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Editorial Commentary: Managing Hip Pain, Athletic Pubalgia, Sports Hernia, Core Muscle Injury, and Inguinal Disruption Requires Diagnostic and Therapeutic Expertise

      Abstract

      Pubalgia means pubic pain. This is different from core muscle injury (implying muscular pathology) or inguinal disruption (different anatomic region). Athletic pubalgia includes a myriad of pathologic conditions involving the pubic symphysis, adductors, rectus abdominis, posterior inguinal wall, and/or related nerves. Moreover, growing evidence supports a link between femoroacetabular impingement (FAI) and pubalgic conditions. Constrained hip range of motion in flexion causing obligatory transitory, even ballistic, posterior tilting of the hemipelvis may produce pathologic transfer stress to not only the pubic symphysis but the sacroiliac joint, lumbar spine, and proximal hamstrings, manifesting in diverse, often-painful, conditions. In select cases of pubalgia, patients may have clinical improvement with concurrent or even isolated treatment addressing FAI. Unlike atypical posterior hip pain from FAI, which may be referred pain that might respond favorably, albeit temporarily, to an intra-articular injection, secondary pubic pain from a transfer stress pathomechanism might not be expected to benefit from such. And, it’s not always FAI. Some patients who do not respond to nonoperative management may not require arthroscopic surgery and might benefit from open or laparoscopic mesh hernia repair, adductor tenotomy, primary tissue (hernia) repair, rectus abdominis repair, or even endoscopic surgery for osteitis pubis and/or pubalgia. And, finally, these may be combined with FAI surgical treatment. Refinement of definitions, pathologic conditions, technical advances, and collaboration with general surgeons will best help us treat our patients.
      You like potato and I like potahto, You like tomato and I like tomahto, Potato, potahto, Tomato, tomahto! Let's call the whole thing off!George and Ira Gershwin
      I congratulate Kraeutler, Mei-Dan, Belk, Larson, Talishinskiy, and Scillia on the publication of “A Systematic Review Demonstrates High Variation of Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.”
      • Kraeutler M.J.
      • Mei-Dan O.
      • Belk J.W.
      • Larson C.M.
      • Talishinskiy T.
      • Scillia A.J.
      A systematic review demonstrates high variation of terminology, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of athletic pubalgia/sports hernia/core muscle injury/inguinal disruption.
      The most common procedures performed were an open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis (RA) repair. The procedures performed differed based on surgeon subspecialty, geographic location, and year of publication. As the classic lyrics state, one may call something by different names (or pronunciations), but we must keep in mind that a potato is not a tomato; indeed, one isn’t even a vegetable. Every now and then, my high school Latin comes into play. Pubalgia actually means pubic pain. In my book, this is quite different from terminology like core muscle injury (implying muscular pathology) or inguinal disruption (different anatomic region). Athletic pubalgia includes a myriad of pathologic conditions involving the pubic symphysis, adductors, RA, posterior inguinal wall, and/or related nerves. This can cloud our understanding and compromise our ability as surgeons (regardless of specialty) to determine and compare outcomes, ultimately affecting accepted best practice and patient care.
      Moreover, growing evidence supports a link between femoroacetabular impingement (FAI) and pubalgic conditions.
      • Verrall G.M.
      • Hamilton I.A.
      • Slavotinek J.P.
      • et al.
      Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury.
      • Phillips E.
      • Khoury V.
      • Wilmot A.
      • Kelly 4th, J.D.
      Correlation between cam-type femoroacetabular impingement and radiographic osteitis pubis.
      • Saito M.
      • Utsunomiya H.
      • Hatakeyama A.
      • et al.
      Hip arthroscopic management can improve osteitis pubis and bone marrow edema in competitive soccer players with femoroacetabular impingement.
      Constrained hip range of motion in flexion causing obligatory transitory, even ballistic, posterior tilting of the hemipelvis may produce pathologic transfer stress to not only the pubic symphysis but the sacroiliac joint, lumbar spine, and proximal hamstrings, manifesting in diverse, often-painful, conditions. In select cases of pubalgia, patients may have clinical improvement with concurrent or even isolated treatment addressing FAI.
      • Saito M.
      • Utsunomiya H.
      • Hatakeyama A.
      • et al.
      Hip arthroscopic management can improve osteitis pubis and bone marrow edema in competitive soccer players with femoroacetabular impingement.
      ,
      • Larson C.M.
      • Pierce B.R.
      • Giveans M.R.
      Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: A case series.
      Unlike atypical posterior hip pain from FAI, which may be referred pain that might respond favorably albeit temporarily to an intra-articular injection, secondary pubic pain from a transfer stress pathomechanism might not be expected to benefit from such.
      And don’t take osteitis pubis off the menu. This year, the American Academy of Orthopaedic Surgeons is presenting a new instructional course lecture entitled “It’s Not Always FAI.” Presented by an orthopaedic surgeon and a general surgeon, the topic of athletic pubalgia/core muscle injury is gaining traction, especially as new endoscopic approaches enter the therapeutic pot. These less-invasive outpatient techniques may offer a seamless option of hip arthroscopy for FAI and concurrent endoscopic surgery for osteitis pubis and/or pubalgia. Kind of like adding ingredients through a straw rather than removing the lid from the pot. Endoscopic pubic symphysectomy, distal RA tendon repair, adductor tenotomy, and most recently adductor longus repair
      • Matsuda D.K.
      • Ribas M.
      • Matsuda N.A.
      • Domb B.G.
      Multicenter outcomes of endoscopic pubic symphysectomy for osteitis pubis associated with femoroacetabular impingement.
      ,
      • Matsuda D.K.
      • Matsuda N.A.
      • Head R.
      • Tivorsak T.
      Endoscopic rectus abdominis and prepubic aponeurosis repairs for treatment of athletic pubalgia.
      have been introduced to “stir” the interest of surgical cooks comfortable using the straw.
      So, are there too many cooks stirring the global pubalgic stew? Should we just call the whole thing off? Absolutely not! Further refinement of definitions, pathologic conditions, meaningful patient-reported outcomes for meaningful outcome studies, technique and technical advancement, and further collaboration (vs competition) between surgical specialists…is just what the chef ordered.

      Supplementary Data

      References

        • Kraeutler M.J.
        • Mei-Dan O.
        • Belk J.W.
        • Larson C.M.
        • Talishinskiy T.
        • Scillia A.J.
        A systematic review demonstrates high variation of terminology, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of athletic pubalgia/sports hernia/core muscle injury/inguinal disruption.
        Arthroscopy. 2021; 31: 2377-2390
        • Verrall G.M.
        • Hamilton I.A.
        • Slavotinek J.P.
        • et al.
        Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury.
        J Sci Med Sport. 2005; 8: 77-84
        • Phillips E.
        • Khoury V.
        • Wilmot A.
        • Kelly 4th, J.D.
        Correlation between cam-type femoroacetabular impingement and radiographic osteitis pubis.
        Orthopedics. 2016; 39: e417-e422
        • Saito M.
        • Utsunomiya H.
        • Hatakeyama A.
        • et al.
        Hip arthroscopic management can improve osteitis pubis and bone marrow edema in competitive soccer players with femoroacetabular impingement.
        Am J Sports Med. 2019; 47: 408-419
        • Larson C.M.
        • Pierce B.R.
        • Giveans M.R.
        Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: A case series.
        Arthroscopy. 2011; 27: 768-775
        • Matsuda D.K.
        • Ribas M.
        • Matsuda N.A.
        • Domb B.G.
        Multicenter outcomes of endoscopic pubic symphysectomy for osteitis pubis associated with femoroacetabular impingement.
        Arthroscopy. 2015; 31: 1255-1260
        • Matsuda D.K.
        • Matsuda N.A.
        • Head R.
        • Tivorsak T.
        Endoscopic rectus abdominis and prepubic aponeurosis repairs for treatment of athletic pubalgia.
        Arthrosc Tech. 2017; 6: e183-e188