Thanks for joining us. Everyone, thanks for tuning in. As always, this is the multi-institutional Fellows Conference. If, look down and make sure to mute your phones just so we don't have any background noise. And as always, this talk, as well as the others from this week, will appear on the AOSSM website next week. And today we have Dr. Benton Emblom, Alabama's finest hip specialist, who joined us to talk about sports hernia slash core muscle injury. He's down at the Andrews Clinic Sports Medicine Orthopedic Center in Birmingham and comes to us today as one of the co-founders of the hip center there. And we're looking forward to hear his talk. How's that looking? I see you're, I got your, I think we got your screen up. All right. And there's your talk, there you go. Perfect. So everything set with that? Yep. All right. You're a truly Alabama born and raised. That's right. How about yourself? That's awesome. I'm from the great state of Ohio, the home of the Ohio State University. Don't forget the the part, that's important. Thanks for joining us. All right. Good to be here. All right, guys. So I've been tasked to speak on core muscle injuries in terms of diagnosis and treatment. Obviously that injury pattern has received a lot of attention over the last several years. And exactly what is a core muscle injury? Is it a sports hernia? Is it a Gilmore's groin? There are a bunch of different terminologies and those have varied over the years. And sports hernia itself is truly a misnomer. It was originally described in the 80s by Dr. Jerry Gilmore over in London and titled Gilmore's groin. And subsequently has been referred to as a sportsman's hernia, athletic pubalgia, slap shot gut, and I've heard it mentioned as a soccer hernia. But more recently, we've tried to collectively call this a core muscle injury in order to prevent confusion. So the understanding of this has been evolving just as much as the nomenclature has and prior technique descriptions are vague. There are multiple potential pathologies in terms of the pain generators and that's what we'll get into. So the current philosophy in terms of sports hernia or athletic pubalgia or core muscle injury is that this is an injury to the common aponeurosis or enveloping fascia between the rectus abdominis and the adductor longus tendons, right at the common attachment point onto the pubis. Athletic activity requires a significant amount of torque across this aponeurosis, particularly in high level explosive activity. And certain sports can indeed experience higher rates or excuse me, higher torques and subsequently higher increased rates of injury such as soccer, hockey, which we don't see much of down in the South, but you guys do up in the Northeast and Midwest, as well as football and baseball pitching. This is a very disabling condition and has led to the cessation of many careers, including NFL careers, which has been documented in a recent study published in 2017. The standard inguinal hernia repair techniques have been implemented in the past with mixed outcomes, both open and laparoscopic. However, many of those patients did fail with that surgery. Dr. Myers, as we know, has had the most comprehensive series of repairs, which vary in both pathology and technique in his 2008 series, which included 8,500 patients. And if you look at that, the overwhelming majority of patients had significant pathology that was described at the adductor and the rectus abdominis attachment, as you can see outlined in this red square here. Most patients had anatomic defects identified at the time of MRI, at the symphysis, the rectus, the adductor, the pectineus, and at the adductor brevis. So if historical surgical treatment was the treatment of choice, but if you look at Dr. Myers' series, we concluded that majority of these patients were from rectus abdominis and adductor pathology. And in his 2008 and 2008, excuse me, his 2000 and 2008 papers clearly highlight the involvement of the rectus and the adductor and discounted inguinal hernia surgery for athletic pubalgia. How come we still continue to treat this with traditional hernia techniques? Okay, and many of these athletes are still being treated with traditional inguinal hernia repairs. It's important to understand this is not a hernia, okay? So traditional hernia techniques are not necessarily applicable here. This is a core muscle injury. It's a high athletic injury at the level of the groin. Seen in over 50% of patients is a sentinel injury, something that they can put a finger on and tell you the date that it occurred and mimics the pain pattern of a traditional inguinal hernia in terms of pain in the groin, pain around the hip region. They would oftentimes complain of exertional symptoms, lack of explosiveness or inability to sprint or cut and would typically have symptoms that migrated into the lower abdomen and therefore usually misinterpreted as an inguinal hernia. Oftentimes, like I said earlier, this is a hernia type symptomatology that you would see in athletes or sportsmen that had this type of pain pattern. So from a pathophysiological standpoint, we would see repetitive unsustainable loads on the terminal abdominal insertions and the adductor origin. More so with hip abduction and extension, there would be an imbalance demonstrated between the rectus and the adductor attachments. And we would oftentimes see this in the setting of reduced hip range of motion, such as femorostabular impingement with compensation by increased pelvic motion, which subsequently resulted in increased stresses on the pelvic stabilizers. From a pathomechanical standpoint, like I mentioned earlier, this would involve an injury or strain to the terminal rectus sheath, the adductor origin and or the posterior inguinal wall. And if you see this schematic that I have here, we have a baseball covering as the common attachment point of the rectus abdominis and the adductor. And when one of these fails, it starts to unravel just like the covering of a baseball right at the attachment point to the pubic symphysis. The pain distribution would obviously be in the inguinal region, typically migrating up into the lower abdominal area, as well as extending down into the adductors. And it's not uncommon for patients to experience referred pain into the scrotum and into the medial thigh. On exam, they would often experience localized tenderness over the pubis and the tendon attachment of the terminal rectus and or the proximal adductor. And would have pain with resisted sit up and hip adduction. And when you perform that simultaneously and have the patients resist with adduction of the hip, as well as a simultaneous resisted sit up, and if you push right there at the common attachment point, it would usually reproduce their symptoms. We typically refer this to a rack test or resisted adduction crunch test. On MRI, the results or imaging findings were highly variable but most of these patients with an oblique axial cut would demonstrate significant signal irregularity and even frank detachment right here at the common attachment point of the rectus and the adductor. You can see what we refer to oftentimes is the cleft sign where they'll have fluid at the origin of the adductor with extension right up into the pubis. You can see here, there's more detachment with these larger arrows and significant bone marrow edema changes on the pubis. Likewise here with a more significant injury pattern with actual detachment of the adductor. And here is another sagittal image demonstrating the cleft sign right here at the common attachment point of the rectus and the adductor demonstrated by these two asterisks. In cases with soft findings, it's highly recommended and for the most part with all of these patients to consult the appropriate gynecological or genital urinary surgeons as well as general surgeons to rule out a traditional inguinal hernia if you're not comfortable doing that yourself. So we performed a study about a year and a half ago that was recently published in the Orthopedic Journal of Sports Medicine looking at the last 100 cases of these in competitive athletes. The purpose of our study was to explore and measure functional outcomes after sports hernia repair, assess recovery and longevity of our repairs and determine the complication rate and severity of that as well as determine predictors of poor outcomes. And as you see here, our surgical plan involved the pubis and very similar to the knee extension mechanism, we're talking about the common attachment point of the rectus and the adductor on the bone similar to the attachment point of the quadriceps tendon and the patella tendon at the attachment of the patella here. And what we would do from a surgical standpoint would go in and basically perform a limited lengthening or excuse me, a fractional lengthening of the adductor and restoring the attachment point of the rectus basically decoupling these two at the attachment point that they share onto the pubis. This is our surgical plan. Obviously, this is the midline right here. This is the pubic symphysis. This is the adductor margin right here. And this right here is this dotted line is the superior and inferior border of the pubic ramus. Here, you can see the attachment of the inguinal ligament onto the pubic tubercle right here. This is the scarpus fascia right here that encases the rectus and the adductor not necessarily the investing fascia or the aponeurosis but the deepest layer of superficial fascia. Here, that's been released and you can see the lateral border of the rectus abdominis and the proximal aspect of the adductor. I can still see the inguinal ligament here which is important to preserve. The spermatic cord has been retracted medially here. And this is a limited fractional lengthening of the most superficial or anterior surface of the adductor. Keep in mind, we're not performing a complete adductor release, just releasing the anterior edge of the attachment site to allow the proximal anterior half of the adductor to lengthen similar to a effective Achilles or gastroc lengthening in the calf. You can see here now we have basically a muscular bed right here where we've released part of the adductor, still have the rectus attachment intact right here. And then we'll come in basically and take part of what we released, fold it up and kind of a reverse turn up flap and imbricate the insertion of the rectus with that tissue including the periosteum of the symphysis, excuse me, of the pubic ramus right here. This is a muscle bed right here with some remaining tenonous structures right here on the deep posterior aspect of the adductors. At the time of our study, I was using a small piece of gel foam and it's inserting that into the bed right there at the area where we did the fractional lengthening. And since then I've started placing a film of amniotic membrane in order to try and minimize scar tissue formation and facilitate a more tendon like reconstitution similar to what our foot and ankle colleagues have done around perineal tendon repairs. When we looked at these, we went back through our database using obviously the appropriate clinical codes and conducting telephone interviews looking at hip outcome scores with questionnaires and additional questions including complications, sexual and urinary dysfunction prior or subsequent surgeries return to play and level of play. We generated a spreadsheet with 102 total patients that had greater than six months follow up, had two patients excluded, one for workers comp and one unfortunately had expired in a motor vehicle crash. So we had 100 patients that we looked at collectively. Overall, 85% of those patients were able to be contacted greater than all of those within the 85% group had greater than six month follow up. The average follow up time was 25.8 months. Average age at surgery was 26 and that was a little bit higher. We had one guy that was 65 years of age and was an avid competitive jujitsu athlete. We had six pro athletes, 42 collegiate athletes, 12 high school athletes and 25 recreational athletes. 73 of those were males, 12 were females. Nine had undergone previous inguinal hernia repair. Seven had bilateral repairs and 67 of those had had a single operation. 18 of those had had more than one operation and on average, 1.3 operations had been performed on patients that were undergoing the surgical procedure. The results, the HIP outcome scores yielded 99% with a range of 76 to 100. The HIP outcome score sports subscale of 96%, overall functional percentage 97.5. The overall sports functional percentage at 91.6% excluding those unable to participate. The average return to sports was 4.2 months and of those, the patient reported level of function, 87% was normal, 8% quote unquote nearly normal and 5% of those abnormal. There was no statistical difference between the unilaterals and bilaterals and the complication rate that we had was 7% and those included wound infection, one re-injury and a re-operation. Of those six complications or 7%, like I said, two had possible re-tears but were not confirmed surgically, two wound infections that resolved with antibiotics, one symptomatic hematoma that resolved with aspiration and one required re-operation for heterotopic ossification. One of those three professional football players was unable to return to their previous level of professional sport. Return to play data was 96% return to play on average four months, 87% required less than six months return to play and three patients were unable to return to play. The return to play of greater than six months or unable, 44% of those had prior hernia repair or multiple surgery at 38% and 25% were female. And the return to play calculations were made when they were unable to return to play or had not returned to play yet at 18 months. So if you look at the sports function kind of breakdown, those with less than 90% versus greater than 90%, the average number of procedures was highly variable but not statistically significant at 1.55 versus 1.15. Males to females return-to-play data was fairly similar. The average number of procedures was significantly higher and statistically significant in females. Return-to-play not statistically statistically significant but slightly higher in the female group. So what is the main factor? What is the main factor that is precluding some of these to return-to-play or the poor outcomes in females? Was it the number of procedures? If you look at single versus multiple surgeries, return-to-play in the single group, which was the surgery that we performed, the single surgery that was performed with the sports hernia or core muscle repair, had 100% return-to-play compared to 84% in the multiple group. Average procedures in that group won versus 2.33 and the return-to-play in months 3.89 compared to almost double or actually more than double that. When you look at the single versus the prior inguinal hernia repair group, likewise it's the recurring theme here average number of procedures being significantly higher with significantly higher return-to-play rates. Likewise with single versus inguinal hernia versus multiple surgeries. So the point that we attempted to make here was that core muscle injuries can cause significant dysfunction. Patients can expect a three to four month return-to-play or full return for full return after an appropriately performed operation with an appropriately made diagnosis. But the important factor and the critical factor here is proper diagnosis and that stands with any procedure we do, whether it's an elbow, a shoulder, or a knee. If our diagnosis is incorrect, the likelihood of our successful surgical procedure is extremely low, likewise with return-to-play. So patients with multiple surgeries and multiple prior inguinal hernia repairs do significantly worse than patients undergoing a single surgery and you know that's obviously the same as what I mentioned above. If you go in and do a flexor pronator repair and a patient with an ulnar collateral ligament injury and they don't have an effective return-to-play and their outcome is poor, even when you go back in and reconstruct the ligament, they're more than likely going to do poor than a patient that just had a primary ulnar collateral ligament reconstruction. And that's just the nature of multiple surgeries on one joint or one single area of the body. Patients who undergo a single surgery obviously do much much better as we mentioned above and the complications with that surgery are rare and typically mild. Thank you from the Andrews Hip Center and I'm obviously open to field any questions that any of you guys may have. Ben, thanks for the talk. That was fantastic. I'm gonna unmute a couple of our faculty here but okay that's my first question. You know I'm a knee guy that does some shoulder a little bit elbow but no hip. You know in terms of when you guys are like seeing athletes you know PPE wise things like that, anything that we need to be aware of in terms of identifying these patients like risk factors, you know functional movement screen stuff that you recommend that we should be routinely asking about or going through as part of the PPE? Right, so I think you know what we found is that a lot of these patients that would have core muscle injuries or develop symptoms of athletic pubalgia whether they required surgery ultimately or not had decreased hip range of motion. And likewise what we've also found and this has been demonstrated in the literature, athletes with decreased hip range of motion and underlying hip impingement were likely to develop symptoms at some point in their career. So I think it's important to screen these athletes for motion about the hip. I'm not saying forgo the auscultation of the heart and lungs in order to do a full assessment of the hips but I'm saying it's important that we look at that. So if we see a kid that has zero internal rotation in the hips and really doesn't have any hip pain whatsoever, I think that's somebody that we need to just keep an eye on and understand that he is at risk for developing either some form of intra-articular hip pathology and maybe even a core muscle injury. Secondarily we see this a lot in these kids that play the skill positions that live in the weight room. You know they're significantly imbalanced in terms of their lower extremities compared to their core. They can squat 500 pounds easily but you know have a difficult time doing a series of abdominal crunches or what have you. And those patients are the ones that I think are probably more at risk when they have significant imbalance from the lower extremities to the core and torso. So looking at those things can certainly be helpful. We have one question for the from the fellows. So thanks for a great talk Dr. Emblom. What's your criteria for clearing the patient to return to sport after these procedures? And then the second part of that question, also do you ever put patients on HO prophylaxis? Yes. So in terms of clearance return to sport, what we obviously will look at just like any other surgery that we do in an athlete is restoration of function without pain and full strength. So we'll reproduce the exams that we will do at the preoperative assessment and ensure that they don't have recurrent symptoms, don't have pain, don't have weakness that would put them at risk for further injury. It's not as difficult as an ACL or a shoulder for example in terms of assessing stability looking at a biodex. We don't do routine isokinetic testing around the hip for something like this but you can generally get a good feel between 8 and 12 months if they have painless functional motion and full strength. And then we put them through a progressive return to play platform just like we do anything else. So we don't ever see somebody in the office that's been under the tutelage or under the supervision of a therapist and just cut them loose out of the gate. So there's always a progressive return to play which is important. In terms of HO, I don't typically put these patients on heterotopic ossification prophylaxis unless they have a significant avulsion from the pubis with significant sharpies fibers composition at the area of injury. And you can see that at the time of surgery. If they've got a significant adductor injury and you can feel kind of a Velcro type sensation at the origin, those are the ones that you have to be really worried about. Those are the ones that we recommend against doing any type of PRP right on the bone acutely. You know there's been some memorandums that have gone out by others advocating against or discouraging injecting PRP in the setting of a core muscle injury. And I think that's a little bit off base in terms of treating all athletic pubalgia type injuries or core injuries the same and saying that you can't inject these with PRP. I think the critical factors here are their bony avulsions and are you going to inject PRP at the area where the avulsion occurred. I think if you do, you're setting yourself up for heterotopic bone formation. But to answer the question, I don't routinely put these patients on HO prophylaxis unless they've got some bony avulsion component. Excellent. And I guess kind of along those lines, so this is from Bob Jack. Thank you for a great talk. So what are your thoughts on using PRP injections for initial management of the core muscle injuries, say the ones without evidence of an avulsion. Is that something that's part of your practice? Absolutely. I'm a fan of it big-time and I think in those settings a couple of things. One is to really study the MRI and confirm that there's not any bony avulsion. Okay. Number two, I like to do my PRP under sedation in these settings and the reason I like to do that is because I like to get the needle with a 16-gauge needle and inject at the insertion of the rectus and the origin of the pubis. And in order to do that well and to do that in multiple sites, the patient can't be completely conscious and awake. It's just too painful and that generates a lot of patient anxiety and subsequent physician anxiety and then I think you do a bad job at doing the injection. So what I will typically do, assuming there's no bony avulsion, is I'll do a injection with PRP under sedation either in a procedure room or in the operating room under flora. Cool. And I guess, you know, obviously, you know, you got a long time for return to play with these athletes and I think that's very necessary. How do you manage sort of the in-season athletes? So you got an athlete who has a suspected core muscle injury and it's, you know, late August and you're looking at getting through a season with that. And what go through your, how you handle that athlete? Yeah, so and unfortunately that's a lot of what we see, you know, and I think we'll probably see a lot of that when we start back this season in particular because of the relative deconditioning component of a lot of these kids being out of the weight room and being imbalanced and we talked about. So say for example, we go back this season to football and come August, we got two or three guys that have groin pain and we do an MRI and they got some fluid around the origin of their adductor. What we'll typically do is I'll typically put them on a MedDRAW dose pack and we'll oftentimes do, excuse me, a steroid injection at the zone of injury, okay. And when I do a steroid injection, I don't typically do that under sedation because I'm just doing kind of a local injection at the zone of injury. And if that doesn't provide any substantial relief after about one to two weeks, I'll do a PRP injection. When we do that, they and the coaches and the trainers need to understand that it's probably going to be a two to three week return to play after that PRP injection, oftentimes about two weeks. And usually we can get somebody through the season with that. Another medication that will oftentimes put them on and you want to stop this if you're going to do PRP is we'll put them on Indusyn, which for some pharmacokinetic reason tends to work well around the hip and pelvis. Traditionally, it was poorly tolerated, but Indusyn SR taken twice a day seems to be more appropriately tolerated. You really need to be careful if you're giving this medication in August, like you mentioned, when it's hot and these kids are sweating and they're losing fluid, just to make sure they don't have any issues with their kidneys or if they develop rhabdo. That's something we need to be aware of. But Indusyn, Medrol dose pack, local steroid injection, and if that fails, we'll do a PRP injection under sedation. And usually with that combination, we can get them through the season. Very rarely do we have to put a plug on a college or a high school level athlete. Now sometimes we will on a pro-athlete just because the circumstances are different, you know, but generally we can get a willing and able athlete through the season. Excellent. So the question from John Hughes, how much stock do you place in MRI findings? And just a comment here, I have noticed various patients being unable to get a pelvis MRI due to insurance denial who instead want an ultrasound to evaluate core muscle injury. Yes, so good question. I was just asked to review an article that was submitted to AJSM looking at the false negative or negative read in the setting of clinical core muscle injury and subsequent improvement in symptoms and favorable patient-reported outcomes after surgery. And it's not uncommon for those athletes to have a quote-unquote normal MRI. However, as we probably all do and as we instill in our fellows, you need to look at all your MRIs yourself and not rely on the radiologist report. It's helpful to have a good report, but at the same time they don't have the luxury of understanding where the symptoms are, what the history has been, etc. So if you look, you'll generally always see a little fluid right at the origin of the adductor and will oftentimes extend up into the pubic symphysis. In the cases of a negative MRI, okay, whether that be from a negative read or them not having an MRI from an insurance denial, an ultrasound can be helpful in terms of looking at the changes of the signal echo changes at the site of the attachment of the adductor. Now you're not going to see generally a big defect or anything like that, but you'll see a change in the kind of the appearance of the adductor at the level of the attachment at the pubis. But, you know, my go-to diagnostic test still is a MRI coupled with a physical exam. Excellent. And then so next question, so thanks Dr. Emblom. This is from Alexander Brown. What are some situations that you might see on MRI or in a patient's history that lead you away from doing your sports hernia procedure? Good question. So I saw a kid today from Nashville that's going to be a college-wide receiver that was sent down to see for a sports hernia because on MRI he had fluid at the origin of the adductor that tracked up into the insertion of the rectus. None of his symptoms were there. All of his pain was in his hip, you know, he had hip pain and he'd recently had a hip injection done elsewhere and had a two-week improvement in his symptoms. So, you know, sometimes we'll see patients that have an MRI that if you just looked at the MRI you would say, ah, they've got some form of a core injury, but a simple history and physical exam will steer you obviously in a different direction. If I see a patient that has a completely normal MRI and an abnormal exam, I still probably won't operate on those unless I take them back through kind of a physiologic stress test, if you will, have them go out and work out and train and see how their symptoms respond in the setting of a normal MRI and an abnormal physical exam. The ones that have an abnormal history, obviously an abnormal physical examination and an abnormal MRI are obvious, those are simple, but the ones that have a normal MRI you just need to be a little bit more careful with. I'll oftentimes refer those to other specialists such as general surgeon and or a urologist or a GYN and if it's a female. I guess along those lines, you know, my teaching and I was sort of fellowship, you know, over 12 years ago and, you know, I thought, you know, at that time and, you know, looking at the stuff from Mushawack and others that, you know, they talk about transversalis fascia weakening, things like that, and it seems like we've learned a lot more about core muscle injury in recent time. Where is that crossover now? What's the thinking about the relation of that transversalis fascia weakening the abdominal wall versus what we're hearing a lot about now with, you know, true cusp core muscle injury? Great question and I think it's important and I tell the fellows this that, you know, I have, you know, if you look at a lot of these abdominal pain syndromes, core muscle injuries, it's kind of like three or four circles creating a Venn diagram and the ones that I typically treat have their own circle, okay. My wheelhouse is going to be at the rectus and the adductor, at the attachment point to the pubis, where the core, excuse me, where the pubic plate, inguinal ligament, the adductor, and the rectus attach. When we're starting to see patients with symptoms that are higher up in the rectus, or more lateral out in the transversalis fascia, maybe the superficial to the internal inguinal ring, those are the ones without a doubt that I see all the other specialists for. To be quite honest with you, those aren't the ones I treat. The ones that I treat are the ones that are rectus, adductor complex pathology. To answer your question, I think all of those circles do move around and have a fair amount of overlap. I think there are different specialists that sit on top of each of those circles. I think it's important for all of those specialists to communicate and understand that everybody has their circle and that there's not one person that can really take care of everybody in all those different circles. Just like everything else we do, I think it's important for us to not tell people that we know how to fix all of these, and I can fix everybody that comes in with groin pain. I have my certain subset of patients that I have a very good understanding of, that I can treat well and feel very confident about getting them back to play. But there are others that other people have a better skill set and background in treating, and it's important to identify those people so that you can utilize them to treat the patients that present somewhat differently than the standard ones that you may see. That was excellent. Are there situations where you're doing this surgery with a general surgery person that you're double-teaming things, addressing multiple pathologies? The only ones that I've done that on are the ones that had a high index of suspicion of an inguinal hernia. What I would do is I'd go in and the general surgeon would explore the spermatic cord and if there was or wasn't anything there, he would or wouldn't do anything with it, and then I would typically do the muscle tendon work. But not routinely unless we feel like there's some concomitant pathology. I love your explanation of the RAC test. I think a lot of us are doing components of that, either the resisted crunches versus the resisted adduction. Is that your go-to test for the most part when you're evaluating? That is my primary go-to test and we're in the process of putting together a large group of patients and trying to validate that so that we can hopefully have something that everybody can fall back on. Then in your world, the hip world, are there a lot of guys like you who are doing not only just the intra-articular stuff, the actual true hip stuff and the core muscle injury stuff or? No, there really aren't. Not at all. In that being said, I still haven't done many combined cases just within myself, in terms of a core injury and a scope. I've done probably a dozen. I haven't had that many patients that have required both operations. I'm not really a fan of doing both of those at the same time anyway. That's just a lot of surgery. Generally speaking, a lot of those will get better if the squeakiest wheel gets more grease. You know what I'm saying? But no, to answer your question, there are not many people that do both of those surgical procedures. How did you get down that path, taking on the core muscle injury? To give you the full story, when I was a fellow in 2008, Dr. Andrews challenged me to take on the hip. He felt that the hip was going to be a big part of sports medicine in the next few years. Dr. Byrd was a fellow with Dr. Andrews in years past, and we coordinated a mini fellowship with me up in Nashville with Dr. Byrd, and that's where I was introduced to hip arthroscopy. I came back and immediately my practice was just overrun with, I shouldn't say overrun because that sounds bad. I was fortunate to have access to all these patients with hip problems, and I was really the only one doing them or seeing them for that matter. At the time, I thought sports hernia stuff, that's nothing that I really want to get into. I think I'll just stick with the hip. I just did a fellowship in sports as well. I got all these other things I can be doing. But you just couldn't run from it. The overlap of those patients was so significant, or at least just the patients that came in with hip pain, and the incidence of those that would have some form of a groin injury was so significant that I felt like I needed to be better at treating that. To be quite honest with you, the only real option was a long ways away, and it cost a lot of money for patients to go have that operation done. Quite frankly, most of the patients that I was seeing, that wasn't an option. I really forced myself to figure it out and started in the cadaver lab, doing cadaver dissections and getting a firm understanding of the pelvic anatomy. Fortunately, where I was a resident, we did a lot of pelvic and gastrointestinal trauma, so I felt comfortable operating on that part of the body. Then just with some collaboration with other surgeons, started treating these. As we got more and more comfortable, I think we started collecting data and looking at our own data. Once we're able to prove that what we were doing was working, we really started taking it to the next level. It's one of those things that never even heard of it when I was a resident. Like I'll tell most of these fellows and residents here, most of what I do surgically, I didn't even hear about when I was a resident. For the most part, I didn't do when I was a fellow. I challenge everybody to have open ears, and open eyes, and learn how to do things that you maybe would never even considered when you were training, because what you're doing 20 years from now will look completely different than what you're doing today. Obviously, if anyone else has any other questions, please chime in. You obviously showed a big difference in presentation and outcomes and stuff with respect to male versus female athletes. Are there any anatomic factors in terms of pelvic inclination, women versus men, that you guys have been able to identify as being drivers of this? To be honest with you, the surgical procedure in a female is a lot easier just because obviously the spermatic core is not there. Most female athletes are pretty thin, so it's a much easier operation, but the outcomes were poor. Initially, we thought, well, maybe we're just wrong. Maybe we're just operating on the wrong diagnosis. But after looking at a lot of the data and the outcomes reports, just like you suggested, I think the female athlete just has a lot more dynamic component to it. I think the pelvic tilt and pelvic inclination change weekly in a female. I think that their ratios in terms of their abductors and adductors are obviously oftentimes mismatched and subsequently around their core. I think in general, female athletes tend to have a weaker core. So I think there are some predisposing risk factors in addition to the fact that the female athlete just is always in a state of flux in terms of their pelvic anatomy, which subsequently affects their knees. So I think there are some factors there that they're really, I hate to say this, but almost out of our control. So any other questions out there for Dr. Emblom? Hey, Latul. Hey, well, how's it going? Going well. Dr. Emblom, that was fantastic. I don't know if I have a question so much as just a comment. I'm kind of one of those that, you know, general sports orthopedists, I do some hip surgery and, you know, certainly not even close to a hip surgery. You know, certainly not even close to the level you are in that sort of center part of the pelvis, but it is absolutely something that anybody that takes on hip needs to know something about because there's a lot of overlap, right? And, you know, I think most of the time, and I want to know your thoughts on it, but most of the time if there is a hip problem and maybe, you know, an adductor slash rectus problem, we probably take care of the hip first. But sometimes that rectus slash adductor problem is still there or it's iliopsoas tendonitis or whatever. So, you know, kind of at least being able to recognize those other causes. In my practice, at least, if the hip, you know, if the FAI surgery doesn't go well, then if they're still having problems, it tends to be in that region. So I really appreciate you elucidating more about where those injuries are and what's going on there. Yeah, I agree. I think, you know, hip, whether it be the joint and the core, it's like shoulder and elbow, you know? I mean, I don't think you can do one without the other. And you don't necessarily have to take on the surgery around the pelvis. And, in fact, I would discourage anyone, just like I would with a scope, to trying to do a surgery like this every blue moon. You know, it's just there's too much downside risk for doing any operation, for that matter, that you don't do frequently. And that's not just the hip and the pelvis. That goes with the knee and the shoulder as well. But you're right. I mean, as a hip specialist, you're going to see this problem. And I would encourage everyone to really pay attention, look for this, because this is one of those things that, you know, like people have once told me, you know, the mind only knows what the eye sees, for example. And if you're not looking for it and you're not going to know what's there, you don't necessarily have to be the one that does the operation if you're not comfortable with that. It's not always about that. You know, I feel like I'm like the old guy now. Maybe I am, but I finished fellowship in 2000. And I swear to God, you know, the hip was like one diagnosis. You know, it was a black box and it was either, you know, it was hip flexor. Yeah. And, you know, it's exciting to be able to, you know, gain some insight and understanding. It's not about necessarily being able to do the surgery on them, but being able to, you know, make a proper assessment and diagnosis for your athlete and then get them dispo to where they can be taken care of instead of, you know, instead of it just being, yeah, I don't know. Yeah, exactly. Patients appreciate it. Athletes really do. Yeah. So I appreciate this talk very much. Thank you. You bet. There's a question here. I'm able to pull them up now. It says, is there a role for just fractionally lengthening the adductor? You know, I'm not a fan of that. I've seen some cases and I've seen them also in the media where, you know, this athlete's going to have a mini procedure, maybe be back in three or four weeks. If it sounds too good to be true, it probably is. You know, if a patient has enough pain in the adductor to require surgery and you're going to do the surgery, I think you need to be certain that you're doing the right surgery and the complete operation. My thought with doing a fractional lengthening of only the adductor is that you're destabilizing the common attachment point of the rectus. And I think a lot of these patients will have adductor injuries and then subsequently develop abdominal pain. And that's kind of what led us down that path of treating the rectus in addition to the adductor. So I don't think just doing a fractional lengthening in the adductor would yield good results reliably enough to take that chance. Cool. And what are your landmarks, or not landmarks, I guess when you're performing the fractional lengthening, how much of the tendon do you go through? Yeah. Is there a kind of general rule with that? So what I do is I'll get down to the tendon and I'll get down, all the way down to the aponeurotic layer because when you go down, the scarpa's layer, it just keeps coming and coming. It's like a multilayered kind of structure. It's almost like there are three layers of it just sitting on top of each other, kind of like three slices of cheese. And you'll get one layer off and then there'll be another one and there'll be another one, and then boom, then you're there. And what I'll do is I'll use a needle tip bovie and I'll touch the pubis and I can feel the bone, and then I'll come off the bone distally, about 8 to 10 millimeters. And then I'll use my finger and I'll palpate the medial border of the adductor longus and the lateral border. And they're very easily defined just with fingertip palpation. And then I'll take the bovie and I'll put it on coag, and I'll just start striping the superficial surface of the adductor. And you'll see some of those kind of tendon fibers, as well as the aponeurosis, will start to retract or basically separate. And then you'll get down to a muscle belly or a muscle tissue, and that's the adductor. The key is that the adductor has kind of an oblique origin to it, and it's longer, more anterior than it is posterior. So I kind of go through the longer anterior fibers and leave the mid and posterior fibers. And then I'll take those anterior fibers and roll those up and imbricate those into the rectus. So I would tell you that I probably go about maybe 4 or 5 millimeters deep at the most, maybe 3 to 4 millimeters, and a little variable in all of them. But you can see it. You'll see tendon, tendon, and then muscle, and then you're done. Any other questions out there? I think you've done a fantastic job. I really enjoyed listening to this lecture today. Yeah, I think Mark Saffron has really put together a phenomenal group here to give these lectures and sort of coordinate things. So, obviously, special thanks to Mark. He's not on the call right now. He's driving back across the country with his son. But certainly thanks, everyone, for the questions. Thanks for joining us here and giving a great lecture. And as always, again, this talk will appear next week on the AOSSM Learning Management System. And we'll see you guys next week for our final week of the Multi-Institutional Sports Fellows Lecture Series. Thank you. Thanks. Thanks very much.

sports hernia

core muscle injuries

terminology

rectus abdominis

adductor longus tendons

pubis

surgical procedure

fractional lengthening