Hi, good afternoon and welcome to the virtual academy and I welcome you to this exciting panel that we have here today. I'm going to go ahead and introduce some of my speakers as we go on, but I'd like to start off by thanking everybody for joining us for the faculty for being here and taking the time out to speak with you today to try and educate you on something that really does need some demystifying and defining as we all know that can become problematic and I'll take you through this journey and begin. My name is Gene Techmeister. I'm the moderator. I'm currently a non-operative and sports medicine specialist at Keck Medicine of USC in Los Angeles. I'd like to begin by really tying everything together in the beginning and then kind of hopefully breaking things apart and educate you and some of you. The sports physician commonly encounters groin pain, different natural diagnosis is broad and both orthopedic, visceral somatic disease and sports hernia is one of those things where it's poorly defined, not greatly understood, there's very little consistency in between the definitions and the algorithms to approach diagnosis as well as treatment. So hopefully we can share some information with you and make it a little bit less problematic for some of us. My lecture is not relevant to this talk. However, I will be discussing some treatment options that have not been approved or evaluated by the FDA and the setting of PRP and prolotherapy as an adjunct treatment, which we'll discuss later on. Session objectives will include diagnosis, rehabilitation and treatment of this condition. I will start off with describing and giving an overview background of diagnosis, not really focusing on physical exam maneuvers, however, let some of the other faculty discuss those in greater detail. I'll also take you through definitions and some interventional treatments. And then we have a surgical approach option that's going to be presented towards the end and tying everything together and hopefully again, being able to address some of the inconsistencies that we see with dealing with sports hernia. As far as the outline, I'll go through some mechanisms, zoology, talk about anatomy very briefly in the relevant setting here, a little bit of diagnosis workup, and then go through some options for treatment. Groin pain really is a common chief complaint about athletes. When you're talking about intra-articular hip pathology, pubic disorders, core muscle injuries were really the term that most of us have been using to encompass any of a number of musculoskeletal injuries in this pubic area. The term has been known as sports hernia, ankle disruption, athletic debalgia, and core muscle injury sort of encompasses and takes a broad overview of what possibilities lie in the etiology and pathology of such disorders. Definition of core muscle injury, which was originally on the sportsman groin or hernia, is common sports-related lower abdominal and groin pain injury. Interestingly, FAI and associated related complications and surgical management and entity of FAI in and of itself has only really been understood and recognized just in this later early part of this century with the work of Ganz et al. Really bringing it to the forefront in 2003, which means largely and the large majority of hip disorders in athletes was significantly under-recognized until about 20 years ago. Now, FAI is still somewhat not treated well in most areas just because there's not a lot of hip arthroscopists that are well-trained to do that procedure well in the country. So it's still gaps in treatment of FAI and sports hernia and core muscle injury, I think, is a little bit behind there, but hopefully we'll be able to get there. And as applied in its name, it's a very common symptomatic groin pain or lower abdominal pain etiology in athletes. And there was a systemic review that was done recently that really shows that there's no consistent definition of treatment, of diagnosis that exists for the pathologies that we will term as core muscle injury, including athletic fibrillation and angular disruption. There's really an overflow of information without real consistency in nomenclature of how you describe sports hernia. And in an attempt to define the underlying pathology, several different hypotheses have emerged. True etiology and epidemiology of sports hernia is really difficult to elucidate. And given the lack of this consistent definition, patients with chronic groin pain from a recent review found that the primary dose diagnosis in 50% of patients, 40 or out of the 50, which is 80% of groin pain of unknown etiology, were found to have a bulge in the posterior inguinal canal at the time of a surgical procedure. And sports hernia in general, when talking about prevalence of all groin pain is probably about 6% of all athletic injuries from a recent review in sports health. Now, pathology and the mechanisms as far as the most commonly cited would be tension in the groin due to twisting, turning, sprinting, and kicking. Personally, I've seen kicking probably being one of the more common injuries that I've seen in dealing with sports hernia. But again, any of these can be problematic and induce symptoms. Sources of pain could be from loss of motion of the hip because of the stress and pubic symphysis. Underlying FAI is definitely a predisposing factor. Muscular imbalance, where adductors work with the abdominal muscles to help stabilize the pelvis and that hip rotates, flexes, kicks. And weakness or abnormality and loss of appropriate sequential motor control of the muscles in that area can result in an overreach injury. And when we expand our definition of sports hernia, we have to approach it as more of a syndrome than really a single pathology. When we have the transverse fascia, the rectus abdominis, of the adductors, the inguinal canal, all of that can play a part in what we turn core muscle injury as, like I said, it can encompass multiple different pathologies and etiologies of a single, not of a single problem area. There could be a deficit in inguinal canal without actual herniation as well. So a lot of different things can be responsible for what is termed sports hernia. Anatomically, and I'm sure Dr. Pierce will go through that a little bit more detail, the iliopsoas tendon, the canal, as well as some of the neurovascular structures in the hip can also be playing a role between the iliopsoas hypergastric, the iliopsoas inguinal, general femoral nerves, as well as the femoral and general branch. And it's really a complex structure conglomeration with no one single structure that may be responsible and the really confluence of symptoms and pathologies. The illustration on the right really showing the locations of the groin pain and some of the associate musculature. Differential diagnosis can be pretty broad when you're talking about groin pain in general, anything from nerve compression, pubic instability, posterior abdominal wall attenuation, inguinal hernia as well, whereas athletic hernias is really an injury without a true hernia, patient can still present with hernias. In particular, hip pathology, adductor strains and such, really there's a need to narrow things down when we think that a patient may be presenting something that can be potentially described as a sports hernia. As far as presentation, you know, physical exam and history can certainly guide the clinician in helping to make the diagnosis. More detailed physical examination will be covered in the next talk by Chantel. I've seen some of her slides and I think she's going to do a tremendous job in explaining some of the movement patterns. So I'm going to leave that off for her. The patient will report groin pain. That's why we're here is to learn about what groin pain is. And it's primarily at the pubic symphysis that radiates through the rectus abdominals or adductor tendon area. Does not have to involve those two structures, but it's in that area. Symptoms are going to be worsened with athletic activity, relief with rest. Coughing may cause pain and the pain may radiate to the thigh and even some of the general structures in males, given the nearby nerve distributions in that pathomorphic area. As far as that criteria for diagnosis, there was a 2014 publication of a systemic review and pseudo guidelines by the British Hernia Society that created criteria for diagnosis. And at least three out of these five should be positive in order to place sports hernia as a diagnosis at the very top of the differential. And that includes, as you see here, pain that's described as dull, radiates to the medial aspect of the thigh, the perineum, or the contralateral side. That patient with tenderness over the pubic tubercle, insertion of the inguinal ligament, tenderness at the beeping balloon ring, or tenderness at the adductor longus tendon area, or the dilation or tenderness of the superficial inguinal ring. And as you can see here, even the criteria could identify or identify multiple structures that can be at play and may be responsible for the symptoms. So really keep an open mind when you talk about groin pain. And the differential is going to remain broad with, ideally, some of the physical exam, the imaging, and other diagnostic tests that I'll go through here in a second, will really narrow things down overall. As far as from an imaging standpoint, the radiographs of the pelvis are in purpose, first step to evaluate the osteostructures and rule out diagnoses such as CAM, pincer, or combined femoracetabular impingement, other pubic symphysis disorders, and the like. Here you see an oblique fat X suppressed MRI image, where there's a complete abulsion, retraction of the adductor longus tendon. And the pubic symphysis, as you can see here, you know, has a hypertrophic with irregularity changes. Again, something that may or may not be seen, because unfortunately, a lot of times there may not be a great detail of abnormality that's seen on advanced imaging. Now, the most common MRI finding is an ipsilateral rectus abdominal strain or tear from the pubic brami with a partial or complete adductor longus detachment. MRI has a decent sensitivity and a very high specificity for rectus abdominal tendon injury. However, you know, pubic symphysis edema alone can present before or even after surgical intervention. I think the important thing to note, as I mentioned and referenced briefly, is that up to one third of patients may not have any noted pathology on MRI. So treatment options, what are we involved here? Well, we have two great speakers coming right after me, each presenting their expertise in both rehabilitative and operative treatment, respectively. As such, I will focus on international options, which is my expertise in the care, the coordination of the necessity of a multidisciplinary approach and a team that's required to adequately and successfully manage the syndrome. Studies recommend waiting at least three to six months prior to surgical treatment in athletes, really encompassing and maximizing the non-operative treatment first. The initial non-operative management should include postural and range of motion assessments, sequential motor control, appropriate activation, time under tension, and building specific exercises to include strengthenings and support specific rehabilitation. However, with the overlapping FAI syndrome, some range of motion and deflection activities may be problematic. And the overall goal is really to emphasize the stabilizers of functional movement and posture. As far as international treatment options, we don't really have great evidence to support it. You know, there's a small series here presented from Australia that showed that compared with the local anesthetic and steroid injection of the problematic or identified etiology, radiofrequency ablation resulted in significant improvement of baseline in all measures and at each time interval up to six months. However, the local anesthetic did provide similar results, but only in one week, which couldn't be used to infer that there may be a diagnostic component to some of the interventional procedures that we do. On the ultrasound image that you see here pictured, we do have a inguinal ligament tear that's demonstrated with the white arrows at the pubic attachment of the inguinal ligament. Now, again, just to remind the viewers that this is only an end of 36, and we only, unfortunately, have case reports. We don't really have any large-scale studies evaluating non-operative international treatment in a large patient population. So all we have to go by is expertise of my colleagues in and around the world that have done these interventions on athletes. As far as regenerative and prolotherapy options, there are several case reports, again, that shows efficacy of a treatment for pain relief and return to sport with PRP or prolotherapy, which may also have a role here. The results and conclusions of all of these studies should be interpreted with caution. However, there is little evidence for use of these modalities. It is a promising future treatment if further and future RCTs can show that these outcomes to be true, consistent, and reproducible. As the entirety of this diagnosis and pathology is relatively new in comparison to other medical conditions, especially since FAI is only about 20 years old, I fully expect and hope that further research on this topic will yield optimal treatment algorithms. And you also have to consider that although the outcomes of many of these applications have not been extensively described in the literature, particularly high-level studies, from my expertise, I have found that symptomatic and functional outcomes are successful in most patients, especially with appropriately selected patients, modalities, and image guidance, particularly the use of PRP. And it has to be in a very controlled setting. And that is a discussion in and of itself. What I do most often is a diagnostic injection. As I showed you a case series looking at radiofrequency ablation, there has shown that there is effect up to one week. And that can be extraordinarily helpful in narrowing down the problematic pathology. A well-placed, well-planned injection with image guidance can be extraordinarily helpful. You know, as you can see here, you have an ultrasound image showing a FAI deformity. The bottom left here, it's a hip joint that has intraarticular contrast before an MRR is done, status post arthrogram. Again, you have a synovial herniation of the hip here and the adductor structure. So the ultrasound can be extraordinarily useful in identifying structures, pathology, but also guiding direct and particular treatment. And kind of tie things up a little bit before I let my co-faculty dive into their expertise is I want to stress that there's really a need to standardize the terminology, definition, and workup in surgical treatment of core muscle injury. Further studies are needed in the large scale, something more than just a case series. And the confluence of symptoms in the hip is sometimes difficult to elucidate. It's not just a one-to-one injury where it's just a hip or just a core muscle injury. There really is a, excuse me, a confluence of symptoms that need to be considered. So I'd like to leave you with one final thought. This is a pretty picture. It was done in Africa. This is up in a tree. And in and of itself, it looks great, but you really need to zoom out and really look at the big picture of athletic performance when you're talking about the hip. Such correlation and such interplay between the intra-articular, the extra-articular, the supporting musculature, that you can't just look at one particular structure. Although problematic, you really have to take a step back, zoom out, and take a look at what the possibilities hold as far as really taking a look at what the etiology is for hip disorders and groin pain in athletes. You have the slides here. These are the references that I used and I've coded and we'll move on and continue with our great speakers lined up here. So what I would like to do now is introduce Chantel. Chantel Phillips is a physical therapist at Vanderbilt Orthopedics in Nashville. She received her doctorate of physical therapy at Azusa Pacific University and she has been participating in outpatient orthopedics for 11 years. She's board certified clinical specialist in orthopedic physical therapy and completed a movement science fellowship. Chantel is the clinical director of the Vanderbilt physical therapy sports residency program and her specialty includes movement analysis, re-education, and neuromuscular facilitation. Thank you so much for inviting me to this talk. I'm a physical therapist at Vanderbilt University Medical Center and I'll be focusing on non-operative management and rehab sports. I have no disclosures. The objectives of my talk is to explain the signs indicative of sports hernia, review over physical therapy sports hernia assessment, illustrate what a non-operative management of sports hernia looks like, and briefly explain a sports a return to sport criteria. So with physical therapy and musculoskeletal conditions we tend to classify it into three main categories. So first we have mobility deficits and this usually has to do with stiffness. So this is our OA, FAI patients and then we have muscle power deficits and this has to deal with weakness. So sport hernia, athletic febalgia, or muscle injury would fall into this category and then we have movement coordination deficits and this has to deal with mostly motor control or structural instability. So today we'll be focusing primarily on muscle power deficits. Here are the five signs that are indicative of sports hernia. They'll have a subjective complaint of deep groin or lower abdominal pain. The pain is exacerbated with increased exertion such as sprinting, cutting, sitting up, and is relieved with rest. They'll have palpable tenderness over the pubic ramus at the insertion of rectus abdominis and or conjoined tendon. They'll have pain with resisted hip adduction at 0, 45, and or 90 degrees of hip flexion and pain with a resisted abdominal prolapse. So when we're dealing with physical therapy a lot of times we just have our eyes in our hands to help guide us diagnostically. So when we're looking at extra articular lower abdominal groin pain there are four main tissue sources as far as musculoskeletal is concerned for us and we have adductor iliopsoas, inguinal, and pubic sources. So with these four sources they'll all have tenderness to palpation specific in that region and that would be a positive result for that source. Then they would also have if it's a muscle involvement they'll have painful manual muscle testing to that muscle and then for iliopsoas and inguinal specifically they'll have a painful thomas test so a hip flexor stretch and then for inguinal it'll be a painful valsalva cough or sneeze and I'll go over each one more specifically. So for diagnostic criteria for a hip adductor source in physical therapy what we'll look at is we'll palpate around the hip adductor muscle and we'll put the patient's leg in a slight bend for comfort and then we'll also test resistance for manual muscle testing in hook lying position and also at hip flexion of zero degrees. There's not really much consensus in literature of what the best position for manual muscle testing is for these muscles so we tend to do what is recorded in literature. Next for iliopsoas we'll palpate in that region and then we'll also test strength at zero degrees of hip flexion and also at 90 degrees as well and then we'll forcefully stretch the hip flexors in a painful thomas test. For inguinal sources they'll have pain in the inguinal canal and then we'll also put our hands on their upper shoulders and resist a sit-up because that will be painful. Oftentimes these patients will have pain from transitioning from supine to a sitting position and they'll have a painful balsalva awkwardness and then pubic is painful in that pubic region. Here are some examples that Cerner et al published in March of this year for some clinical objective measures for acute hip adductor injuries. They encouraged for clinicians to test these measures because they help to guide our clinical reasoning and to objectify progress. So they have hip adductor pain palpation so measuring where the patient has pain and then taking a tape measure and measuring that to see if there's any changes in size. Then there's hip adduction range of motion tests so taking a patient passively into hip abduction to stretch their adductors and then testing that with an inclinometer. We can also test flexibility in a bent knee fallout test in supine measuring how far the knee is from a table and then strength is another big component so we want to assess sideline eccentric hip adduction strength and we can use a handheld ionometer to give us an objective measure of force. For non-operative management of athletic pubalgia they're broken down into four main phases. So the first phase is usually between one to two weeks and that's when we're focusing primarily on pain and edema control. We can start on lower abdominal strengthening, deep abdominal recruitment, gentle range of motion and also some gentle stretches. In phase two lasts about two to four weeks and that's when we can work on cardio warm-up, gait training. We're gonna progress a lot of abdominal and gluteal strengthening. Glute strengthening exercises are really important for sports hernia because they help to stabilize the pelvis and they also work on controlling any rotational forces that may occur at the hip through sport and then we also initiate functional strengthening. In phase three we increase resistance even more and we're progressing a lot of single leg stability, starting some light agility exercises, jogging, running and continued active stretching. And in the last phase that's really when we're working on a lot of sport-specific exercises such as plyometrics, cutting and agility drills. So I'm going to go over each phase a little bit more specifically to give you an example of what it looks like. So with the first phase we're focusing on pain control. We can use modalities such as heat, ice, cupping, dry needling is also another great option. Manual therapy, we can work on cross-section massage. Exercises, that's when we can start on some gentle isometrics. Isometrics are known to reduce pain and then some contract relax as well. In the first phase we can work on some stretches for hip flexors and also hamstrings with stretch strap. And then we can also start working on abdominal exercises. So focusing on transverse abdominus recruitment with posterior pelvic tilts with exhalation. We usually advise our patients to activate their lower abdominals by pulling their belly button in towards their spine. We can also start to introduce side planks and it is recommended to avoid any single leg or split stance exercises because that could be more provocative. For glute strengthening exercises, in research they found that glute maximus was activated most significantly if it was incorporated with exercises that included hip abduction and external rotation. So we can work on double leg bridging exercises and clamshells with a band focusing on abduction and external rotation together. In phase two we work on progressing glute exercises from double leg to single leg and then work on sidewalks because they're weight bearing. The next progression for core and glute strengthening exercises is working on a side plank with a long lever and a front plank adding hip abduction and hip extension. And this is shown in research to have high EMG for glute medius and glute maximus. When it comes to core muscle injury, even though you have identified a source, whether it's hip adductor or hip flexor, it has shown in research that you want to strengthen all the muscles in the core, including hip flexors and adductors. So I'm going to show specific exercises that we use for that. So in phase two, if their tissue source is due to iliopsoas, then it is advised to work on some hip flexor strengthening exercises so we can get some core and also work on hip flexors at the same time. When we are progressing hip adductors strengthening, this is usually our progression. So we start in sideline hip adduction and then we can progress that into standing position with resistance bands. Then we start our Copenhagen progression. So starting with a short lever, just putting the knee on a bench and holding that position. I would challenge you to try these exercises. They're very challenging. You can also progress them into long levers by straightening out the leg and holding on a bench. And then to make it even more challenging, then you lift the lower leg up. We like to incorporate a lot of our strengthening exercises into functional patterns that are to simulate their sport. So we can work on a Bosu lunge, focusing on with a resistance band, activating hip adductors, working on bridging exercises, also focusing on hip adductor activation as well too. If a patient is still having difficulty with any hip range of motions and they have some limitations, then we can work on progressing some self-mobilizations to improve hip flexion, hip extension, or external rotation with some use of some bands. Range of motion is very important, especially in athletes. So working on range of motion in very functional and dynamic patterns is crucial. Here are some examples of phase three range of motion recovery exercises that we can do. We can do a kneeling groiner stretch, a kneeling hip flexor stretch, and on the bottom shows a pigeon loading stretch, which really focuses on external rotation control. In phase three, I mentioned that's when we start on single leg stability, and we can work on starting some agility exercises. So this is an example of a single leg ladder hopping to focus on single leg stability in a lateral direction. And then we also want to work for athletes with deceleration and then their ability to control themselves onto one leg. So working on running, a quick stop, and then a hop onto one. In phase three is the last phase, and that's when we're focusing on a lot of sport-specific training. So plyometrics, cutting, and change of direction. So an example would be holding, turning very quickly, and then going into a sprint. When it comes to return to sport criteria, in this article, they had 81 athletes with acute adductor injury. 58% of those were soccer players, and they followed a standardized rehab program based on active exercises, including nine key groin exercises, five days a week. Here are some examples of the nine groin exercises that was used in this study. It was supervised by a sports physical therapist, and the groin exercises were performed on alternate days, three days a week. These exercises were chosen because of the limited equipment requirements. I won't list them all. You can see pictures of the exercises that was used in the study here. I would say that these exercises are not standard across the board. It just kind of depends on access to gym equipment. Most sports medicine clinics, we have access to a lot of gym equipment, so we can progress exercises a little bit further. In this study, they showed a progression of phases going from clinically free to controlled sports training to full team training, and this was a criteria to meet the milestone of clinically being free, and then on the right side was the criteria to meet controlled sports training, and I would say that with this study, they did a good job because it was very specific and also very challenging to meet these criteria, and what they found was 93 percent of the athletes returned to full team training with those exercises. The athletes who met milestone one, the clinically pain-free criteria resulted in less re-injury than those who did not, and then six, so eight percent of the athletes had re-injury within the first year, and then 83 percent of the five out of six had of the re-injuries occurred in the first two months following full return to full team training. Gene, I think you're still muted. Thought I'd never do that, but thank you, Dr. Phillips. I very much appreciate that. I thought that was great. I had the chance to review your presentation in advance and you would be in for a treat, so I very much appreciate it. I'd like to introduce our next speaker, certainly here, and I appreciate his time as well. Richard Pierce graduated magna cum laude from Duke University and then attended University of Virginia where he completed a combined MD-PhD program focusing on immune recognition of transplant antigens. He performed his general surgery residency training at Washington University in St. Louis, spending two additional years in research in the lab with Dr. Brent Matthews. While there, he developed an interest in minimally invasive foregut and complex hernia surgery while co-authoring two major research grants and more than 25 peer-reviewed publications and book chapters. Dr. Pierce then completed an advanced laparoscopic and endoscopic surgery fellowship in Portland, Oregon under Dr. Lee Swanstrom before starting his career at Duke. In 2014, he joined the faculty of Vanderbilt at the Department of Surgery and Practices at both Vanderbilt and National Veterans VA. He performs all aspects of general surgery at the VA, including complex hernia repair, minimally invasive foregut surgery, robotic surgery, and surgical endoscopy. At Vanderbilt, Dr. Pierce has a particular clinical interest in complex hernia repair, abdominal wall reconstruction, chronic groin pain, and sports hernias, as well as the biological mechanism of hernia formation and recurrence. He's currently the director of the Vanderbilt Center for Hernia Care and Abdominal Core Health. He's also currently the chair of the American Hernia Society Abdominal Core Health Quality Collaborative Research Committee. He previously served for 10 years as a lieutenant commander in the U.S. Navy Reserve as a lieutenant commander. And in his minimal spare time, he enjoys good food paired with great wine, which I second, outdoor activities, travel, working out, and spending time with his wife, Shannon, and their eight-year-old daughter, Rachel. And without further ado, I hand it off to Dr. Pierce. Thanks, Gene. I appreciate the introduction. And I really appreciate being asked to participate in this conference. I think I'm very honored. And as one who's not a member of the society in general, I think it's really nice to be able to do this. I'll move pretty quickly through the first couple of things, but I wanted to pause for a second because I think it's really interesting that the title of this session was demystifying sports hernias. And I think it's actually a very good and pointed title to the point of, I think people don't often understand just how prevalent this is and that it exists. And sometimes when people have groin injuries, they don't always get referred to the right places. And I'll give the quick little caveat because I think we have enough time that I've been here at Vanderbilt now for about seven and a half years. And I'm not sure how long Chantel, Dr. Phillips, has been here, but somehow she and I have never crossed paths until giving this talk, believe it or not. So although I work with several of our physical therapists for other aspects of abdominal core health, she and I have not had the pleasure of meeting. And obviously we've still just done so virtually, but hopefully since we're on the same campus, we can get together here soon and start putting things together. And I think that also will emphasize Dr. Tachmeiser's point about the fact that this really needs to be a multidisciplinary type approach to this because it can be a challenging problem, not only the diagnosis, but then also getting the proper treatment and whether that be surgical or otherwise, I think it's certainly a challenging problem just because it can mimic so many different things. So that I'll move along here. These are my disclosures. None of these have any kind of impact on what I'm going to talk about today. Dr. Pierce, excuse me. This is, I'm not seeing your slide presentation. Can you- Oh, I'm sorry. I'm sorry. Let me, yep. I forgot to share my screen. Okay. I'm still getting used to this here. So everybody can hear me. Great. Okay. I apologize. And there we go. And there we go. And share. There we go. Can we all see that? Yes, go ahead. Great. Okay. Again, I apologize. I think this is the first talk I've actually given like this over Zoom. I've had plenty of meetings and this is the first official talk. So, like I said, and I also agree with Dr. Techmeister too, that this is really, the term sports hernia is not a great terminology, but I chose to go with it because I wasn't quite sure about, I wanted to keep things consistent and we'll touch that in just a second here. So these are my disclosures. None of these are relevant to the talk today. And as I said earlier, I am a hernia surgeon. It's about 90, 95% of my practice or so. And we tell all our patients and our residents that a hernia is just a hole or defect in the abdominal wall through which abdominal contents protrude, usually fat or bowel. We know that there's really no hole associated with a sports hernia. And I think as we've seen, this is an injury to either the rectus abdominis, the adductor longus or the other muscles in the area. And as I said, this is an inaccurate term. It's often used for simplicity. I've gone with it through this talk, but I also prefer Dr. Techmeister's indication of core muscle injury or CMI with the resulting syndrome of pain being athletic pubalgia. So I do think it's better than sports hernia. And hopefully this is going to shift in the future, although I admit it's a lot easier to say sports hernia. As we saw earlier, the important muscles in the area of the groin, the groin actually is, and the pelvis is probably one of those complex areas of the body in terms of musculoskeletal attachments and joints. The symphysis pubis itself is a joint. There's cartilage there. Obviously we have our hip joints on either side. On the posterior, we have our sacroiliac joints. But what we're really focusing on here is the insertion of the rectus abdominis onto the superior pubic ramus here, as well as the insertion of mostly the adductor longus also onto the superior pubic ramus. And you can see from a, if this were a sagittal cut, that the rectus abdominis comes down here, joins at the pubic symphysis, the pubic ramus, and the adductor comes up along here. And they almost come together in a common aponeurosis right here. So distinguishing which muscle is injured, if not both, can be challenging at times. Just to quickly touch on the pathophysiology, as Dr. Teichmeister mentioned, this is a traumatic separation of the insertion of either one of these muscles. And usually there are some people that describe a small separation or tear of the external oblique. In my practice, I think it seems unlikely. To me, that's more of a, of actually a true inguinal hernia as opposed to a sports hernia. We know that this is probably due to unequal forces acting on the pelvis, such as having a significantly higher amount of strength than one's kicking leg, say if you're a soccer player. This can lead to underlying inflammation in bone marrow or edema. And then once you get an injury on one muscular insertion, that can lead to further unequal forces and therefore repeated injury. Again, we're just showing the upward pull of the rectus abdominis here on the superior pubic ramus, as well opposing the downward pull of the adductors and how these can result in injury to the area. So what are our other differential diagnoses? When a patient comes to me, what other things am I thinking about? So maybe A, they do have a true inguinal hernia. That could be it. That might be their first thing. Sometimes they can have a groin strain or hematoma. And I put time course in here. As Dr. Techmeister touched on before, this usually needs to be present for a good three or at least six months. I'll occasionally get referrals from patients that come in with groin pain and ask them, well, when did you injure this? And I'm like, oh, last week. And I'm like, oh gosh, okay. We need to let this kind of play out for a little while before we decide to do anything about this. Patients can have an inflammation of the periosteum on top of the pubic bone, osteitis pubis. As previously mentioned, they can have femoroacetabular impingement or CAM deformities, bone tumors. There are also possibly neuropathies from iliomidal or iliohypogastric nerves. Has the patient ever had any prior surgery? Maybe they've had an inguinal hernia repair that could have caused this injury and they're just experiencing pain now in a delayed fashion. And then there's even the possibility of deeper causes of pain. Does the patient have a problem with their prostate, rectal or ovarian pathology? So from my standpoint, I think the history is an important thing. It can be either unilateral or bilateral. I generally find that the onset is usually more sudden, especially in hockey or soccer players. It can be more insidious in people that are runners, but usually it's pretty quick. Again, it's aggravated by sudden movements and the pain may initially improve with some rest, but then recurs with activity. Again, as we mentioned before, I think we need to have at least a three month level of a time course and probably greater than six is much more likely. Often patients have seen multiple different practitioners before getting to me as a surgeon. The causes, typically it's sport. However, I've seen it in patients that do yoga, maybe even one patient with horseback riding. Here in middle Tennessee, I'd say that probably the majority of my referrals actually come from Fort Campbell down the road as people are, the army guys are paratroopers. So they're hitting the ground with a huge amount of force as they come down, or they pack on a 50 or a hundred pound backpack and then run 40 miles. And that's certainly just asking for groin injury. Probably a little less common than falling off a stretcher, but I thought it was a funny picture. So for my physical exam, I like to do a thorough inguinal exam to make sure there's no inguinal or femoral hernias. Can sometimes feel a dilated superficial ring. I generally check the spermatic cord, the testicles to make sure there's no tenderness there that could be epididymitis or something like that. Occasionally I'll do a rectal exam if things are unclear. In the very rare female, you can have to do a pelvic exam to see if they have pain along the posterior aspect of the pubic symphysis. Then I'm gonna wanna palpate the insertions of the rectus abdominis and the adductor longus. I can usually detect some pain in that area, especially with a resisted sit-up. The adductor longus may give a bow-strung kind of tension that I can feel there. And if I tap right on the insertion of that adductor, it'll often cause some pain. I will generally do some provocative maneuvers such as leg elevation, abduction and adduction along with resisted sit-ups. And I call it a chair squeeze where the patient lays on their back and kind of mimics a chair sitting position and that I provide outward pressure against the knees. And that's a good check for osteitis pubis. This is just showing some pressure along the insertion of the rectus abdominis onto the superior pubic ramus. And then this is kind of doing a resisted sit-up to see if that makes their pain worse. And this can help you lateralize it and get an idea of, is this a rectus injury, an adductor injury or possibly both. In terms of imaging, ultrasound can sometimes rule out testicular pathology or a true hernia. Plane films can help with bony abnormalities, but neither of these really do much in the way of helping me diagnose a core muscle injury. CT can often be helpful to rule out other pathology as well. But again, you really can't see the true pathology on this. So when in doubt, if the patient has a good story and a good history and an exam is appropriate, then I will generally proceed with an MRI. I did have one question in the chat room before about, is there a specific protocol? And I do have one that I can send to you if you want. I said, it's a little confusing to me, but I think the radiologist can figure it out. So sometimes a plain old pelvic MRI is okay, but sometimes you need a true sports hernia protocol to get a better view of it. It involves T1 and T2 weighted fast spin echo images about contrast. It requires a small field of view so that you're really focusing right on the insertion of the rectus and the adductor. You want a 1.5 Tesla magnet. anything less than that can give you lower resolution, anything higher than that can lead to too much background. And then the specifics are how they orient the plane and take these particular slices through the pelvis to look at the insertions. So when we do these MRIs, what do we see? Here on the right side, this looks like a normal insertion of the rectus abdominis coming down here and the adductor coming up here. On this side, you can see this brightness here on a T2 weighted image showing the injury to the rectus insertion and inflammation associated with it. We see a similar finding here where in the parasympathetic region, there's this little cleft side and some fluid in between down here that's not quite present over on this side. See this fluid running along there, that dark line, as well as the marrow edema within the pubic bone itself. So that secondary cleft side is pretty pathognomonic. And here with this adductor injury, we see some inflammation within the adductor longus tendon. So generally, I'll touch on this very quickly since you guys have already gone over it, but I usually have the patients rest for at least three months, often give them some long acting nonsteroidal such as meloxicam or naproxen and give them icing as well. Physical therapy that Chantel just went over, it can be very, very helpful also, especially if patients want to avoid surgery. And sometimes either along with these, or instead of, I'll send them over to some of my sports medicine orthopedic guys and have them do an ultrasound guided injection of bupivacaine and methylprednisolone. They can inject it right onto the insertion of the muscles. And that can both be diagnostic as well as therapeutic in terms of if they go to get a response to this, but then the pain comes back, at least I think we're working in the right area. So let's dive into the operative areas here. There aren't too many, there are options, but there are not a whole lot of options. There are both open and laparoscopic repair when we're thinking about the rectus abdominis, okay? The open repair is actually quite similar to an inguinal hernia repair. You don't always require the use of mesh as we do an inguinal hernia, it's kind of the standard. There is a specific repair described by Dr. Meschowick over in Germany that she calls the minimal repair. It can address the inguinal floor, but in my personal opinion, I'm not entirely sure that it addresses the separation of the rectus abdominis tendon from the punic rayness. Nevertheless, she reports good results with this. And again, a laparoscopic approach does not actually re-approximate the tendon down to the bone, but it does reinforce the area with mesh. If we're talking about an adductor longus injury, this is generally an open tenotomy and either partial or complete. I prefer the complete one, but the partial also has some good results as well with it. If you do the complete tenotomy, then you have to do tenodesis to attach the muscles to the surrounding tendons. So just to show a couple of pictures of what we're talking about here, again, here's a kind of a schematic of what the injury might look like, a partial tear of the rectus abdominis and or adductor longus. And this is actually the view from inside the abdomen. Here's the spine, the sacrum, we're looking down here, here's the anterior abdominal wall. This is the same view that we see laparoscopically when we repair hernias in a minimally invasive fashion, either laparoscopically or with the robot, looking down into the abdomen, the floor of the pelvis here. This shows a kind of standard open repair, tissue-based repair, where we've elevated the spermatic cord, made a cut directly over the groin, elevated the spermatic cord. This is the posterior wall of the inguinal canal being sutured together. And here they are showing that. This shows a piece of mesh in place, similar to what we call our Lichtenstein repair that we standardly do for an inguinal hernia. I think mesh in this area is probably a good idea, unless the patient is very adverse to it. They may say they don't want mesh and I tell them that's fine. But I do think that once we've kind of disturbed this area, the chances of them developing a true hernia is slightly higher. This schematic from a recent publication is actually really nice in showing some of the different approaches. Unfortunately, I don't have photographs of all these. From the time I was asked to do this talk until now, I just happen to not have any on my docket. So again, it's not that common a problem, but this shows kind of that Bessini repair that we just saw in the last diagram. Here's Dr. Meshawick's minimal repair that also incorporates some of the rectus muscle down here. This shows an inductor longus tenotomy, which I do have some photographs of in a minute. And probably the most well-known person in the United States is a guy named Bill Myers, who's based up out of Philadelphia. And although he doesn't publish a ton, we do know a bit about his repair. And actually this re-approximates the repair that I do the most, at least in terms of plicating the rectus abdominis down onto the superior pubic ramus and with a couple of stitches onto the inguinal ligament. And he does a fenestrated type inductor longus tenotomy, not a complete division, but he finds good results with that. What if we're gonna repair the rectus abdominis portion laparoscopically? This is what we call a TEP, or a totally extraperitoneal repair, where we can make an incision at the umbilicus, insert a little dissecting balloon that then opens up the preperitoneal space. We can slide this balloon right down to the pubic symphysis and then we open it up and it gives us a working space. The balloon's removed and we fill the area with carbon dioxide gas, just like we would for, again, a laparoscopic inguinal hernia. And again, we're focusing right here on the insertion of the rectus abdominis onto the superior pubic ramus. Looking down into that pelvis, we would cover this entire area with mesh. Usually when we're repairing a true inguinal hernia, we're focused on either this area that's called the indirect space or this area that's called the direct space. What we're trying to do with the laparoscopic repair for the sports hernia is to reinforce this area where the rectus is inserting onto the superior pubic ramus. So this mesh covers over the entire area and reinforces that. In my practice personally, I like to usually start with the open repair so that I can actually placate that muscle down onto the bone with some stitches. If the patient does not get 100% relief or satisfaction, which sometimes happens, then I will generally proceed with the laparoscopic repair to further reinforce the area. Some people proceed directly to laparoscopic repair and there are some good results seen with that, but it's just my preference to do it the other way. Again, if a patient has a strong preference, they say, no, I don't want an open operation, can we do a laparoscopic? I'm usually, I think that's reasonable and I'll generally accommodate that as well. So what about the adductor longus tenonomy? It's finally something I do have some pictures on. So this is a right-sided athletic pubalgia. Patient's head is to the right and feet are down to the left. So you see here, I just make a very small, about a three centimeter or so incision directly over the adductor longus. You can palpate this tendon. Like I said, it has that kind of that bow-strung sensation to it. I isolate the tendon itself and here it is kind of lifted up right here. So this part right here indicates right as where it's attaching to the, right attaching to the pubic bone there. And then here's going down to the belly of the muscle in the leg. I put a couple of stitches in it using a really strong suture called fiber wire. And then once those locking stitches are in there, then I do the tenotomy and divide the muscle off. And here the muscle has been divided off and it's retracted about centimeter, centimeter and a half, maybe two. I then stitch this muscle to the surrounding adductors. So that's the, after the tenotomy, this is the tenodesis to anchor it in place. And then we close up the deeper layers and eventually the skin, the patient has a very short, a very short incision with a little glue on top there. The nice thing about this is that any of these procedures are pretty much always done in outpatient basis. I don't think I've ever admitted anybody overnight. Open, you can do either, if you're doing the open incision, you can do conscious sedation or general anesthesia. A laparoscopic approach requires a general anesthetic. Patients are usually allowed to, I let them resume kind of normal non-strenuous activity for about four weeks. And then I will put them onto some physical therapy, which Dr. Phillips touched on after their one month time visit. The one exception is that if they get an adductor longus tenotomy, I don't want them stressing that too much. So I put them on crutches for two weeks. They do one week of non-weight bearing and then a one week of toe touch weight bearing, and then they can start walking. And after, so for about two weeks, they do that, then they see me and then they go back to physical therapy. So I like to be able to heal up for about a month before I start really stressing this repair. This, now I wouldn't expect you to read all this, but this shows the rehabilitation protocol that I've used in the past. Hopefully I'll get together with Chantel here in the near future, and maybe she can update me. This is something that I've had around for a couple of years since I came here from Duke. But again, I think it's similar in ways that it would start with stretching, mobilization, some core strengthening, and then more functional activity, and then return to physical activity after up to six weeks. So it takes a little bit of time. So I tell all my patients that if you're going to have surgery for this, you're going to have four weeks of post-op recovery and six weeks of rehab. So minimum of 10 weeks before you're back to doing your sport. So you have to be ready for that. Whereas, so if it's near the end of the season, maybe the patient says, hey, can I do something that can just get me through this till the season's over? And in that case, I'm going to refer them more probably for an injection, see if they can kind of get it done over with, and then say, okay, we'll wait till you're off season and then we'll operate. Then you can take plenty of time to get your surgery and rehab. So I think that works out nicely there. You just have to have options for patients. And obviously it's different if you're dealing with the kind of the weekend warrior that hurts themselves at the pickup basketball game versus the guy who's a professional or collegiate athlete who needs to get back and playing and whose career and livelihood can really depend on this. Just very quickly again, most studies report a pretty high rate of return to full sporting activity, whether rehab versus surgery is better. Unfortunately, there are not really good studies. It's pretty poor, low quality evidence around level four. As seen earlier, most of the studies have very small end numbers, you know, in the 10 to 20 to 30, 40 range, nothing, not many people. And I think we really need larger, more controlled studies that are going to give us more high quality data over time. So this is just one little, this is kind of my last slide here from my friend, Greg Mancini, who's at UT Knoxville, kind of just showing some of the algorithm for workups. You know, if a patient has a true hernia, we're going to fix it. If they have osteitis pubis, we're going to start with NSAIDs and rest and rehab. Aductor longus, we'll also probably start with this, but then maybe give them a release. Nerve entrapment by a prior surgery. I'm often going to proceed to an anorectomy. Obviously we have referrals to orthopedic surgeons for bony problems. And then inguinal floor weakness, we may repair that as well operatively. So, and just to thank everybody, these are all my partners and colleagues here in general surgery at Vanderbilt. I work closely with Warren Fitch and Greg Polkowski, who are some of our sports medicine, HIP, and Warren does all my injections. And Jake Block is, he's kind of my guy in radiology that reads all these MRIs for me and with me. And so I do think that, and hopefully again, after this talk, I'll add Chantal's name to this too, because again, I think that it's really important to have a multidisciplinary approach and the more people you can get involved really, really helps a lot because it can be a tough thing. So with that, I will say thanks to everybody. And I guess I'll, should I unshare my screen at the best? Yes, please do that. Thanks Dr. Pierce, that was great. I like giving these talks because I learned a lot, not only by presenting and doing research, but also listening to the co-presenters and co-faculty. And what's interesting is we've never met, we don't work together, none of us actually are, but in the end, we gave a pretty consistent message, which is very hard to do, especially in something like sports hernia. So I'm glad that different parts of the country, different specialties, and we all approach it the same way and try to do right by our patients. So I thank you for your time and I appreciate your expertise. Thank you so much. Thanks, it was great. It was really enjoyable.

sports hernia

core muscle injury

athletic pubalgia

rectus abdominis

adductor longus

diagnosis

treatment options

non-operative management

surgical treatment