GROIN DISRUPTION 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 1980-2008 TOTAL 7273 MALE 7030 (97%) FEMALE 273 (3%)

PATIENT REFERRAL (1980-2008) INCIDENCE of OPERATION CASES REFERRED 7273 OPERATIONS 4227 (58%)

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

DIRECT TRAUMA FALL KICK PUNCH IMPACT SQUEESE

REFERRED PAIN

GROIN DISRUPTION SPORTSMEN GROIN GILMORE S GROIN

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

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

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

CASE 1 D.M. 27 FULL BACK: TOTTENHAM HOTSPUR FC PRESENTED: 28.08.80 SYMPTOMS: LAST GAME: PAIN INCREASED: 17 WEEKS PAIN RIGHT GROIN AFTER EVERSION INJURY 17 WEEKS SPRINTING KICKING TWISTING & TURNING COUGHING SNEEZING

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

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

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

GROIN DISRUPTION (GILMORE S GROIN) 29 YEARS 1980-2008

PATIENT REFERRAL RELATED TO SPORT 1980-2008 CASES % ASSOCIATION FOOTBALL 4124 57 RUGBY UNION & LEAGUE 700 10 RACQUET GAMES 275 4 ATHLETES 317 4 CRICKET 162 2 HOCKEY 140 2 OTHER SPORTS/GENERAL FITNESS 1555 21 TOTAL 7273

OPERATIONS 1980-2008 TOTAL 4227 MALE 4185 (99%) FEMALE 42 (1%)

INCIDENCE OF OPERATION RELATED TO SPORT 1980-2008 CASES OPN % ASSOCIATION FOOTBALL 4124 2842 69 RUGBY UNION + LEAGUE 700 447 64 RACQUET GAMES 275 93 34 ATHLETES 317 126 40 CRICKET 162 11212 69 HOCKEY 140 81 58 OTHER SPORTS/GENERAL FITNESS 1555 526 34 TOTAL 7273 4227 58

INCIDENCE OF OPERATIONS ASSOCIATION FOOTBALL 1980-2008 TOTAL OPN % PROFESSIONAL 1515 1246 82 SEMI PRO. 735 521 71 AMATEUR 1874 1075 57 TOTAL 4124 2842 69

PROFESSIONAL FOOTBALLERS 1980-2008 CASES 1515 OPERATIONS 1246 (82%)

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

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

ARSENAL F.C.: GILMORE S GROIN OPERATION P.A. 1986 1996 (GRAHAM) 33 3 1997 2007 (WENGER) 10 1 Gary Lewin 2007

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

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

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

EXAMINATION

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

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

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

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

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)

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)

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

INTERNATIONAL SOCCER FOOTBALLERS 1980-2008 ENGLAND 61 SCOTLAND 34 NORTHERN IRELAND 18 EIRE 16 WALES 15 OTHERS 107 251

INTERNATIONALS 1980-2008 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

Ulrike Muschaweck

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

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

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

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

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

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

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

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