Differential diagnosis of hip and groin pain in athletes. Kristian Thorborg, Specialist in Sportsphysiotherapy, Ph.D., Post-doctoral fellow

Transcription

1 Differential diagnosis of hip and groin pain in athletes Kristian Thorborg, Specialist in Sportsphysiotherapy, Ph.D., Post-doctoral fellow

2 , Denmark

3 City Arthroscopic Centre Amager, University Amager Airport

4 Arthroscopic Centre Amager Ass. Prof. Per Hölmich

5 Problems ahead Arthroskopic Centre Amager,

6 The magnitude of the problem (incidens) Incidence of groin injury in soccer: /1000 hours Incidence of groin injury in soccer: 8-13 % of all injuries (Ekstrand and Gillquist, 1983; Ekstrand and Hilding, 1999)

7 Icehockey (Petterson and Lorentzon, 1993)

8 Up for the challenge? Up for a challenge Arthroskopic Centre Amager,

9 The challenge of diagnosing hip and groin injuries

10 Different country - different diagnosis Sportsman s hernia Adductor related groin pain Gilmore s groin Athletic pubalgia Intrinsic hip pathology Osteitis pubis

11 Multidisciplinary Approach In 21 male athletes (age 20 to 40 years) with longstanding unexplained groin pain, a multidisciplinary investigation was performed in order to reveal the underlying cause. These examinations included general surgery for detection of inguinal hernia and neuralgia, orthopaedic surgery for detection of adductor tenoperiostitis and symphysitis, urology for detection of prostatitis, radiology for performing herniography and plain film of the pelvic bones, nuclear medicine for isotope studies of the pubic bone and symphysis. In 19 patients there was a positive diagnosis for 2 or more of the diseases (10 patients had 2 diseases, 6 patients had 3 diseases, 3 patients had 4 diseases). Two patients had only signs of symphysitis. Our results show the complexity of longstanding groin pain in athletes. It also explains why therapy for one specific disease entity may fail. We conclude that this clinical setting demands the recruitment of a team with experience of different aspects of groin pain. (Ekberg et al., 1988)

12 Pathology Arthroskopic Centre Amager,

13 Bony changes in soccer players

14 Changes at the symphysis joint Higher athletic activity is related to more irregularity and bony changes at the pubic symphysis (Harris and Murray, 1974) Increasing age is related to more irregularity and bony changes at the pubic symphysis (Besjakov et al., 2003)

15 FAI- Cam and pincer

16 Pubic bone marrow oedema (Cunningham et al., 2007)

17 Secondary cleft sign (Cunningham et al., 2007)

18 Secondary cleft sign (Cunningham et al., 2007)

19 Functional anatomy (Robertson et al., 2009)

20 Anatomy of the adductor longus musculotendinous junction (Strauss et al., 2007, Tuite et al., 1998)

21 Bone biopsy of the parasymphyseal pubic bone region in athletes with chronic groin injury (Verrall et al., 2008)

22 Asymptomatic icehockey players (Silvis et al., 2011)

23 Asymptomatic icehockey players (Silvis et al., 2011)

24 Main role of diagnostic imaging? Exclusion of serious and obvious pathology..

25 Diagnostic imaging Treat the patient, not the x-ray

26 Where do we go then? Arthroskopic Centre Amager,

27 Reliable clinical examination procedures (Hölmich et al., 2004)

28 Clinical entities Adductor related groin pain* Abdominal related groin pain* Inguinal canal related groin pain Psoas related groin pain* Pubic symphysis related groin pain * Hip related groin pain (Hölmich et al., 2003,*Hölmich et al., 2004)

29 Adductor related groin pain (Hölmich et al., 2004)

30 Abdominal related groin pain (Hölmich et al., 2004)

31 Psoas related groin pain (Hölmich et al., 2004)

32 Pubic symphysis related groin pain (Hölmich et al., 2004)

33 How to test for hip-related groin pain? FABER and FADIR have high sensitivity, but low specificity (Martin et al., 2006) If none of these tests are positive, it is unlikely that an intra-articular hip problem is present

34 How to test for hip-related groin pain? (Martin and Sekiya, 2008)

35 Primary clinical entities in soccer players with groin injury (Hölmich et al., 2007)

36 Treatment of longstanding adductor-related groin pain

37 8-12 year follow up (Hölmich et al., 2011)

38 Mechanism of injury Arthroskopic Centre Amager,

39 Understanding mechanism of injury?

40 Understanding mechanism of injury?

41 Biomechanics of kicking (Charnock et al., 2009)

42

43

44 Clinical scenario Groin surgery, november 2009 Prognosis: 4 weeks rehab % succesrate Full return november 2010

45 Muscle strength Arthroskopic Centre Amager,

46 Assessment of hip muscle strength

47 Assessment of muscle strength is an important part of the clinical examination of patients with hip and groin pain (Hölmich et al., 2004)

48 Weak Intermediate Strong Intra-tester Kappa = Inter-tester Kappa = (Hölmich et al., 2004)

49 Hand-Held Dynamometer (HHD) versus isokinetic testing Inexpensive and easy to administer compared to traditional isokinetic testing

50 Evaluation of hip muscle strength Is it relevant?

51 Hip adduction strength deficit (Soccer) (Thorborg et al., 2011)

52 Hip adduction strength deficit (Soccer) 20 % reduced (Thorborg et al., 2011)

53 Hip adduction strength deficit (Australien Rules Football) (Malliaras et al., 2009)

54 Hip adduction strength deficit (Australien Rules Football) 20 % reduced (Malliaras et al., 2009)

55 Squeeze test (0, 45 and 90 degrees of hip flexion) (Fulcher et al., 2009; Hanna et al., 2009)

56 Hip adduction strength in the squeeze test (Hanna et al., 2009)

57 Mean hip adduction strength across studies Male soccer (Proff./Semi-proff.) 151 Nm (Hanna et al., 2009)

58 Mean hip adduction strength across studies Male soccer (Proff./Semi-proff.) 151 Nm (Hanna et al., 2009) Male soccer (Semi-proff.) 192 Nm (Thorborg et al., 2011)

59 Is the squeeze test a strength or a provocation test?

60 Hip muscle strength as a predictor of injury: (Icehockey) (Tyler et al., 2001) 47 professional players Followed during 2 seasons 11 adductor strains (3 bilateral) Low adduction to abduction strength ratio (< 0.8) increase the hip adductor strain injury risk (17 times)

61 Hip muscle strength as a predictor of injury: (Icehockey) (Tyler et al., 2001) 47 professional players Followed during 2 seasons 11 adductor strains (3 bilateral) Low adduction to abduction strength ratio (< 0.8) increase the hip adductor strain injury risk (17 times)

62 Hip adduction/abduction strength ratio as a predictor of injury: (Icehockey) (Tyler et al., 2001)

63 Hip adductor muscle strength as a predictor of injury: (Icehockey) (Tyler et al., 2001)

64 Hip muscle strength as a predictor of injury: (Icehockey) (Emery et al., 2001) proffessional players Followed during 1 season 36 groin strains No increased injury risk in players with peak adduction force < 142 NM RR 0.63 ( )

65 Hip muscle strength as a predictor of injury: (Icehockey) (Emery et al., 2001) proffessional players Followed during 1 season 36 groin strains No increased injury risk in players with peak adduction force < 142 NM RR 0.63 ( )

66

67 Hip muscle strength testing as we do it

68 Important considerations when using HHD Long lever vs. short lever Eliminate learning effect Positioning of the subject Stabilisation of the subject Intra- and inter-tester reliability

69 Long lever improves reliability Long lever gives better reliability than short lever (Krause et al., 2007; Thorborg et al., 2010)

70 Long lever improves reliability Long lever gives better reliability than short lever (Krause et al., 2007; Thorborg et al., 2010) Shortening the lever by 50% increases force values by a factor N

71 Long lever improves reliability Long lever gives better reliability than short lever (Krause et al., 2007; Thorborg et al., 2010) Shortening the lever by 50% increases force values by a factor N

72 Eliminate learning effect No systematic difference between test and retest for hip strength assessments using HHD.when using best of 4 measurements (Thorborg et al., 2010)

73 Positioning matters! (Malliaras et al., 2009) (Thorborg et al., 2010) ~ 3 Nm ~ 50 Nm

74 Stabilisation matters! (Malliaras et al., 2009) (Thorborg et al., 2010) ~ 14 Nm ~ 140 Nm

75 Hip adduction strength: supine vs. sidelying ICC SEM% ICC SEM% % %

76 Isometric hip adduction strength testing Test-retest variation Best of 4 rep. ICC= SEM%= 6 % No systematic variation (Thorborg et al., 2010)

77 Eccentric hip adduction strength testing Test-retest variation Mean of 2 rep with 5 % force-plateau ICC= 0.91 SEM%= 7 % (Thorborg et al., 2011) No systematic variation

78 Hip adduction strength differences between dominant and non-dominant limb in soccer Eccentric strength difference (14%) Isometric strength difference (3%) (Thorborg et al., BJSM 2011; Thorborg et al., AJSMS 2011)

79 Self-report

80 What about self-reported disability?

81 Important not to underestimate the importance of understanding the athletes perspective! (Martin et al., 2009; Roos, 2001)

82 .from a patients perspective! When we want your opinion we ll give it to you

83 COSMIN recommendations In accordance with COnsensus-based Standards for the selection for health Measurement INstruments (COSMIN) (Mokkink et al., 2010)

84 Artroskopisk Center Amager (Mokkink et al., 2010)

85 Clinical study 101 patients (36 years, range years), with longstanding hip and/or groin pain included: Included in study (n=101) Test-retest reliability (n=44) Construct validity (n=101) Responsiveness (n=87)

86 HAGOS

87

88 For more information concerning HAGOS

89 Acute injury Arthroskopic Centre Amager,

90 The acute case (Thorborg et al., unpublished data)

91 The acute adductor casemechanism of injury?

92 The acute adductor casemechanism of injury?

93 Hip adduction strength

94 Hip flexion strength

95 Self-reported function (Thorborg et al., unpublished data)

96 Adductor longus ruptures in american football Mean time for return to play: Non-operative group: 6.1 (range 3-12 weeks) Operative group: 12.0 (range weeks) (Schlegel et al., 2009)

97 Overuse Overuse injury Arthroskopic Centre Amager,

98 The longstanding adductor casemechanism of injury?

99 Left adductor longus (asymptomatic side)

100 Left adductor longus (asymptomatic side)

101 Right adductor longus (symptomatic side)

102 Right adductor longus (symptomatic side)

103 Normalisation of hip adduction strength in % of affected leg 1. consultation 1 week 6 weeks

104 Normalisation of hip adduction strength in % of affected leg 1. consultation 1 week 6 weeks

105 Normalisation of hip adduction strength in % of affected leg 1. consultation 1 week 6 weeks

106 1. consultation HAGOS profile

107 1 week after HAGOS profile

108 4 months after HAGOS profile

109 2 years after HAGOS profile

110 2 years after HAGOS profile

111 Current project ( ) Matched for age and sports-activity Soccer player with hip and/or groin pain Hip and groin symptom-free soccer players Hip and groin symptom-free runners MR (blinded assessment) US (blinded assessment) X-ray (blinded assessment) Hip strength (blinded assessment) Hip flexibility (blinded assessment) HAGOS (self-report) Clinical examination (clinical entities)

112 Fini THE END