And we kind of talked about our learning objectives broadly already, you know, we want to go through what the causes are, which has already been highlighted in our first talk, which is fantastic. And we're going to talk about my approach here. And, you know, this is, you know, my level five evidence, but hopefully you'll find it helpful. And then talking about the importance of terminology and communication. And so there's a lot of different terms that get thrown around. And it's fine as long as everybody's on the same page. And sometimes what we'll do is we'll run into trouble where you're involving other members of your treatment team, which is, you know, a necessity for this condition, right? This isn't a one person show. You're going to be involving therapists and interventionalists and surgeons and everybody else. Everybody needs to know what the words coming out of your mouth mean, right? And unfortunately, that's not always the case. And so, you know, whenever we hear athletic growing pain, athletic pubalgia, whatever, I kind of feel like this kiddo here, you know, taking a shot right in the area because all these different terms get thrown around. And again, it's often they get thrown around, at least in my opinion, you know, two entirely different diagnoses get kind of lumped together just because they live in the same region. And we never talk about, you know, shoulder dislocations and rotator cuff tears, you know, together, right? They're like two entirely different things. I don't understand why we talk about adductor tears and, you know, sports hernias, like they're the same thing, but that's what gets thrown around in the literature. And so hopefully we can clear some of that up today. So you guys have already seen this and that's great. And we're going to talk a little bit more about it. I love this diagram. I just think it's really well drawn and it's, you know, a useful way to, you know, just start to think about what is in this area. And so we're, and colleagues published this back in 2015. And again, it's already been mentioned, but in terms of dividing this up into a few different clinical entities, so they like to think of it as adductor versus iliopsoas versus inguinal related versus pubic related, and then separating out the hip joint, which is obviously its own beast, but certainly has some overlap and referral pain patterns here. And then a big, huge other category, which we'll go through, which is, you know, an exhaustive list of different things that can cause pain in this region. One thing I don't like about that diagram is where's core muscle injury. You know, this is another buzz term. And I think we even have a talk later today, you know, specifically talking about core muscle injury. And most of our surgical colleagues, I mean, at least I think at this point, this is kind of what they're referring to a lot of these pain syndromes as core muscle injuries. And so I don't think that the DOHA statement really, you know, fully comprehends the concept of core muscle injury. And here's kind of what I think of as a simplified version of what that means. And so we obviously know that across the core here, this is, you know, a large stabilizing portion from the trunk to the lower limbs. And this is why we see so much pathology here in athletes. And it's not just, you know, isolation in the adductors or then, you know, the core in terms of the abdominal muscle, which are coming down, but these things are intimately interrelated. And there's a balance here. And in fact, there's actually anatomic connections. And so the aponeurotic plate between the rectus and the adductor has already been mentioned. This is hugely important, at least for the way I approach this problem. And so we're going to talk a bit more about that in a moment, but just recognizing that, you know, that this complex anatomy here is really critical and vital for how you might choose to manage these athletes. There's also going to be contributions from the conjoined tendon, from your obliques. And there's even some overlap here with actual muscle injury of those abdominal muscles as well. So and then we can see the, you know, inguinal floor sits very close here. And so there's certainly going to be some overlap with these inguinal disorders as well with the core muscle injury. So just to highlight again the complex anatomy that you're going to see here, you know, here's the pubic symphysis. We're going to have our rectus abdominis coming from the top, our adductor coming from the bottom. What's actually interesting is these things will blend across and you'll even get some crossover here. So you'll get some contribution to the opposite side as well as the, you know, both contralateral and ipsilateral sides as things blend across. And so this is one of the reasons why, you know, sometimes you'll get these changes across the pubic symphysis that may not be necessarily related to the pubic symphysis itself, but rather all these muscular and aponeurotic attachments to the bone there. So you can see in the skeletal model here, we've got rectus, we've got the pectineus, which usually, you know, isn't something overly in place. It's a little bit more medial, but this will be an area I have seen pathology there before, kind of strange, but it does happen. Inguinal ligament here. And then as we move down, we're going to see our adductor longus, which is our main main issue here, at least in my clinic, our adductor brevis, muscular attachment, and then even the gracilis, which comes a bit farther down here and certainly gets challenging, but is not something that can't get injured. And so I have seen issues down here as well. So again, complicated anatomy, all this stuff crosses over through this area. And this is kind of what folks are referring to, you know, as really the core muscles. So what about sports hernia? You know, that's probably the most common thing that gets thrown around, at least in the, you know, in the media. And it's come under fire of late, where a lot of people saying, you know, don't use that term, and there's a lot of confusion with it. I honestly don't mind the term, if you know what that term means. And to me, there is an actual definition for sports hernia, and it's going to be weakness or insufficiency of the transversalis fascia. And so there's not a true hernia. And so that's why some folks don't like, you know, to use the sports hernia lingo, because there's not an actual hernia. But, you know, this refers to this, you know, weakening and this bulge of the transversalis fascia. And then often, and what we'll use at least on ultrasound is going to be movement or lateralization of the spermatic core is our kind of our cue that this has become functionally insufficient. For me, I think this is an important thing to recognize, because the location of pain seems to be different than what we're going to see with adductor related. And so it's going to move lateral and superior away from the adductor insertion point. And so I kind of highlighted here, at least for me, I'll sometimes even see this extending up, you know, a bit higher here. And so I always will have the athlete kind of point to where their location of maximal pain is. You know, and if they're pointing off of the, you know, midline, and they're kind of lateralizing up here, then I'm certainly thinking more of this, these sports hernia problems. And so, again, just, you know, I'm fine using this term, as long as you know what it means. I think a lot of folks will use, you know, inguinal disruption, or, you know, what I'm a big fan of is actually just calling the pathology as you see it. So I'll call it transversalis insufficiency, which I think people understand what that is. So here's the list, again, from Weir's paper, the other causes of growing pain. And it's, you know, it makes your head spin, right? You have all these different things going on. But I think, you know, what this mostly highlights here is the importance of being able to make an anatomic diagnosis. So, you know, you've got the usual suspects living over here, and I'll go through how I divide these up actually a little bit further. But I like to be able to have, you know, my clinical history, my physical exam, and my imaging all correlate so that I feel like I have a true anatomic diagnosis. If I don't, then that's whenever you have to start going through the laundry list of all these other things that are going on. And certainly, there may be components of the history that are going to point you over here, you know, things such as stress fractures, you know, or, you know, tumors, those sort of things. But sometimes, you know, the presentation can be pretty similar for these. And so, you know, if I'm having relatively normal imaging of my usual suspects, you know, I'm going to start moving down the list here and making sure I'm not missing something else. So here's how I approach this area, and how I like to divide things up. And I've roughly put this in order of how these will present in my clinic, at least in terms of the prevalence in the athletic population that I see, and that's, by and large, you know, collegiate athletes. So first thing is going to be your isolated adductor tendon or muscle problems. And so these, you know, can certainly have some overlap in pain, but by and large, they're going to point, you know, right to the adductor origin, you know, fairly midline, slightly lateralizing, and then with pain radiating down into the adductor. And we'll go through, you know, the various things you can see with this, but this may be from, you know, acute tears to chronic tendinopathy, but it kind of stays in the adductor region. The next, and what I often see here is really a progression of injury. This is, you know, what I think happens is that it moves from the adductor into the core muscles, from the adductor into the rectus abdominis. And now we start to get, you know, what's really a core muscle injury. It's no longer an isolated adductor problem. And this, to me, you know, these two things I'm going to approach differently. And I think, like I said, this is a progression into this. And I'm going to start thinking, you know, if it's an elite athlete, if time really matters, we're going to start thinking potential surgical interventions earlier than later where that's, you know, almost unheard of for an isolated adductor. Next is going to be the sports hernia or the inguinal related disorders. And again, these are going to be somewhat lateralizing and a little bit above the area that we're talking about down here. And then we have iliopsoas muscle tendon disorders. Usually these present a bit differently. You know, I'm not often having a diagnostic dilemma with, you know, with iliopsoas stuff from the usual growing issues, but you can. And this is another just common problem too. And so it's certainly, you know, certainly on the list. And if you have an athlete with relatively diffuse pain or acute symptoms, it may be hard to tease out exactly what it is. So this is certainly something that should be looked at in the area. Isolated pubic symphysis disorders happen. I don't think they're quite as common as people maybe thought previously. Now that we understand everything else in that area a bit better, I think a lot of times this is a secondary problem. So either we're seeing imaging findings there that are really more related to the adductor and the core muscles across that area, or potentially it's, you know, related to FAI or some of the other things that have already been alluded to. We know that some of these hip conditions are not isolated to the hip and they certainly can change the entire dynamic across the pelvis. And so it's fairly rare to see isolated pubic synthesis disorders. Certainly we'll see them more in females than males. But you can, you know, you can see stuff here, particularly if you take care of, you know, of high trauma athletes. And so we'll get some, you know, rodeo folks that come in, you know, that have unstable pubic synthesis from big trauma, as you can see this, you know, from other high injury sports as well. And so just remembering that as a thing and potentially, you know, assessing for stability there, you know, with ultrasound, with single leg standing x-rays and keeping it on your list. The hip joint, hip joint's its own thing, but certainly people can have varying referral patterns from the hip joint. And so, you know, people can get pain in this whole general area. So you always have to consider that on your list. And then, like I said, what the contribution might be there to secondary sources of pain, you know, elsewhere. Proximal rectus femoris I put on here. Again, usually this is lateralizing. Usually it's not in the same thing, but super common. We see a lot of these, you know, both with rectus and iliopsoas, these hip flexor injuries, right? And so it's always something just to keep, you know, keep on your radar that might be, you know, contributing or clouding the situation here. And then there's the other, the big, the big rest of the thing that, you know, I hope I don't get to, and I'm going to kind of check off all the very common things that we run into in sports clinic. And if I'm not satisfied here, then we gotta, you know, we gotta go pull out the chart and start going down that next pathway. The other thing just to remember that gets really confusing here is that, you know, a lot of times these things aren't happening in isolation. So the easiest growing pain patient I'm going to see is the athlete who comes in with an acute adductor avulsion. They hadn't have any pain. They stepped up and they got tackled plenty. Now they've got horrible growing pain and they pop their adductor off. Like that's the easiest thing in the world. Once these things kind of become chronic and they start to settle in, it gets really difficult sometimes to tease everything out. You know, what really started this problem? What has been, you know, developed, you know, due to secondary issues and compensation and everything else, you know, it gets tricky. And sometimes it's just, you know, peeling away the layers of onion until you can really get down, you know, to what the core of the problem was. And so try not to get too confused with that. You know, the goal is really try to get back to the original presentation of their history, try to find out what, you know, what was going on. And sometimes you just start treating things. It's kind of seeing what you can get better and what kind of hangs around and have to be very patient with your approach in certain cases. So here's how I'm going to approach an athlete if they come into my clinic. And so first and foremost, I'm going to get radiographs. And so we talk a lot about MRIs and ultrasounds and fantastic imaging modalities, and I use them both. But don't forget good old x-rays, because for me, the x-ray is going to frame everything that I'm going to do in that encounter. So it's going to give me a lot of really quick information, gives me the lay of the land, lets me know, you know, what the bony anatomy looks like. And depending on what I see on that radiograph, you know, it might change a little bit in terms of how I approach the history and certainly the physical exam. So I like to get those coming in the door. Then we're going to do a careful history, very careful physical exam. You know, as a, you know, for my job, I'm not really a primary care provider or anything. Most of these folks are coming to me either because people are very concerned and invested in them. They have a very quick timeline to their nature in athletics, or this is a referral, you know, a subspecialty referral. And so I'm getting advanced imaging on every one of these people. It's just the nature of how they're going to present to my clinic. And then certainly diagnostic injections that I mentioned before, and these can be helpful, particularly when you're trying to tease out some of the various components of where the pain's coming from. So we will use these pretty liberally in our clinic, particularly if there's any, you know, surgical planning going on, just so that we have a better sense of what the true pain generator is. And that can be important too, because we know that especially in athletes, there's lots of asymptomatic imaging findings. And so I am a big advocate for imaging, you know, and part of that's my bias as is, you know, my day job is an ultrasound imager, you know, and I think it's very helpful. But you also have to put that in context and realize that you might be seeing things on imaging that have nothing to do with anything. And if you can't sort that out on your history and exam, that's where diagnostic injections can sometimes be very, very helpful. So when I get radiographs, what I'm going to look for are a couple of major things. And so this is going to be kind of your screening. Again, I'm going to look at this before I even go see the patient. Do they have FAI? If they do, I need to make sure that that's not contributing in some manner. Again, common finding may or may not be the deal, but I want to know if they have it. Do they have obvious synthesis changes? Again, that might help me as well. And then something else not to forget is apothecial injuries. And this isn't just something in, like, little kiddos. You know, some of these apotheses do not close until the early mid-20s. And so, you know, even if you're seeing a, you know, collegiate athlete population like I am, you may run into some issues with the apotheosis. And so, you know, x-rays can be helpful just kind of seeing if you, you know, if you pick any of this stuff up going in that might slant your exam a little bit. So the history, I want to know what the mechanism of injury was and what's the chronicity. And so this sometimes gets lost, even though it's like, you know, medicine 101. But this is super important. And so, you know, did our athlete, you know, have a, you know, a tug or a pull in the growing when she was going to kick the ball or going to change direction on the field? You know, has this been lingering and going on for several months? Is this the first time they ever felt the pain? Do they have pain for, you know, 12 hours because they took a shot to the going with the ball, right? Like, that's an entirely different scenario. But I've seen sometimes that stuff get a little bit lost. And then you're kind of going down the wrong pathway. And then the other thing is going to be particularly with the more chronic symptoms is what are the aggravating factors? And so what are the things that reliably aggravate this? And so there's certainly gonna be your sports-specific maneuvers that you wanna determine, but other things, you know, thinking about, you know, scoffing, sneezing, Valsalva, this is gonna help point you maybe in a different direction. So on physical exam, you know, a lot of this is gonna be palpation, and you wanna really know where the tenderness is and what reproduces their usual symptoms. So this is a tender spot. So if everybody, you know, starts poking around on their own growing right now, you're gonna find that most of these areas don't feel so great to have a finger jammed in, right? And so you really are looking for not, you know, does this hurt, but does this reproduce your typical pain that you're describing? And sometimes it can be helpful to poke around on the other side, just to give them a reference point of like, yep, this is kind of an uncomfortable spot. You know, does the other side feel different than this? And as was already mentioned, I mean, this is obviously a, you know, a sensitive area. And so just try to set yourself up for success with this, you know, having, I mean, I think this is pretty standard practice nowadays, but, you know, having chaperones in, you know, making sure that you balance out males and females appropriately based on everybody's comfort level, and just being very open and honest with the patient on what you're gonna do, telling them where you're gonna be at, you know, telling them it's an uncomfortable area. If you're uncomfortable, you know, let me know. I say all that stuff right away, just to kind of set the tone and just try to make the applicant as comfortable as possible. Because there's often a lot of anxiety and apprehension, you know, coming into these appointments, just because it's such a sensitive area that they're having to deal with. So besides your palpatory exam, you're gonna obviously try to stress the area. So you wanna do resistive adduction, trunk flexion, hip flexion, you're gonna have them balsalva. And so there's various things that you're trying to stress all these different regions to evaluate what is gonna reproduce their usual symptoms. You wanna look for true hernia, certainly folks will just get a hernia, and that's why they come in. And you certainly don't wanna lose that diagnosis in the mix of all this other stuff, you know, so make sure you consider that. The hip joint exam is kind of a nonspecific exam, but it certainly helps exclude hip related disorders. And so I think it's helpful to do a hip joint exam on everybody just to see what happens. You know, and sometimes everything's so fired up in the adductors that all the hip provocative stuff kind of hurt, but it hurts over here. But if they have a negative hip joint exam, that's certainly helpful in starting to cross that off the list. As mentioned before, the x-rays as well as the history are really gonna help me focus, you know, this exam. If we see FAI, I'm gonna spend a bit more time on the hip joint exam than if we don't, you know, same thing for pubic symphysial issues. And then, you know, again, I'm somewhat biased here, but ultrasound, I think really helps even if you're not necessarily comfortable with all the advanced level diagnostic stuff here, simply knowing that you're pushing on what you think you're pushing on is really helpful. So there's, this stuff's all super close. And, you know, I'm not necessarily a hundred percent confident that I'm always pushing on the right thing if I'm just doing a regular physical exam. And so I think, you know, a good place for beginners, if you have access to ultrasound, is just making sure that you can identify where these structures are so that you can, you know, precisely correlate your palpation. And then always consider the other stuff, you know, you might need to do a testicular exam. You might need to do something else. You know, you might need to refer that off, you know, depending on what your practice looks like, but certainly just keeping that in the back of your mind. All right, so advanced imaging, you know, you've gotten my bias already. I think you're gonna get a lot of controversy here, but I think advanced imaging is critical in really making an anatomic-based diagnosis. And so I don't like to guess. I like to know what's going on. And, you know, and if imaging's normal versus abnormal, that's really helpful for me in terms of how I'm gonna approach something and what else I might do. So I think it's critical here and I'm a liberal imager, particularly in elite sport. In anybody who deals in elite sport, you know, if you're talking syndromes and gray area, let's give it some time and let's do six months of rehab without a diagnosis, that athlete's going somewhere else and you're not gonna make any headway. All right, so some of this has been touched on in the previous talk, but when we're looking at ultrasound versus MRI, there's different reasons you might pick one of these up over the other. The first thing that I'd like to say, and this is a bit of my soapbox, but everybody always talks about how operator-dependent ultrasound is. And certainly that's true, no doubt, but MRI is every bit as operator-dependent as ultrasound is. And do not forget that particularly in this area. If you order a generic pelvis MRI at, you know, Joe's MRI shack down the street, it's gonna be 100% worthless for this problem. So you really need to work with your radiologist. You need to develop a sports hernia, athletic growing pain, whatever you wanna call it, protocol that actually has the right specs to be able to evaluate any of this stuff. I'll tell you, even with that, you know, MRI is somewhat limited in what it's gonna be able to see for your tendon resolution. You're gonna get a couple of slices through and, you know, people talk about the cleft size and stuff, which certainly can be helpful, but I've seen plenty of adduct related pathology get missed on the MRI simply because it just didn't get the right cuts. And so the advantage with ultrasound is you have an infinite number of imaging planes that you can go through, and you're just gonna get much better resolution for these core muscles than you are on MRI. MRI is gonna give you good bony detail. It's gonna give you much better sense of bone edema, pubic symphysis issues. Certainly it's going to be the imaging modality of choice if you're talking about hip related disorders and gives you a nice big picture, but ultrasound is gonna give you the dynamic assessments. You're really not gonna be able to evaluate a sports hernia with MRI. And again, you're gonna be able to correlate this with the palpatory pain and with your physical exam and not even just palpation. So I'll correlate this with the dynamic stress maneuvers as well while we watch these tissues work. And, you know, and I think ultrasound is certainly the superior imaging modality here, but, you know, with that, it takes a lot of work to get comfortable looking at these areas. And, you know, and it does probably take a relatively high quality ultrasound unit, particularly in some larger patients. Sorry, that one blew through. So diagnostic injections are best for excluding hip joint related pain. And it's the nice thing there is the hip joint is a very confined space, right? So you can put some local anesthetic in the hip joint, you know where you're at, you numb that area up, and that's, you know, is very helpful in ruling in or out hip joint related pathology. Once we start meandering over to the other areas, it gets a little bit confusing because even being very precise where you place, you know, anesthetic injection, you know, you're gonna get some overflow into the surrounding structures a bit. And so it gets a little bit more challenging, but certainly it's very helpful for the joint related issues. Do be aware of volume effects. And so this isn't as big a deal in the hip joint, but, you know, don't put, you know, 15 mLs in the hip joint, right? Because then you're just gonna blow this whole thing up. And even though it's numb inside, you're still gonna have this pressure related pain that's gonna cloud your picture. So be reasonable with volumes. And then particularly if you're trying, if you're considering a diagnostic injection for the pubic symphysis, I hate doing these injections. I try to push all these theology of Naju under fluoro just because they're just uncomfortable injections. I just don't like doing them cause they hurt. And there's not a lot of space in there to take any medication. And so if you try to pump in, you know, two, three mLs into the pubic symphysis, that patient is not going to like you. And it's gonna be really difficult to assess, you know, what their response was to a local anesthetic portion of that. So just be aware, you know, we will use these injections at time and steroid may have some benefit here in terms of the more prolonged effect or at least intermediate. But just remember that some of these spots can be painful. And even with the local anesthetic, folks just don't like the volume in these areas. And that goes for the abdominal region as well. All right, so we're gonna walk through a few different cases just to demonstrate what some of this pathology looks like. And then what, you know, what the approach might be for that athlete. So we'll start with isolated adductor, tendon and muscle injuries. And so, as I said before, this is my favorite case to get because these folks just tend to do well, even though it's the most dramatic presentation. And so here's a NCAA football linebacker, you know, you see him go down on the field, it looks bad, he, you know, limps off, you know, he gets bruising and stuff on his leg. Everything's, you know, seems very dramatic and we scan him and indeed, what we see here, if I orient you, this is proximal, this is distal. So this is gonna be the adductor longus tendon. It's insertion is gonna come down to here. This is the adductor brevis muscle, which has this muscular attachment here. And what we see on our kind of screening exam, and again, this is a big old, you know, D1 linebacker here. So we've got the curve on first just to give us a big picture. And we see, we're not really happy with our image here, right, we don't see really nice tendon fiber definition. This certainly correlates with this area, you know, of pain. And so we switched to a linear transducer to give us a better resolution. And then we can see indeed, he does have a relatively significant tear of the adductor longus acutely here. So this guy, you know, isn't gonna play next week, but almost invariably, you know, these tend to heal up and do fine. And I can't, you know, recall an athlete that we've needed to do anything more than a conservative care post one of these tears. Sorry, my computer is twitchy here today. So here's gonna be another example of an acute proximal adductor longus tear. So this was in one of our Olympic wrestlers. We'll see this a fair amount in wrestlers, both male and female. And here is gonna be this telltale sign of a significant full thickness tear whenever you see this kind of rounded off edge of the tendons. The tendons retracted, it started to ball up here. And then we just see this kind of empty sheet. Now don't get fooled sometimes, you'll kind of still see some tissue planes and such, and that's gonna be fascial planes, you have some hematoma, you have a little bit of residual stuff hanging on. We can see this rounded edge stump here. We know this thing's gonna be completely torn. If we then look at the cine loop, as we continue to scan down into the thigh, again, it's still on the long axis. You can sort of see that this is not a diagnostic dilemma. You know, he's retracted portions of this way down. We got a big free fluid hematoma here in the adductor longus. And we can see in the tissue plane of the brevis underneath, which is intact. So again, surprisingly, these folks always do better than I think they're gonna do. This guy, I actually think was able to wrestle the Olympic trials, you know, albeit not 100%, but was still able to give it a go. I think, man, it was like three weeks after this injury. So it's surprising what some of these athletes were able to do here. And I think this will get to our point in a minute, where some of these folks, if you do adductor tenotomy, you know, actually can be an effective surgical procedure. Here is another example, slightly different case, and just to highlight the importance of completing your protocol as you scan. And so this was one of our running backs. Again, had an acute injury to the adductor region. And his tendon actually looked okay. So when we started up at our usual spot, you know, over the pubis, we saw a tendon looked good. Everything looked fine. When we came down a bit, which is where he was complaining of his maximal pain. And we can see he actually had an acute myotendous junction tear. And so tendon was okay, but he had bulsed off the muscle of that region. So again, you know, dramatic presentation, but you know, not much to do here. These athletes typically tend to do well. One thing I will mention, I should have included a slide for it, but just in terms of orienting and how I'm going to do my imaging here, you know, the biggest pearl I can give you is to get away from doing this frog leg sort of thing that everybody tends to like to do when they're evaluating the adductors. It makes the imaging really difficult. You can't keep, you know, gel on there. You can't keep good contact with your transducer. It's uncomfortable. The patient does not like to be in that position because it's tensing them. There's no way you could get this person even in that position anyways. And usually what you're looking at is much higher than you think. And so you're looking at the midline, you know, really in the pelvic region. And so I have the patient just lying supine with their hip and just a comfortable amount of external rotation. And that allows me good visualization. And I start at the rectus abdominis and then scan down from the rectus to then find the adductor longest insertion. And you'll be surprised how midline this is and that you really don't need to put them in some funny, you know, WWE move to try and evaluate this area. And that's going to be my procedural positioning as well, which makes life considerably easier. I struggled trying to do this frog leg thing, you know, for the first several years of my career and it was horrible. And this has really made a big difference in my ability to get good imaging and do comfortable procedures. All right, so now we'll move on to more of the chronic case. And so this is going to be your usual adductor longest tendinosis. And so, you know, at least in my practice, I'd say 50% of what walks into my clinic with growing pain is this. This we see in, you know, in our collegiate elite athletes, we'll see this really commonly in our slightly older, 30, 40 year old, you know, distance runners and other athletes. This is a very common problem that we'll see. And what we're looking for is, again, as I just mentioned, I like to start and see the rectus abdominis. This is proximal, the patient's head up here. We're going to follow the rectus down. We're going to see where it blends with the adductor here. This is the aponeurotic point region. And then we're going to move and optimize our image to get a good view of the origin of the adductor longus. And so here we can see, here's the bottom fascial plane between the adductor longus and brevis. Here's going to be the superficial aspect. And so we can see this kind of fusiform swelling in the tendon. For your money, usually it's going to be at the deep side. So we can see this cortical regularity here. We see a region of hypoecogenicity, and echogenicity here. So this is a tiny little micro tear, the tendon. But what we don't see is these changes extending up superiorly to involve the rectus. And so that's really the most important thing that I look for in determining, is this an isolated adductor injury? Or are we really starting to go into the rectus? And is this starting to move up the chain to really this core muscle injury pattern? And then that's going to change my treatment options here. So isolated adductor, everything looks good at the rectus. How are we going to manage this? And so this is really a therapy sort of problem. And so you want to do a progressive tendon loading program. And that's really how you should always think about this, is progressive loading. And so a lot of folks, where they go wrong is they don't load the tendon in a progressive manner. They'll start with some very low level exercises and they never progress. And so I usually tell my athletes to Google Copenhagen protocol and look at some of these crazy exercises. And that's the stuff we want them to be able to do if they want to get back on the playing field. And if anybody's tried this, if you haven't, please don't try a level three here because you'll look like one of those adductor tears I showed you before. But these are pretty challenging exercises. And certainly what's going to be required if you want to get back to elite level sport. And so that's usually where I see people go wrong, is not progressing through the protocol enough and staying with things. We certainly will consider PRP as an adjuvant here. I've had anecdotally pretty good success with using a pretty rich plasma at this area, but we always couple it with an appropriate rehabilitation protocol, which is really the core. And we don't have good evidence on who needs PRP, who's going to do well with just rehab if you give them enough time. But I will say PRP has been a safe treatment, at least in my hands without any significant complications. And we've had a response. If this stuff is not working, certainly not, it can be a change in non-response. It's approaches that, which we won't go into in exhaustive detail. So, if you're thinking rehab here, my pearl is just remember Sir Mix-a-Lot. There's nothing wrong with Jane's workout here, but we really need to progress beyond and develop the motor, right? When we're trying to get these athletes back. So here's just a couple of our procedural videos. Just to demonstrate, so in some of these recalcitrant cases, you can consider ultrasound guided needle tenotomy. with platelet-rich plasma. So that's what we're doing in this video here. This is distal on your left, proximal on your right. Here's our area pathology. We can see the needle is kind of coming in and penetrating this area to break up some of this degenerative tissue. Now PRP injection will be performed. The biggest thing to remember here is gonna be to don't fenestrate the spermatic cord. It's kind of like that. And it sits right in your way. So, you know, I'd love to come in right through here every time and it's. always right there and it drives you crazy and so I struggled with this for a long time coming in from this distal to proximal approach and so usually to do this you have to put a little bend in your needle you got a finagle around this thing it's ergonomically you know pretty challenging and so more recently I got away from that approach I typically now use a proximal to distal approach so I'm still in the long axis so here's going to be the pubic tubercle here's going to be the adductor longest tendon coming down here and I typically will come from above and and then down right into the adductor this way and this has worked out ergonomically a bit better for me you know this is an uncomfortable area for the patient you know we try to use good vocal anesthesia with a very small gauge needle before coming in here but but this this unfortunately is an area that that still is you know just a bit uncomfortable to have procedures done in all right so we'll move to the core muscle injury and so as I showed you before you know here's our normal here's our rectus here's our adductor this is what we want it to look like and and this is that progression that I'm looking for so this was a one of our quarterbacks who had you know adductor related pathology but what we can see here is there's you know partial tear of the adductor longest but it's starting to move north it's starting to move proximal and involve that aponeurotic plate with the rectus abdominis and these are when I start to worry a bit because these at least in my experience do not tend to do as well with rehab they don't tend to do as well with injections and in the you know the elite sport world this is somebody who I think is reasonable to start considering earlier surgical consultation for just given the you know the reported success rates with with surgery and our lack of ability to get a lot of these folks back if you've got time on your side certainly there's no reason you can't rehab these you know potentially consider other adjunct treatments like PRP but but I certainly would temper my expectations compared to just the isolated adductor pathology so as mentioned surgery here is certainly a reasonable option this area gets confusing and I'm glad we'll be a talk later about about some of this because it's you know if you read the literature it's all over the place in terms of varying techniques and some of the trouble is what people are treating as well right and so so I think it's just important to have a good working relationship with whoever you know may be doing surgery here and making sure everyone's on the same page with what you were what you're talking about and so are you talking about the case I just showed where there's you know really an injury up into the rectus abdominis and the adductor but the the you know transversalis fascia looks fine there's you know inguinal disorders or sports hernia you know or are you talking about you know a case where where it's a sports hernia and the core muscles are fine that that's an important distinction that really needs to be made and sometimes even even reading through the literature it is not clear that everybody's on the same page and what they're talking about despite that surgery outcomes are really good and so so people just tend to do well you know almost regardless of what you do down here I've even you know had some cases where I felt like the athlete got the wrong surgery and they still did well and so you know it's it's one of these things that because the outcomes seem to be well and the return to play seems to be quick um you know this is an area that I think we are are much more apt to move towards surgical management than any of the other regions where or surgery ends up being a much longer recovery process. Also don't forget that things can happen up in the abdominal muscles themselves that can still refer pain to this area so here was an elite gymnast I saw who had you know pain kind of in this general region and and we thought her aponeurosis looked reasonable but we came up just a little bit proximally into the meat of the rectus abdominis and we can see she actually had an acute tear of the rectus abdominis so you're just showing this with you know pretty pronounced hyperemia throughout that zone so she just had a little lab tear and so this was a you know again a much better scenario for her this just required a little training modification we'll rest for a couple weeks and she was good to go as opposed to you know getting into any of the chronic stuff a bit further down towards the attachment. All right sports hernia so so admittedly I hate sports hernia evaluations I don't like doing this and and I borrowed some videos here from my good friend Tony Joseph who is you know an expert at this area and had much better demonstrative videos than I do but you know the key here is really going to be you know finding the right location on that athlete who has pain you know a bit superior and lateral to where we were just at over that rectus and adductor aponeurosis and then what we want to do is do a dynamic scan with Valsalva so this is going to be the rectus abdominis over here the transversalis fascia is going to form a little hammock that the spermatic cord sits in and as these sine loops play through what you'll see is this tissue right here just lateral to the rectus is going to up the transversalis fascia is going to bulge and the spermatic cord is going to move laterally and so that's what we're seeing on both of these again tissue moves up bulging of the transversalis fascia spermatic cord shoots over to the lateral aspect and when you see that that is that is this insufficiency of the transversalis fascia we're talking about there's not a true hernia the fascia maintains intact here but it's it's an insufficiency and that's that movement of the spermatic cord is kind of what we use as our you know as our key here's just another example slightly more subtle where we have the rectus abdominis muscle here and we'll see the spermatic cord again just shooting over a bit laterally as the muscle kind of sneaks up along the lateral edge of the rectus abdominis here so find your spermatic cord take them through these valsalva maneuvers and then and then see what happens. Admittedly this area is a little confusing as I mentioned Dr. Joseph is an expert here and he gave a really nice webinar in conjunction with AIUM and AMSSM that's available on their website and he goes through all this stuff and I think it's really helpful so if you're interested here you want to you know dive into that a bit more particularly in the nuances the scanning technique and everything you know I definitely recommend that. So this is not a mistake in terms of the slide you know I just kind of crossed off core muscle injury but sports hernia here again just because you know these things get get confusing when you read you know what's going on I feel like we're almost to the point where folks are getting this a bit a bit better handled now and folks are starting to you know recognize you kind of fix what's broken right reattach the rectus if it's bad you know does that go into the inguinal area do you need to do some some augmentation repair there you know making sure that repair you know doesn't allow anything to move lateral to the rectus and and addressing adapters if need be and so again just making sure everybody knows what pathology we think we're treating and that we're not going to you know say do a you know an inguinal you know hernia repair technique whenever we think the pathology all sits in the adapters right now and I've seen that done before unfortunately and I think it was just a confusion of you know what people were were defining as a sports hernia. All right last thing I'll just touch on here briefly is going to be ileus psoas just because I feel like this is something that we see a lot for ultrasound referrals and it's helpful to be able to kind of quickly orient yourself here if you do find yourself a little bit lateral in this region. So here's going to be the ileus psoas kind of in your normal view orienting off of the femoral neurovasculature. So the anatomy here gets a little bit more complicated than I think what a lot of people think about but this is important and key to understanding the dynamic component here if you're looking at a snapping psoas and so the psoas major tendon is going to be what most of us call the ileus psoas tendon and we're going to see it sitting right here over the superior pubic ramus. The iliacus is this huge muscle and the iliacus has two portions there's a medial and a lateral portion you often will see this fascial distinction between the two and that gets important just to recognize because you're going to also start to get a tendon of the iliacus that starts to form and there's some variability in terms of when that tendon is going to form when that's going to blend with the psoas major tendon component and this will lead to a lot of things that might look like you know bifid tendons or you might have two different things that looks you can see a lot of stuff here that looks kind of weird but if you just start back a bit above the ais oriented muscles follow the tendons down you can usually make sense of everything here and then make sure you have a good understanding of the the anatomy before you start moving folks around trying to figure out what's popping or snapping. You know for years people thought that the psoas tendon snapped medial to lateral over this iliopectinal imminence that's been debunked and so what actually happens is there's dyskinetic movement of the tendon in relation to the muscle and because of the the anatomy of the pelvis here you basically have a big amphitheater and so that's why this is going to be one of these few snapping syndromes where you can actually hear it across the room because it's going to get amplified out of the pelvis and so what you should do is as you bring that patient up into hip flexion abduction and external rotation you're going to see the tendon normally will roll it's going to move on top of the muscle so you're going to have tendon which is here muscle underneath of it and then as you start to move back into neutral the tendon usually smoothly moves around the muscle moves out of the way there's kind of this little roll and then it takes its position up against the bone and folks who have snapping here what you'll see is a dyskinetic motion where the tendon will suddenly move and then will snap down onto the bone and that will correlate with their snapping so here's just a few more examples of what that may look like here was a case where where this young athlete's hip felt like a bowl of rice krispies you had this snap crackle pop thing and that's because we have this psoas major tendon component and the iliacus tendon component here and all of them are snapping over everything so this one pops up that one pops up that one pops down this one pops down and we were able to demonstrate that you know quite nicely on the dynamic images this is going to be your usual look and so we've got the tendon here that's you know that I described as kind of being loaded so it's loaded up here right now and then it's going to fire and move down very quickly and you'll feel that right under your transducer oftentimes in this case this is going to make a dramatic popping noise that everybody in the room can hear and then you can you know confirm your diagnosis. All right folks so take-home points from today's lecture as I mentioned at the beginning you know non-specific diagnosis leads to non-specific treatment which leads to non-specific outcomes right so to really try to establish a firm diagnosis if at all possible and the vast majority of these cases that are going to come in are going to be exactly what I presented you know certainly there's going to be you know all those other conditions on the other list those are going to walk into clinic as well and you want to make sure that you pick those up but if you feel pretty confident in the stuff we just went through this is really common pathology and you're going to see a ton of it and I think you can quickly get pretty comfortable with recognizing it you know I would say avoid syndromes and broad general generalized classifications I just don't find it helpful I've never understood this whole syndrome thing to me a syndrome is something if you just can't figure out the diagnosis and so really you know try to get a diagnosis you know along that line I find that that liberal use of imaging here is helpful but you have to understand that you're going to you're going to see asymptomatic findings and you have to correlate your clinical history and your physical exam so you know the image is not the only thing you're looking at you know it's the big picture but I do think this area with all of the various pathology that can happen in a very confined region with overlapping referral pain patterns you know I don't think you can take good care of patients and athletes without without imaging in this location.

2nd Edition, CASE 53

2nd Edition

Thigh

growing pain

athletes

diagnosis

treatment

adductor injuries

sports hernia

imaging

rehabilitation

core muscle injuries