Treatment of groin injuries

Transcription

1 Treatment of groin injuries Per Hölmich Sports Orthopedic Research Center Copenhagen (SORC-C) Department of Orthopedic Surgery Copenhagen University Hospital Hvidovre, Denmark & IOC Research Center Copenhagen Research Center for Injury Prevention and Protection of Athlete Health

2 The epidemiology - elite and non-elite football players 64% (63%) adductor-related 10% (8%) iliopsoas-related 4% (4%) inguinal-related 5% (4%) hip-related 14% of all time-loss injuries Werner et al; BJSM 2009 & % adductor-related 30% iliopsoas-related 19 % inguinal-related Hölmich et al; BJSM 2013 Clinical diagnosis Acute injuries 66% - Adductor 25% - Iliopsoas 23% - Rectus Femoris 10% - Abdominal 6% - Sartorius Andreas Serner et al, AJSM 2015

3 Isometric adductor test The best squeeze test to identify pain related to the adductor longus Lovell G et al Drew M et al Photos courtesy of UEFA Football doctor education program

4 Palpation of the adductor origin Photos courtesy of UEFA Football doctor education program

5 Treatment of longstanding adductor-related groin pain

6 Treatment of longstanding adductor-related groin pain

7 Exercise program for adductor related groin pain training period 8 to 12 weeks h.theapp.mobi/adductorprotocol Created by Roald Otten Hölmich et al, The Lancet 1999 Multimodal treatment RCT Weir et al; Man Ther 2011

8 Important aspects of the program Lots of repetitions 3 times a week, 1½ hour duration,8-12 weeks No pain provoking/exacerbating activities Running allowed after 6 weeks (no pain) Good results achieved in 4 months Hölmich et al, The Lancet 1999 h.theapp.mobi/adductorprotocol

9 Adductor tenotomy (unsystematic review) Five Level 4 studies with great variety in study design Excellent result in 54% - 75% Poor results in 8% - 17 % Complications 5% - 34% h.theapp.mobi/adductorprotocol Active exercise program (Lancet 1999) Excellent 79% Poor 3% Complications 0

10 8-12 year follow up Hölmich et al; AJSM 2011

11 Inguinal-related groin pain - Treatment No evidence-based non-surgical treatment programmes The general principles of the treatment programme used for adductor-related injuries can be used - strengthening muscles, training balance & coordination around the pelvis..including a particular focus on specific abdominal muscle exercises

12 Strengthening the abdominals Sundstrup E et al., 2012

13 Inguinal-related groin pain - treatment With long-standing exercise resistant inguinalrelated groin pain, surgery is an option The basic principles of the surgical procedure and the post-operative regime are identical to those for manifest hernias open or endoscopic - apart from the fact that there is no hernia sac to invert or remove

14 Iliopsoas-related groin pain - Treatment No evidence-based rehabilitation programmes The general principles of the treatment programme used for adductor-related injuries can be used - strengthening muscles, training balance & coordination around the pelvis Including a particular focus on specific exercises for the hip flexor muscles Start with isometric and gentle eccentric exercises Continue with heavy slow resistance training

15 Strength training of hip flexors a RCT 17% strength increase in 6 weeks Thorborg et al., KSSTA 2015

16 Iliopsoas-related groin pain - Treatment No evidence-based rehabilitation programmes The general principles of the treatment programme used for adductor-related injuries can be used Including a particular focus on specific exercises for the hip flexor muscles Start with isometric and gentle eccentric exercises Continue with heavy slow resistance training If it is too painful to do the strength training program ultrasound guided cortisone injections can be helpful

17 Iliopsoas-related groin pain - Treatment No evidence-based rehabilitation programmes The general principles of the treatment programme used for adductor-related injuries can be used Including a particular focus on specific exercises for the hip flexor muscles Start with isometric and gentle eccentric exercises Continue with heavy slow resistance training Return to play in three to six weeks Almost never indication for: Arthroscopic partial iliopsoas tenotomy in athletes

18 Copenhagen Hip and Groin Outcome Score - HAGOS Thorborg, Hölmich et al; 2011 BJSM HAGOS is a profile score Consists of 6 subscales/scores Measuring specific dimensions and constructs relevant to the effects of hip/groin impairment Has been translated into multiple languages

19 AJSM 2018

20 Methods Danish Hip Arthroscopy Registry years old at time of surgery Hip arthroscopy for femoroacetabular impingement syndrome in preceding 6 months to 6 years Cam resection + labral surgery AJSM 2018 Ishøi et al

21 Return to preinjury sport and HAGOS AJSM 2018 Ishøi et al

22 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Return to sport following hip arthroscopy for femoroacetabular impingement syndrome 89,0% 74,0% 57,1% 49,0% Wörner et al., 2018 BJSM (N=127) Ishøi et al., Accepted AJSM (N=189) Combined N=316 21,0% 16,9% Any sport Preinjury sport Same/optimal performance Ishøi et al

23 Groin and hip pain during previous season and at beginning of current season registered HAGOS score at beginning of current season Half of the players report pain in the hip and/or groin during the previous football season The football players with the longest duration of pain in previous season displayed the lowest HAGOS scores in the beginning of the new season..the groin pain carries over to next season

24 Recommendation Use the off-season to focus on treatment and recovery rather than simply resting Examine the athletes at the end of the season Use the off-season to improve any muscular deficits found - combined with sports specific training

25 The between-group difference for EHAD strength increase was 13% - (p=0.044)

26 The Copenhagen 5-second squeeze 5-second isometric hip-adduction contraction with extended legs in the supine position Hölmich et al., 2004

27 A simple idea How much pain 0-10? Thomee, 1997

28 Correlation between HAGOS and pain with The Copenhagen 5-Second Squeeze n=668 football players Thorborg K, Hölmich P et al; BJSM 2017

29 The Copenhagen 5-second squeeze is strongly related to hip- and groin sporting-function..and help you decide to give green or red light for your soccer-player Thorborg K, Hölmich P et al; BJSM 2017

30 Prevention of groin injuries - a joined research project with Oslo and Copenhagen IOC Research Centres A cluster RCT The preventive effect of an Adductor Strengthening Program on groin problems in Norwegian male football players

31 Copenhagen Adduction Significant increase in eccentric strength (35.8%) after 8 weeks training Serner et al; BJSM 2013 Ishøi et al; SJMSS 2015

32 RCT using the Copenhagen Adduction as a single exercise intervention Joar Harøy et al Level 1 Level 2 Level 3 Weekly Week Set per side Repetitions per side sessions In season

33 OSTRC Overuse Injury Questionnaire (Clarsen et al. 2013) 632 players from 34 teams 76% gradual onset 2500 groin problems reported 37% time loss Majority in the dominant leg Joar Harøy et al

34 All groin problems Mean difference in prevalence: 7.8% 41% lower injury risk (OR 0.59, p=0.008) Joar Harøy et al

35 Summary Use sufficient exercise stimulation and.time! - Take another look at the old 1999 Lancet study it still works Restore the associated pelvic muscular deficits Restore the demands and skills needed to participate in sport including endurance Monitor the groin and hip status with HAGOS

36 Summary Use the off season break to avoid continued and new groin injuries Use the Copenhagen 5-Second Squeeze and HAGOS to monitor players on a regular basis Use the Copenhagen Adduction exercise for prevention

37 Thank you