Should femoroacetabular impingement be surgically treated concurrently with athletic groin injury?
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Plan separate surgeries
A 2008 survey of hip injuries in the NFL introduced the “sports hip triad,” consisting of a hip labral tear, adductor injury and rectus abdominis injury.
This concept highlights the frequent coexistence of intra-articular hip pathology — such as femoroacetabular impingement (FAI) — with athletic groin injuries (also known as core muscle injury, athletic pubalgia or “sports hernia”).
When conservative treatment fails, both FAI corrective surgery and groin injury repair reliably return athletes to play. However, when these conditions coexist, should surgery address both issues simultaneously? While it may seem efficient to address both pathologies in a single operative session, I find compelling reasons to plan surgery for these issues separately in my practice.
From a technical standpoint, combining hip arthroscopy and sports hernia repair prolongs operative time, increasing risks such as infection and deep vein thrombosis. In addition, postoperative rehabilitation protocols for FAI and core muscle repair differ, creating conflicting demands on the athlete’s recovery.
Furthermore, not all patients require both procedures. In a 2011 study of athletes with concurrent FAI and groin injury, 85% to 93% returned to sport when both conditions were treated surgically. However, some recovered fully with only groin injury repair (25%) or only FAI correction (50%). Similarly, another study found that 39% of professional athletes with both conditions had complete symptom resolution after FAI surgery alone.
Notably, Christopher M. Larson, MD, and colleagues found no difference in outcomes or return to sport rates between athletes who underwent simultaneous vs. staged surgery, supporting a “wait-and-see” approach. If one procedure resolves symptoms, a second surgery may be unnecessary.
While concurrent surgery may seem expedient, the increased operative time and rehabilitation challenges are significant considerations. In my practice, staging these procedures optimizes recovery and may spare some athletes from an unnecessary operation.
- References:
- Feeley BT, et al. Am J Sports Med. 2008;doi:10.1177/0363546508319898.
- Hammoud S, et al. Arthroscopy. 2012;doi:10.1016/j.arthro.2012.02.024.
- Larson CM, et al. Arthroscopy. 2011;doi:10.1016/j.arthro.2011.01.018.
- For more information:
- Brian D. Busconi, MD, is a professor and chief of the division of sports medicine at UMass Chan Medical School in Worcester, Massachusetts.
One surgery under same anesthetic
Patients with combined groin pain and intra-articular hip pain should be treated with combined surgical management. According to Kostas J. Economopoulos, MD, and colleagues, there is a high incidence of athletic pubalgia (now known as core muscle injuries) in patients with FAI and labral tears due to the stress translation to the pubic symphysis and related structures. In some instances, it can be difficult to determine based on physical exam alone if the hip or the core muscle injury is the main source of pain or if it is related to the combined problem when both are radiographically present.
In cases such as these, a diagnostic local anesthetic injection to the hip joint and a repeat exam can be helpful to determine the appropriate surgical treatment. If combined surgical treatment is indicated, it can be done under the same anesthesia or staged, but patients do better with combined surgical treatment when both pain generators are present. This was demonstrated by Christopher M. Larson, MD, and colleagues. In their case series, if only one problem was treated, the athlete was unlikely to return to sport compared with a return to sport rate of 89% in those that were treated with a combined approach.
In my practice, I treat both problems under the same anesthetic. I begin the procedure with an open core muscle repair with an adductor longus tenotomy if indicated and a rectus abdominus repair. I then treat the intra-articular FAI and labral tear arthroscopically. A standard hip arthroscopy postoperative protocol can be used postoperatively. My experience in treating combined intra-articular pathology and core muscle injuries is in line with the published data outlined above. I would strongly encourage the treatment to be done under one anesthetic to reduce anesthetic events as well as expedite the athletes return to sport. Athletes treated with a combined approach generally return to sport around the same time as a patient with an isolated hip arthroscopy with osteoplasty and labral repair.
- References:
- Economopoulos KJ, et al. Sports Health. 2014;doi:10.1177/1941738113510857.
- Larson CM, et al. Arthroscopy. 2011;doi:10.1016/j.arthro.2011.01.018.
- For more information:
- Scott Mullen, MD, FAAOS, is an associate professor in the department of orthopedics and sports medicine and program director of the sports medicine fellowship at the University of Kansas Health System.
Direct treatment at root cause
Groin pain in professional athletes is multifactorial, and its management risks specialty polarized approaches that may overlook key contributors. While FAI morphology is commonly seen in athletes, its clinical relevance should be based on performance-limiting symptoms rather than imaging findings alone. Accurate diagnostic workup and imaging selection are essential to clarify the primary pathology impacting athletic performance and guide appropriate treatment decisions.
A significant proportion of athletic groin pain has a neural component, in addition to posterior wall abnormalities. The variability in nerve anatomy necessitates a targeted approach to imaging and diagnostic testing. In athletes experiencing pain with coughing, sneezing or sit-ups, or groin pain affecting performance, direct and indirect hernias or subtle structural abnormalities, such as bulging, are often identified. Dynamic ultrasound, when performed by experienced clinicians, is a key modality for assessing the inguinal canal, providing real-time insight into muscular and fascial integrity — which static imaging modalities like MRI may fail to detect.
A systematic diagnostic workup should include selective nerve blocks of the ilioinguinal, iliohypogastric and genital branch of the genitofemoral nerves. The clinical and functional response to these blocks is assessed to determine whether they abolish performance-limiting pain. If FAI morphology is present but does not contribute to symptoms, we do not recommend surgical intervention at that stage, though careful monitoring remains essential. This approach is supported by studies showing that FAI-related changes on imaging do not always correlate with clinical symptoms or functional impairment.
Acute groin injuries in athletes who report a “pop” often involve the adductor longus or other components of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). These injuries frequently require surgical repair of all affected components to restore function and prevent chronic instability. The PLAC classification system, established by me and my colleagues, has helped improve the understanding of adductor injuries and the relationship to the anterior pubic structures. In addition, obturator nerve entrapment is a common but under-recognized cause of ill-defined adductor pain, which is often effectively treated with ultrasound-guided neurolysis. Similarly, inguinal nerve-related groin pain, when no structural abnormality is present, often responds well to targeted nerve interventions rather than surgical approaches.
It is important to recognize that MRI often identifies incidental findings that are not clinically relevant. Overreliance on structural imaging without correlating with clinical symptoms can lead to unnecessary interventions. By improving diagnostic accuracy, selecting the most appropriate imaging modality and prioritizing functional assessments, clinicians can better distinguish primary from secondary pathology, ensuring that treatment is directed at the root cause of performance-limiting pain.
- References:
- Agricola R, et al. Am J Sports Med. 2017;doi:10.1177/0363546512438381.
- Schilders E, et al. Knee Surg Sports Traumatol Arthrosc. 2017;doi:10.1007/s00167-017-4688-2.
- Schilders E, et al. Knee Surg Sports Traumatol Arthrosc. 2021;doi:10.1007/s00167-020-06180-5.
- Silvis ML, et al. Am J Sports Med. 2011;doi:10.1177/0363546510388931.
- For more information:
- Ernest Schilders, MD, FRCS, FFSEM, FRCR, is a professor in orthopedics sports medicine and consultant orthopedic surgeon at the Fortius Clinic in London and the Carnegie School of Sport at Leeds Beckett University in Leeds, United Kingdom.
Address both injuries simultaneously
FAI and athletic pubalgia, also known as a core muscle injury, both occur commonly in athletes. FAI is defined as abnormal contact of an aspherical femoral head with the rim of the acetabulum. Repetitive contact results in damage to the acetabular labrum and, eventually, to the adjacent articular cartilage. Treatment of FAI ranges from physical therapy to an arthroscopic or open surgical correction. There is generally a reported 90% return to sports participation following FAI surgery in healthy individuals with relatively normal cartilage.
Some patients with FAI develop a concomitant core muscle injury. The mechanism for the development of a core muscle injury in the setting of FAI is thought to be an increased force across the pubic bone as a result of decreased hip motion, the hallmark of FAI. This elevated force across the pubic bone results in a tearing of the rectus abdominus muscle from the fibrous pubic plate or an avulsion of the adductor magnus from the pubic tubercle or both.
When evaluating patients with a history and physical exam that is consistent with FAI, a core muscle injury or both, a careful algorithmic approach to the workup is required to determine which of these conditions is symptomatic. Testing includes careful radiographic and MR imaging, CT scan and selective injections with lidocaine, a steroid or both. If it is determined that both FAI and a core muscle injury are present and symptomatic, then the literature supports correcting both conditions.
When a facility is equipped to address both FAI and a core muscle injury simultaneously, we have found that it is better for the patient if both surgeries can be performed under one anesthetic event. At the Vincera Institute in Philadelphia, we have performed hundreds of simultaneous surgeries to address both FAI and core muscle injuries. Our results demonstrate a 90% return to sports at approximately 6 months postoperatively. Complication rates are low. Based on our experience, we strongly recommend addressing both FAI and core muscle injuries simultaneously as it is time- and cost- effective, it is safer than two anesthetic events and the clinical outcome is equivalent to correcting FAI and core muscle injuries in separate settings.
- For more information:
- Struan H. Coleman, MD, PhD, is an attending physician in the sports medicine and hip preservation services at Hospital for Special Surgery in New York, and director of the Hip Preservation Center at the Vincera Institute in Philadelphia.
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