The American Journal of Sports Medicine http://ajs.sagepub.com/
Sonographic Prevalence of Groin Hernias and Adductor Tendinopathy in Patients With Femoroacetabular Impingement Florian D. Naal, Francesco Dalla Riva, Thomas H. Wuerz, Beat Dubs and Michael Leunig Am J Sports Med published online July 17, 2015 DOI: 10.1177/0363546515591259 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/07/17/0363546515591259
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Sonographic Prevalence of Groin Hernias and Adductor Tendinopathy in Patients With Femoroacetabular Impingement Florian D. Naal,*yz MD, Francesco Dalla Riva,y MD, Thomas H. Wuerz,§ MD, Beat Dubs,|| MD, and Michael Leunig,y MD Investigation performed at Schulthess Clinic, Zurich, Switzerland Background: Femoroacetabular impingement (FAI) is a common debilitating condition that is associated with groin pain and limitation in young and active patients. Besides FAI, various disorders such as hernias, adductor tendinopathy, athletic pubalgia, lumbar spine affections, and others can cause similar symptoms. Purpose: To determine the prevalence of inguinal and/or femoral herniation and adductor insertion tendinopathy using dynamic ultrasound in a cohort of patients with radiographic evidence of FAI. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study consisted of 74 patients (36 female and 38 male; mean age, 29 years; 83 symptomatic hips) with groin pain and radiographic evidence of FAI. In addition to the usual diagnostic algorithm, all patients underwent a dynamic ultrasound examination for signs of groin herniation and tendinopathy of the proximal insertion of the adductors. Results: Evidence of groin herniation was found in 34 hips (41%). There were 27 inguinal (6 female, 21 male) and 10 femoral (9 female, 1 male) hernias. In 3 cases, inguinal and femoral herniation was coexistent. Overall, 5 patients underwent subsequent hernia repair. Patients with groin herniation were significantly older than those without (33 vs 27 years, respectively; P = .01). There were no significant differences for any of the radiographic or clinical parameters. Tendinopathy of the proximal adductor insertion was detected in 19 cases (23%; 11 female, 8 male). Tendinopathy was coexistent with groin herniation in 8 of the 19 cases. There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy. Patients with a negative diagnostic hip injection result were more likely to have a concomitant groin hernia than those with a positive injection result (80% vs 27%, respectively). Overall, 38 hips underwent FAI surgery with satisfactory outcomes in terms of score values and subjective improvement. Conclusion: The results demonstrate that groin herniation and adductor insertion tendinopathy coexist frequently in patients with FAI. Although the clinical effect is yet unclear, 5 patients underwent hernia repair. Dynamic ultrasound is a useful tool to detect such pathological abnormalities. Diagnostic hip injections can be helpful to differentiate between the sources of pain. Keywords: femoroacetabular impingement; FAI; groin pain; hernia; adductor tendinopathy; diagnostic hip injection
It is widely accepted that femoroacetabular impingement (FAI) is a common cause of groin pain in younger and
active patients and that FAI can lead to early-onset osteoarthritis of the hip.1,13,34,36 Surgical treatment is indicated when nonoperative measures fail and/or secondary damage to the hip occurs. Success rates of 68% to 96% have been reported at short-term to midterm follow-up.5,9,26,31 However, FAI is not the only source of groin pain. Socalled sportsmen and classic groin hernias, adductor injuries, nerve entrapments, or affections of the lumbar spine are other common diagnoses that can lead to similar symptoms.15,22,28 Sometimes, different pathologic conditions coexist.3,6,14 In a recent investigation on patients who underwent surgery for athletic pubalgia, radiographic FAI criteria were fulfilled in 86% of the cases.12 In another series including patients with long-standing adductorrelated groin pain, the authors could demonstrate that as much as 94% of the symptomatic hips also had radiographic evidence of FAI.40 Besides adductor-related pain,
*Address correspondence to Florian D. Naal, MD, Department of Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland (email: [email protected]). y Department of Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland. z Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. § Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. || Sonografie-Institut Glattpark GmbH, Zurich, Switzerland. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. The American Journal of Sports Medicine, Vol. XX, No. X DOI: 10.1177/0363546515591259 Ó 2015 The Author(s)
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Figure 1. (A) Ultrasound image of the groin region before the Valsalva maneuver and (B) evidence of inguinal herniation during the Valsalva maneuver. A, external iliac artery; E, inferior epigastric artery; H, indirect inguinal hernia; V, external iliac artery. The curved arrow indicates the superior pubic ramus.
groin hernias are very common, and hernia repair is one of the most frequently performed general surgeries in the world.18 Hence, FAI and groin hernias might both be present in symptomatic patients, and differentiating between the sources of pain is of utmost importance before any type of surgery is indicated. To our knowledge, there has yet been no report investigating if groin hernias or adductor insertion injuries coexist in patients diagnosed with FAI. The goal of this study was therefore to determine the prevalence of inguinal and femoral hernias and tendinopathy of the adductor origin in a prospective cohort of patients with FAI based on a dynamic ultrasound examination and to investigate the clinical and radiographic characteristics of patients with and without coexisting disorders.
METHODS In the beginning of 2012, the routine diagnostic protocol of 2 of the authors (F.D.N., M.L.) for patients referred with possible FAI included a clinical examination, conventional anteroposterior pelvis and cross-table lateral hip radiographs, magnetic resonance imaging (MRI) with intra-articular gadolinium contrast, and a dynamic ultrasound examination of the involved groin. In most cases, a diagnostic intra-articular hip injection with use of 5 to 10 mL ropivacaine was also given. Patients were seen the same or the next day after the injection. They were advised to note their improvements from hour to hour using the following levels: no change, relief of about 20% to 25%, relief of about 50%, relief of about 75% to 80%, and complete relief. A positive injection result was defined as pain relief of at least 50% of the typical symptoms. We retrospectively reviewed the data of all patients seen by these 2 authors in the outpatient department between January and April 2012. Inclusion criteria were a final diagnosis of FAI (ie, cam deformity of the proximal femur and/or pincer component) and age between
16 and 55 years. Exclusion criteria were hip disorders other than FAI (eg, dysplasia), osteoarthritis .grade 2 according to the To¨nnis classification, previous hip surgery, and previous groin surgery for any reason. The final cohort consisted of 74 patients (36 female and 38 male) with 83 symptomatic hips. The mean age was 28.7 6 10.2 years. All patients provided written informed consent. Radiographs were studied for the following parameters: lateral center-edge (LCE) angle, acetabular roof (AC) angle, neck-shaft angle, acetabular version, and alpha angle. All measurements were performed using a digital imaging system (JiveX v 4.5.3 RC5; Visus Technology) with use of standardized techniques.24,39 Clinically, the physician recorded hip flexion, internal and external rotation in flexion, abduction, and pain on impingement testing. The ultrasound evaluation was performed by one of the authors (B.D.), an internist specialized in the ultrasound technique and head of an ultrasound institute for 21 years, with the General Electric Voluson E6 sonography system (General Electric Healthcare), using a 7.5- to 10-MHz probe following routine guidelines (Schweizer Gesellschaft fu¨r Ultraschall in Medizin [SGUM] guidelines). While the routinely performed MRI might also serve for hernia detection, this investigation is a static one. Dynamic ultrasound with help of the Valsalva maneuver has been shown to be a reliable method to detect hernias in patients with no or only moderate clinical symptoms.17,35 Other conditions such as osteitis pubis or adductor tendinopathy can also be assessed.8,20 Images were evaluated for signs of herniation (femoral and/or inguinal hernias) and tendinopathy of the proximal insertion of the adductors. Herniation was defined as a reproducibly visible hernia under the Valsalva maneuver and/or reproducible bulging of the abdominal wall (Figure 1). Patients with sonographic evidence of groin herniation and a negative diagnostic hip injection result were referred to a general surgeon. Statistics were performed using GraphPad software. Assessing the prevalence of concomitant groin disorders
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TABLE 1 Radiographic Parameters of the Study Cohorta Parameter, deg
TABLE 2 Clinical Data for the 38 Hips Undergoing FAI Surgerya
Mean 6 SD Outcome Measure
LCE angle AC angle CCD angle Acetabular version Alpha angle
31.6 5.5 133.4 16.4 55.8
3
6 6 6 6 6
5.6 4.5 5.6 5.2 8.7
a AC, acetabular roof; CCD, caput-collum-diaphysis; LCE, lateral center-edge.
was the primary research goal. Analyzing their associations with demographics, radiographic parameters, and diagnostic hip injections was the secondary goal. Differences between patients (female vs male, herniation vs no herniation, tendinopathy vs no tendinopathy) were compared using unpaired t tests after testing for normal distribution. Unless otherwise stated, all data are presented as mean 6 SD. P values \.05 were considered significant.
RESULTS The radiographic parameters of the entire cohort are presented in Table 1. The FAI type was mixed in 49 hips (59.0%), pincer in 20 hips (24.1%), and cam in 14 hips (16.9%). Clinically, the mean hip flexion was 108.2° 6 8.9°, internal rotation was 21.3° 6 12.9°, external rotation was 38.6° 6 10.8°, and abduction was 41.3° 6 7.6°. The impingement test result was positive in 70 hips (84.3%). There were no differences between female and male patients for age, LCE angles, and AC angles (P = .231.797). There was a trend toward higher caput-collumdiaphysis angles in female patients than male patients (134.7° vs 132.3°, respectively; P = .521). Female patients had significantly higher acetabular anteversion (17.7° vs 15.3°, respectively; P = .043) and lower alpha angles (53.3° vs 57.9°, respectively; P = .016) than male patients. Clinically, female patients had significantly higher hip flexion (111.1° vs 105.8°, respectively; P = .006), internal rotation (25.8° vs 17.7°, respectively; P = .004), and external rotation (41.8° vs 35.9°, respectively; P = .18) than male patients. None of the female hips had pure cam FAI, 68.4% had mixed-type FAI, and 31.6% had pincer FAI. In male patients, cam FAI was evident in 31.1% of the hips, mixed-type FAI in 51.1%, and pincer FAI in 17.8%. Evidence of groin herniation was found in 34 hips (41%). There were 27 inguinal (6 female, 21 male; ratio, 1:6.3) and 10 femoral (9 female, 1 male; ratio, 9:1) hernias. In 3 cases, inguinal and femoral herniation was coexistent. Overall, 5 patients underwent subsequent hernia repair. Of these, 4 became free of symptoms after hernia surgery. Patients with groin herniation were significantly older than those without (32.9 vs 26.8 years, respectively; P = .01). There were no significant differences for any of the radiographic or clinical parameters. Tendinopathy of the proximal adductor insertion was detected in 19 cases (22.9%; 11 female and 8 male).
EQ-5D (0-1 scale) EQ-5D VAS (0-100 scale) Oxford Hip Score (0-48 scale) UCLA activity scale (0-10 scale) Subjectively improved or much improved, %
1-Year Preoperative Follow-up P Value 0.53 62.1 32.7 5.6
0.70 72.8 41.1 6.8
.002 .027 \.001 .004
—
81.6
—
a For all measures, higher values represent better health states. EQ-5D, EuroQol; FAI, femoroacetabular impingement; UCLA, University of California, Los Angeles; VAS, visual analog scale.
Tendinopathy was coexistent with groin herniation in 8 of the 19 cases. There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy. An intra-articular injection was given in 63 hips. In the group of patients that had a positive hip injection result (48 hips; 76.2%), 13 (27.1%) had evidence of groin herniation, whereas 12 of 15 (80.0%) had herniation in the group that did not respond to the hip injection (P \ .01). Three of the cases with inguinal herniation underwent subsequent hernia repair. Signs for adductor tendinopathy were seen more frequently in the responder group than in the nonresponders (29.2% vs 20.0%, respectively; P = .041). Age did not differ between responders and nonresponders, but the latter group consisted solely of male patients (n = 15/15). Thirty-six (75.0%) of the hips responding to the diagnostic injection underwent subsequent FAI surgery, but only 2 (13.3%) of the nonresponding hips did. Overall, 38 hips (45.8%) underwent FAI surgery (either hip arthroscopic surgery or surgical dislocation). Thirtythree of these hips had a diagnostic intra-articular injection before surgery. The infiltration was positive in 31 hips (94%). One of the 2 cases (male, 36 years) with a negative infiltration underwent FAI surgery because of persistent symptoms after hernia repair (see paragraph above). The second case, a 17-year-old male patient with cam FAI, had reported pain relief of about 25% after the injection, and this result was therefore considered negative. He underwent nonoperative treatment but had progressive symptoms. Repeated MRI revealed new, large acetabular cartilage delamination, and surgery was then indicated (see paragraph above). The prevalence of groin herniation (42.1% vs 40.0%, respectively; P = .328) and adductor tendinopathy (23.7% vs 22.2%, respectively; P = .542) did not differ between patients who underwent FAI surgery and those who did not. Outcome scores improved significantly from preoperatively to 1 year after surgery (Table 2). Subjectively, surgery improved or much improved symptoms in 81.6% of the cases. There were no differences for preoperative mean scores, postoperative mean scores, change scores, or proportion of improved patients between cases with concomitant groin hernia and those without (P = .28-.99).
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DISCUSSION Groin pain is a common debilitating condition in young and active patients. Various disorders can be responsible for pain and limitation; one of these is FAI. There is increasing evidence that FAI is associated with early hip joint degeneration, and surgical treatment might be indicated in patients after nonoperative treatment has failed.{ However, FAI is not the exclusive source of groin pain. Other disorders such as hernias, adductor tendinopathy, athletic pubalgia, lumbar spine problems, and others can cause similar symptoms.3,6,12,14,15,22,28,40 This study therefore aimed to determine the prevalence of inguinal and/or femoral herniation and adductor insertion tendinopathy using dynamic ultrasound in a cohort of patients with radiographic evidence of FAI. The present results highlight that coexisting disorders are frequent. Groin hernias were detected in more than 40% of the cases, and almost one-fourth had evidence of adductor insertion tendinopathy at the pubic bone. Before interpreting these results, some limitations have to be considered. First, the cohort is relatively small, and the results are therefore not generalizable without caution. Second, the study design is retrospective, and patients who did not undergo surgery were not followed prospectively. Therefore, it is possible that some cases had been operated for FAI somewhere else or for groin herniation later on. Also, this study does not include a control group. A comparative study with matched asymptomatic participants would be of interest in the future. Furthermore, considering the success of a diagnostic hip injection always includes the risk of subjective bias. We therefore chose a relatively high cut-off value of at least 50% pain relief for a positive result, while other authors used lower thresholds.19 Finally, no outcome measures are collected in our outpatient (different to our surgical patients) department; therefore, comparisons of clinical outcomes between operated and nonoperated cases were not possible. On the other hand, the study cohort is very well defined, and the primary research question was to determine the prevalence and not clinical outcomes. The prevalence of groin herniation was very high in this cohort. The values are, however, difficult to compare with those in the literature because we are not aware of normative values based on ultrasound investigations. Ultrasound has been nevertheless considered as the imaging investigation of choice for clinically unrecognized or subclinical hernias.8 The lifetime risk of inguinal hernia repair has been reported to be 27% for male and 3% for female patients.33 In a Danish nationwide investigation covering more than 5 million persons, 46,717 hernia repairs (about 8%) have been performed within 5 years.7 Even higher values were reported by Zendejas et al41 based on a population-based investigation in the United States. While these figures are based on definitive hernia surgery, the prevalence of subclinical disorders might be higher. Although not directly comparable, the herniation prevalence of 41% observed in the current study appears to be high. This is
{
References 1, 5, 9, 13, 21, 26, 30, 31, 34, 36.
particularly the case for female patients. About 16% of the female patients in the present cohort had evidence of inguinal herniation, and as much as 23% showed femoral herniation. These numbers are above values usually reported4,10,16,38 and let us speculate that there might exist a more generalized connective tissue problem in patients with groin pain and different coexisting disorders, as discussed below. Interestingly, the prevalence of groin herniation and adductor tendinopathy did not differ between patients who underwent FAI surgery and those who did not. Also, we could not find differences in outcome scores for those patients with or without hernias who underwent FAI surgery, neither preoperatively nor postoperatively. This observation underlines that groin herniation is in fact a relatively common comorbidity in patients with FAI, but as long as the diagnostic hip injection results in pain relief, the clinical relevance seems to be insignificant. While a positive hip injection result does not exclude the presence of a groin hernia per se, negative diagnostic infiltration seems to have some predictive ability. Considering that, overall, 5 of 83 (6%) painful hips in patients referred for possible symptomatic FAI underwent hernia repair, there is indeed a clinical relevance. Although 1 of these cases had persistent symptoms after hernia repair and underwent successful FAI surgery later on, the present findings indicate that about 4 to 5 of 100 patients with groin pain and FAI require hernia repair and not FAI treatment. Tendinopathy of the adductor insertion is another common condition encountered in physically active patients. The cause is yet rather unknown, also reflected by different treatment recommendations ranging from nonoperative measures to surgical adductor release.11,27,37,40 In the present FAI cohort, adductor insertion tendinopathy was evident in more than 20% of the cases. The clinical relevance of concomitant adductor tendinopathy is, however, unclear. The prevalence was similar in patients who underwent FAI surgery and those who did not. Further, there was an unexpectedly higher prevalence of tendinopathy in patients who had a positive hip injection result. While we are not aware of any adductor-related surgery performed in patients of this cohort, most patients underwent nonoperative treatment. Related to the origin and relatively high prevalence of tendinopathy and also herniation, we speculated that the altered hip biomechanics in patients with FAI, particularly in those with severe cam deformities, might act as stress and strain risers for the soft tissues and musculotendinous structures around the hip. A biomechanical stress-shielding theory in the origin of adductor tendinopathy has been proposed before.3,23,32 However, we did not find any significant differences in clinical and radiographic parameters, particularly alpha angles, between patients with herniation or adductor tendinopathy and those without. The only difference was related to age, with patients with hernias being older than those without herniation. The clinical relevance of this finding might be insignificant. Some sort of association between FAI and other connective tissue injuries might be nevertheless fact, although not yet proven or understood. In this regard, a high prevalence of generalized joint
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History, examination, radiograph, contrast MRI
All positive for FAI, cartilage damage
FAI surgery
All positive for FAI, no cartilage damage
Nonoperative treatment
failure
FAI surgery
success
End of treatment
failure
FAI surgery
success
End of treatment
Mild deformity, none or subtle joint damage, untypical history or examination
Diagnostic hip injection
positive
5
Nonoperative treatment
negative
Dynamic ultrasound for groin hernia
negative
Nonoperative treatment
positive
Presenting to general surgeon
success
End of treatment
failure
Repeated workup, other pathology?
rule out
Nerve entrapment, spine pathology, etc
Figure 2. Diagnostic algorithm for patients with possible femoroacetabular impingement (FAI). hypermobility in patients with FAI has been also observed before.29 Further research is therefore required to understand the role and causes of different coexisting disorders around the groin, including basic science investigations. Almost half of the hips in the present series underwent FAI surgery at a certain point. While this proportion appears to be high, it has to be considered that this cohort already represents a highly selected one with a final diagnosis of FAI. Nonoperative treatment is usually performed as a first-line treatment in all patients before surgery is indicated. This consists of a regular muscle training program focusing on core stabilization, training of hip abductors and flexors, stretching/detonization of adductors and rectus muscles, and local ultrasound treatment of the adductor insertion in cases with tendinopathy. For the latter, a local steroid or autologous conditioned plasma injection might be also considered. The indication for FAI surgery is not only based on radiographic parameters, but it is also more a complete picture of all relevant findings, including typical MRI damage patterns and potentially diagnostic hip injections. Diagnostic hip injections have been considered useful for differentiating between intra- and extra-articular pain. In a study including 72 patients with a mean age of 29.9 years, hip arthroscopic surgery was performed only in patients who responded to an injection within a 2-hour time frame.19 These authors defined a positive response as pain relief of at least 10%. Overall, 11 of the 72 patients had pain relief of less than 50%, and in these cases, labral tears without cartilage damage and extra-articular injuries were observed frequently.19 In a response to this study, Mathews et al25 reported on their experience with diagnostic hip injections. These authors reported a response rate to the injection of 82%, and all of these 55 hips presented intra-articular
injuries upon surgery.25 Similarly, Ayeni and coworkers2 reported on partial or complete pain relief after a hip injection in 81% of their patients with FAI before hip arthroscopic surgery. Patients who did not receive pain relief from the injection were half as likely to have better function and reduced pain at 6 months after surgery using the modified Harris Hip Score as an outcome parameter.2 The response rate to the hip injections in the present study was 76% and is somewhat lower than reported before, but we used more strict criteria to define a positive injection result with at least 50% of the symptoms to be resolved. We found that the prevalence of groin herniation and adductor tendinopathy was increased in the cases with a negative hip injection result, underlining its usefulness to differentiate between intraand extra-articular symptoms. On the basis of these findings, we adapted our diagnostic algorithm (Figure 2). While a diagnostic injection does not always seem necessary in patients with very typical FAI, it can help in those patients with only mild deformities or less characteristic symptoms. A dynamic ultrasound investigation of the groin should be considered if the injection result is negative. Taken together, the present study demonstrates that groin herniation and adductor insertion tendinopathy coexist frequently in patients with FAI, although the results cannot be generalized because the study sample is small and did not include a control group. A diagnostic hip injection seems to be a reasonable method to further differentiate between the sources of pain. A positive injection result does not exclude the presence of a groin hernia but makes its clinical relevance unlikely. Dynamic ultrasound is a useful tool to detect groin disorders and should be considered in patients with FAI in whom a diagnostic hip injection result was negative.
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REFERENCES 1. Agricola R, Heijboer MP, Biema-Zeinstra SM, Verhaar JA, Weinans H, Waarsing JH. Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK). Ann Rheum Dis. 2013;72(6):918-923. 2. Ayeni OR, Farrokhyar F, Crouch S, Chan K, Sprague S, Bhandari M. Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014;22:801-805. 3. Bedi A, Dolan M, Leunig M, Kelly BT. Static and dynamic mechanical causes of hip pain. Arthroscopy. 2011;27:235-251. 4. Bendavid R. Femoral hernias in females: facts, figures and fallacies. In: Abdominal Wall Hernias. New York: Springer; 2001:639. 5. Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 2011;27:270-278. 6. Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med. 2008;42:551-554. 7. Burcharth J, Pedersen M, Bisgaard T, Pedersen C, Rosenberg J. Nationwide prevalence of groin hernia repair. PLoS One. 2013;8:e54367. 8. Campbell R. Ultrasound of the athletic groin. Semin Musculoskelet Radiol. 2013;17:34-42. 9. Clohisy JC, St John LC, Schutz AL. Surgical treatment of femoroacetabular impingement: a systematic review of the literature. Clin Orthop Relat Res. 2010;468:555-564. 10. Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011;2:5. 11. Dojcinovic B, Sebecic B, Staresnic M, Jankovic S, Japjec M, Culjak V. Surgical treatment of chronic groin pain in athletes. Int Orthop. 2012;36:2361-2365. 12. Economopoulos KJ, Milewski MD, Hanks JB, Hart JM, Diduch DR. Radiographic evidence of femoroacetabular impingement in athletes with athletic pubalgia. Sports Health. 2014;6:171-177. 13. Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey. J Bone Joint Surg Am. 2010;92:1162-1169. 14. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy. 2012;28:1388-1395. 15. Ho¨lmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a ‘‘clinical entity’’ approach: a prospective study of 207 patients. Br J Sports Med. 2007;41:247-252. 16. Kark AE, Kurzer M. Groin hernias in women. Hernia. 2008;12:267-270. 17. Kim B, Robinson P, Modi H, Gupta H, Horgan K, Achuthan R. Evaluation of the usage and influence of groin ultrasound in primary and secondary healthcare settings [published online January 10, 2014]. Hernia. doi:10.1007/s10029-014-1212-1. 18. Kingsworth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003;362:1561-1571. 19. Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy. 2011;27:1619-1627. 20. Lesniak BP, Loveland D, Jose J, Selley R, Jacobson JA, Bedi A. Use of ultrasonography as a diagnostic and therapeutic tool in sports medicine. Arthroscopy. 2014;30:260-270. 21. Leunig M, Ganz R. The evolution and concepts of joint-preserving surgery of the hip. Bone Joint J. 2014;96:5-18. 22. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport. 1995;27:75-79.
23. Maganaris CN, Narici MV, Almekinders LC, Maffulli N. Biomechanics and pathophysiology of overuse tendon injuries: ideas on insertional tendinopathy. Sports Med. 2004;34:1005-1017. 24. Mast NH, Impellizzeri F, Keller S, Leunig M. Reliability and agreement of measures used in radiographic evaluation of the adult hip. Clin Orthop Relat Res. 2011;469:188-199. 25. Mathews J, Alshameeri Z, Loveday D, Khanduja V. The role of fluoroscopically guided intra-articular hip injections in potential candidates for hip arthroscopy: experience at a UK tertiary referral center over 34 months. Arthroscopy. 2014;30:153-155. 26. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. 2011;27:252-269. 27. Mei-Dan O, Lopez V, Carmont MR, et al. Adductor tenotomy as a treatment for groin pain in professional soccer players. Orthopedics. 2013;36:e1189-e1197. 28. Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and treatment highlighting a minimal repair surgical technique. Am J Sports Med. 2011;39:1341-1349. 29. Naal FD, Hatzung G, Mu¨ller A, Impellizzeri F, Leunig M. Validation of a self-reported Beighton score to assess hypermobility in patients with femoroacetabular impingement [published online July 5, 2014]. Int Orthop. doi:10.1007/s00264-014-2424-9. 30. Naal FD, Miozzari HH, Scha¨r M, Hesper T, No¨tzli HP. Midterm results of surgical hip dislocation for the treatment of femoroacetabular impingement. Am J Sports Med. 2012;40:1501-1510. 31. Ng VY, Arora N, Best TM, Pan X, Ellis TJ. Efficacy of surgery for femoroacetabular impingement: a systematic review. Am J Sports Med. 2010;38:2337-2345. 32. Orchard JW, Cook JL, Halpin N. Stress-shielding as a cause of insertional tendinopathy: the operative technique of limited adductor tenotomy supports this theory. J Sci Med Sport. 2004;7:424-428. 33. Primatesta P, Goladacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol. 1996;25:835-839. 34. Reichenbach S, Leunig M, Werlen S, et al. Association between camtype deformities and magnetic resonance imaging-detected structural hip damage: a cross-sectional study in young men. Arthritis Rheum. 2011;63:4023-4030. 35. Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH. Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol. 2006;187:1168-1178. 36. Sankar WN, Nevitt M, Parvizi J, Felson DT, Agricola R, Leunig M. Femoroacetabular impingement: defining the condition and its role in the pathophysiology of osteoarthritis. J Am Acad Orthop Surg. 2013;21 Suppl 1:S7-S15. 37. Schilders E, Dimitrakopoulou A, Cooke M, Bismil Q, Cooke C. Effectiveness of a selective partial adductor release for chronic adductorrelated groin pain in professional athletes. Am J Sports Med. 2013;41:603-607. 38. Schouten N, Burgmans JP, van Dalen T, et al. Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality. Hernia. 2012;16:387-392. 39. Tibor LM, Liebert G, Sutter R, Impellizzeri FM, Leunig M. Two or more impingement and/or instability deformities are often present in patients with hip pain. Clin Orthop Relat Res. 2013;471:3762-3773. 40. Weir A, de Vos RJ, Moen M, Ho¨lmich P, Tol JL. Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain. Br J Sports Med. 2011;45:6-9. 41. Zendejas B, Ramirez T, Jones T, et al. Incidence of inguinal hernia repairs in Olmsted County, MN: a population-based study. Ann Surg. 2013;257:520-526.
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Sonographic Prevalence of Groin Hernias and Adductor Tendinopathy in Patients With Femoroacetabular Impingement Florian D. Naal, Francesco Dalla Riva, Thomas H. Wuerz, Beat Dubs and Michael Leunig Am J Sports Med published online July 17, 2015 DOI: 10.1177/0363546515591259 The online version of this article can be found at: http://ajs.sagepub.com/content/early/2015/07/17/0363546515591259
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Sonographic Prevalence of Groin Hernias and Adductor Tendinopathy in Patients With Femoroacetabular Impingement Florian D. Naal,*yz MD, Francesco Dalla Riva,y MD, Thomas H. Wuerz,§ MD, Beat Dubs,|| MD, and Michael Leunig,y MD Investigation performed at Schulthess Clinic, Zurich, Switzerland Background: Femoroacetabular impingement (FAI) is a common debilitating condition that is associated with groin pain and limitation in young and active patients. Besides FAI, various disorders such as hernias, adductor tendinopathy, athletic pubalgia, lumbar spine affections, and others can cause similar symptoms. Purpose: To determine the prevalence of inguinal and/or femoral herniation and adductor insertion tendinopathy using dynamic ultrasound in a cohort of patients with radiographic evidence of FAI. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study consisted of 74 patients (36 female and 38 male; mean age, 29 years; 83 symptomatic hips) with groin pain and radiographic evidence of FAI. In addition to the usual diagnostic algorithm, all patients underwent a dynamic ultrasound examination for signs of groin herniation and tendinopathy of the proximal insertion of the adductors. Results: Evidence of groin herniation was found in 34 hips (41%). There were 27 inguinal (6 female, 21 male) and 10 femoral (9 female, 1 male) hernias. In 3 cases, inguinal and femoral herniation was coexistent. Overall, 5 patients underwent subsequent hernia repair. Patients with groin herniation were significantly older than those without (33 vs 27 years, respectively; P = .01). There were no significant differences for any of the radiographic or clinical parameters. Tendinopathy of the proximal adductor insertion was detected in 19 cases (23%; 11 female, 8 male). Tendinopathy was coexistent with groin herniation in 8 of the 19 cases. There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy. Patients with a negative diagnostic hip injection result were more likely to have a concomitant groin hernia than those with a positive injection result (80% vs 27%, respectively). Overall, 38 hips underwent FAI surgery with satisfactory outcomes in terms of score values and subjective improvement. Conclusion: The results demonstrate that groin herniation and adductor insertion tendinopathy coexist frequently in patients with FAI. Although the clinical effect is yet unclear, 5 patients underwent hernia repair. Dynamic ultrasound is a useful tool to detect such pathological abnormalities. Diagnostic hip injections can be helpful to differentiate between the sources of pain. Keywords: femoroacetabular impingement; FAI; groin pain; hernia; adductor tendinopathy; diagnostic hip injection
It is widely accepted that femoroacetabular impingement (FAI) is a common cause of groin pain in younger and
active patients and that FAI can lead to early-onset osteoarthritis of the hip.1,13,34,36 Surgical treatment is indicated when nonoperative measures fail and/or secondary damage to the hip occurs. Success rates of 68% to 96% have been reported at short-term to midterm follow-up.5,9,26,31 However, FAI is not the only source of groin pain. Socalled sportsmen and classic groin hernias, adductor injuries, nerve entrapments, or affections of the lumbar spine are other common diagnoses that can lead to similar symptoms.15,22,28 Sometimes, different pathologic conditions coexist.3,6,14 In a recent investigation on patients who underwent surgery for athletic pubalgia, radiographic FAI criteria were fulfilled in 86% of the cases.12 In another series including patients with long-standing adductorrelated groin pain, the authors could demonstrate that as much as 94% of the symptomatic hips also had radiographic evidence of FAI.40 Besides adductor-related pain,
*Address correspondence to Florian D. Naal, MD, Department of Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich, Switzerland (email: [email protected]). y Department of Orthopaedic Surgery, Schulthess Clinic, Zurich, Switzerland. z Department of Orthopaedic Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. § Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA. || Sonografie-Institut Glattpark GmbH, Zurich, Switzerland. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. The American Journal of Sports Medicine, Vol. XX, No. X DOI: 10.1177/0363546515591259 Ó 2015 The Author(s)
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Figure 1. (A) Ultrasound image of the groin region before the Valsalva maneuver and (B) evidence of inguinal herniation during the Valsalva maneuver. A, external iliac artery; E, inferior epigastric artery; H, indirect inguinal hernia; V, external iliac artery. The curved arrow indicates the superior pubic ramus.
groin hernias are very common, and hernia repair is one of the most frequently performed general surgeries in the world.18 Hence, FAI and groin hernias might both be present in symptomatic patients, and differentiating between the sources of pain is of utmost importance before any type of surgery is indicated. To our knowledge, there has yet been no report investigating if groin hernias or adductor insertion injuries coexist in patients diagnosed with FAI. The goal of this study was therefore to determine the prevalence of inguinal and femoral hernias and tendinopathy of the adductor origin in a prospective cohort of patients with FAI based on a dynamic ultrasound examination and to investigate the clinical and radiographic characteristics of patients with and without coexisting disorders.
METHODS In the beginning of 2012, the routine diagnostic protocol of 2 of the authors (F.D.N., M.L.) for patients referred with possible FAI included a clinical examination, conventional anteroposterior pelvis and cross-table lateral hip radiographs, magnetic resonance imaging (MRI) with intra-articular gadolinium contrast, and a dynamic ultrasound examination of the involved groin. In most cases, a diagnostic intra-articular hip injection with use of 5 to 10 mL ropivacaine was also given. Patients were seen the same or the next day after the injection. They were advised to note their improvements from hour to hour using the following levels: no change, relief of about 20% to 25%, relief of about 50%, relief of about 75% to 80%, and complete relief. A positive injection result was defined as pain relief of at least 50% of the typical symptoms. We retrospectively reviewed the data of all patients seen by these 2 authors in the outpatient department between January and April 2012. Inclusion criteria were a final diagnosis of FAI (ie, cam deformity of the proximal femur and/or pincer component) and age between
16 and 55 years. Exclusion criteria were hip disorders other than FAI (eg, dysplasia), osteoarthritis .grade 2 according to the To¨nnis classification, previous hip surgery, and previous groin surgery for any reason. The final cohort consisted of 74 patients (36 female and 38 male) with 83 symptomatic hips. The mean age was 28.7 6 10.2 years. All patients provided written informed consent. Radiographs were studied for the following parameters: lateral center-edge (LCE) angle, acetabular roof (AC) angle, neck-shaft angle, acetabular version, and alpha angle. All measurements were performed using a digital imaging system (JiveX v 4.5.3 RC5; Visus Technology) with use of standardized techniques.24,39 Clinically, the physician recorded hip flexion, internal and external rotation in flexion, abduction, and pain on impingement testing. The ultrasound evaluation was performed by one of the authors (B.D.), an internist specialized in the ultrasound technique and head of an ultrasound institute for 21 years, with the General Electric Voluson E6 sonography system (General Electric Healthcare), using a 7.5- to 10-MHz probe following routine guidelines (Schweizer Gesellschaft fu¨r Ultraschall in Medizin [SGUM] guidelines). While the routinely performed MRI might also serve for hernia detection, this investigation is a static one. Dynamic ultrasound with help of the Valsalva maneuver has been shown to be a reliable method to detect hernias in patients with no or only moderate clinical symptoms.17,35 Other conditions such as osteitis pubis or adductor tendinopathy can also be assessed.8,20 Images were evaluated for signs of herniation (femoral and/or inguinal hernias) and tendinopathy of the proximal insertion of the adductors. Herniation was defined as a reproducibly visible hernia under the Valsalva maneuver and/or reproducible bulging of the abdominal wall (Figure 1). Patients with sonographic evidence of groin herniation and a negative diagnostic hip injection result were referred to a general surgeon. Statistics were performed using GraphPad software. Assessing the prevalence of concomitant groin disorders
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TABLE 1 Radiographic Parameters of the Study Cohorta Parameter, deg
TABLE 2 Clinical Data for the 38 Hips Undergoing FAI Surgerya
Mean 6 SD Outcome Measure
LCE angle AC angle CCD angle Acetabular version Alpha angle
31.6 5.5 133.4 16.4 55.8
3
6 6 6 6 6
5.6 4.5 5.6 5.2 8.7
a AC, acetabular roof; CCD, caput-collum-diaphysis; LCE, lateral center-edge.
was the primary research goal. Analyzing their associations with demographics, radiographic parameters, and diagnostic hip injections was the secondary goal. Differences between patients (female vs male, herniation vs no herniation, tendinopathy vs no tendinopathy) were compared using unpaired t tests after testing for normal distribution. Unless otherwise stated, all data are presented as mean 6 SD. P values \.05 were considered significant.
RESULTS The radiographic parameters of the entire cohort are presented in Table 1. The FAI type was mixed in 49 hips (59.0%), pincer in 20 hips (24.1%), and cam in 14 hips (16.9%). Clinically, the mean hip flexion was 108.2° 6 8.9°, internal rotation was 21.3° 6 12.9°, external rotation was 38.6° 6 10.8°, and abduction was 41.3° 6 7.6°. The impingement test result was positive in 70 hips (84.3%). There were no differences between female and male patients for age, LCE angles, and AC angles (P = .231.797). There was a trend toward higher caput-collumdiaphysis angles in female patients than male patients (134.7° vs 132.3°, respectively; P = .521). Female patients had significantly higher acetabular anteversion (17.7° vs 15.3°, respectively; P = .043) and lower alpha angles (53.3° vs 57.9°, respectively; P = .016) than male patients. Clinically, female patients had significantly higher hip flexion (111.1° vs 105.8°, respectively; P = .006), internal rotation (25.8° vs 17.7°, respectively; P = .004), and external rotation (41.8° vs 35.9°, respectively; P = .18) than male patients. None of the female hips had pure cam FAI, 68.4% had mixed-type FAI, and 31.6% had pincer FAI. In male patients, cam FAI was evident in 31.1% of the hips, mixed-type FAI in 51.1%, and pincer FAI in 17.8%. Evidence of groin herniation was found in 34 hips (41%). There were 27 inguinal (6 female, 21 male; ratio, 1:6.3) and 10 femoral (9 female, 1 male; ratio, 9:1) hernias. In 3 cases, inguinal and femoral herniation was coexistent. Overall, 5 patients underwent subsequent hernia repair. Of these, 4 became free of symptoms after hernia surgery. Patients with groin herniation were significantly older than those without (32.9 vs 26.8 years, respectively; P = .01). There were no significant differences for any of the radiographic or clinical parameters. Tendinopathy of the proximal adductor insertion was detected in 19 cases (22.9%; 11 female and 8 male).
EQ-5D (0-1 scale) EQ-5D VAS (0-100 scale) Oxford Hip Score (0-48 scale) UCLA activity scale (0-10 scale) Subjectively improved or much improved, %
1-Year Preoperative Follow-up P Value 0.53 62.1 32.7 5.6
0.70 72.8 41.1 6.8
.002 .027 \.001 .004
—
81.6
—
a For all measures, higher values represent better health states. EQ-5D, EuroQol; FAI, femoroacetabular impingement; UCLA, University of California, Los Angeles; VAS, visual analog scale.
Tendinopathy was coexistent with groin herniation in 8 of the 19 cases. There were no significant differences for any of the radiographic or clinical parameters between patients with or without tendinopathy. An intra-articular injection was given in 63 hips. In the group of patients that had a positive hip injection result (48 hips; 76.2%), 13 (27.1%) had evidence of groin herniation, whereas 12 of 15 (80.0%) had herniation in the group that did not respond to the hip injection (P \ .01). Three of the cases with inguinal herniation underwent subsequent hernia repair. Signs for adductor tendinopathy were seen more frequently in the responder group than in the nonresponders (29.2% vs 20.0%, respectively; P = .041). Age did not differ between responders and nonresponders, but the latter group consisted solely of male patients (n = 15/15). Thirty-six (75.0%) of the hips responding to the diagnostic injection underwent subsequent FAI surgery, but only 2 (13.3%) of the nonresponding hips did. Overall, 38 hips (45.8%) underwent FAI surgery (either hip arthroscopic surgery or surgical dislocation). Thirtythree of these hips had a diagnostic intra-articular injection before surgery. The infiltration was positive in 31 hips (94%). One of the 2 cases (male, 36 years) with a negative infiltration underwent FAI surgery because of persistent symptoms after hernia repair (see paragraph above). The second case, a 17-year-old male patient with cam FAI, had reported pain relief of about 25% after the injection, and this result was therefore considered negative. He underwent nonoperative treatment but had progressive symptoms. Repeated MRI revealed new, large acetabular cartilage delamination, and surgery was then indicated (see paragraph above). The prevalence of groin herniation (42.1% vs 40.0%, respectively; P = .328) and adductor tendinopathy (23.7% vs 22.2%, respectively; P = .542) did not differ between patients who underwent FAI surgery and those who did not. Outcome scores improved significantly from preoperatively to 1 year after surgery (Table 2). Subjectively, surgery improved or much improved symptoms in 81.6% of the cases. There were no differences for preoperative mean scores, postoperative mean scores, change scores, or proportion of improved patients between cases with concomitant groin hernia and those without (P = .28-.99).
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DISCUSSION Groin pain is a common debilitating condition in young and active patients. Various disorders can be responsible for pain and limitation; one of these is FAI. There is increasing evidence that FAI is associated with early hip joint degeneration, and surgical treatment might be indicated in patients after nonoperative treatment has failed.{ However, FAI is not the exclusive source of groin pain. Other disorders such as hernias, adductor tendinopathy, athletic pubalgia, lumbar spine problems, and others can cause similar symptoms.3,6,12,14,15,22,28,40 This study therefore aimed to determine the prevalence of inguinal and/or femoral herniation and adductor insertion tendinopathy using dynamic ultrasound in a cohort of patients with radiographic evidence of FAI. The present results highlight that coexisting disorders are frequent. Groin hernias were detected in more than 40% of the cases, and almost one-fourth had evidence of adductor insertion tendinopathy at the pubic bone. Before interpreting these results, some limitations have to be considered. First, the cohort is relatively small, and the results are therefore not generalizable without caution. Second, the study design is retrospective, and patients who did not undergo surgery were not followed prospectively. Therefore, it is possible that some cases had been operated for FAI somewhere else or for groin herniation later on. Also, this study does not include a control group. A comparative study with matched asymptomatic participants would be of interest in the future. Furthermore, considering the success of a diagnostic hip injection always includes the risk of subjective bias. We therefore chose a relatively high cut-off value of at least 50% pain relief for a positive result, while other authors used lower thresholds.19 Finally, no outcome measures are collected in our outpatient (different to our surgical patients) department; therefore, comparisons of clinical outcomes between operated and nonoperated cases were not possible. On the other hand, the study cohort is very well defined, and the primary research question was to determine the prevalence and not clinical outcomes. The prevalence of groin herniation was very high in this cohort. The values are, however, difficult to compare with those in the literature because we are not aware of normative values based on ultrasound investigations. Ultrasound has been nevertheless considered as the imaging investigation of choice for clinically unrecognized or subclinical hernias.8 The lifetime risk of inguinal hernia repair has been reported to be 27% for male and 3% for female patients.33 In a Danish nationwide investigation covering more than 5 million persons, 46,717 hernia repairs (about 8%) have been performed within 5 years.7 Even higher values were reported by Zendejas et al41 based on a population-based investigation in the United States. While these figures are based on definitive hernia surgery, the prevalence of subclinical disorders might be higher. Although not directly comparable, the herniation prevalence of 41% observed in the current study appears to be high. This is
{
References 1, 5, 9, 13, 21, 26, 30, 31, 34, 36.
particularly the case for female patients. About 16% of the female patients in the present cohort had evidence of inguinal herniation, and as much as 23% showed femoral herniation. These numbers are above values usually reported4,10,16,38 and let us speculate that there might exist a more generalized connective tissue problem in patients with groin pain and different coexisting disorders, as discussed below. Interestingly, the prevalence of groin herniation and adductor tendinopathy did not differ between patients who underwent FAI surgery and those who did not. Also, we could not find differences in outcome scores for those patients with or without hernias who underwent FAI surgery, neither preoperatively nor postoperatively. This observation underlines that groin herniation is in fact a relatively common comorbidity in patients with FAI, but as long as the diagnostic hip injection results in pain relief, the clinical relevance seems to be insignificant. While a positive hip injection result does not exclude the presence of a groin hernia per se, negative diagnostic infiltration seems to have some predictive ability. Considering that, overall, 5 of 83 (6%) painful hips in patients referred for possible symptomatic FAI underwent hernia repair, there is indeed a clinical relevance. Although 1 of these cases had persistent symptoms after hernia repair and underwent successful FAI surgery later on, the present findings indicate that about 4 to 5 of 100 patients with groin pain and FAI require hernia repair and not FAI treatment. Tendinopathy of the adductor insertion is another common condition encountered in physically active patients. The cause is yet rather unknown, also reflected by different treatment recommendations ranging from nonoperative measures to surgical adductor release.11,27,37,40 In the present FAI cohort, adductor insertion tendinopathy was evident in more than 20% of the cases. The clinical relevance of concomitant adductor tendinopathy is, however, unclear. The prevalence was similar in patients who underwent FAI surgery and those who did not. Further, there was an unexpectedly higher prevalence of tendinopathy in patients who had a positive hip injection result. While we are not aware of any adductor-related surgery performed in patients of this cohort, most patients underwent nonoperative treatment. Related to the origin and relatively high prevalence of tendinopathy and also herniation, we speculated that the altered hip biomechanics in patients with FAI, particularly in those with severe cam deformities, might act as stress and strain risers for the soft tissues and musculotendinous structures around the hip. A biomechanical stress-shielding theory in the origin of adductor tendinopathy has been proposed before.3,23,32 However, we did not find any significant differences in clinical and radiographic parameters, particularly alpha angles, between patients with herniation or adductor tendinopathy and those without. The only difference was related to age, with patients with hernias being older than those without herniation. The clinical relevance of this finding might be insignificant. Some sort of association between FAI and other connective tissue injuries might be nevertheless fact, although not yet proven or understood. In this regard, a high prevalence of generalized joint
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History, examination, radiograph, contrast MRI
All positive for FAI, cartilage damage
FAI surgery
All positive for FAI, no cartilage damage
Nonoperative treatment
failure
FAI surgery
success
End of treatment
failure
FAI surgery
success
End of treatment
Mild deformity, none or subtle joint damage, untypical history or examination
Diagnostic hip injection
positive
5
Nonoperative treatment
negative
Dynamic ultrasound for groin hernia
negative
Nonoperative treatment
positive
Presenting to general surgeon
success
End of treatment
failure
Repeated workup, other pathology?
rule out
Nerve entrapment, spine pathology, etc
Figure 2. Diagnostic algorithm for patients with possible femoroacetabular impingement (FAI). hypermobility in patients with FAI has been also observed before.29 Further research is therefore required to understand the role and causes of different coexisting disorders around the groin, including basic science investigations. Almost half of the hips in the present series underwent FAI surgery at a certain point. While this proportion appears to be high, it has to be considered that this cohort already represents a highly selected one with a final diagnosis of FAI. Nonoperative treatment is usually performed as a first-line treatment in all patients before surgery is indicated. This consists of a regular muscle training program focusing on core stabilization, training of hip abductors and flexors, stretching/detonization of adductors and rectus muscles, and local ultrasound treatment of the adductor insertion in cases with tendinopathy. For the latter, a local steroid or autologous conditioned plasma injection might be also considered. The indication for FAI surgery is not only based on radiographic parameters, but it is also more a complete picture of all relevant findings, including typical MRI damage patterns and potentially diagnostic hip injections. Diagnostic hip injections have been considered useful for differentiating between intra- and extra-articular pain. In a study including 72 patients with a mean age of 29.9 years, hip arthroscopic surgery was performed only in patients who responded to an injection within a 2-hour time frame.19 These authors defined a positive response as pain relief of at least 10%. Overall, 11 of the 72 patients had pain relief of less than 50%, and in these cases, labral tears without cartilage damage and extra-articular injuries were observed frequently.19 In a response to this study, Mathews et al25 reported on their experience with diagnostic hip injections. These authors reported a response rate to the injection of 82%, and all of these 55 hips presented intra-articular
injuries upon surgery.25 Similarly, Ayeni and coworkers2 reported on partial or complete pain relief after a hip injection in 81% of their patients with FAI before hip arthroscopic surgery. Patients who did not receive pain relief from the injection were half as likely to have better function and reduced pain at 6 months after surgery using the modified Harris Hip Score as an outcome parameter.2 The response rate to the hip injections in the present study was 76% and is somewhat lower than reported before, but we used more strict criteria to define a positive injection result with at least 50% of the symptoms to be resolved. We found that the prevalence of groin herniation and adductor tendinopathy was increased in the cases with a negative hip injection result, underlining its usefulness to differentiate between intraand extra-articular symptoms. On the basis of these findings, we adapted our diagnostic algorithm (Figure 2). While a diagnostic injection does not always seem necessary in patients with very typical FAI, it can help in those patients with only mild deformities or less characteristic symptoms. A dynamic ultrasound investigation of the groin should be considered if the injection result is negative. Taken together, the present study demonstrates that groin herniation and adductor insertion tendinopathy coexist frequently in patients with FAI, although the results cannot be generalized because the study sample is small and did not include a control group. A diagnostic hip injection seems to be a reasonable method to further differentiate between the sources of pain. A positive injection result does not exclude the presence of a groin hernia but makes its clinical relevance unlikely. Dynamic ultrasound is a useful tool to detect groin disorders and should be considered in patients with FAI in whom a diagnostic hip injection result was negative.
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The American Journal of Sports Medicine
REFERENCES 1. Agricola R, Heijboer MP, Biema-Zeinstra SM, Verhaar JA, Weinans H, Waarsing JH. Cam impingement causes osteoarthritis of the hip: a nationwide prospective cohort study (CHECK). Ann Rheum Dis. 2013;72(6):918-923. 2. Ayeni OR, Farrokhyar F, Crouch S, Chan K, Sprague S, Bhandari M. Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014;22:801-805. 3. Bedi A, Dolan M, Leunig M, Kelly BT. Static and dynamic mechanical causes of hip pain. Arthroscopy. 2011;27:235-251. 4. Bendavid R. Femoral hernias in females: facts, figures and fallacies. In: Abdominal Wall Hernias. New York: Springer; 2001:639. 5. Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 2011;27:270-278. 6. Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med. 2008;42:551-554. 7. Burcharth J, Pedersen M, Bisgaard T, Pedersen C, Rosenberg J. Nationwide prevalence of groin hernia repair. PLoS One. 2013;8:e54367. 8. Campbell R. Ultrasound of the athletic groin. Semin Musculoskelet Radiol. 2013;17:34-42. 9. Clohisy JC, St John LC, Schutz AL. Surgical treatment of femoroacetabular impingement: a systematic review of the literature. Clin Orthop Relat Res. 2010;468:555-564. 10. Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011;2:5. 11. Dojcinovic B, Sebecic B, Staresnic M, Jankovic S, Japjec M, Culjak V. Surgical treatment of chronic groin pain in athletes. Int Orthop. 2012;36:2361-2365. 12. Economopoulos KJ, Milewski MD, Hanks JB, Hart JM, Diduch DR. Radiographic evidence of femoroacetabular impingement in athletes with athletic pubalgia. Sports Health. 2014;6:171-177. 13. Gosvig KK, Jacobsen S, Sonne-Holm S, Palm H, Troelsen A. Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey. J Bone Joint Surg Am. 2010;92:1162-1169. 14. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy. 2012;28:1388-1395. 15. Ho¨lmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a ‘‘clinical entity’’ approach: a prospective study of 207 patients. Br J Sports Med. 2007;41:247-252. 16. Kark AE, Kurzer M. Groin hernias in women. Hernia. 2008;12:267-270. 17. Kim B, Robinson P, Modi H, Gupta H, Horgan K, Achuthan R. Evaluation of the usage and influence of groin ultrasound in primary and secondary healthcare settings [published online January 10, 2014]. Hernia. doi:10.1007/s10029-014-1212-1. 18. Kingsworth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003;362:1561-1571. 19. Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy. 2011;27:1619-1627. 20. Lesniak BP, Loveland D, Jose J, Selley R, Jacobson JA, Bedi A. Use of ultrasonography as a diagnostic and therapeutic tool in sports medicine. Arthroscopy. 2014;30:260-270. 21. Leunig M, Ganz R. The evolution and concepts of joint-preserving surgery of the hip. Bone Joint J. 2014;96:5-18. 22. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport. 1995;27:75-79.
23. Maganaris CN, Narici MV, Almekinders LC, Maffulli N. Biomechanics and pathophysiology of overuse tendon injuries: ideas on insertional tendinopathy. Sports Med. 2004;34:1005-1017. 24. Mast NH, Impellizzeri F, Keller S, Leunig M. Reliability and agreement of measures used in radiographic evaluation of the adult hip. Clin Orthop Relat Res. 2011;469:188-199. 25. Mathews J, Alshameeri Z, Loveday D, Khanduja V. The role of fluoroscopically guided intra-articular hip injections in potential candidates for hip arthroscopy: experience at a UK tertiary referral center over 34 months. Arthroscopy. 2014;30:153-155. 26. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. 2011;27:252-269. 27. Mei-Dan O, Lopez V, Carmont MR, et al. Adductor tenotomy as a treatment for groin pain in professional soccer players. Orthopedics. 2013;36:e1189-e1197. 28. Minnich JM, Hanks JB, Muschaweck U, Brunt LM, Diduch DR. Sports hernia: diagnosis and treatment highlighting a minimal repair surgical technique. Am J Sports Med. 2011;39:1341-1349. 29. Naal FD, Hatzung G, Mu¨ller A, Impellizzeri F, Leunig M. Validation of a self-reported Beighton score to assess hypermobility in patients with femoroacetabular impingement [published online July 5, 2014]. Int Orthop. doi:10.1007/s00264-014-2424-9. 30. Naal FD, Miozzari HH, Scha¨r M, Hesper T, No¨tzli HP. Midterm results of surgical hip dislocation for the treatment of femoroacetabular impingement. Am J Sports Med. 2012;40:1501-1510. 31. Ng VY, Arora N, Best TM, Pan X, Ellis TJ. Efficacy of surgery for femoroacetabular impingement: a systematic review. Am J Sports Med. 2010;38:2337-2345. 32. Orchard JW, Cook JL, Halpin N. Stress-shielding as a cause of insertional tendinopathy: the operative technique of limited adductor tenotomy supports this theory. J Sci Med Sport. 2004;7:424-428. 33. Primatesta P, Goladacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol. 1996;25:835-839. 34. Reichenbach S, Leunig M, Werlen S, et al. Association between camtype deformities and magnetic resonance imaging-detected structural hip damage: a cross-sectional study in young men. Arthritis Rheum. 2011;63:4023-4030. 35. Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH. Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol. 2006;187:1168-1178. 36. Sankar WN, Nevitt M, Parvizi J, Felson DT, Agricola R, Leunig M. Femoroacetabular impingement: defining the condition and its role in the pathophysiology of osteoarthritis. J Am Acad Orthop Surg. 2013;21 Suppl 1:S7-S15. 37. Schilders E, Dimitrakopoulou A, Cooke M, Bismil Q, Cooke C. Effectiveness of a selective partial adductor release for chronic adductorrelated groin pain in professional athletes. Am J Sports Med. 2013;41:603-607. 38. Schouten N, Burgmans JP, van Dalen T, et al. Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality. Hernia. 2012;16:387-392. 39. Tibor LM, Liebert G, Sutter R, Impellizzeri FM, Leunig M. Two or more impingement and/or instability deformities are often present in patients with hip pain. Clin Orthop Relat Res. 2013;471:3762-3773. 40. Weir A, de Vos RJ, Moen M, Ho¨lmich P, Tol JL. Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain. Br J Sports Med. 2011;45:6-9. 41. Zendejas B, Ramirez T, Jones T, et al. Incidence of inguinal hernia repairs in Olmsted County, MN: a population-based study. Ann Surg. 2013;257:520-526.
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