Curbside Consult

Sports Hernias, Adductor Injuries, and Hip Problems Are Linked

Bert R. Mandelbaum, MD


February 23, 2017

A Challenging Diagnosis

Diagnosis can be challenging because it's easy to focus on only one body part. There is no message that ever pops up to say, "You missed the other two." So you have to be very alert and systematic in taking the history. Did it happen in a particular day? Was there a pop? Was it sudden and acute or did it evolve in its intensity?

In my 27 years of practicing sports medicine, I have learned that it's hard for a single clinician to make a diagnosis in an efficient way. You need a hip specialist, a hip arthroscopist, a general surgeon who understands sports hernia, and a physical therapist. Our research so far suggests that we can reduce the incidence of these injuries by more than 25% in soccer. (Mandelbaum B, Silvers HJ, et al. Unpublished research.)

At the same time, a misdiagnosis can be costly. If you commit the athlete to taking 6 weeks off, and you're wrong and they need an operation, then you're 6 weeks behind the 8 ball.

So, proceed methodically. After taking a detailed history, speak to trainers and others who may have worked with the athlete to get their perspectives. Then begin a careful physical examination. Start by palpating the abdomen, especially the lower third. Ask the athlete to identify the location of the pain. Circle it. If it radiates, put a mark where it radiates. Often, just by creating that diagram on the patient's abdomen, you can get a good understanding.

Range-of-Motion Maneuvers

Next, move on to dynamic testing. Ask the patient to do some crunches and see if there is pain. Then have the patient do a crunch with the leg in slight flexion. That puts a little load in certain areas of the abdomen. Next, have the patient crunch with a leg in flexion against resistance.

Move the patient through hip flexion, then resisted hip flexion, then adduction and abduction of the leg. Record which movements are the most painful and tender, as well as all other details as the patient goes through flexion, extension, internal external rotation, adduction, and abduction.

Look for pain associated with any of these range-of-motion maneuvers. Palpitate each of the muscles coming in and out of the pelvis, finding the points of maximum tenderness. A lot of athletes have asymmetric ranges of motion. If you find that the athlete is missing 15 degrees of external rotation and it's asymmetric, you're getting close to understanding where the problems are.

Diagnostic Imaging

Next, get to the x-ray. Do anteroposterior and lateral views (projections), looking for a femoroacetabular impingement. This can take the form of a cam defect, which is a thickening of bone on the lateral femoral neck and grinds the cartilage in the acetabulum. Or it can be a pincer deformity, in which extra bone extends out over the rim of the acetabulum, crushing the labrum and creating the impingement. Or you may find a combination of the two.[4]

In 2012, we looked at the x-rays taken during routine physicals of the US Men's National Soccer team and two Major League Soccer teams, and found that 68% of the players had cam deformities. In a professional women's team, 50% had these deformities. Most players didn't even know it.

When they become aware, players present with insidious, deep, strong pain localized to the pubic and adductor regions during activity. In soccer players, kicking the ball may cause a sharp pain. This pain may radiate. Thirty percent of males experience testicular pain, and 40% have tenderness in the adductor region.[2] The pain may become chronic and bilateral over time. (Mandelbaum B, Silvers HJ, et al. Unpublished research.)[3]

The next step is MRI, and most of the time we do this with gadolinium because we can better illuminate labral tears, loose bodies, and other characteristics of femoroacetabular impingement. We have a sports hernia protocol whereby we look specifically at the rectus and the insertion into the pelvis, the groin, and the adductor tendons coming in and out of the pelvis.

Finally, we put all of this together and figure out where the patient is in the Venn diagram. Do they have a labral tear, a cam deformity, a pincer deformity, a sports hernia, an impingement, or an adductor syndrome? Or do they have some combination? Sometimes they have all of it.

Treatment depends on these findings. I'll dive into those details in my next column.


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