My Approach to the Anterior Pelvis Rectus and Beyond Brian D. Busconi, MD Chief of Sports Medicine & Arthroscopy UMass Memorial Medical Center Brian.Busconi@umassmemorial.org
Disclosure • Consultant – Arthrex – Mitek
Doc, It Hurts HERE! Anterior Lateral Posterior Abdominal Medial
Hip Pain Location,Location,Location!!!! Anterior Lateral Posterior Hip Joint Greater trochanter Referred pain: spine stenosis, disk, facets Hip Flexors Iliotibial band SI joint Iliopsoas Meralgia paresthetica Hip extensors Stress fracture Gluteus Medius Tear External rotators Inguinal Disruption Hamstrings L3 nerve root Pirifomis Ishiofemoral Impingement Microinstabilty
Anterior/Medial Groin Pain Differential Diagnosis – Intra-Articular – Snapping Hip Syndrome • FAI – Infection • Labral Tear – Microinstability • Loose Bodies • Condral Injury – Nerve Entrapment • Ligamentum Teres Rupture • DJD – Bone – Medial Groin Pain • Traumatic Fracture • Adductor Strain/ Tear • Dislocation • Inguinal Hernia • Femoral neck stress fracture • Genitourinary related • Osteonecrosis • Dysplasia – Bursitis • Iliopsoas • Iliopectineal – Muscular • Quadriceps • Iliopsoas
Abdominal Pain Differential – Hernia • Core Muscle (Sports Hernia) • Inguinal – Direct vs Indirect • Femoral – Osteitis Pubis – Stress fracture – Rectus – Genitourinary conditions – Gastrointestinal conditions – Nerve entrapment
Poorly understood • Lack of specific clinical tests • Few well designed clinical trials • Co-existence of multiple pathologies • Pain is not a good localizer of original pathology • Lack of agreement of diagnostic criteria • Association with hip pathology
Core Muscle Injury or Inguinal Disruption • Aka “Gilmore’s Groin”, “ Sports Hernia”, “Peripubic Pain Syndrome”, “Athletic Pubalgia” • Exertional Chronic Inguinal or Pubic Area Pain in Athletes – EXERTIONAL ONLY – No Palpable Hernia Tear of Adductor Longus or Rectus Abdomini s Attachment • • “Chronic Symphysis Syndrome” – Patient has Abdominal, Groin and Adductor Pain • Occurrence: Males >> Females
Clinical History • Hyperextension Injury and/or Abduction – Pivoting Around Anterior Pelvis or Pubic Symphysis • Disabling Lower Abdominal Pain at Extremes of Exertion • Resolves with Cessation of Activity • Often found in Soccer or Hockey – Sports Involving Frequent Change of Direction
Mechanism of Injury
Physical Exam • Tender to Palpation over Peripubic Area, Symphysis Pubis, or Adductor Area • No Palpable Hernia • Pain with firing of Rectus (situps) and/or resisted Adduction • Must perform Full Hip Exam • Neuro Exam Normal
Core Muscle Injuery if > 3 symptoms • 1. Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint tendon; • 2. Palpable tenderness over the deep inguinal ring; • 3. Pain and/or dilation of the external ring with no obvious hernia evident; • 4. Pain at the origin of the adductor longus tendon; • 5. Dull, diffuse pain in the groin, often radiating to the perineum and inner thigh or across the midline .
Imaging • MUST Rule Out Other Causes of Pain – FAI • MRI may Show: – Rectus Tear Lysis consistent – Adductor tear with osteitis pubis – Avulsion Fracture – Symphyseal Edema – FAI – LABRAL TEAR – Hernia – May Be Normal • Bone Scan or XR may Show Concurrent Osteitis Pubis • ? Role of Herniography
Treatment • Conservative – Rest, Ice, NSAID, PT, US Guided Injection – Pt to fix anterior pevlvic tilt – Evaluate as to Pre,Mid,Post Season • Surgical Open primary pelvic repair without mesh • – Bassini, Shouldice, McVay – Minimal repair with decompression or resection of genital branch of genito-femoral nerve • Open repair with mesh • Laparoscopic repair with mesh • Adductor – Leave alone if no clinical involvement – Inject with steroid or PRP if symptomatic but nl MRI – Release if severely involved on MRI • Divide Epimyseal Fibers of Longus about 2-3cm from Pubis, leave muscle belly alone
UMASS Surgical Technique 3 Primary Goals: 1. Reinsertion of the rectus abdominus to the pubis 2. Stabilization of interface between the rectus and conjoined tendon 3. Reinforcement of the posterior wall of the inguinal canal
Iliopsoas Bursitis • Coexists with Mechanical Irritation of Tendon – Implicated in “Snapping Hip” Syndrome •Elicited by Moving from ABducted, Externally Rotated and Flexed to an ADducted, Internally Rotated and Extended Position – Very Loud “CLUNK” CAN HEAR IT DISLOCATE • MRI Shows Fluid • Ultrasound and Concomitant Injections of Anesthetic and Steroid can be Diagnostic and Therapeutic • Treatment – Anti-Inflammatories Morelli & Smith. Groin Injuries in Athletes. – Activity Modifications & Rest American Family Physician. Vol 64/8 Oct 2001 – Surgery – Consider Lengthening IP Tendon
Imaging in Snapping Hip • Plain Radiographs Tend to be Normal • Bursography – Iliopsoas Bursa Injected and Visualized under Fluoro • Dynamic ultrasound – “SEE” Snapping – Dependent on Experience of Technician • MRI and MR Arthrogram – Fluid around tendon – Intra-Articular Pathology – May show anterior labral pathology
Conservative Treatment • Conservative Treatment is Recommended for Internal and External Causes – Avoidance of Aggravating Activities – Anti-Inflammatory Medication – Physical Therapy – Local Corticosteroids – Resolution May Take 12 Months • Pathology Specific Treatment for Intra-Articular Causes – Usually Amenable to Hip Arthroscopy
Treatment of Internal Snapping Hip Arthroscopic • Iliopsoas Release – Peripipheral • NO TRACTION - USE FLUORO • Hip flexed 30 degrees and ER – Central • Traction • Capsulotomy between anterior labrum and femoral head • 3 o’clock in R hip • 50/50 RULE • Release Proximal and distal
Rectus Femoris Strain • Only 2 Joint Muscle in Quadriceps – Most commonly injured of the group – Reflected Head – most commonly involved
Rectus injuries • Rectus femoris is a unique Biarticular muscle spanning both knee and hip joints – Direct head of rectus originating at the AIIS – The reflected head originates at the acetabular ridge and anterior hip capsule
Rectus Injuries • THE KICK • Initiation of the forward swing phase – Forceful contraction of the illiospoas and quadriceps to flex the hip and extend the knee • This allows the foot to propel forward with enough force to strike the ball – These contractions are initially eccentric
Rectus Strain • Incomplete intrasubstance tear at the tendon muscle junction • Involves the reflected head • Post injury sequelae – May demonstrate anterior thigh mass – Chronic pain – Asymmetry compared the other limb(rare) • MRI T1 with gadolinium – Bull’s eye lesion in the intramuscular tendon of the indirect head
Rectus Strain Treatment • NSAIDS, rest, ice stretching/strengthening usually sufficient treatment • US Evaluation and Injection with PRP/MSC • Tend to Resolve in 4-6 weeks • Dedicated preseason hip strengthening and stretching found to decrease rectus injury during regular season
Chronic Rectus Tear Late excision of the reflected head of rectus femoris was found to reduce pain in rare cases of chronic tears. Wittstein, Am J Sports Med 2011 Delayed repair of chronic musculotendinous avulsion injury to the direct head of the rectus femoris can yield an excellent result. Straw.Br J Sports Med 2014
Anterior inferior illac spine Avulsion • Avulsion injury more common in skeletally immature • Adolescents aged 14-17 • More often occurring in males
Anterior inferior illac spine Avulsion • Result of violent contraction of the rectus femoris, usaully eccentric in nature • Can feel a “pop” • Occurrs with hip extension and knee flexion • Periosteum and fascia can limit extreme displacement
Anterior inferior illac spine Avulsion Symptoms – Sudden pop in the pelvis – Anterior hip Pain and hip flexion weakness – Antalgic gait – Must rule out neoplasm in adults that have no history of trauma
Anterior inferior illac spine Avulsion Management • Place the hip in a position of comfort • Protected weight bearing with crutches • Light stretching and weight bearing – advance as the pain resolves
Subspine Impingement • 21 year old female, collegiate soccer player • Presents with left sided groin pain – “Grinding Sensation” on FADIR – Hip flexion limited to 105 deg – Larson 2 011 by the Arthroscopy Association of North America )
Subspine Impingement • AIIS impingement – Abnormal contact stress against the distal femoral neck – Due to excessive distal and or anterior extension • Causes – Developmental – Prior AIIS avulsion – Pelvic Osteotomy
Subspine Impingement History and physical examination • Anterior/groin pain with straight hip flexion • Anterior pain with prolonged hip flexion • Limited hip flexion range of motion • Tenderness to palpation over AIIS that re- creates pain •
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