I want to thank our chairman, Dr. Mark Safron. It's a pleasure to do this and organize this in such these unprecedented times. And Latula for actually moderating the session. I hope everyone's doing well and the families are well and happy to do this. I'm gonna start actually about, this has been a passion of mine about talking about athletic groin injuries and then breaking them down. I've seen in the program, it's not just myself talking about, we have other speakers as well talking about sports hernias. So today's talk is gonna be about adductor related groin injuries in the athlete. And interestingly enough, if you look at this paper in AJSM, just if you break down on groin injuries, a good percentage of them are actually adductor related. And the reason being is that the adductor actually, particularly the longest biomechanically is at a disadvantage. And hence, this is why you see these injuries in athletes, particularly in high performance athletes. And this cohort study was just presented by Per Homlick published this past month. And it showed that actually, when they looked at cohort of acute adductor injuries, and we'll get into this a little bit further, but most of them actually that took and returned to play back to sports, that it took longer if the adductor longest insertion was involved off the bone tendinous interface, a palpable defect, and also confirmed on MRI. And basically what they're getting at is an adductor avulsion injury, which we'll talk about. You know, you look at the terms in the literature and also when we discuss amongst each other about groin injuries, and it just has many terms. There's about 19 of them, if you counted them in the literature, I try to break it down systematically. So if you look at this, well, where does a zone of injuries occur? I look at it between layers one above the pubic symphysis at the level of the symphysis, layer two, and then three below where you see the adductor problems. So I was lucky enough to partner up with Ernest Shoulders, my good colleague and friend from the UK. And we did this anatomical study looking at fresh frozen cadavers, looking at the relationship between the adductor complex and its relationship to the muscle tendons surrounding. And if you look, first we did was just look at the fascia connections here, and here you're looking at the spermatic cord cut out, but you're looking at the area where the fascia is making two connections to the fascia lata and over the external obliques. And then in the middle is the lumbar alvea, which tensions the groin. And then if we take the next layer over here, then you start to see the layer, the deep layer, which encompasses what we call the pyramidalis muscle. And that's the muscle anterior to the rectus abdominis. And then you see its role here and has a separate fascial sheath. And this adds tensioning to the linea alvea, particularly in core engagement. Now we break down this further and remove the fascia. Now you're looking at the anal ligament, and this is here outlined, okay? And the block arrows is where you see the anterior pubic ligament, and that provides a stability. And this is gonna be important to represent the complex. So if you look here, here's the pyramidalis, and in our specimens, we found it both in right and left. And then on the back of that is the rectus abdominis. Here you have the pectineus, and then the adductor longus. Now, if you look at systematically, okay, and this is important because when you look at MRI of the pelvis, this is what you're looking at, and this is what you wanna see. And here you see the rectus abdominis coming to its insertion, and in front of it, you see the pyramidalis. So in our study, when we looked at this, the only muscle that's anterior to the pubic symphysis is actually the pyramidalis, not the rectus abdominis, okay? And then you see the fibrous connection here to the pubis. And then systematically, we break this down, and here you see the insertion of the rectus abdominis. The internal tendon fibers go to the gracilis of the rectus. And then here's the pyramidalis that I was talking to you about before, that Ernst Schildes was first to recognize this when he saw multiple players of this during his procedures and looking at multiple MRI correlation with this, okay? Then we actually looked at the footprints, and if you break this down, this isn't intact, okay, but this is the footprint in the rectus abdominis, right here laterally on the pubis, and then the insertion of the adductor longus onto the pubis in relation to the gracilis, which is medial. And then if you break this down, here's the pubis and the tubercle in relation to the insertions and the footprints. And then we simulated a rectus abdominis, I'm sorry, an adductor avulsion injury where you see we recreated the injury here, and you notice the pyramidalis is attached to that, okay? And this is what happens when you have a disruption. It's not just also the tendon, but the whole complex being avulsed. Hence, this is why these athletes have debilitating groin pain. So if you break this down in a differential between adductor and hip related, okay, the good thing about the adductors, the hip joint's a deep socket joint. It's difficult to palpate structures like you could do for the elbow, the knee, or the wrist, or the ankle. But in the adductors, you can palpate certain structures to point tenderness and then also manual testing with resistance, whereas in the hip, it's dull, achy pain, the C-sign that we learned from Thomas Bird, positive impingement sign test, and no pain with resistance. There's also differential, particularly in runners that you see in high performance athletes where they mimic groin pain or adductor related pain, but they have a pubic stress reaction, okay? The other thing is that they can have a size of cificans, which you see in the soccer player. If you take appropriate views of this inlet view, you can see that there is my size of cificans is right there, and then he did well with just removing this large peritopic ossified piece. Well, if you break down for just like anything we do in medicine, it's very important to get a detailed groin history. So I break down adductors between acute and repetitive. And the groin exam is based on one, I break it down to inspection, palpation, provocative testing, and strength test. Palpating the pubic symphysis, the pops, the adductor insertion, the rectus insertion border, spend a lot of time in the inguinal canal, and also performing a dilated superficial ring, but also an internal exam too as well. And just with this day and age, it's always important, I always document that I have somebody in the room because this area is very private and it's always good to have somebody there when you're conducting these exams. Also, it's important to learn from parahomic too is doing important strength tests with the resistant adduction, both extension and flexion. If it's an adductor problem, they'll have more pain in extension because of the lever arm that occurs. And also you could do your resistant sit-up test at 30 degrees of hip flexion. It's also important to also test manual strength testing. And in position for adduction, both and also in isolated and allowed to give us position. Next is about the imaging. Just like we learned from the hip, it's also important to get detailed imaging of the pelvis. If you get an MRI of the hip and include, like I just saw an MRI just day before yesterday for real adductor problems, but it was really just an MRI of the hip. And so it's important to get oblique, axial obliques. They try to do between under three millimeter cuts and sagittal plane as well. And we're looking at here for another differential is adductor enthesopathy. And the way you can differentiate where this is a musculotendinous injection or the problem at the insertion site is a pubic cleft injection. Because if you try doing an ultrasound guided injection of the musculotendinous junction, they still can have their pain. So this is a good diagnostic image and this can be done under fluoroscopic guidance or under ultrasound. And it's also important as we know from doing diagnostic injections of the hip joint is the opportunity to re-examine them and see if that takes away their pain generator. Most of these adductor enthesopathies do get better with the strengthening program, but it's important not to do stretching in this. And that's what most physical therapists wind up doing with this. And it just causes an increase in pain. So I just wanna show you where you put your needle when you're doing a pubic cleft injection. You wanna get to the area through the insertion site. Hence, this is where doing this as opposed to doing a musculotendinous injection would be more effective. This is just a busy slide showing the algorithm when you have adductor dysfunction and most of it involves rehab or conservative management. You can do what I'll go into next with the adductor lengthening. And then this is the column which we'll talk about adductor invulsion. So this is a technique that I developed for patients who are recalcitrant to rehab and fail conservative management. And instead of doing a complete adductor release, I do what's called adductor lengthening to de-tension the tendon because that's what the problem is in these patients. And this is just how we do our setup and figure port position. You have to be careful of the neurovascular bundle in this case. And I'll also try to do this with minimal amount of fluid to avoid fluid extravasation. And here we're just making a portal distal and proximal just two, three centimeters from the inguinal crease. And we're introducing just additional scope instrumentation that we use. And I use a 30 degree scope to do this. And this is just showing a portal, a second portal placement and a direct visualization. And this is one of the nerve branches that you also have to be careful of when you're doing this. And so here I'm looking at a 30 degree scope distally. My shave is coming approximately. We've taken off the sheath and now you're looking at the ductal longest tendon. Here's I'm utilizing the RF probe to de-tension the tendon to Z type of lengthening that we're doing. And it's important also to maintain some of the fibers. As you can see, the tendon is in this area. We just want to de-tension the tendon, but there's some variation to this tendon in an athlete. So it's important to understand, but you also get a better view of doing this when you're doing this with a scope as opposed to doing it perpetaneously. And here's a 16 year old gold tender that we did. You can see how well the contracture was preoperatively. And that's what it looks like postoperatively. Going on next to proximal ductal revulsions. These typically occur with the eccentric load. Most players would describe an abduction extension injury and then a sudden pop and immediate debilitating groin pain. Some of them are professional athletes where we had the advantage to actually see them while during play on TV, and then they show the video and you can see no one was even near them. And then most of the injuries happened with extension abduction. And this is just an example, just like you see in proximal hamstring injuries where you get significant thigh ecchymosis. Most of the time, these occur medial and posteriorly. You typically handle it with a talgic gait pattern and pain with passive abduction. So if you look here carefully, now I'm going to show you, this is the axial oblique and you can see that this patient actually had a complete fibrocartilage revulsion. If you look on the sagittal view, and this is the blue arrow showing the abductor revulsion. This is another case where you see further retraction. And now you see in the complex is displaced. And here's the rectus abdominis. And here's the pyramidalis attached to the fibrocartilage. Okay, this is not the rectus abdominis coming off. This is the pyramidalis. And this is correlation of the anatomy study that we did prior. And then this is another case where the pubic ligament is actually disrupted off. And you can see this massive amount of hematoma, which also contributes to being a pain generator. And then further detachment of the fibrocartilage and the adductor longus. Okay, so what happens here? And most of the time, these patients, if it's non-displaced, could treat them non-operatively. There's this famous case series that was published 2009. The only thing I have with this is published in the NFL series. This is just more of a review though. We don't have any detail about the athletes and how they were treated, other than just looking at the NFL data. So we came out with our own data just published two years ago with outcomes. My series. And we looked at patients who under, high-level athletes who underwent surgical reattachment with adductor bulging injuries, and also had disabling groin pain. And this is just the players in this initial series. The average retraction is approximately three centimeters. And this is just one of the first cases I did, but just showing you the technique using a proximal incision, and then placing your anchors. And then tensioning them is the most important thing to do. We do that neutral about 30 degrees of flexion. And then after we do a layer closure after that. This is just showing another case of a complex disruption. You can see how this extension of zone of injury went to approximately above the inguinal ligament as well. And this in case we did using an inguinal approach. This is just showing an example of reattachment, but also reattachment of the pyramidalis. We have sutures over there as well for that complex injury. And this is just showing the return in our series. We're faster than this now because we have a little more confidence about the rehab postoperatively. But basically we do put them on crutches, weight bearing as tolerated for about a couple of weeks. They do use a hip brace for that first two weeks or so. And then a gradual strengthening to program. We had one infection of a sinus tract infection that improved with just removal of the sinus tract and that Athi was able to return. And these are the results, the high level of return. And then the average time to return and our series is 4.8 months. We have had patients that came back at four months to return to sports. But it's most important when you get them to return back to sports based upon their function, no pain, but also their strength deficits, also return of the strength deficits. So last thing I'm gonna share to you that we just did a biomechanical study that we just submitted and presented on the Optimal Repair. And we compared this on an MTS instrument machine comparing two versus four anchor configuration. And what we found was that the four anchor repair actually was to our control to the attack tendon where the failure occurred at the fibrocartilage junction with the two anchor, but the four anchor was just like the control where the failure occurred at the musculotendinous junction. So in summary, I think it's important to take a systematic approach to groin injuries when we evaluate the patients. But it's also important for communication as well with to the player, to the team sport physician, and as well as communication with the radiologist of what our findings are and communication of the appropriate imaging. Once we start to get that correlation better, just like with the hip, we have a better understanding about the injury patterns, recognizing these type of injury patterns and provide a better treatment algorithm. So Latul, I actually have a case presentation. If you wanna go to that next or you wanna entertain some questions, either way. Latul, I'm sorry, I can't hear you. So yeah, sorry about that. Great talk. So we have a question before we get to the case presentation. So from Josh Everhart, great talk, Dr. Barham. What is your criteria for return to sport after adductor repair? Yeah, hi, Josh. Well, thank you for your question. The most important thing is besides no pain, okay? We wanna see before we even get to sport-specific training, we wanna see, we do strength testing on them. And with the adductors, you can do ratios between the abductors. So we compare the ratio with adductor to abductor using a dynamometer. And then we compare it to the non-injured side. So we like to get the strength to about 80, over 80%. Once we do that, then I give the green light to start doing some sport-specific drills with that in anticipation for non-contact to contact sport. Excellent. And another question from Josh. So if you see a patient with chronic symptoms of both FAI and adductor pain, what is your algorithm for differentiating between the two? And then do you rule out the hip first with an injection? Yep, another great question. And I see this quite often. I'll go to where, this is where the history and exam comes in, come into play. So for me, the most important thing is the exam. And so if you do a detailed exam, perfect example is somebody who has adductor-related groin pain. And then they get an MRI, orthogram showing a label tear, x-ray showing FAI. And then you do an impingement sign test, and it's positive, okay? Really, somebody who has pain in the adductor, and you do an impingement sign test, and you bring them up further internal, it's gonna reproduce that adductor pain. But the other thing to help with your differential is also the diagnostic injection. But just like any other injections, also it's dependent upon either the radiologist or the physician doing the injection. And also the opportunity to re-examine the patient again. So what I noticed with the sports medicine fellows in their training in the last past few years that they're getting training, better training in ultrasound guided injections. I think that's great. This is a perfect case example why we as orthopedic surgeons should start getting involved in doing our own injections. Cool. All right, another question from Miguel Pelton. Fantastic talk. Seems like an underreported diagnosis. What are some anatomical landmarks you use for both open and endoscopic release? And the second part is, what was your learning curve for both techniques? Yeah, I came to, because I had a patient who had an open, that did open, and he had a lot of adductor weakness. This was about eight years ago. And I noticed that also another patient also had a little superficial wound irritation to it because every time he was an attorney, so every time he'd sit eight hours, right over his incision, it was just irritating over it. And because of those two patients, then I looked at the concept, well, maybe we could just do this endoscopically. With that, what I noticed about it endoscopically was the advantage of seeing the tendon long too as well. So that, because when you do it percutase or small, you have a small view of focus. And this way I can see the length of the tendon. That also helped me too, because I started doing this after I started doing adductor volume surgery. So I was looking at the variation of the length of the tendon. So the most important thing actually, the patients that you indicate to do the lengthenings, the ones I do, they all have a contracted adductor tendon. So it's very palpable and very easy for the adductor longus. And when you put them together in a figure four position, that increases your landmarks, okay? So your landmarks are gonna be the adductor longus, outlining it, the inguinal ligament for the inguinal crease and the bigger tubercle. And also should palpate the femoral artery to know the location of that too as well. So next question from Alexander Brown, is there a role for PRP injections? Yeah, I was on a webinar with Shane Nose Group with Shane Nose Group, and it was myself, Stu Coleman, Dean Matsuda and Robby Westerman. And Stuart asked me about PRP because he found, and himself and Dr. Myers, a series of patients who had PRP over the adductors and got heterotopic ossification. And they asked me if I ever seen that before. I haven't, but they have. So right now, since I haven't seen it, but I'm just hoping that they'll publish their results about that, because I encourage them to do that. My biggest concern is actually steroid injections, especially in the professional athletes where they're trying to get them back to play. And this is what Ernest Shilders have also seen too as well, where he's reported infections from steroid injections of the groin. And he's done some cultures to it too. So my biggest concern than the PRP is the steroid injections, besides also potentially weakening the tendon, but also causing infection, risk for infection too in that area. But like anything else, I think PRP is an option, particularly when you're dealing with, in this type of tendon injury, where you see a lot of tendinopathy can occur, that it could be a role. Excellent. And then from Jonathan Hughes, what is your criteria for operative fixation of acute adductor tears? And in the second part, does this change for the in-season elite athlete? Yeah, so great question. So, you know, when these patients come in, before when I first started doing this, it was a question of, well, how much retraction is there? Because we're new to this, right? So now understanding after an anatomic study and working with Ernest Shilders, we're understanding more why these adductor vulses are disabling. Because it's more than just the fibrocartilage, it's the complex that gets torn or disrupted. So that takes somebody with somebody who may have a partial fibrocartilage revulsion, or where somebody is more disabled where it's a complete displacement. We always give the option to the athlete, you can try conservative management, right? But same thing with any other muscle tendon injury, like a distal bicep tendon rupture, where the data is gonna be important. Can we make the patient better outcomes with surgical management and reattachment versus conservative management? If it's an in-season athlete, when they get this injury, they're pretty much done. It would be hard unless it's in the beginning of the season. So we give them the options, but it's not something when they have an adductor vulsion injury that they can return back. They could potentially get, if they go non-operatively, at six to eight weeks. But if they go surgical, though, we usually tell them the earliest return is after those three months to four months. So, Shrino, that brings up a good question. Can you hear me, Shrino? Yeah, yes, Mark. So that brings up a good question. I mean, you've got Tom Gill's data that was published in AJSM that suggests that NFL athletes are back within six weeks if treated non-operatively for a complete adductor and a vulsion and no surgery, versus if they have surgery, then that may end the season. I mean, so how do you reconcile that? They're saying that the outcomes and their only measurement, they didn't measure adductor strength necessarily. They measured performance and said the performance was the same with or without surgery. So, or no drop-off when they've had the avulsion and not had it operated on. So how do you reconcile that? Yeah, so, you know, I kind of got to look at the data to see because, you know, A, we're, sometimes, like, well, can I answer that question? Because I want to go to this case report first. Yeah. And then, Mark, I want to answer your question after, but I don't want to talk because if I say something right now, it's going to kind of get, leads into this case report that I want to get to. Would that be okay? Okay, well, I just, that was, because I think that's kind of what Jonathan Hughes was kind of getting at, at his question, I think, but that's the one thing that always, you know, certainly you've seen, you saw Tom's data and everybody said, oh, see, so you don't need to operate on these things, but there's certainly been a bunch of small case series, a lot of them coming out of Europe on operating on, you know, these adductor injuries. So, you know, and so, yeah, I just wanted to get your take, because I know this is something that you've been studying and looking at for a long time. And so, but yeah, why don't you get to the case series first and then- Yeah, and that's an important question that can go out after. So- And if anyone else has any questions, go ahead and send those over so we can- Yeah. Have some more discussion. That would be great. So let me get to the, I had it, sorry, I had it in the middle here of my talk for some reason. Let me just get back to that. Yeah, okay, here it is. Okay, so this is a 38-year-old male who presented to his orthopedic surgeon wakeboarding, okay? He had noticed a sudden pop, and when he was wakeboarding, he noted his leg was extended and he felt like someone just smacked him against his thigh. Had trouble walking, he needed some assistance, and this is his proximal thigh right over here. Okay, you can see the ecchymosis there. That's a typical pattern of what you see. They get an MRI of it, and then they sent him over to me for consultation. So on his exam, you know, he was still, I saw him now, this is after, when I saw him, he was on his second week already, he had a talgic gait pattern, he had pain with any intent, even getting on the table, on the examination table. Point tenderness was highly over, not only the pubic tubercle, but over just above where the inguinal ligament is. Very point tender there. Obviously very painful with an induction, the tentative deduction squeeze test, both extension and flexion, and a limited hip exam because of his groin pain. A lot of it is also due to the swelling. So if you look here, I took the most important cut here, and this, if you look in proximal, I'll orient you guys, here's the hamstrings coming down here, okay, here's the anterior, here is pubis coming here, and then here's where the ecchymosis is here, right over here. So maybe Mark, if you want to call on one of your fellows to what their interpretation is and what they would do. You want me to call out one of my fellows? They've already been on the hook for this whole thing, but that's like double torture. We won't do that then, we won't do that then. They've been very nice, very kind, so we won't do that. They have to suffer with me, and they have to be at all these conferences every time. Yeah, what you just mentioned about yourself, yeah, I get it, yeah. We won't do that. But the reason why I bring this case up as a teaching point, and is because, especially for the fellows, is that it's important to read your MRI, because the radiologist said that there was fibrocartilage avulsion and complete retraction, right? And you guys have seen this before with proximal hamstrings. This is non-surgical, because this is not a fibrocartilage avulsion, this is actually a musculotendinous disruption, okay? So this is why it's important to read your own imaging and get the appropriate imaging, because this patient presented, gave the history, just like all my other proximal duct avulsions, and presented just like on the exam, and he looked at his thigh, and he said, yeah, this guy needs a reattachment, saw the report. Then I looked at it carefully, and I was like, you know what, this is a musculotendinous injury. So this patient actually did well with non-operative treatment, okay? So we rehabbed him back, and a few months back, after about, I think it took about around that 12-week mark to get back to activities. But that's why I didn't want to get into your answer yet, because getting back to that study, it's also important to look at, because I know when we're looking at NFL, you're just kind of looking at what's reported and everything else, but you need to look at the exam, you need to look at the imaging, because sometimes the imaging interpretation, especially back then, where they're truly adductor avulsions, because sometimes, I also, I'll get patients, Mark, who say that they have an adductor tear, and it's acute, but then you look at the MRI, they have adductor tendinopathy, and it's not a tear. They may have some acute inflammation, because they're acute on chronic, because they had an injury at that time, but there were also sometimes labels of an adductor injury and avulsion. Those patients are athletes who will do fine getting back to sports in six weeks, you know? And then we also don't know about, like, how are they treated with any injections or anything else, and also their length of play, because you know, as good as I do, you can get on the field and say, you returned back in the NFL, and how much time did you play? So, you know, that's why the outcomes and looking at the data, it's important, though. My next project, because I already got our outcomes, now we're looking at midterm outcomes on our patients, right? But our next thing is actually those patients that, because we have patients who went non-operatively, but we're looking at those patients now and seeing how they do. Because I also see the other spectrum of this, too, okay? Because I don't get to see the patients who've been treated non-operatively and did well. I've seen the patients who've been treated non-operatively and still have pain and issues. And we're getting a cohort of those patients that are a year out. The furthest that we have are two years out, where I have a series of this college athlete, soccer player, who had MRI showing the ductal revulsion, and then two years after, continued to try to play, and the common scenario is they try to get back to play, and then they re-injure their groin, and then they're out again. So he was out for about 18 months, and this is one of the worst cases I've seen, because as that doctor actually retracted distally, another three centimeters, so he's off from eight centimeters off the pubis, which we had to take a lot of scar tissue and reattach back. That's interesting, but like I said, again, the best that you can read from that study, and I remember when I spoke to Tom about it specifically, when he was saying the athletes get back, and when they look at their performance level, number of yards per game and that kind of stuff, for the running backs and all was the same before and after, and the return was much faster, and I said, well, don't you ever have anybody that comes back later or has problems later? He said, usually, the ones that have pain were those that were incomplete avulsions, and he went, we'd go in and cut the rest of it, so they can get back faster as opposed to repairing. Yeah, and I hear you. It makes sense. That part I understand, because I'm seeing this player tomorrow who I just saw his MRI before I'm actually seeing him, on a telehealth visit, and he's got a partial adductor avulsion injury, and yeah, those are painful too, because it's chronically tugging on it, but it also goes back to when you take an injury like that, and then they completely tear it, and then they feel a little bit better versus somebody who tears the complex. That's where the understanding about the whole complex, I think, is going to play a bigger role into this, because when some of these injury patterns that we see, this is why the MRI is important. We start to see some of these injury patterns, because it's not just the adductors, it's the whole complex between the rectus, the pyramidalis, and the pubic ligament. When the pubic ligament also gets disrupted too, that's where all the disabling groin pain occurs. So I've been thinking another question here. So when you look at this and you say, well, these athletes that we see, we're not talking necessarily professional athlete now, so our everyday sports medicine patient, small college athlete, they get a groin injury. Many times, I think a lot of us look at it, it can have a period of disability. We're not necessarily getting MRIs. How aggressive should we be about hearing what you say today and the importance of recognizing the anatomy? The athlete with the ecchymosis who has a prolonged, who has a lot of pain, a lot of disability, how aggressive should we be looking at MRIs on those patients? Well, yeah, a patient like that who has an acute groin injury and ecchymosis, in my opinion, they need an MRI right away. And that, to me, is a clearest indication for a groin injury that you can see on an MRI, as opposed to athletic pubalgia or what you want to call inguinal disruption, where the MRI could be nebulous or not show anything. But that, the MRI would be very helpful for. Yeah, I think many of us have treated these kind of like hamstring, mid-substance hamstring strains, you know, like, is that anything that we're going to do operatively for that? But I guess hearing your talk kind of makes me sort of rethink how we manage some of these athletes in terms of trying to define the anatomy and get them treated sooner. Yeah, and I think it's important to, when you get the MRI, about the sequences of patterns, because what happens is, and this goes back to, Mark, there was a study, and I can't remember which one, showing that someone treated non-operatively, and then it showed that the MRI showed that the adductor was reattached after being retracted three centimeters, which really can't happen, okay? But you can miss some of these injuries, okay, with the cuts. So it's very important to get the appropriate sequences. That's why it's important to focus on the axial obliques and the saggels, because you can jump sequences, and I've seen this because I'll see a patient who has an MRI little, and then I get my own MRI, and then you see that it missed where the zone of the injury is. That's why it's important to know between the midline and the pubic symphysis where attachment is, because some of these can be missed. Absolutely. I can just comment to Dr. Pelton's comment about this being an underreported diagnosis. I mean, say, adductor injuries are significant loss of playing time, it's certainly not an underappreciated or underreported in Europe, because soccer is such a big sport there. And inguinal groin pain in the athlete is a very prevalent problem, and being able to differentiate between adductor-related, iliopsoas-related, the so-called sports injury, that's why I asked Srino to talk about this, because he's kind of the guy, and obviously he's got his own technique for the endoscopic approach for this, but I mean, he's actually sat and really thought it, because this is a much more complex area than a lot of people give it credit for, and all you have to do is take care of a soccer team or two, and you'll realize how important this is, and you see it in track athletes as well. The adductor is one of those few muscles that is active through the entire phase of gait or running, whereas a lot of the other muscles are phasic, the adductor is always firing and that's why it can be so disabling to the athlete. And again, trying to understand it is, I still think we're still very much in our infancy in spite of how common it is. But I don't know. Very well said, yeah. Obviously, if we have any of our other HIP faculty who want to chime in. I see Winston there. Yeah, I just unmuted Winston. Yeah, I mean, I treat this in my practice a lot like what Dr. Barrett was saying as far as, you know, you see a lot of soccer players, lacrosse players, you know, I kind of go back and forth between repairing them and releasing them. When I was in Boston with Dr. Gill, we released these with really good results. But I think now the paradigm might be shifting a little bit. So I think the jury's still out on that. Yeah, no, that's, you know, I think there's a role. But you know, Winston, I think it's important also to differentiate between acute injuries and repetitive because they behave differently, right? So with an adductor groin problem that has adhesive apathy is going to be different than somebody who has an acute adductor bulge injury, right? So where you get a contracted adductor, and then just doing a little lengthening will help with them, you know, so and then we're all talking about the adductors too, but it's also a complex, you have to also look at what's happening above the inguinal ligament too, as well, between the, you know, inguinal disruption or, or any type of sports training you have to exclude, you know, because they're, they interplay with each other. And then Serino, any role for ultrasound in your practice for diagnostic purposes, dynamic examinations? Yeah, I think that, you know, the, the, I tend to start looking a little bit more on the ultrasound with the adductor, especially, I mean, what I've been using the ultrasound also is post-operatively too, because one, I'm just, after having one patient that had this sinus tract that developed, I want to make sure there's no fluid around there, but I'm also looking also for the tendons healing to that, to the pubis as well, any fluid. But diagnostically, I think the ultrasound will help us with the injection part, diagnostic part of it too. I think though the, the using it dynamically though, it's, we have to, it's going to take a little bit of time and also dependent upon the ultrasound, you know, you need a good ultrasound to do that. Serino, when you repair, when you repair Serino, and I saw you doing some biomechanics stuff to show the best way to, to repair it, are you bracing at all to limit range of motion or anything like that post-op? Yeah, I use our hip brace. One is to kind of just to slow them down a little bit. I find that because most of them after around that third week, they don't need it. And then they're, they're much more mobile. And then that's when their gait's also starting to improve too as well. So I just learned from my patients that probably are up to that third, second to third week is important. One of the things that they'll report back to me is that they feel connected again after I see him after a week or so. So, but that's, there's nothing more to it than, other than some precaution. So, and back to the patient with sort of the chronic avulsion injury, what kind of things are you seeing in terms of sequela from that injury? On physical exam, what are you seeing in terms of their complaints, deficits in terms of activity? I'm sorry, which, which type of patient was it? The patient with the chronic avulsion. So they, they come in and. Oh, the chronic avulsion. Yeah. Okay. Yeah. So they will have a lot of, it's actually pain. And then they also feel some weakness too as well. If, so for instance, a classic example are the soccer players, right? So if you ask a soccer player, well, does it hurt you kicking the long ball? And that's a kicking leg. That's, what's going to trigger it over. For any of the other, the, the athlete of the sport, it's that it's not like something that we do for the hips where most of the athletes were FAI that complain about pain after it's during their activity, during their motion that they're feeling. It's not something where it hurts them and then they get sore and pain, typically like the FAI it's during the activity. Cool. Any other questions out there from our fellows? You definitively defined, defined it for us and made it all clear. Thank you. I tried, but I appreciate all the feedback. I mean, I learned tremendously, honestly, from, from everyone's feedback and I greatly appreciate it. And Mark can't thank you enough for the opportunity and Latula as well. Thank you for great job moderating. Appreciate it. Thank you. Let me, let me ask you, Shreena, the association between adductor injuries and, and core muscle injury, since you want to, I mean, you showed the pyramidalis does, you know, go across and connect to the adductor itself, right? Yeah. And a lot of times people have issues differentiating between the two. You want to talk a little bit about, about that overlap? Yeah. You know, typically with the core muscle injuries or the inguinal disruption, those are repetitive muscle imbalance type of injuries, weakness over from repetitive use and a different type of mechanism of what you see with, with, with purely adductor injuries, right? And, and no goes along, goes along with the cutting and the hyperextension of the trunk, whereas these are repetitive and traumatic injuries where you have abduction extension, eccentric contraction that happens or eccentric load that happens. So that's where the, the difference between a repetitive type of injury and an acute type that we see. But as far as the understanding the pyramidalis and its role that that's where the complex comes in with the acute adductor bulging injuries in the complex, whereas core muscle injury patterns, you see there's weakness, muscle imbalance of the inguinal floor, potentially even some true hernias and older athletes. So it's also important on your examination to also examine your inguinal canal. I quite often do an internal exam too, as well, because sometimes there's overlap. If you're dealing with somebody with adductor athenopathy and the chronic adductor, adductor related groin pain. So for me, Mark, I like to break it down to inguinal related groin pain or adductor related groin pain or a combination of both. What about you've seen in kids that have adductor type of injury, that's really more of this subtle adductor avulsion, you know, because it's the physis, right? Because that physis stays around longer, if you will. So you can get that avulsion. Do you manage them any different than the ones that are, that are not, you know, the physio avulsion, if you will, of the adductor? Yeah. I mean, I haven't seen a kid that needed surgical reattachment for them. The ones I've seen, I've never saw anyone either that at that age, that, that acutely, only saw them after weeks to months after. So they all did fine with, with just conservative management. One of them actually had a guy had an MRI repeat on that and it completely healed. So, but that's a good, another good cohort to start carefully looking at too, as well. But this goes back to Latul's question too, about how the, because I think these are being underreported. And that's why we're not seeing as many adolescent ones because we're probably not getting imaging on them. So Latul, you bring up a great point about how aggressive should we be. I think though, the more aware, just like with the hip FAI, right? And labeled tears, the more awareness, the more we're going to stand about the MRIs and more interpretation of that and correlate. Excellent. And, you know, we talk about enthesophytes and your management, you know, obviously there's some question about acuity and things like that, but we see these patients who have adductor injuries and they have also enthesophytes when you get the MRI. And I know there's some old, not old literature, but you know, I guess early two thousands, you know, alluding to how to manage those and the role for corticosteroid when you see these injuries in the setting of enthesophytes. Any comments on that or? Yeah. I, you know, I probably like a few years back, I probably said, yeah, I tried to steroid injection, but now knowing what I know now, I would avoid the steroid injection for them. But this is also, even though you have enthesophytes on the imaging though, I would first see diagnostically to see a pubic cleft injection, to see if the pain's coming from that insertion enthesophyte versus a muscle tendon disjunction. And in correlation with the exam too. So that would be my first thing to do on that. Excellent. There's a question from Keelan. Do you see these isolated injuries as risk factors for combined core athletic fibrillology injuries further down the line? Great question. Yeah. Great question. I mean, I think, you know, we're, we're, we're seeing if I take it a step further even, well, what about, we haven't really touched about the correlation with the hip. So, what I'm seeing in, in adductor bulging injuries, quite a few of them also have some underlying FAI decreased internal rotation. And there was a study that showed that if you, if you, also, if you look at fixing the adductor problem, sometimes the internal rotation will improve too as well. I've seen that in one of my professional athletes actually. And I asked him, I was like, were you working and doing a lot of internal rotation work? And he's like, no, but it's actually internal rotation was back to normal. So that made me think a little bit about, but getting back to your, your question about for the, I think it puts it at risk, but if they get to a point where the, get to the point where they get this traumatic injury, I think the, what it does is that it puts you up to set you up for proper training, rehab and training. And then they learn about for preventative, for further risk of, for the core. Because I think a lot of these core injuries also are happening too, because of poor training and muscle imbalances, right? And also breathing. We never talked about that too, but I've also learned that breathing also during exertion and exhalation during your movements are also important for preventing core injuries too. So I think that, that when they get these types of injuries, it can be a little protective in that way because they learn about the proper rehab and retraining of the muscles around that area. All right, Trina, I'm going to open you up to this thing here because you actually showed a slide of it. So in the beginning, when you showed the, if you want to call it a osteophyte versus HO, if you will, of the, over the pubic symphysis, right? Crossing there. Do you see those, because you do see those not infrequently, especially in your soccer players, you know, do you see those as a source of pain? And if so, do you treat those? I know it's not a deductive thing, but. Yeah, like that soccer player I showed you, I mean, that thing was huge, right? It was, it was three centimeters. So obviously, you know, it was very painful. But I think if it's true, not an enthesiophyte, but it's a true HO and, and, and it's been, you know, everything you've done concerning management, because PTs, if it's, that's what's really the pain generator, PT is really not going to help it. Then I think it's reasonable to do a surgical excision of that, the HO. All right. And since we also have then, do you, how are you, in a nutshell, because we're not covering this during the lecture series, your management of osteitis pubis, true osteitis pubis? Yeah, I mean, to me, osteoporosis, pubis is more of a radiological imaging diagnosis. But I think it's, it's important that most, if it's just that that's causing the pain, I think you got to look a little further to the real pain generator, right? So to me, just giving somebody, I won't give somebody a diagnosis of osteoitis pubis, it's going to be a duct related groin pain, or angular related groin pain. And then I work from that. But it does tell you that there's some activity going on there. But I won't just look at that just as a pure diagnosis and treatment algorithm for it. So do you not? But I'm sorry, but but but there is a subset of patients, however, you postpartum, right, or post traumatic, that have pain, and they get osteoarthritis of the pubic syphilis. That's a different category than the than than than you have for the athletes from that. So I'm talking about athletes that you know, that may have this pain that is related to the, you know, the pubic symphysis, their MRI shows that the thing lights up, maybe you even give them a symphysial injection, and also, you know, it's got an injection in the symphysis, they get, they get temporary relief. But the sit, but it comes back. Where, where's their pain, though, like, their exam? Well, when you when you compress the pelvis, it hurts, it hurts in the midline. When you push right on the pubic symphysis, it hurts. When you inject it, you relate, you relieved it. Do you think they have any instability in that area? Well, so I guess the the thing I'm getting at is that, you know, we used to say, you know, that all the group pain right there in the midline, you know, it's not that bad. It's just you know, that all the pain right there in the middle was osteitis pubis. And I've sent people for what I thought was core muscle injury, and they get come back from a general surgeon with osteitis pubis as their diagnosis. And, and I guess the issue is, it's, you know, other things, right? We got to worry about the sports hernia, sports, whatever, core muscle injury, got to worry about the adductor, we got to worry about real hernias, but, and you got to worry about the bony injuries in that area as well. But I guess, you know, there are some people that still talk about resecting, you know, the, the cartilage at the, at the symphysis, there are people that have plated the symphysis, do you see any role for that? Have you done any of that stuff in your practice? I haven't, I, you know, minus those patients that we I talked about postpartum, or somebody had a traumatic, post traumatic pelvic injury, right? Minus those patients. We talked about the athletes, right? Yeah, I haven't indicated somebody that that would that could do a resection. You know, I know D Matsuda has some, you know, his technique of endoscopic resection of that area. But, you know, I haven't seen a patient that I needed to consider to do that. You know, I think it's important to differentiate where, where their, their pain, pain generator is in their exam, and not just to label them just because they have pain around that area, and they call a size pubis. But, you know, there's important also, when you when you do the injection, you know, where you're injecting, right, that's, so when I'm injecting the pubic symphysis, I'm injecting over to where the pubic tubercle, when the assertion is of the fiber cartilage, because I'm seeing whether or not it's generated from the attachment of the adductor versus musculotendinous where the pain is. So you have to kind of look at, you know, their exam and what what you're trying to correlate with the injection. But I think what's happening, Mark, is that some of these patients are start will sometimes get labeled and lumped into a size pubis, just like we we did for football players back in the early 2000s, where they had a hip pointer. Do you ever give a diagnosis of the hip pointer? No. All right. You know, it's I'm not I'm not saying that there's that the diagnosis of pubis doesn't exist. But I think that a lot of patients get lumped into that, you know. Yeah, I think I agree with you. I think it's kind of a wastebasket term that I think we've gotten past that ideally. And, you know, as again, not everything is a hip flexor strain, if you will, right. And, but there are certainly hip flexor strains, but correct. Yeah, I agree. Yeah. Excellent. So any further questions? So Serino, fantastic talk. Thank you so much. Appreciate it. As always, now I feel smarter. Better able to take care of my athletes. So we, so again, this lecture will be available next week, as with the other lectures from this week. And then we have more hip, I think next week, starting on Monday. Fantastic. That's great. Excellent. Thanks. Thanks again for coming on. Winston, thanks for your comments. And Mark, as always, thank you for your comments. Thank you, Mark. Latul, thank you. And Serino, awesome. Really appreciate you enlightening us. And I hope everybody has a great weekend. You know, thank you so much. Be well. Thanks. Thanks, everybody. Thank you. Hey, Latul, make sure you hit end meeting, yeah? Yep. Appreciate it. Will do. Thank you. Take care, Serino. Take care, guys. Thank you, Mark. Appreciate it.

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