07/05/2018

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Doc…..I’ve done my groin

Peter Brukner OAM, MBBS, FACSP

Professor of Sports Medicine

Sport and Exercise Medicine ResearchCentre

Latrobe University, Melbourne, AUSTRALIA

The groin is a very sensitive area ……..

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The Patient

• 24 year old footballer

• 6 months right groinpain

• Gradual onset

• Able to train and play

– but not any more

• Pain not well localised

– adductor insertion, pubic

symphysis, inguinal region

• Sl aggravated bycoughing

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The Patient

• Pain on resisted adduction

• Pain on iliopsoas stretch

• No obvious hernia

The Patient

• X ray moth eaten appearance

• Isotope bone scan increaseduptake

• MRI oedema in pubicsymphysis

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What is yourdiagnosis

?

One of these?

• Groin strain

• Osteitis pubis

• Sports hernia

• Athletic pubalgia

• Conjoint tendon tear

• Incipient hernia

• Adductor tendinitis

• Rectus abdominis tendinitis

• Hip pathology

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Geographical

• Australia – post wall weakness, osteitis pubis

• USA – groin strain, athletic pubalgia, hockey groin

• UK – Gilmore’s groin, inguinal ligament

• Germany – minimal repair

• Denmark – adductor-related pain

189 cases of groin pain (Lovell 1995)

• incipient hernia 95 50%

• adductor lesions 36 19%

• osteitis pubis 26 14%

• pubic instability 8 4%

• Iliopsoas injury 5 3%

• ilioinguinal nerve 5 3%

• referred pain 4 2%

• hip lesions 3 1%

• stress fracture 2 1%

Lovell G. The diagnosis of chronic groin pain in athletes : a review of 189 cases. Aust J Sci Med Sport 1995;27:76–9

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Bradshaw CJ et al. Br J Sports Med 2008;42:851-854

Copyright ©2008 BMJ Publishing Group Ltd.

218 consecutive groin pain patients(Bradshaw 2008).

So how are we

going to treat this

patient of ours?

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Surgery

• Hernia repair

• Post wall reinforcement• Mesh insertion• Minimal repair

• Conjoint tendon repair

• Inguinal ligament release• Adductor tenotomy• Obturator nerve release• Curettage

• Wedge resection symphysis

Surgery with the lot

• hernia repair

• repair of the conjoint tendon

• adductor tenotomy

• obturator nerve release

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Athletic Groin Pain

The evidence …….

Evidence – surgical treatment

• Inguinal wall repair

• Laparoscopic herniorraphy

• Endoscopic mesh

• Adductor longus release

• Curettage

• Wedge resection symphysis

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Outcomes

• All positive

• No matter what surgery is done

• ? Common mechanism

–Nerve decompression

–Fascial release

• ? Quality of research

• ? Recurrence rates

Evidence -treatment

• Rest (Verrall, 2007)

• Corticosteroid injections (Holt et al, 1995)

• Compression shorts (McKim & Taunton,2001)

• Biphosphonates (Maksymowych et al, 2001;

Stewart et al, 2005)

• Prolotherapy (Topol, 2005)

• Core stability (Cowan, 2004)

• Radiofrequency denervation (Comin et al, 2013)

• Physical therapy (Holmich, 1999)

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Confused?

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Pubic overload PUBIC BONE OVERLOAD

PAIN

TIGHTNESS

WEAKNESSDYSFUNCTION

OVERLOAD

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Pubic bone overload

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And don’t forget thehip The Doha Agreement

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The Doha Agreement Terms we are NOT going touse

• adductor and iliopsoas tendinitis or tendinopathy

• athletic groin pain

• athletic pubalgia

• biomechanical groin overload

• Gilmore’s groin

• groin disruption

• Hockey-goalie syndrome

• Hockey groin

• osteitis pubis

• sports groin

• sportsman’s groin

• sports hernia

• sportsman’s hernia

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Classification system

• Defined clinical entities for groin pain:

– adductor-related

– iliopsoas-related

– inguinal-related

– pubic-related

• Hip–related groin pain

• Other causes of groin pain inathletes

Clinical entities

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Other possible causes of groinpain Stress fractures

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PUBIC OVERLOAD

• Adductor

• Psoas

• Rectus

abdominis

Pubic Overload

• Increased load on pubiccomplex

• Poor “core stability” (lumbo-pelvic control)

• ? Role of restricted hip ROM

• ? Role of gluteal muscles

• ? Role of lumbar pathology

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Management

Reduce the load

Rest

Reduce muscle tone

HOW?

• Stretch

• Soft tissue release

• Dry needling

• Surgery

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The role of strength

In athletes with nonspecific groin pain, it seems that bilateral isometric hip adductor strength is decreased by 20% to 25% compared with asymptomatic controls when using a sphygmomanometer in the squeeze test.

Malliaras P, Hogan A, Nawrocki A, Crossley K, Schache A. Hip flexibility

and strength measures: reliability and association with athletic

groin pain. Br J Sports Med. 2009;43:739-744.

Nevin F, Delahunt E. Adductor squeeze test values and hip jointrange

of motion in Gaelic football athletes with longstanding groin pain. J Sci Med Sport.2014;17(2): 155-9.

Strengthen -Holmich et al, Lancet 1999

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Holmich et al,

Lancet 1999Copenhagen adduction exercise

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Hip flexors Long lever planks

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Dynamic with eccentric emphasis MANAGEMENT

• Progress slowly

• Use clinical indicators

• Progress to functional

activities

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Surgery

? ? ?

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Early Warning Signs

• tight/stiff during or after activity

• loss of acceleration

• vague discomfort deceleration

• loss of maximal sprinting speed

• loss of distance withkick

PREVENTION

• Manage load– Esp in younger andolder players

• Good lumbo-pelvic control

• Good adductor strength

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PREVENTION -Load

Monitoring playing and training load

• Game time

• Training time

• GPS

• Match data

• Heart rate

• RPE

Monitoring

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PREVENTION -Monitoring

Adductor squeeze dynamometer strength

reduced prior to groin injury

Crow JF, Pearce AJ, Veale JP et al. Hip adductor muscle strength is reduced preceding

and during the onset of groin pain in elite junior Australian football players J Sci Med

Sport 2010;13(2):202–04

Engebretsen AH, Myklebust G, Holme I et al. Intrinsic risk factors for groin injuries

among male soccer players. Am J Sports Med 2010;38(10):2051–7

Now used regularly during the footballseason

to identify those at risk of developing groin

pain

What about thehip?

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OA hip …and then these guys came on the scene

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A whole new world was opened to them…... What is FAI?

What is FAI?

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What morphology is typically seen inFAI?

• Normal– scoop on NOF,

acetabularanteversion

• Cam

– bony growth on

anterior/superior neck

of femur

• Pincer

– Acetabular retroversion

– Deep socket

FAI -Cam FAI -Pincer

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Is there a standard definition ofFAI?

BJSM 201

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Warwick Consensus Agreement

For a patient to be diagnosed with FAI Syndrome, must have:

1. Positive imaging findings

2. Symptoms of hip orgroin

pain

3. Signs of FAI, including

physical impairments and

positive impingement tests.

BJSM 2016

Does itmatter?

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Time line of lifespan of hip patient

camFAI HipOA5-20 years

Agricola 2013, 2013, Nicholls2011

Does itmatter?cam – develops 13-15

yearsAgricola AJSM 2014, Siebenrock 2011, Pollard2010

FAI, labral, chondral (35y.o)Kemp BJSM2013

Painful FAI +/- labral (25y.o)Kemp BJSM2012

Clinical hip OA (40+y.o)McCarthy 2011, Tuominen2009

camFAI Hip OA5-20yearsAgricola 2013, 2013, Nicholls2011Pain, poor PROs, physicalimpairments

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Does FAImatter?Yes!!While most people with cam morphology do notdevelop FAI, for those that do, the impact is enormous

Quality of life scores similar to people with end stage hip OA.

Young and middle aged people with large family and work commitments

Unable to exercise = big consequences for general health

Increased risk of end stage hip OA and THA

Rates of hiparthroscopy

• USA 465% increase between

2005-2013 Maradit Kremers et al 2017, Montgomery etal

2013

• Australia 200% increase

Medicarebetween 2010 and2013data 2015

• Europe registry data becoming available

• Asia rates unknown

• Surgery for developed nations

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Hip arthroscopy

Hip arthroscopy:

currentevidence

for outcomes

Surgical management?

Large amount of anecdotal and

opinion piece evidence supporting

hip arthroscopy to improve

symptoms and stop progressionto

hip OA inFAI.

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Surgical management? Surgical management?

Large amount of anecdotal andopinion

piece evidence supporting hip

arthroscopy to improve symptoms and

stop progression to hip OA in FAI.

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What is theevidence

for surgery?Methodological quality poor and

thus limits confidence in results

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Outcomes for hip OA appear worse but unclear

Adverse events were minimal (7% of participants in 12 studies);

transient neuropraxia (83%).

Large positive within-subject effect sizes for improved pain and function

for up to 10 years (no femoral osteoplasty) and 3 years (femoral

osteoplasty)

Current evidence for non-

surgical treatment of FAI

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• Outcomes of operative treatment of FAIare

significantly better than non-surgical

management.

• 28 surgical studies vs 1 PT study

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Fairley J et al, Osteoarthritis Cart 2016

Fairley J et al, Osteoarthritis Cart 2016

• Although there is evidence that surgery improves

symptoms and bone shape in thosewith FAI, there are no data directly comparing surgical and non-

surgical approaches.

• Given the potent placebo effect of surgical

intervention demonstrated at the knee joint,non-

blinded RCTs cannot delineate actual vs placebo

effect of surgical intervention.

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FAI in longstanding groinpain

The prevalence of radiological signs

of FAI was 94% (64/68)

Weir A, de Vos RJ, Moen M, et al. Prevalence of radiological signsof

femoroacetabular impingement in patients presenting with long-

standing adductor-related groin pain Br J Sports Med 2011 45: 6-9

SUMMARY

• Dramatic changes in ourunderstanding

of both groin and hippain

• The entities are much betterdefined

• The role of surgery has diminished

• The role of physiotherapy has increased

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Thank you