Diagnosing and Treating Hip Pain: Q&A With a Sports Medicine Orthopedic Surgeon

The possible causes of hip pain are widely varied, especially among athletes. In recent years, there has been an increasing focus on 2 particular sources of pain in the hip and surrounding areas: femoracetabular impingement (FAI) and athletic pubalgia (AP).

AP is also commonly known as a sports hernia–though that name is misleading because the condition is not a true hernia–and more recently, core muscle injury (CMI).

Not only is it often difficult to differentiate between FAI and AP, but the 2 disorders sometimes co-occur in the same patient. The rates of co-occurrence vary widely, however: A systematic review published in 2015, for example, found that between 12% and 94% of patients with AP or adductor-related groin pain have comorbid FAI.¹

Regardless of the prevalence, if a patient presents with both disorders, surgical outcomes are far better when these are treated together as opposed to separately–with a difference of 89% vs 33%.¹

Christopher Larson, MD, a sports medicine orthopedic surgeon with Twin Cities Orthopedics in Edina, Minnesota, and the head team physician for the Minnesota Vikings, recently co-authored a separate review on the topic.²

Clinical Pain Advisor interviewed him about the growing recognition of the FAI-AP link, as well as proposed underlying mechanisms, differential diagnosis, and treatment options.

Clinical Pain Advisor (CPA): What prompted the increasing recognition of an association between FAI and AP, and what does the link appear to be? 

Dr Larson: We originally noticed a number of high-level athletes that either had prior surgery for both AP and FAI, or presented to us with symptoms of both disorders. We then began to track how these individuals did with various surgical and non-surgical approaches. We ultimately hypothesized that limited hip range of motion from FAI combined with high level cutting and pivoting sports could lead to or aggravate lower abdominal or groin disorders such as AP.

CPA: How is the differential diagnosis made between FAI and AP and other types of hip and groin pain?

Dr Larson: A complete history and physical examination is extremely important, as imaging studies such as MRI often show hip joint and AP pathology even in asymptomatic athletes more than 50% of the time.

FAI is indicated by limited hip range of motion and pain with specific passive range of motion tests (impingement tests). AP is indicated by pain to palpation over the lower abdomen and groin muscles and a recreation of pain with resisted sit ups and resisted adduction of the legs. Ultimately, it can be challenging to differentiate between these 2 disorders, and diagnostic injections can be helpful.

CPA: How does treatment differ between FAI and AP, and what if a patient experiences both?

Dr Larson: Treatment for FAI often involves an arthroscopic correction with repair of cartilage tears and reshaping of the abnormal bone structure. Treatment for AP can vary depending on the surgeon and generally involves repair of the injured lower abdominal and groin muscles. 

If both are present and symptomatic, they can be addressed in a staged manner weeks apart or at the same surgical setting if a specialist in both areas resides at the same hospital. We have shown in a study that the rate of return to sports is better when both are managed if both are symptomatic.³

CPA: Is there anything else on the topic that our audience of pain clinicians should know about?

Dr Larson: There is a greater than 85-90% rate of return to sports after treatment for FAI and Athletic Pubalgia in high-level athletes. The long-term implications with or without surgery are unclear. It is important to remember that this combination of hip joint and lower abdominal disorders are primarily seen in a unique subset of high-level athletes and much less common in the general population.

Summary and Clinical Applicability

Distinguishing femoracetabular impingement from athletic pubalgia can be challenging, and the disorders may co-occur. When they do, surgical outcomes are optimal when both are treated together.

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References

1. Munegato D, Bigoni M, Gridavilla G, Olmi S, Cesana G, Zatti G. Sports hernia and femoroacetabular impingement in athletes: A systematic review. World J Clin Cases. 2015; 3(9):823-30.

2. Ross JR, Stone RM, Larson CM. Core muscle injury/sports hernia/athletic pubalgia, and femoroacetabular impingement. Sports Med Artrosc. 2015; 23(4):213-20.

3. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014; 6(2): 139–144.