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Treating, Preventing Hip and Groin Problems in the Athlete

Bert R. Mandelbaum, MD, DHL (Hon)


April 05, 2017

The Complexity of Hip and Groin Injuries

Athletes' hip and groin problems confound many surgeons because of the complex way in which these problems interact.

It's probably the most challenging issue in all of sports medicine: If you say you have a sports hernia, what's the cause of it? Impingement? Weakness of the abdominal wall? A strained adductor tendon? These injuries are very common among professional athletes, especially in hockey, soccer, and American football.


I believe that the pathogenesis begins in pubescence, when the physes are open. The capital slips slightly. I call it an "altered slipped capital femoral epiphysis." It's what might be considered a microslip.

After this slip, a cam lesion begins to develop. Soccer players in particular put tension on their hips and pelvises as they are kicking and trapping balls. Without full range of motion in the hip, they compensate with greater movement of the pelvis. This puts more stress on the lower pelvis and the rectus abdominus.

The issues can be so confusing that some general surgeons don't even believe that real injuries have taken place. But to the athlete, the pain is all too real.

Hip and Groin Injuries Often Require a Dual Diagnosis

As I explained in my last column, I see the resulting sports hernias, adductor injuries, and hip injuries as overlapping in a Venn diagram. I like to quote William Osler in this context: "There are, in truth no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs."

Some athletes only have one of these injuries, but in many cases these injuries can cause or exacerbate each other. In a recent prospective study of 100 US professional soccer players, my colleagues and I found that 66% of hip and groin issues involved a dual diagnosis (Mandelbaum B, Silvers HJ, et al. Unpublished research).

You have look at it in this complex way, because you only get one crack at it. The player is in the middle of the season, and with surgery, they're out for 4 months. You can take the athlete to the operating room and treat a labral tear, only to find out the athlete still has pain from a sports hernia.

That's why the rate of revision is so high—30% overall in our study of professional soccer players (Mandelbaum B, Silvers HJ, et al. Unpublished research). Too often the wrong procedure was used, or the surgeon failed to understand the multiplicity of the injuries.

For the typical orthopedic surgeon, this is really going into scary waters. The most important thing is to do the homework on the front end. Following the diagnostic procedure I outlined in my last column, I recommend referring these patients to a surgeon with expertise in this area.


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