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Hip and Core Muscle Injuries in Soccer
ABSTRACT
Soccer is the most popular sport in the world and has the fourth highest number of sports injuries. Hip and groin injuries account for 14% of soccer injuries and can be difficult to recognize and treat as they often require a high level of suspicion and advanced imaging. Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain. Conservative approaches are typically the first line of treatment, but operative intervention has been reported to result in higher rates of return to sport in athletes with hip-related and inguinal-related groin pain injuries. In patients with concurrent hip-related and inguinal-related groin pain, the failure to recognize the relationship and treat both conditions may result in lower rates of return to sport. Preseason screening programs can identify high-risk athletes, who may benefit from a targeted prevention program. Further study on exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.
Continue to: Each year, the global audience for soccer grows...
Each year, the global audience for soccer grows. Soccer has long surpassed all other sports as the most popular sport in the world, reaching 3.2 billion viewers during the 2014 World Cup.1 In the latest Fédération Internationale de Football Association (FIFA) Big Count survey, the organization estimated that 265 million people are actively involved in soccer, accounting for approximately 4% of the world’s population.2 Moreover, the number of people playing soccer increased by 9.5% within 6 years after the previous Big Count Survey.2 In the United States, soccer accounts for the fourth most common cause of sports injuries next to basketball, exercise, and football with approximately 228,000 injuries per year.3 The total cost of treatment related to worldwide soccer injuries tops $30 billion.4 The most common body parts injured are the thigh (25%), knee (18%), and hip and/or groin (14%).5
Hip and groin injuries in soccer players can be separated into 3 main categories based on the Doha Agreement:6 (1) defined clinical entities for groin pain, (2) hip-related groin pain, and (3) other causes of groin pain in athletes. Defined clinical entities include adductor-related, iliopsoas-related, inguinal-related (sports hernia/athletic pubalgia), and pubic-related groin pain; while hip-related groin pain includes hip morphologic abnormalities, labral tears, and chondral injuries. Included in other causes of groin pain are injuries not clinically defined. The Doha Agreement has acknowledged that not all causes of groin pain fit into the classification system including injuries of the rectus femoris, but they will be included under defined clinical entities for groin pain in this review. While they are not a cause of groin pain, proximal hamstring and gluteal and piriformis injuries are important causes of posterior and lateral hip pain in soccer players and will also be covered in the first section of this review.
DEFINED CLINICAL ENTITIES FOR GROIN PAIN IN SOCCER ATHLETES
ADDUCTOR-RELATED GROIN PAIN
Acute groin pain in soccer players is most commonly caused by muscle strain.7 Of the muscle strains, 66% involve the adductor longus, 25% the iliopsoas, and 23% the rectus femoris.7 The Doha Agreement defines adductor-related groin pain as adductor tenderness and pain on resisted adduction.6 Adductor longus strains in soccer players are typically noncontact injuries (62.5%) and most commonly the result of kicking (40%).7-9 Many athletes will remember a pop at the time of the original injury.9 The combination of history and physical examination is usually sufficient for diagnosis; however, magnetic resonance imaging (MRI) may be helpful in complicated situations with a reported 86% sensitivity and 89% specificity.10 The average playing time lost is 2 weeks.5 Management includes rest, anti-inflammatory medication, physical therapy with core strengthening, and avoidance of aggressive stretching. While partial and distal avulsions can heal with conservative measures, proximal osseous and retracted avulsions of the adductor longus can be treated surgically.11
Continue to: ILIOPSOAS-RELATED GROIN PAIN...
ILIOPSOAS-RELATED GROIN PAIN
Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.6 Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.
INGUINAL-RELATED GROIN PAIN
Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,9,13-15 athletic pubalgia,16 core muscle injury,17 athletic hernia,18 Gilmore’s groin,15 osteitis pubis,19 sportsman’s hernia,20,21 sportsmen’s groin,22 symphysis syndrome,23 and inguinal disruption.24 It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”6 The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.25,26
One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.28,29
Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.33 However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.34 Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.
Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.25 A study by Paajanen and colleagues36 suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.36 In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.36 If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger37described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.30
Continue to: PUBIC-RELATED GROIN PAIN...
PUBIC-RELATED GROIN PAIN
Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.6 Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.12 If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.38Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.12,39
RECTUS FEMORIS INJURIES
The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.12 In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.40 Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.12
PROXIMAL HAMSTRING INJURIES
Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.25 In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.25 Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.25 We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.
GLUTEAL INJURIES
Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.25Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.25 A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.25 Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.41
PIRIFORMIS INJURIES
Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.12 Zeren and colleagues42 published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.42 The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.42 Both players returned to professional soccer after 6 months and played for an average of 7 years.42
Continue to: HIP-RELATED GROIN PAIN IN SOCCER ATHLETES...
HIP-RELATED GROIN PAIN IN SOCCER ATHLETES
Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.44 FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.45,46
FEMOROACETABULAR IMPINGEMENT
FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.47 During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.25 Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.25 Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.48
We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues49 documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.50
Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues51 measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.51 A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.51 Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.52 While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.6 Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).33 Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.
Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.53 In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.54 Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.54
Continue to: LABRAL TEARS...
LABRAL TEARS
Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.25Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.55 Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.57 Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.58 Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.59 It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.
CHONDRAL INJURIES
Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.60 Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.60 There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues54 have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.
RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT
The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.25 In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues61 found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.
DISCUSSION AND FUTURE DIRECTIONS
Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues48 identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues62 developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.63 Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.
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51. Wyss TF, Clark JM, Weishaupt D, Notzli HP. Correlation between internal rotation and bony anatomy in the hip. Clin Orthop Relat Res. 2007;460:152-158. doi:10.1097/BLO.0b013e3180399430.
52. Reiman MP, Goode AP, Cook CE, Holmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2015;49:811. doi:10.1136/bjsports-2014-094302.
53. Papalia R, Del Buono A, Franceschi F, Marinozzi A, Maffulli N, Denaro V. Femoroacetabular impingement syndrome management: arthroscopy or open surgery? Int Orthop. 2012;36(5):903-914. doi:10.1007/s00264-011-1443-z.
54. Locks R, Utsunomiya H, Briggs KK, McNamara S, Chahla J, Philippon MJ. Return to play after hip arthroscopic surgery for femoroacetabular impingement in professional soccer players. Am J Sports Med. 2018;46(2):273-279. doi:10.1177/0363546517738741.
55. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy. 2005;21(12):1496-1504. doi:10.1016/j.arthro.2005.08.013.
56. Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res. 2004;426:145-150. doi:10.1097/01.blo.0000136903.01368.20.
57. Domb BG, Hartigan DE, Perets I. Decision making for labral treatment in the hip: repair versus débridement versus reconstruction. J Am Acad Orthop Surg. 2017;25(3):e53-e62. doi:10.5435/JAAOS-D-16-00144.
58. Frank JS, Gambacorta PL, Eisner EA. Hip pathology in the adolescent athlete. J Am Acad Orthop Surg. 2013;21(11):665-674. doi:10.5435/JAAOS-21-11-665.
59. Singh PJ, O'Donnell JM. The outcome of hip arthroscopy in Australian football league players: a review of 27 hips. Arthroscopy. 2010;26(6):743-749. doi:10.1016/j.arthro.2009.10.010.
60. Crawford K, Philippon MJ, Sekiya JK, Rodkey WG, Steadman JR. Microfracture of the hip in athletes. Clin Sports Med. 2006;25(2):327-335. doi:10.1016/j.csm.2005.12.004.
61. Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy.2011;27(6):768-775. doi:10.1016/j.arthro.2011.01.018.
62. Wollin M, Thorborg K, Welvaert M, Pizzari T. In-season monitoring of hip and groin strength, health and function in elite youth soccer: implementing an early detection and management strategy over two consecutive seasons. J Sci Med Sport. 2018;21(10):988. doi:10.1016/j.jsams.2018.03.004.
63. Charlton PC, Drew MK, Mentiplay BF, Grimaldi A, Clark RA. Exercise interventions for the prevention and treatment of groin pain and injury in athletes: a critical and systematic review. Sports Med. 2017;47:2011. doi:10.1007/s40279-017-0742-y.
ABSTRACT
Soccer is the most popular sport in the world and has the fourth highest number of sports injuries. Hip and groin injuries account for 14% of soccer injuries and can be difficult to recognize and treat as they often require a high level of suspicion and advanced imaging. Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain. Conservative approaches are typically the first line of treatment, but operative intervention has been reported to result in higher rates of return to sport in athletes with hip-related and inguinal-related groin pain injuries. In patients with concurrent hip-related and inguinal-related groin pain, the failure to recognize the relationship and treat both conditions may result in lower rates of return to sport. Preseason screening programs can identify high-risk athletes, who may benefit from a targeted prevention program. Further study on exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.
Continue to: Each year, the global audience for soccer grows...
Each year, the global audience for soccer grows. Soccer has long surpassed all other sports as the most popular sport in the world, reaching 3.2 billion viewers during the 2014 World Cup.1 In the latest Fédération Internationale de Football Association (FIFA) Big Count survey, the organization estimated that 265 million people are actively involved in soccer, accounting for approximately 4% of the world’s population.2 Moreover, the number of people playing soccer increased by 9.5% within 6 years after the previous Big Count Survey.2 In the United States, soccer accounts for the fourth most common cause of sports injuries next to basketball, exercise, and football with approximately 228,000 injuries per year.3 The total cost of treatment related to worldwide soccer injuries tops $30 billion.4 The most common body parts injured are the thigh (25%), knee (18%), and hip and/or groin (14%).5
Hip and groin injuries in soccer players can be separated into 3 main categories based on the Doha Agreement:6 (1) defined clinical entities for groin pain, (2) hip-related groin pain, and (3) other causes of groin pain in athletes. Defined clinical entities include adductor-related, iliopsoas-related, inguinal-related (sports hernia/athletic pubalgia), and pubic-related groin pain; while hip-related groin pain includes hip morphologic abnormalities, labral tears, and chondral injuries. Included in other causes of groin pain are injuries not clinically defined. The Doha Agreement has acknowledged that not all causes of groin pain fit into the classification system including injuries of the rectus femoris, but they will be included under defined clinical entities for groin pain in this review. While they are not a cause of groin pain, proximal hamstring and gluteal and piriformis injuries are important causes of posterior and lateral hip pain in soccer players and will also be covered in the first section of this review.
DEFINED CLINICAL ENTITIES FOR GROIN PAIN IN SOCCER ATHLETES
ADDUCTOR-RELATED GROIN PAIN
Acute groin pain in soccer players is most commonly caused by muscle strain.7 Of the muscle strains, 66% involve the adductor longus, 25% the iliopsoas, and 23% the rectus femoris.7 The Doha Agreement defines adductor-related groin pain as adductor tenderness and pain on resisted adduction.6 Adductor longus strains in soccer players are typically noncontact injuries (62.5%) and most commonly the result of kicking (40%).7-9 Many athletes will remember a pop at the time of the original injury.9 The combination of history and physical examination is usually sufficient for diagnosis; however, magnetic resonance imaging (MRI) may be helpful in complicated situations with a reported 86% sensitivity and 89% specificity.10 The average playing time lost is 2 weeks.5 Management includes rest, anti-inflammatory medication, physical therapy with core strengthening, and avoidance of aggressive stretching. While partial and distal avulsions can heal with conservative measures, proximal osseous and retracted avulsions of the adductor longus can be treated surgically.11
Continue to: ILIOPSOAS-RELATED GROIN PAIN...
ILIOPSOAS-RELATED GROIN PAIN
Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.6 Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.
INGUINAL-RELATED GROIN PAIN
Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,9,13-15 athletic pubalgia,16 core muscle injury,17 athletic hernia,18 Gilmore’s groin,15 osteitis pubis,19 sportsman’s hernia,20,21 sportsmen’s groin,22 symphysis syndrome,23 and inguinal disruption.24 It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”6 The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.25,26
One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.28,29
Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.33 However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.34 Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.
Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.25 A study by Paajanen and colleagues36 suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.36 In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.36 If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger37described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.30
Continue to: PUBIC-RELATED GROIN PAIN...
PUBIC-RELATED GROIN PAIN
Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.6 Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.12 If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.38Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.12,39
RECTUS FEMORIS INJURIES
The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.12 In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.40 Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.12
PROXIMAL HAMSTRING INJURIES
Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.25 In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.25 Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.25 We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.
GLUTEAL INJURIES
Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.25Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.25 A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.25 Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.41
PIRIFORMIS INJURIES
Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.12 Zeren and colleagues42 published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.42 The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.42 Both players returned to professional soccer after 6 months and played for an average of 7 years.42
Continue to: HIP-RELATED GROIN PAIN IN SOCCER ATHLETES...
HIP-RELATED GROIN PAIN IN SOCCER ATHLETES
Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.44 FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.45,46
FEMOROACETABULAR IMPINGEMENT
FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.47 During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.25 Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.25 Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.48
We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues49 documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.50
Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues51 measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.51 A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.51 Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.52 While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.6 Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).33 Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.
Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.53 In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.54 Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.54
Continue to: LABRAL TEARS...
LABRAL TEARS
Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.25Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.55 Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.57 Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.58 Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.59 It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.
CHONDRAL INJURIES
Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.60 Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.60 There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues54 have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.
RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT
The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.25 In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues61 found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.
DISCUSSION AND FUTURE DIRECTIONS
Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues48 identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues62 developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.63 Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.
ABSTRACT
Soccer is the most popular sport in the world and has the fourth highest number of sports injuries. Hip and groin injuries account for 14% of soccer injuries and can be difficult to recognize and treat as they often require a high level of suspicion and advanced imaging. Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain. Conservative approaches are typically the first line of treatment, but operative intervention has been reported to result in higher rates of return to sport in athletes with hip-related and inguinal-related groin pain injuries. In patients with concurrent hip-related and inguinal-related groin pain, the failure to recognize the relationship and treat both conditions may result in lower rates of return to sport. Preseason screening programs can identify high-risk athletes, who may benefit from a targeted prevention program. Further study on exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.
Continue to: Each year, the global audience for soccer grows...
Each year, the global audience for soccer grows. Soccer has long surpassed all other sports as the most popular sport in the world, reaching 3.2 billion viewers during the 2014 World Cup.1 In the latest Fédération Internationale de Football Association (FIFA) Big Count survey, the organization estimated that 265 million people are actively involved in soccer, accounting for approximately 4% of the world’s population.2 Moreover, the number of people playing soccer increased by 9.5% within 6 years after the previous Big Count Survey.2 In the United States, soccer accounts for the fourth most common cause of sports injuries next to basketball, exercise, and football with approximately 228,000 injuries per year.3 The total cost of treatment related to worldwide soccer injuries tops $30 billion.4 The most common body parts injured are the thigh (25%), knee (18%), and hip and/or groin (14%).5
Hip and groin injuries in soccer players can be separated into 3 main categories based on the Doha Agreement:6 (1) defined clinical entities for groin pain, (2) hip-related groin pain, and (3) other causes of groin pain in athletes. Defined clinical entities include adductor-related, iliopsoas-related, inguinal-related (sports hernia/athletic pubalgia), and pubic-related groin pain; while hip-related groin pain includes hip morphologic abnormalities, labral tears, and chondral injuries. Included in other causes of groin pain are injuries not clinically defined. The Doha Agreement has acknowledged that not all causes of groin pain fit into the classification system including injuries of the rectus femoris, but they will be included under defined clinical entities for groin pain in this review. While they are not a cause of groin pain, proximal hamstring and gluteal and piriformis injuries are important causes of posterior and lateral hip pain in soccer players and will also be covered in the first section of this review.
DEFINED CLINICAL ENTITIES FOR GROIN PAIN IN SOCCER ATHLETES
ADDUCTOR-RELATED GROIN PAIN
Acute groin pain in soccer players is most commonly caused by muscle strain.7 Of the muscle strains, 66% involve the adductor longus, 25% the iliopsoas, and 23% the rectus femoris.7 The Doha Agreement defines adductor-related groin pain as adductor tenderness and pain on resisted adduction.6 Adductor longus strains in soccer players are typically noncontact injuries (62.5%) and most commonly the result of kicking (40%).7-9 Many athletes will remember a pop at the time of the original injury.9 The combination of history and physical examination is usually sufficient for diagnosis; however, magnetic resonance imaging (MRI) may be helpful in complicated situations with a reported 86% sensitivity and 89% specificity.10 The average playing time lost is 2 weeks.5 Management includes rest, anti-inflammatory medication, physical therapy with core strengthening, and avoidance of aggressive stretching. While partial and distal avulsions can heal with conservative measures, proximal osseous and retracted avulsions of the adductor longus can be treated surgically.11
Continue to: ILIOPSOAS-RELATED GROIN PAIN...
ILIOPSOAS-RELATED GROIN PAIN
Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.6 Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.
INGUINAL-RELATED GROIN PAIN
Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,9,13-15 athletic pubalgia,16 core muscle injury,17 athletic hernia,18 Gilmore’s groin,15 osteitis pubis,19 sportsman’s hernia,20,21 sportsmen’s groin,22 symphysis syndrome,23 and inguinal disruption.24 It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”6 The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.25,26
One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.28,29
Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.33 However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.34 Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.
Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.25 A study by Paajanen and colleagues36 suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.36 In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.36 If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger37described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.30
Continue to: PUBIC-RELATED GROIN PAIN...
PUBIC-RELATED GROIN PAIN
Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.6 Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.12 If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.38Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.12,39
RECTUS FEMORIS INJURIES
The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.12 In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.40 Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.12
PROXIMAL HAMSTRING INJURIES
Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.25 In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.25 Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.25 We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.
GLUTEAL INJURIES
Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.25Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.25 A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.25 Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.41
PIRIFORMIS INJURIES
Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.12 Zeren and colleagues42 published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.42 The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.42 Both players returned to professional soccer after 6 months and played for an average of 7 years.42
Continue to: HIP-RELATED GROIN PAIN IN SOCCER ATHLETES...
HIP-RELATED GROIN PAIN IN SOCCER ATHLETES
Hip-related groin pain has garnered more attention in the last several years after being a previously underdiagnosed entity. One study found that practitioners treated groin pain in athletes for 7 months on average before recognizing that the pathology was intra-articular.44 FAI, labral tears, and chondral injuries are the major intra-articular pathologies that cause groin pain in athletes and ultimately impaired performance.45,46
FEMOROACETABULAR IMPINGEMENT
FAI is caused by pincer-type, cam-type, or combined-type deformities. Pincer lesions are defined as an increased acetabular overhang, while cam lesions are described as an increased bone at the femoral head/neck junction. These deformities in isolation or in combination cause decreased hip motion and increased contact pressures between the anterolateral acetabulum and femoral head-neck junction, which may ultimately lead to labral tears, chondral lesions, and osteoarthritis.47 During hip flexion, cam deformities impact the anterolateral acetabulum, preferentially causing articular cartilage damage, while sparing the labrum.25 Conversely, pincer deformities cause repetitive microtrauma to the labrum, crushing it between the acetabular rim and femoral neck with secondary damage to the articular cartilage.25 Over time, the damage to the labrum and articular cartilage may lead to premature osteoarthritis, which occurs at a much younger age in the athletic population.48
We know from previous studies that soccer athletes have a high prevalence of morphologic abnormalities of the hip, most commonly FAI. Gerhardt and colleagues49 documented the prevalence of hip morphologic abnormalities in elite soccer players and found abnormalities in 72% of men and over 50% of women. It should be noted that this series looked at asymptomatic athletes; however, it has been shown that hip dysmorphia is a risk factor for hip and groin injuries and may provide an opportunity for injury prevention strategies.50
Physical examination findings in FAI include decreased hip internal rotation and pain with provocative testing. Wyss and colleagues51 measured hip internal rotation in athletes with and without FAI. They found that the athletes with FAI have an average of 4° of internal rotation compared with that of the non-FAI athletes with 28°.51 A worsening internal rotation deficit has been linked to increasing severity of the deformity and when <20° was correlated with joint damage.51 Provocative testing has a high sensitivity with a recent meta-analysis demonstrating the most sensitive tests to be the anterior impingement test (flexion-adduction-internal rotation) with 94% to 99% sensitivity and the flexion-internal rotation test with 96% sensitivity.52 While provocative tests are sensitive, there is no current consensus on physical examination findings that are specific in the diagnosis of FAI.6 Diagnosis is made with both positive physical examination and radiographic morphologic findings (alpha angle >55°).33 Advanced imaging with an MRI arthrogram can be helpful in diagnosing underlying injuries such as labral tears in athletes presenting with compatible symptoms.
Symptomatic patients are typically treated surgically through either open or arthroscopic procedures, which have favorable and comparable functional results, biomechanics, and return to sport.53 In soccer players, return to sport at the professional level after arthroscopic surgery was found to be 96%.54 Players returned to sport on average 9.2 months postoperatively and played an average of 70 games after surgery.54
Continue to: LABRAL TEARS...
LABRAL TEARS
Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.25Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.55 Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.57 Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.58 Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.59 It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.
CHONDRAL INJURIES
Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.60 Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.60 There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues54 have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.
RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT
The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.25 In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues61 found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.
DISCUSSION AND FUTURE DIRECTIONS
Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues48 identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues62 developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.63 Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.
1. Kantar Media. 2014 FIFA World Cup Brazil television audience report. https://resources.fifa.com/mm/document/affederation/tv/02/74/55/57/2014f...(draft5)(issuedate14.12.15)_neutral.pdf. Accessed March 20, 2018.
2. Fédération Internationale de Football Association. FIFA Big Count. http://www.fifa.com/mm/document/fifafacts/bcoffsurv/emaga_9384_10704.pdf. Published July 2007. Accessed March 20, 2018.
3. United States Consumer Product Safety Commission. Neiss data highlights - 2015. https://www.cpsc.gov/s3fs-public/2015 Neiss data highlights.pdf. Accessed March 20, 2018.
4. Hassabi M, Mohammad-Javad Mortazavi S, Giti MR, Hassabi M, Mansournia MA, Shapouran S. Injury profile of a professional soccer team in the premier league of Iran. Asian J Sports Med. 2010;1(4):201-208.
5. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. 2011;45(7):553-558.
6. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-774.
7. Serner A, Tol JL, Jomaah N, et al. Diagnosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med. 2015;43(8):1857-1864. doi:10.1177/0363546515585123.
8. Eckard TG, Padua DA, Dompier TP, Dalton SL, Thorborg K, Kerr ZY. Epidemiology of hip flexor and hip adductor strains in national collegiate athletic association athletes, 2009/2010-2014/2015. Am J Sports Med. 2017;45(12):2713-2722. doi:10.1177/0363546517716179.
9. Hopkins JN, Brown W, Lee CA. Sports hernia: definition, evaluation, and treatment. JBJS Rev. 2017;5(9):e6. doi:10.2106/JBJS.RVW.17.00022.
10. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings. Radiographics. 2008;28(5):1415-1438. doi:10.1148/rg.285075217.
11. Vogt S, Ansah P, Imhoff AB. Complete osseous avulsion of the adductor longus muscle: acute repair with three Wberwire suture anchors. Arch Orthop Trauma Surg. 2007;127:613-615. doi:10.1007/s00402-007-0328-5.
12. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521-533. doi:10.1177/03635465010290042501.
13. Choi HR, Elattar O, Dills VD, Busconi B. Return to play after sports hernia surgery. Clin Sports Med. 2016;35(4):621-636. doi:10.1016/j.csm.2016.05.007.
14. Garvey JF, Hazard H. Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia. 2014;18(6):815-823. doi:10.1007/s10029-013-1161-0.
15. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. 1998;17(4):787-793, vii. doi:10.1016/S0278-5919(05)70119-8.
16. Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding athletic pubalgia: a review. R I Med J. 2016;99(10):31-35.
17. Ross JR, Stone RM, Larson CM. Core muscle injury/sports hernia/athletic pubalgia, and femoroacetabular impingement. Sports Med Arthrosc Rev. 2015;23(4):213-220. doi:10.1097/JSA.0000000000000083.
18. Swan KG Jr, Wolcott M. The athletic hernia: a systematic review. Clin Orthop Relat Res. 2007;455:78-87. doi:10.1097/BLO.0b013e31802eb3ea.
19. Matikainen M, Hermunen H, Paajanen H. Athletic pubalgia in females: predictive value of MRI in outcomes of endoscopic surgery. Orthop J Sports Med. 2017;5(8):2325967117720171. doi:10.1177/2325967117720171.
20. Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do? Hernia. 2010;14(1):17-25. doi:10.1007/s10029-009-0611-1.
21. Paksoy M, Sekmen U. Sportsman hernia; the review of current diagnosis and treatment modalities. Ulusal Cerrahi Derg. 2016;32(2):122-129. doi:10.5152/UCD.2015.3132.
22. Pokorny H, Resinger C, Fischer I, et al. Fast early recovery after transabdominal preperitoneal repair in athletes with sportsman's groin: a prospective clinical cohort study. J Laparoendosc Adv Surg Tech A. 2017;27(3):272-276. doi:10.1089/lap.2016.0188.
23. Biedert RM, Warnke K, Meyer S. Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes. Clin J Sport Med. 2003;13(5):278-284.
24. Sheen AJ, Stephenson BM, Lloyd DM, et al. 'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014;48(14):1079-1087.
25. Miller M, Thompson S. DeLee & Drez's Orthopaedic Sports Medicine. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2015.
26. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. J Sci Med Sport. 1995;27:76-79.
27. Dimitrakopoulou A, Schilders E. Sportsman's hernia? An ambiguous term. J Hip Preserv Surg. 2016;3(1):16-22. doi:10.1093/jhps/hnv083.
28. Strosberg DS, Ellis TJ, Renton DB. The role of femoroacetabular impingement in core muscle injury/athletic pubalgia: diagnosis and management. Front Surg. 2016;3:6. doi:10.3389/fsurg.2016.00006.
29. Muschaweck U, Berger LM. Sportsmen's groin-diagnostic approach and treatment with the minimal repair technique: a single-center uncontrolled clinical review. Sports Health. 2010;2(3):216-221. doi:10.1177/1941738110367623.
30. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139-144. doi:10.1177/1941738114523557.
31. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med. 2000; 28(1):2-8. doi:10.1177/03635465000280011501.
32. Gerhardt MB, Mandelbaum BR, Hutchinson WB. Ancillary modalities in the treatment of athletic groin Pain: Local Anesthetics, Corticosteroids, and Orthobiologics. In: Diduch DR, Brunt LM, eds. Sports Hernia and Athletic Pubalgia: Diagnosis and Treatment. Boston, MA: Springer US; 2014:183-187.
33. Notzli HP, Wyss TF, Stoecklin CH, et al. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
34. Brennan D, O’Connell MJ, Ryan M, et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology. 2005;235(1):162-167. doi:10.1148/radiol.2351040045.
35. Byrne CA, Bowden DJ, Alkhayat A, Kavanagh EC, Eustace SJ. Sports-related groin pain secondary to symphysis pubis disorders: correlation between MRI findings and outcome after fluoroscopy-guided injection of steroid and local anesthetic. Am J Roentgenol. 2017;209(2):380-388. doi:10.2214/AJR.16.17578.
36. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery. 2011;150(1):99-107. doi:10.1016/j.surg.2011.02.016.
37. Muschaweck U, Berger L. Minimal repair technique of sportsmen's groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia. 2010;14(1):27-33. doi:10.1007/s10029-009-0614-y.
38. Lynch TS, Bedi A, Larson CM. Athletic hip injuries. J Am Acad Orthop Surg. 2017;25(4):269-279. doi:10.5435/JAAOS-D-16-00171.
39. Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes. Results of corticosteroid injections. Am J Sports Med. 1995;23(5):601-606.doi:10.1177/036354659502300515.
40. Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal Radiol. 2001;30(3):127-131. doi: 10.1007/s002560000319.
41. Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010;2(3):191-196. doi:10.1177/1941738110366829.
42. Zeren B, Canbek U, Oztekin HH, Imerci A, Akgun U. Bilateral piriformis syndrome in two elite soccer players: report of two cases. Orthop Traumatol Surg Res. 2015;101(8):987-990. doi:10.1016/j.otsr.2015.07.022.
43. Keskula DR, Tamburello M. Conservative management of piriformis syndrome. J Athl Train. 1992;27(2):102-110.
44. Byrd JW, Jones KS. Hip arthroscopy in athletes. Clin Sports Med. 2001;20(4):749-761.
45. Nepple JJ, Goljan P, Briggs KK, Garvey SE, Ryan M, Philippon MJ. Hip strength deficits in patients with symptomatic femoroacetabular impingement and labral tears. Arthroscopy.2015;31(11):2106-2111.
46. Mullins K, Hanlon M, Carton P. Differences in athletic performance between sportsmen with symptomatic femoroacetabular impingement and healthy controls. Clin J Sport Med.2018;28(4):370-376. doi:10.1097/JSM.0000000000000460.
47. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112-120. doi:10.1097/01.blo.0000096804.78689.c2.
48. Wyles CC, Norambuena GA, Howe BM, et al. Cam deformities and limited hip range of motion are associated with early osteoarthritic changes in adolescent athletes: a prospective matched cohort study. Am J Sports Med. 2017;45(13):3036-3043. doi:10.1177/0363546517719460 .
49. Gerhardt MB, Romero AA, Silvers HJ, Harris DJ, Watanabe D, Mandelbaum BR. The prevalence of radiographic hip abnormalities in elite soccer players. Am J Sports Med. 2012;40(3):584-588. doi:10.1177/0363546511432711.
50. Larson CM, Ross JR, Kuhn AW, et al. Radiographic hip anatomy correlates with range of motion and symptoms in national hockey league players. Am J Sports Med. 2017;45(7):1633-1639. doi:10.1177/0363546517692542.
51. Wyss TF, Clark JM, Weishaupt D, Notzli HP. Correlation between internal rotation and bony anatomy in the hip. Clin Orthop Relat Res. 2007;460:152-158. doi:10.1097/BLO.0b013e3180399430.
52. Reiman MP, Goode AP, Cook CE, Holmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2015;49:811. doi:10.1136/bjsports-2014-094302.
53. Papalia R, Del Buono A, Franceschi F, Marinozzi A, Maffulli N, Denaro V. Femoroacetabular impingement syndrome management: arthroscopy or open surgery? Int Orthop. 2012;36(5):903-914. doi:10.1007/s00264-011-1443-z.
54. Locks R, Utsunomiya H, Briggs KK, McNamara S, Chahla J, Philippon MJ. Return to play after hip arthroscopic surgery for femoroacetabular impingement in professional soccer players. Am J Sports Med. 2018;46(2):273-279. doi:10.1177/0363546517738741.
55. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy. 2005;21(12):1496-1504. doi:10.1016/j.arthro.2005.08.013.
56. Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res. 2004;426:145-150. doi:10.1097/01.blo.0000136903.01368.20.
57. Domb BG, Hartigan DE, Perets I. Decision making for labral treatment in the hip: repair versus débridement versus reconstruction. J Am Acad Orthop Surg. 2017;25(3):e53-e62. doi:10.5435/JAAOS-D-16-00144.
58. Frank JS, Gambacorta PL, Eisner EA. Hip pathology in the adolescent athlete. J Am Acad Orthop Surg. 2013;21(11):665-674. doi:10.5435/JAAOS-21-11-665.
59. Singh PJ, O'Donnell JM. The outcome of hip arthroscopy in Australian football league players: a review of 27 hips. Arthroscopy. 2010;26(6):743-749. doi:10.1016/j.arthro.2009.10.010.
60. Crawford K, Philippon MJ, Sekiya JK, Rodkey WG, Steadman JR. Microfracture of the hip in athletes. Clin Sports Med. 2006;25(2):327-335. doi:10.1016/j.csm.2005.12.004.
61. Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy.2011;27(6):768-775. doi:10.1016/j.arthro.2011.01.018.
62. Wollin M, Thorborg K, Welvaert M, Pizzari T. In-season monitoring of hip and groin strength, health and function in elite youth soccer: implementing an early detection and management strategy over two consecutive seasons. J Sci Med Sport. 2018;21(10):988. doi:10.1016/j.jsams.2018.03.004.
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1. Kantar Media. 2014 FIFA World Cup Brazil television audience report. https://resources.fifa.com/mm/document/affederation/tv/02/74/55/57/2014f...(draft5)(issuedate14.12.15)_neutral.pdf. Accessed March 20, 2018.
2. Fédération Internationale de Football Association. FIFA Big Count. http://www.fifa.com/mm/document/fifafacts/bcoffsurv/emaga_9384_10704.pdf. Published July 2007. Accessed March 20, 2018.
3. United States Consumer Product Safety Commission. Neiss data highlights - 2015. https://www.cpsc.gov/s3fs-public/2015 Neiss data highlights.pdf. Accessed March 20, 2018.
4. Hassabi M, Mohammad-Javad Mortazavi S, Giti MR, Hassabi M, Mansournia MA, Shapouran S. Injury profile of a professional soccer team in the premier league of Iran. Asian J Sports Med. 2010;1(4):201-208.
5. Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med. 2011;45(7):553-558.
6. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-774.
7. Serner A, Tol JL, Jomaah N, et al. Diagnosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med. 2015;43(8):1857-1864. doi:10.1177/0363546515585123.
8. Eckard TG, Padua DA, Dompier TP, Dalton SL, Thorborg K, Kerr ZY. Epidemiology of hip flexor and hip adductor strains in national collegiate athletic association athletes, 2009/2010-2014/2015. Am J Sports Med. 2017;45(12):2713-2722. doi:10.1177/0363546517716179.
9. Hopkins JN, Brown W, Lee CA. Sports hernia: definition, evaluation, and treatment. JBJS Rev. 2017;5(9):e6. doi:10.2106/JBJS.RVW.17.00022.
10. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings. Radiographics. 2008;28(5):1415-1438. doi:10.1148/rg.285075217.
11. Vogt S, Ansah P, Imhoff AB. Complete osseous avulsion of the adductor longus muscle: acute repair with three Wberwire suture anchors. Arch Orthop Trauma Surg. 2007;127:613-615. doi:10.1007/s00402-007-0328-5.
12. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29(4):521-533. doi:10.1177/03635465010290042501.
13. Choi HR, Elattar O, Dills VD, Busconi B. Return to play after sports hernia surgery. Clin Sports Med. 2016;35(4):621-636. doi:10.1016/j.csm.2016.05.007.
14. Garvey JF, Hazard H. Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia. 2014;18(6):815-823. doi:10.1007/s10029-013-1161-0.
15. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. 1998;17(4):787-793, vii. doi:10.1016/S0278-5919(05)70119-8.
16. Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding athletic pubalgia: a review. R I Med J. 2016;99(10):31-35.
17. Ross JR, Stone RM, Larson CM. Core muscle injury/sports hernia/athletic pubalgia, and femoroacetabular impingement. Sports Med Arthrosc Rev. 2015;23(4):213-220. doi:10.1097/JSA.0000000000000083.
18. Swan KG Jr, Wolcott M. The athletic hernia: a systematic review. Clin Orthop Relat Res. 2007;455:78-87. doi:10.1097/BLO.0b013e31802eb3ea.
19. Matikainen M, Hermunen H, Paajanen H. Athletic pubalgia in females: predictive value of MRI in outcomes of endoscopic surgery. Orthop J Sports Med. 2017;5(8):2325967117720171. doi:10.1177/2325967117720171.
20. Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do? Hernia. 2010;14(1):17-25. doi:10.1007/s10029-009-0611-1.
21. Paksoy M, Sekmen U. Sportsman hernia; the review of current diagnosis and treatment modalities. Ulusal Cerrahi Derg. 2016;32(2):122-129. doi:10.5152/UCD.2015.3132.
22. Pokorny H, Resinger C, Fischer I, et al. Fast early recovery after transabdominal preperitoneal repair in athletes with sportsman's groin: a prospective clinical cohort study. J Laparoendosc Adv Surg Tech A. 2017;27(3):272-276. doi:10.1089/lap.2016.0188.
23. Biedert RM, Warnke K, Meyer S. Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes. Clin J Sport Med. 2003;13(5):278-284.
24. Sheen AJ, Stephenson BM, Lloyd DM, et al. 'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014;48(14):1079-1087.
25. Miller M, Thompson S. DeLee & Drez's Orthopaedic Sports Medicine. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2015.
26. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. J Sci Med Sport. 1995;27:76-79.
27. Dimitrakopoulou A, Schilders E. Sportsman's hernia? An ambiguous term. J Hip Preserv Surg. 2016;3(1):16-22. doi:10.1093/jhps/hnv083.
28. Strosberg DS, Ellis TJ, Renton DB. The role of femoroacetabular impingement in core muscle injury/athletic pubalgia: diagnosis and management. Front Surg. 2016;3:6. doi:10.3389/fsurg.2016.00006.
29. Muschaweck U, Berger LM. Sportsmen's groin-diagnostic approach and treatment with the minimal repair technique: a single-center uncontrolled clinical review. Sports Health. 2010;2(3):216-221. doi:10.1177/1941738110367623.
30. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139-144. doi:10.1177/1941738114523557.
31. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med. 2000; 28(1):2-8. doi:10.1177/03635465000280011501.
32. Gerhardt MB, Mandelbaum BR, Hutchinson WB. Ancillary modalities in the treatment of athletic groin Pain: Local Anesthetics, Corticosteroids, and Orthobiologics. In: Diduch DR, Brunt LM, eds. Sports Hernia and Athletic Pubalgia: Diagnosis and Treatment. Boston, MA: Springer US; 2014:183-187.
33. Notzli HP, Wyss TF, Stoecklin CH, et al. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br. 2002;84(4):556-560.
34. Brennan D, O’Connell MJ, Ryan M, et al. Secondary cleft sign as a marker of injury in athletes with groin pain: MR image appearance and interpretation. Radiology. 2005;235(1):162-167. doi:10.1148/radiol.2351040045.
35. Byrne CA, Bowden DJ, Alkhayat A, Kavanagh EC, Eustace SJ. Sports-related groin pain secondary to symphysis pubis disorders: correlation between MRI findings and outcome after fluoroscopy-guided injection of steroid and local anesthetic. Am J Roentgenol. 2017;209(2):380-388. doi:10.2214/AJR.16.17578.
36. Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery. 2011;150(1):99-107. doi:10.1016/j.surg.2011.02.016.
37. Muschaweck U, Berger L. Minimal repair technique of sportsmen's groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia. 2010;14(1):27-33. doi:10.1007/s10029-009-0614-y.
38. Lynch TS, Bedi A, Larson CM. Athletic hip injuries. J Am Acad Orthop Surg. 2017;25(4):269-279. doi:10.5435/JAAOS-D-16-00171.
39. Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes. Results of corticosteroid injections. Am J Sports Med. 1995;23(5):601-606.doi:10.1177/036354659502300515.
40. Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skeletal Radiol. 2001;30(3):127-131. doi: 10.1007/s002560000319.
41. Grumet RC, Frank RM, Slabaugh MA, Virkus WW, Bush-Joseph CA, Nho SJ. Lateral hip pain in an athletic population: differential diagnosis and treatment options. Sports Health. 2010;2(3):191-196. doi:10.1177/1941738110366829.
42. Zeren B, Canbek U, Oztekin HH, Imerci A, Akgun U. Bilateral piriformis syndrome in two elite soccer players: report of two cases. Orthop Traumatol Surg Res. 2015;101(8):987-990. doi:10.1016/j.otsr.2015.07.022.
43. Keskula DR, Tamburello M. Conservative management of piriformis syndrome. J Athl Train. 1992;27(2):102-110.
44. Byrd JW, Jones KS. Hip arthroscopy in athletes. Clin Sports Med. 2001;20(4):749-761.
45. Nepple JJ, Goljan P, Briggs KK, Garvey SE, Ryan M, Philippon MJ. Hip strength deficits in patients with symptomatic femoroacetabular impingement and labral tears. Arthroscopy.2015;31(11):2106-2111.
46. Mullins K, Hanlon M, Carton P. Differences in athletic performance between sportsmen with symptomatic femoroacetabular impingement and healthy controls. Clin J Sport Med.2018;28(4):370-376. doi:10.1097/JSM.0000000000000460.
47. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112-120. doi:10.1097/01.blo.0000096804.78689.c2.
48. Wyles CC, Norambuena GA, Howe BM, et al. Cam deformities and limited hip range of motion are associated with early osteoarthritic changes in adolescent athletes: a prospective matched cohort study. Am J Sports Med. 2017;45(13):3036-3043. doi:10.1177/0363546517719460 .
49. Gerhardt MB, Romero AA, Silvers HJ, Harris DJ, Watanabe D, Mandelbaum BR. The prevalence of radiographic hip abnormalities in elite soccer players. Am J Sports Med. 2012;40(3):584-588. doi:10.1177/0363546511432711.
50. Larson CM, Ross JR, Kuhn AW, et al. Radiographic hip anatomy correlates with range of motion and symptoms in national hockey league players. Am J Sports Med. 2017;45(7):1633-1639. doi:10.1177/0363546517692542.
51. Wyss TF, Clark JM, Weishaupt D, Notzli HP. Correlation between internal rotation and bony anatomy in the hip. Clin Orthop Relat Res. 2007;460:152-158. doi:10.1097/BLO.0b013e3180399430.
52. Reiman MP, Goode AP, Cook CE, Holmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2015;49:811. doi:10.1136/bjsports-2014-094302.
53. Papalia R, Del Buono A, Franceschi F, Marinozzi A, Maffulli N, Denaro V. Femoroacetabular impingement syndrome management: arthroscopy or open surgery? Int Orthop. 2012;36(5):903-914. doi:10.1007/s00264-011-1443-z.
54. Locks R, Utsunomiya H, Briggs KK, McNamara S, Chahla J, Philippon MJ. Return to play after hip arthroscopic surgery for femoroacetabular impingement in professional soccer players. Am J Sports Med. 2018;46(2):273-279. doi:10.1177/0363546517738741.
55. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy. 2005;21(12):1496-1504. doi:10.1016/j.arthro.2005.08.013.
56. Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res. 2004;426:145-150. doi:10.1097/01.blo.0000136903.01368.20.
57. Domb BG, Hartigan DE, Perets I. Decision making for labral treatment in the hip: repair versus débridement versus reconstruction. J Am Acad Orthop Surg. 2017;25(3):e53-e62. doi:10.5435/JAAOS-D-16-00144.
58. Frank JS, Gambacorta PL, Eisner EA. Hip pathology in the adolescent athlete. J Am Acad Orthop Surg. 2013;21(11):665-674. doi:10.5435/JAAOS-21-11-665.
59. Singh PJ, O'Donnell JM. The outcome of hip arthroscopy in Australian football league players: a review of 27 hips. Arthroscopy. 2010;26(6):743-749. doi:10.1016/j.arthro.2009.10.010.
60. Crawford K, Philippon MJ, Sekiya JK, Rodkey WG, Steadman JR. Microfracture of the hip in athletes. Clin Sports Med. 2006;25(2):327-335. doi:10.1016/j.csm.2005.12.004.
61. Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy.2011;27(6):768-775. doi:10.1016/j.arthro.2011.01.018.
62. Wollin M, Thorborg K, Welvaert M, Pizzari T. In-season monitoring of hip and groin strength, health and function in elite youth soccer: implementing an early detection and management strategy over two consecutive seasons. J Sci Med Sport. 2018;21(10):988. doi:10.1016/j.jsams.2018.03.004.
63. Charlton PC, Drew MK, Mentiplay BF, Grimaldi A, Clark RA. Exercise interventions for the prevention and treatment of groin pain and injury in athletes: a critical and systematic review. Sports Med. 2017;47:2011. doi:10.1007/s40279-017-0742-y.
TAKE-HOME POINTS
- Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need surgical intervention.
- Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain.
- Acute groin pain in soccer players is most commonly caused by muscle strain involving the adductor longus, the iliopsoas or the rectus femoris.
- Inguinal-related groin pain is a common cause of chronic groin pain and typically is the most challenging to treat with a complex pathophysiology and a high association with femoroacetabular impingement.
- Hip-related groin pain (femoroacetabular impingement, labral tears, and chondral injuries) usually respond well to surgical intervention and has high rates of return to sport.
Minimally Invasive Anatomical Reconstruction of Posteromedial Corner of Knee: A Cadaveric Study
Take-Home Points
- Injuries to the medial knee are the most common knee ligament injuries, and often occur in the athletic population.
- Complete posteromedial corner injuries require surgical treatment to restore joint stability and biomechanics.
- Biomechanical evidence has demonstrated an important load-sharing distribution between the sMCL and the POL.
- Valgus instability caused by a medial side injury, can lead to both ACL/posterior cruciate ligament reconstruction graft failure if the medial sided injury is not concurrently repaired or reconstructed.
- Anatomic posteromedial corner reconstruction yields excellent biomechanical and patient-reported outcomes.
Most injuries of the medial structures of the knee are treated conservatively.1-3 In severe acute injuries and chronic symptomatic instabilities, however, surgical treatment is needed to restore knee stability and to prevent degenerative changes secondary to instability.4 Three structures involved in medial stability are the superficial medial collateral ligament (sMCL), which is the primary valgus restraint; the posterior oblique ligament (POL), which is the primary restraint to internal rotation and the secondary valgus restraint; and the semimembranosus.5,6
Surgical techniques for posteromedial knee reconstruction include direct repair,7 repair with augmentation,8,9 advancement of the tibial insertion of the sMCL,10 and transfer of the pes anserine tendons.11 In anatomical reconstruction of the posteromedial corner, which has been described before, the sMCL and the POL are reconstructed to reproduce the native motion and stability of the knee.12 Clinically, repair and reconstruction have similar patient-reported outcomes and medial opening evaluations over the short term.
These approaches require large incisions and extensive dissection of soft tissue on the medial aspect of the knee.5 Given these drawbacks, it is reasonable to consider less invasive options. Minimally invasive surgery has the advantages of reduced scarring and blood loss, less disruption of surrounding tissue, faster recovery, and improved aesthetics.4
We conducted a study of a minimally invasive technique for reconstructing the posteromedial structures of the knee. We compared medial compartment stability measured on valgus stress radiographs in intact, sectioned, and reconstructed states in cadaveric knees. We hypothesized that a minimally invasive technique using autogenous hamstring graft in the appropriate anatomical location would return valgus stability to its nearly native state.
Materials and Methods
This study was conducted at the Buenos Aires British Hospital in Buenos Aires, Argentina, and at the University of Colorado Hospital in Aurora. Ten fresh-frozen cadaveric knees with no evidence of ligamentous injuries, osteoarthritis, or previous surgery were used. Mean donor age was 69.4 years (range, 45-87 years). Each specimen was maintained at room temperature for 24 hours before use. The femur was sectioned 20 cm proximal to the knee joint. The tibia was sectioned 12.5 cm distal to the knee joint.
Identification and Sectioning of Posteromedial Structures
After intact-state evaluation, each knee’s sMCL, dMCL, and POL were sectioned at their tibial insertion. Valgus stress radiograph was repeated and medial compartment gap was remeasured for comparison of the sectioned state with the intact and reconstructed states.
Anatomical Reconstruction With Mini-Invasive Technique
After sectioning of medial stabilizing structures, minimally invasive reconstruction was performed through 2 small incisions on the medial aspect of each of the 10 knees, as follows. First, the semitendinosus tendon was identified through the oblique incision that had been used for sectioning. Then, an open-ended tendon stripper was placed around the circumference of the semitendinosus and was passed proximomedially, transecting the tendon at its musculotendinous junction. While the tendon stripper was being passed, care was taken to maintain the nearby tibial insertion of the sartorius fascia (Figures 1D-1F).
With the semitendinosus tendon looped around the wire, isometricity was tested by pulling the suture within the tendon and moving the knee through a full range of motion. The isometric point was confirmed by tendon migration of <2 mm.13 Migration was measured by marking the graft 2 mm from its insertion; the graft was then pulled to ensure correct isometric point position. An 18-mm cannulated spiked screw and washer (Arthrex) were then passed over the wire and partially secured to the femur—the attachment point for the proximal sMCL portion of the semitendinosus graft. The semitendinosus tendon was then secured beneath the spiked washer with the knee in 20° of flexion with neutral rotation, recreating the sMCL.
Posteriorly, the distal insertion site of the POL was identified at the posteromedial aspect of the tibia through the oblique incision previously described. A 7-mm tunnel was drilled starting posteromedial (10 mm under tibial articular surface) and exiting just distal and medial to the Gerdy tubercle. 
After final fixation, the medial knee was openly dissected to assess the inverted-V ligament reconstruction for anatomical placement and avoidance of crucial structures.
Stability Testing
Per International Knee Documentation Committee guidelines for stressing the medial compartment,14 valgus stress radiographs were obtained for all specimens at 0° and 20° of flexion in intact, sectioned, and reconstructed states. 
The medial gap formed by the femoral condyle and its corresponding tibial plateau (at site of maximal separation) was tested in all 3 state conditions (intact, sectioned, reconstructed). Distances were digitally measured with a picture archiving and communication system viewer (Imagecast; IDX Systems Corporation). Medial gap was measured by taking the shortest distance between the subchondral bone surface of the most distal aspect of the medial femoral condyle and the corresponding medial tibial plateau. Three independent examiners took all the measurements; each examiner was blinded to the others’ measurements.
Statistics
Paired Student t tests were used to compare the 3 conditions, and the Shapiro-Wilk test was used to check for a normally distributed population. Statistical significance was set at P < .05. Statistical analyses were performed with GraphPad software.
Results
In all 10 specimens, the sMCL, the dMCL, and the POL were successfully identified and sectioned through a medial oblique incision over the distal insertion of the structures.
During all valgus testing states, there was no loss of graft fixation, and there was no gross graft slippage. In addition, all grafts remained in continuity with no evidence of failure, and there were no failures or breakages of the proximal or distal screw.
After posteromedial sectioning, mean medial gap was statistically significantly larger (P = .0002) at full extension (11 mm vs 3.3 mm) and at 20° of flexion (12.6 mm vs 3.8 mm). There was no statistically significant difference between the value of the intact state and the value after minimally invasive reconstruction at 0° (P = .56) or 20° (P = .102) of flexion. 
Discussion
In this article, we describe a minimally invasive technique for anatomical posteromedial reconstruction of the knee in a cadaveric model. This technique restores the knee’s native valgus stability without causing extensive damage to the surrounding soft tissues and thereby potentially prevents scar formation and reduces blood loss.
Superficial MCL injury, one of the most common knee ligament injuries, is often associated with POL injury.7 Although most sMCL injuries are treated nonoperatively, with good results,3 surgical treatment is needed for severe (grade III) instabilities, symptomatic chronic instabilities, and knee dislocations.12,17 Most posteromedial reconstruction techniques require an extensive approach that causes damage to surrounding soft tissue,6,7,9,10 which in turn may compromise healing and positive patient outcomes. Surgical techniques include direct repair with sutures or anchors,18 capsular procedures,19 augmentations,9 internal bracing,6 and complete reconstruction of the posteromedial corner.20
LaPrade and Wijdicks12 have previously described anatomical reconstruction of the posteromedial corner. In their technique, a split semitendinosus autograft is used to reconstruct the sMCL and the POL separately, using 4 implants and reproducing each ligament’s anatomical attachment site. In this proposed technique, the distal attachment of the semitendinosus insertion is left intact, and uses 1 attachment point on the distal femur and 1 on the proximal tibia, allowing use of only 2 implants. In addition, it is performed with a minimally invasive approach, reduces cost, limits surgical exposure, and with experience may shorten operative time. To reduce the graft failure rate, the technique of LaPrade and Wijdicks12 positions the sMCL tibial attachment as posterior as possible, which can be performed with this minimally invasive approach as well.
To reduce the graft failure rate, the technique of LaPrade and Wijdicks12 positions the sMCL as posterior as possible. Despite the potential for increased graft stress with an anterior position, as in our modified technique, our group of 10 knees had no graft fixation failures in isolated valgus stress testing in either extension or flexion. Our minimally invasive posteromedial knee reconstruction significantly improved knee stability over the sectioned state as well as medial compartment gapping with valgus stress. There was no significant difference in medial compartment gapping between the intact and reconstructed states.
Our technique was built on open procedures (described by Kim and colleagues13) that carefully identify the isometric point of the graft. In addition, it adopted the modification (proposed by Lind and colleagues21) in which a fixation point is added at the distal insertion of the POL instead of being sutured to the direct arm of the semitendinosus tendon.
Furthermore, our technique, despite being similar to those described by Dong and colleagues22 and Borden and colleagues,23 has the advantages of minimally invasive surgery and reduced disruption of soft tissues. Dong and colleagues22 reported on 64 patients with a mean follow-up of 34 months; patients’ medial opening measurements were significantly decreased at follow-up and fell within the normal range.
The present study had several limitations. First, the age of our specimens was higher than the mean age of patients with knee ligament injury, potentially leading to firmer or more fibrotic tendons less susceptible to elongation. Second, we did not evaluate the knees’ rotational stability, and anterior cruciate ligaments (ACLs) were intact. As most posteromedial injuries co-occur with ACL injuries, a more realistic situation would have been reproduced by assessing rotational stability while performing both ACL reconstruction and the proposed posteromedial reconstruction. Third, static specimen measurements do not reflect the dynamic function of the posteromedial corner. Prospective clinical studies are needed to assess the true effectiveness of the posteromedial corner in the clinical scenario.
Knowledge of the anatomy of the medial aspect of the knee is vital to reconstruction of the medial side of the knee. Our results suggest that a minimally invasive technique can restore valgus stability without the need for extensive dissection and disruption of surrounding soft tissues. More research is needed to determine the results of this technique in vivo.
1. Ellsasser JC, Reynolds FC, Omohundro JR. The non-operative treatment of collateral ligament injuries of the knee in professional football players. An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically. J Bone Joint Surg Am. 1974;56(6):1185-1190.
2. Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65(3):323-329.
3. Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Rel Res. 1990;(256):174-177.
4. Jeng CL, Bluman EM, Myerson MS. Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int. 2011;32(1):21-30.
5. Coobs BR, Wijdicks CA, Armitage BM, et al. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38(2):339-347.
6. Lubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech. 2014;3(4):e505-e508.
7. Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am. 1973;55(5):923-940.
8. Gorin S, Paul DD, Wilkinson EJ. An anterior cruciate ligament and medial collateral ligament tear in a skeletally immature patient: a new technique to augment primary repair of the medial collateral ligament and an allograft reconstruction of the anterior cruciate ligament. Arthroscopy. 2003;19(10):E21-E26.
Take-Home Points
- Injuries to the medial knee are the most common knee ligament injuries, and often occur in the athletic population.
- Complete posteromedial corner injuries require surgical treatment to restore joint stability and biomechanics.
- Biomechanical evidence has demonstrated an important load-sharing distribution between the sMCL and the POL.
- Valgus instability caused by a medial side injury, can lead to both ACL/posterior cruciate ligament reconstruction graft failure if the medial sided injury is not concurrently repaired or reconstructed.
- Anatomic posteromedial corner reconstruction yields excellent biomechanical and patient-reported outcomes.
Most injuries of the medial structures of the knee are treated conservatively.1-3 In severe acute injuries and chronic symptomatic instabilities, however, surgical treatment is needed to restore knee stability and to prevent degenerative changes secondary to instability.4 Three structures involved in medial stability are the superficial medial collateral ligament (sMCL), which is the primary valgus restraint; the posterior oblique ligament (POL), which is the primary restraint to internal rotation and the secondary valgus restraint; and the semimembranosus.5,6
Surgical techniques for posteromedial knee reconstruction include direct repair,7 repair with augmentation,8,9 advancement of the tibial insertion of the sMCL,10 and transfer of the pes anserine tendons.11 In anatomical reconstruction of the posteromedial corner, which has been described before, the sMCL and the POL are reconstructed to reproduce the native motion and stability of the knee.12 Clinically, repair and reconstruction have similar patient-reported outcomes and medial opening evaluations over the short term.
These approaches require large incisions and extensive dissection of soft tissue on the medial aspect of the knee.5 Given these drawbacks, it is reasonable to consider less invasive options. Minimally invasive surgery has the advantages of reduced scarring and blood loss, less disruption of surrounding tissue, faster recovery, and improved aesthetics.4
We conducted a study of a minimally invasive technique for reconstructing the posteromedial structures of the knee. We compared medial compartment stability measured on valgus stress radiographs in intact, sectioned, and reconstructed states in cadaveric knees. We hypothesized that a minimally invasive technique using autogenous hamstring graft in the appropriate anatomical location would return valgus stability to its nearly native state.
Materials and Methods
This study was conducted at the Buenos Aires British Hospital in Buenos Aires, Argentina, and at the University of Colorado Hospital in Aurora. Ten fresh-frozen cadaveric knees with no evidence of ligamentous injuries, osteoarthritis, or previous surgery were used. Mean donor age was 69.4 years (range, 45-87 years). Each specimen was maintained at room temperature for 24 hours before use. The femur was sectioned 20 cm proximal to the knee joint. The tibia was sectioned 12.5 cm distal to the knee joint.
Identification and Sectioning of Posteromedial Structures
After intact-state evaluation, each knee’s sMCL, dMCL, and POL were sectioned at their tibial insertion. Valgus stress radiograph was repeated and medial compartment gap was remeasured for comparison of the sectioned state with the intact and reconstructed states.
Anatomical Reconstruction With Mini-Invasive Technique
After sectioning of medial stabilizing structures, minimally invasive reconstruction was performed through 2 small incisions on the medial aspect of each of the 10 knees, as follows. First, the semitendinosus tendon was identified through the oblique incision that had been used for sectioning. Then, an open-ended tendon stripper was placed around the circumference of the semitendinosus and was passed proximomedially, transecting the tendon at its musculotendinous junction. While the tendon stripper was being passed, care was taken to maintain the nearby tibial insertion of the sartorius fascia (Figures 1D-1F).
With the semitendinosus tendon looped around the wire, isometricity was tested by pulling the suture within the tendon and moving the knee through a full range of motion. The isometric point was confirmed by tendon migration of <2 mm.13 Migration was measured by marking the graft 2 mm from its insertion; the graft was then pulled to ensure correct isometric point position. An 18-mm cannulated spiked screw and washer (Arthrex) were then passed over the wire and partially secured to the femur—the attachment point for the proximal sMCL portion of the semitendinosus graft. The semitendinosus tendon was then secured beneath the spiked washer with the knee in 20° of flexion with neutral rotation, recreating the sMCL.
Posteriorly, the distal insertion site of the POL was identified at the posteromedial aspect of the tibia through the oblique incision previously described. A 7-mm tunnel was drilled starting posteromedial (10 mm under tibial articular surface) and exiting just distal and medial to the Gerdy tubercle.
After final fixation, the medial knee was openly dissected to assess the inverted-V ligament reconstruction for anatomical placement and avoidance of crucial structures.
Stability Testing
Per International Knee Documentation Committee guidelines for stressing the medial compartment,14 valgus stress radiographs were obtained for all specimens at 0° and 20° of flexion in intact, sectioned, and reconstructed states.
The medial gap formed by the femoral condyle and its corresponding tibial plateau (at site of maximal separation) was tested in all 3 state conditions (intact, sectioned, reconstructed). Distances were digitally measured with a picture archiving and communication system viewer (Imagecast; IDX Systems Corporation). Medial gap was measured by taking the shortest distance between the subchondral bone surface of the most distal aspect of the medial femoral condyle and the corresponding medial tibial plateau. Three independent examiners took all the measurements; each examiner was blinded to the others’ measurements.
Statistics
Paired Student t tests were used to compare the 3 conditions, and the Shapiro-Wilk test was used to check for a normally distributed population. Statistical significance was set at P < .05. Statistical analyses were performed with GraphPad software.
Results
In all 10 specimens, the sMCL, the dMCL, and the POL were successfully identified and sectioned through a medial oblique incision over the distal insertion of the structures.
During all valgus testing states, there was no loss of graft fixation, and there was no gross graft slippage. In addition, all grafts remained in continuity with no evidence of failure, and there were no failures or breakages of the proximal or distal screw.
After posteromedial sectioning, mean medial gap was statistically significantly larger (P = .0002) at full extension (11 mm vs 3.3 mm) and at 20° of flexion (12.6 mm vs 3.8 mm). There was no statistically significant difference between the value of the intact state and the value after minimally invasive reconstruction at 0° (P = .56) or 20° (P = .102) of flexion.
Discussion
In this article, we describe a minimally invasive technique for anatomical posteromedial reconstruction of the knee in a cadaveric model. This technique restores the knee’s native valgus stability without causing extensive damage to the surrounding soft tissues and thereby potentially prevents scar formation and reduces blood loss.
Superficial MCL injury, one of the most common knee ligament injuries, is often associated with POL injury.7 Although most sMCL injuries are treated nonoperatively, with good results,3 surgical treatment is needed for severe (grade III) instabilities, symptomatic chronic instabilities, and knee dislocations.12,17 Most posteromedial reconstruction techniques require an extensive approach that causes damage to surrounding soft tissue,6,7,9,10 which in turn may compromise healing and positive patient outcomes. Surgical techniques include direct repair with sutures or anchors,18 capsular procedures,19 augmentations,9 internal bracing,6 and complete reconstruction of the posteromedial corner.20
LaPrade and Wijdicks12 have previously described anatomical reconstruction of the posteromedial corner. In their technique, a split semitendinosus autograft is used to reconstruct the sMCL and the POL separately, using 4 implants and reproducing each ligament’s anatomical attachment site. In this proposed technique, the distal attachment of the semitendinosus insertion is left intact, and uses 1 attachment point on the distal femur and 1 on the proximal tibia, allowing use of only 2 implants. In addition, it is performed with a minimally invasive approach, reduces cost, limits surgical exposure, and with experience may shorten operative time. To reduce the graft failure rate, the technique of LaPrade and Wijdicks12 positions the sMCL tibial attachment as posterior as possible, which can be performed with this minimally invasive approach as well.
To reduce the graft failure rate, the technique of LaPrade and Wijdicks12 positions the sMCL as posterior as possible. Despite the potential for increased graft stress with an anterior position, as in our modified technique, our group of 10 knees had no graft fixation failures in isolated valgus stress testing in either extension or flexion. Our minimally invasive posteromedial knee reconstruction significantly improved knee stability over the sectioned state as well as medial compartment gapping with valgus stress. There was no significant difference in medial compartment gapping between the intact and reconstructed states.
Our technique was built on open procedures (described by Kim and colleagues13) that carefully identify the isometric point of the graft. In addition, it adopted the modification (proposed by Lind and colleagues21) in which a fixation point is added at the distal insertion of the POL instead of being sutured to the direct arm of the semitendinosus tendon.
Furthermore, our technique, despite being similar to those described by Dong and colleagues22 and Borden and colleagues,23 has the advantages of minimally invasive surgery and reduced disruption of soft tissues. Dong and colleagues22 reported on 64 patients with a mean follow-up of 34 months; patients’ medial opening measurements were significantly decreased at follow-up and fell within the normal range.
The present study had several limitations. First, the age of our specimens was higher than the mean age of patients with knee ligament injury, potentially leading to firmer or more fibrotic tendons less susceptible to elongation. Second, we did not evaluate the knees’ rotational stability, and anterior cruciate ligaments (ACLs) were intact. As most posteromedial injuries co-occur with ACL injuries, a more realistic situation would have been reproduced by assessing rotational stability while performing both ACL reconstruction and the proposed posteromedial reconstruction. Third, static specimen measurements do not reflect the dynamic function of the posteromedial corner. Prospective clinical studies are needed to assess the true effectiveness of the posteromedial corner in the clinical scenario.
Knowledge of the anatomy of the medial aspect of the knee is vital to reconstruction of the medial side of the knee. Our results suggest that a minimally invasive technique can restore valgus stability without the need for extensive dissection and disruption of surrounding soft tissues. More research is needed to determine the results of this technique in vivo.
Take-Home Points
- Injuries to the medial knee are the most common knee ligament injuries, and often occur in the athletic population.
- Complete posteromedial corner injuries require surgical treatment to restore joint stability and biomechanics.
- Biomechanical evidence has demonstrated an important load-sharing distribution between the sMCL and the POL.
- Valgus instability caused by a medial side injury, can lead to both ACL/posterior cruciate ligament reconstruction graft failure if the medial sided injury is not concurrently repaired or reconstructed.
- Anatomic posteromedial corner reconstruction yields excellent biomechanical and patient-reported outcomes.
Most injuries of the medial structures of the knee are treated conservatively.1-3 In severe acute injuries and chronic symptomatic instabilities, however, surgical treatment is needed to restore knee stability and to prevent degenerative changes secondary to instability.4 Three structures involved in medial stability are the superficial medial collateral ligament (sMCL), which is the primary valgus restraint; the posterior oblique ligament (POL), which is the primary restraint to internal rotation and the secondary valgus restraint; and the semimembranosus.5,6
Surgical techniques for posteromedial knee reconstruction include direct repair,7 repair with augmentation,8,9 advancement of the tibial insertion of the sMCL,10 and transfer of the pes anserine tendons.11 In anatomical reconstruction of the posteromedial corner, which has been described before, the sMCL and the POL are reconstructed to reproduce the native motion and stability of the knee.12 Clinically, repair and reconstruction have similar patient-reported outcomes and medial opening evaluations over the short term.
These approaches require large incisions and extensive dissection of soft tissue on the medial aspect of the knee.5 Given these drawbacks, it is reasonable to consider less invasive options. Minimally invasive surgery has the advantages of reduced scarring and blood loss, less disruption of surrounding tissue, faster recovery, and improved aesthetics.4
We conducted a study of a minimally invasive technique for reconstructing the posteromedial structures of the knee. We compared medial compartment stability measured on valgus stress radiographs in intact, sectioned, and reconstructed states in cadaveric knees. We hypothesized that a minimally invasive technique using autogenous hamstring graft in the appropriate anatomical location would return valgus stability to its nearly native state.
Materials and Methods
This study was conducted at the Buenos Aires British Hospital in Buenos Aires, Argentina, and at the University of Colorado Hospital in Aurora. Ten fresh-frozen cadaveric knees with no evidence of ligamentous injuries, osteoarthritis, or previous surgery were used. Mean donor age was 69.4 years (range, 45-87 years). Each specimen was maintained at room temperature for 24 hours before use. The femur was sectioned 20 cm proximal to the knee joint. The tibia was sectioned 12.5 cm distal to the knee joint.
Identification and Sectioning of Posteromedial Structures
After intact-state evaluation, each knee’s sMCL, dMCL, and POL were sectioned at their tibial insertion. Valgus stress radiograph was repeated and medial compartment gap was remeasured for comparison of the sectioned state with the intact and reconstructed states.
Anatomical Reconstruction With Mini-Invasive Technique
After sectioning of medial stabilizing structures, minimally invasive reconstruction was performed through 2 small incisions on the medial aspect of each of the 10 knees, as follows. First, the semitendinosus tendon was identified through the oblique incision that had been used for sectioning. Then, an open-ended tendon stripper was placed around the circumference of the semitendinosus and was passed proximomedially, transecting the tendon at its musculotendinous junction. While the tendon stripper was being passed, care was taken to maintain the nearby tibial insertion of the sartorius fascia (Figures 1D-1F).
With the semitendinosus tendon looped around the wire, isometricity was tested by pulling the suture within the tendon and moving the knee through a full range of motion. The isometric point was confirmed by tendon migration of <2 mm.13 Migration was measured by marking the graft 2 mm from its insertion; the graft was then pulled to ensure correct isometric point position. An 18-mm cannulated spiked screw and washer (Arthrex) were then passed over the wire and partially secured to the femur—the attachment point for the proximal sMCL portion of the semitendinosus graft. The semitendinosus tendon was then secured beneath the spiked washer with the knee in 20° of flexion with neutral rotation, recreating the sMCL.
Posteriorly, the distal insertion site of the POL was identified at the posteromedial aspect of the tibia through the oblique incision previously described. A 7-mm tunnel was drilled starting posteromedial (10 mm under tibial articular surface) and exiting just distal and medial to the Gerdy tubercle.
After final fixation, the medial knee was openly dissected to assess the inverted-V ligament reconstruction for anatomical placement and avoidance of crucial structures.
Stability Testing
Per International Knee Documentation Committee guidelines for stressing the medial compartment,14 valgus stress radiographs were obtained for all specimens at 0° and 20° of flexion in intact, sectioned, and reconstructed states.
The medial gap formed by the femoral condyle and its corresponding tibial plateau (at site of maximal separation) was tested in all 3 state conditions (intact, sectioned, reconstructed). Distances were digitally measured with a picture archiving and communication system viewer (Imagecast; IDX Systems Corporation). Medial gap was measured by taking the shortest distance between the subchondral bone surface of the most distal aspect of the medial femoral condyle and the corresponding medial tibial plateau. Three independent examiners took all the measurements; each examiner was blinded to the others’ measurements.
Statistics
Paired Student t tests were used to compare the 3 conditions, and the Shapiro-Wilk test was used to check for a normally distributed population. Statistical significance was set at P < .05. Statistical analyses were performed with GraphPad software.
Results
In all 10 specimens, the sMCL, the dMCL, and the POL were successfully identified and sectioned through a medial oblique incision over the distal insertion of the structures.
During all valgus testing states, there was no loss of graft fixation, and there was no gross graft slippage. In addition, all grafts remained in continuity with no evidence of failure, and there were no failures or breakages of the proximal or distal screw.
After posteromedial sectioning, mean medial gap was statistically significantly larger (P = .0002) at full extension (11 mm vs 3.3 mm) and at 20° of flexion (12.6 mm vs 3.8 mm). There was no statistically significant difference between the value of the intact state and the value after minimally invasive reconstruction at 0° (P = .56) or 20° (P = .102) of flexion.
Discussion
In this article, we describe a minimally invasive technique for anatomical posteromedial reconstruction of the knee in a cadaveric model. This technique restores the knee’s native valgus stability without causing extensive damage to the surrounding soft tissues and thereby potentially prevents scar formation and reduces blood loss.
Superficial MCL injury, one of the most common knee ligament injuries, is often associated with POL injury.7 Although most sMCL injuries are treated nonoperatively, with good results,3 surgical treatment is needed for severe (grade III) instabilities, symptomatic chronic instabilities, and knee dislocations.12,17 Most posteromedial reconstruction techniques require an extensive approach that causes damage to surrounding soft tissue,6,7,9,10 which in turn may compromise healing and positive patient outcomes. Surgical techniques include direct repair with sutures or anchors,18 capsular procedures,19 augmentations,9 internal bracing,6 and complete reconstruction of the posteromedial corner.20
LaPrade and Wijdicks12 have previously described anatomical reconstruction of the posteromedial corner. In their technique, a split semitendinosus autograft is used to reconstruct the sMCL and the POL separately, using 4 implants and reproducing each ligament’s anatomical attachment site. In this proposed technique, the distal attachment of the semitendinosus insertion is left intact, and uses 1 attachment point on the distal femur and 1 on the proximal tibia, allowing use of only 2 implants. In addition, it is performed with a minimally invasive approach, reduces cost, limits surgical exposure, and with experience may shorten operative time. To reduce the graft failure rate, the technique of LaPrade and Wijdicks12 positions the sMCL tibial attachment as posterior as possible, which can be performed with this minimally invasive approach as well.
To reduce the graft failure rate, the technique of LaPrade and Wijdicks12 positions the sMCL as posterior as possible. Despite the potential for increased graft stress with an anterior position, as in our modified technique, our group of 10 knees had no graft fixation failures in isolated valgus stress testing in either extension or flexion. Our minimally invasive posteromedial knee reconstruction significantly improved knee stability over the sectioned state as well as medial compartment gapping with valgus stress. There was no significant difference in medial compartment gapping between the intact and reconstructed states.
Our technique was built on open procedures (described by Kim and colleagues13) that carefully identify the isometric point of the graft. In addition, it adopted the modification (proposed by Lind and colleagues21) in which a fixation point is added at the distal insertion of the POL instead of being sutured to the direct arm of the semitendinosus tendon.
Furthermore, our technique, despite being similar to those described by Dong and colleagues22 and Borden and colleagues,23 has the advantages of minimally invasive surgery and reduced disruption of soft tissues. Dong and colleagues22 reported on 64 patients with a mean follow-up of 34 months; patients’ medial opening measurements were significantly decreased at follow-up and fell within the normal range.
The present study had several limitations. First, the age of our specimens was higher than the mean age of patients with knee ligament injury, potentially leading to firmer or more fibrotic tendons less susceptible to elongation. Second, we did not evaluate the knees’ rotational stability, and anterior cruciate ligaments (ACLs) were intact. As most posteromedial injuries co-occur with ACL injuries, a more realistic situation would have been reproduced by assessing rotational stability while performing both ACL reconstruction and the proposed posteromedial reconstruction. Third, static specimen measurements do not reflect the dynamic function of the posteromedial corner. Prospective clinical studies are needed to assess the true effectiveness of the posteromedial corner in the clinical scenario.
Knowledge of the anatomy of the medial aspect of the knee is vital to reconstruction of the medial side of the knee. Our results suggest that a minimally invasive technique can restore valgus stability without the need for extensive dissection and disruption of surrounding soft tissues. More research is needed to determine the results of this technique in vivo.
1. Ellsasser JC, Reynolds FC, Omohundro JR. The non-operative treatment of collateral ligament injuries of the knee in professional football players. An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically. J Bone Joint Surg Am. 1974;56(6):1185-1190.
2. Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65(3):323-329.
3. Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Rel Res. 1990;(256):174-177.
4. Jeng CL, Bluman EM, Myerson MS. Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int. 2011;32(1):21-30.
5. Coobs BR, Wijdicks CA, Armitage BM, et al. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38(2):339-347.
6. Lubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech. 2014;3(4):e505-e508.
7. Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am. 1973;55(5):923-940.
8. Gorin S, Paul DD, Wilkinson EJ. An anterior cruciate ligament and medial collateral ligament tear in a skeletally immature patient: a new technique to augment primary repair of the medial collateral ligament and an allograft reconstruction of the anterior cruciate ligament. Arthroscopy. 2003;19(10):E21-E26.
1. Ellsasser JC, Reynolds FC, Omohundro JR. The non-operative treatment of collateral ligament injuries of the knee in professional football players. An analysis of seventy-four injuries treated non-operatively and twenty-four injuries treated surgically. J Bone Joint Surg Am. 1974;56(6):1185-1190.
2. Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am. 1983;65(3):323-329.
3. Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Rel Res. 1990;(256):174-177.
4. Jeng CL, Bluman EM, Myerson MS. Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity. Foot Ankle Int. 2011;32(1):21-30.
5. Coobs BR, Wijdicks CA, Armitage BM, et al. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38(2):339-347.
6. Lubowitz JH, MacKay G, Gilmer B. Knee medial collateral ligament and posteromedial corner anatomic repair with internal bracing. Arthrosc Tech. 2014;3(4):e505-e508.
7. Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am. 1973;55(5):923-940.
8. Gorin S, Paul DD, Wilkinson EJ. An anterior cruciate ligament and medial collateral ligament tear in a skeletally immature patient: a new technique to augment primary repair of the medial collateral ligament and an allograft reconstruction of the anterior cruciate ligament. Arthroscopy. 2003;19(10):E21-E26.
