Doc..I ve done my groin
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- Abigayle Hodges
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1 The groin is a very sensitive area.. Doc..I ve done my groin Peter Brukner OAM, MBBS, FACSP Professor of Sports Medicine Sport and Exercise Medicine ResearchCentre Latrobe University, Melbourne, AUSTRALIA 1
2 2
3 The Patient 24 year old footballer 6 months right groinpain Gradual onset Able to train and play but not any more Pain not well localised adductor insertion, pubic symphysis, inguinal region Sl aggravated bycoughing 3
4 The Patient Pain on resisted adduction The Patient X ray moth eaten appearance Pain on iliopsoas stretch No obvious hernia Isotope bone scan increased uptake MRI oedema in pubicsymphysis 4
5 One of these? What is yourdiagnosis? Groin strain Osteitis pubis Sports hernia Athletic pubalgia Conjoint tendon tear Incipient hernia Adductor tendinitis Rectus abdominis tendinitis Hip pathology 5
6 Geographical 189cases of groin pain (Lovell 1995) Australia post wall weakness, osteitis pubis USA groin strain, athletic pubalgia, hockey groin UK Gilmore s groin, inguinal ligament Germany minimal repair Denmark adductor-related pain incipient hernia 95 50% adductor lesions 36 19% osteitis pubis 26 14% pubic instability 8 4% Iliopsoas injury 5 3% ilioinguinal nerve 5 3% referred pain 4 2% hip lesions 3 1% stress fracture 2 1% Lovell G. The diagnosis of chronic groin pain in athletes : a review of 189 cases. Aust J Sci Med Sport 1995;27:76 9 6
7 218 consecutive groin pain patients (Bradshaw 2008). So how are we going to treat this patient of ours? Bradshaw CJ et al. Br J Sports Med 2008;42: Copyright 2008 BMJ Publishing Group Ltd. 7
8 Surgery Hernia repair Post wall reinforcement Mesh insertion Minimal repair Conjoint tendon repair Inguinal ligament release Adductor tenotomy Obturator nerve release Curettage Wedge resection symphysis Surgery with the lot hernia repair repair of the conjoint tendon adductor tenotomy obturator nerve release 8
9 Athletic Groin Pain The evidence. Evidence surgical treatment Inguinal wall repair Laparoscopic herniorraphy Endoscopic mesh Adductor longus release Curettage Wedge resection symphysis 9
10 Outcomes All positive No matter what surgery is done? Common mechanism Nerve decompression Fascial release? Quality of research? Recurrence rates Evidence -treatment Rest (Verrall, 2007) Corticosteroid injections (Holt et al, 1995) Compression shorts (McKim & Taunton, 2001) Biphosphonates (Maksymowych et al, 2001; Stewart et al, 2005) Prolotherapy (Topol, 2005) Core stability (Cowan, 2004) Radiofrequency denervation (Comin et al, 2013) Physical therapy (Holmich, 1999) 10
11 Confused? 11
12 Pubic overload PUBIC BONE OVERLOAD PAIN OVERLOAD TIGHTNESS DYSFUNCTION WEAKNESS 12
13 Pubic bone overload 13
14 And don t forget the hip The Doha Agreement 14
15 The Doha Agreement Terms we are NOT going touse adductor and iliopsoas tendinitis or tendinopathy athletic groin pain athletic pubalgia biomechanical groin overload Gilmore s groin groin disruption Hockey-goalie syndrome Hockey groin osteitis pubis sports groin sportsman s groin sports hernia sportsman s hernia 15
16 Classification system Defined clinical entities for groin pain: adductor-related iliopsoas-related inguinal-related pubic-related Hip related groin pain Other causes of groin pain inathletes Clinical entities 16
17 Other possible causes of groinpain Stress fractures 17
18 PUBIC OVERLOAD Pubic Overload Adductor Psoas Rectus abdominis Increased load on pubic complex Poor core stability (lumbo-pelvic control)? Role of restricted hip ROM? Role of gluteal muscles? Role of lumbar pathology 18
19 Management HOW? Reduce the load Rest Reduce muscle tone Stretch Soft tissue release Dry needling Surgery 19
20 The role of strength In athletes with nonspecific groin pain, it seems that bilateral isometric hip adductor strength is decreased by 20% to 25% compared with asymptomatic controls when using a sphygmomanometer in the squeeze test. Strengthen -Holmich et al, Lancet 1999 Malliaras P, Hogan A, Nawrocki A, Crossley K, Schache A. Hip flexibility and strength measures: reliability and association with athletic groin pain. Br J Sports Med. 2009;43: Nevin F, Delahunt E. Adductor squeeze test values and hip jointrange of motion in Gaelic football athletes with longstanding groin pain. J Sci Med Sport.2014;17(2):
21 Holmich et al, Lancet 1999 Copenhagen adduction exercise 21
22 Hip flexors Long lever planks 22
23 Dynamic with eccentric emphasis MANAGEMENT Progress slowly Use clinical indicators Progress to functional activities 23
24 Surgery??? 24
25 Early Warning Signs PREVENTION tight/stiff during or after activity loss of acceleration vague discomfort deceleration loss of maximal sprinting speed loss of distance withkick Manage load Esp in younger andolder players Good lumbo-pelvic control Good adductor strength 25
26 PREVENTION -Load Monitoring Monitoring playing and training load Game time Training time GPS Match data Heart rate RPE 26
27 PREVENTION -Monitoring What about the hip? Adductor squeeze dynamometer strength reduced prior to groin injury Crow JF, Pearce AJ, Veale JP et al. Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players J Sci Med Sport 2010;13(2): Engebretsen AH, Myklebust G, Holme I et al. Intrinsic risk factors for groin injuries among male soccer players. Am J Sports Med 2010;38(10): Now used regularly during the footballseason to identify those at risk of developing groin pain 27
28 OA hip and then these guys came on the scene 28
29 A whole new world was opened to them... What is FAI? What is FAI? 29
30 What morphology is typically seen infai? FAI -Cam FAI -Pincer Normal scoop on NOF, acetabular anteversion Cam bony growth on anterior/superior neck of femur Pincer Acetabular retroversion Deep socket 30
31 Is there a standard definition offai? BJSM
32 Warwick Consensus Agreement For a patient to be diagnosed with FAI Syndrome, must have: Does it matter? 1. Positive imaging findings 2. Symptoms of hip or groin pain 3. Signs of FAI, including physical impairments and positive impingement tests. BJSM
33 Does it matter? cam develops years Agricola AJSM 2014, Siebenrock 2011, Pollard 2010 FAI, labral, chondral (35y.o) Kemp BJSM 2013 camfai 5-20 years Agricola 2013, 2013, Nicholls2011 Hip OA camfai Hip OA Pain, 5-20 poor years PROs, physicalimpairments Agricola 2013, 2013, Nicholls2011 Time line of lifespan of hip patient Painful FAI +/- labral (25y.o) Kemp BJSM 2012 Clinical hip OA (40+y.o) McCarthy 2011, Tuominen
34 Does FAI matter? Yes!! While most people with cam morphology do not develop FAI, for those that do, the impact is enormous Quality of life scores similar to people with end stage hip OA. Young and middle aged people with large family and work commitments Unable to exercise = big consequences for general health Increased risk of end stage hip OA and THA Rates of hip arthroscopy USA 465% increase between Maradit Kremers et al 2017, Montgomery etal 2013 Australia 200% increase between 2010 and 2013 Medicare data 2015 Europe registry data becoming available Asia rates unknown Surgery for developed nations 34
35 Hip arthroscopy Hip arthroscopy: current evidence for outcomes Surgical management? Large amount of anecdotal and opinion piece evidence supporting hip arthroscopy to improve symptoms and stop progressionto hip OA infai. 35
36 Surgical management? Surgical management? Large amount of anecdotal andopinion piece evidence supporting hip arthroscopy to improve symptoms and stop progression to hip OA in FAI. 36
37 What is theevidence for surgery? Methodological quality poor and thus limits confidence in results 37
38 Current evidence for nonsurgical treatment of FAI Large positive within-subject effect sizes for improved pain and function for up to 10 years (no femoral osteoplasty) and 3 years (femoral osteoplasty) Outcomes for hip OA appear worse but unclear Adverse events were minimal (7% of participants in 12 studies); transient neuropraxia (83%). 38
39 Outcomes of operative treatment of FAI are significantly better than non-surgical management. 28 surgical studies vs 1 PT study 39
40 Fairley J et al, Osteoarthritis Cart 2016 Although there is evidence that surgery improves symptoms and bone shape in thosewith FAI, there are no data directly comparing surgical and nonsurgical approaches. Given the potent placebo effect of surgical intervention demonstrated at the knee joint,nonblinded RCTs cannot delineate actual vs placebo effect of surgical intervention. Fairley J et al, Osteoarthritis Cart
41 FAI in longstanding groinpain SUMMARY The prevalence of radiological signs of FAI was 94% (64/68) Weir A, de Vos RJ, Moen M, et al. Prevalence of radiological signsof femoroacetabular impingement in patients presenting with longstanding adductor-related groin pain Br J Sports Med : 6-9 Dramatic changes in ourunderstanding of both groin and hippain The entities are much better defined The role of surgery has diminished The role of physiotherapy has increased 41
42 Thank you 42
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