Professor Ernest Schilders

clinical cases discussed by expert panel

Introduction Femoroacetabular impingement (FAI) is a recognised cause of pain and disability in athletes. The purpose of this study is to report the clinical outcomes in soccer athletes following hip arthroscopic surgery for FAI. Methods Soccer players were undergoing hip arthroscopy for symptomatic FAI. Demographic data, radiographic features of FAI and operative findings were recorded. The time to return to play soccer and their level of playing were documented. Athletes completed a patient satisfaction questionnaire, a visual analogue scale for pain (VAS for pain), the modified Harris Hip Score (mHHS) and Sports-score from the Hip Osteoarthritis Outcome Score (HOOS) pre and postoperatively. Results We included 50 soccer players with a mean age at the time of operation 26 (16-47, SD 7.8). Ten players underwent bilateral hip arthroscopy with a mean interval between the two operations 6.4 months (2-16, SD 2). The mean follow-up was 3.6 years (SD 14.09). During clinical examination all the athletes had anterior impingement test positive and log-roll test was negative to all. All of the athletes had FAI with 53 hips (88.3%) of mixed-type impingement. Labral repair was performed in 54 hips (90%) and in 10 hips (16.6%) os acetabulae was present. The status of the acetabular articular cartilage according to Outerbridge classification was of grade 4 in 22 hips and of grade 4 on femoral head in 4 hips. Three patients required re-operation for division of adhesions. Forty-seven players (94%) returned to play at the same level but two athletes elected not to return to play because of ageing and one player abandoned soccer following spinal surgery. The players returned to their pre-injury level to play at a mean of 14 weeks (8-54, SD 9.6). The mean patient satisfaction was 9.01 and the mean VAS scale for pain decreased considerably from 7.06 preop to 0.75. The mean mHHS (from 65.55 to 93.72) and sports-score (from 54.67 to 92.93) were improved for both groups. Conclusion This study demonstrates that arthroscopic treatment for FAI and associated intra-articular pathology in soccer players provides a significant clinical improvement and allows athletes to return to play promptly at the same level.

Sex-related differences in groin anatomy as well as pelvic and hip joint morphology may be of relevance in explaining why groin pain is more common in male than female athletes.

Purpose Hamstring muscle strain injury is very common in sports involving high-speed running. Hamstring muscles originate from the ischial tuberosity and thus pelvic position may influence hamstring strain during different sports movements like sprinting, but this has only been evaluated by indirect methods. This study tested the hypothesis that a change in anterior pelvic tilt causes elongation of the overall hamstring complex and disproportionately elongates proximal relative to distal muscle regions. Methods Seven fresh-frozen specimens (full lower limb with pelvis and lumbar spine) were used for this in vitro study. Specimens were dissected to enable visualization of the hamstring muscles and then fixed into a custom-made testing bench that allowed controlled movement of the pelvis over a fixed femur and tibia. Nine markers were inserted into the hamstring muscles to allow intra- and intermuscle difference measurements. Then, six different anterior pelvic angles were used to measure the difference in hamstring muscle lengthening through a three-dimensional reconstruction system based on stereoscopic machine vision technology. Results An increase in anterior pelvic tilt produced a significant non-uniform increase in tissue elongation in all regions of the three hamstring muscles (semitendinosus, semimembranosus [SMB] and biceps femoris long head), which was greater in the proximal (>1 cm every 5°) compared to the distal region (≈0.4 cm every 5°). At the proximal hamstring region, SMB showed significantly greater length changes compared to conjoint tendons with nonstatistically significant elongation differences between muscles at the distal region. Conclusion Considering the results of the study, the pelvis segment will likely play a fundamental role as a strain regulator of hamstring muscles. These results will have an impact on injury rehabilitation and prevention processes of hamstring injuries, as well as optimize future musculoskeletal models and avoid potential underestimation of the hamstring muscle-tendon complex lengthening during high-speed running.

Purpose: The aim of this review was to correlate the preoperative clinical diagnoses and the diagnostic arthroscopic findings in preadolescents with knee problems. We also studied the incidence of different types of knee pathology in this age group. Type of Study: Consecutive case series. Materials and Methods: Twenty-three preadolescents, 13 girls and 10 boys under the age of 13 yeas, presenting with mechanical knee problems underwent knee arthroscopy after clinical assessment. Results: Symptomatic plica synovialis was found to be the most frequent pathology (n = 8). This pathology was far more common in girls compared with boys. Anterior cruciate ligament injuries (n = 4) followed symptomatic plica synovialis in frequency. This was an isolated injury in all cases. The arthroscopic findings were negative in 4 patients. Conclusion: In 61% of preadolescent patients, the clinical diagnoses and arthroscopic findings were compatible and correct. The main error tended to be misdiagnosis of meniscal pathology (4 patients) and overdiagnosis (5 cases of negative arthroscopy).

This study reports the early results for clinical and radiological outcome of fixation of completely displaced or grossly angulated (>90°) 2 and 3 part fractures of the proximal humerus using the PlantTan Fixator Plate (Medizentechnik, Aachen, Germany). Using a deltopectoral approach the humeral head articular fragment was reduced onto the humeral shaft and fixed with the implant, tuberosity fragments were held with transosseous sutures. Early passive, progressing to active, physiotherapy was instituted from the first postoperative day. No other fixation or bone graft was used. In 15 patients, with 16 injured shoulders and an average age of 63 years the mean follow up was 17 months. As a percentage of the normal side the Constant-Murley score for those patients retaining the implant was mean 74% (range 36%-100%). There were six shoulders with score >80% (Good), four shoulders with score between 60 and 79% (Satisfactory) and four shoulders <60% (Poor). Four shoulders (all in patients over the age of 70 years), developed avascular necrosis. Of these, one patient underwent shoulder replacement hemiarthroplasty and one patient underwent removal of the implant. We have demonstrated functional outcome similar to other modes of internal fixation in patients under 70 years. It cannot be recommended for elderly patients (over 70 years) as it is associated with a high incidence of avascular necrosis and fixation failure. © 2005 Elsevier Ltd. All rights reserved.

Hamstring strains are common. They are usually treated conservatively, with good results. Thus far, the only subset of patients who have been considered for surgery are those with complete avulsions of the attachments. We describe a new clinical entity: partial rupture of the distal semitendinosus tendon; which has failed to settle with conservative treatment; and has been successfully treated by tenotomy. © 2005 Elsevier B.V. All rights reserved.

OBJECTIVE: The purpose of this article is to define the relations of the symphysis pubis and capsular tissues to the adductor and rectus abdominis soft-tissue attachments on cadaver dissection and correlate with MRI of the anterior pelvis. SUBJECTS AND METHODS: Seventeen cadavers (8 males and 9 females; mean age, 80 years) were dissected bilaterally. Rectus abdominis and adductor muscles were traced to the pubis and further attachments to the pubic symphysis were defined. Ten asymptomatic (mean age, 17; age range, 16.5-29 years) male athletes underwent 1.5-T MRI of the anterior pelvis with two surface microcoils (each 42 mm in diameter). An axial T2-weighted turbo spin-echo (TSE) sequence (TR/TE, 2,609/106; voxel size, 0.4 mm) was obtained. Axial and sagittal 3D T1-weighted fast-field echo (FFE) sequences (25/4.9; voxel size, 0.3 mm) were obtained. Sequences were repeated incorporating fat suppression and i.v. gadolinium. The relation of the symphysis pubis, disk, and capsular tissues to the insertions of the rectus abdominis, adductor muscles, and gracilis were independently evaluated by two experienced radiologists blinded to all clinical details. RESULTS: In all 17 cadaver specimens, the adductor longus and rectus abdominis attached to the capsule and disk of the symphysis pubis, whereas the adductor brevis had an attachment to the capsule in seven specimens and the gracilis in one. All adductor tendons attached to the pubis. In all 10 athletes, the adductor longus and rectus abdominis bilaterally contributed to the capsular tissues and disk. This was only the case for the adductor brevis in four athletes. No other tendons involved the capsular tissues. CONCLUSION: Cadaver and MRI findings show an intimate relationship between the adductor longus; rectus abdominis; and symphyseal cartilage, disk, and capsular tissues.

Background: Adductor dysfunction is a condition that can cause groin pain in competitive athletes, but the source of the pain has not been established and no specific interventions have been evaluated. We previously defined a magnetic resonance imaging protocol to visualize adductor enthesopathy. The aim of this study was to elucidate, in the context of adductor-related groin pain in the competitive athlete, the role of the adductor enthesis (origin), the relevance of adductor enthesopathy diagnosed with magnetic resonance imaging, and the efficacy of entheseal pubic cleft injections of local anesthetic and steroids. Methods: We reviewed the findings in a consecutive series of twenty-four competitive athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. Magnetic resonance imaging was performed to assess the adductor longus origin for the presence or absence of enthesopathy. Seven patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and seventeen patients (Group 2) had enthesopathy confirmed on magnetic resonance imaging. All patients were treated with a single pubic cleft injection of local anesthetic and steroid into the adductor enthesis. At one year after this treatment, the patients were assessed for recurrence of symptoms. Results: On clinical reassessment five minutes after the injection, all twenty-four athletes reported resolution of the groin pain. At one year, none of the seven patients in Group 1 had experienced a recurrence. Sixteen of the seventeen patients in Group 2 had a recurrence of the symptoms (p < 0.001) at a mean of five weeks (range, one to sixteen weeks) after the injection. Conclusions: A single entheseal pubic cleft injection can be expected to afford at least one year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan; however, it should be employed only as a diagnostic test or short-term treatment for a competitive athlete with evidence of enthesopathy on magnetic resonance imaging. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2007 by The Journal of Bone and Joint Surgery, Incorporated.

Metatarsal stress fractures are uncommon in the children. They usually occur in the distal part of the metatarsal and common in second and third metatarsals. Stress fracture in the proximal fourth metatarsal in a child is very rare. We report a stress fracture in the proximal fourth metatarsal in an 8-year-old boy, which was successfully treated with non-operative management.

We report a rare case of late knee locking after an open knee injury in a polytrauma patient with a pelvic fracture and a contralateral femoral artery injury. Once the life and limb threatening injuries were addressed, debridement and washout of the knee wound was performed. X-rays and subsequent CT revealed only an undisplaced patella fracture. The patient presented 6 months later to a knee surgeon with recurrent locking. An arthroscopy was performed and a 10 mm plastic soft drink bottle cap was retrieved leading to the immediate resolution of symptoms without complications.Open knee injuries require thorough debridement washout and joint assessment. Late locking should raise the suspicion of an intra-articular loose or foreign body. Arthroscopy is an excellent first line tool in the diagnosis and late management of this unusual problem.

The management of Achilles tendon rupture is a much-debated subject. In recent years, there has been much interest in early postoperative mobilization. We present the results of our Achilles tendon repair technique and accelerated rehabilitation program. The technique we propose uses the strength of a 1-loop polydioxanone "suture frame" to enable restoration of the tendon length, immediate positioning of the foot in a near-plantigrade position, and an accelerated rehabilitation program. We followed up 15 cases of Achilles tendon rupture treated with this technique. The initial follow-up was a review of case notes and a telephone questionnaire. All patients were subsequently invited for a clinical follow-up visit, and 11 patients (68.75%) attended. No cases of infection or repeat rupture occurred. The return to work (mean 5.6 weeks) and return to sport (mean 4.8 months) were relatively rapid. Regarding overall satisfaction on a scale of 0 to 10, the median was 9 (range 8 to 10). Of the 11 patients who attended the clinical follow-up visit, the mean American Orthopaedic Foot and Ankle Surgery ankle-hindfoot score was 94.5 points (range 83 to 100). The Achilles rupture repair scores (including isokinetic muscle strength) were good or excellent in all but 1 patient, whose result was fair. Of the 11 patients, 10 reported complete satisfaction with their outcome. Our technique withaccelerated rehabilitation is safe and effective in the management of acute Achilles tendon rupture. It facilitates an early return to work and recreational sports, with excellent overall patient satisfaction. © 2012 American College of Foot and Ankle Surgeons.

Femoroacetabular impingement (FAI) is a condition reintroduced by Ganz in 2003. The overall incidence has been estimated to be around 10-15%, and there is growing scientific evidence that FAI leads to arthritis of the hip.

BACKGROUND: Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. AIM: The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. METHODS: A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. RESULTS: Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. CONCLUSIONS: The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.

Objective: To evaluate gadolinium-enhanced MR imaging in athletes with chronic groin pain and correlate with the clinical features. Design and patients: MR examinations performed in 52 athletes (51 male, 1 female; median age 26 years) with chronic groin pain and 6 asymptomatic control athletes (6 male; median age 29 years) were independently reviewed by two radiologists masked to the clinical details. Symptom duration (median 6 months) and clinical side of severity were recorded. Anatomical areas in the pelvis were scored for abnormality (as normal, mildly abnormal or abnormal) and an overall assessment for side distribution of abnormality was recorded, initially without post-gadolinium sequences and then, 3 weeks later (median 29 days), the post-gadolinium sequences only. Correlation between radiological and clinical abnormality was calculated by Spearman's correlation. Results: Abnormal anterior pubis and enthesis enhancement significantly correlated with clinical side for both radiologists (both P=0.008). Abnormal anterior pubis and adductor longus enthesis oedema was significant for one radiologist (P=0.009). All other features showed no significant correlation (P>0.05). In the control cases there was no soft tissue abnormality but symphyseal irregularity was present (n=2). For both radiologists assessment of imaging side severity significantly correlated with clinical side for post-gadolinium (P=0.048 and P=0.023) but not non-gadolinium sequences (P>0.05). Conclusion: The extent and side of anterior pubis and adductor longus enthesis abnormality on MR imaging significantly and reproducibly correlates with the athletes' current symptoms in chronic adductor-related groin pain. © ISS 2004.

Muscle injuries may be direct or indirect. Indirect injuries ('strains') are extremely common in athletes and most settle with conservative treatment. Myositis ossificans (MO-extra skeletal ossification) is a rare complication of indirect muscle injury that tends to occur following a direct blow (i.e. muscle contusion-direct injury). It is rarely reported as a consequence of a muscle strain.

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CASE REPORT A 32-year-old male, professional footballer who played as goalkeeper at international level sustained a groin injury while performing a goal kick during a premiership football game. The mechanism was abduction in combination with extension of his right kicking leg. He felt a sharp pain in his right adductor area and was unable to continue playing. The patient had a history of adductor enthesopathy treated with a pubic cleft injection (2). Magnetic Resonance Imaging (MRI) revealed a partial avulsion of the right adductor longus fibrocartilage (25%, butterfly broken wing sign). The patient was treated non-operative with RICE and progressively he regained about 85% of his normal level of activity but was not able to sprint flat out and do long goal kicks. During his training he reinjured himself and the MRI scan demonstrated further avulsion of his right adductor longus fibrocartilage (75%). The recurrent injury was further managed non-operatively but the patient was not able to return to his full activity. He sustained a third injury during training and the MRI showed a complete avulsion with displacement of the fibrocartilage. He was unable to play and clinical examination revealed pain during palpation on adductor area and resisted adduction. The footballer was treated surgically 3 months after his first injury. An incision was made over the adductor longus origin, the crural fascia was incised and the fibrocartilage was found avulsed and 3cm displaced. The fibrocartilage footprint measured 1.5x2.5 cm. Six non-absorbable anchors 2.4mm (Mitek G2, De Puy) were positioned within the footprint of the fibrocartilage to reattach the enthesis. Excellent apposition was achieved. There were no immediate postoperative complications. A staged functional training programme of adductors was initiated consisting of close chain adductor strengthening followed by open chain and football specific adductor strengthening work. At eight weeks postoperatively, the patient had full range of movement without pain, with good strength of adductors/abductors (5/5). The patient had no limitations in his activities, returning to full training at 9 weeks and return to play at the same level at 11 weeks. This case report highlights the progressive staged avulsion of the fibrocartilage of the adductor longus enthesis. Reviewing the MRI scans we can clearly demonstrate that the avulsion of the fibrocartilage occurs from lateral to medial as it is progressed from a partial to a complete avulsion. Patients with a partial avulsion of the fibrocartilage of adductor longus when they are not able to regain 100% of their pre-injury level of performance after non-operative management should be considered as candidates for surgical treatment. Selective partial adductor reléase (3) is the operation of choice and footballers return to play 4-6 weeks postoperatively. Further progression of this injury to a complete avulsion necessitates surgical reattachment of the fibrocartilage (1) and footballers return to play 10-12 weeks postoperatively. Therefore, the decision for surgical treatment is crucial for footballers to return to play promptly and at the same level. References 1. Dimitrakopoulou A, Schilders E, Talbot JC, Bismil Q. Acute avulsion of the fibrocartilage origin of the adductor longus in professional soccer players: a report of two cases. Clin J Sport Med. 2008;18(2):167-169. 2. Schilders E, Bismil Q, Robinson P et al. Adductor-related groin pain in competitive athletes: role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89: 2173-2178. 3. Schilders E, Dimitrakopoulou A, Cooke M, Bismil Q, Cooke C. Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes. Am J Sports Med. 2013;41(3):603-7.

Over the past 10-15 years the important physiological and mechanical role of labrum has become more established. The need to preserve the labrum has been supported by several studies demonstrating better pain/ function outcomes following labral repairs[1-3]. More recently the technique has been described to substitute absent labrum with an auto or allograft. For the purpose of this chapter we will define the technique to substitute absent, atrophic or resected labrum with a graft labral reconstruction.The technique is very complex and is probably only mastered by experienced hip arthroscopy surgeons. The indications are clear for young patients with well preserved cartilage and absent labrum. This can occur following a resection of a complex tear associatiated with femoroacetabular impingement. There are a number of circumstances when labral resection + labral reconstruction can be favoured. In patients with pincer type impingement we often see calcified or ossified labra. Following resection of the ossifications and calcifications quality of the labrum, often very degenerative, may not be suitable for repair. This can also be the case in patients with acetabular rimfracture, when there is not enough labrum left following resection of the rim fragment. The indications however are not always very clear. While it has been demonstrated that microinstability occurs when a fragment greater than 2 cm has been resected, we dont know yet when labrum is too atrophic to have a normal function or when a partial resection of the labrum is too extensive to preserve normal function. What approach do we take in patient with hip dysplasia who have a torn dyplastic labrum? These patients have often a very degenerative labrum and it is not clear yet if these patients would be benefit from labral reconstruction. Currently the consensus would be to preserve labral grafting for younger patients and patients without advanced degenerative changes. Several types of graft material can be used for labral reconstruction although the use of allografts might be limited in certain countries due to availability and health economic policies. The first type of graft reported on was the ligamentum teres[4]. The most commonly used grafts are the iliotibial band and semitendinosus auto and allografts[5-7]. Other grafts that can be used are the quadriceps tendon[8] and gracilis[9]. As an alternative a segmental labral defect can be reconstructed using capsular tissue of the hip[10]. My personal choice goes to allograft when available because we avoid any donor site issues. As an alternative a distal iliotibial band autograft gives a good quality graft, which I find better than the proximal one, which often can be too flimsy and this can affect handling of the graft intra-articularly. A study comparing ITB auto and semitendinosis allografts showed that both grafts gave a significant increase in contact area and reduction in peak force compared to a labrum deficient acetabulum[11]. With excessive acetabular coverage such as a coxa profunda or protrusion 360 degrees labral reconstruction might be necessary[12]. A systematic review of the outcomes of labral reconstruction shows short term improvement in patient reported pain function scores. The main indication for reconstruction was in young patients with a deficient labrum and no significant arthritis[13].

Introduction: Recent literature has suggested that a direct anatomic connection exists between the proximal origin of the adductor longus (AL) and the adjacent rectus abdominus. This assertion has been used to support the theory that an acute AL avulsion can propagate into the adjacent musculature; possibly resulting in a concomitant rectus abdominus tear. However, several anatomic textbooks have identified only the Pyramidalis muscle, and not the rectus tendon, to contain direct anatomic connections with the proximal AL. Therefore, the purpose of this study was to perform a layered dissection of the proximal AL origin to further investigate possible anatomical continuity with the adjacent musculature. Methods: Eight fresh-frozen cadaveric pelvises were dissected layer by layer down to the level of the AL origin on the pubic symphysis. All adjacent musculature was identified, with the presence of individual fascial planes and anatomic continuity systematically investigated and noted for each muscle group. Results: A Pyramidalis muscle was found bilaterally in all specimens. The proximal AL origin was found to lie in direct continuity with the Pyramidalis and Pubic ligament forming a Pyramidalis-Adductor Longus-anterior pubic ligamentous complex (“PLAC”) in all specimens. The Rectus Abdominus was contained within its own fascial sheath was not confluent with the proximal AL origin in any of the specimens examined. Conclusions: The proximal AL origin does not lie in continuity with the rectus sheath, suggesting that the theory of proximal AL injuries propagating into the adjacent rectus musculature lacks an anatomical basis. Knowledge of these anatomic relationships, and specifically of the attachments of the Pyramidalis muscle, should be employed to aid in image interpretation and treatment planning in the setting of proximal adductor avulsion injury.

Pelvic apophyseal avulsion can limit young athletes' performance for months and may result in permanent disability. Nonoperative treatment is most commonly preferred, while surgical management with reduction and fixation is reserved for selected cases. Our aim was to evaluate outcomes of operative management of pelvic apophyseal avulsions in a series of adolescents and young adult athletes.Operative room registries and medical records were reviewed to identify patients who received surgical treatment for pelvic apophyseal avulsions who were younger than 24 years and with a minimum of 12 month follow-up.Thirty-two patients (16.8 years ± 2.6) were identified. The most common avulsion sites were anterior inferior iliac spine (34.4%, N = 11) and ischial tuberosity (34.4%, N = 11). Other avulsions were five cases (15.6%) of the pubic apophysis, four cases (12.5%) of the anterior superior iliac spine apophysis and one case of the iliac crest apophysis. Seventeen cases (53.1%) underwent surgery early, i.e., during the first 3 months after the acute injury. Twenty-two cases (68.8%) involved reduction with internal fixation, and six cases (18.8%) involved resection of the fragment. Twenty-six athletes (81.3%, N = 26) reported good outcomes and were able to return to preinjury sports level. Six patients (18.8%) had moderate outcome and reported activity limitations during high-level sports. Large displacement (> 20 mm) or delayed (> 3 months) surgery was not associated with inferior outcomes (P = 0.690 and P = 0.392, respectively). Injury side (P = 0.61) or gender (P = 0.345) did not affect outcomes.Operative management of pelvic apophyseal avulsion results in return to the preinjury sports level in more than 80% of the cases. However, while both acute surgery for large displacement and delayed intervention for failed nonoperative treatment are generally successful in improving sports function in these cases, comparative studies are required to refine criteria for surgery.Case series, IV.

Anatomy of the inguinal and symphyseal area and causes of non-articular groin pain. The inguinal canal is a passage through the abdominal wall which contains the spermatic cord. The anterior border is formed by the external oblique fascia which has an opening, the external inguinal ring, through which the spermatic cord exits. The lateral border is formed by the inguinal ligament. The medial border is formed by the falx inguinalis-a distal extension of the transversalis muscle, the lateral rectus abdominis tendon and the pyramidalis muscle. The posterior wall is formed by the fascia transversalis. A direct inguinal hernia is a defect in the fascia transversalis, just medial to the deep inguinal ring, also known as Hesselbach triangle. In athletes we often see a bulging of the posterior wall, which can be symptomatic. The deep inguinal ring can be widened allowing fat or bowel content to protrude in the inguinal canal, if so this is called an indirect inguinal hernia. Inguinal hernias are seen most commonly in older men and a non-obstructed hernia is typically pain free. This is different pathology to the painful groins we see in athletes which are often related to neuropathies, such as neuromas and hypertrophic nerves. Adhesions around the nerves are also commonly found. The ilioinguinal and iliohypogastric nerve, both sensory nerves, run in the inguinal area and pierce the surface of the internal oblique muscle. The ilioinguinal nerve is most lateral nerve which joins the spermatic cord at the level of the deep inguinal ring running from cranial to caudal and either exits through the external inguinal ring or pierces the external oblique fascia. It innervates the inguinal area but often also the adductor area. The iliohypogastric nerve’s course is more medial and distally pierces the external oblique fascia medial to the external inguinal ring. The genital branch of the genitofemoral nerve enters the inguinal canal through the deep inguinal ring and runs deep to the spermatic cord. The genital branch has a sensory and motoric function. It innervates the cremaster muscle and with neuropathy, male patients can experience testicular retraction. It innervates the testicular area and patients can experience combined inguinal with testicular pain. It is a fairly unknow cause of testicular pain and often leads to numerous urology visits without resolution of their pain symptoms. Selective ultrasound guided diagnostic nerve blocks are the most appropriate test to diagnose these neuropathies. The anatomical concept of the PLAC was introduced in 2017. PLAC is acronym which stands for Pyramidalis-Anterior Pubic Ligament-Adductor Longus complex. The acronym helps clinicians to remember which additional anatomical structures to assess with adductor longus avulsions. In addition the pectineus muscle should also be assessed. In the majority of cases more anatomical structures are involved with adductor longus avulsions. The triangular shaped pyramidalis muscle originates on the anterior pubic ligament distally and inserts onto the linea alba thereby connecting with the rectus abdominis. The adductor longus tendon has 2 proximal anchor points: the fibrocartilage which anchors onto the pubic body and the anterior pubic ligament. The anterior pubic ligament consists of a superficial and a deep portion. The superficial part of the APL has obliquely orientated fibers and covers the pubic area. The superficial part of APL is formed by external oblique fascia proximally and fascia lata distally. The deep portion of the anterior pubic ligament has transversely orientated fibers and spans between the pubic tubercules, attaches to pubic ridge and bridges the symphyseal joint. We see different patterns types of PLAC injuries with adductor avulsions and this determine symptoms they experience. Athletes with an adductor avulsion where the adductor longus is still connected to pyramidalis (type 3) often experience inguinal pain. It is important to recognise because this can result in unnecessary groin repairs. The Pyramidalis muscle is the only abdominal muscle that lies anterior to the pubic bone. The rectus abdominis inserts on top of the pubis and has a distinct internal and external tendon in males. In 2/3 of females we find this distinction as well. In males the internal tendon of the rectus abdominis interdigitates with the contralateral one and runs deep to the anterior pubic ligament.

An increased Tonnis angle correlates with poorer surgical outcomes in patients with acetabular dysplasia receiving arthroscopic treatment for labral tears. Introduction: Labral tears are a common finding in patients with acetabular dysplasia. Currently, the role of arthroscopic treatment and the factors that might influence the outcome of labral treatment are still uncertain. The aim of this study is to assess if the size of the Tonnis angle influences the clinical outcomes in patients with acetabular dysplasia receiving arthroscopic treatment for labral tears. Methods: From prospective collected data were retrieved 30 patients with acetabular dysplasia and an associated labral tear treated with hip arthroscopy. Inclusion criteria were centre edge (CE) angle < 25, Tonnis grade 0, lateral sourcil height ≥2mm. The Tonnis angle was measured. Intraoperative findings were recorded and the type of labral treatment: resection or repair. Patients were assessed using a 100 point Modified Harris Hip Score (MHHS) pre- and post-operatively after an average of 2 years. A linear regression model was used to assess the relation of the difference in MHHS (preop-postop) and the Tonnis angle (explanatory variable). A linear regression model was also fitted within each of the treatment groups separately. Results: There were 30 patients; 23 females and 7 males (mean age 37  years, range 23-51) were assessed pre-operatively and at 2-year-follow-up. The average CE angle was 21 degrees (range 15-24).  The average Tonnis angle was 13.8 degrees (6-25). Eleven patients had a labral debridement and 19 patients a labral repair. Our study demonstrates a significant (p=0.0013) relation between the reduction in MHHS score difference (preop-postop) as the Tonnis angle increases. Conclusion: This study demonstrates that in patients with dysplasia who received arthroscopic treatment for labral tears, the surgical outcome (MHHS) is depending on the Tonnis angle. Patients with an increased Tonnis angle, independent of the type of treatment, have a poorer outcome and possibly, a different treatment option should be considered.

Title: Hip arthroscopy for femoroacetabular impingement in professional and non-professional footballers and time to return to play. Introduction: Femoroacetabular impingement (FAI) with associated intra-articular hip pathologies is a recognised cause of pain and disability in athletes. The purpose of this study is to report the clinical outcomes and time to return to play football between professional and non-professional athletes following hip arthroscopic surgery for femoroacetabular impingement (FAI). Methods: Football players were undergoing hip arthroscopy for symptomatic FAI. Demographic data, radiographic features of FAI and operative findings were recorded. The time to return to play soccer and their level of playing were documented. Athletes completed a patient satisfaction questionnaire, a visual analogue scale for pain (VAS for pain), the modified Harris Hip Score (mHHS) and Sports-score from the Hip Osteoarthritis Outcome Score (HOOS) pre and postoperatively after an average of 3.6 years. For tatistical analysis a Cox proportional hazards model was used to examine whether professional or non-professional footballers were more likely to return faster to soccer at the same level. Results: We included 50 soccer players (60 hips); 29 were professional players (36 hips) with a mean age at the time of operation 22.3 (16-35, SD 5.18) and 21 were non-professional (24 hips) with a mean age 31.6 (17-47, SD 7.78). The mean follow-up was 43.1 months (SD 14.09). Two non-professional athletes (2 hips) did not return to play because of ageing and one professional (2 hips) because of spinal surgery. For professional footballers the mean patient satisfaction was 9.2 and for non-professional footballers was 8.75. The mean VAS scale for pain decreased considerably from 7.3 preop to 0.38 postoperatively for professional and from 6.5 preop to 1.29 postoperatively for non-professional athletes. The mean mHHS, sports-score were improved for both groups.                                 Professional footballers returned to their pre-injury level to play at a mean of 13.26 weeks (8-22, SD 2.95) and non-professional at a mean 23.3 weeks (8-54, SD 12.7).                                                                   Statistical analysis showed that the hazard ratio was 1.99 (p-value 0.016) suggesting that the professional players were about twice as likely to return to play football faster, at the same level than non-professional athletes. Conclusion: This study demonstrates that arthroscopic treatment for FAI and associated intra-articular pathology in football players provides a significant clinical improvement and allows athletes to return to play at the same level. Professional football players are significantly more likely to return to play football faster compared to non-professional athletes.

Background: Adductor dysfunction can cause groin pain in athletes and may emanate from the adductor enthesis. Adductor enthesopathy may be visualized with magnetic resonance imaging and may be treated with entheseal pubic cleft injections. We have previously reported that pubic cleft injections can provide predictable pain relief at one year in competitive athletes who have no evidence of enthesopathy on magnetic resonance imaging and immediate relief only in patients with findings of enthesopathy on magnetic resonance imaging. In this follow-up study, we attempted to determine if the same holds true for recreational athletes. Methods: We reviewed a consecutive case series of twenty-eight recreational athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. A period of conservative treatment had failed for all of these athletes. The adductor longus origin was assessed with magnetic resonance imaging for the presence or absence of enthesopathy. All patients were treated with a single pubic cleft injection of a local anesthetic and corticosteroid into the adductor enthesis. The patients were assessed for recurrence of symptoms at one year after treatment. Results: On clinical reassessment five minutes after the injection, all twenty-eight athletes reported resolution of the groin pain. Fifteen patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and thirteen patients (Group 2) had findings of enthesopathy on magnetic resonance imaging. At one year after the injection, five of the fifteen patients in Group 1 had experienced a recurrence; these recurrences were noted at a mean of fourteen weeks (range, seven to twenty weeks) after the injection. Four of the thirteen patients in Group 2 had experienced a recurrence of the symptoms at one year, and these recurrences were noted at a mean of eight weeks (range, two to nineteen weeks) after the injection. Overall, nineteen (68%) of the twenty-eight athletes had a good result following the injection. Of the remaining nine athletes, two were treated successfully with repeat injection; therefore, overall, twenty-one (75%) of the twenty-eight athletes had a good result after entheseal pubic cleft injection. Conclusions: Most recreational athletes with adductor enthesopathy have pain relief at one year after entheseal pubic cleft injection, regardless of the findings on magnetic resonance imaging. There were similarities between this group of recreational athletes and the competitive athletes in our previous study, in that the adductor enthesis was the source of pain and entheseal pubic cleft injection was a valuable treatment option. The main difference was that, in this group of recreational athletes, magnetic resonance imaging evidence of adductor enthesopathy did not correlate with the outcome of the injection. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. Copyright © 2009 by The Journal of Bone and Joint Surgery, Incorporated.

Abstract

We present a case of a high‐level rugby player with severe groin pain following a partial rupture of his left adductor longus enthesis during a game. Conservative treatment proved unsuccessful and the athlete had persistent symptoms, affecting his quality of life and ability to play sports. Further assessments revealed a large bony spur/enthesophyte at adductor longus origin. The patient underwent a successful surgical resection of the active bone formation.

The spectrum of recognisable hip conditions has broadened significantly over the past five years through improved imaging techniques and hip arthroscopy. Hip arthroscopy may increasingly provide new treatment options for the plethora of hip pathologies. Femoro-acetabular impingement (FAI), a condition relatively unknown until its introduction by Ganz, is now thought to be the most common cause of hip pain in the young adult with an incidence around 10-15% of the population. FAI is responsible for labral tears and chondral injuries and there is growing evidence that it is a precursor of osteoarthritis. Although there are few studies assessing open and arthroscopic treatment of FAI, the early results are promising. Labral tears may be associated with dysplasia and instability, and can be degenerative or post-traumatic. With regard to articular degeneration hip arthroscopy appears to offer some benefits in treating localized articular cartilage lesions although its role for more diffuse osteoarthritis is limited. It is likely that the hip arthroscopist will become a valuable addition to the staffing in an orthopaedic department. © 2009.

Introduction Adductor injuries are a common problem in football resulting in days of absence from sports and in high reinjury rate. Acute avulsion of the adductor longus through its fibrocartilagenous enthesis is an uncommon injury. The purpose of this study is to highlight the injury of the adductor longus at its enthesis, be it complete or partially avulsed, and to report the functional outcome and return to play following surgical treatment. Materials and Methods We included footballers who presented with an acute injury of the adductor longus origin. Demographic data, clinical examination, strength testing measurements, imaging features and level of sports were recorded. Athletes were assessed for pain using a visual analogue scale. The time and the level to return to play football following selective partial adductor release (for partial avulsion with minimal displacement) (2) or adductor longus reattachment (for complete avulsion) (1) were documented. Results We included 58 out of 73 football players with acute adductor injury; 43 were professional players with a mean age at the time of operation 25 (18-36, SD 4.7) and 15 were non-professional with a mean age 38 (23-48, SD 7.3). There were 32 professional and nine non-professional footballers with complete avulsion, 11 professional and six non-professional with partial avulsion with minimal displacement. Previous history of adductor enthesopathy was noted in 31 professional of which 21 had undergone more than two corticosteroid injections and in seven non-professional, all of them had undergone corticosteroid injections. The mean VAS scale for pain was decreased and adductor strength was increased considerably. All of the athletes returned to play football but one player with incomplete tear at 8 weeks sustained a complete avulsion and underwent surgical reattachment. The footballers with reattachment returned to full training at a mean 11.75 weeks (SD 6.5) and returned to play at a median 13 weeks (IQR 8). The footballers with selective partial adductor release returned to full training at a mean 6.4 weeks (SD 2.07) and returned to play at a median 8 weeks (IQR 4). Conclusion This study demonstrates that acute avulsion of the adductor longus should be treated taking into account the degree and type of injury. Surgical treatment be it reattachment of the enthesis or selective partial adductor release provides a significant clinical improvement and allows athletes to return to play promptly and at the same level. References 1. Dimitrakopoulou A., Schilders EM., Talbot JC., Bismil Q.Acute avulsion of the fibrocartilage origin of the adductor longus in professional soccer players: a report of two cases. Clin J Sport Med. 2008;18(2):167-169. 2. Schilders E, Dimitrakopoulou A., Cooke M., Bismil Q., Cooke C. Effectiveness of a Selective Partial Adductor Release for Chronic Adductor-Related Groin Pain in Professional Athletes. Am J Sports Med 2013;41(3):603-7

Groin pain is common in athletes. Yet, there is disagreement on aetiology, pathomechanics and terminology. A plethora of terms have been employed to explain inguinal-related groin pain in athletes. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term inguinal disruption based on the pathophysiology while lately the Doha agreement in 2014 defined it as inguinal-related groin pain, a clinically based taxonomy. This review article emphasizes the anatomy, pathogenesis, standard clinical assessment and imaging, and highlights the treatment options for inguinal disruption.

Introduction: Life expectancy has increased and elderly people have the desire to live an active lifestyle with participation in sports. Hip arthroscopy has not yet been established as standard treatment in this group of patients. The purpose of this study is to assess the outcomes after hip arthroscopy for FAI in patients aged over 50, as well as to report the factors that can lead to conversion to a hip replacement. Methods: Prospectively collected data were retrieved from our database in patients aged 50 years or older undergoing hip arthroscopic surgery for FAI and disabling pain. Demographics, clinical examination, imaging signs of impingement and operative findings were recorded. Patients completed MHHS pre and postoperatively and patients’ satisfaction. Factors that may indicate a conversion to a hip replacement were statistically analysed. Results: We included 149 patients (163 hips) with a mean age 56.7 years (50 -80). There were 75 males and 74 females. Median follow-up was 19 months. All patients had signs of FAI on radiographs and osteoarthritic changes 0-3 according to Tonnis classification. Hip replacement was required in 12 patients (8.05%). The MHHS improved from mean 57.14 (26-96)preoperatively to 79.24 (28-100) postoperatively. The mean patients’ satisfaction was 85 (0-100). Statistically hip arthroscopy was significantly more likely to fail in patients who were older at the time of surgery (OR=1.09, p=0.05). Patients were also significantly more likely to progress to a hip replacement with poor acetabular articular cartilage (OR=2.59, p=0.05) and with severe cartilage changes on the femoral head (OR=6.63, p=0.008). It was significantly more likely for patients with a higher age at the time of surgery to undergo a labral resection (OR=1.09, p=0.007). The group of patients who underwent a labral resection was significantly more likely to need a hip replacement when compared with the group of patients who had a labral repair (OR=10.67, p=0.028). Patients with lateral sourcil height less than <2mm were significantly more likely to undergo a total hip replacement ((OR=9.11, p=0.05). Conclusion: In patients with FAI aged 50 years or older good results can be achieved with therapeutic hip arthroscopy and with low conversion to a hip replacement. Factors that can lead to a failure of hip arthroscopy are >2mm joint space, labral resection, higher age and severe osteoarthritic changes, especially on the femoral head.

© 2016 Wichtig Publishing. Groin pain encompasses a number of conditions from the lower abdomen, inguinal region, proximal adductors, hip joint, upper anterior thigh and perineum. The complexity of the anatomy, the heterogeneous terminology and the overlapping symptoms of different conditions that may co-exist epitomise the challenges in diagnosis and treatment. Inguinal-related and adductor-related pain is the most common cause of groin pain and will be discussed in this article.

Introduction Acetabular rim ossicles known as os acetabuli are considered as unfused secondary centres of ossification or fatigue fractures caused by overload. Competitive athletes subject their hips to a significant amount of stress and therefore make them more prone to hip injuries. The purpose of this study is to assess the presence of os acetabuli in athletes undergoing hip arthroscopy and to report its prevalence for different type of sports. Methods A mixed group of athletes were assessed following hip arthroscopy for femoro acetabular impingement (FAI) and associated pathology. Clinical examination, radiographic features and operative findings were documented. The level and type of sports were recorded and categorized according to their movement required per sport in predictable and unpredictable movements. The return to sports was also mentioned. Results From our database we retrieved 378 athletes from different type of sports treated for FAI. Imaging modalities showed the presence of os acetabulae in 30 athletes. There were 139 (36.7%) athletes with predictable movements during their sport; golf 34 (24.4%) athletes, in cycling were 64 (46%), dressage were 13 (9.3%) and ballet 28 (20.14%). In this group of predictable movements were found 3 athletes with os acetabuli: 2 in cycling (3.1%) and 1 in golf (2.9%). There were 239 (63.2%) athletes in sports with unpredictable movements; in soccer 177 (74%) athletes, rugby 42 (17.5%) and cricket 20 (8.3%). In this group 27 athletes had the presence of os acetabuli: soccer 21 (11.8%), rugby 5 (11.5%) and cricket 1 (5%). Conclusion This study demonstrates a higher prevalence of os acetabuli in sports with unpredictable movements such as soccer, rugby and cricket compared to those sports with predictable movements such as golf, cycling, dressage and ballet. It is not unreasonable then in sports to refer to it as a rim fracture rather than as os acetabulae.

Résultats suivants arthroscopie de la hanche pour conflit fémoroacétabulaire chez les patients plus de 50 ans d' âge Introduction Life expectancy has increased and elderly people have the desire to live an active lifestyle with participation in sports. Hip arthroscopy has not yet been established as standard treatment in this group of patients. The purpose of this study is to assess the outcomes after hip arthroscopy for FAI in patients aged over 50, as well as to report the factors that can lead to conversion to a hip replacement. Methods Prospectively collected data were retrieved from our database in patients aged 50 years or older undergoing hip arthroscopic surgery for FAI and disabling pain. Demographics, clinical examination, imaging signs of impingement and operative findings were recorded. Patients completed MHHS pre and postoperatively and patients’ satisfaction. Factors that may indicate a conversion to a hip replacement were statistically analysed. Results We included 149 patients (163 hips) with a mean age 56.7 years (50 -80). There were 75 males and 74 females. Median follow-up was 19 months. All patients had signs of FAI on radiographs and osteoarthritic changes 0-3 according to Tonnis classification. Hip replacement was required in 12 patients (8.05%). The MHHS improved from mean 57.14 (26-96)preoperatively to 79.24 (28-100) postoperatively. The mean patients’ satisfaction was 85 (0-100). Statistically hip arthroscopy was significantly more likely to fail in patients who were older at the time of surgery (OR=1.09, p=0.05). Patients were also significantly more likely to progress to a hip replacement with poor acetabular articular cartilage (OR=2.59, p=0.05) and with severe cartilage changes on the femoral head (OR=6.63, p=0.008). It was significantly more likely for patients with a higher age at the time of surgery to undergo a labral resection (OR=1.09, p=0.007). The group of patients who underwent a labral resection was significantly more likely to need a hip replacement when compared with the group of patients who had a labral repair (OR=10.67, p=0.028). Patients with lateral sourcil height less than <2mm were significantly more likely to undergo a total hip replacement ((OR=9.11, p=0.05). Conclusion In patients with FAI aged 50 years or older good results can be achieved with therapeutic hip arthroscopy and with low conversion to a hip replacement. Factors that can lead to a failure of hip arthroscopy are >2mm joint space, labral resection, higher age and severe osteoarthritic changes, especially on the femoral head.

Introduction The painful groin is a challenging entity. The complexity of groin anatomy, the similarity of symptoms for different pathologies that may co-exist may lead to a diagnostic dilemma and delays in treatment. The purpose of the study is to determine the prevalence of adductor enthesopathy in patients require arthroscopic surgery for treatment of femoroacetabular impingement (FAI) and to evaluate the results of treatment for both of these disorders. Methods Prospectively collected data were retrieved to identify patients with both symptomatic FAI and adductor enthesopathy at the time of presentation. Demographics, clinical examination, imaging signs of hip impingement and adductor enthesopathy were recorded. Isometric strength testing of the adductors and abductors was measured in both legs using a handheld dynamometer. Patients completed the modified Harris hip score (MHHS) pre and postoperatively and pain was evaluated on a visual analog scale (VAS). Results From our database of 1135 patients were included 38 (3.34%) patients with 44 hips. There were 31 males and 7 females with a mean age 36.8 years (20-63, SD 11.6). Mean follow-up was 27.7 months (SD 19.7). Pubic cleft injections were carried out in 37 (84.09%) hips and 20 (45.4%) hips underwent selective partial adductor release. All of the patients (100%) underwent hip arthroscopic surgery for FAI. Maximum improvement in strength was observed at two months postoperatively both on the operated and non-operated side compared to preoperative strength. The MHHS improved from mean 60 (21-74, SD 16.2) preoperatively to 79 (30-100, SD 17.6) postoperatively and VAS for pain from 6.9 (SD 1.7) to 2.8 (SD 2.6). Conclusion When FAI and adductor enthesopathy are present then both pathologies should be addressed simultaneously or in a staged manner to optimize the postoperative outcomes. Pubic cleft injections and selective partial adductor release are valuable therapeutic procedures in patients treated for symptomatic FAI.

Introduction Femoroacetabular impingement (FAI) is a recognised cause of pain and disability in athletes. The purpose of this study is to report the clinical outcomes in soccer athletes following hip arthroscopic surgery for FAI. Methods Soccer players were undergoing hip arthroscopy for symptomatic FAI. Demographic data, radiographic features of FAI and operative findings were recorded. The time to return to play soccer and their level of playing were documented. Athletes completed a patient satisfaction questionnaire, a visual analogue scale for pain (VAS for pain), the modified Harris Hip Score (mHHS) and Sports-score from the Hip Osteoarthritis Outcome Score (HOOS) pre and postoperatively. Results We included 50 soccer players with a mean age at the time of operation 26 (16-47, SD 7.8). Ten players underwent bilateral hip arthroscopy with a mean interval between the two operations 6.4 months (2-16, SD 2). The mean follow-up was 3.6 years (SD 14.09). During clinical examination all the athletes had anterior impingement test positive and log-roll test was negative to all. All of the athletes had FAI with 53 hips (88.3%) of mixed-type impingement. Labral repair was performed in 54 hips (90%) and in 10 hips (16.6%) os acetabulae was present. The status of the acetabular articular cartilage according to Outerbridge classification was of grade 4 in 22 hips and of grade 4 on femoral head in 4 hips. Three patients required re-operation for division of adhesions. Forty-seven players (94%) returned to play at the same level but two athletes elected not to return to play because of ageing and one player abandoned soccer following spinal surgery. The players returned to their pre-injury level to play at a mean of 14 weeks (8-54, SD 9.6). The mean patient satisfaction was 9.01 and the mean VAS scale for pain decreased considerably from 7.06 preop to 0.75. The mean mHHS (from 65.55 to 93.72) and sports-score (from 54.67 to 92.93) were improved for both groups. Conclusion This study demonstrates that arthroscopic treatment for FAI and associated intra-articular pathology in soccer players provides a significant clinical improvement and allows athletes to return to play promptly at the same level.

Introduction Acetabular rim ossicles known as os acetabuli are considered as unfused secondary centres of ossification or fatigue fractures caused by overload. Competitive athletes subject their hips to a significant amount of stress and therefore make them more prone to hip injuries. The purpose of this study is to detect the presence of os acetabuli in soccer and to report its prevalence. Methods Athletes were assessed following hip arthroscopy for femoroacetabular impingement (FAI) and associated pathology. Clinical examination, radiographic features, operative findings and the return to sports were documented. The presence of os acetabuli in soccer was recorded and its prevalence in comparison with other sports was calculated. Results From our database we retrieved 378 athletes treated for FAI. The sports were categorized according to their movement required per sport in predictable and unpredictable movements. There were 139 (36.7%) athletes from sports with predictable movements (golf, cycling, dressage, ballet) and 239 (63.2%) athletes with unpredictable movements (soccer, rugby, cricket). Imaging modalities showed the presence of os acetabulae in 30 athletes. In sports with predictable movements were found only 3 athletes (2.15%) with os acetabuli and in sports with unpredictable movements 27 athletes (11.29%) had the presence of os acetabuli. Specifically in soccer there were 177 (74%) players with 21 (11.8%) had the presence of os acetabuli. Conclusion This study demonstrates that os acetabulae is present in sports with most unpredictable and uncoordinated movements compared to sports require smooth and predictable movements. The higher prevalence of os acetabulae seems to be in soccer compared to other sports. This suggests that might be said in soccer as a rim fracture rather than os acetabulae.

Introduction Chronic adductor enthesopathy is a cause of groin pain in athletes. When conservative treatment fails and long-standing adductor-related pain becomes debilitating for the athletes operative treatment should be considered. Methods: Professional soccer players with chronic adductor enthesopathy were included in this study. Patients with femoroacetabular impingement or coexisting sports’ hernia were excluded. They were assessed in a standard way for adductor dysfunction and underwent a specifically designed magnetic resonance imaging groin study protocol. Pain and functional improvement were assessed with visual analog scale (VAS) for pain and time to return to sport. Results: We treated 36 athletes (nine players having bilateral symptoms) with a selective partial adductor release. The duration of symptoms was 9.7 months (2-36, SD 8.4) and the average follow-up was 41 months (24-72, SD 13.2). The VAS scale for pain was improved from 5.7 (3-8, SD 1.08) preoperatively to 0.1 (0-1, SD 0.31) postoperatively. All of them (100%) returned to their pre-injury level of sport after an average of 9.3 weeks (4-24, SD 4.9). Conclusion: A selective partial adductor longus release provides excellent pain relief for chronic adductor enthesopathy and promptly return to the pre-injury level of competition in soccer players.

Introduction Adductor pain is a common finding in soccer players. However, when femoroacetabular impingement (FAI) is present it can be difficult to differentiate between hip-related adductor pain and adductor-related groin pain. We hypothesize that isometric strength testing of the adductors/abductors can be a useful tool. Materials and Methods We assessed athletes, predominantly soccer players, with unilateral adductor pain and divided them in two groups; Group I: Hip-related adductor pain. Inclusion criteria: FAI, adductor pain alleviated with a hip injection. Patients with co-existing conditions such sports hernia and adductor enthesopathy were excluded. Group II: Adductor-related groin pain. Inclusion criteria: adductor enthesopathy, adductor pain alleviated with a pubic cleft injection. Patients with associated FAI, sports hernia and acute onset of symptoms were excluded. A handheld dynamometer (Microfet 2) was used for isometric strength testing. Both groups were assessed for the difference in adductor strength in symptomatic/asymptomatic side, and the ratio of adductor/abductor strength. For statistical analysis: a Kolmogorov-Smirnov test, an independent t-test and ANOVA. Results In our database 28 athletes fulfilled the criteria to be included in group I. The athletes (12 football players) with hip-related adductor pain, had a mean age of 36 years. Group II contained 20 athletes (17 football players: 15 professional and 2 recreational) with adductor-related groin pain, with a mean age of 28.6 years. Athletes in group I were weaker on the symptomatic side and the difference in adductor strength between the symptomatic/asymptomatic side was 3.71 % (SD 13.06). In Group II athletes adductors were 28.4% (SD 20.3) weaker on the symptomatic side. There was a significant difference (p<0.01) in adductor strength difference between group I and II. The ratio of adductor/abductor strength in Group I was 0.93 on the symptomatic and 0.92 on the asymptomatic side and in Group II was 0.67 and 0.95 respectively. There was a significant difference in adductor/ abductor strength ratio (p<0.01) between groups. Conclusion This study demonstrates successfully how isometric strength testing can help to differentiate between the two types of adductor pain; the hip-related adductor pain and the adductor-related groin pain. The data suggest that higher adductor strength on the symptomatic side occurs in patients with hip-related adductor pain.

Introduction Pubalgia is a known cause of groin pain in athletes and represent a challenging entity in diagnosis and treatment. The complexity of the groin anatomy and the overlapped symptoms from different pathologies that may co-exist leading to chronic lower abdominal pain and disability in athletes. The purpose of this study is to report the clinical outcomes together with a new surgical technique and to determine if athletes could return to the same high level of performance promptly. Materials and Methods We included professional footballers who presented with chronic groin pain, pubalgia, pain resistant to non-operative treatment. Patients with associate sports’ hernia (or inguinal disruption), osteitis pubis, adductor enthesopathy or hip pathology were excluded. Demographic data and type of sports were noted. Medical history, clinical examination of the lower abdomen, groin and hip joint, imaging investigation and strength testing measurements were recorded. All athletes were assessed for pain using a visual analogue scale and if they returned to sports at the same level as preoperatively. Results We assessed 18 footballers; 13 were professional and five were non-professional. All of them were males with a mean age 28 (SD 7.6) years old. All of the athletes (100%) had constant pain during acceleration and some of them while striking a ball. The pain was localised on suprapubic area radiating to midline 2-3 cm below the umbilicus (linea alba) and adductors area affecting their level of performance. Duration of symptoms was 7.46 months (SD 6.8, 2-24 months). Seven athletes had a pubic cleft injection (2,3) prior to the surgery with short-term partially improvement of symptoms. All athletes (100%) underwent bilateral pyramidalis muscle release and rectus abdominis fascioplasty (1). The pain was improved and ranged from 0 to 3 postoperatively. All of the patients (100%) returned to full training at a mean of 8.3 weeks (SD 1.49, 6-12 weeks) and at their previous level of sporting activity 12 weeks post surgery but one athlete elected to stop playing due to ageing. Conclusions Pyramidalis muscle may cause long-standing pubalgia in footballers leading to disability and potential career-ending for the athlete. A bilateral pyramidalis muscle release associated with rectus abdominis fascioplasty is a promising technique when prior non-operative treatment has failed. Athletes have a prompt recovery and return to the same level of sports with this technique. References 1. Martens MA, Hansen L, Mulier JC. Adductor tendinitis and musculus rectus abdominis tendopathy. Am J Sports Med. 1987;15(4):353-356. 2. Schilders E, Bismil Q, Robinson P et al. Adductor-related groin pain in competitive athletes: role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007; 89: 2173-2178. 3. Schilders E, Talbot JC, Robinson P, Dimitrakopoulou A et al. Adductor-related groin pain in recreational athletes: role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2009; 91: 2455-2460.

Objectives: An imaging classification for pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) injuries has been described. The study objective is to assess intra- & inter-observer agreement to diagnose and classify PLAC injuries with MRI, and assess the correlation with surgical findings. Methods: Retrospective study approved by our institution’s Research & Ethics Committee. The PLAC injury database was interrogated for the following inclusion criteria: - Acute post-traumatic PLAC injury - Dedicated MRI groin protocol - Surgical PLAC repair, between 2017-2020 2 experienced musculoskeletal radiologists (A&B) blinded for demographic & clinical data, scored the scans twice with a 6-week interval. The MRIs were scored for: type of PLAC injury (1-5), presence of pyramidalis, continuity or separation of pyramidalis -adductor longus connection, avulsion of the adductor longus (AL) fibrocartilage (FC), tear of the inguinal ligament (IL), injury to the pectineus. The surgical notes were scored by the same criteria. MRI classification of the different types of PLAC injuries Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Schilders E., Mitchell, A., Johnson, R., Dimitrakopoulou A., Kartsonaki C., Lee, J. Proximal adductor avulsions are rarely isolated but usually involve injury to the PLAC and pectineus: descriptive MRI findings in 145 athletes. Knee Surg Sports Traumatol Arthrosc 29, 2424–2436 (2021). https://doi.org/10.1007/s00167-020-06180-5 Statistical method: Cohen’s weighted & unweighted Kappa were used to calculate intra- & inter-rater agreement for scoring the MRI & to calculate agreement between each radiologist with the surgical findings. A kappa score of 0.61-0.80 is substantial agreement, a score of 0.81-1.00 almost perfect agreement. Results: 80 athletes fulfilled the criteria Main sports were football 36(45.05%) & rugby 21(26.2%) 50 (64.95%) Professional athletes 26 (53.1%) competed in the premier league 45 (56.2%) Right sided injuries & 35 (43.8%) left sided with 50 (79.4%) of the athletes right foot dominant The surgical observations were: The pyramidalis muscle was present in 76 cases (95%), the AL was separated from the pyramidalis / anterior pubic ligament in 44 cases (55.0%) & in continuity in 35 cases (43.8%). All athletes had a full thickness AL FC avulsion. The FC was displaced in 55 (68.8%) & in situ in 25 (31.2%). An IL injury was found in 41 (51.2%) athletes & a partial pectineus avulsion in 39 (48.8%). Scoring the PLAC injury type: the intra-observer estimated weighted Kappa score for scorer A was 1, unweighted score 1, estimated weighted Kappa score for scorer B was 1.00 & unweighted Kappa score was 0.98. The interobserver estimated weighted Kappa score was 0.98, unweighted Kappa score 0.98 for first scoring of the type of PLAC injury on MRI. Interobserver agreement between scorer A & B for the criteria scored on MRI Interobserver Agreement Kappa Unweighted Kappa Weighted lower estimate upper lower estimate upper Type of PLAC 0.95 0.98 1 0.98 0.98 0.98 Pyramidalis 1 1 1 1 1 1 Pyramidalis oedema 0.74 0.85 0.96 0.73 0.73 0.73 Pyramidalis- Adductor Longus separation 1 1 1 1 1 1 Partial/ complete separation 0.9 0.96 1 0.9 0.9 0.9 Inguinal ligament injury 0.75 0.87 0.98 0.75 0.87 0.98 Partial pectineus avulsion 1 1 1 1 1 1 The comparison of the PLAC type on MRI with surgical findings were: Scorer A: estimated weighted Kappa score of 0.96 & unweighted score of 0.90 Scorer B: estimated weighted Kappa score of 0.98 & unweighted score of 0.92 Conclusions: This is the first study looking at the correlation between MRI and surgical findings in AL/ PLAC injuries. The study demonstrates almost perfect intra- & inter-observer agreement in classifying the type of PLAC injury, and excellent correlation between the MRI findings and surgical findings. A dedicated MRI groin is a reliable method to accurately diagnose and classify PLAC injuries, and aid surgical planning.

© 2018 BMJ Publishing Group Ltd. All rights reserved. Groin pain is a common problem in athletes. The diagnosis can be difficult because of the complexity of the groin anatomy, the numerous clinical entities presenting with similar symptoms, the concurrence of those entities and the confusing terminology. Thus, a dilemma in diagnosis may arise leading to long-standing symptoms, disabling groin pain, mismanagement and therefore to poor treatment. Hereby, we present such a case of a recreational athlete complaining for excruciate pubic pain after being misdiagnosed and subsequently mistreated affecting her quality of life. We report on a new interesting finding, the focal osteopenia over the pubic parasymphyseal bone, together with administration of bisphosphonates for first time, as a treatment, for this condition in this body area. Our purpose is to shed light on the pathomechanism of groin pain labelled as osteitis pubis. We also outline the importance of thorough history and physical examination combined with appropriate advanced imaging.

Background The postoperative management of femoroacetabular impingement (FAI) is variable with favourable surgical outcomes. Yet, there is no evidence on the efficacy of hydrotherapy in athletes undergoing hip arthroscopy for FAI. The purpose of this study was to evaluate the role and the impact of hydrotherapy on return to sports following hip arthroscopy for symptomatic FAI. Methods Two cohorts of mixed level of athletes from various sports: a hydrotherapy group that followed land-based exercises in combination with hydrotherapy exercises and a control group that followed solely the same land-based exercises. Hip-specific outcome scores, pain pre and postoperatively were completed and patient satisfaction was rated. Results A total of 88 hip arthroscopies were included with a minimum of two years follow-up; the hydrotherapy group engaged 36 hips and the control group 52 hips. There was a significant improvement in time to return to previous performance (HR = 1.91, 95% CI 1.21-3.01, p = 0.005) in the hydrotherapy group compared with the control. The hipspecific scores and patient satisfaction were considerably improved in the hydrotherapy group. Conclusions The analysis of our data indicates that the incorporation of hydrotherapy into postoperative rehabilitation for hip arthroscopy for FAI accelerates the return of athletes to their previous performance since the recovery time decreased significantly.

The Anterior Pubic ligament spans the Symphyseal joint and forms part of the Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC). A recent MRI study demonstrated that anterior Pubic ligament (APL) tears of the bridging part are often associated with PLAC injuries and Pectineus injuries. No cases have previously been reported of isolated APL tears in professional football. The aim of this study is to desccribe this new entity, detail the clinical symptoms and MRI findings. Material and Methods Our PLAC database was interrogated for APL tears. Adductor Longus avulsions, partial or complete, were excluded. Demographics, type of sport and level were recorded. The mechanism of injury, clinical presentation and MRI findings were evaluated. All athletes in our clinic presenting with acute groin pain are imaged using a specific MRI protocol. Results Four professional Football players fulfilled the inclusion criteria (average age 24 years (21-28)). Injury occurred when two players did the splits and two were taking a penalty. All players felt a pop and developed severe immediate pubic related groin pain. None of the players could continue playing. Clinically there was exquisite pain on palpation of the Symphyseal joint. One player had a feeling of unstable pubic bones. All had reduced adductor strength bilaterally (Table 1). The MRI showed a typical APL ligament tear where it bridges the Symphyseal joint (Figure 1). Three of the four players had previous MRI imaging which did not demonstrate the APL tear. Time between injury and diagnosis was 28-388 days. Conclusion Isolated APL tears are a newly reported cause of Pubic-related groin pain. Players who feel a pop and develop severe post traumatic Pubic pain should routinely have a dedicated MRI groin protocol. Axial oblique images through the Symphyseal area, thinly sliced, are essential to diagnose this condition which is easily missed with incorrect MRI protocols. Age injury mechanism Pain location ADD R ABD R ADD L ABD L ADD/ABD R ADD/ABD L 28 split Pubis/Perineal 13 36 11 30 0.36 0.36 25 split Pubis/Adductor 19 33 21 27 0.57 0.77 25 Penalty kick Pubis/Adductor 12 18 15 23 0.66 0.65 21 Penalty kick Pubis/Adductor 26 34 27 33 0.76 0.82 Table 1: Clinical presentation of anterior pubic ligament tear. Strength measurements of Adductors and Abductors in pounds (Microfet) and as a ratio (ADD = adduction; ABD = abduction). Figure 1: T2 axial oblique: yellow arrow demonstrates anterior pubic ligament tear.

Introduction and Purpose A recent MRI study defined the different types of PLAC injuries (Table 1) and noted that Adductor Longus Avulsions are seldom isolated, being most commonly associated with injuries to the Pyramidalis and Pectineus. Mechanisms of injury of the Adductor Longus and PLAC differ between different sports. The aim of the study was to examine the hypothesis that the prevalence of the type of PLAC injury is dependent on the type of sport. Materials and Methods Retrospective study. The PLAC injury database in our institution was interrogated using the following inclusion criteria: acute post traumatic PLAC injury; PLAC injury score (type 1-6); type of sport, n>3 per sport. The distribution of PLAC injury types across sports was examined alongside the incidence of associated partial Pectineus tears. Hypotheses were tested using Chi-square test, effect size using Cramer’s V. Results 257 athletes fulfilled the inclusion criteria. The experimental hypothesis, that the type of PLAC injury is dependent on the type of sport is accepted and is significant across all sports. (X2 (30, 257) = 63.7 (LR), p = 0.0003; small effect size (Cramer’s V = 0.232)). Football (n=188, 73%) with (n=128, 50%) professional, Rugby (n=43, 17%), Racket sports (n=11, 4%), professional Ice Hockey (n=5, 2%), Martial Arts (n=6, 2%), Water Skiing (n=4, 2%). The occurrence of a partial Pectineus Avulsion is also significant across all sports (X2 (3, 192) = 10.2, p = 0.017;small effect size (Cramer’s V = 0.230)). Associated Pectineus Avulsions were: Football (24%), Rugby (44%), Martial Arts and Water Skiing (100%). Conclusion The study confirms different PLAC injury patterns across different sports, including a considerable variation in the prevalence of associated Pectineus injuries. This is clinically relevant and important knowledge to facilitate accurate MRI assessment of these injuries, and appropriate planning of surgical treatment. Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Type 6 Partial FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Table 1: Types of PLAC injuries PLAC TYPE Total Football Professional Football Rugby Racket Sports Ice Hockey Martial Arts Water Skiing Type 1 67(25) 8(14) 40(31) 12(28) 7(64) 0 0 0 Type 2 45(18) 12(20) 19(15) 7(16) 0 0 4(66) 3(75) Type 3 63 (24) 15(25) 36(28) 8(19) 2(18) 2(40) 0 0 Type 4 21 (8) 2(3) 9(7) 7(16) 0 1(20) 1(17) 1(25) Type 5 9(4) 1(2) 2(2) 5(12) 0 0 1(17) 0 Type 6 52 (21) 22(36) 22(17) 4(9) 2(18) 2(40) 0 0 Total 257 60 128 43 11 5 6 4 Table 2: Frequency of PLAC type by sport (integers in brackets are percentages)

Introduction and Purpose An imaging classification for Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC) injuries has recently been described. The objective of this study was to assess intra-and inter-observer agreement on MRI PLAC injury classification and make comparisons with surgical findings. Methods: Retrospective study The PLAC injury database in our institution was interrogated using the following inclusion criteria: Acute post-traumatic PLAC injury, dedicated MRI protocol, complete Adductor Longus (AL) Avulsion, surgical PLAC repair 2017-2020. Two expert musculoskeletal radiologists, blinded for demographic and clinical data, scored the MRI scans twice in a 6-week interval. Both MRI and surgical findings were scored for type of PLAC injury (1-5), injury to Pectineus and Lacunar Ligament (LL). Cohen’s weighted and unweighted Kappa were used to calculate intra- and inter-rater agreement for scoring the MRI scan and to calculate agreement between each radiologist with the surgical findings. Results: 80 athletes fulfilled the inclusion criteria. Main sports were Football (n=36, 45%), Rugby (n=21, 26%), Other (n=23, 29%). Surgical findings: The Pyramidalis was present in (n=76, 95%). AL was separated from Pyramidalis (n=44, 55.0%), in continuity (n=35, 43.8%). The AL was displaced in (n=55, 68.8%) and in situ in (n=25, 31.2%). LL injury (n=41, 51.2%). Partial Pectineus Avulsion (n=39, 48.8%). Scoring PLAC injury type, the intraobserver weighted Kappa score was 1 for both radiologists, the interobserver weighted Kappa score 0.98. The weighted Kappa score for MRI/Surgical correlation for PLAC injury type was 0.96 for first scorer and 0.98 for the second. Conclusion This original study established excellent correlations between MRI and surgical findings in AL/PLAC injuries. There was an almost perfect intra- and inter-observer agreement on the PLAC injury type diagnosis. A dedicated MRI groin study protocol is a reliable method to accurately diagnose PLAC injury, assess the different anatomical structures and facilitate effective planning for surgical treatment. Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Type 6 Partial FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Table 1 Types of PLAC injuries Interobserver agreement Kappa unweighted Kappa weighted lower estimate upper lower estimate upper Type of PLAC 0.95 0.98 1.00 0.98 0.98 0.98 Pyramidalis 1 1 1 1 1 1 Pyramidalis oedema 0.74 0.85 0.96 0.73 0.73 0.73 Pyramidalis-AL separation 1 1 1 1 1 1 Partially/complete 0.9 0.96 1.0 0.9 0.9 0.9 Lacunar ligament injury 0.75 0.87 0.98 0.75 0.87 0.98 Partial pectineus avulsion 1 1 1 1 1 1 Table 2: interobserver agreement between radiologist for the first score

Introduction and purpose: To date, Proximal Adductor Longus Avulsions and Pyramidalis-Anterior Pubic Ligament-Adductor Longus Complex (PLAC) injuries are reported uniquely in male athletes. This study compared the Symphyseal anatomy of males and females to establish whether anatomical variations could account for the observed sex difference in occurrence of PLAC injuries, and aid MRI image interpretation. Methods: The anterior Symphyseal area was systematically dissected in six female and eight male fresh-frozen cadavers to examine PLAC and Rectus Abdominis (RA), and their anatomical relationship. The level of agreement for the observers was measured using the Bland and Altman method. Results: A PLAC was found in all specimens. The RA was found to have both an external and internal tendon (IT) in 100% of male and 66.6 % of female cadavers. The small bias of -0.17% + 3.58% in the mean of differences in the percentage width of the total RA insertion between the two scorers was not significant (paired t test, P>0.05). In males the IT of RA decussates with the contralateral tendon and runs deep to the Anterior Pubic ligament (APL), to insert caudally. In females the IT of the RA tendon, when present, by contrast inserts cranial to the deep portion of the APL, and does not interlace with the IT from the contralateral side (Figure 1 and 2). Conclusions: The PLAC is present in both sexes and therefore does not account for the difference in occurrence of proximal adductor avulsions. However, in males the IT runs deep to the APL forming a pulley system which can be disrupted with forced abduction of the leg. The absence of this pulley system in women and the parallel orientation of the internal tendons of the RA is protective against PLAC injuries, and allows widening of the pubic symphysis during pregnancy and childbirth.

Objectives: Proximal adductor longus avulsions and pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) injuries are reported uniquely in male athletes and appear underreported in female athletes. The aim of the study is to investigate potential variations in the symphyseal anatomy between males and females which could account for the difference in occurrence of PLAC injuries, and aid MRI image interpretation. Methods: Approval was obtained from our institution’s Local Research and Ethics Committee. A layered dissection of the soft tissues of the anterior symphyseal area was performed on six female and eight male fresh-frozen cadavers to systematically investigate anatomical structures of the anterior pubic area, namely the pyramidalis muscles and the rectus abdominis, and their anatomical relationship with the adductor longus. The ratio between the internal tendon (IT) and total width (TW) of the rectus abdominis was calculated independently by 2 observers. The level of agreement between the observers was measured using the Bland and Altman method. Results: A PLAC was found in all specimens. The rectus abdominis was found to have both an external and internal tendon in 100% of the male and 66.6 % of the female cadavers. The mean IT/TW ratio was 40.1% (25.8%-59.2%) in males and 38.0% (31.6%-48.9%) in females. The small bias of -0.17%, as shown by the mean of differences between the two scorers’ percentages was not significant (paired t test, P>0.05). In males the internal tendon of rectus abdominis decussates with the contralateral tendon and runs deep to the anterior pubic ligament, to insert caudally. In females the internal tendon of the rectus abdominis tendon, when present, by contrast inserts cranial to the deep portion of the anterior pubic ligament, caudally to the pelvic ridge. It does not interlace with the internal tendon from the contralateral side. Female anterior symphyseal anatomy (Pyramidalis removed) Male anterior symphyseal anatomy (Pyramidalis removed) Conclusions: The PLAC is present in both males and females and therefore does not account for the difference in occurrence of proximal adductor avulsions. When present, the relative width of the internal tendon of the rectus abdominis is similar for both genders. However, in males the internal tendon runs deep to the anterior pubic ligament forming a pulley system. With abduction and extension of the leg, the internal tendon can cause a disruption of the anterior pubic ligament and adductor longus fibrocartilage which can account for the higher incidence of adductor avulsions/ PLAC injuries in male athletes. The absence of this pulley system in women and the parallel orientation of the internal tendons of the rectus abdominis is protective against PLAC injuries, and also allows widening of the pubic symphysis during pregnancy and childbirth.

Purpose The purpose of the study is to review the MRI findings in a cohort of athletes who sustained acute traumatic avulsions of the adductor longus fibrocartilaginous entheses, and to investigate related injuries namely the pyramidalis- anterior pubic ligament - adductor longus complex (PLAC). Associated muscle and soft tissue injuries were also assessed. Methods The MRIs were reviewed for a partial or complete avulsion of the adductor longus fibrocartilage, as well as continuity or separation of the adductor longus from the pyramidalis. The presence of a concurrent partial pectineus tear was noted. Demographic data was analysed. Linear and logistic regression was used to examine associations between injuries. Results The mean age was 32.5 (SD 10.9). The pyramidalis was absent in 3 of 145 patients. 85 of 145 athletes were professional and 52 competed in the football Premier League. 132 had complete avulsions and 13 partial. The adductor longus was in continuity with pyramidalis in 55 athletes, partially separated in seven and completely in 81 athletes. 48 athletes with a PLAC injury had a partial pectineus avulsion. Six types of PLAC injuries patterns were identified. Associated rectus abdominis injuries were rare and only occurred in five patients (3.5%). Conclusion The proximal adductor longus forms part of the PLAC and is rarely an isolated injury. The term PLAC injury is more appropriate term. MRI imaging should assess all the anatomical components of the PLAC post-injury, allowing recognition of the differentpatterns of injury.

Currently there is no consensus on the most appropriate management of Adductor Longus Avulsions and selection of athletes for operative or non-operative treatment. An MRI study identified 6 types of injury to the Pyramidalis-Anterior Pubic Ligament- Adductor Longus Complex (PLAC) following Adductor Longus Avulsions, often associated with partial Pectineus Avulsions. Alternate hypothesis: the distribution of PLAC injuries associated with Adductor Avulsions is different in athletes with failed conservative treatment compared to athletes with successful conservative or surgical treatment. Methods The PLAC injury database was examined at our institution for the following inclusion criteria: High level or Professional Athletes, PLAC injury score type 1-6 (Table 1), with further division into: Group A: Failure of non-operative treatment (> 44 days after index injury), completion of structured rehabilitation program Group B: Successful non-operative or surgical treatment (<20 days of the index injury). Hypotheses were tested using Chi-square, effect size Cramer’s V and post hoc cell differences using Bonferroni adjustment (p< 0.004). Results: Group A (n=120), Group B (n=109) Most common PLAC types found in group A were type 3 and 6 (Table1), n=39 (33%) and n=40 (33%) respectively. Most common types found in group B were type 1 and 3, n=37 (34%) and n=21 (19%) respectively. Overall, PLAC type distribution and groups were dependent (X2 (5, 229) = 26, p = 0.00009; moderate effect size (Cramer’s V = 0.304)). The variation between frequency of type 1 and 6 injuries between the groups reflected the significant cell differences between observed and expected values (p=0.0002 and p=0.0001 respectively). Conclusion Variability exists in PLAC injury patterns between athletes who had successful conservative or surgical management compared to athletes who had failed conservative treatment. This original study can help to select the appropriate treatment for PLAC injuries associated with Adductor Avulsions. Type 1 Complete fibrocartilage (FC) avulsion–Pyramidalis separated from Adductor Longus–intact Pectineus Type 2 Complete FC avulsion–Pyramidalis separated from Adductor Longus–partial Pectineus tear Type 3 Complete FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Type 4 Complete FC avulsion–Pyramidalis connected to Adductor Longus–partial Pectineus tear Type 5 Complete FC avulsion–Pyramidalis partially separated from Adductor Longus–partial Pectineus tear Type 6 Partial FC avulsion–Pyramidalis connected to Adductor Longus–intact Pectineus Table 1: Types of PLAC injuries Type 1 2 3 4 5 6 Group A 120 16 (13%) 16 (13%) 39 (33%) 6 (5%) 3 (3%) 40 (33%) Group B 82+27 30 +7 (34%) 18 +1 (18%) 15+6 (19%) 8+1 (8%) 5+2 (6%) 6+10 (15%) Table 2: Distribution of PLAC injury types between Group A (failed non-operative treatment) and Group B (successful surgical or non-operative treatment)

Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade > 2, lateral sourcil height < 2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection.

Labral tears have been described as a cause of hip pain in young, active patients [1]. It has been shown that those lesions can initiate joint osteoarthritis [2]. Some authors suggest that labral tear is a highly prevalent lesion with up to 90 % of labral detachment in elderly people [3]. On the other side, studies like the one of Wenger et al. [4] conclude that is a rare lesion in the absence of any structural or mechanic evident cause. That means that labral tear treatment is a complex one, because even if we decide a labral debridement, repair, or substitution, biomechanics must be restored, and that means that bony structural abnormalities must be addressed. Acetabular labrum is a complex structure, with an inner part of circumferential fibrocartilage fibers, surrounded by dense connective tissue where we can find nerves and vascular vessels. The shape of that labrum can be different in the different acetabular areas, and some shapes can predispose to labral tears, while different attachment patterns may difficult tear recognition [5]. Thorough knowledge of labral vascularity is important to understand healing patterns of labral detachment and repair [6].

PURPOSE: Adductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions. METHODS: A layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined. RESULTS: The pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis. CONCLUSION: The study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

Background: Adductor avulsions are complex injuries often involving multiple structures, as indicated by several magnetic resonance imaging (MRI) studies. However, no studies have compared MRI assessments using a dedicated groin protocol with surgical findings. Hypothesis: It was hypothesized that MRI assessments using a dedicated groin protocol would correlate closely with surgical findings, applicable to both experienced and novice users of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC) classification. Study Design: Case series; Level of evidence, 4. Methods: This retrospective study analyzed 161 athletes who underwent MRI using a dedicated groin protocol, followed by surgical repair of the PLAC. Two musculoskeletal radiologists—1 experienced (rater A) and 1 inexperienced (rater B) in the use of the PLAC classification—independently assessed the MRI scans twice, 6 weeks apart, using a structured 3-step protocol to evaluate (1) adductor longus fibrocartilage (intact, partially avulsed, or completely avulsed), (2) pyramidalis separation from adductor longus (intact, partially separated, or completely separated), and (3) pectineus status (intact or partially avulsed). Agreement between MRI and surgical findings was evaluated using a PLAC injury classification (types 1-5), with intra- and interobserver reliability measured by Cohen kappa. Results: Among the 161 athletes, 93 played soccer, of whom 69 were professional. All athletes exhibited complete fibrocartilage avulsion, with 83 athletes (52%) showing adductor longus separation from the pyramidalis. Isolated adductor longus avulsions (PLAC type 1) were observed in only 36 athletes (22%). The interobserver kappa score between MRI assessments and surgical findings was 0.942 for rater A and 0.858 for rater B. Intraobserver ratings were 0.967 for rater A and 0.875 for rater B. Both inter- and intraobserver scores indicated almost perfect agreement. In combination, these statistical findings support the validity, reliability, and applicability of the MRI protocol using the PLAC classification system for 2 users with varying levels of experience. Conclusion: Adductor avulsions were rarely isolated, typically involving multiple muscles. The PLAC classification effectively captured the complexity of these injuries. When used in conjunction with a dedicated MRI protocol, the PLAC classification demonstrated almost perfect agreement and concordance with surgical findings. Together, the PLAC classification and MRI protocol offered a more comprehensive and accurate representation of patients’ clinical and radiological features and provided valuable guidance for surgical planning.