So I'm happy to introduce Craig Morrow, who I've known for quite some time, actually, since I was a fellow at Pittsburgh. Craig was actually a resident, and Craig joined Jim Bradley and Chip Burke in their practice at the University of Pittsburgh Medical Center. He's the Associate Director of the Fellowship now, working very closely with Volcker, working with the Pittsburgh Steelers, and has a great experience with the hip and the core. So tonight, Craig's gonna bless us with a talk about the hip, the core, and the pubic symphysis. So Craig, thanks for joining us, and we're glad to have you. Great, thanks, Steve. And thanks to everybody listening, and the OSSM, and Mark for organizing this, and this opportunity to talk. So feel free to put questions through to the chat, or if they're urgent, and Steve, they come up, feel free to interrupt me, I'm fine kinda making this a little bit less formal in that way. This, I kinda just had given this talk as a bit of a case presentation. So it'll follow a little bit of a case presentation flow, and then we'll get into some of the issues with the core and pubic symphysis that I wanted to talk about tonight. So let me see if I can get this to advance. There's my disclosure. So just to set the stage, we'll start with the case, and basically this is a player that we saw through the Steelers, who was a 23-year-old middle linebacker at the time. He had come to us as a mid-round draft pick. He had several years of groin pain on history as a collegiate player. He was treated at that time non-surgically with hip joint injections, pubic symphysis injections, and basically showed up to rookie camp and training camp with persistent groin pain. So had an outside opinion, was diagnosed at that time with a core muscle injury at an outside facility. So, and Steve, Mark, Latul, I welcome any input here, but I think this brings up what we see very commonly, which is what do you do with these early preseason injuries? And James Booth faced this this past year. What do you do when a guy comes in with core and groin pain early in the year? And it's a tough dilemma. We went through it in Pittsburgh here, Sidney Crosby, as many people know, just went through this surgery this year. When it happens early in the year, do you rest and try to get them through? Do you try injections? Do you do surgery? Do you do an open repair? Do you do a laparoscopic mesh repair? Do you work on the adductor? And these are some of the issues that we'll kind of touch on here tonight. But just setting the stage, I think another part of this is what do you do early in the season for the sports team physician? I bring this up, Brian Zuckerbron and I just published this paper in JAMA Surgery about management of sports hernia. And we had some pictures, which I kind of wanted to set the stage a little bit. And I think you guys have a talk about this for the fellows this week. But, and Serino, I think gave a talk about the adductors last week. But we just want to be thinking about what is this syndrome we're talking about around the hip and around the core, this groin pain syndrome. We've kind of used this term because it encompasses kind of a lot what we're gonna talk about tonight. So classically, if we look at the anatomy here, a number of different repairs have been talked about. Classic reinforcement of the posterior inguinal canal, the Bassani and Gilmore repair, adding in MUSHOAC, which is also kind of working up super pubic, or you get into the Myers repair, which are more kind of pubic based repairs, where, as you can see in these pictures, involve reinforcement of the lateral edge of the rectus. And so we'll talk a little bit more about that. But the long story short, these have been looked at pretty extensively. And the literature is supportive for you and your consultants, really any type of repair, whether it's a mesh repair, which this series talks about with return to sport and 90 plus percent, no mesh repair, 80, 90% return, adductor tenotomy, which is very commonly used in Europe, again, high return to sport rates. And then the combined approaches, which Myers series is in here from 2008 with 5,000 plus patients, again, all pretty high repair. So I think this area really in some ways gets a bad name because there's not one definitive way to do the surgery. And it seems that no matter what you do, you can get good results, but we're gonna kind of parse through some of this here tonight. The consensus statement that came out of the British Hernia Society in 2014, basically said the surgery relies on identifying pathology, releasing abnormal tension and restoring anatomy. And so there's no evidence really to support one type of operation over another. And so that brings us to kind of what this player we had done. He basically had a pelvic floor repair, adductor longus release prior to his rookie season, the classic kind of Myers type procedure. So then the player comes back, he's four to six months after the surgery, has recurrence of pain, and he's unable to continue to play. So the question is, what do you do then? So we got radiographs, which we thought was a good next step. And as you can see on this left side, his left tip, and we'll talk about this a little bit more. He has obvious signs of FAI with a low hanging AIS. He's got CAM morphology, his proximal femur. And then he's got some, you know, symphysial changes as well, kind of a mixed hip and core type of picture. At that time, an MRI was done. Really his symphysis looked okay. He had a little bit of fluid in the symphysis, some very mild erosions, but typical appearance for a professional football player. He was treated with pubic symphysis injections at that time. Tried to get back to his next training camp and really was unable to continue to perform. He tried to plant, he couldn't implant and internally rotate. He had deep pelvic pain. He was tender over his pubic symphysis. He was tender over his core, his hip hurt. He just kind of had a combined pattern, which was not letting him get back to any sort of performance. At that time, we performed a follow-up radiograph and we'll talk about this a little bit more, but you can see just from a weight bearing radiograph. At this time, he has some widening of his pubic symphysis and then a follow-up MRI, which shows again that widening, but some edema and basically an infusion of his pubic symphysis joint. And then on the right, this cleft that's classically described showing some signs of progressive changes at the aponeurosis there on the anterior part of his pelvis. So we have a player who's now has symptomatic FAI. He's got signs of pubic symphysis instability and he's already undergone a open core repair. So what do we do with him? So again, I'll kind of put this out there. We don't have to answer now. We can talk about it afterward, but really kind of what you're thinking about at this point is, and this is gonna be the crux of the discussion tonight. Do we treat him with just correction of his FAI and a labral repair? Do we do a revision open core repair? Do we do a laparoscopic core repair? Do we do a combined hip arthroscopy core repair? Do we do something to his pubic symphysis and how do these all fit together? So let's talk a little bit about the hip and core and how they function. I'm just gonna minimize this a little bit. So we know the pubic symphysis is really a fulcrum for the anterior pelvis. It provides stability through the tendinous attachment and the vectors that are generated by both the adductor compartment and the rectus abdominis layer. There's a bony, like most of the joints, we talk about a bony layer, a muscular layer that contribute to stability and imbalances in this muscle group may lead to, because of weakness, because of overuse, because of coordination may exacerbate these stresses. So classically, we talk about osteitis pubis and we've all read about this as residents and it's defined as inflammation of the pubic symphysis and surrounding muscle insertions. I really don't know that that's an accurate definition in some ways and sometimes it's described as infectious or possibly infectious. I think what we need to start to think about is instability as a cause of osteitis pubis in our athletes. So we know that this repetitive stress and microtrauma at the pubic symphysis leads to these altered biomechanics and we can get these changes that we see in the pubic bone with edema, we can see these erosive changes and we can see frank signs of symphysial instability when we see this. So I would just challenge you to reframe what you think about in terms of what osteitis pubis is and start to think about it, how the stability of the joint may be contributing to this picture that we see radiographically. So we know that players and patients that are at risk for problems around the pubic bone are those with repetitive microtrauma, American football, soccer, rugby, extreme sports. Oftentimes these players with either quote unquote sports hernia or groin pain syndrome or problems with their pubic symphysis will present with groin or pubic symphysis pain. It can be ill-defined, it may increase with weight bearing or performing their sports, they may get some radiation into their perineum which is actually quite common with some of these groin pain syndromes where the patient will get radiation into the scrotum, will get radiation into the perineum and they may describe some mechanical symptoms at the symphysis with grinding and instability sensation at the symphysis. So classically if we're talking about true pubic symphysis problems, the player will oftentimes have tenderness over the symphysis, they'll have compensatory tenderness over the adductor origins, they'll have pain with resisted adduction and resisted sit up and adduction. And the challenging part is that oftentimes they'll have overlap with hip impingement symptoms with reproduction of their symptoms with deep hip flexion positions, fader and favor position and any of these provocative positions around the hip can oftentimes exacerbate these symptoms. So we'll talk a little bit more later about the role for local anesthetic injections and how we use them to sort through what's coming from the pubic symphysis, the core and the hip joint. So I mentioned this earlier, a bit about the role for pelvic weight bearing radiographs. So our standard weight bearing series, our standard x-ray series will include AP pelvis and some sort of lateral view, I use a done lateral view of the hip. If I'm concerned about some sort of instability pattern with the symphysis, we'll also utilize flamingo views, which is a single leg weight bearing view of the pelvis. And you can see this x-ray on the left is just with weight bearing changes. The one on the right is with a flamingo view where one leg is on a step and the other leg is just hanging. And you'll see some changes through the symphysis in certain patients. A group out of Duke looked at this several years ago in JB Jess and published that patients can actually have a normal amount of motion at the symphysis up to two millimeters for physiologic motion, one way or the other, which does increase with pregnancy. But when you start seeing more than that, that seems to be a kind of a number that threshold for some abnormal motion across the symphysis. And then when we start getting into MRI, and we'll talk about this a little bit later, these findings are really quite common. And so we need to really kind of consider them in the clinical settings, particularly like the case we talked about. But the very common settings you'll see around the pubic symphysis, the common findings you'll find are the bone marrow edema, which we see on that bottom MRI, subchondral cystic changes, symphysial widening, which we saw in that previous MRI, and effusion, and then pubic plate pathology, which has been described. And I think Serino probably talked about that in his talk. But that classically, particularly out of Philadelphia, Steve, you might be able to comment about that later, is a very common sign that Adam Zoga and Bill Myers will talk about as kind of the lesion for some of the sports hernia, core muscle injuries that they see. But these changes are, I guess, kind of bigger picture changes that just you wanna be concerned that there may be something going on at the symphysis or at the core when you see these changes. So what about these combined injury patterns? So that's kind of the crux of the talk here tonight. So we did this paper a few years back with Brian Kelly. It was published in Sports Health, looking at why do we get pain when patients come in with hip problems, at the pubic bone, at the SI joint, and other areas. And really the idea is that when you have FAI and you're putting increased stresses across this joint, if the hip can't get into the position that it wants to get into for the athletic competition, that athlete's gonna find a way to get their body into that position. And oftentimes that leads to some compensatory mechanical changes around the pelvis. And so that can be at the pubic symphysis, like we're talking about tonight. Sometimes it's the SI joints that become symptomatic. Sometimes it's the lumbar spine. But I think this is the most important kind of principle that we're thinking about here is these compensatory problems that the primary hip disorder can cause. And there's a lot of early schematics that Patrick Birmingham and Brian Kelly put together a number of years ago, which bring out this idea that when there is a mechanical problem in the hip joint, such as in this hip with CAM-type impingement, and again, this schematic is maybe a bit exaggerated, but it shows you the effect of the hip joint on the hemipelvis. And so I think that that's really important to consider is when your patients come in with problems around the core, problems around the back, we need to be thinking about how the effect of their hip joint mechanics, sometimes it's bony, sometimes it's more of a soft tissue contracture, or even an instability, and Mark may wanna comment on this later, an instability around the hip joint, which leads to these compensatory problems around both the core and the associated joints of the pelvis. So this was done in 2012, a follow-up study from that schematic that Birmingham and Brian basically did a cadaveric model where they placed some wooden buttons to replicate a CAM-type impingement scenario. And they saw that with the CAM lesion that the symphysis saw 35% more motion than those without the CAM lesion that was created, albeit in a cadaveric model, but it kind of strikes that point again. So what do we do in these scenarios? So again, like most of the initial treatment for hip and core problems, non-surgical management really is our go-to. And so if we have, whether it's the core or the combined core-hip, it's engaging your physical therapist, it's identifying deficiencies, it's resolving these imbalances around the hip and pelvic stabilizers. We're typically not advocating for aggressive range of motion with these, but it's more of a stability type of rehab program. And then it's an attempt at gradual return to sport-specific activities. So getting back to our first discussion earlier in the year when somebody comes in with some of these symptoms in training camp, it can be a difficult decision about which direction, how aggressive to be with them. What's the role for injections, including biologics? Well, I tried to do some literature search for biologics around the hip and core, around the core and pubic symphysis in the Journal of Canadian Chiropractic Association was really all I found, which was a multidisciplinary approach to PRP in a hockey player. So really there's not much out there. We use it, but I know it's controversial. We'll use it in the adductor. I've even used it in the pubic symphysis for chronic pain, like we do in other arthritic joints, but really it's a limited, I have a pretty limited experience around the core with it for chronic problems. I think the main point of the kind of multidisciplinary program is that you really need to engage early your athletic trainer, your general surgeon, your physical therapist to make sure you're all on the same page with these combined patterns. Certainly the general surgeons that we work with are evaluating the patients and most importantly are kind of on the same page with the workup and management of these players. And I think when you're going out into practice, you wanna find a general surgeon who is interested in this pathology. For them, this surgery is very straightforward in terms of the technical aspects of it. You wanna find someone who is interested in seeing these people, who has an athletic kind of mindset for return to play. And it's not just your bread and butter general surgeon who's doing hernia work and doesn't care about taking care of athletes. So we involve our general surgeon very early when we have these combined hip and core problems, just to get a combined approach, have a true good exam for direct and indirect hernias, as well as to have them involved for the surgical decision-making. So what's the literature say? So when we start talking about pubic symphysis, there's really, besides the sports hernia literature, I talked about earlier, the core muscle repair and kind of mesh, non-mesh literature. The only real literature out there for pubic symphysis instability comes out of a lot of the soccer and rugby centers around the world, frankly, from Australia, New Zealand, Brazil. This paper from AJ Assentment 2000, the group looked at seven rugby players with pubic instability who had failed non-surgical care. And they were treated at that time with ORF, with bone grafting and compression plating. And they all returned to play with plate across their symphysis. This group looked at 23 athletes who had failed non-surgical care as well. And they treated them with an open curatage of their pubic symphysis for recalcitrant, quote unquote, osteitis pubis. And these athletes had improvement as well. Group out of Brazil looked at 30 professional soccer players and they treated their group with a symptomatic symphysis with resection of the symphysis and adductor tenotomy and got their players back by 16 weeks. Ben Dome and Dean Matsuda have a group that they published and they published a couple of papers on this approach actually, looking at a kind of endoscopic approach to osteitis pubis generally when associated with FAI. And their approach, as you can see from the pictures on the right, involves more of an endoscopic approach to the symphysis with resection. And initially, I think I have the next paper. Yeah, initially they didn't have any attention to the soft tissues adjacent, and then published a subsequent follow-up technique where they reattached the prepubic aponeurosis with the repair as well. So many different approaches, some resections, some fusions, some soft tissue, some bony for management of the symphysis when it's involved in these combined patterns. I found this to be an interesting paper out of China that used a, this was more in the trauma scenario, but they used a tight rope across the symphysis to stabilize it in 26 patients and and compared them to percutaneous screws and found pretty similar outcomes. So there's a lot of interest out there, at least in a limited way, for different ways of either stabilizing or bringing pain down in the symphysis in these scenarios. So the question is, and kind of one of the one of the take-home points here tonight, is when we have these combined injury patterns or combined pain patterns around the hip and core, when do we operate on the hip? When do we operate on the core? What kind of surgery do we do? And how do we work this all up? So I'm going to credit Chris Larson here because he did a very eloquent job at the Physician Society last year giving a talk that I've taken some points from because it's a tough problem. It's a tough problem in the NFL and the question is, when do we manage the hip? How do we manage the core? And how do we work these up? So dilemma one that Chris outlined, which I think was pretty clearly stated here. So when we get these MRIs, 50% of our players will have some sort of labral abnormality regardless of symptoms. 90% will have some imaging findings of FAI regardless of symptoms. And at least a third will have signs of athletic pubalgia, core muscle injury, regardless of symptoms. So how do we confirm? How do we decide where we need to put our energy and our management? Well it really again comes back to history, physical exam, diagnostic injections. And since most of these players are positive in one way or the other, our decision making really is not based on MRI imaging. X-rays I think are probably more important in some ways than MRI for decision making around the hip and core. So then the second part of this is, if you've got a player who you know we're talking about time frames earlier, we know that after a simple core muscle surgery players can get back usually by three months, sometimes faster to play. If you add in a hip arthroscopy though, it's a longer recovery. It's five to seven months. It's very successful as well, maybe not so much for Lyman, but generally it's a successful surgery but it takes longer. So is there the question, if we have these findings, should we be doing both and who should we be doing both surgeries for? Could fixing one, either the hip or core, lead to resolution the symptoms of the other? So Chris Larson has published on this. He was one of the earlier reports, 2011 in arthroscopy, published on 37 hips with both symptomatic pubalgia and symptomatic intra-articular pathology. And basically concurrent or eventual surgical treatment in a staged fashion of both areas led to improved post-operative outcome scores in return to full activity and sporting in 89% of those patients. So this was one of the earlier papers kind of for a push for treating when there's symptoms and findings in both areas for treating both sides, both the hip and the core. Brian Kelly had a paper as well with Bill Myers and Summer and Ashish looking at the same type of patient population with FAI and core findings, athletic pubalgia findings. And basically if they just had core surgery alone and they had underlying symptomatic FAI, they were not able to return to competition and patients with combined surgery returned at a better rate to all those patients. So this was again support for doing surgery in both areas when indicated. I thought this was an interesting paper that came out last year out of Japan where the group looked at competitive soccer players who were undergoing arthroscopic management of FAI and they had documented how much bone marrow edema these players had in their pubic bones prior to treatment of their hip and that no surgery was done on their core or their pubic symphysis. And basically with just treating their FAI, follow-up MRI demonstrated resolution in all cases of the bone marrow edema around the core. So the question is maybe getting back to the mechanics that we talked about earlier, if we correct the underlying mechanical problem in the hip joint, does this core and pubic problem resolve itself? So what do we do when, again kind of getting back to this, when clinical imaging suggests both the hip and the core? And my approach basically is to use injections to help guide us. Certainly physical exam history, as I mentioned, it helps us to get most of the story, but injection can be really helpful. So if you have, we have a player who has, you know, these what seemingly or maybe combined type of symptoms around both the hip and core and we do a local anesthetic injection into the hip joint, I would typically just, and they get complete relief of their symptoms, I'll typically just treat their hip because this pain around the core may be just a radiating pain or we can expect it to resolve when the hip's treated because of the response to the local anesthetic injection. If they really have no response with the hip joint injection and they have the same kind of continued anterior pelvic pain, then maybe just core surgery is indicated. So you may be dealing with just a core problem. If the harder group is when they have a kind of relief of their hip symptoms, but they don't get relief of their adductor and lower abdominal pain. So that may be suggestive of a combined problem that doing the combined procedure may be indicated for. And that's the more difficult scenario to tease out, but I think these local anesthetic, I use primarily in these scenarios, a local anesthetic injection for diagnosis. I don't typically add in cortisone in a lot of these cases, but if you're thinking about using for the therapeutic effect of the cortisone, I think a single cortisone injection is fine to use as well. But going back from a diagnostic standpoint, I think that you really have to rely on the local anesthetic effect rather than having them come back a week later and them saying, yeah, I felt better. And you're not sure whether that's local anesthetic or just the global spillover of the cortisone effect. So in general, these patients can be delayed until, if they're able to compete, you're able to delay them till after the season. If they're not able to compete, then maybe you need to think about it more of an earlier in the season or mid-season type of timing. The other difficult part is if you have pain with physical exam that does not recreate their symptoms, i.e. you move their hip around and they say, yeah, you know what, that pinches, but that's not really what is driving me to limit my play or cause me pain, then you really need to think about is this, do we really need, usually for me, that's when their hip, when you can drive their hip into a deep flexion position, but that may not be what they're complaining of. And that's a little bit harder or vice versa. If you push on their pubic bone, they may say, you know what, that hurts. But if you really get to the root of it, that's not where their pain is that's limiting their play or causing them symptoms that they're coming to you for. So then the last group of these combined that we just need to think about, if patients that have mild symptoms and particularly if they have mild radiographic findings, but it's not affecting their performance, I would tell you that these athletes should be treated generally without surgery. And so I will kind of frame it as, is this kind of limiting you or is this just a little background noise that we can work with the trainers to try to manage through the season? Generally, no surgery is better for those patients. They will want to know, well, if I don't do something, is my core going to lead to long-term problems? And the answer is, there's really no supporting evidence that there's long-term consequences for leaving any of these core pubic symphysis problems left untreated. That being said, we do know that large cam deformities, particularly in our younger athletes that are left untreated can lead to further cartilage disease, delamination, degenerative change. So that's a group that you're probably going to want to be a little more aggressive on is someone who presents with a large cam deformity early in their teens or in their 20s. So what do we do in this case, just to bring it full circle, because I think this is an interesting case that shows some of these features. And in this case, we did treat him with a combined hip and pubic symphysis surgery, which I'll talk about a little bit more. And so let me go through the pathology. And basically, we did an arthroscopy of his hip first, which we can kind of see the typical superior labral tear. As we saw in his initial radiographs, he had a large subspine lesion. So we fully exposed that and decompressed the subspine. And this is looking from lateral to medial now. And just really want to extend up. If you're going to do subspine work, and I think this is a talk for another day, but I would encourage you to really get a full exposure, both directly and with fluoroscopy of where you're working in that region. We did a labral repair, in this case, simple stitches, because he had a quite small labrum. He had a large erosive kind of trough in his femur from cam impingement, so kind of classic cam findings. Cam femoroplasty was performed. And then we did a technique, which we wrote up a couple years ago in arthroscopy, where we basically, I don't know if Justin Arner's on the call, but we stabilized his pubic symphysis. Justin's a fellow out in Vail right now. And so Justin did great work putting these videos together a few years ago when he was resident with us. So basically what we do in these cases, if we want to address the pubic symphysis, I work together with our general surgeon, and we expose through a extraperitoneal approach, the pubic symphysis. And you really can, you can expose the symphysis this way with a general surgeon who's comfortable with laparoscopic techniques quite easily. They work in this area all the time doing hernia repairs. The reason this came to us was they were plating unstable pelvises at our trauma center through this approach. So we said, if they can put a plate and screws in this way, we can certainly put in suture anchors. So we used fluoroscopy to localize where we are on the symphysis. And basically we use kind of a quote unquote internal brace across the symphysis to stabilize it. So there's a little video here, you know, we use fluoro, we're on just lateral to the symphysis there in the pubic bone, placing an anchor with tape sutures. And one side's done. And then we use fluoro to kind of confirm where we are on the other side of the symphysis. And again, we're doing a kind of a 90-90 construct. And then with some compression across the symphysis, we're providing some stability. We're not fusing like the rugby players that we saw there with plates and screws, but we're giving some stability to the capsular ligaments into the pubic symphysis with our brace technique here. We also added in kind of a mesh reinforcement. I think that's plus minus. But again, this is a technique used by some of the general surgeons for some of these core muscle repairs. Here's post-operative radiographs, which show that we had decompressed the subskine and the CAM region, and the pubic symphysis had widening, had resolved to some degree. So he had a successful outcome. Primarily his issue was his perineal symptoms, which I do think comes from the pubic symphysis. These patients will, you know, you know, classically describe this pain radiating down into the perineum. And for him, that was the most satisfying part, that that resolved. His anterior hip pain resolved as well, just correcting his FAI. He got back to OTAs and training camp, and had a successful return with this approach. So I think my take-home points here are to be comprehensive with your treatment of the hip and core. Use a multidisciplinary team. Get to know your general surgeons locally who are interested in helping to manage these problems with you. Get your physical therapists involved. Get your PM&R doc or whoever can do injections for you and give you that feedback. You know, for me, it's helpful to have somebody in the office doing that, because I think that gives you real-time feedback, and you can re-examine the hip after the injections that we talked about. Number two point is don't over-treat or treat asymptomatic imaging findings, because these are everywhere. So you really need to go back to your basics of physical exam, of history, of injection response, in addition to the imaging findings that we see in a lot of these players. And then again, kind of last point, these imaging findings are quite common, and we just need to be aware of them and not over-treat them, either in the hip or the core, when we see them. Yeah, so that's it, and that's my take on the hip and core in a nutshell, and I'm gonna... I think we can open it up now, Steve or Mark, if somebody has access to the questions. Great, thank you so much. Let me see if we got any questions on the chat line. Nothing there. Craig, can you just do me a favor and just talk about some of your physical exam techniques that you really kind of go to, to help differentiate between the core and between the hip, and which ones cross, you know, paths, and which ones that you feel like you can really localize to. And while you're doing that, I'll go ahead and unmute some of the faculty here. Yeah, so I think that the history is really important, as we talked about, and then we move into the exam. So, you know, I don't use that, you know, the list of a million tests around the hip that I think, you know, Mark probably could teach us about instability, and everyone kind of has their, you know, their specific tests they like. I just generally am trying to understand, is this an irritable hip joint? And usually that involves a deep flexion maneuver, fader, favor position, kind of taking the hip through the arc of motion, I, you know, so I really first am trying to understand how symptomatic is their hip, is their hip joint, and then I'll move over to the core, and I'll start with palpation. I think palpation is really important, and I'll do it bilaterally, because it's not a comfortable area. So if you just start jamming on somebody's pubic bone, they're probably gonna be like, oh yeah, that doesn't feel good, but you need to kind of compare it to the other side. Sometimes the other side is symptomatic as well, but I'll really use manual palpation of the lateral, you know, of the of the inguinal canal, extending onto the pubic bone, up onto the adductor, on the lateral border of the rectus abdominis, and then provocatively I'll have them do, you know, resisted adduction with their hips in more of an extension position on the bed, then I'll have them flex their hips and knees, and do a resisted adduction test. I'll have them do a sit-up while they're doing that, and have them pull their legs together, just to try to, just to try to provoke the core. I'll have them do some single leg instability type testing sometimes, to see if that brings it out, but I really rely on more on the resisted tests while I'm palpating their core and pubic symphysis. So this is, can you hear me, Craig? Yeah, we can hear you, Mark. Okay, so from Alex Brown, thank you for the talk. Is there a role for adductor lengthening with pubic symphysis stabilization, and then does vertical instability equate with widening of the pubic symphysis? And lastly, does the internal brace only prevent widening? So first question is, is there a role for adductor lengthening with pubic symphysis stabilization? Yeah, I think there, I think there's a role for adductor lengthening across the spectrum of groin pain syndromes, core muscle injury, pubalgia, however you want to frame it. I think you really want to know, is the adductor involved? And so I think, you know, I don't think it should be a one-stop operation for all players. If they are having no adductor symptoms, and it's primarily inguinal canal pain, and they, you know, have a weakening of their posterior canal, usually those patients, you know, the general surgeons will tell you they can be treated more with a proximal-based surgery. However, if the, if the player is having symptoms, adductor, quite a bit of adductor symptoms, or tight, you know, tenderness at the aponeurosis there on the pubic bone, and the vector of an overly tight adductor and a weak abdominal wall could be corrected by lengthening that adductor. I think that's where the adductor comes in. I mean, Europeans are, in general, tend to be pretty aggressive with using the adductor lengthening. So I think it can be done with a, with a pubic stimulus stabilization type procedure as well, if the patient has adductor symptoms. This guy, our player here, kind of had symptoms all over the map, and we were just kind of starting to work through some of these symptoms when we, when we did that surgery. And I probably wouldn't use a mesh on him now. We, plus or minus whether we would use an adductor lengthening. I can't remember exactly how symptomatic he was through his adductors. But yes, I think that, I think, so I think you just need to, to consider where, where the symptoms are coming from. Second question there, Mark, was about controlling the symphysis. Vertical instability equate with widening of the pubic symphysis? I don't know. I mean, long story short is, I think for me, I'm just, I'm trying to understand still the symphysis and how, how it, for me, I think a lot of these radiographic signs are just a sign to me that something's going on. I don't know that we have gotten, we certainly haven't gotten where we are with like the shoulder with an anterior instability, posterior instability combined. To me, it's a lot of these radiographic features are just signs that there is some disruption there. There's some instability at the symphysis. I don't know that, you know, we should be stabilizing all these. This is kind of a novel approach we did in this guy because he had failed kind of classic sports hernia surgery and had, was going back for a second time around and we wanted to give him some stability there. So I, you know, I put it out there to anyone going into hip help to explore this area because I think it, these are questions we need to answer is, you know, is vertical instability the problem? Is it when it widens, that's the problem? I don't know, but I think they're all part of the same kind of spectrum of disease. I mean, I, the way I look at this is that the, you know, when they look at the biopsies of the pubic symphysis or the pubis itself next to the symphysis is that there's a bony resorption. So I think the widening is a function of the stresses on that area. So I think the instability and or the, the, at which, you know, I, you do see if you look for the stork view, you do see it, but even if you don't have the, a lot of vertical instability, I think that those stresses, compressive stresses across the pubic symphysis is leading to some bony resorption, kind of like a, for lack of a better term, very much analogous to a weightlifter shoulder, right? And so I think that it's some of those forces there. The problem is that I think, you know, I worry that if you cure a Taj and you make it more unstable, you certainly won't get the compression, but you'll make it more unstable. But I, the plating has always concerned me because when you really look back at the literature at, at the plating for other problems, like an unstable pubic symphysis after, after pregnancy, that sort of thing, you'll see the literature talks about down the road, they develop SI joint problems. There's got to be motion there for a reason. And if you're not getting the motion there, you're making it up somewhere else. And if you, and so the only other place you're making it up is going to be at the SI joint. So I think when you fuse the SI joint, I worry about the front. I think you fuse the front, I worry about, you worry about the SI joint, that if you don't get that mobility there, you're gonna get the pain. So, you know, it's kind of, you know. I mean, I thought that the internal brace was interesting because the internal brace will give you some motion, kind of like a tightrope. And so maybe it doesn't over-constrain it, and maybe you don't get that as much. I thought that was very, that's a very novel technique, but. Yeah, that was our thinking as well. I mean, we wanted to provide some stability, but, you know, you run the risk of either, yeah, over-constraint of a joint that's already showing some degenerative change, or like you said, fusing it is not what you want. We need some motion there. So we're hoping that that technique, which we probably used in, you know, half a dozen, no, maybe not even half a dozen, probably half a dozen athletes and another four or five women post-pregnancy who had just chronic pain and instability at the symphysis with, over the years, some, you know, I think pretty good results. We haven't published it, but we've been happy with the results in that group of patients as well. I think you should publish it. It'd be great. Greg, here's another question from Jonathan Hughes. It says, in an athlete at the beginning of a season that has choropathology, if you start with non-op and they continue to be symptomatic, when do you decide to operate versus continue non-op considering length of season? Yeah, I mean, I think that's why I brought that up. I was, I had given that talk and I think James Woos was on the panel. And so I put that to him because they dealt with that last year. But in Cleveland, I think it's a really tough problem. I mean, you know, a lot of these players with appropriate management during the season, depending how severe the symptoms are, can quote unquote kind of get through the season. So you've got to think about, you know, the NFL season's a long season. So if you've got someone showing up at day one, maybe you're better off, you know, fixing them and you get them back by week three or week four, and then they can get through the year versus if they start to become symptomatic, you know, one quarter of the way through the year and then they try and, you know, that's where the agent, the player, the general manager all comes in. There's certainly a role for it, but like anything, I think it just depends on the severity of the symptoms, how much it's interfering with their performance, and then the timing as well. I don't know if Steve or Latul or Mark, if you guys have other thoughts about how you counsel the player or the agent with those. Baker Mayfield said that that was not the appropriate way to manage it. Yeah. Yeah, I agree, Craig. That was a great talk. I think you kind of pointed out the correct timeframe and things to think about, you know, certainly if it starts early in the season, I think you're spot on with that. I try to manage, I mean, I don't think there's any negative thing to waiting on the sport, you know, if they can play. There's no negative to waiting out this, you know, till the end of the season because they're going to miss, you know, several weeks because of it. But if it's, you know, my approach to the FAI, you know, again, you want to make sure it's based on the examination, as you said. I mean, there was a pro tennis player that I took care of that had clear CAM FAI, had some os acetabuli, things like that. And it clearly looked like FAI, but he had no symptoms in his joint. All his symptoms were related to a sports hernia and or core muscle injury, whatever. And then ended up sending him to Bill Myers where he got the core muscle surgery, was back playing in three months. Within the year, he had broken the top 100 for the first time. He's now eight years or so down the road from that. And it continues to be on the pro tour, never having anything done for his hip. So again, treat the symptom, not the x-ray as kind of Craig was talking about. My approach, because I don't have a guy here directly that, because I don't have a guy here directly that does a sports hernia surgery. My general approach has been treating, if they have both hip and core issue, I treat the hip. And a lot of the rehab post-op for the hip, especially early on is very much similar to the core rehab you're gonna do for your non-operative core muscle injury. And if three months into the rehab, they're not feeling significantly better from the core, then we get the core surgery at that time. And then by that six month mark, they'll be ready from both perspectives. So that's the approach I have, because I agree with you, Craig, I think that some of the core muscle injury comes from the motion at the pubic symphysis or the body trying to stabilize that motion. And they have that excessive motion because of the core muscle, because of the FAI. So that's kind of the scoop. Steve, you can't unmute, you can't unmute Winston? No, I'm trying. As much as I'd like to leave him muted, I'm trying to unmute him and it's just not working. Winston, unmute yourself. Come on now, there you go. See, he's doing it himself. He's totally- I have no power, I have no control. So Craig, I have a question for you. One of the issue, obviously we're close to Bill, I operate probably right around the corner from him, you know, is that, and we have baseball players and I think that all sports are different, you know, hockey versus football versus baseball or tennis. You know, you send somebody to Bill Myers and he says, I'll have him back to you in three weeks. Now there's almost nothing in baseball that can happen that you can get somebody back in less than three weeks. What's your experience with returning after core surgery and the timeframe, you know, we've had, we have a tight end here that got back in like two and a half, three weeks, but do you think that's more the unusual or you think that's the norm? Yeah, I think, I mean, I think that's the exception. I mean, there are certainly different degrees of dissection and, you know, physiologic reserve that some of these guys have and how quickly they bounce back, but our experience has generally been, and we tend to frame it the other way because of that, that it takes somewhere between six and 12 weeks, even though it's these athletes. And I think it just gets confusing to them and they may be released to full participation at four weeks or six weeks, but they're just not back in football shape and ready to perform at that level at four to six weeks. They're ready to start, you know, and our coach knows this and our gym knows this, and it usually takes them that kind of six to 12 weeks even to get back from core muscle surgery. And so we generally try to get them through the year or do them very early in the year if somebody shows up with it, or if they're so symptomatic as we talked about, or we try to get them through the year and just do it in January or usually in February in our case. Well, you know, and it's funny because Mushewek gets them back at like 10 days, but, you know, to me, I think that's a little deceiving because I think Mushewek cuts the genitofemoral nerve when she does the surgery. So if you're numb, you can't feel the pain, but I don't know that her surgical intervention has healed, quote, unquote. But I find that an interesting challenge. I agree, you know, you get athletes all the time saying, I was told I'll be back in two, three weeks. And I'm like, not what I've seen here, but Winston, you guys have a guy, right? Well, here, my comment is this, Craig, awesome talk. I really enjoyed that case. Thanks, Winston. But, you know, finding a sports hernia guy in your community is like, I mean, it's not that easy. I had a guy, we had a guy here, John Hanks, who was doing sports hernia surgeries EVA for a while and was doing an awesome job. And when he retired, there's a void left here. The general surgeon sort of fell into that void. He really has no interest in athletes. He is a hernia surgeon. He kind of thinks sports hernia is a fake diagnosis. He has a hard time figuring out a bill for it. And so a lot of times, if it's a high school athlete, he doesn't really know how to go through insurance. And that's what they didn't actually talk about. Some of these surgeries aren't necessarily, they don't really fall under the CPT code that's billable by an insurance company. I've had some trouble getting them authorized. And so, honestly, I've been sending them up to Brian Busconi up in Boston from Charlottesville, which seems kind of silly to me, but he's been really easy as far as getting them up there. But as Dr. Saverin's point, I always start with the hip joint, just like Craig was saying, that I think pelvic instability is a hallmark of FAI and of hip joint instability. And so I certainly try to make sure the hip joint's not driving this symptomatology. Like you said, it's nice to be able to get an athlete back three or four weeks after a sports hernia type surgery, whereas a hip surgery takes four or five months, if, you know, at best, but sometimes it's not always that easy. And so I certainly try to tease out the hip joint as being part of the issue here. But I wish I had a guy, if you know a guy, I'm looking for a guy. You had a guy, he was good. He was great, but he retired. Like, it's too bad. He went over to Germany and learned that German repair and he was doing an awesome job for athletes. But, you know, it's interesting that you make that very, you know, it's a very interesting thing. There's nobody at Stanford who does sports hernia. We have some hernia people. Every time I send them a hernia, they say, oh, he's got osteitis pubis or something like that. And I'm like, not, no, they don't, because they had an, we gave them an injection of the pubic symphysis and showed it didn't relieve any of their pain. You know, I mean, you're right. They don't always agree that there's a, that sports hernia is an entity, if you will. And it is hard to find somebody around that does it. And then sometimes you'll find people around who do it all too often and it becomes a big marketing type of thing. So finding the- Not in Philadelphia. Yuki, huh? Not in Philadelphia. Yeah, I found everybody who goes to Philadelphia typically has some type of surgery, some type of complicated surgery, so. When they go, no, no, in Philadelphia, they don't get just the sports hernia surgery. They get a scope too, hip scope. Yeah, yeah, one-stop shop. Yeah. Sorry, Will, I was trying to unmute you. We're having trouble unmuting you, I'm sorry. I just did it. Oh, okay. So ask your question. Yes, thank you. Excellent talk. I, being sort of a, you know, community hip guy, if there's such a thing, yeah, I think I'm pretty solid on FAI, but, you know, those patients that either continue to have sort of groinish anterior pain or they present with multiple pain, trying to figure out clinically what's going on, whether it's, you know, iliopsoas or adductor or pubic symphysis type pain. I get all the kind of mechanics of that, but teasing it out clinically, I think, can be challenging. And you alluded to that. I guess my question, well, amongst many, is how often is the MRI positive at the synthesis when there's actually something you're concerned about at the synthesis? Well, the real question should be, how often is it positive in the synthesis when you're not concerned about the synthesis? Yeah, yeah, I suppose that too, yeah. Yeah. I mean, the pattern that for me is, you know, when they have unilateral pubic bone edema and they have, you know, what Adam Zoga has described as that cleft, I think those findings are really reproducible where you get that aponeurosis kind of peeling away. And they have, particularly if they've got unilateral pain and they've got, you know, a pubic bone that's kind of lighting up and they hurt there with palpation. For me, those are the ones that the core is involved. Then the question becomes, well, can you just treat the hip and that'll go away? Right. Like Mark, you're describing and then reassessing. And I certainly think that there's a role for that. I mean, I'm not advocating every person with pubic bone edema needs a sports hernia surgery as well. I think we, you know, we don't have great algorithms for it. I think this brings, for me, more questions sometimes. And sometimes the professional athlete, as I showed in some of the slides, you know, you may want to do the less is more approach. And so if we have, if I have a worker's comp, you know, labor her who wants to take one time off of work and has got symptoms in both areas, you know, then maybe we'll just do all at once to just try to take care of it and get him back and minimize the potential that he's going to need another surgery six months from now. So I think that the questions are good ones. I don't have a clear cut. This one I would operate on the core, this one I wouldn't. But that getting back that kind of pubic bone edema with the cleft that Zoga has described in the setting of FAI, I think is probably for me, the kind of classic combined pattern. Can I ask a question of the panel? So there's out there, you know, people say don't give PRP for sports hernia because there's the risk of HO. Has anybody seen HO? With, I've not seen it, so, but I don't give a lot of PRP, but for that, but has anybody on this call seen HO developed from a PRP injection for sports hernia? So I received an email, I think from Dr. Myers three or four years ago. It was like a desperation type email saying, don't do PRP for adductor injuries. I haven't done one since I got that email. Honestly, I haven't seen it there personally, but it was pretty resounding email that I got. So I hadn't done it in the past very much either. I think a lot of us have gotten that email. I don't know that I've ever seen it, so. I haven't seen it, but I've seen Bill Myers' slide where he shows that ball of HO that he's taken out. But I mean, this is like a cross state, you know, battle of the titans between Jim Bradley and Bill Myers about the role of PRP in the adductor. And I think they're kind of going, I don't know, I see it from the inside. I mean, Bradley is a big advocate, our Steelers that, but this is typically not the case. Bradley is a big advocate, our Steelers that, but this is typically with acute adductor strains. He's a big advocate for using it in the adductor, particularly the myotenitus strains, but we'll do it, you know, at the core with, and claims that he's never seen it in his experience of doing it over the years. I haven't really seen it clinically, but yeah, we're definitely in the mix of it. But at the same point, I've seen Bill give like 30 cc's of Marcane into like an adductor too. So it's, you know, obviously there's varied treatments. Now, Craig, do you have like Jeff Towers who does like, do you have a core protocol for scanning? I would imagine at like Cleveland Clinic, at UVA, at Stanford, I mean, does everybody have like some core protocol that they can, that their musculoskeletal radiologists go by? Yeah, I think that's a great question, Steve. We do, and so that's when ordering a hip or a pelvic MRI, I'll order it based on kind of what I, what information I think will be most helpful. So if it's just a standard, you know, hip FAI problem, I'll order a, you know, a non-arthrogram unilateral hip, which will just get the hip. And we'll get usually one sequence through the whole pelvis. But if I'm concerned about the core, I'll put it, we still label it as a sports hernia series. And we've been fortunate that Jeff Towers, as you know, Steve, our radiologist comes to the combine with us and sits with Adam Zoga in our room. And the two of them for years have been kind of going through these core MRI sequences. And so we basically have taken some of the sequences that they do in FinSera and incorporated those. So yeah, we wanna look, you know, basically a sagittal through the midline that can see that aponeurotic cleft. You wanna have, you know, axial and coronal basically through there. But there are some kind of oblique views that they'll do through the midline. I'd be interested to see what the other faculty, if you have specific oblique views through the pelvis to look at that. We do. We actually use essentially a mild variation of Zogas. And I've had a couple of patients, a couple of athletes that had regular MRs of the pelvis that were read as normal. And partly, I don't know if it's so much the angle or so much if it was a thicker cut MR, but because it was both of those were issues, but we picked it up on, you know, our so-called sports hernia protocol. So we do have a separate protocol that we do get when we suspect it. Winston, you guys have a separate protocol? Yeah, we have a quote sports hernia protocol as well, but exactly those oblique slices, like we've heard that, you know, that cleft side, the aponeurotic, you know, junction between the rectus and the adductor. So we've got a great, in this K group, we can pick it up pretty well. It's crazy how often you don't see much until it has classic symptoms, which makes it kind of frustrating, so. Yeah. You're back in Cleveland, Atul. Yeah, you know, yeah, we do have a protocol, MR protocol. I know our sports hernia general surgery, general surgeon who's actually really good. He does some PRP and back to that question, we don't see any HO in our athletes. And I know besides the MRI protocol, he also gets dynamic ultrasounds in all those patients if he's really concerned about it. Cool. Yeah, I think that's a great point. We've started to try to utilize ultrasound as well with our PM&R doc in these workups. Again, I don't know the sensitivity, specificity, but it's kind of fun to see. Cool. Got it all covered, got it all figured out. Yes. All right. Steve, you gonna take us home? You're on mute, Steve. We have lost Steve. You're on mute still. Sorry, my internet was kind of acting funky for a second. So Craig, I appreciate you hopping on board. I'm sure everybody learned a ton from this. Look forward to extending the hip for the rest of the week. I think Winston, you're bringing it home tomorrow. Yeah, I got the labor on my, much, yeah, that's much about my alley. Good. So thanks for everybody. This will be posted to the AOSSM learning management system next week, and we look forward to seeing everybody tomorrow. Awesome, guys. Thanks, Steve. Thanks, Steve. Thanks, Craig. Winston, thank you. Good job, Craig. Again, Mark, thanks, Craig. See you guys. See you guys. Steve, can you end the meeting? Where'd he go?

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