So let me go to this last case. This is a 21-year-old professional men's tennis player. One-year history of right hip and groin pain. His ranking was falling because of this pain. He couldn't move around on the court as well, and his world ranking was dropping. His pain was deep in the groin, lower abdomen, and inner thigh. He had pain doing sit-ups. He was seen by a local physician who got x-rays and told him that he had FAI, and they recommended FAI surgery for him, and he came to see me for a second opinion. On his examination, his Trendelenburg was negative bilaterally, had some slight decreased strength in his iliopsoas on the symptomatic side. Hip flexion was symmetric, as was external rotation. Internal rotation was 15 bilaterally, but not associated with pain. His impingement labral stress tests were negative bilaterally. He did have pain with resisted sit-up and what I call a Hesselbach's test, which is where I palpate the lower end of the rectus as it inserts into the pubic symphysis and have him do a sit-up, and that reproduces pain and caused pain. His adduction strength was decreased both in flexion and extension associated with pain on that side and that side only. This is actually a CT that he had sent along, but you can see from the scan or the scout view on the CT, clearly has some FAI anatomy, has little rim injuries as well, so osteoacetabuli bilaterally, and he got an intra-articular injection and provided him zero relief of pain. He did have an MRI on the sports hernia protocol, if you will, and it does show that he has some change at the pubic symphysis on that side. So you've got a 21-year-old male tennis player, one-year history of right hip pain affecting his play, FAI anatomy, but no discernible intra-articular source of pain, and a core muscle injury. So what would you do with that? I'm going to have just five minutes since we're running out of time. Yeah, I've only seen a couple of these so far in practice, but yeah, I try to PT them Most of them, obviously, non-surgical, a lot of people get better, I think, and then the few that haven't, kind of a handful of them, I try to send them to Philadelphia, have a hard time getting them sometimes because of the insurance issues and stuff, so I don't have a good sense of what goes on for them. At the same time, when you brought us back here, it was a combination of patients and FAI at this point in his hernia. If I wanted to produce six examples, we would use a pubic lab suggestion, or an early initial presentation. I don't know where you put that. It's really not in favor of the PR people. It has to be more difficult. It pays more at some point. It has to go through a show by a doctor. It has to go through a high-resolution stand-by practice partner. It has to go through a generalist. It has to go through a program that's similar. It has to go through a program that's similar. And some of it isn't. If that isn't working, they take a trip on such a no-guess. I actually have someone who I consider setting up to help me with this. I'm going to consider talking to this patient. I really did not want to prescribe anything. I'm like, well, I need to go grab it. I can't guarantee it. I just need some sort of objective finding to go after, I used to put these associated conditions that used to be like very narrow and any other, anything that didn't fit exactly. I think I've gotten a little bit more accepting of the idea that sometimes you just need to accept some posterior pain or something else that might be going on. Alright, we're almost at 8.30 so we'll ask Dr. Rosnick there, what would Dr. Rosnick at the Cleveland Clinic do with this guy since they're the home of IMG and so they take care of a lot of, they manage a lot of pro tennis players. So Dr. Rosnick, what would you guys do at your table? Yeah, so I think you're telling us a couple things with this athlete. His performance is decreasing so something needs done. He came to you as a second opinion with a diagnosis of a labral tear so you have to prove it's not his labral tear that's symptomatic so he did that with an anesthetic injection that didn't work and all of his exam and his imaging findings, not imaging findings, but his exam findings are going towards the core muscle component than the joint. So putting that all together, the typical story for a core muscle patient is you rest, you rehab, and you get better and then as soon as you start your sporting activity again it comes back. So this is an athlete, you have a low threshold to enlist your general surgery or your colleagues who do the sports hernia core muscle procedures at your institution. I would feel confident not treating his hip based on the response to the injection, although we do know that from the literature that treating both generally does better, but I would just say if they're both symptomatic and then this guy is not. So again, decreasing performance, high level athlete, you proved that it was his core muscle that was the problem, so would focus on that and get it treated. Yeah, so some people do say, well, I mean, the reason they have the core muscle injury is because of the limited range of motion potentially from the FAI, so you don't feel like freeing that up at the same time as, you know, freeing up some range of motion and doing an FAI surgery at that time is beneficial or? I would not. Dr. Busconi, you're the sports hernia specialist here in our group, the only one probably here who does that surgery. Thoughts? Yeah, I mean, I agree with the algorithm itself. I look at this player, I just went through 11 NHL players last week, so I think the most important thing that you actually talked about is looking at the athlete's back exam. We found that with great flexibility working on their back and posterior core, that actually frees up the FAI and changes the range of pelvic cells and allows you to work on going into your core muscle. I would, I think, if this athlete would have come to me, and again, thank you, Mark, for doing the right work, I would have just injected him first. I would do the cortisone, parking cortisone injection, so the rectus attachment, apoptosis, as well as an adductor attachment, ultrasound guidance, the apoptosis, there is no ultrasound that you can use, and then I would do a structured four or five week recovery, so I've looked at this person for a long time, fixed their deficits, fixed their back. Tom's group, Mike Boyd, has talked extensively about physical therapy on these athletes in terms of being able to change their body mechanics, and in my case, about 75% of the time. Yep, that's great. So, so it ended up, you know, he had done a bunch of therapy over the course of time, not a specific program, but he had worked on good glute strength, and did work on his core strength and flexibility, still a bit symptomatic, and he was concerned because in pro tennis, they're not playing, they're not making money, and so he was very concerned about it, and I told him I didn't think FAI surgery would be beneficial, and with the FAI surgery, he'd be out for probably at least six months from the tour as well, and so he ended up having a core muscle only, we talked about mid-season, but you know, if you know pro tennis, the season is 11 months long, so it's not really, there's not really an off-season, if you will, but he returned to play within six weeks, he broke the top 100 within a year, which was his highest personal ranking, and he was the youngest player on the tour in the top 100, and he ended up reaching the top 50, he's now 12 years since then, not had any other surgery for the core, or for his hip itself, so he's still playing, so any comments or questions about that case, we hopefully we covered as best we could in an hour and a half, a variety of sports hip and groin cases, but I want to thank our faculty for giving their time, you know, and their expertise in this, I'm very grateful to you all for doing that, and I appreciate we have a great crowd coming in to learn about the hip stuff, so I appreciate you all participating in this ICL, so again, thanks a ton to the faculty, and thank you all for attending.

tennis player

hip and groin pain

FAI surgery

core muscle injury

conservative treatment