Athletic Pubalgia: Activity related Groin and Hip Pain Brett Cascio, M.D. Orthopaedic Specialists Lake Charles, LA MCNEESE SPORTS MEDICINE Athletic Pubalgia         Muscle strains Osteitis pubis Sports Hernia Neuralgia SI joint Sciatica/referred back pain Stress fracture Intraarticular causes Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? Muscle Strains Adductor Magnus Strain Rectus Strain Sofka 2007 Avulsion Fractures www.learningradiology.com/archives06/COW%20205-Ischial%20Avulsion%20Fx/avulseischiumcorrect.htm Treatment Supportive MRI Steroid Platelets Surgery rarely needed Platelets: Platelet Rich Plasma  Blood drawn from patient (10-60 ml)  Centrifuged for 5 minutes  Plasma retrieved from sample  Injected into desired location Osteitis pubis Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? Chronic pubic pain, no injury, better with rest and NSAIDS Treatment Supportive Injections Sports Hernia Athlete – soccer, football, hockey c/o – groin pain, worse with activity pain with coughing aching into testicle PE - Valsalva, running, twisting palpation over pubis sit-up or crunch What is a Sports Hernia?  Syndrome of chronic pain caused by weakness or disruption of the posterior inguinal canal and conjoined tendon  Posterior inguinal canal = fascia transversalis + Insertion of internal oblique & transversus Finding the Sports Hernia Sports Hernia/ilioinguinal n. entrapment Sofka 2007 Treatments Nerve resection Surgical repair SI Joint Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? MRI is frequently negative FABER test FABER Test SI Joint Vad et al. Am J Sports Med 2004 Treatments Supportive Steroid injection? Piriformis syndrome Greater Troch Bursitis Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? Palpate area of pain Treatments Supportive: stretching, modalities, NSAIDS Injection? Surgical release Radiculopathy Spondylolysis/listhesis Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? Back pain increases with extension Straight leg raise Treatments Refer to surgeon for evaluation Conservative treatment is usual Stress Fracture Sofka 2007 Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? Heal strike pain with weightbearing MRI – does not appear on xray Treatments Refer to surgeon Protected weightbearing Surgery to repair Intraarticular causes SCFE Labral tear Chondral lesion FAI Psoas tendon impingment on labrum Log Roll Test intraarticular pathology SCFE http://www.aafp.org/afp/20000215/1011.html Treatments Refer to surgeon Protected weightbearing Surgery to repair Labrum tear  Abnormality of hip biomechanics that leads to pain, labral damage, and eventually cartilage damage and arthritis ©2008 Smith & Nephew, Inc. Impingement Tests Anterior Impingement Passive flexion to 90° followed by forced adduction and IR Leunig et al. Op Tech Orthop 2005 Femoroacetabular Impingement Parvizi JAAOS 2007 Hip Dysplasia too little bone on cup or cup too shallow opposite of FAI Chondral lesion Figure it out Was there an injury? Is the athlete able to play at their best level with the pain? Is there a specific move that recreates the pain? Superficial or deep? Can you touch the pain? Groin pain Buttock pain Clicking, popping, locking Impingement Tests Anterior Impingement Passive flexion to 90° followed by forced adduction and IR Leunig et al. Op Tech Orthop 2005 Impingement, dysplasia, or Injury Tear/Loose Bodies OA Ganz et al. CORR 2003 Psoas tendinitis/impingement Internal Snapping Hip Sofka 2007 Treatments Refer to surgeon Arthroscopy Bruised labrum FAI/Labrum tear video Importance of Labrum Repair Loss of labrum leads to degenerative changes FAI/Labrum tear video Psoas tendon video Thank you Palpation Physical Exam Point of maximal tenderness (psoas, greater trochanter, pubic symphysis, adductor origin, rectus ) Strength testing Neurological testing Range of motion flexion, extension, internal rotation, external rotation, abduction (Thomas test—flexion contracture) Impingement test - flexion, adduction, internal rotation Clicking - psoas versus Tensor Fascia Lata versus Labrum SLR - radiculopathy/sciatica Resisted SLR - intra-articular pain Ober - IT band tightness FABER - sacroiliac joint Heel strike - femoral neck Log roll - intra-articular pathology Physical Exam Supine Passive ROM Normal ranges: Adduction 30° Abduction 45° Flexion 120° Extension 0° IR 30° ER 50° Impingement (FADIR) Flexion/adduction/internal rotation Reproducible pain with most intra-articular pathology Thomas Test: Tight Psoas/capsule Patrick/Faber’s Pain posterior is positive for SI joint pathology Pain anteriorly is positive for anterior joint/capsule irritation McCarthy’s Hip Extension Sign With both hips flexed, extend the affected hip in int/ext rot