So we can All right We are ready to go. We're gonna buzz through some of this early stuff But again, we're gonna keep everybody video and audio muted. If you have any questions, look me up My name is Sterling Herring. If you click your participants list, I should be up near the top somewhere you can double click my name and you should be able to Send me a message directly and then as question time Arises either in the middle or at the end of the lecture we can I can present them to the lecture that kind of allows us to Maintain some semblance of control in terms of maintaining Privacy and and all that Any questions about this in general? You can email Candace at that email address They're c-street.org and again her Twitter handle. So without further ado Welcome, dr. Bailowitz. Thank you for joining us Yeah, thanks for having me can you guys hear me, okay, yes, awesome Let me see if I can figure out how to share my screen here Perfect that's great. Is that working? Yes. Okay, cool Yeah, thanks again. Certainly for organizing this. This has been awesome So far, I want to do a quick shout-out to Dr. Bowers, that was an awesome talk and I think in addition to being really interesting His talk is really board relevant. I am also new out of training. I just finished fellowship 2019 And I can tell you that from a PM&R board standpoint The entrapment neuropathy since show up a fair bit So definitely If you're, you know coming up on taking boards here pretty soon that's a good talk to To take a look at again I hope that my talk will be just as interesting I don't know that it will be quite as board relevant, but i'm going to try and at least keep you guys entertained So quick background for me. I'm a sports medicine Doctor in the orthopedics department at kaiser in oakland california I did my residency at carolina's medical center in charlotte and then my sports medicine fellowship was at columbia in new york And I recently Joined as volunteer clinical faculty for the UCSF sports medicine fellowship as well. So i'll be helping out with some of their ultrasound teaching This Talk I have no disclosures I just want to say thank you to all of you for being here Talk I have no disclosures. Um I just wanted to also give a quick shout out again as sterling has mentioned. Thank you to all the frontline workers Certainly, it's affected all of us differently And while we haven't been affected as hard as some of the other places around the country We're still seeing changes every day And hopefully we can try and find silver linings from this terrible tragedy Um I think certainly people have been able to find ways that their life has been better although obviously this is a terrible thing overall that happened to the country, but Um, so shout out to everybody that's helped out Um, so today we're going to talk about groin pain nomenclature Um, we'll talk about why this is such a diagnostic conundrum talk about some common and uncommon causes and then move on to diagnosis and treatment um quickly I should mention last week mindy loveless from washington gave an awesome talk on hip pain in the athlete and There will be some overlap. Um, i'm going to try to focus on some topics that she did not discuss. Um And I think you know This is such a broad topic and she did a great job of emphasizing how important it is to keep a broad differential So i'm going to kind of take a deeper dive into a few select topics, um, including one that she did not talk about um So I chose this topic because I saw a lot of groin pain both in residency and fellowship Um, and the literature supports this it's a common diagnosis And not only is it common, but it also can represent significant time lost for athletes. Um, And a lot of times this is the case because we have Difficulty diagnosing it and if we can't diagnose it, it's it's challenging to treat Um, and then the other problem is that we keep changing the diagnosis of what exactly groin pain entails and so That makes it challenging to to treat as well Um, so a good portion of this talk is going to be talking about um, something that we used to call a sports hernia Um, you may also see this as athletic pubalgia But for the purpose of this talk, we're going to use the term core muscle injury And so I just briefly wanted to define that essentially We use the definition to mean that damage to any skeletal muscle or tendon between the area of the chest and the thigh obviously, that's a really broad group of differentials and we should think about it as A group of diagnoses rather than a single discrete entity And one of the reasons this has become such a hot topic is because it's hard to know who should treat this In different health care systems general surgery may be the predominant. Um Team that treats these injuries some places orthopedics is involved And in some cases even the urology and gynecology is involved depending on exactly the pathology that's going on um, and really this becomes a lot of times no man's land and the interesting thing about pm and r is that A lot of times we end up falling in that no man's land. Um, you know, you guys may have experienced that pm and r often gets these referrals of patients who No one else could figure out what's going on. And so this this is a place where A knowledge of of the pathologies and knowledge of treatment options can be beneficial for a pm and r or sports medicine doctor So we'll start out with the case, um, this was a patient I saw in fellowships as a 28 year old guy Previous semi-professional tennis player and he presented with five years of anterior pelvic and groin pain Um, he was still able to play through the pain, but um reported that it has continued to bother him Um, he's done multiple rounds of physical therapy without any improvement um and I guess the first thing I would say is make sure when you're having these discussions with patients is talking about what the Goals are because if he's still able to play And he's still able to do the things that he likes. What are what are the reasons that he's still seeking treatment? So in his case, it was um pain relief and the feeling that he could even improve his play If he were pain-free Um, obviously there's a huge broad differential diagnosis again, dr. Loveless, uh last week, um highlighted a lot of these uh things and it's important to think about When you're evaluating this not just musculoskeletal causes but non-orthopedic causes urologic gynecologic and even gi causes so when i'm thinking about these patients, I Go back to one of my favorite movies Which is uh shrek and I think about the scene where he's mentioning that ogres are like onions Because they have lots of layers and I think that's a good analogy for thinking about groin pain Because there are so many layers both from an anatomic perspective and also just from the diagnosis perspective There's so many layers to the groin and thinking about exactly what could be causing the symptoms And if we look just from a musculoskeletal standpoint, there's at least 14 muscles that attach Somewhere in the vicinity of the groin, uh in this kind of anterior pubic region And so all of these muscles are directing forces in different directions And that can make for a complex diagnostic picture So a little bit of a simpler diagram, but one that I really like is this concept of the pubic clock and so thinking about the pubic synthesis, which is This region right here, I don't know if you guys can see my mouse but pubic synthesis where the pubic bones join There's forces in different directions and they're sort of pulling in the different directions of the clock And so you think about the rectus abdominis sort of pulling Kind of upwards in like the one o'clock direction Or the adductor longus is kind of pulling downwards more at the six seven o'clock Uh direction and then you have other forces pulling kind of a nine o'clock and three o'clock So you've got all kind of different stresses on the on the pubic synthesis Um, and because of how complex the anatomy and the pathology is here, there's been multiple Research studies to try and explain what's going on. Um, probably the most uh Cited one is called the doha agreement. This was 23 groin experts Um who were given two cases and as you can see With case one they came up with 18 different names for what was going on and with case two They came up with 22 different names for what was going on. And so Clearly even amongst experts. It's difficult to pinpoint exactly what's going on what the consensus is but what they came up with was a A decision to say that there's five main areas of groin pain So it's the adductor as one of the main causes the pubic synthesis the inguinal ligament The psoas tendon and then the fifth would be the hip joint Um, and then of course acknowledging that there are other other causes as well nerve entrapment stress fractures, etc Um, there have been other papers as well that have tried to um define and Create nomenclature around groin pain. Um, this was in 2014 and these guys came up with this term of inguinal disruption um, basically this generic statement of pain Which occurs predominantly in the groin near the pubic tubercle without other obvious pathology. So again this very generic kind of statement um this paper They had this sort of sesame street approach of like define and align listen and localize palpate and create Again, all sorts of different attempts to try and define and come up with ways to approach this this issue And so, um, I came up with my own consensus statement this is not randomized controlled trial this is not uh peer reviewed Um, but this is sort of the way that I approach a patient with groin pain um, so I think about I think about it from a musculoskeletal musculoskeletal standpoint as Breaking it up into the joints versus the musculotendinous Components and as well as the cartilage and so that if it's a joint issue, then it's not technically a core muscle injury Whereas if it's a musculotendinous issue or a cartilage issue that becomes more along the lines of a true core muscle injury And then again, don't forget about the other possibilities other musculoskeletal pathologies as well as non-msk causes So the first thing we'll talk about is osteitis pubis Classically, this is uh defined as inflammation of the cartilaginous disc that sits between the two pubic pubic bones Um clinically you can palpate that region and if they're painful there that can be a sign of osteitis pubis imaging is challenging in these patients because uh There's a lot of asymptomatic irregularities that can be seen Um, this study showed 76 of soccer players had um abnormalities at this location, even though they were asymptomatic And when you look at some of the literature that describes symptoms of osteitis pubis it again becomes fairly generic These guys said there's concomitant pain in the adductor musculature Well, that sounds a lot like adductor tendinopathy to me And then they said that the pain can be felt in the lower abdominal muscles That's a core muscle injury in the peroneal region Maybe that's a pedendal neuritis or in the inguinal region, which could be like a genital femoral neuritis And then they also described other physical exam findings that can include Range of motion deficits of the hip which could fit with fai. So again A lot of generic and overlapping symptoms here, which is why this is so complex Um, most athletic patients have some degree of inflammation that relates to disruption and compensation of the muscles that attach there Rather than an intrinsic inflammatory condition of the disc that that joins those two parts. So this is a study this was bill myers who's a big surgeon when it comes to core muscle injury and He feels that the pubic Synthesis itself is not actually that implicated in pathology We can look on mri, this is an axial cut of the pubic synthesis and you can see that the the left Pubic bone here has some increased signal that would indicate Some swelling kind of within this region um There's there's also this uh description of something called Uh of this kind of secondary cleft sign And you can see this increased signal here on the right side of the pubic synthesis um Which can be another kind of gold, uh, gold standard that we can see on the mri here Um in terms of treatment options for osteitis pubis, um, again, the evidence is not uh, Not significant we have a lot of case theories uh and sort of General descriptions, but no randomized controlled trials highlighting treatment options This was one paper that talks about the judicious use of corticosteroid injections As you can imagine putting a steroid into this region would undoubtedly help with pain if they truly have inflammation Of the pubic synthesis whether or not that's something that's beneficial for the patient overall Um, and whether or not that leads to healing would be a different different animal altogether There are a couple of studies that highlight prolotherapy of this region, um, this is one that you'll I've seen cited by a few different uh papers since and it's interesting because they had good success and their their Conclusions in the abstract says they were successful But when you look at the paper 22 out of 24 patients were unrestricted Return to sport after 17 months And so if you told an athlete that they're going to be feeling really well in a year and a half I don't know that you'd have an athlete that's happy with that as a treatment option Um, so i'm not sure that this is exactly exactly the best. Um Study to support this the other thing is that they injected eight different sites you can see them numbered one through eight kind of over here and um, so, you know, is this specific to Uh osteitis pubis or were they just treating a lot of muscular issues as well Um, it is hard to know certainly From an anecdotal standpoint. I have used prolotherapy for osteitis pubis with some success and I will try it for patients um But it's important to realize that the literature on this is not not great Um, so moving on we'll talk about femoral acetabular impingement syndrome, um, i'll be referring to it as fai throughout the talk um And again, I know I know that dr. Loveless kind of talked briefly about this Um, but fai is this motion related clinical disorder of the hip? with a triad of symptoms signs and imaging findings And typically this is seen with overgrowth either of the acetabular covering of the ball and socket joint or of the femoral neck here In the in the case of a cam deformity. Um, it can also be a combined picture as well Um, so the war warwick agreement, uh on fai Um define this a little bit better. They said that this is motion related hip and groin pain um at fader, so, um Flexion adduction and internal rotation was the most sensitive although not as specific for this Um, and that with imaging findings we would look with x-ray and then mri to evaluate um And x-ray is used a lot to look at this, but it's important to know that there are asymptomatic individuals with x-ray findings of fai so this study, um from 2017 looked at 114 patients and found that 71 percent of them had radiographic evidence of either cam pincer or both and they were asymptomatic and so Again, that's the reason that this is a syndrome. You have to take it in clinical context. Is there actually? Um symptoms or are they just asymptomatically having this x-ray finding? Similarly we see that even on mri there are asymptomatic abnormalities this study looked at 100 individuals And 97 percent of them had labral tears on their symptomatic side, but as many as 42 Uh had labral tears on their asymptomatic side So again, this is something good to stress to patients that yes, the mri can provide us with some help here in Defining your diagnosis, but it doesn't tell us the whole story Your symptoms are are also a big part of this Um, so if you're curious about the um The intra-articular portion of the patient's pain probably the best diagnostic tool that we have would be an intra-articular hip injection I do these with ultrasound. They can also be done with fluoroscopy And it's important to note that a negative response to intra-articular hip injections was a strong predictor of poor surgical outcomes And so the surgeons I work with in the ortho department here know this study And they understand the implications here So a lot of them even if a patient has clinical evidence of fai and they're planning to do the Surgery, they will send them to me first for a hip injection Uh, just to diagnostically prove to themselves and to the patient that the surgery will or will not Be a good idea to try with them Treatment options for fai we talk about non-operative options versus operative. Um And I initially struggled with this I don't understand why would physical therapy work for this mechanical issue you have bone that's Enlarged you have bone. That's um Abnormal, why would physical therapy work for this? And this was a great study that helped me understand it a little better These guys looked at 3d computer models of 50 hips with fai And they looked first at them in neutral and then they looked with a 10 degree anterior and 10 degree posterior pelvic tilt And what those did is those resulted in changes to the rotation of the pelvis Or sorry of the of the hip joint. Um, you had decreased internal rotation of about six to eight degrees And an anterior shift of the impingement location And then similarly with a posterior pelvic tilt you have a supralateral shift in the impingement location and so this is a nice sort of Study to explain to patients why physical therapy works. We're trying to change the location of where your hip is pinching To try and decrease some of the stress on that region And I think the physical therapists really enjoy that you know as physiatrists, obviously we have an understanding of the interactions with physical therapy and how important that is and so I think this is a great study to highlight in terms of surgical treatments the literature is still um conflicting in terms of Whether or not hip arthroscopy should be considered as sort of a first-line treatment Um this study from a couple years ago looked at 350 patients 170 got a hip scope and 177 had personalized hip therapy, which was their physical therapy and Both groups improved but as you can see from the line over here The hip arthroscopy was statistically significantly better In their measure of the IHOP33 at one year out Notably there were five serious adverse events related to the treatment um But then conversely this other study from the same year 2018 looked at 93 adolescent hips followed for 26 months And I liked this study because instead of just saying you get surgery you don't It sort of followed patients in the trajectory you would normally use so it started with physical therapy Those that didn't do well got an injection and then those that didn't do well with that eventually got surgery And you can see the numbers of the patients that needed that Um, so this is the sort of diagram of the patients. You can see that Down here 65 of the patients of the hips needed physical therapy only and they were successfully able to return back to their sport um 11 of them ended up getting a hip injection and that was sufficient treatment. Whereas 17 did require a hip surgery And so this is typically the way i'll progress with patients. I'll start them off with physical therapy We'll talk through injection options and then Only after they've failed those will I send them to my surgeons for further consideration Interestingly from that study four They were four times more likely to progress the surgery if they had cam or mixed versus a pincer lesion And those in team sports were three times as likely to return as individual sport I don't know what to make of that, but I thought it was interesting Okay, so going back to our patients This this guy who the 28 year old guy the tennis player Um when he came to me he had already had both his pubic symphysis and hip joints injected and he had not had any improvements And his uh radiographs were not consistent with fai Nor did he have hip impingement signs on exam. And so From there. We sort of took fai off the table And uh didn't didn't first have a diagnosis and I think a lot of patients find this to be frustrating. Um You know, they've they've had this sort of extensive workup and a lot of people still struggle with making a diagnosis So now we'll talk about core muscle injury and this is sort of the bulk of the talk So this has damaged any skeletal muscle area between the chest and the thigh Again, there's muscles that attach there and the main ones we'll talk about are the adductor longus and the rectus abdominus And then there's also this fibrocartilaginous plate which sits over the top of the pubic bone And that's where the muscles actually insert Again bill myers you're going to see his name quite a bit. Um He and his group, uh feel that the psoas and rectus femoris can be involved Although you can see a lot less likely than some of the other muscles in the region Um, so again taking a look at this diagram, uh, this was the doha agreement and um Uh, excuse me, sorry, this was the warwick agreement and these these these patients did not or these these uh, physicians did not even Consider the rectus abdominus as being part of the pathology here. So, um again, that's why I think this is such a challenging diagnosis to make So let's think about the pathophysiology for a second here. Um We kind of break up the compartments here of the anterior compartments of the thigh and uh abdomen versus the medial compartments. And you've got forces kind of pulling in multiple directions that leads to an imbalance of unequal distribution of forces and the anterior compartment takes the brunt of this. So most commonly we'll see pathology at the anterior lateral rectus abdominis and the adductor longus. The other thing that can happen is the pubic plate can actually be pulled off the bone due to this imbalance of forces. There are some interesting gender differences. The biomechanics are different as we know between men and women. Women have this more kind of centrally directed force. And so because of that, they actually tend to get more injuries to the knees, whereas core muscle injury is more commonly seen in men. And that's because you have the adductor, sorry, the forces are more directed in a straight line here. And coming from the rectus abdominis, it's kind of all in the center and then the forces are distributed out here. And so that becomes a little bit more pulling of the forces in comparison to women. Obviously also it's important to think about non-musculoskeletal causes. This is a female with ovarian cysts and that was a cause of this person's groin pain. And so something we wouldn't necessarily see in men. So how do we think about these patients? How should we approach them? So number one, physical exam, obviously any bruising and swelling over the distal rectus abdominis or the adductors that would indicate a rupture of the muscle or tendon. Tenderness just lateral to the symphysis. So where we talked about with osteitis pubis, palpating right in the center on that pubic disc. Here you're gonna be palpating just a little bit lateral to the pubic symphysis. And then the physical exam maneuver that you wanna think about most is pain with resistance sit up. And then also pain with adducting. And sometimes you can combine them and do that maneuver at the same time. And so this maneuver is really probably the most widely used to think about a core muscle injury. It's also good to look at psoas flexibility. So you can have them sort of scoot to the edge of the table and drop their hip down and see how much flexibility they have. A tight psoas can be contributing to this. In terms of imaging, MRI is definitely the gold standard. And then we'll talk about the role of ultrasound in imaging these patients. So there are specific MRI protocols that need to be used in order to get the proper images to look at that pubic plate. On the left, so this is a sagittal image looking straight down through the pubic symphysis. You can see here the symphysis and then that darker area here is that fibrocartilaginous plate. And you can see that there's no space between the fibrocartilaginous plate and the pubic bone itself. However, on this side, this is an abnormal patient. You can see this hyper intense signal right here sitting underneath the pubic plate, but on top of the bone. So this is a disruption of the pubic plate and would be indicative of a core muscle injury. Again, this is a coronal cut of the same type of injury. Again, here's the pubic symphysis. There's no signal here, but on this image on the right, you see a lot of increased signal just under the pubic plate or pubic symphysis. That would indicate a disruption there. So can we use ultrasound in these circumstances? How is it helpful and what do we use it for? So we can certainly image the muscles that are implicated in this pathology. The adductor longus and rectus abdominis can definitely be imaged. Here you have the adductor longus coming in on the right-hand side of the screen. Here's the pubic bone, pubic symphysis with some cortical disruptions here. And then the rectus abdominis comes from this way. It's kind of coming in at an oblique angle on the left here. So not the optimal image to look at the rectus abdominis, but this is looking at adductor pathology here. The other thing to think about with ultrasound is that in addition to looking at this pathology, you can also use ultrasound to rule out some of the other things. So things like actual hernias, inguinal hernias, and then also dynamic evaluations for things like snapping hip can be used, ultrasound can be used for that as well. I've definitely had a few patients that are referred to me for evaluation of core muscle injury, and I put the ultrasound on and they actually have an inguinal hernia. And so that's a great way to respond in this case. This was a nice paper to kind of show the sonographic evaluation and how we look at it. This image here labeled A, here's the rectus abdominis coming down and attaching right here onto the pubic bone. And then this is a kind of an axial cut or transverse image. And you can see the two various, as the rectus abdominis gets smaller and smaller, it sort of is divided in half here, the linea alba, and then you've got the two ends of the rectus abdominis here. And then this is the pubic plate here with the pubic symphysis right in the middle. Now, one thing that's important to note is that we cannot see underneath the pubic plate. And so if you can't see a rectus abdominis or adductor longus injury, you won't be able to evaluate the pubic plate disruption with ultrasound and the MRI is important. But you can see musculotendinous injuries. And so here's an adductor longus partial tear. You can see this hypoechoic defect right here with the rest of the tendon kind of stretching out here. And then this is a full avulsion of the adductor longus tendon. You can see there's a gap measured here and then the correlating MRI image here that shows this gap with the avulsed tendon. And so certainly ultrasound has a utility. We don't have literature comparing ultrasound versus MRI accuracy, but it is something that can be used. The other thing, of course, that we would consider using it for would be for interventions. And so here's a, from this paper, here's a needle tip coming in and doing presumably a tenotomy of the adductor longus. So how do we treat core muscle injury? Again, we kind of break this up into conservative options, injection options, and then surgical treatments. In terms of rehab options, this was a great paper that had a full eight week protocol to describe the best ways to think about treatment options from a rehab standpoint. And I think the important thing to note is that the most important muscle to help patients improve from a rehab standpoint is the transversus abdominis. And so the transversus abdominis is that deep layer of muscle in the abdomen. It's underneath the obliques and underneath the rectus abdominis. And if this isn't firing and active, you're gonna lose your pelvic stabilization, lose your ability to keep other muscles from firing too much, including the rectus abdominis. And so you can see that this protocol really focuses on TA recruitment, even on to week four, still doing kind of more advanced rehab, but maintaining transversus abdominis contraction. And then out to week six to eight, doing more dynamic and functional work. This is where it becomes a little bit more controversial in terms of injection options. Certainly steroids can be used in these circumstances, in these patients. Again, this was a paper with Bill Myers' group out of Philadelphia. And they talk about the fact that adductor tendons are short and there are some actual direct muscle to bone attachments without a tendon. And so because of that, they say that you can use some steroid. And even if you have some tendon degeneration, you still have muscular attachments onto the bone. And so you could get something like a partial tendon release from putting steroid in there. But the risk of total rupture is low again, because the tendon is surrounded by muscle. I have a little bit of an issue with the way that these guys approach this issue. I don't feel like saying a tendon is okay to rupture just because there's muscular attachment is an okay approach because I feel like it changes the overall biomechanics. That being said, there are some biomechanical disadvantages that we see in some of these patients and they may need that. I tend to be very judicious with my use of steroid injections in these patients and try to use them only for patients who really have failed rehabilitation and have some sort of time constraint where they need to get back into their sport rather quickly. This was a small cohort study that looked at 12 patients and they all returned to their pre-injury levels by pain by six weeks, and none of them opted for surgical repair. So again, steroid injections are an option. I just try to be judicious with them. There's not a lot of great literature in terms of regenerative injections. Most of what we have is case reports. This was a report of a 28-year-old soccer player that had a full adductor tendon rupture, and then he got PRP injections and a PT program and returned to sport. This was another one with a 31-year-old who had an inguinal disruption, had two PRP injections followed by manual therapy over the healing tendon, which I thought was a bit unusual, and he had a full return to play at four weeks. Those of us that do a lot of PRP understand that literature typically suggests an improvement usually more along the lines of six to 12 weeks. So I think this was a bit unusual as well. But again, these are kind of two case studies that we have right now. Something to point out, and I have not seen this in other areas of the body, but again, here's Bill Myers' group out of Philly, but they reported that four out of five patients that had had PRP injections previously had heterotopic ossification observed on MRI, whereas the incidence of heterotopic ossification in athletes not with PRP was two out of 1,100. And so they have a sort of statement that they shy away from PRP because of this risk, and they've had to do surgeries to remove the heterotopic ossification. Again, I think there's probably some bias because they're probably only seeing patients who had PRP and did not get better. And so I don't know that I would fully say that this is a risk of every patient that's gonna get PRP, but it's definitely something for me to note. Other options would be to try needle tenotomy. Again, this would be more targeting the muscle tendon units of the adductor and the rectus abdominis. This paper talks about excellent outcomes in patients with chronic low-grade injuries that wanna avoid surgery. And then this was another one with needle tenotomy combined with PRP, and the patient was full return to play at eight weeks. And so regenerative options, again, the literature is not very good for this region. It is still something I will offer patients. I'll talk them through, again, risks and benefits, understanding that there is that heterotopic ossification description. But I have had anecdotally good success with PRP in this location, and it is something I would consider discussing with patients. Surgical treatments, obviously, not a part of the scope of this talk, but just to know that there are a lot of different options. Many papers describe tons of different techniques. Do we use mesh? Do we not use mesh? Do we disrupt the adductor and reattach it? Do we just try to repair it? There's a lot of different techniques. All the papers talk about their excellent successes. But I think, in general, just to know that there are treatment options out there from a surgical standpoint, if all other options fail. Probably one of the most read papers about this topic is, again, from, here's Bill Myers' group again. And I was lucky enough to be able to go to Philadelphia, to the Vinceri Institute, and hang out with him for a couple days. This is a picture I took from hanging out in the operating room with him and his group. And, you know, for better or for worse, they see a lot of these patients. And he walks into the room and says to them before even examining them, I do this surgery, I have a 95% success rate, and I'm gonna get you back to your sport within six weeks. And his literature supports these claims overall. And so certainly he's been successful in treating these. Whether or not every patient needs surgery for this is another issue. But these guys are certainly leaders in the field for better or for worse. I would be, let's see how much time I have. Okay, I'd be remiss to talk about core muscle injury if I didn't talk about the relationship of it to FAI. There is a loss of clearance between the femoral neck and acetabular rim with FAI that may put increased stress on the pubic synthesis. And so it's important to think about FAI as a pathology with core muscle injury. This study looked at torque that was applied to hip joints with CAM and normal forces. And then they measured rotational forces at the pubic synthesis. And you can see that the patients with a CAM lesion had significantly higher rotational forces at the pubic synthesis compared to those that did not. And so again, FAI can be related directly to a core muscle injury and should be thought about when you see these patients. This was a cohort study of 38 athletes with FAI and athletic pubelgia. 12 patients previously had athletic pubelgia and were unable to return until they had their FAI surgically corrected. And 15 patients had symptoms of FAI and athletic pubelgia that resolved with FAI surgery alone. And so there is the option to talk about this with patients and make sure that when you see a patient, you're getting the radiographs to look for FAI and that you're thinking about that as being involved as well. Okay, so we talked about core muscle injury. What are we missing? We talked about this with our patient and it turns out he did not have pain with resisted sit-up. He did not have pain with adduction and his MRI did not show any evidence of adductor rectus abdominis or pubic plate disruption. So what are we missing? What else can be causing this groin pain in athletes? And I think this lands us on the SI joint. I think there was a talk yesterday on SI joint interventions. I wasn't able to make it, but hopefully there's not too much overlap here. But as a review, the SI joint has an articular portion and then this sort of non-articular portion that's more just spanned by interosseous ligaments. We see SI joint pathology in athletes who do repetitive and asymmetric loading. So basketball, soccer, football, gymnastics. In general, it's a difficult joint to diagnose because there's so many ligamentous interactions here. There's also this actual synovial joint, but it doesn't move like other synovial joints. So it's a challenging diagnosis to make. There are lots of different exam maneuvers and there was a paper put out a few years ago that said if you can get three of these five exam maneuvers to be positive, then your sensitivity of diagnosing the SI joint increases significantly. But then just recently, this is your boy out of Vanderbilt, Dr. Kennedy, put out this paper that looked at SI joint maneuvers before and after an injection was performed. And they concluded that the physical exam maneuvers did not correlate to a positive injection. And so again, the SI joint is sort of the great equalizer in my mind because it can replicate a lot of back pain and it can replicate a lot of groin pain. And it's something to kind of always consider and understand that even if your physical exam doesn't point you in that direction, to keep it on your differential. This study looked at the referral patterns for SI joint dysfunction. And so you can see this location here is where the SI joint would typically palpate, but patients had referrals down the side of their leg, all the way down to the shin and lo and behold, front of the thigh and in the groin. This was another paper that described similar pain pattern distributions looking at sacroiliac joint and the facet joints. And again, we see the groin as being one of the places that the SI joint refers. You can see in this paper, the patients that had groin pain from SI joint dysfunction was up to 46% of them. Lumbar spinal stenosis and lumbar disc herniation was far lower. So I don't think about those pathologies nearly as often, but in someone with groin pain, that's a little bit difficult to diagnose, I will think about the SI joint. This paper was really, really neat. They took 50 patients with SI joint pain and they injected four different areas of the SI joint with contrast. And they asked the patient to describe the location of the referred pain. Groin pain was reproduced in only one of those patients, but was relieved by the periarticular injection of the SI joint in all 22 patients with this complaint. And so again, we still don't understand exactly why the SI joint would refer there. And it doesn't seem that a needle in that location reproduced it. So if you're pushing on the patient and it doesn't reproduce their groin pain, that doesn't necessarily mean that the SI joint is not indicated. We do SI joint injections under fluoro or under ultrasound. Certainly with ultrasound, we talk about less radiation as being an advantage and it is less expensive because you can do it right there in your office. Of course, there are some disadvantages because we can't confirm intraarticular flow like we can with a fluoroscope. And it's seen to be a bit less accurate according to this study. Although I think there are other studies that are more recent that have shown the accuracy to be, I think, fairly consistent. But one of the biggest reasons I like to use ultrasound for these rather than fluoro is because you can also see the periarticular structures including the ligaments. And I think a lot of the time, the pathology that's implicated here is not just the joint itself, but the ligaments that are surrounding it. So because of that, I will often shy away from steroid injections and I'll think about prolotherapy. This was a study that looked at 48 patients steroid versus prolo. And while they had no difference between the groups at two weeks, there were significant differences starting at about eight months out to 14 months. And so you can see from this graph here that the changes in sustained pain were far greater with prolotherapy. And again, I think a lot of that is because of the ligaments that are involved in SI joint pathology and the reason that we call it sacroiliac dysfunction sometimes rather than sacroiliac joint pain. And so in our patient, after going through everything that we went through, we ended up diagnosing him with sacroiliac joint dysfunction manifesting as groin and anterior hip pain. We performed an ultrasound guided intra and periarticular prolotherapy injection around the SI joint and the patient had a complete resolution of his pain and was able to go back to plain tense pain. So in conclusion, core muscle injury is injury to the muscles attaching to the pubic bone, most commonly the rectus abdominis and aggregor longus, but there can be other culprits. It often coincides with FAI and it may be better to treat both. It's important to remember the SI joint is a culprit and the sports hernia is not a hernia. So make sure you keep that in mind when thinking about this case. So here are my references. Thanks so much. And I'll take any questions. That was fantastic. Thank you very much. We do have one question that came in from Dr. Shaw. He said, what are the orthopedic surgeons you're working with considered to be a positive response to an FAI injection? Is it immediate post-injection pain relief at rest or during physical exam maneuvers like FADER? And what are you injecting exactly? Yeah, that's a good question. So what I'll typically do is I'll perform a exam beforehand. And usually, again, like you said, Steve, FADER, FABER, Logroll and Stinchfield are kind of the four main ones that I'll use. And note their pain kind of as I'm doing those injections, ask them to give me a rating of pain relief. Or sorry, a rating of their pain symptoms. And then after the injection, usually I'll give it about five or 10 minutes and then go back in and do the same maneuvers again. My surgeons wanna see an 80% change in their pain. So if they were a seven out of 10 before, they wanna see a zero or a one. That's typically what they like to see from me. I also think that when you're using steroid, every once in a while, you'll get not as much pain relief from the diagnostic injection, but then pain relief down the line. I've talked to my surgeons about this, whether or not they would consider that a positive block. And I think that's a little bit more controversial just because we really wanna see it from the lidocaine itself. But in general, I think it's more the diagnostic portion and the pain relief. Okay, thank you very much. I appreciate that. I'm not seeing any other questions. This was a fantastic review of all this. I appreciate you joining us today and sharing all your expertise with us. If people have questions, we have your Twitter information here. They can reach out to you directly. Is that okay? Yeah, absolutely. Happy to. Excellent. So thank you again for joining us. We appreciate it. And thank you everybody. Thanks for having me. Yes, absolutely. And thank you everybody who joined us today. Again, if you want to reach out to Dr. Bailewitz directly, that is his Twitter handle there, and then mine and AAP. Obviously, as I mentioned before, all of the daily schedules and then the link to the recorded versions of these videos are available here at physiatry.org slash webinars. And thank you for joining us, everybody. We look forward to having you tomorrow. Thanks.

groin pain

athletes

core muscle injury

FAI

sacroiliac joint dysfunction

diagnostic challenges

treatment options

Dr. Bailewitz