My Approach to the Anterior Pelvis Rectus and Beyond Brian D. - - PowerPoint PPT Presentation

My Approach to the Anterior Pelvis Rectus and Beyond

Brian D. Busconi, MD

Chief of Sports Medicine & Arthroscopy UMass Memorial Medical Center Brian.Busconi@umassmemorial.org

Disclosure

• Consultant

– Arthrex – Mitek

Doc, It Hurts HERE!

Abdominal Lateral Posterior Anterior Medial

Hip Pain Location,Location,Location!!!!

Anterior Lateral Posterior

Hip Joint Hip Flexors Iliopsoas Stress fracture Inguinal Disruption L3 nerve root Ishiofemoral Impingement Microinstabilty Greater trochanter Iliotibial band Meralgia paresthetica Gluteus Medius Tear Referred pain: spine stenosis, disk, facets SI joint Hip extensors External rotators Hamstrings Pirifomis

Anterior/Medial Groin Pain Differential Diagnosis

– Intra-Articular

• FAI
• Labral Tear
• Loose Bodies
• Condral Injury
• Ligamentum Teres Rupture
• DJD

– Bone

• Traumatic Fracture
• Dislocation
• Femoral neck stress fracture
• Osteonecrosis
• Dysplasia

– Bursitis

• Iliopsoas
• Iliopectineal

– Muscular

• Quadriceps
• Iliopsoas

– Snapping Hip Syndrome – Infection – Microinstability – Nerve Entrapment – Medial Groin Pain

• Adductor Strain/ Tear
• Inguinal Hernia
• Genitourinary related

Abdominal Pain Differential

– Hernia

• Core Muscle (Sports Hernia)
• Inguinal

– Direct vs Indirect

• Femoral

– Osteitis Pubis – Stress fracture – Rectus – Genitourinary conditions – Gastrointestinal conditions – Nerve entrapment

Poorly understood

• Lack of specific clinical tests
• Few well designed clinical trials
• Co-existence of multiple pathologies
• Pain is not a good localizer of original pathology
• Lack of agreement of diagnostic criteria
• Association with hip pathology

Core Muscle Injury or Inguinal Disruption

• Aka “Gilmore’s Groin”, “ Sports Hernia”, “Peripubic Pain Syndrome”,

“Athletic Pubalgia”

• Exertional Chronic Inguinal or Pubic Area Pain in Athletes

– EXERTIONAL ONLY – No Palpable Hernia

• Tear of Adductor Longus or Rectus Abdominis Attachment
• “Chronic Symphysis Syndrome”

– Patient has Abdominal, Groin and Adductor Pain

• Occurrence: Males >> Females

Clinical History

• Hyperextension Injury and/or Abduction

– Pivoting Around Anterior Pelvis or Pubic Symphysis

• Disabling Lower Abdominal Pain at Extremes of Exertion
• Resolves with Cessation of Activity
• Often found in Soccer or Hockey

– Sports Involving Frequent Change of Direction

Mechanism of Injury

Physical Exam

• Tender to Palpation over

Peripubic Area, Symphysis Pubis,

• r Adductor Area
• No Palpable Hernia
• Pain with firing of Rectus

(situps) and/or resisted Adduction

• Must perform Full Hip Exam
• Neuro Exam Normal

Core Muscle Injuery if > 3 symptoms

• 1. Pinpoint tenderness over the pubic tubercle at the

point of insertion of the conjoint tendon;

• 2. Palpable tenderness over the deep inguinal ring;
• 3. Pain and/or dilation of the external ring with no
• bvious hernia evident;
• 4. Pain at the origin of the adductor longus tendon;
• 5. Dull, diffuse pain in the groin, often radiating to the

perineum and inner thigh or across the midline.

Imaging

• MUST Rule Out Other Causes of Pain

– FAI

• MRI may Show:

– Rectus Tear – Adductor tear – Avulsion Fracture – Symphyseal Edema – FAI – LABRAL TEAR – Hernia – May Be Normal

• Bone Scan or XR may Show Concurrent

Osteitis Pubis

• ? Role of Herniography

Lysis consistent with osteitis pubis

Treatment

• Conservative

– Rest, Ice, NSAID, PT, US Guided Injection – Pt to fix anterior pevlvic tilt

– Evaluate as to Pre,Mid,Post Season

• Surgical
• Open primary pelvic repair without mesh

– Bassini, Shouldice, McVay – Minimal repair with decompression or resection of genital branch of genito-femoral nerve

• Open repair with mesh
• Laparoscopic repair with mesh
• Adductor

– Leave alone if no clinical involvement – Inject with steroid or PRP if symptomatic but nl MRI – Release if severely involved on MRI

• Divide Epimyseal Fibers of Longus about 2-3cm from Pubis, leave

muscle belly alone

UMASS Surgical Technique 3 Primary Goals:

• 1. Reinsertion of the rectus abdominus to the

pubis

• 2. Stabilization of interface between the rectus

and conjoined tendon

• 3. Reinforcement of the posterior wall
• f the inguinal canal

Iliopsoas Bursitis

• Coexists with Mechanical Irritation of

Tendon

– Implicated in “Snapping Hip” Syndrome

• Elicited by Moving from ABducted, Externally Rotated

and Flexed to an ADducted, Internally Rotated and Extended Position – Very Loud “CLUNK” CAN HEAR IT DISLOCATE

• MRI Shows Fluid
• Ultrasound and Concomitant Injections of

Anesthetic and Steroid can be Diagnostic and Therapeutic

• Treatment

– Anti-Inflammatories – Activity Modifications & Rest – Surgery – Consider Lengthening IP Tendon

Morelli & Smith. Groin Injuries in Athletes. American Family Physician. Vol 64/8 Oct 2001

Imaging in Snapping Hip

• Plain Radiographs Tend to be Normal
• Bursography

– Iliopsoas Bursa Injected and Visualized under Fluoro

• Dynamic ultrasound

– “SEE” Snapping – Dependent on Experience of Technician

• MRI and MR Arthrogram

– Fluid around tendon – Intra-Articular Pathology – May show anterior labral pathology

Conservative Treatment

• Conservative Treatment is Recommended for Internal

and External Causes – Avoidance of Aggravating Activities – Anti-Inflammatory Medication – Physical Therapy – Local Corticosteroids – Resolution May Take 12 Months

• Pathology Specific Treatment for Intra-Articular Causes

– Usually Amenable to Hip Arthroscopy

Treatment of Internal Snapping Hip Arthroscopic

• Iliopsoas Release

– Peripipheral

• NO TRACTION - USE FLUORO
• Hip flexed 30 degrees and ER

– Central

• Traction
• Capsulotomy between anterior labrum and femoral

head

• 3 o’clock in R hip
• 50/50 RULE
• Release Proximal and distal

Rectus Femoris Strain

• Only 2 Joint Muscle in Quadriceps

– Most commonly injured of the group – Reflected Head – most commonly involved

Rectus injuries

• Rectus femoris is a unique

Biarticular muscle spanning both knee and hip joints – Direct head of rectus originating at the AIIS – The reflected head originates at the acetabular ridge and anterior hip capsule

Rectus Injuries

• THE KICK
• Initiation of the forward swing phase

– Forceful contraction of the illiospoas and quadriceps to flex the hip and extend the knee

• This allows the foot to propel

forward with enough force to strike the ball – These contractions are initially eccentric

Rectus Strain

• Incomplete intrasubstance tear at the

tendon muscle junction

• Involves the reflected head
• Post injury sequelae

– May demonstrate anterior thigh mass – Chronic pain – Asymmetry compared the other limb(rare)

• MRI T1 with gadolinium

– Bull’s eye lesion in the intramuscular tendon of the indirect head

Rectus Strain

Treatment

• NSAIDS, rest, ice

stretching/strengthening usually sufficient treatment

• US Evaluation and Injection with

PRP/MSC

• Tend to Resolve in 4-6 weeks
• Dedicated preseason hip

strengthening and stretching found to decrease rectus injury during regular season

Chronic Rectus Tear

 Late excision of the reflected head of rectus femoris was found to reduce pain in rare cases of chronic tears.

Wittstein, Am J Sports Med 2011

 Delayed repair of chronic musculotendinous avulsion injury to the direct head of the rectus femoris can yield an excellent result.

Straw.Br J Sports Med 2014

Anterior inferior illac spine Avulsion

• Avulsion injury more common in skeletally immature
• Adolescents aged 14-17
• More often occurring in males

Anterior inferior illac spine Avulsion

• Result of violent contraction of the rectus femoris, usaully

eccentric in nature

• Can feel a “pop”
• Occurrs with hip extension and knee flexion
• Periosteum and fascia can limit extreme displacement

Anterior inferior illac spine Avulsion

Symptoms – Sudden pop in the pelvis – Anterior hip Pain and hip flexion weakness – Antalgic gait – Must rule out neoplasm in adults that have no history of trauma

Anterior inferior illac spine Avulsion

Management

• Place the hip in a position of comfort
• Protected weight bearing with crutches
• Light stretching and weight bearing

– advance as the pain resolves

Subspine Impingement

• 21 year old female, collegiate soccer player
• Presents with left sided groin pain

– “Grinding Sensation” on FADIR – Hip flexion limited to 105 deg – Larson 2011 by the Arthroscopy Association of North America )

Subspine Impingement

• AIIS impingement

– Abnormal contact stress against the distal femoral neck – Due to excessive distal and or anterior extension

• Causes

– Developmental – Prior AIIS avulsion – Pelvic Osteotomy

Subspine Impingement

History and physical examination

• Anterior/groin pain with straight hip flexion
• Anterior pain with prolonged hip flexion
• Limited hip flexion range of motion
• Tenderness to palpation over AIIS that re-

creates pain

Subspine Impingement

Imaging AP pelvis, Crosstable lateral, 45 degree Dunn, False profile. CT scan with 3D reconstruction, MRI

• Evidence of Previous AIIS avulsion
• Calcific deposits at rectus femoris origin
• Excessive anterior and distal extension of AIIS on the false

profile radiograph

• Acetabular retroversion with increased anterior rim sclerosis
• Impingement cysts located at distal femoral neck

Subspine Impingement

• Classification System AIIS Variants

–

• Hetstroni. , Clin Orthop Related Res 2013
• Type I smooth Ilium wall Between the AIIS and the acetabular rim
• Type II AIIS extended to the level of the rim
• Type III AIIS extended distally to the acetabular rim

Subspine Impingement

• Classification System AIIS Variants Hetstroni. , Clin Orthop Related

Res 2013

• TYPE I TYPE II TYPE III

Subspine Impingement

• Management
• Non-surgical: PT (pelvic tilt, quad stretching), activity

modificion, CSI

Surgical: arthroscopy, subspine decompression Hetsroni., Artrhoscopy 2012

• Arthroscopic decompression of the AIIS yields excellent short term results.
• As opposed to an open procedure it allows the surgeon to address multiply hip

pathologies with a single procedure.

• Arthroscopic AIIS decompression results in predictable pain relief, improved outcomes

scoring and improved hip felxion

• Larson., Arthroscopy 2011