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1 GROIN DISRUPTION MR O J A GILMORE MS FRCS FRCS (ED) F. INST. SPORTS MED.

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3 5% ALL SPORTS INJURIES AFFECT GROIN

4 PATIENT S REFERRED with GROIN PAIN TOTAL 7273 MALE 7030 (97%) FEMALE 273 (3%)

5 PATIENT REFERRAL ( ) INCIDENCE of OPERATION CASES REFERRED 7273 OPERATIONS 4227 (58%)

6 Basketball OTHER SPORTS GROIN PAIN GROIN Fencing PAIN Handball Equestrian MANY CAUSES Gaelic football Martial Arts American ORTHOPAEDIC Football Dancers Hurling Gymnasts SOFT TISSUE INJURY Waterpolo Kick Boxing Ice Hockey CO-EXISTENT PATHOLOGY Skiing & Snowboarding

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8 DIRECT TRAUMA FALL KICK PUNCH IMPACT SQUEESE

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10 REFERRED PAIN

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12 GROIN DISRUPTION SPORTSMEN GROIN GILMORE S GROIN

13 GILMORE S GROIN TYPICAL PATIENT YOUNG MALE ACTIVE SPORTSMEN RARE OVER 45 RARE IN FEMALES (1%)

14 GROIN PAIN: SITE IMPLICATIONS ABOVE INGUINAL LIGAMENT Gilmore Groin. BELOW INGUINAL LIGAMENT Mid Inguinal Point HIP Adductor Insertion ADDUCTOR

15 GROIN DISRUPTION MUSCULO TENDINOUS INJURY ALL LAYERS GROIN INGUINAL REGION MUSCLE DISLOCATION

16 CASE 1 D.M. 27 FULL BACK: TOTTENHAM HOTSPUR FC PRESENTED: SYMPTOMS: LAST GAME: PAIN INCREASED: 17 WEEKS PAIN RIGHT GROIN AFTER EVERSION INJURY 17 WEEKS SPRINTING KICKING TWISTING & TURNING COUGHING SNEEZING

17 CASE 1 D.M. PREVIOUS INVESTIGATIONS: 3 ORTHOPAEDIC OPINIONS X-RAY CT SCAN: IRREGULARITY - NO INSTABILITY U/S SCAN PREVIOUS TREATMENT: COMPLETE REST PHYSIOTHERAPY MANIPULATION LOCAL STEROIDS

18 CASE 1 D.M. PHYSICAL SIGNS INSPECTION: PALPATION: N.A.D. N.A.D. PALPATION VIA SCROTUM: - RIGHT SUPERFICIAL INGUINAL RING DILATED - COUGH IMPULSE - TENDER INSERTION OF FINGER PAIN COMPARED TO OPPOSITE SIDE

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20 GROIN DISRUPTION: PATHOLOGY Found at Operation TORN EXTERNAL OBLIQUE DILATED SUPERFICIAL INGUINAL RING TORN CONJOINED TENDON CONJOINED TENDON INGUINAL LIGAMENT } DEHISCENCE

21 GROIN DISRUPTION (GILMORE S GROIN) 29 YEARS

22 PATIENT REFERRAL RELATED TO SPORT CASES % ASSOCIATION FOOTBALL RUGBY UNION & LEAGUE RACQUET GAMES ATHLETES CRICKET HOCKEY OTHER SPORTS/GENERAL FITNESS TOTAL 7273

23 OPERATIONS TOTAL 4227 MALE 4185 (99%) FEMALE 42 (1%)

24 INCIDENCE OF OPERATION RELATED TO SPORT CASES OPN % ASSOCIATION FOOTBALL RUGBY UNION + LEAGUE RACQUET GAMES ATHLETES CRICKET HOCKEY OTHER SPORTS/GENERAL FITNESS TOTAL

25 INCIDENCE OF OPERATIONS ASSOCIATION FOOTBALL TOTAL OPN % PROFESSIONAL SEMI PRO AMATEUR TOTAL

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27 PROFESSIONAL FOOTBALLERS CASES 1515 OPERATIONS 1246 (82%)

28 ENGLISH FOOTBALL LEAGUE CLUBS (92 CLUBS) PATIENTS REFERRED BY 87 CLUBS

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30 AETIOLOGY:MUSCLE IMBALANCE 1. STRONG HIP FLEXORS (QUADS) 2. TILTED PELVIS PULL PELVIS DOWN STRETCH ABDO MUSCLES 3. STRETCHED ABDO MUSCLES BECOME WEAK (OBLIQUES) FAIL TO STABILIZE PELVIS 4. OVERUSE 5. MALE > FEMALE (99%) RECURRENT TEARS GROIN DISRUPTION

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32 ARSENAL F.C.: GILMORE S GROIN OPERATION P.A (GRAHAM) (WENGER) 10 1 Gary Lewin 2007

33 ONSET OF SYMPTOMS INSIDIOUS 72% SPECIFIC INJURY 28% OVERSTRETCHING MISKICKING ABDUCTION EVERSION

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35 SYMPTOMS DURING EXERCISE PAIN IN GROIN INCREASES WITH RUNNING STRIDING SPRINTING SUDDEN MOVEMENT TWISTING & TURNING SIDE STEPPING JUMPING DEAD BALL KICKING LONG BALL KICKING

36 SYMPTOMS AFTER EXERCISE STIFF & SORE PAIN IN GROIN INCREASES WITH TURNING IN BED GETTING OUT OF BED GETTING OUT OF CAR SIT UPS COUGHING SNEEZING SUDDEN MOVEMENT

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38 EXAMINATION

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41 GROIN DISRUPTION: PHYSICAL SIGNS (ALL ELICITED VIA SCROTUM) S.I.R: DILATED (+/-) COUGH IMPULSE TENDER (PALPABLE TEAR) TENDERNESS: MAY BE EXQUISITE DIMINISHES WITH REST

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43 INDICATION FOR SURGERY: PROFESSIONALS GAME INHIBITED TRAINING INHIBITED LOSS OF SPEED LOSS OF FITNESS

44 INDICATION FOR SURGERY: AMATEURS SYMPTOMS AFFECT EVERYDAY LIFE LOSS OF SPORT AFFECTS QUALITY OF LIFE

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46 Torn external oblique Groin Disruption: Pathology found at operation Dilated superficial inguinal ring Torn conjoined tendon Conjoined tendon Inguinal ligament } Dehiscence

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49 Operation (1) Restore Normal Anatomy REPAIR EACH ELEMENT OF DISRUPTION Conjoined tendon repair ( 0 vicryl) Transversalis fascia plicated (0 vicryl) Rectus abdominis (if torn) repair (No.1 ethilon)

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51 Operation (2) Conjoined tendon reattached to pubic tubercle with No.1 ethilon (Anchor Stitch) TENSION FREE NYLON DARN between ING LIG & CONJ. TENDON External oblique repair (0 vicryl) Scarpa s fascia closed (0 vicryl) Subcuticular skin closure (3/0 vicryl rapide)

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53

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55 RESULT - OPERATION SUCCESSFUL 97% AVERAGE RETURN TO PROFESSIONAL FOOTBALL 5 WEEKS 1209 OUT OF 1246 PLAYERS RANGE 3 9 WEEKS

56 INTERNATIONAL SOCCER FOOTBALLERS ENGLAND 61 SCOTLAND 34 NORTHERN IRELAND 18 EIRE 16 WALES 15 OTHERS

57 INTERNATIONALS SOCCER 251 RUGBY UNION 43 ATHLETES 24 CRICKET 21 RUGBY LEAGUE 16 HOCKEY 14 HANDBALL 4 RACQUET GAMES 3 SKIING 2 BASKETBALL 2 FENCING 2 LACROSSE 2 MARTIAL ARTS 2 SQUASH 1 GYMNASTICS 1 WATERPOLO 1 ROWING 1 VOLLEYBALL 1 "STRONGMAN" 1 WEIGHT LIFTING 1 ICE HOCKEY 1 TOTAL 391

58 Ulrike Muschaweck

59 D.N. Act 24. English International Jan 2008 Right Minimally Invasive Groin Repair Ulrike Mushaweck 2 weeks: Playing 3 1/2 weeks: Pain recurred Struggled for the rest of the season

60 DN Ulrike Mushaweck: TECHNIQUE According to operation report: Just the defect of the transverse fascia is opened reverse doubling fascia is made, achieving a tension free defect closure No mention of sutures used. No mention of ilio-inguinal nerve division

61 D.N. ( Repair in Jan 2008 ) : Increasing problems same groin:next Season Early Oct 08: Not played: Referred to: Symptoms & Signs: Right Groin Pain Severe 3 weeks OJAG Typical GG

62 D.N 7 Oct 2008: Re-Exploration Right Groin by OJAG Findings: Dense Scar Tissue No permanent sutures seen Dehiscence between Inguinal ligament and conjoined tendon Spermatic Cord bent in Inguinal canal Standard GG Repair with Nylon Darn

63 D.N Post op review: Running, sprinting: At 3 weeks 90% capacity Patient comment This Repair feels completely different, it feels more sound and more solid

64 D.N Missed no games following re-exploration & repair right groin with nylon darn Until developed Left Gilmores Groin 10 June 09 Left standard GG Repair with nylon darn 9July 09 Full involvement in pre-season training No problems either side since

65 CONCLUSION Reliable: Preferable to: Solid Repair Each Layer + Non Absorbable Nylon Darn Dissolvable Sutures + Division of Ilio inguinal nerve Allowing early pain free return but often recurrent symptoms

66

67

68 THANK YOU

Groin Disruption

Groin Disruption Groin Disruption 1980-2009 (30 Years) MR O J A GILMORE MS FRCS FRCS (ED) F. INST. SPORTS MED. 5% ALL SPORTS INJURIES AFFECT GROIN PATIENT S REFERRED with GROIN PAIN 1980-2009 TOTAL 7535 MALE 7284 (97%)

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