Accepted Manuscript Successful Treatment of Athletic Pubalgia in a Lacrosse Player with UltrasoundGuided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report Paul M. Scholten, MD Stephen Massimi, MD Nick Dahmen, MS, ATC, CSCS Joanne Diamond, RN James Wyss, MD, PT PII:
S1934-1482(14)01328-8
DOI:
10.1016/j.pmrj.2014.08.943
Reference:
PMRJ 1328
To appear in:
PM&R
Received Date: 29 December 2013 Revised Date:
11 August 2014
Accepted Date: 12 August 2014
Please cite this article as: Scholten PM, Massimi S, Dahmen N, Diamond J, Wyss J, Successful Treatment of Athletic Pubalgia in a Lacrosse Player with Ultrasound-Guided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report, PM&R (2014), doi: 10.1016/j.pmrj.2014.08.943. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Nick Dahmen, MS, ATC, CSCS St. John’s University, Department of Athletics 8000 Utopia Parkway Queens, NY 11439 Tel: 718-990-6198 Fax: 718-990-2198 e-mail: [email protected] Joanne Diamond, RN Hospital for Special Surgery th 75 Street Campus th th 429 East 75 Street, 4 Floor New York, NY 10021 Tel: 212-606-1731 Fax: 212-774-7040 e-mail: [email protected]
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Stephen Massimi, MD Hospital for Special Surgery th 75 Street Campus th th 429 East 75 Street, 4 Floor Tel: 212-606-1731 Fax: 212-774-7040 e-mail: [email protected]
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AUTHORS: Paul M. Scholten, MD New York-Presbyterian Hospital – Columbia and Cornell st Harkness Pavilion 1 Floor, Rm 180 180 Fort Washington Avenue New York, NY 10032 Tel: 212-305-8592 Fax: 212-305-4258 e-mail: [email protected]
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Successful Treatment of Athletic Pubalgia in a Lacrosse Player with Ultrasound-Guided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report
James Wyss, MD, PT Hospital for Special Surgery th 75 Street Campus th th 429 East 75 Street, 4 Floor New York, NY 10021 Tel: 212-606-1731 Fax: 212-774-7040 e-mail: [email protected] Funding: No sources of funding were used for this case presentation.
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Successful Treatment of Athletic Pubalgia in a Lacrosse Player with Ultrasound-Guided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report
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ABSTRACT:
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Athletic pubalgia is a syndrome of persistent groin pain due to chronic, repetitive trauma
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or stress involving the pelvic joints and many musculotendinous structures that cross the
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anterior pelvis. As a result, the differential diagnosis can be complex, but insertional
5
tendinopathies are the most common. This case report describes a novel approach to
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the treatment of distal rectus abdominis tendinopathies with ultrasound-guided needle
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tenotomy and platelet rich plasma (PRP) injection. Following injection, the patient
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returned to pain-free play at his previous level of intensity. This suggests PRP may be a
9
useful treatment for this diagnosis.
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INTRODUCTION:
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Athletic pubalgia is a syndrome of persistent groin pain due to chronic, repetitive trauma
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or stress involving the pelvic joints and many musculotendinous structures that cross the
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anterior pelvis. It occurs most commonly in sports that require sudden changes in
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direction or intense twisting such as soccer, hockey, rugby, skating, fencing, cross
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country skiing, basketball1 and lacrosse. The etiology often involves abnormal or
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imbalanced movements at the hips, pelvis or lumbosacral spine. The mechanism of
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injury is chronic tensile overload with repetitive microtrauma. In the majority of cases the
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pathoanatomical structures responsible for symptoms of insertional tendinopathy at the
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anterior pelvis are the distal rectus abdominis or hip adductor group2. Other less
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common causes of pelvic pain in athletes include osteitis pubis and “sportsman’s
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hernias” (disruptions of the posterior abdominal wall).
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Initial treatment of insertional tendinopathy of the hip adductors or the rectus abdominis
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consists of rest, ice, oral non-steroidal anti-inflammatory drugs (NSAIDs) and physical
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therapy. Therapeutic exercises should aim to restore normal range of motion and correct
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abnormal shear across the pelvis generated by relative weakness of any of the major
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muscle groups attaching there, including hip flexors, hip extensors, lumbar extensors,
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trunk flexors, hip adductors or hip abductors. Once a relatively weak muscle group is
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identified, an eccentric strengthening program can be beneficial3. Any tight muscle
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groups should also be targeted in a stretching program to minimize any compensatory
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adaptations that could lead to additional injuries. If symptoms fail to improve with
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conservative measures, injection of the tendon sheath and enthesis with corticosteroids
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may be considered4, and in cases of “sportsman’s hernia” early surgical intervention may
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be recommended5.
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Previous reports have suggested a role for PRP in the treatment of lateral epicondylitis6-
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Given its reported success in the treatment of pathologically similar conditions, the
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authors considered PRP as a reasonable treatment option in an elite athlete who was
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otherwise not able to return to competition.
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, patellar tendinopathy12,13, Achilles tendinopathy14, and rotator cuff tendinopathy15,16.
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We report a case of athletic pubalgia due to distal rectus abdominis tendinopathy treated
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with targeted ultrasound-guided PRP injection and tenotomy with complete resolution of
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symptoms and discuss the potential roles and advantages of this technique.
45 CASE PRESENTATION:
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A 20-year-old male Division I collegiate lacrosse player presented with a 1-year history
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of gradual onset lateral left hip pain with a positive “C-sign” and groin pain that
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intermittently radiated to the left testicle. At the time of his evaluation at our center he
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had already been diagnosed with a left hip labral tear based on clinical examination,
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magnetic resonance imaging (MRI) findings and a positive response to an intra-articular
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left hip injection with corticosteroid and anesthetic. He subsequently underwent
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arthroscopic labral debridement. Postoperatively, his left antero-lateral hip pain
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improved, however his groin pain persisted. This was despite treatment with NSAIDs,
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injection with corticosteroid and anesthetic to the pubic symphysis that was performed
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prior to evaluation at our institution and a total of 12 months (6 months post-operatively)
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of an active rehabilitation program. This was performed under the supervision of his
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athletic trainer and included range of motion exercises for the hip and lumbar spine as
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well as eccentric core and lower extremity strengthening. He made small gains and was
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relatively pain-free at rest, however his symptoms worsened with activity, limited his
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ability to practice and prevented participation in competition. He denied having any back
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pain.
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Examination revealed tenderness at the insertion of the distal rectus abdominis muscle
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at the margin of the left pubic symphysis that reproduced his characteristic pain. There
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was no tenderness overlying the lumbosacral spine, paraspinal musculature or sacral
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sulcus. Internal rotation of the hip was 10 degrees on the left and 20 degrees on the
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right. Strength, sensation and reflexes were all normal. Flexion, abduction and external
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rotation (FABER) of the left hip and resisted left hip adduction both elicited mild
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ipsilateral groin pain, but were not his typical sport-limiting symptoms and when tested
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on the right were normal. Straight leg raise, seated slump test, Gaenslen, thigh thrust
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and gapping tests were all negative bilaterally.
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Radiographs of the hips revealed a small cam lesion on the left and were otherwise
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unremarkable. MRI prior to his left hip labral debridement demonstrated 1) a central fluid
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cleft along the articular disc of the pubic symphysis; 2) increased signal along the
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insertion of the left rectus abdominis when compared to the right; 3) marrow edema
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within the right parasymphyseal pubis; 4) an antero-superior left acetabulum labrum tear
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(since debrided); and 5) disc protrusions at L4/5 and L5/S1 (Figure 1). Given the left-
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sided rectus abdominis MRI findings, and his persistent post-operative left-sided pain
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and tenderness at the insertion of this muscle at the pelvis, a diagnosis of distal rectus
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abdominis tendinopathy was made. The authors postulate that altered biomechanics
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due to a tendinopathic and relatively weakened left rectus abdominis muscle may have
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contributed to increased shear at the pubic symphysis and resulted in the observed
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marrow edema on the asymptomatic right side. The lumbar disc protrusions were not
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believed to be symptomatic.
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Given his poor response to an appropriate rehabilitation program and conservative
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medical management, two surgical consultations were obtained for possible
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“sportsman’s hernia” repair. Both surgeons recommended that he continue non-
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operative treatment. At this point, the authors felt that additional therapeutic exercise
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was unlikely to return the athlete to play. The risks, benefits, alternatives and limited
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evidence for ultrasound-guided needle tenotomy and PRP injection of the left distal
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rectus abdominis muscle were discussed with the patient and he provided informed
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consent for this procedure.
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The PRP procedure was conducted as follows. First, 52 mL of peripheral whole blood
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was withdrawn from the patient into a syringe containing 8 mL of Anticoagulant Citrate
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Dextrose – Formula A resulting in a final volume of 60 mL that was processed with a
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Magellan® Autologous Platelet Separator (Arteriocyte Medical Systems, Inc., Cleveland,
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OH) according to manufacturer instructions to produce 5 mL of leukocyte-rich platelet
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rich plasma. Then, with the patient supine, the skin overlying the pubic symphysis was
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prepared and draped in the usual sterile fashion before being anesthetized with 1%
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lidocaine. Next, a 22-gauge 3.5-inch spinal needle was advanced under ultrasound
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guidance (M-MSK Ultrasound System, SonoSite, Inc., Bothell, WA) using a high
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frequency linear transducer (HFL50x/15-6 MHz SonoSite, Inc., Bothell, WA) with the
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needle in-plane (i.e. longitudinal or long axis) relative to the transducer and tendon fibers
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in a cephalo-caudad manner through the skin and left rectus abdominis tendon to its
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insertion at the pubic crest between the pubic tubercle and the pubic symphysis. Then,
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needle tenotomy was performed, and a total of 5mL of autologous PRP was injected in
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two aliquots at the tendon insertion near the pubic crest and the musculotendinous
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junction with the rectus sheath. Adequate distension of the sheath was visualized at that
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site (Figure 2). The needle was then removed and a sterile bandage was applied. The
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patient tolerated the injection well. He followed the post-procedure rehabilitation
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guidelines outlined by Finoff, et al.17 with the modification that he was permitted to
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advance the program more rapidly if he was able to perform all activities at the current
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level without significant pain.
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Four weeks post-injection the patient had 0/10 pain and there was no tenderness at the
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pubic symphysis. By six weeks post-injection he was given clearance to begin sport
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specific training and modified practice under the supervision of his athletic trainer. With
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continued progressive rehabilitation he returned to full pain-free play at his previous level
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of intensity eight weeks after the injection, including an entire Division I lacrosse season
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without recurrence of symptoms.
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DISCUSSION:
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This is the first reported case, to our knowledge, of complete resolution of athletic
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pubalgia symptoms, specifically distal rectus abdominis tendinopathy, following PRP
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injection. Singh, et al.18 have reported a case of successful treatment with PRP for a
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complete adductor longus tendon tear from its insertion at the anterior surface of the
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pubis, which anatomically lies near the insertion of the rectus abdominis, but represents
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a pathologically distinct process.
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There is a close biomechanical relationship between the hip, pelvis and lumbosacral
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spine that can lead to the co-occurrence of several related diagnoses with similar pain-
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referral patterns, as was observed in this patient presenting with groin pain and
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diagnosed with both an intra-articular hip pathology and a distal rectus abdominis
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tendinopathy. Such cases can be a diagnostic challenge. Patients may require extensive
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workup and treatment of multiple diagnoses before their symptoms resolve.
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Observational studies have noted a high incidence of athletic pubalgia symptoms in
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professional athletes with symptomatic femoroacetabular impingement (FAI)19. Patients
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with FAI have decreased hip range of motion (ROM) due to cam- or pincer-type lesions
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or a combination of the two. It has been proposed that a compensatory increase in
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lumbar spine, sacroiliac joint and pubic symphysis ROM occurs in order to achieve
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functional ROM. This results in abnormal dynamic muscle forces across the pelvis and
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abnormal strains on the muscles attaching in this region20. This theory has been
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substantiated in a more recent cadaveric study demonstrating that cam lesions increase
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rotational motion at the pubic symphysis21. The increased motion across the pelvis and
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resultant repetitive overload in the tendons attaching there can contribute to
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tendinopathy, as occurred in this patient.
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In this case, initial treatment was targeted at the patient’s hip pathology. After a course
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of rehabilitation failed to return him to competition, he underwent surgical labral
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debridement. This operation does not correct the underlying anatomical abnormality and
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it is postulated that although he completed an adequate post-operative rehabilitation
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program, he was unable to make significant functional gains and return to lacrosse
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because his painful rectus abdominis tendinopathy symptoms continued to be
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exacerbated by the underlying biomechanical alterations caused by his FAI. An
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alternative first surgical option for this patient would have been an osteochondroplasty to
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correct the cam lesion which has been shown to be effective in alleviating concomitant
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athletic pubalgia symptoms19. Furthermore, having not had the underlying anatomic
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abnormality corrected likely places him at increased risk of having recurrent
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tendinopathy symptoms.
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At the time of this athlete’s initial evaluation at this institution his primary source of pain
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was determined to be the rectus abdominis muscle at its insertion on the anterior pelvis.
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A reasonable initial step in such a patient is to complete a course of physical therapy
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aimed at correcting any relative weaknesses in the muscles attaching to the pelvis. If this
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is not successful in returning the athlete to play, it is then important to employ a patient-
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centered approach that takes into account the athlete’s goals and the risks and benefits
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of the available treatment options. In this case, options included continued therapeutic
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exercise, ultrasound-guided needle tenotomy with PRP injection and
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osteochondroplasty. Having already undergone extensive physical therapy and one
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operation without complete relief of pain, or the ability to return to play, the athlete was
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reluctant to pursue either of these options. His primary goal was to return to play as soon
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as possible and the authors felt that needle tenotomy with PRP offered him a reasonable
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chance of accomplishing this safely. Ultimately, the patient decided to proceed with this
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treatment plan.
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Following the injection he began a progressive rehabilitation program and had an
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excellent outcome with full return to play at his previous level of intensity. It is difficult to
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prove which of these interventions had a greater impact on his successful outcome
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because they were administered in close proximity to one another, however, given the
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extensive rehabilitation that he had both pre- and post-operatively without significant
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improvement in his pain, the therapeutic exercise alone is unlikely to account for his
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complete resolution of symptoms.
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Hip pathology often refers to the groin, which makes it difficult to distinguish between
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intra-articular sources of pain and those originating from extra-articular sources such as
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insertional tendinopathies of the rectus abdominis. Given this diagnostic challenge, and
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the common co-occurrence of these disorders, the author’s believe clinicians treating
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athletes with FAI or labral tears should investigate a diagnosis of chronic rectus
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abdominis insertional tendinopathy with or without hip adductor involvement early in their
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evaluation. Furthermore, in carefully selected patients with groin pain that fails to
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improve with nonsurgical treatment, it may be beneficial to consider treatment with
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ultrasound guided needle tenotomy and PRP injection prior to referring for surgery in
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order to avoid the added costs, potential morbidity, and the prolonged rehabilitation
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course that is associated with surgery.
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CONCLUSION:
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This case presentation suggests that athletic pubalgia, specifically distal rectus
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abdominis insertional tendinopathy, should be carefully considered in the differential
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diagnosis of refractory groin pain in patients with known FAI and labral tears.
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Furthermore, ultrasound-guided needle tenotomy and PRP injection can be a safe and
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effective treatment option in refractory cases of athletic pubalgia.
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ACKNOWLEDGEMENTS:
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The authors would like to thank Dr. Alissa Burge (Division of Magnetic Resonance
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Imaging, Department of Radiology and Imaging, Hospital for Special Surgery, New York,
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NY) for her assistance in interpreting the magnetic resonance images used in this
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manuscript.
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18. Singh JR, Roza R, Bartolozzi AR. Platelet Rich Plasma Therapy in an Athlete with
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Adductor Longus Tendon Tear. University of Pennsylvania Orthopedic Journal 2010; 20.
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19. Hammoud S, Bedi A, Magennis E, Meyers WC, Kelly BT. High incidence of athletic
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Figure 1: Pre-operative coronal STIR MRI images reveal in (A) marrow edema within
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the right parasymphyseal pubis (arrow) and a central fluid cleft along the articular disc of
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the pubic symphysis (open arrow) and in (B) a left antero-superior acetabulum labral
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tear. Sagittal proton density fat suppressed sequence images demonstrate disc
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protrusions at L4/5 and L5/S1 (C) and increased signal along the insertion of the left
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rectus abdominis (D) when compared to the right (E).
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Figure 2: Ultrasound guided PRP injection to the distal rectus abdominis. (A)
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Thickening and heterogeneous distal rectus abdominis tendon at insertion to pubic bone.
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(B) Initial trajectory of needle. (C) Injection of PRP. (D) Removal of needle.
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S1934-1482(14)01328-8
DOI:
10.1016/j.pmrj.2014.08.943
Reference:
PMRJ 1328
To appear in:
PM&R
Received Date: 29 December 2013 Revised Date:
11 August 2014
Accepted Date: 12 August 2014
Please cite this article as: Scholten PM, Massimi S, Dahmen N, Diamond J, Wyss J, Successful Treatment of Athletic Pubalgia in a Lacrosse Player with Ultrasound-Guided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report, PM&R (2014), doi: 10.1016/j.pmrj.2014.08.943. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
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Nick Dahmen, MS, ATC, CSCS St. John’s University, Department of Athletics 8000 Utopia Parkway Queens, NY 11439 Tel: 718-990-6198 Fax: 718-990-2198 e-mail: [email protected] Joanne Diamond, RN Hospital for Special Surgery th 75 Street Campus th th 429 East 75 Street, 4 Floor New York, NY 10021 Tel: 212-606-1731 Fax: 212-774-7040 e-mail: [email protected]
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Stephen Massimi, MD Hospital for Special Surgery th 75 Street Campus th th 429 East 75 Street, 4 Floor Tel: 212-606-1731 Fax: 212-774-7040 e-mail: [email protected]
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AUTHORS: Paul M. Scholten, MD New York-Presbyterian Hospital – Columbia and Cornell st Harkness Pavilion 1 Floor, Rm 180 180 Fort Washington Avenue New York, NY 10032 Tel: 212-305-8592 Fax: 212-305-4258 e-mail: [email protected]
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Successful Treatment of Athletic Pubalgia in a Lacrosse Player with Ultrasound-Guided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report
James Wyss, MD, PT Hospital for Special Surgery th 75 Street Campus th th 429 East 75 Street, 4 Floor New York, NY 10021 Tel: 212-606-1731 Fax: 212-774-7040 e-mail: [email protected] Funding: No sources of funding were used for this case presentation.
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Successful Treatment of Athletic Pubalgia in a Lacrosse Player with Ultrasound-Guided Needle Tenotomy and Platelet Rich Plasma Injection: A Case Report
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ABSTRACT:
2
Athletic pubalgia is a syndrome of persistent groin pain due to chronic, repetitive trauma
3
or stress involving the pelvic joints and many musculotendinous structures that cross the
4
anterior pelvis. As a result, the differential diagnosis can be complex, but insertional
5
tendinopathies are the most common. This case report describes a novel approach to
6
the treatment of distal rectus abdominis tendinopathies with ultrasound-guided needle
7
tenotomy and platelet rich plasma (PRP) injection. Following injection, the patient
8
returned to pain-free play at his previous level of intensity. This suggests PRP may be a
9
useful treatment for this diagnosis.
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INTRODUCTION:
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Athletic pubalgia is a syndrome of persistent groin pain due to chronic, repetitive trauma
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or stress involving the pelvic joints and many musculotendinous structures that cross the
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anterior pelvis. It occurs most commonly in sports that require sudden changes in
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direction or intense twisting such as soccer, hockey, rugby, skating, fencing, cross
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country skiing, basketball1 and lacrosse. The etiology often involves abnormal or
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imbalanced movements at the hips, pelvis or lumbosacral spine. The mechanism of
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injury is chronic tensile overload with repetitive microtrauma. In the majority of cases the
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pathoanatomical structures responsible for symptoms of insertional tendinopathy at the
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anterior pelvis are the distal rectus abdominis or hip adductor group2. Other less
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common causes of pelvic pain in athletes include osteitis pubis and “sportsman’s
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hernias” (disruptions of the posterior abdominal wall).
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Initial treatment of insertional tendinopathy of the hip adductors or the rectus abdominis
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consists of rest, ice, oral non-steroidal anti-inflammatory drugs (NSAIDs) and physical
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therapy. Therapeutic exercises should aim to restore normal range of motion and correct
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abnormal shear across the pelvis generated by relative weakness of any of the major
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muscle groups attaching there, including hip flexors, hip extensors, lumbar extensors,
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trunk flexors, hip adductors or hip abductors. Once a relatively weak muscle group is
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identified, an eccentric strengthening program can be beneficial3. Any tight muscle
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groups should also be targeted in a stretching program to minimize any compensatory
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adaptations that could lead to additional injuries. If symptoms fail to improve with
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conservative measures, injection of the tendon sheath and enthesis with corticosteroids
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may be considered4, and in cases of “sportsman’s hernia” early surgical intervention may
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be recommended5.
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Previous reports have suggested a role for PRP in the treatment of lateral epicondylitis6-
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Given its reported success in the treatment of pathologically similar conditions, the
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authors considered PRP as a reasonable treatment option in an elite athlete who was
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otherwise not able to return to competition.
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, patellar tendinopathy12,13, Achilles tendinopathy14, and rotator cuff tendinopathy15,16.
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We report a case of athletic pubalgia due to distal rectus abdominis tendinopathy treated
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with targeted ultrasound-guided PRP injection and tenotomy with complete resolution of
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symptoms and discuss the potential roles and advantages of this technique.
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A 20-year-old male Division I collegiate lacrosse player presented with a 1-year history
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of gradual onset lateral left hip pain with a positive “C-sign” and groin pain that
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intermittently radiated to the left testicle. At the time of his evaluation at our center he
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had already been diagnosed with a left hip labral tear based on clinical examination,
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magnetic resonance imaging (MRI) findings and a positive response to an intra-articular
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left hip injection with corticosteroid and anesthetic. He subsequently underwent
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arthroscopic labral debridement. Postoperatively, his left antero-lateral hip pain
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improved, however his groin pain persisted. This was despite treatment with NSAIDs,
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injection with corticosteroid and anesthetic to the pubic symphysis that was performed
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prior to evaluation at our institution and a total of 12 months (6 months post-operatively)
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of an active rehabilitation program. This was performed under the supervision of his
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athletic trainer and included range of motion exercises for the hip and lumbar spine as
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well as eccentric core and lower extremity strengthening. He made small gains and was
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relatively pain-free at rest, however his symptoms worsened with activity, limited his
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ability to practice and prevented participation in competition. He denied having any back
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pain.
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Examination revealed tenderness at the insertion of the distal rectus abdominis muscle
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at the margin of the left pubic symphysis that reproduced his characteristic pain. There
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was no tenderness overlying the lumbosacral spine, paraspinal musculature or sacral
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sulcus. Internal rotation of the hip was 10 degrees on the left and 20 degrees on the
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right. Strength, sensation and reflexes were all normal. Flexion, abduction and external
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rotation (FABER) of the left hip and resisted left hip adduction both elicited mild
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ipsilateral groin pain, but were not his typical sport-limiting symptoms and when tested
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on the right were normal. Straight leg raise, seated slump test, Gaenslen, thigh thrust
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and gapping tests were all negative bilaterally.
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Radiographs of the hips revealed a small cam lesion on the left and were otherwise
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unremarkable. MRI prior to his left hip labral debridement demonstrated 1) a central fluid
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cleft along the articular disc of the pubic symphysis; 2) increased signal along the
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insertion of the left rectus abdominis when compared to the right; 3) marrow edema
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within the right parasymphyseal pubis; 4) an antero-superior left acetabulum labrum tear
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(since debrided); and 5) disc protrusions at L4/5 and L5/S1 (Figure 1). Given the left-
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sided rectus abdominis MRI findings, and his persistent post-operative left-sided pain
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and tenderness at the insertion of this muscle at the pelvis, a diagnosis of distal rectus
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abdominis tendinopathy was made. The authors postulate that altered biomechanics
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due to a tendinopathic and relatively weakened left rectus abdominis muscle may have
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contributed to increased shear at the pubic symphysis and resulted in the observed
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marrow edema on the asymptomatic right side. The lumbar disc protrusions were not
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believed to be symptomatic.
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Given his poor response to an appropriate rehabilitation program and conservative
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medical management, two surgical consultations were obtained for possible
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“sportsman’s hernia” repair. Both surgeons recommended that he continue non-
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operative treatment. At this point, the authors felt that additional therapeutic exercise
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was unlikely to return the athlete to play. The risks, benefits, alternatives and limited
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evidence for ultrasound-guided needle tenotomy and PRP injection of the left distal
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rectus abdominis muscle were discussed with the patient and he provided informed
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consent for this procedure.
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The PRP procedure was conducted as follows. First, 52 mL of peripheral whole blood
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was withdrawn from the patient into a syringe containing 8 mL of Anticoagulant Citrate
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Dextrose – Formula A resulting in a final volume of 60 mL that was processed with a
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Magellan® Autologous Platelet Separator (Arteriocyte Medical Systems, Inc., Cleveland,
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OH) according to manufacturer instructions to produce 5 mL of leukocyte-rich platelet
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rich plasma. Then, with the patient supine, the skin overlying the pubic symphysis was
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prepared and draped in the usual sterile fashion before being anesthetized with 1%
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lidocaine. Next, a 22-gauge 3.5-inch spinal needle was advanced under ultrasound
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guidance (M-MSK Ultrasound System, SonoSite, Inc., Bothell, WA) using a high
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frequency linear transducer (HFL50x/15-6 MHz SonoSite, Inc., Bothell, WA) with the
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needle in-plane (i.e. longitudinal or long axis) relative to the transducer and tendon fibers
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in a cephalo-caudad manner through the skin and left rectus abdominis tendon to its
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insertion at the pubic crest between the pubic tubercle and the pubic symphysis. Then,
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needle tenotomy was performed, and a total of 5mL of autologous PRP was injected in
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two aliquots at the tendon insertion near the pubic crest and the musculotendinous
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junction with the rectus sheath. Adequate distension of the sheath was visualized at that
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site (Figure 2). The needle was then removed and a sterile bandage was applied. The
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patient tolerated the injection well. He followed the post-procedure rehabilitation
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guidelines outlined by Finoff, et al.17 with the modification that he was permitted to
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advance the program more rapidly if he was able to perform all activities at the current
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level without significant pain.
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Four weeks post-injection the patient had 0/10 pain and there was no tenderness at the
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pubic symphysis. By six weeks post-injection he was given clearance to begin sport
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specific training and modified practice under the supervision of his athletic trainer. With
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continued progressive rehabilitation he returned to full pain-free play at his previous level
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of intensity eight weeks after the injection, including an entire Division I lacrosse season
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without recurrence of symptoms.
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DISCUSSION:
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This is the first reported case, to our knowledge, of complete resolution of athletic
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pubalgia symptoms, specifically distal rectus abdominis tendinopathy, following PRP
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injection. Singh, et al.18 have reported a case of successful treatment with PRP for a
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complete adductor longus tendon tear from its insertion at the anterior surface of the
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pubis, which anatomically lies near the insertion of the rectus abdominis, but represents
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a pathologically distinct process.
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There is a close biomechanical relationship between the hip, pelvis and lumbosacral
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spine that can lead to the co-occurrence of several related diagnoses with similar pain-
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referral patterns, as was observed in this patient presenting with groin pain and
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diagnosed with both an intra-articular hip pathology and a distal rectus abdominis
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tendinopathy. Such cases can be a diagnostic challenge. Patients may require extensive
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workup and treatment of multiple diagnoses before their symptoms resolve.
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Observational studies have noted a high incidence of athletic pubalgia symptoms in
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professional athletes with symptomatic femoroacetabular impingement (FAI)19. Patients
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with FAI have decreased hip range of motion (ROM) due to cam- or pincer-type lesions
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or a combination of the two. It has been proposed that a compensatory increase in
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lumbar spine, sacroiliac joint and pubic symphysis ROM occurs in order to achieve
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functional ROM. This results in abnormal dynamic muscle forces across the pelvis and
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abnormal strains on the muscles attaching in this region20. This theory has been
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substantiated in a more recent cadaveric study demonstrating that cam lesions increase
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rotational motion at the pubic symphysis21. The increased motion across the pelvis and
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resultant repetitive overload in the tendons attaching there can contribute to
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tendinopathy, as occurred in this patient.
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In this case, initial treatment was targeted at the patient’s hip pathology. After a course
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of rehabilitation failed to return him to competition, he underwent surgical labral
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debridement. This operation does not correct the underlying anatomical abnormality and
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it is postulated that although he completed an adequate post-operative rehabilitation
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program, he was unable to make significant functional gains and return to lacrosse
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because his painful rectus abdominis tendinopathy symptoms continued to be
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exacerbated by the underlying biomechanical alterations caused by his FAI. An
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alternative first surgical option for this patient would have been an osteochondroplasty to
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correct the cam lesion which has been shown to be effective in alleviating concomitant
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athletic pubalgia symptoms19. Furthermore, having not had the underlying anatomic
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abnormality corrected likely places him at increased risk of having recurrent
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tendinopathy symptoms.
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At the time of this athlete’s initial evaluation at this institution his primary source of pain
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was determined to be the rectus abdominis muscle at its insertion on the anterior pelvis.
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A reasonable initial step in such a patient is to complete a course of physical therapy
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aimed at correcting any relative weaknesses in the muscles attaching to the pelvis. If this
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is not successful in returning the athlete to play, it is then important to employ a patient-
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centered approach that takes into account the athlete’s goals and the risks and benefits
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of the available treatment options. In this case, options included continued therapeutic
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exercise, ultrasound-guided needle tenotomy with PRP injection and
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osteochondroplasty. Having already undergone extensive physical therapy and one
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operation without complete relief of pain, or the ability to return to play, the athlete was
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reluctant to pursue either of these options. His primary goal was to return to play as soon
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as possible and the authors felt that needle tenotomy with PRP offered him a reasonable
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chance of accomplishing this safely. Ultimately, the patient decided to proceed with this
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treatment plan.
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Following the injection he began a progressive rehabilitation program and had an
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excellent outcome with full return to play at his previous level of intensity. It is difficult to
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prove which of these interventions had a greater impact on his successful outcome
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because they were administered in close proximity to one another, however, given the
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extensive rehabilitation that he had both pre- and post-operatively without significant
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improvement in his pain, the therapeutic exercise alone is unlikely to account for his
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complete resolution of symptoms.
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Hip pathology often refers to the groin, which makes it difficult to distinguish between
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intra-articular sources of pain and those originating from extra-articular sources such as
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insertional tendinopathies of the rectus abdominis. Given this diagnostic challenge, and
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the common co-occurrence of these disorders, the author’s believe clinicians treating
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athletes with FAI or labral tears should investigate a diagnosis of chronic rectus
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abdominis insertional tendinopathy with or without hip adductor involvement early in their
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evaluation. Furthermore, in carefully selected patients with groin pain that fails to
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improve with nonsurgical treatment, it may be beneficial to consider treatment with
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ultrasound guided needle tenotomy and PRP injection prior to referring for surgery in
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order to avoid the added costs, potential morbidity, and the prolonged rehabilitation
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course that is associated with surgery.
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CONCLUSION:
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This case presentation suggests that athletic pubalgia, specifically distal rectus
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abdominis insertional tendinopathy, should be carefully considered in the differential
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diagnosis of refractory groin pain in patients with known FAI and labral tears.
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Furthermore, ultrasound-guided needle tenotomy and PRP injection can be a safe and
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effective treatment option in refractory cases of athletic pubalgia.
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ACKNOWLEDGEMENTS:
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The authors would like to thank Dr. Alissa Burge (Division of Magnetic Resonance
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Imaging, Department of Radiology and Imaging, Hospital for Special Surgery, New York,
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NY) for her assistance in interpreting the magnetic resonance images used in this
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manuscript.
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Figure 1: Pre-operative coronal STIR MRI images reveal in (A) marrow edema within
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the right parasymphyseal pubis (arrow) and a central fluid cleft along the articular disc of
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the pubic symphysis (open arrow) and in (B) a left antero-superior acetabulum labral
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tear. Sagittal proton density fat suppressed sequence images demonstrate disc
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protrusions at L4/5 and L5/S1 (C) and increased signal along the insertion of the left
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rectus abdominis (D) when compared to the right (E).
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Figure 2: Ultrasound guided PRP injection to the distal rectus abdominis. (A)
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Thickening and heterogeneous distal rectus abdominis tendon at insertion to pubic bone.
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(B) Initial trajectory of needle. (C) Injection of PRP. (D) Removal of needle.
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