Management of athletic hip injuries typically begins with nonsurgical care, consisting of cessation or modification of the offending sport, anti-inflammatory medications, and physical therapy. Rehabilitation should emphasize core strengthening and stabilization and postural retraining with normalization of the dynamic relationship between the hip and pelvic muscles. Local injections can be helpful in some cases to allow high-level athletes to continue to participate during the season. Aggressive stretching to improve range of motion should be avoided to prevent aggravation of hip pain in athletes with underlying FAI. Other exercises that should be avoided include deep hip flexion and low repetition and heavyweight strength training. After the athlete is pain free, a gradual return to play can be initiated.
In addition to first-line treatment strategies, adjuncts to the nonsurgical care of adductor injuries can include entheseal pubic cleft injections after a period of rest, anti-inflammatory drugs, and physical therapy. The injection is directed into the adductor enthesis (Figure 7). Schilders and colleagues13,22 investigated the role of such injections in elite and recreational athletes. In elite athletes, the investigators found that individuals with chronic adductor-related groin pain and normal MRI findings had no recurrence of pain at 1 year.13 However, symptoms recurred at a mean 5 weeks after injection in athletes who had evidence of enthesopathy on MRI.13 This finding suggests that athletes with a chronic adductor injury but no evidence of enthesopathy on MRI have early, mild disease that could resolve with nonsurgical treatment, including corticosteroid injection. However, corticosteroid injection appears to be less effective in patients with more advanced adductor disease. In a separate study of recreational athletes with adductor related groin pain, the same injection produced successful results despite evidence of enthesopathy on MRI.22 This conclusion emphasizes the importance of considering the athlete’s level when treating such an injury and suggests that injections can be used for diagnostic purposes or to provide short-term pain relief.
Most adductor injuries are low-grade strains or partial tears that generally are amenable to nonsurgical care. In athletes who have sustained complete ruptures of the proximal adductor longus, surgical reattachment has allowed a return to play but with the added cost of extended time out for healing and recovery.23,24 In a study of NFL players with adductor longus tendon ruptures treated nonsurgically, Schlegel et al25 reported that the players returned to play in half the time (ie, an average of 6 weeks) compared with surgical reattachment (12 weeks). For athletes with recalcitrant adductor enthesopathy, however, selective adductor release has been found to be beneficial. Schilders et al26 concluded that selective partial adductor release in 43 professional athletes provided considerable pain relief. All but one of the athletes returned to their preinjury level of sport at approximately 2 months.
Corticosteroid injections also have been useful adjunctive treatments that provide relief of pain associated with osteitis pubis and accelerate an athlete’s return to play.27,28 Athletes who received corticosteroid injections into the symphyseal cleft and those who received injections within 2 weeks of diagnosis had the best results.28 Nonsurgical care is generally successful in relieving symptoms; however, return to play can take time, and pain-free play can take even longer. Verrall et al29 investigated pubic bone stress injuries in professional Australian football players. They found that 89% of athletes were able to return to play by the next football season, 20 to 24 weeks after the diagnosis and initiation of treatment. Only 41% of athletes were symptom free, however. By the end of the first season after injury, 67% of all athletes had no symptoms, and after the second season (ie, 24 months after diagnosis), 81% were symptom free.
Nonsurgical treatment fails in approximately 5% to 10% of athletes, who then require surgical treatment.30 For the athletic population, surgical options include pubic symphyseal fusion, débridement of the pubic symphysis through open or endoscopic approaches, wedge resections, or surgical treatment of associated symptomatic FAI and/or athletic pubalgia31-34 (Table 1). Surgical indications are not well defined, and considerable geographic differences in treatment and diagnosis exist. Some clinicians consider osteitis pubis to be an isolated entity, whereas others attribute the symptoms to associated FAI and/or athletic pubalgia. Procedures directed at the pubic symphysis alone have been described in small series and can have important long-term complications, such as hemospermia, scrotal swelling, and stress fractures through the symphyseal arthrodesis.31
Moderate to severe symptoms of athletic pubalgia rarely improve with nonsurgical care and eventual surgical repair for symptom relief is typically required to allow the athlete to return to play.35,36 Some factors to remember regarding treatment include the level at which the athlete is competing and the timing of the sports season. During the season, if the athlete can continue to function, then the previously described strategies can be used, along with a potential corticosteroid injection for immediate pain relief to help the athlete get to the off-season, when surgical intervention can be considered without substantial time lost from sport. Surgery should be considered for the in-season athlete who cannot continue despite nonsurgical measures (Figure 8).
Surgical options are numerous, and no consensus on a preferred surgical technique has been observed in the literature. Surgical procedures are divided into three general categories: open repair with or without mesh reinforcement, laparoscopic repair with mesh, and broad pelvic floor repair with possible adductor release/repair and neurectomy. Primary repairs can be subdivided further into a modified Bassini-type repair with or without adductor releases and a minimal repair with decompression of the genital branch of the genitofemoral nerve. Athletes are able to return to play at a rate of 80% to 100% regardless of the repair type6,20,34,37-42 (Table 2).
Meyers et al20 described a primary repair in which the inferolateral border of the rectus abdominis is repaired to the pubis and the inguinal ligament to provide stability to the rectus. For athletes with adductor pathology and pain, a repair or release also can be performed to help restore core muscle balance. In this series of high performing athletes, approximately 88% were performing at or above their preinjury level within 3 months. This percentage increased to 96% at 6 months. The minimal repair technique of the transversalis fascia has been described by Muschaweck and Berger.39,43 This technique focuses on the decompression of the genital branch of the genitofemoral nerve with tension-free repair of the posterior inguinal wall deficiency or defect. Athletes undergoing the minimal repair procedure can resume running and cycling on postoperative day 2, can begin sports-specific training on postoperative day 3 or 4, and can train fully on postoperative day 5. This accelerated return to play is attributed to the tension-free repair that enables athletes to return to play within 2 weeks.
Postoperative rehabilitation varies by surgical technique and surgeon preference, but programs should focus on a step-wise progression of exercise activity, with a focus on core and lower extremity strength, stability, flexibility, and balance. Emphasis should be placed on achieving proper muscle activation, and recruitment-pattern training is essential to proper recovery. Walking can be initiated early, and light jogging can be started by 3 to 4 weeks postoperatively. In our experience, athletes generally can return to sport within 6 to 8 weeks of surgery, regardless of the approach used.
Femoroacetabular Impingement and Athletic Hip Injuries
The details of FAI anatomy, pathomechanics, and treatment options are beyond the scope of this article, but the presence of FAI has been implicated in the development of the athletic hip injuries described here. FAI is a condition of the hip in which abnormal, repetitive contact occurs, most commonly between the anterolateral femoral head-neck junction and the anterolateral rim of the acetabulum. There are two primary forms of FAI: cam type and pincer type. Cam deformities have an osteochondral asphericity at the femoral head-neck junction that leads to a loss of femoral offset. Pincer deformities have an overcoverage of the femoral head by the acetabulum. These deformities can exist independently or in a mixed pattern that can cause a cascade of intra-articular breakdown, including but not limited to disruption of the chondrolabral junction.
The prevalence of FAI has been found to be substantially higher in collegiate football players than in the general population.44 A total of 67 male athletes (134 hips) were evaluated radiographically, and 95% of hips had at least one radiographic finding of FAI; 77% had more than one sign. A total of 78% had at least one sign of cam deformity, and 66% had at least one sign of pincer impingement. In ice hockey players, 39% of collegiate and professional players were found to have considerably higher alpha angles.45 Finally, in male and female professional soccer players, 72% of males and 50% of females had at least one radiographic finding of FAI. Despite exhibiting no current symptoms, 50% of male soccer players and 25% of female soccer players reported a previous groin or hip injury.46
As described previously in the section on the layered approach, the loss of internal rotation from the presence of a cam deformity or retroverted neck causes abnormal contact with the acetabular rim earlier in the arc of motion. This block to further motion can initiate impingement and cause injury to the labrum and adjacent articular cartilage, which can lead to osteoarthritis.47 The loss of motion also produces compensatory hip and pelvic dysfunction through increased extra-articular pelvic motion. The compensatory forces place more stress on the pelvic stabilizers and ultimately can cause a breakdown of the pelvic soft-tissue structures, potentially leading to the athletic hip injuries described previously.
In a prospective study of athletes with long-standing adductor longus tendinopathy, Weir et al7 found that 64 of 68 hips (94%) demonstrated radiographic evidence of FAI; cam morphology was found in 27 hips (40%). Only nine hips (13%), however, exhibited a positive result on the anterior impingement test.
Groin injuries and osteitis pubis have been associated with a loss of internal hip rotation in Australian football players.48 Larson et al49 evaluated this association in a subset of elite athletes with symptomatic intra-articular hip pathology and extra-articular core muscle injury. The authors found that, when intra-articular and extra-articular pain was present, isolated surgical treatment of athletic pubalgia symptoms resulted in 25% of athletes returning to play. When arthroscopic FAI correction alone was performed, 50% of athletes were able to return to sports, but when both pathologies were addressed concurrently or in separate settings, the rate of return to sport was 85% to 93%. Hammoud et al50 also investigated this overlap of diagnoses in professional athletes. Players with isolated athletic pubalgia surgery could not return to play because of persistent pain until they underwent additional treatment for FAI. Conversely, in >60% of athletes, the symptoms of athletic pubalgia resolved with FAI treatment. This finding emphasizes the importance of counseling the athlete about arthroscopic or open FAI correction and the potential need for an athletic pubalgia procedure if symptoms do not resolve. In the high-level athlete, considerations should be made for staged or simultaneous surgical corrections of FAI and athletic pubalgia for a more predictable return to sport with minimal time lost.
The connection between FAI and athletic hip injuries has been confirmed not only clinically, but also biomechanically and radiographically. Birmingham et al51 verified the association between dynamic cam impingement and athletic pubalgia. Cam lesions were simulated in 12 hips from six fresh-frozen cadavers by implanting a dome-shaped wood button with a 5-mm dome height and a base diameter of 25 mm on the femoral head-neck junction at the 1:30 position. A custom loading jig that placed the leg in 90° of flexion with neutral adduction and internal rotation was applied to the femur for the simulation. This investigation supported previous theories that cam impingement causes rotational motion at the pubic symphysis after bony contact. This motion occurred in all planes, but most importantly in the transverse plane. The investigators found that this motion was present in the native hip as well as in the hip with simulated cam lesion, and they also found 35% more motion at the pubic symphysis with the cam lesion. This repetitive loading of the pubic symphysis is a known precursor of athletic pubalgia and can be a source of pain in athletes with limited hip motion.
Economopoulos et al52 retrospectively reviewed 43 athletes who underwent surgical intervention (56 procedures) for athletic pubalgia. Plain radiographs were assessed for signs of FAI, and 86% of patients had at least one sign of FAI. The average alpha angle was 66.7°, 83.7% of athletes had a cam deformity, and 28% had pincer pathomorphology. In addition, a previous study assessing long-standing adductor tendinopathy found that 94% of patients had radiographic evidence of FAI.7 Larson et al53 evaluated 125 NFL prospects (239 hips) who had a radiographic evaluation at the NFL Scouting Combine. Of all athletes, 90% (87% of hips) had at least 1 radiographic sign of FAI. The players were separated based on the presence of hip symptoms (75 symptomatic, 164 asymptomatic). The authors found that an increased alpha angle on plain radiography was the only predictor of athletic hip/groin pain.
Athletic hip injuries can be a diagnostic challenge, and defining the ideal treatment strategy can test even the most seasoned sports medicine provider. Within the past 15 years, not only has recognition of hip pathology increased tremendously, but the treatment modalities to return athletes to the field safely and quickly also have improved. In general, management of athletic hip injury begins with nonsurgical measures, such as temporary activity modification, anti-inflammatory medications, and rehabilitation focused on core strengthening and pelvic balance restoration. Surgical intervention is reserved for athletes in whom nonsurgical treatment fails. The recognition of FAI and its biomechanical relationship to compensatory disorders about the hip and pelvis are paramount for achieving a successful clinical outcome and minimizing the disability time for athletes. FAI is the most common cause of prearthritic hip pain in the nondysplastic hip and appears to have a strong association with a multitude of hip and pelvis disorders typically seen in athletes.
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 6, 15, and 16 are level II studies. References 1, 41, 44, and 45 are level III studies. References 7, 11-13, 18-21, 25-35, 37-40, 43, 47-50, 52, and 53 are level IV studies. References 23 and 24 are level V expert opinion.
References printed in bold type are those published within the past 5 years.
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Keywords:© 2017 by American Academy of Orthopaedic Surgeons
athletic hip injuries; athletic pubalgia; sports hernia; osteitis pubis; adductor strain; femoroacetabular impingement; FAI; sports hip injuries; hip arthroscopy