Okay, so thanks very much, Drew, that was great, and Gee, thanks for putting this on. I think this will be some great talks here with the cases as well. I'm going to try to boil down the hip in 15 minutes and see if we can't get through a bunch of different MRIs and clinical scenarios here. Here's my disclosure. So the question is, you know, from our standpoint as team physicians, a player comes in, why does my hip hurt? And a lot of what we do is really is diagnostic and trying to understand, as we know from seeing patients, the hip differential diagnosis is so broad. You know, is it the front of the hip, is it the back of the hip, where's my pain coming from? What we see in athletes, I really want to boil it down to, is this a bony injury, is this an articular injury, is this a muscular injury, and we'll go through some of the work up there. So a little bit sideline, because this is the Team Physician Update, you know, you really want to treat your hip like the shoulder and knee, you want to get a good history with the hip. You want to know, were they having symptoms previously, is this a guy that's had chronic groin pain, where is their pain? Is this groin pain, is this radicular pain coming from their back, and what are the associated symptoms like, anything? So our exam, pretty typical gait, tenderness exam, specific for the hip, and particularly in this talk, you know, we really want to understand, is this the hip joint that's causing problems? So we're going to look at the hip gait or Faber exam, trying to elicit, is this hip joint pain? And then doing some of these core exams, you know, really trying to see if engaging their core while you're examining their hip brings out their pain, it's really helpful in this group of patients, so you really want to get comfortable with the core examination, both palpation and some of the specialty exams for the core. The hamstring, we'll talk a little bit about proximal hamstring, John Norwick's test, John's here today, our head athletic trainer at the bottom right, really trying to bring out hamstring pain when that player presents with pain in the back of their hip. You really want to have a standardized group of radiographs that you use, particularly, you know, I've, all across all offices, it's pretty variable how much detail you're going to, but you really want to understand, does this patient have some underlying femorostabular impingement morphology? So this lateral view you see on the right where you can really understand the shape of the femur is really helpful for your workup. And then we use MRI, we use MRI very liberally in our players, this is a pubic bone edema, core muscle injury. I pulled a couple MRIs to show, even just what we had in the last year, just to really understand the pattern of injury, pretty typical anterior labral tear. We want to understand, is this something like a stress fracture we see on the bottom left or AVN that's smoldering on the right? This is one of our wide receivers last year with just kind of soft tissue strain in the back of the hip, in the deep pelvic musculature, this is the obturator externus, one of our players last year, so really helpful for guiding the GM, the coaches, is this something that's going to be a bony injury or this deep pelvic injury, really just a deep muscular strain. We've seen more and more of these adductor avulsion injuries, not just in, we've seen them in football, in soccer it's a big injury, so this is, we really want to know, is this just a muscular strain or is this an adductor avulsion, which we're recognizing more and more may be a problem in the long term. This is a tight end, a collegiate tight end with a posterior acetabular fracture, which is treated with typical open reduction internal fixation. So you really want to use your imaging, this is what you'll see sometimes with a posterior instability event, so this player had a posterior subluxation event, you can see the large loose body in the back of the hip with edema and a non-displaced fracture in the acetabulum. I'm going to skip through a couple more of these just to get into the meat of this and then we'll talk about hamstring in the back a little bit. So the common pathologies I really want to touch on are FAI and labral tears, this groin pain syndrome, which we'll talk about, hip instability, and dislocation, subluxation in hamstring and adductor. So what are the common causes of groin pain in the athlete? Darren DeSalle, one of our former fellows, put this out. Really FAI or exacerbation of FAI, sports hernia, which G talked about earlier, as well as adductor-related pathology are really common in these and we're recognizing more and more. So FAI, what is FAI for those that are just kind of dabbling in the hip? It's really a group of disorders that leads to some usually chronic conflict between the femoral head-neck junction and the acetabulum. Important thing for the team physician, I think for conveying to our players, this really is a syndrome. It's not just a radiographic diagnosis. It's not that you have a bump on your femur, you have FAI. You really need to have radiographic signs, you need to have clinical exam, specific clinical signs as well as symptoms for the patient. Most commonly, this is groin pain, but it can also present in a C-shaped fashion around the hip joint. Sometimes I'll have mechanical symptoms, but the player will notice, you know, I've always had stiff hips or my hip hurts when I rotate in, pretty classic rotational loss. Sometimes they'll come in with compensatory problems in their SI joints, in their spine, in their core as a result of their FAI and just to be aware of those. So what do we do? As Drew said, with the spine, we spend a lot of time with non-operative treatment for the hip, particularly with exacerbations of FAI. Spanning modification, core work, NSAIDs, and usually shutting these players down. You can't get them through the season. They get an MRI. They're concerned they have a hip labral tear. You can be very comfortable kind of shutting most of these players down, rehabbing them, and a lot will get better and be able to return to play. We do use injections in season, out of season. I don't typically use cortisone in the joint because of potential detrimental effects, but we do oftentimes use PRP or visco supplementation. Even the hip, it's hard to get commercially, but in your training room, you'll be able to get it, and we've had good experience using visco in the hip with PRP for some of these acute exacerbations. Again, PT based on core and stability and a gradual progression back to sport. So when do we think about surgery for hip FAI? Really it's a patient with a clear diagnosis. They have minimal degenerative disease. They have good capacity to rehab, which all of our players do, and we're going to try to address the mechanical factors, and I'm not going to get into too much of the details, but just for the team physician, it's really not an urgent decision. A lot of times these patients initially should be managed non-surgically. And again, the high rate of return to sport, we know most of our players can get back to sport with an arthroscopic approach to their hip FAI. So let's talk a little bit about groin pain syndrome, classically kind of quote unquote sports hernia syndrome. So I use this term because there's been some misnomers out there. Is it athletic pubalgia? Is it sports hernia? What is this process that we're talking about? Groups, particularly in Europe, have been leaders in trying to define what these problems are. The kind of term came out of groin pain syndrome out of that Italian consensus statement. There was a Doha agreement that really tried to look at where is this pain coming from? Is it the hip joint? Is it the adductor? Is it the inguinal canal where the general surgeons really help us out? Is it the pubic bone? Where is this pain coming from? So Brian Zuckerbron, who's our general surgery colleague in Pittsburgh, and I published this paper for the general surgeons, JAMA Surgery, to try to spell out for them what is quote unquote sports hernia and what are we trying to achieve with some of these surgical repairs. And we really need to think about the location of the pain. We all know that the pubic bone is really the fulcrum for the anterior pelvis. So we want to be thinking about the contribution of both the rectus and the adductors as well as the inguinal canal. So when we think classically about osteitis pubis, when we were residents, it was taught as a kind of an inflammatory problem. But I think what we've come to realize is that this is the third joint of the pelvis and likely a lot of this problem in the core and around the pubic symphysis is related to the loads placed across it. And in conjunction with the hip mechanics, this can really be an instability problem with the athletes. So we like to think about this as kind of two defined areas around the core. A lot of the problems come from the rectus adductor pathology. So you've got these opposing forces kind of pulling on the pubic bone and you'll get these kind of chronic tendinopathy, you'll get some attenuation of the muscular attachments there and very common MRI findings including pubic bone edema. Or you can get this inguinal canal pathology, which oftentimes has a negative MRI. They may be a little more suprapubic in where they hurt. They may describe some neural symptoms and these are the patients oftentimes they get worked up for hernia that's told they're told it's negative. And they really can have many different pathologies in their inguinal canal. So we work with our general surgeons on this. We'll sometimes see some intraoperative findings. There can be some internal oblique tears. There can be some attenuation in the inguinal canal floor, the start of a direct hernia in some ways. But patients can be very simply treated with suture-based repairs here and have significant improvement. So this really shows from a team physician standpoint how important this involvement of multidisciplinary approach with the orthopedic surgeon, the general surgeons, the athletic trainers, the physical therapists, all working down this kind of workup and management of this groin pain in your athlete. The part that I'm going to kind of hit on a little bit more here with this is this idea of when do we treat the hip, when do we treat the core, and when do we treat both? Chris Larson gave a great talk two years ago at the NFL Physician Society. He shared some of his slides with me and I've really just kind of reproduced them here. So credit is given to him. But a lot of us have started to think this way because the athletes, it's confusing. It's confusing for the front office. It's confusing for the athletes. So we know that 50% of our players plus will have some documented abnormality to their labrum. Probably 90% will have some documented evidence of FAI structurally, regardless of symptoms. And a large percent will have some evidence on imaging of athletic pubalgia. So what do we do with this? How do we confirm it? And for us, it's really, it comes down to your basics, your history and physical exam, your diagnostic injections. And really, this is not just a decision for surgery based on imaging. Just because they have a labral tear and they've got some core pain does not mean they need hip arthroscopy surgery. So then you start thinking about, okay, return to sport. Well, 90% return after core muscle surgery at three months, 90% return after hip arthroscopy takes a little longer, five to seven months. Should we be treating both? When do we treat the hip? When do we treat the core? When do we treat both? You know, the hip arthroscopy, once you go into the hip, it's a longer recovery and that hip really is never the same. So if we can avoid going into the hip joint, if it's not the problem, you know, we shouldn't be doing an arthroscopy. So we use the injection. We want to see how patients are responding, how the players are responding. Do they get complete relief of their symptoms, of their hip symptoms? Do they get relief of their core symptoms or not? And that helps them make the decision. So again, we may consider doing surgery after the season, particularly for those core injuries, if we can get them through. Pain that does not recreate what they're presenting with. If you jam anybody's hip into deep flexion, internal rotation, they're going to say, yeah, that kind of hurts. But if that's not what they're presenting for, generally ignore it. The only players, patients that we really are a little more aggressive with surgically with hip arthroscopy are those with these large CAM lesions. We see these patients come in with a symptomatic hip at 18, 19 years old. You know, they're already breaking down their articular cartilage. We tend to be a little more aggressive with those patients when they're symptomatic. Basically the literature here is published by Chris Larson and Brian Kelly that shows if you have pathology and symptoms in both areas, you probably should treat both areas. And that's kind of the take-home message from there. So salient points for the hip and core. Be comprehensive. Use your multidisciplinary team. Don't over-treat or treat asymptomatic findings. And these imaging findings are quite common in athletes, and we just need to be aware of that. I'm going to skip through this case example just because I think we're a little short on time. I don't want to run over too much. This was a case where we did some stability stabilization. I want to get to a little bit about hip instability in kind of the discussion here. So this is a case example, 18-year-old high school basketball player landed awkwardly, kind of presents to the training room, presents to the office, still just not right six weeks after sport. And this is just something to be aware of. Loss of motion, very, you know, kind of generic exam. The hip hurts, and patient's a little bit guarding, x-rays are normal. So this is where your MRI is helpful. In this case, we saw a posterior labral tear, but more importantly, we see a chondral defect of the femoral head. So this patient had a subluxation event of their hip, and we're starting to recognize more and more of these athletic hip injuries. Although benign, the x-rays are benign, it can behave like the shoulder. You can have a subluxation event. There's a loose body in the joint, and this patient was taken to arthroscopy. You can see the central femoral head chondral defect, loose body, and the posterior labral tear from the posterior subluxation event that was repaired. Last case, before we kind of move on, just to kind of show you kind of where we're going in the hip preservation world. This was a little higher skiing accident, a little higher energy. X-rays relatively normal. If you look critically, maybe a little defect in the femoral head, but what we've noticed here is, again, a subluxation event where there's a small femoral head fracture, and this was treated with an open OATS procedure to the femoral head from the CAM lesion. And so we're collaborating quite a bit these days with our open hip preservation colleagues for some of these instability events to the head, which we previously would be just kind of treated with benign neglect. I'm going to skip through this as well. This is just kind of the management of the dislocated hip, which we sometimes see in our football players. We do treat these non-surgically. The point here is that sometimes they have continued pain, and there can be a role for arthroscopy to go in, remove loose bodies, repair the labrum as the kind of sequelae of a hip dislocation. Last point is the soft tissue work, the hamstrings, the adductors. So we've all become very comfortable with the diagnosis of proximal hamstring avulsion. This is a different animal than hamstring strain, and I think we're all kind of comfortable that this is something we need to consider surgically. We've become quite aggressive. My partner Jim Bradley has really been a leader in kind of helping us to understand this injury and treating it, and really the overall literature results suggest that we should be repairing these in our athletes. Acute repair does better than chronic. It does better than non-operative treatment. Chronic treatment or non-operative treatment, the problem is it's just unpredictable. Some patients do fine, but there's a subset of patients that get this chronic hamstring syndrome, they get chronic ischial pain, and our recommendation generally, these patients with a hamstring avulsion, is to repair them acutely. So then the question becomes what do we do with these adductors, and you may be in your training room seeing more and more of these. We see a lot of groin pain, particularly in August and September with our football players. Most of the time it's an adductor strain. It's a myotendinous injury that can be treated with rest and rehab. But this is where the MRI is helpful. We recognize more and more that some of these injuries are true adductor avulsions, and what do we do with these? Should we be treating these like the hamstring avulsion? The only real literature that's out there about non-operative treatment comes from about 20 years ago from the Giants, which said that we can treat these non-surgically in the NFL. But the question is, are they going to get chronic groin pain that we're recognizing more and more, and then a year later, two years later, be dealing with this kind of sports hernia, chronic groin pain syndrome? The only literature out there is from Serino Barnum in New York. He published on repairing six adductors with the idea that it's going to reduce chronic groin pain. We've gone to repairing these all as well through the same approach. Mike Gerhart, who I just saw here this morning, published doing these through a suprapubic approach and repairing the adductor when there's an avulsion. This has been our approach as well. So acute adductor avulsions, we've been more aggressive with repairing over the last few years with good outcomes. They actually get better faster than the hamstring. So when you see that, I think it does warrant some attention. So hopefully I didn't go over too much, and thanks for your attention here, and I'm looking forward to the cases.

hip pain

athletes

diagnostic process

treatment options

groin pain syndrome