Injury “Risk Reduction” & Non-Surgical Treatment for Groin Pain

Injury “Risk Reduction”
&
Non-Surgical Treatment for Groin Pain
Dr Ralph Rogers MD PhD MBA
FACN FECSS FACSM FFSEM
Consultant Sports Medicine
The London Sports Injury Clinic
108 Harley Street
London
Terminology
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Athletic Pubalgia
Chronic Symphysis Syndrome
Groin Pull
Sports Hernia
Gilmore’s Groin
Sports Physician Perspective
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Mechanism of Injury
Complaints, History, Symptoms
Physical Examination
Diagnostic Tools
Differential Diagnosis
Injury Risk Reduction
Referral
Treatments
Cases
Rehabilitation
Diagnosis of Groin Pain
“requires
an understanding
of the pelvic anatomy”
Disruption
Imbalance between weak
abdominal muscles in
relation to strong leg
muscles
Complex Anatomy
Note the
relationship of the
adductor longus
and rectus &
transverse
abdominis
Mechanism of Injury
• A tremendous amount of torque or
twisting in the midportion of the body
• Opposing their forces is the adductor
longus
Core Muscles are Weaker than Leg Muscles
• These opposing forces cause disruption
of the muscles at their insertion
• Essential the conjoined tendon pulls up
and rotates the trunk and the adductor
pulls down and rotates the upper leg
This is not the Answer
Strength & Conditioning Coach
Chief Complaints
• “I pulled my groin”
• Pain with sit-ups, Valsalva, sneezing, coughing
• “Dull ache” for extended time with no improvement
• “Pressure in my groin”
History
– Typically insidious in runners or sudden
onset in Footballers
– Pain may radiate to perineum or testicles
– Resistant to conservative treatment
– Local tenderness over conjoined tendon
and inguinal canal
– No hernia clinically detectable
Symptoms Exacerbated
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running
cutting/twisting
forward flexion/sit-ups
side-stepping
coughing
sneezing
What are the Symptoms
Typically begins with a slow onset of aching
pain in the lower abdominal region.
– Pain in the lower abdomen
– Pain in the groin
– Pain in the testicle
How to Diagnose Groin Disruption
There are no diagnostic tests that can be
used to detect a disruption. The
diagnosis is made by the patient's history
and physical examination.
Other tests may be performed to “rule
out” other causes of groin pain.
Physical Examination
Inguinal canal low abdominal muscles
Most common finding is point tenderness at the
insertion of the conjoined tendon and adductor
longus
Physical Examination
Team Approach
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Inspection
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Palpate the bones and soft tissue in and around your pelvis
and groin area (symmetry), recognize differences and
identify pain and tenderness.
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Any abnormalities,
Mild or severe inflammation
Fluid, bone or tissue deformity
Weakened muscles.
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Movements hip!!!
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Diagnostic tests will not identify ”Disruption”, used to rule out
other conditions that cause groin and abdominal pain.
Examination
Physical Exam
•Palpable tenderness
–conjoined tendon insertion
–along inguinal canal
–adductor longus origin & belly
•Usually unilateral
–May be bilateral
•Diagnosis of exclusion
Provocative Testing
• Sit ups
• Active adduction
• This portion of the examination is
important because many athletes feel
well at rest but have reproduction of
groin pain with activity
No Palpable Hernia
Imaging & Special Tests
•No imaging will show/diagnose a Disruption
–But good for ruling out other diagnoses
•MRI
stress fracture/reaction
–AVN
–muscle pathology
–hip labral tears
•Other test
–urinalysis
Ultrasound
• Cost effective
• Accessible
• Inexpensive
• Operator dependent
Differential Diagnosis
•Genitourinary problems
–Prostatitis/epididymitis
–Referred testicular pain
–Hydrocele/varicocele
–Urinary tract infections
•Referred low back pain
•Gynecologic problems
–Urinary tract infection
–Menstrual pain
–Endometriosis
Differential Diagnosis
•Stress fracture
–pubic ramus
–femoral neck
•Muscle injury
–distal rectus abdominus strain/avulsion
–adductor strain/avulsion
–iliopsoas strain
•Osteitis pubis
•Referred hip problems
–degenerative joint
–labral tear
Nerve Entrapment Ilioinguinal Nerve
Direct Trauma or
Intense Muscle
Training
Patient describes;
Burning shooting pain to
groin
Injury Risk Reduction
Screen (FMSTM)
Motor Control within fundamental
movement patterns to capture:
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Asymmetry
Imbalances
Limitation
Weakness
The Idea
• View Movement quality
• Simple grading system
Functional Movement Screen
7 Fundamental Movement Tests
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Deep Squat
Hurdle Step
In-line Lunge
Shoulder Mobility
Active Straight Leg Raise (SLR)
Trunk Stability Push Up
Rotary Stability
Functional Training Is Not
• Machine based - applying
force in a pre-guided motion
while the body is supported
• Muscle Isolation Training
• Single planar or single joint
Deep Squat Movement Pattern
Jumping & Power
• Ankle Mobility – heels off the ground
• Hip Mobility – tight glutes and /or hamstrings
• Hip Stability – gluteus medius weakness
• Shoulder Mobility – tight lats, pec minor,
lower traps, serratus anterior
Hurdle Step
“locomotion acceleration & stride mechanics”
Inline Lunge Movement Pattern
component of deceleration and change of direction
Shoulder Mobility Reaching Movement Pattern
Breathing and Overhead throwing
Active –Leg Raise Movement Pattern
Pelvic Control, Core & Hamstring
Trunk Stability Pushup Movement Pattern
Reflex core stabilization
Rotary Stability Movement Pattern
Neuromuscular coordination energy transfer through the torso
The idea
• Attempting to measure in isolation does
a disservice to pattern
• The body is too complex to take isolated
movements seriously.
• Attempting to measure in isolation
does a disservice to pattern
• The body is too complex to take
isolated movements seriously.
Non Surgical Treatment
2000
10mg Depo-Medrone
1.5 ml Traumeel,other Biotheraputics & Prolotherapy
2009
Platelet Rich Plasma (PRP)
Platelet Rich Plasma (PRP)
PRP
Increased concentration
of platelets and growth
factors which are
associated with the
healing process
What Does PRP Look Like?
Blood
Soft
centrifugation
Plateletcontaining
plasma (PRP)
5 min / 1500 rpm
(350g)
RB
Cs
What Exactly Is PRP?
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A system that concentrates
platelets and growth factors
within a plasma layer separate
from red and white blood cells
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Growth Factors and other
molecules within the plasma
layer modulate healing
Platelet Activation
Releases growth factors
and other cytokines from
α-granules
Unactivated platelets
Activated platelets
Case Study
42 year Old Male (Manager)
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2004 slight twinge while kicking a football
2005 Seen by Sports Physician steroid injection
2006 groin surgery some benefit
2007 different surgeon exercise
2008 pain again
• Seen by a 3rd surgeon MRI
• Grade 2 tear at the musculo-tendionous
origin of the right adductor longus
muscle.
• Referred to me
• Clinically palpation tenderness to the
insertion and belly
• Ist injection Depo-medrone, Traumeel,
Lymphomyosot, Co-enzyme to the insertion
Traumeel Lymphomyosot to muscle
• 2nd slight improvement Traumeel, Spascupreel
• 3rd Traumeel Spascupreel Lymphomyosot
• 2 week review significant improvement able to play
5 aside.
“So you decided the problem is surgical”
“To Who”
Understand the surgery
Major Financial Implications
Rehabilitation
Post Op Rehabilitation
General Principles
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Research in this area is sparse
Protocol is very open
Listen to your body; if you are
having pain stop
Every athlete progresses at an
individual rate
Generally speaking return to full
activity is projected at 3-4 week
Professional athletes
6-8 weeks general public
General Principals
Core stretching especially of the operative site.
Core strengthening is slowly advanced as
tolerated.
While post-surgery rehabilitation may take 6-8
weeks
Motivated athletes can complete sports hernia
rehab and reach 100% of sport specific activity in
4-6 weeks following surgery.
Yes…. Sex is OK
Note
First week Jog on a treadmill for 20 minutes per day.
Treadmill there is less resistance and bars are
available for balance.
Compression Garments
Compression Garments
Considered beneficial for recovery
• Recognized action
– DOMS prevention
– By increasing microcirculation
Jonker et al 2001
Week 1
• Straight line physical activity only
• Start out with low impact exercises
• By end of the week athlete should be
back to jogging and running (treadmill)
• Continue core strengthening and
flexibility treatments
Week 2
• Exercises consisted of:
– Isometric core strengthening
– Gentle abdominal stretching
• Ice following rehabilitation session
• Pace increases on treadmill but still at a
Progression of core strengthening
• Body weight movement such as
– Lunges
– Side lunges
Week 3
• Core strengthening and machine upper
body exercises which did not create a
valsalva maneuver
• Body weight movements progressed into
movements with weight
– Lunges
– Squats
– Side lunges
Week 3
• 55 meter fast running
– Add in tempo change of direction
• Box drills
• “Figure 8”
• 90 degree cutting drills
Week 3
was a progression of tempo during linear and
change of direction exercises
– Begin to incorporate position specific drills
– Continue drills from week 2
– Add reactionary change of direction
movements
Week 4
• week allowed to progress into football
training activities
– No limitations by the end of the week
General Concepts to Rehabilitation
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Understand the surgery
Demands of the sport
Account for
– Amount of whole body de-conditioning an athlete
may have
– Make sure that the athlete can tolerate activity level
– Make sure not to rush return which may lead to
other injuries
“Heart Sink” Athlete
Rogers, R. N. Worth, C. Mahoney. A new concept “The Heart
Sink Athlete”. European College of Sports Science. Annual
Congress. Lausanne, Switzerland, July 2006
Thank You
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