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Treating, Preventing Hip and Groin Problems in the Athlete

Bert R. Mandelbaum, MD, DHL (Hon)


April 05, 2017

Choosing the Right Surgeon and Surgical Procedure

Although there may in truth be no specialties in medicine, we all have to recognize the value of collaboration with colleagues whose experience or training exceeds our own.

If you can determine that only one area of the anatomy is injured (for example, a sports hernia uncomplicated by hip or adductor issues), then the athlete may do well when treated only by a person with that expertise. But many athletes will fare best when treated with a team of subspecialists, including someone who specializes in hips and someone who specializes in hernias. They can work together and develop a treatment algorithm for that athlete.


In our study, we found that the rate of revisions with laparoscopic repairs was 38%. For open repairs without mesh, it was 43%. On the other hand, for open repairs with mesh, it was 0% (Mandelbaum B, Silvers HJ, et al. Unpublished research).

We think that the rate of revision was lower in the group that underwent an open procedure with mesh because the surgeons dealt with all of the problems concurrently. With an endoscopic procedure, you won't see any impingement of the nerve, and you won't see any weakness on the other side of the abdominal wall.

One reason I like to get the collaboration of hip specialists in these procedures is that cam lesions themselves can be complicated. Our understanding of femoroacetabular impingement is increasing rapidly. In fact, the concept of hip preservation is probably the hottest area in orthopedic medicine now.

Cam lesions can be treated with femoroplasty, in which the femoral head and neck junction are reshaped into a normal sphere. These procedures have helped a lot of young athletes. But athletes older than 40 years generally have more arthritis. At that point, the horse is out of the barn. These older athletes will probably not be able to perform at the level they could before the injury; they have lost too much range of motion.

Exercises to Prevent Injury, Enhance Performance

That's why, as sports physicians, we must work to prevent these injuries from developing. Together with our colleagues at the Santa Monica Sports Medicine Foundation, Holly Silvers, MPT, and I have developed a set of exercises that we call PEP: Prevent injury and Enhance Performance.

We designed the program with knee injuries in mind, and have shown that it (and the related FIFA 11+ program) can significantly reduce the risk for lower-extremity injuries in general.[1,2] We have added some exercises aimed at further strengthening the hips and abdominal muscles and elongating the low back muscles, improving range of motion and neuromuscular control. These exercises included bridging with alternating hip flexion, abdominal crunches, single and double knee to chest (supine), figure four piriformis stretch (supine), and a seated butterfly stretch.[3]

Holly and I recently compared four teams using the PEP program with the additional exercises with four teams doing their typical conditioning and warm-up. The teams that used the enhanced PEP program had a 28% lower incidence of hip and groin problems (Mandelbaum B, Silvers HJ, et al. Unpublished research).

Despite the proof we can offer from clinical trials, coaches and trainers have hesitated to embrace these injury prevention programs. That's where we need sports physicians to speak up. We must advocate for our athletes so that they never end up on our operating tables.


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