Cam morphology and inguinal pathologies: is there a possible connection?

The Role of MRI in Groin Pain Syndrome in Athletes

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Relationship between Femoroacetabular Impingement and Pubalgia in Professional Soccer Players

Objective  To analyze the relationship between pubalgia and femoroacetabular impingement (FAI) in professional athletes of a soccer club, defining the prevalence of these conditions in the sample studied. Methods  It is an epidemiological, cross-sectional, and analytical study including 90 professional soccer players active from 2019 to 2021. We accessed the medical records of the subjects to retrieve information from the modified Pre-Competition Medical Assessment (PCMA) protocol, orthopedic physical examination, and anteroposterior pelvic radiographs to assess pubalgia and FAI, respectively. Inclusion criteria were athletes playing in the professional soccer club in the 2019 to 2021 season, who underwent a modified PCMA upon admission, and who signed an informed consent form. Results  FAI was highly prevalent (85.6%) in the sample. This prevalence may occur because, in Brazil, people start playing sports early, not always in suitable fields, or with no proper equipment and supervision. In addition, the CAM-type impingement was the most frequent (62.2%). These injuries are related to high-intensity movements, including those associated with soccer. Furthermore, there is no dependency correlation between pubalgia and FAI. FAI was present in only 20% of athletes with pubalgia complaints. Conclusion  There was a high prevalence of FAI in professional soccer players in the studied population (85.6%) but with no relationship between FAI and pubalgia.

Is Cam Pincer Deformity a Predisposing Factor for Patellofemoral Pain Syndrome?

Purpose

This study aimed to investigate whether cam and pincer deformities (CPDs) are a risk factor for patellofemoral pain syndrome (PFPS) in women. In addition, it sought to compare the hip joint range of motion and the hip muscle strength of extremities with and without CPDs and PFPS.

Materials and Methods

A total of 82 hips of 41 women with PFPS were included in the study. The mean age of participants was 32.07 ± 7.13 years. The presence of CPDs was detected on digital anterior pelvis radiographs. Pain was evaluated using the visual analog scale, and function using the Kujala scoring system. Maximum isometric muscle strength around the hips was measured using a hand-held dynamometer. Hip joint range of movement angles were measured in all three planes using a universal goniometer.

Results

CPDs were found to predict PFPS in women (p = 0.011, p = 0.048). The rate of CPDs was significantly higher in extremities with PFPS compared to those without PFPS (p = 0.007). The Kujala scores of extremities with cam deformity were significantly lower than those of extremities without pincer deformity (p = 0.043). The internal/external muscle strength ratio was greater, and the abduction/adduction muscle strength ratio was lower in extremities with cam and PFPS than in those without (p = 0.040, p = 0.049). The external rotation and abduction range of movement angles were significantly smaller in extremities with pincer and PFPS compared to those without (p = 0.043, p = 0.035).

Conclusion

CPDs may be a structural predisposing factor in the development of PFPS in women. CPDs assessment when evaluating predisposing factors for PFPS may present an opportunity for the management of PFPS.

A multidisciplinary assessment of 320 athletes with long-standing groin pain syndrome in keeping with the Italian consensus agreement: the high incidence and the multiple causes of inguinal and hip pathologies and pubic osteopathy

BACKGROUND

Groin pain syndrome is an important and increasing problem in numerous sports (e.g. soccer, football, ice hockey, handball and rugby). Long-standing groin pain syndrome is a form of groin pain syndrome in which the cohort of symptoms reported by the patient is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. Long-standing groin pain syndrome is potentially career-ending for elite athletes.

METHODS

A descriptive epidemiological study was carried out on 320 athletes (290 men and 30 women) affected by long-standing groin pain syndrome, following the Guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athlete.

RESULTS

Amongst the clinical tests for inguinal pathologies, only the External Inguinal Ring Exploration proved conclusive (sensitivity: 0.97; specificity: 0.95; positive predictive value: 0.98; negative predictive value: 0.90; likelihood ratio: 19.4). In testing for adductor tendinopathies, only the Isometric Squeeze with flexed knee and distal resistance (sensitivity: 0.86; specificity: 0.45; positive predictive value: 0.48; negative predictive value: 0.85; likelihood ratio: 5.7) and the Palpatory Test at the pubic insertion of the adductor longus (sensitivity: 0.93; specificity: 0.89; positive predictive value: 0.96; negative predictive value: 0.79; likelihood ratio: 8.5) proved, respectively, useful at times and moderately useful. Among the tests for hip pathologies, only the Flexion Abduction External Rotation Test was seen to be conclusive (sensitivity: 0.90; specificity: 0.93; positive predictive value: 0.98; negative predictive value: 0.72; likelihood ratio: 12.9). In the male population on average, long-standing groin syndrome presents either a single cause or multiple causes in respectively 74% and 26% of cases. Furthermore, almost 58% of all cases traced to a single clinical cause can be attributed to inguinal pathologies alone. Long-standing groin syndrome in the female population shows only one pathological cause with inguinal pathologies, and acetabular labrum tear representing the most frequent etiologies.

CONCLUSIONS

Men and women exhibit different causes for long-standing groin pain syndrome. Several routine tests used in the clinical evaluation of this condition furnish a low likelihood ratio. Consequently, in order to optimize clinical evaluation and minimize patient discomfort, clinical evaluation should be based on tests with a greater likelihood ratio.

Arthroscopic Correction of Femoroacetabular Impingement for Concomitant Inguinal Disruption in Athletes With Dual Pathology

BACKGROUND

Inguinal disruption and femoroacetabular impingement (FAI) are well-recognized sources of groin pain in athletes; however, the relationship between inguinal disruption and FAI remains unclear. In cases of dual pathology, where both entities coexist, there is no definitive consensus regarding which pathology should be prioritized for treatment in the first instance.

PURPOSE

(1) To examine the 2-year effectiveness and clinical outcome in athletes presenting with dual pathology in which the FAI component alone was treated with arthroscopic deformity correction. (2) To compare 2-year patient-reported outcome measures between athletes undergoing only hip arthroscopy (HA) and athletes undergoing groin repair and HA.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients undergoing HA for the treatment of FAI with concomitant clinical signs of inguinal disruption at initial consultation were between 2010 and 2016 were included in this study. Inclusion criteria were male sex, age <40 years, and involvement in competitive sporting activity. Athletes with previous HA on the symptomatic side, Tönnis grade >1, or lateral center-edge angle <25° were excluded. Revision HA or subsequent groin surgery was documented. Outcome evaluation consisted of validated patient-reported outcome measures (modified Harris Hip Score; University of California, Los Angeles Activity Scale; 36-Item Short Form Health Survey; Western Ontario and McMaster Universities Osteoarthritis Index) completed preoperatively and a minimum 2 years postoperatively. The minimal clinically important difference was assessed by using a distribution-based technique (SD, 0.5) and an anchor-based technique (percentage of possible improvement). Level of satisfaction and return to play were assessed.

RESULTS

A total of 113 cases of dual pathology were included in 91 patients with a mean ± SD age of 26.3 ± 5.1 years. The index surgical procedure was HA for 104 cases (92%) and groin repair for 9 (8%). For patients undergoing HA as the index procedure, 98.1% (102/104 cases) were successfully followed up to establish survivorship. In 89.2% (91/102 cases), no additional groin surgery was required. In 11 cases (10.8%), additional groin surgery was required for persisting inguinal-related groin pain. At 2 years after the operation, there was no difference for any patient-reported outcome measure (P > .099), improvement from baseline (P > .070), or proportion of cases achieving the minimal clinically important difference (P > .120) between the HA-only group and the group undergoing HA and groin repair at any stage. There was also no difference between groups in terms of return-to-play rate (P = .509) or levels of satisfaction (pain, P = .204; performance, P = .345).

CONCLUSION

In patients with dual pathology, treatment of the FAI component alone using arthroscopic hip surgery results in a successful outcome without need for groin repair in 89.2% of cases. No statistical difference in clinical outcome 2 years after surgery was observed between athletes undergoing 1 procedure (HA alone) and those undergoing 2 procedures (HA and groin repair at any stage).

Femoroacetabular impingement: correlation between imaging parameters, sport activity, and chondral damage

BACKGROUND

Femoroacetabular impingement is characterised by an abnormal contact between the acetabulum and the femoral head-neck junction. Femoroacetabular impingement shows three main clinical frameworks: Pincer-FAI, Cam-FAI and Cam-Pincer mixed form. The aim of the study was to investigate the correlation between femoroacetabular impingement, imaging, activity and chondral damages.

METHODS

Forty-one patients, undergoing arthroscopic chondroartroplasty for Cam and Cam-Pincer mixed form were considered. All patients underwent an X-ray hip evaluation (G1 group), while 15 patients also underwent a pelvis MRI evaluation (G2 subgroup). For G1 patients, the superior-inferior offset ratio and alpha angle were calculated from the X-ray examinations. For G2 patients, the antero-posterior offset ratio was also calculated from pelvis MRI. Chondral damage was classified according to the Outerbridge classification.

RESULTS

The superior-inferior offset ratio and the antero-posterior offset ratio were respectively 0.50 ± 0.23 and 0.33 ± 0.19. The α angle predictive for a chondral damage of IV degree was 81.5°.The chondral damage of the patients suffering from Cam-FAI and Cam-Pincer mixed form were respectively 3.53±0.80 and 3.00±1.41.

CONCLUSIONS

From the results was possible to: - Elaborate two tables providing a reliable indirect calculation of the alpha angle. - Establish an alpha angle cut-off value indicative for a IV degree chondral damage. - Show that Pincer-FAI does not represent an aggravating factor for chondral damage - Show that the level of sports activity was related to the severity of chondral damage. - Show that a physically demanding occupation was not an aggravating factor for chondral damage.

The prevalence of femoroacetabular impingement anatomy in Division 1 aquatic athletes who tread water

Femoroacetabular impingement (FAI) is a disorder that causes hip pain and disability in young patients, particularly athletes. Increased stress on the hip during development has been associated with increased risk of cam morphology. The specific forces involved are unclear, but may be due to continued rotational motion, like the eggbeater kick. The goal of this prospective cohort study was to use magnetic resonance imaging (MRI) to identify the prevalence of FAI anatomy in athletes who tread water and compare it to the literature on other sports. With university IRB approval, 20 Division 1 water polo players and synchronized swimmers (15 female, 5 male), ages 18-23 years (mean age 20.7 ± 1.4), completed the 33-item International Hip Outcome Tool and underwent non-contrast MRI scans of both hips using a 3 Tesla scanner. Recruitment was based on sport, with both symptomatic and asymptomatic individuals included. Cam and pincer morphology were identified. The Wilcoxon Signed-Rank/Rank Sum tests were used to assess outcomes. Seventy per cent (14/20) of subjects reported pain in their hips yet only 15% (3/20) sought clinical evaluation. Cam morphology was present in 67.5% (27/40) of hips, while 22.5% (9/40) demonstrated pincer morphology. The prevalence of cam morphology in water polo players and synchronized swimmers is greater than that reported for the general population and at a similar level as some other sports. From a clinical perspective, acknowledgment of the high prevalence of cam morphology in water polo players and synchronized swimmers should be considered when these athletes present with hip pain.

Articular and peri-articular hip lesions in soccer players. The importance of imaging in deciding which lesions will need surgery and which can be treated conservatively?

Soccer is one of the most popular sports worldwide engaging millions of participants each year. During play, injuries occur rather frequently and most of them involve the hip joint and the surrounding structure. In professional athletes, injuries are often complex scenarios and in the case of misdiagnosis, patients' return to play is delayed or it may progress to a more serious injury with consequent damage for their career and for the soccer team. The most frequent articular pathologies are Femoro-acetabular impingement and labral tears. Stress fracture, avulsion, ischiofemoral impingement, subspine impingement, athletic pubalgia, muscle injuries and Morel-Levallèe lesion are the most frequent hip peri-articular pathologies whereas snapping hip may be both intra- or extra-articular pathology. With an increasing number of football players, the radiologist plays a crucial role in the detection and characterization of the extent of the injuries. This article reviews the current imaging concepts frequently seen in injuries around the hips of professional football players focusing in particular on the most suitable therapeutic approaches, whether surgical or conservative.