should be used to exclude other conditions than core muscle injuries. Again, your standard x-rays are very important. And again, my go-to is the MRI. There are specific sequences that I use on my MRI imaging techniques. My first portion of my study is to screen the pelvis initially, getting a large field of views with coronal T1 and axial STIRs. This will not only allow you to see the pelvis, but also allow you to see the hip joint as well to see if there's any bad concurrent pathology going on. Then you focus on the pubic symphysis, getting a small field of view, coronal T1, STIR, sag and oblique axial. By far, I feel that the small field of view is the best for core muscle injuries, specifically the core, the sag and the oblique images will help show you what's going on in this region of the pelvis. Axial and sagittal findings will show you tears of the rectus abdominis and the adductor aponeurosis. They will show you bone marrow edema signal intensity in and around the pubic symphysis. And the coronals will show you the secondary cleft sign, which is an indication of tears of both the adductors as well as the rectus musculature. Adductor tendon injuries are often common with these and can be frequently underdiagnosed. Again, that large field of view will show you whether or not there are CAM deformities, will show you whether there's inflammation in the joint. And again, if you look close enough, it may also show you tears of the labrum. And in your discussion with the patient, it's impossibly important in terms of your recommended treatment protocols. Nonoperative intervention is the hallmark of what I do in terms of management of these injuries. And again, here, as Dr. Chawla talked about earlier, injections are essential. It is important to be able to differentiate for the patient whether the pain is coming from the hip joint itself, whether it's coming from the rectus attachment, the pubis, or whether it's coming from the adductor tendons. And here, lidocaine injections will help you out quite a bit and help the patients out in terms of determining how much of the pain is coming from each of the areas. Using ultrasound is something that you should become familiar with. And again, whether you add in steroids, PRP, or stem cells is totally up to you. But I think that your lidocaine injections are very important. Once you do these injections, and I commonly will do them with a steroid mixture, the next step will be putting it in appropriate physical therapy phases. In here, and here's my conservative management protocols, and again, my talk is available for you. Again, basically what it is, it's about a six-week period of time where we achieve functional range of motion, and then we work to functional activities. What do we do if that doesn't work, or if the athlete is five months preseason, or if they're just after postseason, what do we do with failed non-operative intervention? And in my hands, the treatment is operative intervention. Now, there's a lot of talk about different surgical options. In my hands, and I believe the hands of the majority of people that are actually doing this surgery, especially in the young athletes, is to do an open primary pelvic repair without a mesh. These mimic the Bassini, Scholdeis, or McVeigh repairs. I rarely put in a mesh to these types of injuries, and for my patients above the age of 35, I will opt to do a laparoscopic repair with mesh, as I do not feel that the tissue quality is as good in this patient population. In terms of the adductor tendons, I usually leave them alone if there's no clinical involvement. If there is mild clinical involvement, I'll eject them. If there is major clinical involvement, I will do a release. I do not feel that repairs are important in this, as I've had excellent results from dividing the fibers about two to three centimeters from the pubis and leaving the muscle belly behind alone. There are other options out there for treatment to this. You'll hear some tonight, but in my hands, this is 96% successful. Our goals are to reinsert the rectus, to stabilize the interface between the rectus and the conjoined tendon, and to reinforce the posterior wall of the inguinal canal. Here's what I do in the operating room. The standard McVeigh-Bassini incision, you come down, and you can see the inguinal ring. You want to take that away, and then in the OR, you can see the actual defect. Here is the direct hernia component or weakness of the posterior wall. Here's the rectus tendon pulled off the pubis, and basically what we do is we reinforce this and repair that, re-tensioning the rectus and taking care of the posterior wall of the inguinal canal. What do we do with the adductor tendon? We'll only inject the majority of them, but if that doesn't work after injections preoperatively, then we do a release. You want to do the release. I like to allow it to release about a centimeter down, and then I'll restitch it back into the fascia layers so it doesn't jettison down the leg. Then you just got to make sure that there's good bleeding. The largest complication from this portion of the surgery is wound dehiscence, so you need to be careful that you do a good job of your skin repair. Our study shows that 213 patients with a three-year follow-up, excellent results where we've had no revisions. We've had two patients go on to have hip arthroscopies on that side, but again, if you do a good job of your preoperative planning and diagnosis, these patients do very, very well. I have been unable to reproduce some of the results, especially in the European literature of getting my patients back in three to four weeks. In general, my return to sports were for unilateral surgery three months and for bilateral surgery four months. Rehabilitation, again, which is on my talk, which you're more than likely that you can ask for and get, involves a three to four phase recovery, rest, healing, remodeling. First two weeks, I allow them just to heal. I really don't do much to them at all. The next three to four weeks is to help out with hip range of motion and core strength. The key here is to get their back and their posterior chain working again. Fix the anterior pelvic tilt, give them good balance and strength and core, and this repair works very, very well. Again, at phase three, which is the final phase of sports-specific exercises, getting them back to whatever competition they need to get. In conclusion, groin pain is not a single entity, but part of a syndrome of pelvic instability. That failure to recognize and address the interarticular pathology, in addition to treating the compensations that occur around the pelvis, can result in continued disability. I hope this has been helpful. I can't wait to see Dean's talk as to what he's doing with these athletes. Again, I thank you for your attention and I hope you enjoy the rest of this course. Please be safe.

core muscle injuries

athletes

rectus abdominis

adductor longus

posterior wall of the inguinal canal