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High Incidence of Athletic Pubalgia Symptoms in ProfessionalAthletes With Symptomatic Femoroacetabular Impingement

Sommer Hammoud, M.D., Asheesh Bedi, M.D., Erin Magennis, B.A.,William C. Meyers, M.D., and Bryan T. Kelly, M.D.

Purpose: The purpose of this study was to identify the incidence of symptoms consistent withathletic pubalgia (AP) in athletes requiring surgical treatment for femoroacetabular impingement(FAI) and the frequency of surgical treatment of both AP and FAI in this group of patients. Methods:Thirty-eight consecutive professional athletes, with a mean age of 31 years, underwent arthroscopicsurgery for symptomatic FAI that limited their ability to play competitively. In all cases a cam and/orfocal rim osteoplasty with labral refixation or debridement was performed. In 1 case concomitantintramuscular lengthening of the psoas was performed. Retrospective data regarding prior AP surgeryand return to play were collected. Results: Thirty-two percent of patients had previously undergoneAP surgery, and 1 patient underwent AP surgery concomitantly with surgical treatment of FAI. Nopatient returned to his previous level of competition after isolated AP surgery. Thirty-nine percenthad AP symptoms that resolved with FAI surgery alone. Of the 38 patients, 36 returned to theirprevious level of play; all 12 patients with combined AP and FAI surgery returned to professionalcompetition. The mean duration before return to play was 5.9 months (range, 3 to 9 months) afterarthroscopic surgery. Conclusions: There is a high incidence of symptoms of AP in professionalathletes with FAI of the hip. This study draws attention to the overlap of these 2 diagnoses andhighlights the importance of exercising caution in diagnosing AP in a patient with FAI. Level ofEvidence: Level IV, therapeutic, retrospective case series.

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Femoroacetabular impingement (FAI) describes 2main variations of morphologic abnormalities of

he hip and resultant observed patterns of chondral andabral injury: (1) cam impingement resulting from lossf offset of the femoral head-neck junction and (2)incer impingement due to focal rim lesions or ceph-lad retroversion.1 Current treatment for FAI involves

From the Hospital for Special Surgery (S.H., E.M., B.T.K.), NewYork, New York; MedSport, Section of Sports Medicine and Shoul-der Surgery, University of Michigan (A.B.), Ann Arbor, Michigan;and Department of Surgery, Drexel University (W.C.M.), Philadel-phia, Pennsylvania, U.S.A.

The authors report that they have no conflicts of interest in theauthorship and publication of this article.

Received April 20, 2011; accepted February 22, 2012.Address correspondence to Asheesh Bedi, M.D., MedSport, Uni-

versity of Michigan, 24 Frank Lloyd Wright Dr, Lobby A, AnnArbor, MI 48106, U.S.A. E-mail: abedi@umich.edu

© 2012 by the Arthroscopy Association of North America

0749-8063/11247/$36.00doi:10.1016/j.arthro.2012.02.024

1388 Arthroscopy: The Journal of Arthroscopic and Related Surg

steoplasty of proximal femoral and acetabular dys-orphology with labral debridement or refixation.oth open and arthroscopic approaches have been

eported with favorable clinical outcomes in 75% to5% of patients, with up to 93% of athletes returningo sport.2-9

Athletic pubalgia (AP) refers to a syndrome ofdisabling lower abdominal and inguinal exertionalpain with progression to include adductor pain inhigh-performance athletes.10-12 Symptoms occur withesisted hip adduction or with resisted abdominal con-ractions. The mechanism is postulated to be a com-lex injury to the flexion/adduction apparatus of theower abdomen and hip.10 To enhance the comprehen-

sion of the spectrum of injuries observed in AP, the“pubic joint” has been described as the second jointwithin the pelvis, with the hip joint being the first.13

This second joint comprises the entirety of the rightand left pubic symphyses with all of their musculo-

tendinous attachments. Asymmetric distribution of ex-

ery, Vol 28, No 10 (October), 2012: pp 1388-1395

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1389AP AND FAI IN PROFESSIONAL ATHLETES

treme forces around this joint, as is most commonlyseen in the elite athlete, may result in the constellationof abdominal and pelvic injuries found in AP.11,13

Surgical repair is aimed at the various structures thatnormally attach to the pubic symphysis and/or selec-tive epimysiotomy or detachment.13-15 An overall suc-cess rate of greater than 95% in returning patients totheir previous level of activity has been reported.13

Both FAI and AP are frequently reported in high-performance athletes, most commonly in soccer, hockey,football, and baseball players.7,13,16 When viewed as agroup, such injuries account for a significant proportionof lost playing time and early retirement in profes-sional athletes. Although it has been suggested thatthese should be viewed in concert when examining anathlete presenting with groin pain, an association be-tween the 2 has not previously been shown. Bothconditions often present with a similar constellation ofclinical symptoms, including groin discomfort andrestricted range of motion (ROM).

The hip is a ball-and-socket type of joint with 3degrees of freedom. Loss of clearance between thefemoral neck and acetabular rim may compromisemaximum hip excursion in multiple planes.17-19 Thisbnormal bony contact and resultant restriction inerminal motion in the high-performance athlete dueo FAI may result in compensatory stresses on theumbar spine, pubic symphysis, sacroiliac joint, andosterior acetabulum. These alterations in hip jointechanics due to underlying impingement may result

n excessive strains and secondary injury to the pos-erior inguinal wall, resulting in symptomatic AP. Theurpose of this study was to identify the incidence ofymptoms consistent with AP in athletes requiringurgical treatment for FAI. Our hypothesis was thatome athletes may manifest AP symptoms due toompensatory stresses from FAI; moreover, surgicalorrection of FAI may resolve these symptoms.

METHODS

This study was approved by our institutional reviewoard. From April 2005 to April 2010, 38 consecutiverofessional athletes underwent arthroscopic surgeryor the treatment of symptomatic FAI that limited theirbility to return to competitive play. The group in-luded 9 baseball players, 13 football players, 8ockey players, 5 soccer players, 2 basketball players,nd 1 skater (Table 1). All patients were men, with aean age of 31 years (range, 19 to 35 years).Throughout our article, we describe patients as hav-

ng FAI symptoms, defined as hip or groin pain,

nd/or AP symptoms, defined as lower abdominal ordductor pain. Three subsets of patients are described.he first consists of 12 patients who presented withoth FAI and AP symptoms and required surgicalreatment of both the FAI and AP. Of these, all but 1nitially presented to a general surgeon specializing inhe treatment of AP. The last patient initially pre-ented to the senior author’s sports medicine/hip pres-rvation practice. Because of a lack of complete ob-ective data in the records, we cannot report the exactime line between AP and FAI surgery for all theatients. The second subset comprises 15 patients whoresented with both FAI and AP symptoms, in whomoth sets of symptoms resolved after surgical treat-ent of FAI alone. The final subset, consisting of 11

atients, presented with FAI symptoms alone and un-erwent surgical treatment. The algorithmic approachaken by the senior authors (W.C.M. and B.T.K.) wille described.For the first subset of patients who presented to a

eneral surgeon with both FAI and AP symptoms,istories and physical examinations were conductedith careful attention to 3 sets of diagnoses: AP, hip,

nd other causes. Patients with AP pain describe ab-ominal/adductor pain that is primarily exertional inature (resisted sit-ups) and often predictable withnitiation of forceful activities such as sprinting andhanges of direction.11 The pain may also affect nor-

mal activities such as coughing, sneezing, or rollingover in bed at night.11 The pain may vary from side toside, depending on patterns of compensation, and in-volve multiple sites of soft-tissue attachments, includ-ing the rectus abdominis and specific adductor mus-cles. Specific resistance tests for each of the musclesattaching to or crossing the pubic symphysis or jointwere used in assessing the patient with AP symptoms.Localized tenderness over the pubic symphysis, distalrectus abdominis/conjoined tendon, or proximal ad-

TABLE 1. Preoperative Sporting Activities of 38Professional Athletes

Sport No. of PatientsNo. of Patients Undergoing

AP Surgery

ootball 13 4aseball 9 2ockey 8 4occer 5 2asketball 2 0kating 1 0otal 38 12

ductor tendon is also helpful in localization of the

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1390 S. HAMMOUD ET AL.

pathology.20 Specialized pelvic magnetic resonancemaging (MRI) and magnetic resonance arthrographytudies of the hip were performed on all patients tossess for AP and overlapping ball-in-socket hip in-uries. At the time of magnetic resonance arthrogra-hy, the use of dedicated Sensorcaine (AstraZenecaP, Wilmington, DE) or lidocaine protocols allowed

or both diagnostic and therapeutic benefits. Thoseatients with diagnosed AP but who had relief ofoncomitant FAI symptoms after intra-articular injec-ion and had findings of a labral tear on clinicalxamination and MRI were diagnosed with FAI, andurgical treatment of FAI was planned to follow theP surgery. Surgical treatment of AP varied depend-

ng on the precise pathology with both direct repairs ofefects and repairs or releases of compensatory inju-ies.

The diagnosis of symptomatic FAI was made basedn clinical examination and imaging studies per-ormed by a sports medicine orthopaedist, specializingn hip preservation (B.T.K.). A complete examinationf the hip and surrounding structures was performedy use of the positionally based method described byartin et al.21 Intra-articular hip lesions were identi-

fied with pain during flexion, adduction, and internalrotation (FADIR test).22 All athletes in the study werexamined with an anteroposterior pelvis radiograph,n anteroposterior radiograph of the affected hip, anlongated-neck lateral view (Dunn lateral radiograph),nd a false-profile radiograph (Fig 1).23 The Dunnateral view has been validated to characterize the cameformity of FAI, with a sensitivity of 91%, specific-ty of 88%, positive predictive value of 93%, negativeredictive value of 84%, and accuracy of 90%.24 Ra-

diographic assessment included the femoral neck-shaft angle, the Tönnis angle, the center-edge angle ofWiberg (normally �25°), the femoral head-neck off-set, and acetabular version (the so-called crossoversign represents a retroverted acetabulum).25 MRI ofhe hip was performed by use of coronal inversionecovery and axial fast spin-echo body coil images, asell as high-resolution surface coil images of theip in the sagittal, axial, and oblique coronal planesy fast spin-echo techniques, for evaluation of in-rinsic lesions, including the articular cartilage (Fig).26 Athletes with a documented labral tear and

pain with the FADIR test were administered aninjection of lidocaine with corticosteroid under ul-trasound guidance.27 Those who had temporary re-ief of their FAI symptoms were treated with hiprthroscopy. Computed tomography was used to

ssess femoral version and the extent of osseous

bnormalities and to evaluate the amount of resec-ion to be addressed during hip arthroscopy.23

All patients who underwent hip arthroscopy had analpha angle greater than 50° and a documented an-terosuperior labral tear. In all cases an arthroscopiccam and/or focal rim osteoplasty with labral refixationor debridement was performed (Fig 3). In 1 case,concomitant intramuscular lengthening of the psoaswas performed for symptomatic psoas impingement.Postoperatively, patients’ extremities were placed in acontinuous passive motion device daily for 4 weeks,with flexion of the hip from 30° to 70°. Weight bear-ing was restricted to 20-lb foot-flat weight bearing onthe affected leg for 4 weeks. Gradual physical therapyand strengthening were started at 4 weeks. Retrospec-

FIGURE 1. (A) Anteroposterior and (B) Dunn lateral radiographsof right hip showing loss of femoral offset and focal cephaladretroversion of acetabulum consistent with FAI in a football playerwith groin pain.

tive data regarding subjective clinical outcome, previ-

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1391AP AND FAI IN PROFESSIONAL ATHLETES

ous AP surgery, ability to return to play, and durationuntil return to play were collected on all patients.

Arthroscopic Procedure

Hip arthroscopy was performed by a senior surgeonwith the patient in a supine position as described byByrd.28 The central compartment was addressed firstin all cases. An interportal capsulotomy was created inall cases to fully visualize and address the intra-articularand extra-articular sources of impingement. A rimosteoplasty was performed to correct cephalad retro-version and eliminate focal rim impingement lesionsas assessed by labral pathology and confirmed withintraoperative fluoroscopy. Labral refixation was per-formed if tissue quality and tear pattern were amena-ble to repair and the labrum was not ossified. Anchorswere placed 2 mm from the margin of the rim, and anon-everting mattress stitch was used. The femoralosteoplasty was performed in the peripheral compart-ment after removal of traction and gentle hip flexionof approximately 30° to 40°. A T-capsulotomy alongthe anterior femoral neck was performed in almost allcases to improve proximal-distal and medial-lateralvisualization of the entire cam lesion and to ensureoptimal restoration of offset in all safely accessiblelocations between the superior and inferior retinacular(epiphyseal) vessels. The T-capsulotomy was repairedat the conclusion of the procedure in all cases. Internaland external rotation of the leg improved access to thelateral and medial head-neck junctions, respectively.In cases of large superior or posterosuperior cam

FIGURE 2. T2-weighted coronal magnetic resonance image show-ng edema and injury to adductor musculature origin (arrow), asell as abdominal wall musculature and fascia.

lesions, access was improved with leg extension d

and/or reapplication of traction. Intraoperative fluo-roscopy was used to confirm restoration of offset onthe extended-neck lateral radiograph and proximal-distal correction from the physeal scar to the intertro-chanteric line (Fig 3). A dynamic assessment of clear-ance with direct hip flexion and internal rotation wasperformed in all cases.

RESULTS

The mean age of the professional athletes at thetime of surgery was 31 years (range, 19 to 35 years).Of the patients, 32% (12 of 38) had previously under-gone AP surgery by an outside referring general sur-geon, and 1 of these underwent AP surgery concom-itantly with surgical treatment of FAI. Three patientsunderwent AP and FAI surgery within 1 month’s time.Most other patients underwent a trial period of return-ing to play after AP surgery to assess the absoluteneed for surgical intervention for the symptomaticFAI. None of these athletes was able to return to hisprevious level of competition after isolated AP sur-gery. However, 39% (15 of 38) had AP symptoms thatresolved with FAI surgery alone. Of the 38 patients,36 returned to their previous level of play, and all 12patients with combined pubalgia and FAI surgerywere able to return to professional competition. Themean time between arthroscopic surgery and return toplay was 5.9 months (range, 3 to 9 months).

Arthroscopic Treatment of FAI

Of the athletes, 25 (65%) were treated for combinedacetabular and proximal femoral deformity. Eight ath-letes (21%) were treated for a loss of femoral offset,and 5 athletes (13%) were treated for focal rim im-pingement lesions. All athletes had anterosuperiorlabral tears. Labral refixation was performed after rimtrimming with suture anchors (mean of 3.5 anchorsper patient [range, 3 to 5 anchors]) in 6 patients(15.7%). The remaining patients underwent capsularelevation, rim recession, and labral advancement.Concomitant additional procedures included adductorlongus release (n � 1), partial psoas release (n � 1),nd chondroplasty with microfracture of a cam delam-nation lesion (n � 1). Adductor release was per-ormed for symptomatic athletic groin pain localizedo the adductor longus tendon. One patient underwentevision arthroscopy consisting of loose body re-oval, debridement of scar tissue, and revision cam

ecompression. This patient was a football player who

1392 S. HAMMOUD ET AL.

FIGURE 3. (A) Intraoperative arthroscopic image of significant, unstable anterosuperior labral tear. (B) Rim recession is performed toeliminate the focal rim impingement lesion, with debridement of the degenerative anterosuperior labral tear. (C) A T-capsulotomy isperformed to provide extensile exposure of the femoral-offset deformity. (D) Femoral osteoplasty is performed to restore the normal

head-neck offset. Care is taken to confirm correction circumferentially and in a proximal-distal orientation along the femoral neck. (E) TheT-capsulotomy is repaired in a side-to-side fashion after femoral offset has been restored.

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1393AP AND FAI IN PROFESSIONAL ATHLETES

had not previously undergone AP surgery and was notable to return to play.

DISCUSSION

The purpose of our study was to highlight the fre-uent overlap of AP and FAI diagnoses and to showhe frequency of concomitant AP and FAI symptoms.

e hypothesized that some elite athletes may mani-est AP symptoms due to compensatory stresses fromAI and that these symptoms may resolve with sur-ical correction of FAI. In a consecutive series of 38rofessional athletes treated for symptomatic FAI, wedentified 12 (32%) who had undergone previous APurgery. Interestingly, these 12 patients were not ableo return to play after isolated AP surgery. After thedditional treatment of FAI, however, all 12 patientsere able to return to their previous level of profes-

ional sport. The remaining 24 patients who were ableo return to play improved after surgical treatment ofAI alone, 15 of whom had AP symptoms that re-olved with isolated treatment of their hip pathology.ur findings show that in a select group of high-erformance athletes, FAI and AP symptomatologynd diagnoses may overlap; having a high level ofuspicion is essential to correctly diagnose both pa-hologies and not overtreat. With successful diagnosisnd treatment, one can reliably return such profes-ional athletes to their previous level of competition.

It is important to note that in those athletes requiringoth AP and FAI surgery, the hip pathology wasiagnosed at presentation to the general surgeon, andurgery to address this problem was planned to followP surgery. Many underwent short trials of returning

o play after the AP surgery to determine the absoluteecessity for subsequent surgical intervention forreatment of the FAI.

Adequate femoral head-neck offset prevents contactetween the femoral neck and acetabular rim within aormal ROM. However, with increased bone volumet the femoral head-neck junction or with focal orlobal acetabular overcoverage (as seen with pincer-ype FAI), insufficient clearance mechanically limitserminal ROM in multiple planes.17,18 Although the

specific deficiencies in motion are correlated with thelocation of deformity, FAI has typically been shownto decrease maximal hip flexion, internal rotation, andabduction.17 Moreover, internal rotation decreases

ith increasing flexion and adduction.17

When the functional ROM required to compete insports is greater than the physiologic motion allowed

by the hip, a compensatory increase in motion may be c

provided by the lumbar spine, sacroiliac joint, pubicsymphysis, and posterior hip subluxation. Subse-quently, alterations in the mechanics of the hip jointdue to underlying FAI may lead to changes in thedynamic muscle forces across the pelvis. The result isexcessive strain at these joints and on the muscles thatattach to them. In select patients, treatment of the camor rim impingement lesion may restore sufficient mo-tion to restore joint mechanics to a more physiologicstate. The muscles most typically affected by dynamicimpingement include the adductor longus, proximalhamstrings, abductors, iliopsoas, and hip flexors.29

Patients with FAI may adopt an alternative motionstrategy, recruiting different muscles, with an altera-tion in hip and pelvic biomechanics occurring evenduring gait.30 During level gait, cam FAI causes adecrease in peak hip abduction and total frontal ROM,slight reduction in sagittal hip ROM, and attenuatedpelvic mobility in the frontal plane.30 It seems un-ikely that these altered motions result from mechan-cal limitations or bony contact as would occur at thextremes of motion. This suggests a soft-tissue com-onent to FAI that is adaptive in nature to reduce hipain during ambulation.30 Limited sagittal pelvicOM has also been shown in patients with FAI asompared with control subjects; moreover, patientsith FAI could not squat as low as the control group.18

Together, these findings may support compensatory oradaptive changes in pelvic motion and periarticularmusculature due to FAI that may precipitate AP symp-toms. This explanation is supported by the results ofour study, in that 39% of athletes with concomitantpubalgia and FAI symptoms had a complete resolutionof pain and dysfunction with FAI surgery alone.

In the high-performance athlete, restriction of ter-minal flexion and internal rotation at the hip joint mayresult in secondary abnormal motion of the hemipel-vis. This motion may be responsible for injury to theposterior inguinal wall, rectus abdominis, and adduc-tor musculature associated with a sports hernia.13 In aecent study of hip injuries in National Footballeague players, Feeley et al.31 found that the mostommon type of hip injury was muscle strain, fol-owed by contusion, intra-articular injury, and sprain.lthough these injuries may occur in isolation, a

sports hip triad” has been described, consisting of aabral tear, adductor strain, and rectus strain.31 There-ore intra-articular pathology, such as FAI, may bemplicated in exacerbating muscle injuries around theelvis in athletes. Proximal hamstring tendinitis, rec-us femoris avulsions, and psoas tendinitis are other

auses of groin pain that may have a similar associa-

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1394 S. HAMMOUD ET AL.

tion with FAI.20,31,32 As with all muscle injuries, pre-ention is the key, consisting of preseason stretching,alance, and ROM exercises. Treatment of musclenjuries consists of rest, ice, physical therapy, andOM exercises. Injections into the adductor enthesisave been described by Schilders et al.,33 with successn both competitive and recreational athletes. Surgeryas been described for the treatment of recalcitrantroximal hamstring and iliopsoas tendinitis.31,32

Larson et al.34 recently published an article evalu-ting the results of surgical treatment of athletes withssociated intra-articular hip pathology and extra-rticular AP, further supporting the not infrequentverlap of these 2 diagnoses. They followed a seriesf 37 hips (mean patient age, 25 years) that wereiagnosed with both symptomatic AP and symptom-tic intra-articular hip joint pathology. Hip arthros-opy was performed in 32 hips (30 cases of FAIreatment, 1 traumatic labral tear, and 1 borderlineysplasia). Of 16 hips that had AP surgery as thendex procedure, 4 (25%) returned to sports withoutimitations and 11 (69%) subsequently had hip ar-hroscopy at a mean of 20 months after pubalgiaurgery. Of 8 hips managed initially with hip arthros-opy alone, 4 (50%) returned to sports without limi-ations and 3 (43%) had subsequent pubalgia surgeryt a mean of 6 months after hip arthroscopy. Thirteenips had AP surgery and hip arthroscopy at 1 setting.oncurrent or eventual surgical treatment of both dis-rders led to improved postoperative outcome scoresP � .05) and an unrestricted return to sporting activ-ty in 89% of hips (24 of 27).

Limitations of our study include those inherent to aetrospective study and to a relatively small case se-ies. The small series is comparable, however, to sim-lar published series documenting hip pathology inrofessional athletes.7,34,35 Furthermore, no objective

outcome measurements were used; instead, return toplay was the final outcome assessed. Although objec-tive outcome measures would have strengthened thefollow-up data, current outcome instruments such asthe modified Harris Hip Score have not yet beenvalidated for use in high-level athletes and may lead toan underestimation of debilitation in high-performanceathletes, with a shown ceiling effect.35 We believe thatreturn to play, however, is an appropriate endpoint foranalysis of success of any surgical intervention in thissubgroup of patients. There is also an inherent selec-tion bias involving the study of professional athletes.These patients have financial incentives to return tocompetitive play and are possibly less likely to report

symptoms and complications that would prevent a

return to play. Nevertheless, these patients’ participa-tion in physically demanding professional sportingactivities was possible after surgical intervention forFAI and/or AP.

In summary, surgical treatment of FAI may result inresolution of all symptoms, because abnormal restric-tion in terminal hip motion due to FAI may precipitatecompensatory stresses that weaken the posterior in-guinal wall and place excessive strains on the muscu-lature around the hip and hemipelvis. In certain casessurgical treatment of both conditions may be neces-sary to facilitate a successful return to professionalcompetition.

CONCLUSIONS

There is a high incidence of symptoms of AP inprofessional athletes with FAI of the hip. This studydraws attention to the overlap of these two diagnosesand highlights the importance of exercising caution indiagnosing AP in a patient with FAI.

REFERENCES

1. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphologyinfluences the pattern of damage to the acetabular cartilage:Femoroacetabular impingement as a cause of early osteoar-thritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018.

2. Bardakos NV, Vasconcelos JC, Villar RN. Early outcome ofhip arthroscopy for femoroacetabular impingement: The roleof femoral osteoplasty in symptomatic improvement. J BoneJoint Surg Br 2008;90:1570-1575.

3. Byrd JW, Jones KS. Arthroscopic femoroplasty in the man-agement of cam-type femoroacetabular impingement. Clin Or-thop Relat Res 2009;467:739-746.

4. Guanche CA, Bare AA. Arthroscopic treatment of femoroac-etabular impingement. Arthroscopy 2006;22:95-106.

5. Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-Rodríguez E,Camacho-Galindo J. Arthroscopic treatment of cam-typefemoroacetabular impingement: Preliminary report at 2 yearsminimum follow-up. J Arthroplasty 2008;23:226-234.

6. Larson CM, Giveans MR. Arthroscopic management of femo-roacetabular impingement: Early outcomes measures. Arthros-copy 2008;24:540-546.

7. Philippon M, Schenker M, Briggs K, Kuppersmith D. Femo-roacetabular impingement in 45 professional athletes: Associ-ated pathologies and return to sport following arthroscopicdecompression. Knee Surg Sports Traumatol Arthrosc 2007;15:908-914.

8. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomesfollowing hip arthroscopy for femoroacetabular impingementwith associated chondrolabral dysfunction: Minimum two-yearfollow-up. J Bone Joint Surg Br 2009;91:16-23.

9. Stähelin L, Stähelin T, Jolles BM, Herzog RF. Arthroscopicoffset restoration in femoroacetabular cam impingement: Ac-curacy and early clinical outcome. Arthroscopy 2008;24:51-57.e1. Available online at www.arthroscopyjournal.org.

10. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum

BR. Management of severe lower abdominal or inguinal painin high-performance athletes. PAIN (Performing Athletes with

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

1395AP AND FAI IN PROFESSIONAL ATHLETES

Abdominal or Inguinal Neuromuscular Pain Study Group).Am J Sports Med 2000;28:2-8.

11. Minnich JM, Hanks JB, Muschaweck U, Brunt LM, DiduchDR. Sports hernia: Diagnosis and treatment highlighting aminimal repair surgical technique. Am J Sports Med 2011;39:1341-1349.

12. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH,Garrett WE Jr. Abdominal musculature abnormalities as acause of groin pain in athletes. Inguinal hernias and pubalgia.Am J Sports Med 1991;19:239-242.

13. Meyers WC, McKechnie A, Philippon MJ, Horner MA, ZogaAC, Devon ON. Experience with “sports hernia” spanning twodecades. Ann Surg 2008;248:656-665.

14. Meyers WC, Szalai LJ, Potter ND, Naik A, Ryan J. Extraar-ticular sources of hip pain. II. Athletic pubalgia. In: Byrd JW,ed. Operative hip arthroscopy. Ed 2. New York: Springer,2005;86-97.

15. Meyers WC, Yoo E, Devon ON, et al. Understanding “sportshernia” (athletic pubalgia): The anatomic and pathophysio-logic basis for abdominal and groin pain in athletes. Oper TechSports Med 2007;15:165-177.

16. Hootman JM, Dick R, Agel J. Epidemiology of collegiateinjuries for 15 sports: Summary and recommendations forinjury prevention initiatives. J Athl Train 2007;42:311-319.

7. Kubiak-Langer M, Tannast M, Murphy SB, Siebenrock KA,Langlotz F. Range of motion in anterior femoroacetabularimpingement. Clin Orthop Relat Res 2007;458:117-124.

8. Lamontagne M, Kennedy MJ, Beaulé PE. The effect of camFAI on hip and pelvic motion during maximum squat. ClinOrthop Relat Res 2009;467:645-650.

9. Tannast M, Kubiak-Langer M, Langlotz F, Puls M, MurphySB, Siebenrock KA. Noninvasive three-dimensional assess-ment of femoroacetabular impingement. J Orthop Res 2007;25:122-131.

0. Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sportshernias: A systematic literature review. Br J Sports Med 2008;42:954-964.

1. Martin HD, Kelly BT, Leunig M, et al. The pattern andtechnique in the clinical evaluation of the adult hip: Thecommon physical examination tests of hip specialists. Arthros-copy 2010;26:161-172.

2. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock

KA. Femoroacetabular impingement: A cause for osteoarthri-tis of the hip. Clin Orthop Relat Res 2003:112-120.

3. Manaster BJ, Zakel S. Imaging of femoral acetabular impinge-ment syndrome. Clin Sports Med 2006;25:635-657.

4. Barton C, Salineros MJ, Rakhra KS, Beaulé PE. Validity of thealpha angle measurement on plain radiographs in the evalua-tion of cam-type femoroacetabular impingement. Clin OrthopRelat Res 2011;469:464-469.

5. Shindle MK, Voos JE, Heyworth BE, et al. Hip arthroscopy inthe athletic patient: Current techniques and spectrum of dis-ease. J Bone Joint Surg Am 2007;89:29-43 (Suppl 3).

6. Mintz DN, Hooper T, Connell D, Buly R, Padgett DE, PotterHG. Magnetic resonance imaging of the hip: Detection oflabral and chondral abnormalities using noncontrast imaging.Arthroscopy 2005;21:385-393.

7. Byrd JW, Jones KS. Diagnostic accuracy of clinical assess-ment, magnetic resonance imaging, magnetic resonance ar-thrography, and intra-articular injection in hip arthroscopypatients. Am J Sports Med 2004;32:1668-1674.

8. Byrd JW. Hip arthroscopy: The supine position. Instr CourseLect 2003;52:721-730.

9. Bedi A, Dolan M, Leunig M, Kelly BT. Static and dynamicmechanical causes of hip pain. Arthroscopy 2011;27:235-251.

0. Kennedy MJ, Lamontagne M, Beaulé PE. Femoroacetabularimpingement alters hip and pelvic biomechanics during gaitwalking biomechanics of FAI. Gait Posture 2009;30:41-44.

1. Feeley BT, Powell JW, Muller MS, Barnes RP, Warren RF,Kelly BT. Hip injuries and labral tears in the National FootballLeague. Am J Sports Med 2008;36:2187-2195.

2. Anderson SA, Keene JS. Results of arthroscopic iliopsoastendon release in competitive and recreational athletes. Am JSports Med 2008;36:2363-2371.

3. Schilders E, Talbot JC, Robinson P, Dimitrakopoulou A, Gib-bon WW, Bismil Q. Adductor-related groin pain in recre-ational athletes: Role of the adductor enthesis, magnetic reso-nance imaging, and entheseal pubic cleft injections. J BoneJoint Surg Am 2009;91:2455-2460.

4. Larson CM, Pierce BR, Giveans MR. Treatment of athleteswith symptomatic intra-articular hip pathology and athleticpubalgia/sports hernia: A case series. Arthroscopy 2011;27:768-775.

5. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, HayCJ. Arthroscopic labral repair and treatment of femoroacetabu-lar impingement in professional hockey players. Am J Sports

Med 2010;38:99-104.