Myriad of hip joint pain impedes groin injury diagnosis
Commonly found among male athletes who participate in cutting and pivoting sports, such as soccer, football, basketball and hockey, groin injuries have been associated with a myriad of descriptions and causes of pain.
“As we have been seeing an increase in hip and pelvic injuries and pain, we have also started to identify that there are also myriads of pain that are related to the hip joint,” Shane J. Nho, MD, MS, of Rush University Medical Center, told Healio | Orthopedics Today. “There are some that are secondary to the hip joint, and there can be separate entities altogether.”
Source: Virginia Smith
Anatomical structure
When diagnosing groin injuries, Srino Bharam, MD, MBA, director of hip preservation at Lenox Hill Hospital and board member of the International Society of Hip Preservation, said he focuses on the anatomical relationships of the symphyseal region to identify groin injury patterns. This is based on cadaveric studies Bharam performed in collaboration with Ernest Schilders, MD, FRCS, FFSEM, FRCR, professor of orthopedic sports medicine in the Carnegie School of Sport at Leeds Becket University.
“Our understanding of groin anatomy may improve our imaging interpretation and clinical diagnosis,” Bharam said.
According to William C. Meyers, MD, an important concept in anatomy is that the area from mid-thigh to mid-chest should be considered one unit, which he calls the core.
“The second concept is to think in terms of there being two types of joints in the pelvis that work together,” Meyers, president of The Vincera Institute and professor at Jefferson University Health System, Sidney Kimmel Medical School, Drexel University College of Medicine and Duke University Health System, said. “The first joint is the hip joint, which we defined then as just the ball and socket, and we realized that this had an intimate relationship to the muscles. The second joint I called a ‘pubic bone joint,’ for lack of another term, where you think of everything that is hard down there basically as being the center of all of this muscular activity in the body.”
Meyers said the pubic bone has a fibrocartilage cover that extends to other muscles in the pelvis, including the main rectus abdominus and abductor muscles. If a muscle injury occurs somewhere in the core, he said the fibrocartilage cover can become loose and be in danger of pulling off.
“Fluid accumulates where there are those injuries within the cover, and [that] fluid is what is often called osteitis pubis,” Meyers told Healio | Orthopedics Today. “It is inflammation around the pubic bone and, with time and pounding, it crosses the cortex and gets into the bone marrow, so you can end up with increased bone marrow edema.”
He continued, “There is a whole complex relationship with muscles, but the muscles take the hit. Even if it is a structural hip issue, the muscles will overpull, try to compensate for and defend the hip, and bad things happen. You have to figure out where is the main pain coming from. Is the main problem in terms of pain or is it muscles or is it the hip, and what combination?”
Clinical exam, imaging
According to Bharam, groin symptoms can be classified as inguinal or adductor related groin pain either alone or combined and traumatic vs. repetitive groin injury. He said a detailed groin examination should include provocative testing, assessing strength deficits and hip exam.
“Advanced MR imaging should focus on dedicated sequences of the parasymphyseal region to enhance imaging interpretation,” Bharam told Healio | Orthopedics Today.
One area that has been considered “the crucial pathoanatomy in core muscle injury” is the prepubic aponeurotic complex, according to Dean K. Matsuda, MD, CEO of Premier Hip Arthroscopy and chair of the International Hip Preservation Society Traveling Fellowship Committee.
“It is conceivable that some cases of failed surgery for core muscle injury — then called sports hernia or athletic pubalgia — were from a failure to appreciate and address the fibrocartilage avulsion of the prepubic aponeurotic complex, also known as the pubic plate,” Matsuda, a Healio | Orthopedics Today Editorial Board Member, said.
In addition, Matsuda said femoroacetabular impingement (FAI) has not only been associated with groin pain attributed to osteitis pubis and core muscle injury but has also been cited as a possible cause since a constrained range of hip motion may cause pathologic transfer stress to the pubic area.
“The athlete with osteitis pubis and/or core muscle injury should be checked clinically and radiographically to ensure they do not have FAI, as the latter may not be only a pain generator, but a cause of central pubic pathology,” Matsuda told Healio | Orthopedics Today. “Moreover, missing treatable FAI may have adverse degenerative consequences. If both conditions are indicated for surgery, we now have a seamless outpatient alternative that harnesses the advantages of less invasive surgery.”
Prevention
Because most groin injuries are noncontact-related, Bharam said it may be possible to prevent it from occurring with a comprehensive groin and hip rehabilitation program. However, he said structural consideration and movement patterns that place athletes at greater risk for these injuries should be included in the assessment of athletic performance.
But, when a groin injury does occur, Nho said patients with complaints of chronic pain will start with NSAIDs and undergo physical therapy.
“I would say that with a large majority, these entities could be treated conservatively,” Nho said.
Injections
Christopher M. Larson, MD, of Twin Cities Orthopedics, said athletes with mild symptoms should be enrolled in a core stabilization program and avoid activities in the weight room that may irritate their injury.
“If they do have some osteitis pubis or pain right in that area, you could try a corticosteroid injection into the pubic symphysis,” Larson, a Healio | Orthopedics Today Editorial Board Member, said. “It can sometimes also help with a core muscle injury, because there is oftentimes a tear in that region that may communicate with the pubic symphysis.”
He said trigger-point injections into the rectus abdominus have been recommended, while anesthetic injections should be rarely used and reserved for professional athletes trying to get through the season.
But Meyers said not to use platelet-rich plasma or mesenchymal stems cell injections for treatment of groin injuries, as these have been shown to produce heterotopic bone.
“In one large group of NFL patients, [core muscles and adjacent soft tissues] turned to bone. There was heterotopic bone there, and it did not help any of the cases that we could find,” Meyers said.
Injections to the groin can play a diagnostic and therapeutic role for the acute management of groin pain, according to Bharam. However, he said multiple injections should be done cautiously for risk of masking symptoms. He added there is also no evidence on the long-term effects of multiple injections to the groin and whether there is a potential risk of infection.
Surgical treatment
Although conservative treatment is the first approach in treatment of groin injuries, “there is weak evidence to support the efficacy of nonoperative rehabilitation programs at returning athletes to their preinjury levels of participation,” according to Matsuda. He said research has shown patients who undergo conservative treatment have a 9% failure rate and a 25% recurrence rate.
According to Larson, it can also be difficult to treat groin injuries in elite athletes nonoperatively in the long term.
“If somebody is disabled by it, there are some studies that suggest that maybe upward of 50% of these athletes could be helped with a nonoperative approach, but it can take up to 1 year,” Larson told Healio | Orthopedics Today. “We do not have that kind of time for these elite athletes to wait a year.”
Meyers said surgery may also be necessary depending on which muscles are injured and to what degree. For patients with a groin injury at the insertion and adductor muscles, Meyers said surgery would be necessary if they wanted to continue to play to prevent the fibrocartilage from being removed.
“Once the muscles of the fibrocartilage plate are loose, you are in danger of pulling right off,” Meyers said. “But we can see on imaging plus physical exam evidence that it is going to rip off soon. When we identify that, which is in the minority of cases, it is best to pull somebody right out in terms of not letting them play and [we] fix it.”
Groin injury with FAI
When groin injury is associated with FAI, research has shown treatment of both pathologies may yield a better outcome compared with treatment of the groin injury or FAI alone.
“We have realized over time that there is an intimate relationship with underlying FAI in these core muscle injuries,” Larson said. “Athletes can come in with both and ... if you just [treated] the core muscle injury, not many of them return to sport. If you just did the FAI surgery, which improves their range of motion, upward of half of these athletes will get back to their sport and the core muscle resolves. But, if you [treat] both, 90% to 100% of the athletes get back.”
However, Bharam said while groin injuries and FAI can coexist, “not every athletic groin injury that has hip labral tears needs a surgical hip intervention.”
Source: Dean K. Matsuda, MD
Developed by Matsuda, endoscopic pubic symphysectomy (Figure 1) to be an effective procedure for recalcitrant osteitis pubis.
“I usually perform this concurrently with arthroscopic FAI surgery in co-afflicted athletes and will perform endoscopic repair of an avulsed pubic plate, adductor tendon or distal rectus abdominis insertion dependent on the individual’s pathologic findings,” Matsuda said.
More research needed
When it comes to treatment of groin injuries, Bharam said collecting outcome scores in the form of a registry would allow clinicians and researchers to track these athletes to identify prevention strategies and advance clinical guidelines.
Long-term clinical studies are also needed as are studies identifying a treatment algorithm for groin injuries, according to Nho.
“There has been some early work in terms of cadaveric and biomechanical testing on some of the surgical repair techniques that have been introduced and discussed, but some of these things might require multidisciplinary approaches,” Nho said.
Matsuda also said future research should identify clinical or imaging findings “that might predict whether a given athlete with FAI syndrome and osteitis pubis/core muscle injury will favorably respond to improvement in hip range of motion via arthroscopic CAM decompression alone or if endoscopic pubic symphysectomy and/or prepubic aponeurotic complex repair should be performed as primary surgery.”
In addition to identifying surgical interventions, Larson said more research should be conducted to fine-tune nonsurgical approaches for groin injuries.
“We need to look more in-depth at our nonsurgical approaches to see if there are things that we can do to help these athletes depending on how they present,” Larson said.
However, Meyers said for research to expand more physicians and researchers need to become interested in identifying and treating groin injuries. He said the problem is the lack of support from hospitals and medical schools, as these institutions do not receive reimbursement for groin injury procedures.
“There is this big blockade against advancement in the field, and we just need more physicians to be gutsy and to join us in fellowship when the funding is not there,” Meyers said. “When [surgeons] are trained in it, they will realize there is a whole field there that they can develop.”
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- For more information:
- Srino Bharam, MD, MBA, of Lenox Hill Hospital, can be reached at sbharam@northwell.edu.
- Christopher M. Larson, MD, of Twin Cities Orthopedics, can be reached at chrislarson@tcomn.com.
- Dean K. Matsuda, MD, of Premier Hip Arthroscopy, can be reached at saltandlight777@hotmail.com.
- William C. Meyers, MD, of The Vincera Institute, can be reached at wmeyers@vincerainstitute.com.
- Shane J. Nho, MD, MS, of Rush University Medical Center, can be reached at shane.nho@rushortho.com.
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