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Management of Hip and Core Muscles Injuries in the Hockey Player

Brian R. Neri, MDFebruary 5th, 2016

No Disclosures

Overview

• Introduction

• Anatomy

• Differential Diagnosis

• Sports hernia (Core Muscle Dys-CMD) • Femoroacetabular Impingement (FAI)

• Pathogenesis• History and physical exam

• Imaging• Nonoperative treatment

• Surgical technique

• Outcomes/Literature• Cases

Farber. J Am Acad Orthop Surg. 2007

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Introduction-Core Muscle Dysfunction

• Groin pain is common in athletes that use musculature of proximal thigh and lower abdomen.

• Soccer• Ice hockey

• Skiing

• Running/Hurdling

• Groin injuries account for 5-8% of all injuries in soccer players and 10-43% of all

injuries in elite ice hockey players.

• CMD is a common diagnosis in athletes with chronic groin pain, occurring up to 50% of

the time.

• CMD, osteitis pubis, and adductor dysfunction are significantly more common in male

athletes, but have been reported in females

Farber J. Am Acad Orthop Surg. 2007.Ekstrand Scand J Med Sci Sports 1999.Lovell. Aust J Sci Med Sport. 1995.Minnich. Am J Sports Med. 2011

Anatomy

Anatomy

Falvey. Br J Sports Med. 2009

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Anatomy

Khan. Magn Res Imaging Clin N Am. 2013

Rectus abdominis

Pubic tubercle

Adductor longus

Pubic symphysis

Differential

Diagnosis of Groin

Pain

Leibold. J Man Manip Ther. 2008.

Musculoskeletal causes of groin pain

•EXTRA-ARTICULAR•Sports hernia•Adductor tendinopathy•Osteitis Pubis•Rectus abdominus injuries

•JUXTA-ARTICULAR•Psoas tendinopathy•Rectus fem. injury

•INTRA-ARTICULAR•Labral tears•Loose bodies•Femoroacetabularimpingement

•Instability/capsular laxity•Ligamentum teres tears•Chondral damage•Osteoarthritis

Atkins. Curr Sports Med Reports 2010.

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Extraarticular causes of chronic groin pain

Falvey. Br J Sports Med. 2009

•Terms in the literature:•Sports hernia•Sportsman’s hernia•Athletic pubalgia•Gilmore’s groin•Groin disruption•Groin pain syndrome•Hockey groin syndrome•Hockey player’s syndrome

•Slap-shot gut•Incipient hernia•Athletic hernia•Core Muscle Dysfunction

Caudill. Br J Sports Med. 2008.Gerhardt. Practical Orthopaedic Sports Medicine & Arthroscopy. 2007

CMD: pathogenesis

• Imbalance between strong adductor muscles of the thigh and relatively weak lower abdominal musculature

Farber J Am Acad Orthop Surg. 2007.Zoga. Radiol Clin N Am. 2010

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CMD: pathogenesis

• Trunk hyperextension and thigh abduction lead to shear forces across pubic symphysis

Gerhardt. Practical Orthopaedic Sports Medicine & Arthroscopy. 2007

CMD: pathogenesis

•Shear forces on inguinal wall musculature leads to attenuation of local soft tissues:

•Tearing of transversalis fascia or conjoined tendon

•Abnormalities at insertion of rectus abdominis

•Avulsion of internal oblique muscle fibers at pubic tubercle

• Intrasubstance tear of internal oblique muscle

•Attenuation of external oblique muscle and aponeurosis

CMD: history

• Insidious onset/Occasional identifiable ‘event’

• Asymptomatic with rest, painful with activity

• Pain may radiate to adductor region, perineum, rectus

muscles, inguinal ligament, and testicular area• Ilioinguinal nerve• Genitofemoral nerve

• Obturator nerve

• Aggravated by sudden movements, coughing,

sneezing, sit-ups, sprinting, and stride.

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CMD: physical examination

• No detectable inguinal hernia

• Four elements consistently found:

1. Inguinal canal tenderness

2. Dilated superficial inguinal ring

3. Pubic tubercle tenderness

4. Hip adductor origin tenderness

• Location, Location, Location

•Nam. J Am Coll Surg. 2008.

CMD: physical examination

• Pain provocation tests

1. Patient squeezes knees together while supine with 45deg hip flexion and 90deg knee flexion

2. Patient squeezes feet together while supine with 30deg hip flexion and slight abduction-internal rotation

3. Hip flexion-abduction-external rotation (FABER) or Quadrant tests

4. Resisted SLR (Stinchfield)

5. Resisted crunch or sit-up

•Verrall. Scand J Med Sci Sports. 2005

CMD: imaging

• Plain radiographs of hip, pelvis, and lumbar spine should be included in evaluation of athletes with groin pain, but are usually unremarkable in patients with CMD

• MRI is nonspecific, useful to rule out other causes of groin pain

• Increased signal in pubic bone• Increased signal in one or more groin muscles• Attenuation or bulging of musculofascial layers of abdominal wall

• Lifting of the aponeurotic plate

Albers. Skeletal Radiol. 2001

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CMD: imaging – aponeurotic plate

CMD: nonoperative treatment

• 2-6 weeks• NSAIDs

• Heat or ice• Massage• Modalities

• Progressive resistance hip adductor strengthening and stretching exercises

• Hockey-specific functional tasks

• Gradual return to full when pain free

• Success at long term pain relief < 20%

Caudill. Br J Sports Med. 2008.Hackney. Br J Sports Med. 1993.

Sports hernia: surgical technique

Minnich. Am J Sports Med. 2011

Rectus abdominis

Spermatic cord

Disruption in transversalis fascia

Repair augmented

with mesh

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Sports hernia: surgical technique

• Pathogenesis of sports hernia involves imbalance between strong adductor muscles of the thigh and relatively weak lower abdominal musculature

• Contracted or overdeveloped adductors should be addressed at time of sports hernia repair, with tenotomy of adductor longus

Farber J Am Acad Orthop Surg. 2007.Zoga. Radiol Clin N Am. 2010Meyers. Am J Sports Med. 2000.

Sports hernia: outcomes

• Meyers et al reported results on 157 athletes with chronic groin pain

• Surgery consisted of broad surgical reattachment of inferolateral edge of rectus abdominis with fascial investment to pubis

• 36 (23%) patients underwent concurrent adductor release

• 152 patients (97%) returned to their preinjury activity levels

Meyers. Am J Sports Med. 2000.


• Van Der Donckt et al prospectively reviewed 41 male athletes with chronic groin pain

• Surgery consisted open Bassini hernia repair and percutaneous adductor longus tenotomy in all patients

• All patients resumed sporting activity, at an average of 6.9 months

• 37 patients (90%) reported to perform at same or improved levels, 4 patients (10%) reported to perform at lower levels

• Recommended hernia repair and concomitant adductor longus tenotomy when conservative treatment unsuccessful

Van Der Donckt. Acta Orthop Belg. 2003

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• Ingoldby retrospectively reviewed 30 hernia repairs in 28 patients

• 14 patients (14 hernias) were repaired open and 14 patients (16 hernias) were repaired laproscopically

• All patients returned to preinjury activity levels

• Return to sporting activity <4 weeks occurred in 9/14 patients in open group and 13/14 in laproscopic group (p < 0.05)

Ingoldby. Br J Surg. 1997.


• Jakoi et al reviewed 43 National Hockey League players who underwent sports hernia

repair from 2001-2008

• Compared statistics in 2 seasons prior to surgery with 2 seasons after recovery

• 40 players (93%) were able to resume NHL career

• Younger players had no difference in number of goals, assists, or time on ice.

• Older players had a decrease in goals, assists, and games played

Jakoi. Am J Sports Med. 2012.


• Caudill et al. performed a metanalysis of 104 studies on sports hernia

• Success rate of laproscopic (96%) repair was no different than open repair (93%)

• Laproscopic repair offers advantage of faster rehabilitation and earlier return to

unrestricted activity

• Recurrence rate with laproscopic approach may be higher, since unable to visualize

entire lesion during surgery

• Surgical release of hip adductors may help restore balance between abdominal and

hip adductor muscle forces at pubic bone

Caudill. Br J Sports Med. 2008.

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Sports hernia: Postoperative Rehabilitation

•Phase I-V (6 week) •I: walking, light stretching, wound care

•II: AROM hip, Backwards walking, bike, abdominal contraction

•III: Scar mob/ART, skating/stick handling

•IV: Advanced strengthening, core

•V: Weight room, conditioning, full practice

•Accelerated (3 week)•Week 1: Walk 1 mile/day•Day 7-10: pool, gentle stretching, jogging, easy skate

•Day 11-21: Resistive exercises, sprinting, adv strengthening, skating++

•Day 18+: Full team participation as tolerated

L. Michael Brunt, MD – St. Louis Blues

Extraarticular causes of chronic groin pain

Adductor dysfunction: imaging

•MRI•Increased signal in adductor longus enthesis

•Complete tear of tendinous insertion

Maffulli. Am J Sports Med. 2012.Schlegel. Am J Sports Med. 2009.

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Adductor rupture: imaging

Adductor tendon ruptures: nonoperative treatment

• Schlegel et al reviewed 19 National Football League players with adductor longus tendon ruptures

• 14/19 players were managed nonoperatively

• All 14 players returned to the NFL at an average of 6.1 weeks post-injury

• Treatment program:

• Week 1: NSAIDs, heat, ice, electrical stimulation• Week 2: Nonresistance exercise bicycle, pool walking, light stretching• Weeks 3-4: Core strengthening, light plyometrics, light treadmill running

• Weeks 5-6: heavier running, light strengthening, gradual participation in practice drills, and return to sports

Schlegel. Am J Sports Med. 2009.

Combined injuries

• Larson et al reviewed 37 patients diagnosed with both sports hernia and intra-articular hip joint pathology

• 16 patients had sports hernia surgery as index procedure• 4/16 returned to sports without limitation

• 11/16 required hip arthroscopy

• 8 patients had hip arthroscopy as index procedure

• 4/8 returned to sports without limitation• 3/8 required sports hernia surgery

• Outcomes suboptimal when surgery only addressed one component of combined injury

Larson. Arthroscopy. 2011.

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• Understanding groin anatomy is key to making the correct diagnosis and instituting the

appropriate treatment plan

Femoroacetabular Impingement (FAI)

•Osseous morphologic

abnormalities result in abnormal

contact between the femoral

neck/head and the acetabular

margin during terminal motion of

the hip

Parvizi et al: JAAOS 2007.

Femoroacetabular Impingement

•Repetitive abnormal contact leads to

labral and chondral damage

•Continued progression leads to

premature degenerative arthritis

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Predisposing factors

•Legg-Calve-Perthes disease

•Slipped capital femoral ephiphysis

•Avascular necrosis

•Malunited fractures (acetabulum or femoral neck)

•Prior periacetabular or proximal femoral osteotomy

•Retroverted acetabulum

•Most patients/athletes lack a clear history for any predisposing

condition-likely adaptive changes during formative years

Background

•14% prevalence of Cam-Type FAI Morphology inasymptomatic adults.

�25% in men (5% in women)�3.5% Bilaterally

Hack et al. JBSJ 2010

•75% of youth ice hockey players vs. 42% of age matched

youth skiers had an Alpha Angle ≥ 55°Philippon et al. AJSM 2013

•Elite Soccer Players (Frog Leg Views)�Cam = 68% prevalence in Men, 50% in Women

�Pincer = 27% Men and 10% Women�Average Alpha Angle was 65.5

Gerhardt et al. AJSM 2012

NHL study…

•Hockey players during 2014-2015 preseason entrance examinations for 3 NHL Hockey Clubs.

•All players underwent physical examination, ROM measurements and pelvis/hip radiographs

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Results – Cam-Type FAI By Position

� Difference in the prevalence of FAI in the Right Hips of Centers and Goaliesapproached statistical significance by Fischer exact test (P = 0.076)

NHL study…

A quarter of the elite hockey players in this study

reported a history of hip pain.

The prevalence of cam-type FAI morphology in

elite hockey player is considerable.�Roughly 70% Cam-Type FAI morphology in at least one hip

�61% Cam-Type FAI morphology bilaterally.

Pincer-type FAI

contracoup injury

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Pincer-type FAI

Cam type FAI

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Cam-type FAI

Clinical History: FAI

•Insidious, absence of trauma•Pain after activity/sport, prolonged sitting, bus/plane rides •Occasional mechanical symptoms•Failure of typical nonoperative treatments

•Average duration of symptoms ~1 year at presentation

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Case #1

•18 y/o M elite-level ice hockey player with c/o 1 year of

left hip pain, progressive. Typically activity related, also

bothersome sitting.

•Underwent 6 months of PT/NSAIDS

•No sign. PSH/PMH

•Physical examination:•Hip ROM 120/10/30, contra IR 15-20

•+Stinchfield/FABER/Ant (Ganz) impingement test

•No adductor/rectus or peritrochanteric tenderness

Preop Imaging

Preop Imaging

Alpha >80deg

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Preop Imaging

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Osteoplasty

Postoperatively

•FFWB x 6 weeks, then weaned

•Skating with difficulty at 4.5 months

•Did not feel comfortable on the ice—described pinching

with crossing over

Postop CT

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Second Look

Persistent Cam Lesion

Osteoplasty

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Case #2

•24 y/o M ice hockey player with c/o 6 months right hip

pain. Typically activity related, also bothersome sitting.

•Underwent PT/NSAIDS

•No sign. PSH/PMH


•+Stinchfield/FABER/Ant (Ganz) impingement test

•No adductor/rectus or peritrochanteric tenderness

Preop Imaging

Preop Imaging

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Preop Imaging

Preop Imaging

Preop Imaging

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Literature

Literature

•39 pts (1999-2010)

•Hockey, soccer, baseball, tennis, golf

•30/39 (77%) vs. control (84%) returned to play

•No stat difference + or - microfracture

Case #3

•21 y/o M OHL player with c/o 3 year of progressive left

hip pain.

•Underwent yrs of PT/NSAIDS

•No sign. PSH/PMH

•Physical examination:•Hip ROM 115/15/25

•+Stinchfield/FABER/Ant impingement test

•No abdominal/peritroch findings

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Literature

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Literature

•Retrospective review 21 athletes (23 hips)

•Ipsi ITB graft

•81% returned to same level at avg 41mos f/u

•20 pt increase in mHHS, HOS scores

Case #4

•39 y/o professional ice hockey player with c/o 1 month of

progressive groin pain.

•Shut down, rehab 3 weeks

•No sign. PSH/PMH


•Mild Ganz impingement, neg FABER, +stinchfield

•+TTP at rectus/adductor origin, +pain with sit-up

Preop Imaging

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Preop Imaging

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Literature

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Literature

•38 pro athletes with symptomatic FAI

•32% had prior CMD surgery with persistent pain

•High incidence of symptoms of CMD with FAI

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