6/05/2018. Aspetar, Qatar. Why the Bermuda triangle of Sports Medicine?

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Lynn Hudson
5 years ago
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difficulty Variability in terminology/classification

Physiotherapist, 00115M PhDcand @AndreaBMosler

traditionally considered difficult to manage latrobe.

based classification system Groin pain in athletes 3

study example Aspetar, Qatar Important features of

1 Why the Bermuda triangle of Sports Medicine? Complex anatomy Mul factorial ae ology diagnos c difficulty Variability in terminology/classification systems Clinical reasoning for hip and groin pain navigating the Bermuda triangle! Andrea Mosler Specialist CRICOS Sports Provider Physiotherapist, 00115M Challenge to synthesise literature Groin pain traditionally considered difficult to manage latrobe.edu.au CRICOS Provider 00115M 2 Clinical examination based classification system Groin pain in athletes 3 4 Navigate with clinical reasoning Use typical case study example Aspetar, Qatar Important features of history Clinical examination classification Evidence based management plan based on findings 5 6 1

Athlete related information 19 year old male professional soccer player National player past 3 years Midfielder Pre season phase currently Signed huge professional

over pubis when rolls over in bed Sprinting; inguinal> adductor pain 7/10.

work/cough/sneeze; inguinal pain 4/10 Os good Schlatters when 13 yrs, better now am stiff walking 10 mins then ok ppm wakes up with pain and clicking on turning over,

pain in football Groin pain started 3 months ago with minor acute strain R adductor longus, resolved in one week Two months later developed mild discomfort in the

Osgood Schlatters R knee, L ankle sprain but no current symptoms Red flags all High prevalence male football players 21% per season 1,2 3rd most common injury,

2 Athlete related information 19 year old male professional soccer player National player past 3 years Midfielder Pre season phase currently Signed huge professional contract and anxious ++ to be better before season starts Not sure about the medical staff at the new club 7 8 Area of Symptoms Behaviour symptoms p&n numb clicking over pubis when rolls over in bed Sprinting; inguinal> adductor pain 7/10. Jogging Change direction; adductor> inguinal 5/10 Intermittent deep ache Kicking; adductor> inguinal 7/10 sharp pain Occasional sharp grabbing pain Upper body gym work/cough/sneeze; inguinal pain 4/10 Os good Schlatters when 13 yrs, better now am stiff walking 10 mins then ok ppm wakes up with pain and clicking on turning over, but goes back to sleep Minor ankle sprain last year, fully resolved 2 months No symptoms on rest days apart from morning stiffness 9 10 History Epidemiology of groin pain in football Groin pain started 3 months ago with minor acute strain R adductor longus, resolved in one week Two months later developed mild discomfort in the inguinal region Adductor pain came back 1 week ago Now the pain is severe enough to affect performance, especially kicking power and change in direction Past history of Osgood Schlatters R knee, L ankle sprain but no current symptoms Red flags all High prevalence male football players 21% per season 1,2 3rd most common injury, frequency 13% (4 19%) of all time loss injuries in male football 3 Less common in females 7% (2 11%) 3 High burden and recurrence rate 1,2,3,4,5 Complex and multifactorial aetiology 4,5 1 Mosler et al Werner et al Walden et al Whittaker et al Ryan et al

Clinical reasoning considerations in examination Diagnosis/classification groin pain Source of pain Contributing factors Diagnosis based on the clinical entity approach 1 A systematic clinical

established 1 1 Hölmich et al 1997, 2004, 2007 13 14 Physical Examination Physical Examination Pain provocation tests Hip joint specific tests negative (FADIR/FABER) Resistance tests Squeeze 0 and 45

pain on R Palpation tenderness inguinal region R, slight bulge on palpation inguinal canal adductor insertion very tender R no other tenderness on palpation significant tone adductor muscles 15 16

tenderness and pain on resisted adduction testing Two clinical entities: Iliopsoas related groin pain Inguinal related groin pain Iliopsoas tenderness, more likely if pain on resisted hip flexion

More likely if pain aggravated by Adductor related groin pain abdominal resistance or Valsalva/cough/sneeze Pubic related groin pain Additional Categories Local tenderness of the pubic symphysis and

3 Clinical reasoning considerations in examination Diagnosis/classification groin pain Source of pain Contributing factors Diagnosis based on the clinical entity approach 1 A systematic clinical approach to classifying hip and groin pain in athletes 1 Aim to identify a diagnostic pattern Palpation, resistance testing and stretching Athlete related factors Management plan Reliability has been established 1 1 Hölmich et al 1997, 2004, Physical Examination Physical Examination Pain provocation tests Hip joint specific tests negative (FADIR/FABER) Resistance tests Squeeze 0 and 45 = R adductor pain 7/10 Resisted hip flexion= 0/10 Abdominal sit up= 5/10 inguinal pain R inguinal pain on cough Stretch tests Hip flexor stretch= 0/10 Adductor stretch= 5/10 adductor and inguinal pain on R Palpation tenderness inguinal region R, slight bulge on palpation inguinal canal adductor insertion very tender R no other tenderness on palpation significant tone adductor muscles Clinical diagnosis Classification system of groin pain in athletes, adapted from Weir et al 2015 Defined clinical entities Adductor related groin pain Symptoms and examination findings Adductor tenderness and pain on resisted adduction testing Two clinical entities: Iliopsoas related groin pain Inguinal related groin pain Iliopsoas tenderness, more likely if pain on resisted hip flexion and/or pain on hip flexor stretching Pain located in the inguinal canal region and tenderness of the inguinal canal. No palpable inguinal hernia is present. More likely if pain aggravated by Adductor related groin pain abdominal resistance or Valsalva/cough/sneeze Pubic related groin pain Additional Categories Local tenderness of the pubic symphysis and the immediately adjacent bone. No particular resistance tests to test specifically for pubic related groin pain Inguinal related groin pain Hip related groin pain Clinical suspicion that the hip joint is the source of groin pain, either through history or clinical examination Any other orthopaedic, neurological, rheumatological, urological, Other gastrointestinal, dermatological, oncological or surgical condition causing pain in the groin region Mosler et al

Examination contributing factors Strength/endurance Range of motion Functional

specialists for assessment Diagnosis, contributing factors, management plan

Psychology Nutrition Podiatry 21 22 Management plan Diagnosis; treatment and

Contributing factors/impairments Athlete related factors; age, level of play,

4 Examination contributing factors Strength/endurance Range of motion Functional testing Knee examination Taylor et al 2017 Ankle examination Refer to other specialists for assessment Diagnosis, contributing factors, management plan Podiatry Gait and running biomechanics Radiology Strength and conditioning Psychology Nutrition Podiatry Management plan Diagnosis; treatment and rehabilitation specific to address adductor and inguinal related groin pain Contributing factors/impairments Athlete related factors; age, level of play, position, coach, match schedule, acute and chronic training load Patient reported outcome measures HAGOS

Criterion based rehabilitation Impairments

determine load progression 25 26 The Hölmich

(Hölmich et al, 1999, Jansen et al, 2009, Weir

28 What about inguinal related groin pain?

Standardised definitions and terminology

5 Criterion based rehabilitation Impairments found in assessment Evidence based management Outcome measures determine exercise progression Sensitive pain provocation tests determine load progression The Hölmich protocol First 2 weeks: adductor and abdominal (Hölmich et al, 1999, Jansen et al, 2009, Weir et al 2011, Paajanen et al, 2011) 2 weeks until symptom free: adductor, abductor, abdominal, low back, What about inguinal related groin pain? Summary Very little evidence for efficacy of conservative management Should we trial conservative? Yes, it is a complex area! Standardised definitions and terminology Examination aimed at diagnosis and impairments Directs the management/rehabilitation plan

resisted adduction testing Evidence based

Mosler Specialist Sports Physiotherapist,

related groin pain Inguinal related groin

canal a) resisted hip flexion No palpable

groin pain No specific clinical test Good

6 Adductor related groin pain Local tenderness of the adductors Pain on resisted adduction testing Evidence based assessment of hip and groin pain Andrea Mosler Specialist Sports Physiotherapist, CRICOS Provider 00115M latrobe.edu.au CRICOS Provider 00115M 32 Iliopsoas related groin pain Inguinal related groin pain Local tenderness of the iliopsoas Pain in the inguinal canal region More likely if pain on: Tenderness of inguinal canal a) resisted hip flexion No palpable inguinal hernia b) hip flexor stretching More likely if pain on: valsalva/cough/sneeze resisted abdominal contraction Pubic related groin pain Hip related groin pain Tenderness of pubic symphysis and adjacent bone No specific resistance test Common cause of groin pain No specific clinical test Good sensitivity, poor specificity Rule out/not in If ROM normal, FABER, FADIR ve = hip less likely

$fracture (AIIS, ASIS, pubic bone,$ $Stress fracture (femoral neck, pubic$ rami, acetabulum) Hip joint (slipped

7 Other causes True inguinal or femoral hernia Nerve entrapment (obturator, ilioinguinal, genitofemoral) Referred pain (lumbar spine, SIJ) Apophysitis or avulsion fracture (AIIS, ASIS, pubic bone, lesser trochanter) immature athletes Stress fracture (femoral neck, pubic rami, acetabulum) Hip joint (slipped capital femoral epiphysis, Perthes disease, AvN, reactive or infectious arthritis) Medical (inguinal lymphadenopathy, intra abdominal abnormality, prostatitis, UTI, kidney stone, appendicitis, diverticulitis, gynaecological) Spondyloarthropathies Tumours (testicular, bone, prostate, urinary, digestive, soft tissue) Impairment testing Strength Endurance Range of Motion Functional tests Strength Strength other options as appropriate Eccentric Adduction Eccentric Abduction Squeeze test Range of motion Endurance Internal and External Rotation at 90 Prone Hip Internal Rotation Hip Abduction Bent Knee Fall Out

8 Fucntional tests Single leg stance/squat Star Excursion Balance Test Single leg hop for distance: anterior/medial/lateral Triple hop Change of direction tests (t test, Illinois) 43 8

Hip & Groin pain. M Hassabi (MD) Assistant professor Department of Sports & Exercise Medicine Shahid Beheshti University of Medical Sciences

Hip & Groin pain. M Hassabi (MD) Assistant professor Department of Sports & Exercise Medicine Shahid Beheshti University of Medical Sciences Hip & Groin pain M Hassabi (MD) Assistant professor Department of Sports & Exercise Medicine Shahid Beheshti University of Medical Sciences EPIDEMIOLOGY Groin pain and injury is common with sports that