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

Transcription

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

2 EPIDEMIOLOGY Groin pain and injury is common with sports that involve kicking, rapid acceleration and deceleration, and sudden change of direction Hip and groin pain is the 3 rd most common injury reported in the Australian Football League (AFL) 5 15% of all injuries In soccer (according to a systematic review of 34 articles)* groin injuries in male club soccer accounted for 4 19% of all injuries groin injuries in female club soccer accounted for 2 14% of all injuries Male>Female groin injury rates in males /1000 hours groin injury rates in Fmale /1000 hours Our experience** 40% of acute & Chronic injuries occurred in groin and thigh * Br J Sports Med 2015;49(12):792 **Asian J Sports Med Dec; 1(4):

3 Patient history The athlete experiences groin pain, which is usually located in the medial upper thigh around the proximal adductors and pubic rami. The pain can also be more central in the upper thigh inferior to the inguinal ligament around the hip joint/distal iliopsoas region. The pain frequently starts in one region and is unilateral, but it can gradually spread to other regions and become bilateral. Pain superior to the inguinal ligament can be felt in the region of the inguinal canal. Groin pain in athletes is aggravated by exercise, with running, twisting/turning and kicking being the most challenging activities. The athlete and coach usually notice a decrease in sports performance, especially related to performing explosive sporting actions such as kicking, accelerating/decelerating, turning and so on.

4 Pain pattern The onset of groin pain in athletes can be acute or gradual, but with both types of onset, groin pain can become longstanding. In the early stages, the longstanding groin pain patient typically presents late during the physical activity or after activity, with pain and stiffness next morning. The pain and stiffness then gradually lessen with daily activities and warming-up for the next training session or match. When the condition worsens, pain is present immediately upon exercise. Non-steroidal anti-inflammatory drugs (NSAIDs) tend to decrease pain, but will usually not result in a lasting cure. Short periods of rest reduce the severity of the symptoms, but on resumption of sporting activities the pain often returns to its original intensity and severity. The natural history is one of progressive deterioration with continued activity until symptoms prevent participation in the sporting activity.

5 RISK FACTORS of groin pain in athletes previous groin injury (level 1) higher level of play (level 1) reduced hip adduction strength (level 2) lower levels of sport-specific training (level 2)

6 Doha agreement meeting on terminology and definitions in groin pain in athletes The preferred term : groin pain in athletes. This was favoured over others (e.g. athletic pubalgia, athletic groin pain, sports groin pain, athletes groin)

7 Classification of groin pain in athletes The classification system has three major subheadings 1. Defined clinical entities for groin pain 2. Hip-related groin pain 3. Other conditions The main categories are orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological and surgical Br J Sports Med Jun; 49(12):

8 1. Defined clinical entities for groin pain History: pain in the affected region that worsens on exercise PE: Palpation, resistance testing and stretching of affected muscle groups are used to categorise athletes into these entities: adductor related iliopsoas related inguinal related pubic related some groin injuries such as proximal rectus femoris injuries would not readily fit into the classification system currently proposed

9 Hip-related groin pain History should focus on the onset, nature and location of the pain and mechanical symptoms such as catching, locking, clicking or giving way Most clinical tests for the hip joint have good sensitivity but poor specificity. This means that clinical tests can be useful in practice for excluding hip-related groin Anterior pain causes Femoroacetabular impingement synovitis Labral tears Chondropathy OA LIGAMENTUM TERES TEARS Stress fractures Joint instability Not to be missed slipped capital femoral epiphysis (adolescents) Perthes disease (children and adolescents) avascular necrosis /transient osteoporosis of the head of the femur arthritis of the hip joint (reactive or infectious)

10 Other conditions Other musculoskeletal causes Inguinal or femoral hernia Post-hernioplasty pain Nerve entrapment: obturator ilioinguinal genitofemoral Iliohypogastric Referred pain lumbar spine sacroiliac joint Apophysitis or avulsionfracture anterior superior iliac spine anterior inferior iliac spine pubic bone Not to be missed Stress fracture neck of femur pubic ramus acetabulum Inguinal lymphadenopathy Intra-abdominal abnormality prostatitis urinary tract infections kidney stone appendicitis diverticulitis Gynaecological conditions Spondyloarthropathies Tumours

11 hip adductors The hip adductors include pectineus, gracilis and adductor longus, brevis and magnus. The adductors are the most commonly injured groin muscle in soccer Side-to-side movements, kicking, twisting and turning activities which aggravate the pain suggest adductor-related groin pain

12 the adductor longus the most commonly injured adductor muscle inserts at the middle one-third of the linea aspera of the femur It has an interesting proximal origin. The origin is predominantly muscular (around 60%) The anterior tendinous portion continues across the front of the symphysis to fuse with the distal rectus and external oblique forming an aponeurosis. This aponeurosis has fibres that insert from the adductors and rectus directly into the pubic symphysis joint capsule and disc.

13 the adductor longus The adductor longus not only acts as an adductor but also as an important hip flexor when the hip is in an extended position therefore is also highly involved in kicking

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15 Iliopsoas-related groin pain The iliopsoas is the primary hip flexor Frequently injured during kicking Iliopsoas-related groin pain is the second most common injury in the groin region

16 Iliopsoas-related groin pain It is characterised by pain in the anterior part of the proximal thigh, more laterally than adductor-related groin pain Straight-line running or jogging suggests iliopsoas-related groin pain iliopsoas-related groin pain is more likely if there is pain on resisted hip flexion AND/OR pain on stretching the hip flexors.

17 Inguinal related groin pain Different terms used for this condition: sports hernia, sportsman s groin, posterior wall weakness, incipient hernia, Gilmore s groin and hockey groin The exact underlying problem is unknown ; some proposed underlying pathologies are: Bulging of the posterior wall bulging causing entrapment neuropathy tendinopathy of the inguinal ligament tears of the external oblique aponeurosis tearing of the conjoined tendon

18 The diagnostic criteria for inguinal-related groin pain pain in inguinal canal region and tenderness of the inguinal canal no palpable inguinal hernia is present more likely if aggravated with abdominal resistance (sit-ups) or Valsalva/cough/sneeze

19 Pubic symphysis The pubic symphysis is the site of numerous musculotendinous attachments, which act to dynamically stabilise the anterior pelvis and the transference of large forces acting across this joint, especially during specific sporting activities such as kicking and cutting

20 Pubic related groin pain Traditionally described as Ostitis pubis local tenderness of the pubic symphysis and the immediately adjacent bone No particular resistance test to provoke symptoms ; however squeeze test is most relevant

21 The hip functions Allowing mobility of the lower limb, Transmitting loads between the upper body, trunk and lower limb Providing a stable base in weightbearing activities

22 Passive supports of hip joint bony morphology The acetabulum position Femoral head anteversion Head neck offset Labrum capsule and ligaments

23 Ligaments of the hip The iliofemoral ligament ( Y ligament of Bigelow ) reinforces the anterior capsule. It is taut in hyperextension and also provides stability in relaxed standing The pubofemoral ligamentis taut in abduction and extension and also reinforces the anterior capsule ischiofemoral ligament arises from the posterior surface, Its fibres run in a spiral pattern and are also taut in hyperextension These three ligaments act to restrain hyperextension, which is of particular relevance in relaxed standing

24 transverse acetabular ligament traverses the acetabular notch, connecting the anterior and posterior edges of the labrum The deepest layer of labral tissue blends into this ligament The transverse acetabular ligament is under greatest load in weight-bearing important proprioceptive role, especially in weight-bearing activities

25 Active supports of hip joint (Muscles) The concept of deep hip stabilisers as the hip rotator cuff has grown in popularity in recent years The six short hip external rotators provide hip joint compression and hence dynamic stability during most weight-bearing and nonweight-bearing activities The gluteus medius is the dominant hip abductor and is the primary lateral stabiliser of the hip during one-leg stance activities

26 the primary hip stabilisers provide a posterior, medial and inferior force on the femur to control the position of the head of femur within the acetabulum minimise stress on structures, such as the anterosuperior acetabular labrum and the anterosuperior acetabular rim

27 FEMOROACETABULAR IMPINGEMENT pincer impingement This refers to a morphological or orientational abnormality of the acetabulum leading to an overcoverage of the femoral head. This can either manifest as a deep acetabulum or as a retroverted acetabulum Particularly during hip flexion, the femoral neck can impinge against the over-covered acetabulum, causing an impaction on the labrum

28 FEMOROACETABULAR IMPINGEMENT cam impingement the morphological abnormality is located on the femoral side of the hip joint extra bone formation at the anterolateral head neck junction, causing a non-spherical femoral head During hip motion, particularly flexion and internal rotation, the cam deformity can be forced into the acetabulum, causing shear forces at the chondrolabral junction A cam deformity and a pincer deformity may coexist

29 a cam deformity or a pincer deformity will not always cause FAI The prevalence of cam deformity in the general asymptomatic population has been estimated at around 10 25% pincer deformity is present in about 20% of the population Hip loading during adolescence is emerging as a key factor in the aetiology of a cam deformity The prevalence was higher in both football players and basketball players than in non-athletic controls. In these young athletes, the extra bone formation in the anterolateral head neck junction becomes radiographically visible from around the age of 13 years After growth plate closure, the morphology of the proximal femur appears to change minimally. the cam deformity develops gradually until the growth plate closes This is supported by the high prevalence of cam deformity in adult athletes participating in high-impact sports ranging from 60% to 89% Genetics might also play a role, as a cam deformity might have a familial pattern, with siblings being three times more likely to have a cam deformity than controls

30 Cam impingement is associated with intra-articular pathology, whereas the association between pincer impingement and intra-articular pathology is less clear.

31 Acetabular labral tears Acetabular labral tears are seen frequently in the athletic population In 22% of athletes with groin pain In 55% of patients with mechanical symptoms and hip pain cam-type FAI and developmental dysplasia of the hip (DDH) risk The prevalence of labral tears is greatest anteriorly Patients with labral tears are 40% more likely to have coexisting chondropathy. (May be due to reduced chondral nutrition and load-bearing capacity of a damaged labrum)

32 Classification Tears of the acetabular labrum are usually classified as type I or type II tears Type I is described as a detachment of the labrum from the articular hyaline cartilage at the acetabular rim Type II is described as cleavage tears within the substance of the labrum

33 LIGAMENTUM TERES TEARS Ligamentum teres tears can occur in isolation, but often coexist with FAI, dysplasia and synovitis, probably due to the altered joint loads seen in these conditions Studies have found up to 70% of athletes undergoing hip arthroscopy for FAI and labral tears also have tears of the ligamentum teres The mechanism of injury for ligamentum teres most commonly involves forced flexion and adduction, and often internal or external rotation the ligamentum teres playing a large proprioceptive and stabilization role of the hip

34 Classification type I is a partial tear type II is a complete rupture type III is a degenerate ligament

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