REVIEW ARTICLE

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement James R. Ross, MD,* Rebecca M. Stone, MS, ATC,w and Christopher M. Larson, MDw

Abstract: Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders. Key Words: sports hernia, athletic pubalgia, hip, femoroacetabular impingement

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ip and groin injuries are common problems that may cause pain and disability in athletes. Sports hernia/ athletic pubalgia has recently received increasing attention as a cause of hip and groin pain among athletes and resultant time lost from sport. Since the original report of “Gilmore’s groin” over 35 years ago, many terms have been used to describe this condition. The clinical and diagnostic presentation of these conditions, however, overlaps with other hip conditions such as femoroacetabular impingement (FAI), thus leading to difficulty with regards to diagnosis and treatment.1 Surgical treatment for core muscle injury/athletic pubalgia/sports hernia has grown in popularity over the past decade, with many studies reporting predictable return to athletics. There are a variety of procedures that have been described and performed, and it is therefore difficult to determine the optimal surgical approach. In this review, we outline the clinical entity and treatment of core muscle injury/athletic pubalgia/sports hernia, and describe the relationship between athletic pubalgia and FAI.

ANATOMY AND BIOMECHANICS Core muscle injury/athletic pubalgia/sports hernia is activity-related lower abdominal and proximal adductorrelated pain that is seen in athletes and may be a source of From the *BocaCare Orthopedics, Boca Raton Regional Hospital, Florida Atlantic University College of Medicine, Boca Raton, FL; and wTwin Cities Orthopedics, Edina, MN. Disclosure: The authors declare no conflict of interest. Reprints: Christopher M. Larson, MD, Twin Cities Orthopedics, 4010 West 65th Street, Edina, MN 55435 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.

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disability. The pubic symphysis is a nonsynovial amphiarthrodial joint, with stability imparted due to 4 ligaments and a fibrocartilaginous interpubic disk. The arcuate or inferior ligament has attachments to the inferior articular disk, the inferior attachment of the rectus abdominus, and the adductor and gracilis aponeurosis. The superior ligament spans between pubic tubercles. The arcuate and superior ligaments are the main stabilizers of the pubic symphysis. The anterior ligament blends with the fibers of the external oblique and rectus abdominus, whereas the posterior ligament is less developed. The pubic symphysis acts as a fulcrum for the anterior pelvis and the generated forces. It represents the common attachment site of the confluence of the rectus abdominus and the adductor longus, which merge to form a common sheath anterior to the pubis. The various structures in this region of the pubis symphysis are often implicated in the development of sports hernia/athletic pubalgia. The pubic aponeurosis is created by the confluence of the rectus abdominus, the conjoint tendon (a fusion of the internal oblique and transversus abdominus), and the external oblique. This pubic aponeurosis is also confluent with the origin of the adductor and gracilis, the combination of which is termed the rectus abdominus/adductor aponeurosis (Fig. 1). Core muscle injury/athletic pubalgia/sports hernia may occur secondary to an injury to any one of the above named structures, as they insert on the pubis. The term “sports hernia” is a misnomer, in that the core muscle injury typically occurs without the presence of a clinically recognizable hernia.3 Injury or deconditioning to one of the previously described anterior pelvic structures can result in increased stress and strain placed on the adjacent structures. In addition, some authors have proposed that entrapment of the ilioinguinal, iliohypogastric, and genitofemoral nerves may also result in deep anterior and lateral hip pain that can mimic or coexist with pubalgia-type symptoms.4,5

CLINICAL PRESENTATION Core muscle injury/athletic pubalgia is primarily seen in athletes who are involved in cutting and pivoting activities, as well as athletes who require rapid lateral motion, acceleration, and deceleration. Ice hockey, soccer, Australian rules football, and rugby have a proportionally high incidence of groin-related injuries.6–8 Athletes usually present with symptoms of gradually increasing activityrelated lower abdominal and/or proximal adductor-related pain.9,10 Trunk hyperextension and/or hip hyperabduction can also lead to increased tension in the pubic region and the development of acute pain if associated with partial or complete ruptures of the rectus abdominus/adductor

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FIGURE 1. A, Schematic of the rectus abdominis (RA) and adductor longus (AL) at the pubic tubercle. The RA creates a superoposterior tension, whereas the AL creates inferoanterior tension. B, Gross specimen demonstrates the confluence of the RA (arrow), with the AL (curved arrow) at the pubic tubercle. This is the attachment of the RA/adductor aponeurosis (arrowhead). Image (A) reprinted with permission from Khan et al2 and image (B) reprinted with permission from Palisch et al.1 Copyright Elsevier, Kidlington, Oxford, UK. All permission requests for this image should be made to the copyright holder.

aponeurosis.1 Patients often complain of anterior groin or lower abdominal pain that is brought on by physical activity and resolves with rest.9 The pain can also radiate proximally into the abdominal musculature or distally into the thigh, groin, or genitalia.1

PHYSICAL EXAMINATION Examination often begins with identification of the inguinal ligament and palpation of the external obliques

followed by palpation of the conjoint tendon or rectus abdominus insertion on the pelvis. Next, the pubic tubercle and pubic symphysis are palpated for tenderness, which have been found to be painful in up to 22% of patients.9,11 The hip is flexed and abducted, while the origins of the pectineus, adductors, and gracilis are palpated. It is helpful to have the patient perform resisted hip adduction in both flexion and extension to elicit pain related to these structures. Finally, a resisted sit-up or crunch with palpation of the rectus abdominus insertion may recreate the symptoms.9

FIGURE 2. Anteroposterior pelvis (A) and Dunn lateral (B) images of a 23-year-old male with combined femoroacetabular impingement/athletic pubalgia. Reprinted with permission from Larson and Rowley.13 Copyright AAOS, Rosemont, IL. All permission requests for this image should be made to the copyright holder.

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Core Muscle Injury/Sports Hernia/Athletic Pubalgia/FAI

A comprehensive examination also includes an examination of the superficial inguinal ring and posterior inguinal canal. Sensory examination is important to evaluate for entrapment of the iliohypogastric, ilioinguinal, and genitofemoral nerves. Core muscular injury/athletic pubalgia can often coexist with intra-articular pathology, in particular with FAI, and therefore examination of bilateral hip range of motion and provocative maneuvers such as the anterior impingement (FADIR’s), FABER’s, and DEXTRIT/DIRIT/Scour tests may be helpful to evaluate any associated intra-articular pathology and motion restriction. It may be that the ROM limitations associated with FAI lead to compensatory patterns around the pelvis and trunk.12

IMAGING Initial radiographic evaluation should include a wellaligned anteroposterior (AP) pelvis and lateral hip radiograph(s) (Fig. 2).14,15 In addition to evaluation for any concomitant intra-articular disorders, such as FAI and acetabular dysplasia, these initial radiographs may demonstrate osteitis pubis, acute or chronic pelvic avulsion fractures/apophyseal injuries, apophysitis, and stress fractures. Chronic cases of osteitis pubis (> 6 mo) can present with cystic changes, sclerosis, or widening of the symphysis on AP pelvis radiographs (Fig. 5A). A 1-legged stance AP pelvis radiograph (Flamingo view) can be used to evaluate for associated pubic instability. Widening (> 7 mm) or vertical shift (> 2 mm) indicates instability at the pubic symphysis.11,16 Magnetic resonance imaging (MRI) continues to evolve and recent “athletic pubalgia-dedicated” MRI protocols have been developed to improve the sensitivity and specificity of various causes of athletic pubalgia.17 Although full-thickness tears of the rectus abdominus are uncommon, MRI is 68% sensitive and 100% specific for rectus abdominis pathology when compared with findings at surgery.18 In addition, MRI is 86% sensitive and 89% specific for adductor pathology and 100% sensitive for osteitis pubis.18 These disruptions are seen as a cleft sign with increased signal on T2-weighted images at the rectus abdominus/adductor aponeurosis (Fig. 3). However, 1 study found MRI findings consistent with athletic pubalgia (36%) and intra-articular pathology (64%) in asymptomatic collegiate and professional hockey players.20

DIAGNOSTIC INJECTIONS Diagnostic injections have become a useful modality in the work-up of patient with core muscular injury and athletic pubalgia given the coexistence of various hip and pelvis disorders among athletes. A fluoroscopic or ultrasound-guided intra-articular hip injection followed by physical examination or exercise challenge can assist with the evaluation of hip joint–related pain.21 Persistent pain in the lower abdominal/adductor regions despite an intraarticular injection may be indicative of athletic pubalgia/ sports hernia as the primary or concomitant pain generator. Fluoroscopic-guided injections into the pubic symphysis can also be performed when osteitis pubis is suspected. Occasionally, radiopaque contrast from this injection will tract into the rectus abdominus/adductor aponeurosis, which may also be a sign of athletic pubalgia. Finally, pubic cleft and psoas bursal injections can be performed in the setting of adductor and psoas-related pains, respectively.22 Copyright

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FIGURE 3. Magnetic resonance imaging of the hip and pelvis in a 22-year-old football player with left-sided lower abdominal and proximal adductor-related pain. This demonstrates a cleft sign, as a disruption of the distal rectus abdominus/adductor aponeurosis on the left (solid arrow). Reprinted with permission from Larson.19 Copyright SAGE Publications, Thousand Oaks, CA. All permission requests for this image should be made to the copyright holder.

TREATMENT Management of core muscular injuries/athletic pubalgia should initially begin with nonsurgical treatment; however, there are often unique considerations among elite athletes with regards to timing and the relation to the athlete’s season. If the athlete is able to function at their high level despite pain, nonsurgical treatment with therapeutic exercises and occasional nonopioid analgesics are appropriate. At the end of the season, should the patient continue to have symptoms, surgical intervention may be considered at that time. If the athlete, however, has limitations and difficulty with participation due to pain despite nonsurgical measures, surgery may be warranted. Depending on the timing of surgery and the length of the season, an in-season surgery may be season-ending and should be discussed with the athlete. Corticosteroid injections may also be attempted; however, the efficacy is currently not fully known.23

NONSURGICAL TREATMENT Relative rest and avoidance of the activities that provoke pain should be the initial treatment in patients with core muscle injury/athletic pubalgia. Physical therapy should be initiated with focus on core strengthening and stabilization, with postural training. Identification of any muscular weakness/imbalance is critical for developing a physical therapy plan.9 Attempts at improving range of motion should be discouraged, as this may result in increased hip pain with underlying hip pathology/FAI, or may induce compensatory motion in pelvic segments which may contribute to the patient’s symptoms. After a period of rest, activity modification, and physical therapy, gradual progression to sport-specific activities may be performed.

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Ultimately, the length of nonsurgical treatment and timing of potential surgery is variable depending on the level of athlete and timing with regards to sport season. If there is no improvement by 3 months, surgery might be considered.9 A prospective, randomized study of athletes with chronic groin pain/sports hernia compared nonsurgical treatment consisting of physical therapy and corticosteroid injections with surgical treatment (laparoscopic mesh repair).24 Twenty-three percent (7/30) of the patients in the nonsurgical group crossed over into the surgical arm secondary to continued symptoms. In addition, only 50% of the nonsurgical patients returned to sport at 1-year follow-up. Ninety-seven percent (29/30) of the athletes in the surgical group were pain free and returned to full sport at 1-year follow-up.24

OPERATIVE TREATMENT Athletic Pubalgia/Sports Hernia In 1980, Gilmore25 described an open plication of the transversalis fascia, with reapproximation of the conjoint tendon to the inguinal ligament, and approximation of the external oblique aponeurosis. Patients had a return to sport rate of 96% at 15 weeks.26 Since this initial description, there have been many variations for open surgical techniques described. These have included open repairs of external oblique aponeurosis tears with mesh repairs of posterior inguinal canal,27 open repair of the external inguinal ring with plication of the transversalis fascia and reapproximation of the conjoined tendon to the inguinal ligament,28 imbrication of the transversalis fascia with attachment to the inguinal ligament,29 and open internal oblique flap repair with mesh reinforcement.30 Furthermore, in the setting of the potential underlying pelvic muscle imbalance, treatment of a contracted or overdeveloped adductor muscle has been also recommended. In addition, when symptomatic adductor pain/dysfunction cannot be corrected preoperatively, some clinicians recommend the addition of an adductor tenotomy/repair.9,30–33 Meyers et al9,10 published the largest series of nearly 8500 patients and nearly 5500 operations. This current technique involves a broad, open pelvic floor repair with reattachment of the anterior inferolateral edge of the rectus abdominis with its fascial investment to the pubis and anterior ligaments. In a report utilizing this technique over 20 years, 95% of athletes were able to return to sports at 3 months postoperatively.10 In a study of professional hockey (NHL) players who underwent a sports hernia surgery, it was noted that 80% of players were able to return to play for 2 or more seasons, with fewer predictable results in veteran players.34 Multiple authors have also published on their experience with laparoscopic repairs with mesh, offering the potential advantage of a more rapid recovery and earlier return to sport than open procedures.24,35–39 Most athletes among these various studies have been noted to return to sports participation with 2 to 6 weeks after laparoscopic repair compared with between 1 and 6 months after an open repair. Currently, the largest experience has been among 132 patients who underwent bilateral laparoscopic repair with mesh utilizing the transabdominal preperitoneal technique with 100% return to sport within 2 to 3 weeks.40 Ingoldby37 compared laparoscopic versus open (Lichtenstein) repairs and noted equal effectiveness with an earlier return to activity with a laparoscopic approach (3 vs. 5 wk).



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Recently, a “minimal repair” technique has been developed and investigated by Muschaweck and Berger,41 which involves decompression of the genital branch of the genitofemoral nerve and a tension-free suture-only repair of the posterior inguinal wall deficiency/defect. At 4 weeks after the operation, 96% of the athletes had resumed training. Among the professional athletes, 84% had returned to unrestricted sporting activities at a median of 14 days (range, 10 to 28 d). In addition, Economopoulos et al42 noted a quicker return to sports in a retrospective comparison of the minimal repair technique and the Bassini repair (5.6 vs. 25.8 wk). Only 64% of open Bassini repair athletes returned to their preinjury level of sports, compared with 93% of the athletes undergoing the minimal repair technique. Further investigations among larger groups need to be done with open approaches, laparoscopic, and “minimal repair” techniques to determine the optimal surgical approach if one does exist. The most common postoperative complaint is edema in the abdomen, thighs, genitals, and perineum. Wound infection (0.4%) and hematoma requiring reoperation (0.3%) are also reported. Nerve dysesthesia (< 1%) usually affects the anterior/lateral femoral cutaneous nerve distribution, ilioinguinal nerve, and/or the genitofemoral nerve.10 Penile vein thrombosis is reported in the literature but all resolved. Most recent studies have reported return to full activity 1 to 6 months after repair, depending on the type of repair.18,37

Adductor Strain Adductor strains are most common among athletes who participate in pivoting and cutting activities and kicking, such as seen in football, hockey, soccer, and dance. The predisposition of the adductor longus to injury has been thought to be due to the small cross-sectional area of the pelvic origin when compared with the size of the muscle belly.43–45 Another etiology for adductor strain is the muscular imbalance that may be seen between the strong abductors and weak adductors. Adductor strains are usually self-limiting requiring minimal treatment with very high rates of return to play. Tyler et al46 reported that professional hockey players were 17 times more likely to have an adductor strain if their adductor strength was 50% cross-sectional area involvement, fluid collections, and muscle tears. Adductor longus tears with a palpable defect usually show retraction of the tendon of 3 cm or greater on MRI48 (Fig. 4). Activity modification, ice, compression, NSAIDs, and gentle range of motion exercises are the mainstay of initial treatment after adductor injury, followed by a strengthening program with focus on core strengthening, plyometrics, and gentle straight ahead running.43 Activities are gradually advanced with sport-specific drills and patients are able to return to play at a mean of 6 weeks. Injections may be indicated in patients who fail the first-line conservative treatment. Platelet-rich plasma, corticosteroid, and local

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FIGURE 4. Adductor tendon avulsion. A, Coronal STIR image of the pelvis shows detachment of the left adductor origin from the aponeurosis (arrow) with the retracted tendon fibers distally (arrowhead). B, Small field-of-view coronal oblique T2 fat saturated FSE image using a pubalgia protocol demonstrates the detachment of the left anterior adductor origin from the aponeurotic plate (arrow). “Anterior adductor avulsions” refer to the detachment of the pectinius and adductor longus, which are the 2 most anterior muscles at the pubic attachment. Reprinted with permission from Palisch et al.1 Copyright Elsevier, Kidlington, Oxford, UK. All permission requests for this image should be made to the copyright holder.

anesthetic injections into the adductor enthesis have been described with some success in competitive and recreational athletes.49 Surgical treatment may be considered in an athlete who has failed 3 to 6 months of conservative treatment. Akermark and colleagues published a case series of 16 competitive athletes with chronic isolated adductor

pathology that failed conservative treatment and underwent an open tenotomy of the adductor longus approximately 1 cm from the pelvic origin. All patients improved or were free of symptoms and 94% were able to return to sporting activities. Sixty-three percent (10/16) were pain free and able to return to sport at the same level at final follow-up. Decreased muscle strength was also observed,

FIGURE 5. A, Anteroposterior radiograph of collegiate soccer player with bilateral femoroacetabular impingement and osteitis pubis. The preoperative radiograph shows a crossover sign (line drawing) indicative of pincer-type impingement, cam impingement (solid arrow), and lytic changes at the pubic symphysis (dashed arrow) consistent with osteitis pubis. Copyright Elsevier, Kidlington, Oxford, UK. Coronal (B) and axial (C) MRI scans of a patient with chronic osteitis pubis (circled areas). Image (A) reprinted with permission from Larson et al12 and images (B) and (C) reprinted with permission from Larson and Rowley.13 Copyright AAOS, Rosemont, IL. All permission requests for this image should be made to the copyright holder.

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although it did not seem to influence sport participation.33 Schilders et al50 demonstrated excellent pain relief and 98% of elite athletes returning to preinjury level of sport after an average of 9.2 weeks after a selective partial adductor longus release for recalcitrant chronic adductor enthesopathy. The senior author (C.M.L.) prefers a fractional lengthening 3 cm distal to the origin to minimize postoperative weakness. Caution should be exercised when considering releases in soccer strikers as this might lead to detrimental adductor weakness. Schlegel et al48 noted that nonoperative treatment of complete proximal adductor tendon rupture was associated with a faster return to play in a series of 19 NFL players. The nonoperative group returned to play at 6 weeks compared with 12 weeks in the operative group. Twenty percent of the operative group also experienced wound complications, which further favors nonsurgical treatment in these instances.51,52

Osteitis Pubis Osteitis pubis is thought to be a stress injury of the perisymphyseal pubic bones secondary to increased strain on the anterior pelvis.53,54 Bone biopsies of the superior pubic ramus of 10 athletes with chronic groin pain showed formation of new woven bone, osteoblasts, and neovascularization, with an absence of inflammatory cells and no signs of osteonecrosis, consistent with a bone stress injury.55 There are also reports of infectious etiologies and osteomyelitis of the pubis, which can present in a similar manner.56 Patients may present with pain similar to core muscle injury/athletic pubalgia; however, they may also have tenderness to palpation over the pubic symphysis and adjacent rami.57 Osteitis pubis in athletes is often a chronic condition that can progress to inability to compete secondary to pain and discomfort.55 MRI will often show subchondral bone marrow edema, which is usually bilateral but often asymmetric with increased signal on the more symptomatic side. Subchondral cysts, resorption of the subchondral bone, and articular erosions can also be present on MRI.17 (Figs. 5B, C) Nonoperative management consists of rest, ice, NSAIDs, activity modification, corticosteroid/platelet-rich plasma injections, and physical therapy focusing on core strengthening, with a 90% of greater return to sport.55 Operative treatment is indicated primarily for demonstrable instability on radiographs or failure of prolonged nonsurgical management. Techniques include open and endoscopic curettage of symphysis, wedge resection, mesh reinforcement, arthrodesis using compression plating, and broad pelvic floor core muscle procedures.11,57,58 Potential complications, however, include hemospermia, scrotal swelling, continued symphyseal instability, and chronic anterior groin pain.53

Combined Athletic Pubalgia and FAI There is often overlap between intra-articular and extra-articular pathology for patients presenting with lower abdominal, groin, or hip pain. Recently, using a cadaveric model, Birmingham and colleagues demonstrated that the presence of cam morphology places increased stresses and motion on the pubic symphysis. This was postulated to predispose patients to athletic pubalgia.59 A subset of patients will present with combined FAI and core muscle injury/athletic pubalgia. Often, however, it remains difficult to determine the extent of the pain or disability that is attributable to each individual entity. In these cases,

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anesthetic intra-articular and extra-articular injections can assist in the diagnosis. Treatment of only one of the symptomatic pathologies can lead to a suboptimal result. Pubalgia surgery alone has demonstrated a 25% return to the previous level of sport, whereas arthroscopic treatment of FAI alone resulted in a 50% return to the previous level in 1 study.12 When both conditions were surgically managed either simultaneously or in a staged manner, 89% returned to sports without limitations.12 Similar results were noted in a series of professional athletes60; however, no patient within this series was able to return to sport after athletic pubalgia surgery alone. Therefore, it may be reasonable to counsel the athlete about FAI corrective surgery with later pubalgia surgery if symptoms do not fully resolve, given that half of the patients are able to return in this manner. However, when treating high-level athletes, surgical management of both the core muscle injury/athletic pubalgia and FAI in a staged or simultaneous manner may allow for a more predictable return to sport with minimal time lost.

SUMMARY Core muscular injury/athletic pubalgia/sports hernia in athletes has been recognized as a cause of significant pain, disability, and time lost from sport. The understanding of core muscular injury/athletic pubalgia and groin pathology is constantly expanding, as previously these disorders were thought to be a number of isolated pathologies. However, there is now substantial evidence supporting the coexistence and compensatory relationship between intra-articular and extra-articular hip and pelvis disorders in patients presenting with hip and groin pain. A thorough history and physical examination, combined with newer advanced imaging techniques, may improve the ability to diagnose and treat specific hip-related/groinrelated pathology. When nonsurgical treatment is unsuccessful, various surgical approaches addressing core muscle injury/athletic pubalgia/sports hernia have resulted in a predictable return to sporting activity. In addition, there is a subset of athletes that will present with both symptomatic core muscle injury/athletic pubalgia and symptomatic intraarticular hip disorders such as FAI. Therefore, all athletes presenting with groin or pelvic pain should be evaluated for both entities clinically and radiographically. Surgical treatment for both disorders may be necessary, when symptomatic and limiting, to predictably return athletes to their previous level of activity/sport. REFERENCES 1. Palisch A, Zoga A, Meyers W. Imaging of athletic pubalgia and core muscle injuries: clinical and therapeutic correlations. Clin Sports Med. 2013;32:427–447. 2. Khan W, Zoga AC, Meyers WC. Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice. Magn Reson Imaging Clin N Am. 2013;21:97–110. 3. Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007;15: 507–514. 4. Poultsides LA, Bedi A, Kelly BT. An algorithmic approach to mechanical hip pain. HSS J. 2012;8:213–224. 5. Draovitch P, Edelstein J, Kelly BT. The layer concept: utilization in determining the pain generators, pathology and how structure determines treatment. Curr Rev Musculoskelet Med. 2012;5:1–8. 6. Gilmore J. Groin pain in the soccer athlete: fact, fication, and treatment. Clin Sports Med. 1998;17:787–793.

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Sports Med Arthrosc Rev



Volume 23, Number 4, December 2015

57. Radic R, Annear P. Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med. 2008;36:122–128. 58. Grace JN, Sim FH, Shives TC, et al. Wedge resection of the symphysis pubis for the treatment of osteitis pubis. J Bone Joint Surg Am. 1989;71:358–364. 59. Birmingham PM, Kelly BT, Jacobs R, et al. The effect of dynamic femoroacetabular impingement on pubic symphysis motion: a cadaveric study. Am J Sports Med. 2012;40:1113–1118. 60. Hammoud S, Bedi A, Magennis E, et al. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy. 2012;28:1388–1395.

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Athletic Pubalgia, and Femoroacetabular Impingement.

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain ...
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