Hello, my name is Craig Morrow, and I come from the University of Pittsburgh Medical Center. I'd like to thank the course chairs, Al Stubbs and John Cristoforetti, for the opportunity to present this talk on hip groin syndrome. Here are my disclosures. I'd like to start this talk with a case study that illustrates some of the issues that we see in patients with a hip groin syndrome. This patient is a 23-year-old professional middle linebacker who presented to our team with several years of groin pain as a collegiate player. He was treated at that time with hip joint and pubic symphysis joint injections. He was a mid-round draft pick. He had persistent groin pain at rookie camp, and he was diagnosed with a core injury at an outside facility. As a background to this core muscle injury, or what Brian Zuckerbraun and I termed groin pain syndrome, known as sports hernia, in a recent JAMA surgery article, there are many different options for repair, which you will hear about in a separate lecture. The take-home from our standpoint is that the outcomes reported in the literature are consistent with good to excellent outcomes and return to play with either mesh repairs, repairs without mesh, as seen here, treatment with an adductor tenotomy, or with combined approaches, as listed here, the largest series of which comes from Dr. Myers et al. from 2008. Interestingly, at the Manchester Consensus Conference, the British Hernia Society presented in 2014 that the surgery itself relies on identifying pathology, releasing abnormal tension, and restoring anatomy with either suture or mesh. There is no evidence to support any superiority of any type of operation. So it's interesting to keep in mind this background as we move forward into this combined hip and groin syndrome. Our patient underwent a core muscle repair prior to his rookie season, which involved a open bilateral pelvic floor repair with adductor longus and pectineus release. Our patient, however, had persistent groin and perineal pain four to six months after his surgery and was not able to return to play. He presented to our clinic for initial evaluation with these x-rays at that time. As you can see, he has some erosions at the pubic symphysis, as well as signs of subspine impingement on the left hip with a low-hanging AIIS and a mild CAM morphology. An MRI was performed at that time, which demonstrated very mild changes at the pubic symphysis without evidence of re-tear of his core repair. He was treated at that time with a cortisone injection into his pubic symphysis at the outside institution. One year after his initial surgery, he again had recurrent pain and had to be pulled out of training camp. He was unable to plant and internally rotated his hip and had persistent deep pelvic and perineal pain associated with his anterior hip pain. His exam demonstrated tenderness over the pubic symphysis and tenderness with fader position, as well as decreased internal rotation and tenderness over his adductor origin. At that time, follow-up radiographs were performed, which demonstrated widening of his pubic symphysis on weight-bearing. An MRI was again performed, which demonstrated an effusion at the pubic symphysis, as seen on the left axial view, as well as a significant cleft through his pubic plate, consistent with a more extensive injury to his pubic plate. Our assessment at this time was that this athlete had left hip femoracetabular impingement with a combined CAM morphology of his proximal femur and subspine impingement. He had pubic symphysis instability, and now was one year status post prior failed core muscle repair. I put these treatment options out there, and we will circle back to this at the end of the presentation. Do we proceed with a hip arthroscopy with FAI correction and labor repair? Or do we proceed with an open core muscle revision repair, a laparoscopic mesh repair, a combined hip arthroscopy and core muscle surgery? Or do we introduce some sort of pubic symphysis stabilization? I'd like to review the literature with regard to the pubic symphysis, the core, which we previously discussed, and associated combined injury patterns. As a review, the anatomy and biomechanics of the pubic symphysis are shown in this schematic. The pubic symphysis acts as a fulcrum for the anterior pelvis. Stability of the pubic symphysis is imparted through tendinous attachments and vectors of force generated at the pubic symphysis. There is a bony layer and a muscular layer, which both contribute to stability. And imbalances in this muscle group strength, endurance, and coordination may exacerbate stresses across the pubic symphysis. Classically, osteitis pubis has been defined as inflammation of the pubic symphysis and surrounding muscle insertions. However, in the athletes that we're treating, it's my opinion and that of others that osteitis pubis really is the result of instability across the pubic symphysis. These repetitive stress forces lead to accumulative microtrauma and altered biomechanics at the pubic symphysis. As a result, there is symphysial instability and the subsequent radiographic and clinical findings that we have discussed. The at-risk populations for injury or microtrauma to the pubic symphysis include those participating in American football, rugby, heavyweight lifting, and extreme sports. Oftentimes, these symptoms in these players are nonspecific. They may have groin or pubic symphysis pain. They may have pain with increased weight bearing and performing their sport. Frequently, they may note pain radiating to the perineum and may describe an instability sensation or grinding at the pubic symphysis. Physical examination will oftentimes demonstrate tenderness over the pubic symphysis and the adductor origins. The athlete may demonstrate a painful or resisted adduction exam or the pelvis springing in the lateral decubitus position. There is significant overlap with hip impingement findings as these players may also complain of pain in the fader or favor position. Injections with local anesthesia may be helpful as a diagnostic tool into the pubic symphysis. Standard radiographs are performed of the hips and pelvis, including a weight bearing pelvis. In cases where instability is suspected at the pubic symphysis, Flamingo views are helpful to evaluate the vertical instability. Garris et al. in 2008 published in JBGS that the upper limit of physiologic motion is two millimeters with a five millimeter total translation with single leg stance radiographs. MRI is helpful to understand the injury pattern as the most common MRI findings include subchondral bone marrow edema, subchondral cyst formation at the pubic symphysis, symphysial widening or diffusion, a pubic plate lesion, as well as adductor and rectus pathology. We will now go into a discussion of the combined injury patterns involving both the hip joint and the core in pubic symphysis. We published this paper in 2014 in Sports Health with Brian Kelly, illustrating the compensatory injury patterns that may be seen in patients with mechanical hip pain and FAI. What we know is that when there are increased stresses across the bony hemipelvis, an athlete will try to achieve super physiologic terminal ranges of motion. This athlete may then see some secondary motion around the hemipelvis, which we see in these combined injury patterns involving the core. This illustration, courtesy of Patrick Birmingham, demonstrates schematically what may happen with a hip when there is some femorisotabular impingement and the associated instability that may be seen at both the SI joint and pubic symphysis. Birmingham et al. followed this up with a cadaveric study, which looked at the effect of CAM impingement on the pubic symphysis and found that hips with a CAM lesion experienced up to 35% more symphysis motion than those without FAI pathology. We'll next move to discussing treatment of these combined injury patterns. Our initial treatment in almost all cases is non-surgical with some activity modification, period of rest, NSAIDs, and a very focused rehabilitation program involving core strengthening instability and resolution of the imbalance between the hip and pelvic muscle stabilizers. We then, if we're able to achieve resolution of symptoms, proceed with a gradual progression back to sport-specific activities. The key to this approach is a multidisciplinary approach involving both orthopedic surgery, general surgery, physical therapy, oftentimes an athletic trainer as well for the care of the athlete. The treatments that have been described for instability of the pubic symphysis are several-fold. The first of which was in 2000 by Williams et al., where they treated seven rugby players with pubic symphysis instability with open reduction internal fixation with bone grafting. Subsequent series have utilized curatage of the pubic symphysis, as in this paper from Radek et al. in 2008, as well as open trapezoidal resection of the pubic symphysis with adductor tenotomy as performed by the group from Brazil in 30 male professional soccer players. Matsuda and Dohm et al. described treating seven patients with FAI surgery and an endoscopic pubic symphysectomy and showed significant improvement in symptoms. This was followed up in a subsequent report by Matsuda et al. that described endoscopic rectus abdominis and pre-pubic aponeurosis repairs for the treatment of athletic pubalgia. So the question then becomes, when do we do surgery on the hip, when do we do surgery on the core, and when do we do surgery on the pubic symphysis? Chris Larson gave a fantastic report at the NFL Physician Society in 2019 with regard to when do we manage the hip and how do we manage the core injuries in our NFL players. I've summarized his points here. The first dilemma is that 50% plus of NFL players will have a documented MRI labral abnormality regardless of symptoms, 90% plus will have some imaging evidence of FAI regardless of symptoms, and about one-third of players will have imaging evidence of athletic pubalgia regardless of symptoms. How do we confirm what's causing the pain? Well, it gets back to physical exam, history, diagnostic injections, and really this diagnosis is not based primarily on imaging. The second dilemma is that upwards of 90% of NFL players return to play after core muscle surgery at around three months, 85 to 90% of NFL players return to play after hip arthroscopy and FAI correction, although this is less predictable for Lyman. However, the return to play timing is slightly longer than an isolated core muscle repair, usually around five to seven months. Question is, is there evidence to support doing both procedures when both are symptomatic? Could fixing one be enough or lead to resolution of the other? So what does the literature say? Well, Chris Larson reported in 2011 that 37 hips with symptoms in both the core and the intra-articular hip joint, when treated concurrently, led to resolution of symptoms and improved post-operative outcomes in 89% of these hips. Samar Mood and Brian Kelly reported on a series of athletes that underwent hip arthroscopy surgery for symptomatic FAI. They found that the group that underwent a combined core muscle surgery and FAI surgery returned to professional competition, while those that only underwent surgery for the athletic pubalgia were not able to return to play. Interestingly, a group from Japan recently reported that hip arthroscopy surgery alone can result in resolution of bone marrow edema and the pubic symphysis that is seen in these combined injury patterns, even when the core is not operated on. So how do we put this into action? Well, when there is clinical and imaging to suggest both the hip and core, we utilize the injection and the response to the injection is key in these cases. If the player has near complete relief of symptoms with an intra-articular hip local anesthetic injection, we proceed with a hip arthroscopy only. If there is minimal relief and continued anterior pelvis pain and the symptoms localized to the core, then the player will undergo a core muscle surgery with an expected recovery of two to three months. If there is still a combined pattern where there is some relief of symptoms, but persistent lower abdominal or adductor pain, this is an indication for a combined procedure involving both the hip and the core. This really follows the hip arthroscopy recovery, which is about a five to seven month recovery. I think it is important to consider treatment after the season if the athlete is able to compete and reasonably be productive. And finally, physical examination pain that does not recreate the presenting symptoms we generally ignore, i.e. if the player says, that's not my limiting pain. In general, we recommend treating athletes non-surgically who have mild symptoms, but they are not affecting performance. Secondly, there is no evidence to support any long-term consequences for pubic symphysis or core muscle pathology left untreated. However, a word of caution, patients with large cam deformities are at risk for secondary risk of further chondral delamination and degenerative change. So this is the group to be a bit more proactive with arthroscopically in the hip. So in conclusion, let's move through some of the surgical images and outcomes. In our case, we treated the patient with a left hip arthroscopy with subskine decompression, labor repair, and femoroplasty. We then addressed the instability across the pubic symphysis with a laparoscopic pubic symphysis stabilization with an internal brace and reinforcement of the anterior pelvis with mesh with bilateral adductor longus tenotomies. Here are the intraoperative images, the hip arthroscopy demonstrating a superior labral tear. The subspine lesion is demonstrated adjacent to the labrum in this image. The subspine decompression was then performed and is seen in this view as well. A labral repair with circumferential tape suture was performed. The cam lesion was then identified with the hip out of traction, and the femoroplasty was performed. We then performed the laparoscopic pubic symphysis stabilization as was described by our group in arthroscopy techniques in 2018. In this case, the pubic symphysis is exposed with an extraperitoneal exposure. The pubic symphysis stabilization is then performed with fluoroscopic guidance. Suture anchors are placed with the fluoroscopic guidance into the pubic bone through this extraperitoneal approach. The tape suture is then crisscrossed across the pubic symphysis, and fluoroscopy is used to confirm the position in the contralateral pubic bone. The second set of anchors are then placed on the contralateral pubic bone, and with gentle compression across the pelvis, the final tightening is performed. This achieves a 90-90 construct to provide dynamic stability to the pubic symphysis without fusion. The final construct is shown here. We then reinforced the repair in this case with a mesh, as would be performed in a mesh repair for core muscle injury. Postoperative radiographs demonstrated decompression of the subspine lesion and the CAM femoroplasty, and the pelvic x-ray demonstrated a stable appearing pubic symphysis with relative reduction. This player followed the standard post-surgical FAI protocol. His peroneal and anterior hip pain resolved and was released to unrestricted football activity six months postoperatively. He made a successful return to training camp the following season. In conclusion, be comprehensive with your treatment of the hip and core using a multidisciplinary collaborative team. But don't over-treat or treat asymptomatic imaging findings. These imaging findings without symptoms are extremely common in athletes. Thank you very much for your time and attention.

hip groin syndrome

groin pain syndrome

pubic symphysis

instability

combined injury patterns

multidisciplinary approach