Both arthroscopic and open operative treatment of femoroacetabular impingement (FAI) can reproducibly relieve hip pain with correction of the underlying osseous deformity and treatment of the associated labral pathology, particularly in patients without substantial articular cartilage injury at the time of surgery. Between 75% and 90% of athletes undergoing FAI surgery return to sports at their pre-injury level of function. There is no peer-reviewed evidence to date reporting on the efficacy of nonoperative treatment and return to play with FAI. Successful operative treatment of impingement requires appropriate and complete correction of the mechanical injury that led to the symptomatic labral pathology. Early intervention prior to the onset of irreversible chondral damage is critical to the long-term success of FAI surgery. Complex deformities involving combinations of static and dynamic mechanical factors often coexist, so careful preoperative evaluation of the underlying structural anatomy is critical to successful treatment planning. 

Femoroacetabular Impingement

Mechanical hip pain typically has been associated either with dynamic factors resulting in abnormal stress and contact between the femoral head and acetabular rim when the hip is in motion or with static overload stresses related to insufficient congruency between the head and acetabular socket in the axially loaded (standing) position. Compensatory motion may adversely affect the dynamic muscle forces in the pelvic region, leading to further strain and pain. Hip pain related to static overload stresses may also be localized to the anteromedial groin, but compensatory dysfunction of the periarticular musculature may lead to muscular fatigue and associated pain throughout the hip. As our understanding of hip joint mechanics has advanced, it has become increasingly apparent that hip pain in the absence of osteoarthritis may be due to a complex combination of mechanical stresses, both dynamic and static. With an emphasis on findings in the recent literature, this review will describe the dynamic and static factors associated with mechanical hip pain, the combinations of dynamic and static stresses that are commonly identified in hip pain, and common patterns of compensatory injury in patients with femoroacetabular impingement.

Static and dynamic mechanical causes of hip pain.

This review summarises the existing knowledge about pathogenesis, differential diagnosis, conservative treatment, surgery and post-surgical rehabilitation of sports hernias. Sports hernias occur more often in men, usually during athletic activities that involve cutting, pivoting, kicking and sharp turns, such as those that occur during soccer, ice hockey or football. Sports hernias generally present an insidious onset, but with focused questioning a specific inciting incident may be identified. The likely causative factor is posterior inguinal wall weakening from excessive or high repetition shear forces applied through the pelvic attachments of poorly balanced hip adductor and abdominal muscle activation. There is currently no consensus as to what specifically constitutes this diagnosis. As it can be difficult to make a definitive diagnosis based on conventional physical examination, other methods, such as MRI and diagnostic ultrasonography are often used, primarily to exclude other conditions. Surgery seems to be more effective than conservative treatment, and laparoscopic techniques generally enable a quicker recovery time than open repair. However, in addition to better descriptions of surgical anatomy and procedures and conservative and post-surgical rehabilitation, well-designed research studies are needed, which include more detailed serial patient outcome measurements in addition to basing success solely on return to sports activity timing. Only with this information will we better understand sports hernia pathogenesis, verify superior surgical approaches, develop evidence-based screening and prevention strategies, and more effectively direct both conservative and post-surgical rehabilitation.

https://bjsm.bmj.com/content/bjsports/42/12/954.full.pdf

Sports Hernias: A Systematic Literature Review

Background: Groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the efficacy of these treatments is unknown. Objective: Systematically review the literature on the efficacy of treatments for groin pain in athletes. Methods: Nine medical databases were searched in May 2014. Inclusion criteria: treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n>10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and two authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Review registration number CRD42014010262. Results: 72 studies were included for quality analysis. Four studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman's hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p<0.001, r=-0.41), but not between study quality and publication year (p=0.09, r=0.20). Conclusions: Only 6% of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. There is moderate evidence for the efficacy of conservative treatment (active exercises and multimodal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for efficacy of surgical treatment in sportsman's hernia.

https://bjsm.bmj.com/content/bjsports/49/12/813.full.pdf

Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes

OBJECTIVE. Groin pain in elite athletes is a common yet challenging diagnostic and management dilemma for the sports clinician, accounting for a significant proportion of athletic injuries. It is often debilitating and, if severe enough, may compromise an athlete's career. Traditionally, groin pain has been poorly understood by radiologists.CONCLUSION. A major reason groin pain has been misunderstood is the complexity of the anatomy of this region, which this article discusses in detail in an effort to inform the reader.

https://www.ajronline.org/doi/pdfplus/10.2214/AJR.07.3410

Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings.

ObjectiveTo investigate the results of surgical treatment on athletes presenting with chronic symphysis syndrome (lower abdominal, groin, and adductor pain).DesignRetrospective nonrandomized study.SettingSwiss Olympic Medical Center associated with Institute of Sports Sciences.PatientsTwenty

Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes

WISSENSCHAFTLICHER BEITRAG: 8. GOTS-Schweiz Tagung Universität Basel, 2. Februar 2006: Sportfähigkeit nach Verletzungen und Operationen

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Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes

WISSENSCHAFTLICHER BEITRAG: 8. GOTS-Schweiz Tagung Universität Basel, 2. Februar 2006: Sportfähigkeit nach Verletzungen und Operationen