Learning outcomes. Rehabilitation of Adductor-related & Iliopsoas-related Groin Pain. Chronic Hip & Groin Pain

Transcription

1 Rehabilitation of Adductor-related & Iliopsoas-related Groin Pain Benoy Mathew MSc, MCSP Extended Scope Practitioner Learning outcomes Overview of Groin pain (Articular & Extra-articular) Differential Diagnosis (Osteitis Pubis, Sports Hernia, FAI) Adductor related Groin Pain Ilio-psoas related Groin Pain (Risk factors, Clinical findings & Rehab) Appraisal of Current Literature Chronic Hip & Groin Pain 10% - General Population 10-20% - Sporting Injuries 30% - May go undiagnosed (Picavet et al, 2003; Ekstrand et al, 1999; Leblanc et al, 2003)

2 Groin Pain ( MSK & Non - MSK Pain Referrals) Deep Location of the Hip Joint Lumbo-Pelvic- Hip Complex (LPHC) Direct InEluence of 22 Muscles on the Hip Confusing terminology in Literature (Gilmore groin, Sports hernia, Osteitis Pubis, Athletic Pubalgia) Multiple clinical entities are common in chronic groin pain (63.6%) (Falvey et al, 2016) N= 382 patients Differential Diagnosis Chronic Groin Pain Intra- Articular Extra- Articular Referred Pain Femoro-acetabular Impingement (FAI) Acetabular Labral tears (ALT) Chondral lesions Osteoarthritis Hip Dysplasia (HD) Ligamentum Teres tears Hip Joint Instability / Capsular Laxity Adductor related Groin Pain Hip Flexor related Groin Pain Gluteus Medius tendinopathy & tears Rectus Abdominis Strain Pubic Groin Pain (Osteitis Pubis) Snapping Hip Syndrome (External & Internal) Atheltic Pubalgia (Sports Hernia) Lumbar Spine (Disc, Pars Injuries, Facet arthropathy) & SIJ Lower abdominal (Gastrointestinal) Pelvis (Genitourinary) Abdominal Muscle Strains / Side Strain

3 1. Defined Clinical Entities 2. Hip Related Groin Pain 3. Other causes of groin pain (Weir et al, 2015) 1. Defined Clinical Entities Adductor- related groin pain Iliopsoas - related groin pain Inguinal - related groin pain Pubic - related groin pain Hip Adductors (5 Muscles) Peanut Butter Leaves Me Greasy Pectineus Brevis Longus Magnus Gracilis Unique Role 4 th Hamstring Proximal Attachment - Ischial tuberosity Powerful Hip Extensor Assists in Post Pelvic Tilt

4 Role of Hip Adductors Not as prime movers, but in reflex response to gait changes. Work Synergistically with abductors to provide stabilisation of the pelvis Mainly active in bilateral stance Gracilis (2 joint muscle) - Medial Knee Stabiliser (Neumann, 2009) Larger than Hamstrings 22.5% of total LL Mass Combined Peak Forces > GMax Acute Groin Injury Adductor injuries account for the majority of acute groin injuries. Ilio-psoas and proximal rectus femoris injuries are also common Serner et al, (2015) n=110 Very common in Male Football! N = 695 (all male) 49 % report Hip & Groin pain in one season (Thorborg et al, 2016)

5 ê ê ê ê Risk Factors Adductor Strength (10% difference) Adductors / Abductors Ratio Hip External Rotation ROM Hamstrings Strength (Kloskowska et al, 2016) Weakness may precede pain onset by 2 weeks Adductor Related Groin Pain (Localised medially in the groin) Mainly Adductor Longus Pain on squeeze test Pain on passive stretching Pain on palpation Weakness is common Clinical Tests

6 21% of athletes had negative imaging (especially Iliopsoas & Rectus Femoris) Clinical examination appears sufficient to diagnose acute adductor injuries (Serner et al, 2016) Squeeze Test The adductor squeeze test was sensitive for athletic groin pain, but not specific to adductor pathology (Falvey et al, 2015) Soft Tissue Adductors Rectus Abdominis Obliques Pubic bone Symphysis Bone 6 degrees = Real Change in Muscle Flexibility (Cejudo et al, 2016)

7 Entrapment Neuropathies Chronic Adductor Related Groin Pain Common MRI Findings (Branci, 2013) Osteitis Pubis (Pubic BMO: 70-94%) Symphysis Joint (Deg Changes) Adductors Enthesis Pathology (Male Footballers) Co-exis(ng Pathologies Ostei&s Pubis Sports Hernia (Athle&c Pubalgia) FAI

8 Osteitis Pubis (OP) DOHA Terminology (Pubic related groin pain) Overuse Injury Kicking, Sprinting, COD Bone Stress Response Co-exist with Ch ARGP Pain on Squeeze test TOP- Symphysis Pubis MRI (Bone Marrow Oedema) Rectus Abdominis Levator Ani A Brevis A Longus Gracilis Inadequate Hip ROM (Extension or Rotation) The Football Kick Excessive compensatory motion through the Pubic Symphysis Body Part Action Key Muscles Trunk Right Hip Left Hip Stabilisation of rotation to the right Extension External Rotation and Eccentric Extension Abdominals, Psoas Major, Erector spinae, Spinal postural muscles GMax and Hams GMed, GMin, Hamstring, Adductor Magnus Right Knee Left Knee Right Ankle Flexion Eccentric extension Plantar flexion Hamstrings and Popliteus Quadriceps Plantar-flexors

9 Athletic Pubalgia /Sports Hernia Not a Hernia Myo-tendinous Injury External Oblique tear, Disruption of Conjoined tendon (Weakness of Posterior abdominal wall) Abdominal Wall Related Groin Pain Clinical Presentation - Professional Male Football or Golf - Supra-pubic pain, Fullness - Burning Pain - MRI can be normal - Dynamic Ultrasound is useful Extremely Rare in Primary Care (Very Rare in Women)

10 Prevalence of radiological signs of FAI in long-standing adductor related groin pain was 94% (Weir et al, 2011) N= 34 athletes Groin Pain > 2 months AP Pelvic X-ray FAI is a critical topic, because it is common, incompletely understood, but certainly associated with pain and perhaps arthritis progression in some patients (Nardo et al, 2015)

11 Dx of FAI Syndrome = Subj + Obj + Imaging Hip Pain > 3 months Internal Rotation < 20 (In 90 of hip flexion) Radiological confirmation (CAM - Alpha< 60, PINCHER - LCEA > 40 ) MRI (Labral or Chondral damage) Diagnostic injection (Articular or Extra-articular) No clinical evidence of inflammatory arthritis (no morning stiffness) (Nepple et al, 2013) Hip Related Groin Pain Groin Pain Limping (7 times than LBP) Clicking, Catching & Snapping Stiffness & Limited IR Sitting, Squatting, Socks (Transition & Loaded Rotation Movements) Management of Adductor Related Groin Pain

12 Phase 1 Reduce Pain Restore ROM Maintain aerobic fitness Adductor Strength Phase 2 Progress Adductor Strength Address associated deficits Progress to global LL Strengthening Phase 3 Eccentric Hip Adductor Sports Specific Training Graded RTP RCT (N=26) 12.8 weeks Vs 17.3 weeks Van den Akker Technique The mul&-modal program resulted in a significantly quicker return to sports (Weir et al, 2010) RCT (Holmich et al, 1999) Active Training Vs Passive Rx Graded Ex Programme (8-12 weeks) RTP (23 out of 29; 4 out of 30)

13 Best for Prevention of AGRP - Copenhagen Adduction - Hip Adduction with elastic band - Hip Adductor machine (Serner et al, 2014) 35.7% increase in Eccentric Hip Adduc&on Strength in 8 weeks (Ishoi et al, 2015) Initial Stage

14 Progression Late Stage Correct Associated Deficits Adductor / Abductor Strength Ra&o Knee Flexor Strength ROM Deficits (External ROM) Add/Abd Strength Ra(o 17 &mes more likely to sustain adductors strain if adductor strength was less than 80% of abductor strength (Tyler et al, 2001)

15 Hip Mobility Deficits Decreased Hip ROM is associated with more hip and groin related symptoms, independent of the presence of a cam deformity (Tak et al, 2015) Patients with CLBP had decreased hip extension and IR compared to healthy controls (Lee et al, 2015) Hip rotation ROM was less in patients with CLBP who participate in rotational sports (Dillen et al, 2008) Hip Mobility Drills

16 Self MWMs with bands may be beneficial, when used to augment therapist induced MWMs Pilot RCT - (Walsh et al, 2016) RTP Testing Movement Screening Strength Ratio CV Fitness Performance Testing Psychological Readiness

17 Return to Play Holmich et al (1999) Weir et al (2011) Supervised exercise programme 18.5 weeks Home exercise programme 17.3 weeks Weir et al (2011) Multi-modal treatment 12.8 weeks Approach Full Return to Sports Athletes seeking to reduce demand on the hip adductors may benefit from the use of direc&onal compression shorts (Chaudhari et al, 2008)

18 Summary Clinical Diagnosis of Chronic Groin pain can be challenging Adductor related Groin Pain - Common cause of acute groin pain - Previous Injury & Adductor Strength (Key Risk Factors) - Co-existing pathologies (OP, Sports hernia, FAI) - Correct associated deficits (Strength ratio, ROM) - Return to Play in Athletic Population (12 weeks to 18 weeks)

19 Ilio-psoas Related Groin Pain Anatomy Psoas Major (Transverse processes, sides of the bodies and discs from T12- L5) Iliacus (Inner aspect of iliac fossa, lip of iliac crest) Psoas Major (Anterior to Psoas major, Bodies and discs of T12 L1 to pubis) Absent in 40% of cases Iliopsoas Tendon (Usually 2 disenct tendons) Main tendon (Psoas) (Originates at level of inguinal ligament, most medial) Accessory tendon (Iliacus) (Medial fibres of iliacus, blends with main tendon over a length of 6-8cm)

20 Ilio-psoas Bursa Dimensions (5-7cm in length; 2-4 cm width) Communica5on with hip capsule (15% of populaeon) Prime generator of Hip Flexion Stabiliser of the femoral head (0-15 degrees of Hip Flexion) Stability of the Lumbar Spine Unique Dual Func5on PM-t (Lx Extension + Hip Flexion) PM-v (Trunk Flexion + Hip Flexion) (Yoshio et al, 2002; Park et al, 2013) Primary aim during gait is swing ini5a5on Control Hip Extension at end of stance phase

21 Hip Flexor Power Most prevalent limi5ng factor in sprint speed, is not hip extension, but inadequate hip flexor power Dr. Stuart McGill Iliopsoas Syndrome (Mul%ple Pathologies) Acute lesion (usually kicking or sprineng related) Chronic Lesions (> 3 months) Iliopsoas tendinopathy (+/- BursiEs) Iliopsoas Impingement (Labral tears) Iliopsoas in internal snapping hip syndrome Post-opera5ve over-use (Post THR or Hip Arthroscopy) Co-exist with Intra-arJcular Hip Pathology Decreased hip internal rota5on and extension resul5ng from intra-ar5cular pathology oxen leads to a shortened, painful iliopsoas tendon (Brophy & Prather, 2014)

22 DD: Snapping Hip (Coxa Saltans) Internal - Iliopsoas External - IT Band or GMax Tendon Common - Dancers, Gymnasts, Yoga Mechanism of Labral Tears Chronic Tight or Inflammed Iliopsoas Adherent to anterior capsulo-labral complex Traction Phenomenon (Tightness or Snapping-Tendinopathy-Tears) Clinical Profile Young females Extreme Extension (eg. Dance) All hips in this series had labrum injury at the 3 o clock posi5on (Domb et al, 2011)

23 Case Series Mean 5me = 20 months (2-96) Painful ac5ve hip flexion Painful and weak ASLR (O Sullivan et al, 2007) Clinical Findings Pain and weakness with resisted hip flexion Stretch Pain during Thomas test Pain on palpa5on of Psoas above the inguinal ligament (poor reliability) Aggravated by - Running (especially uphill) - Speed training Management of Iliopsoas Tendinopathy (without co-exis5ng Ar5cular Hip Pathology)

24 Early Stage Educa5on Ac5vity Modifica5on (No Speed) Op5mise Pelvic Stability Isometrics Avoid Aggressive Stretching Eccentric Psoas March

25 Eccentric Exercises To Improve Flexibility (Lengthen with Load) Step-up and Raise Bulgarian Split Squat Resistance (Cables or Bands) Knee Tucks on Gymball Sling Based training

26 HST group increased their hip flexion strength of the trained leg by 17% (Thorborg et al, 2015) 6 weeks training, 3 Emes/week Speed based Training (Wall Drive) Not Responding to Rehab Ar5cular Hip pathology (eg, FAI, ALT) Inflammatory Component (BursiEs) Speed, only ater adequate Hip Flexor Strength & Pelvic control

27 Management algorithm of iliopsoas tendinopathy (Garala et al, 2014) Summary Iliopsoas (Key Stabiliser of Hip and Lx Spine) Iliopsoas Syndrome (MulEple Pathologies) Can co-exist with Intra-ar5cular Hip Pathology Thank You! CPD Courses: