A Sports Physician s Perspective

Transcription

1 Groin Pain Non-Surgical Treatments & Rehabilitation A Sports Physician s Perspective A Dr Ralph Rogers MD PhD MBA FACN FECSS FACSM FFSEM Sports & Musculoskeletal Physician London Orthopaedic Clinic 30 Devonshire Street London Princess Grace Hospital

2 Terminology (the condition very much misunderstood) Athletic Pubalgia Chronic Symphysis syndrome Groin Pull Sports Hernia Hockey player s syndrome Gilmore s Gilmore

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5 Sports Physician s Perspective Mechanism of Injury Complaints, History, Symptoms Physical Examination Diagnostic Tools Differential Diagnosis Referral Treatments Cases Rehabilitation

6 Diagnosis of Groin Pain requires an understanding of the pelvic anatomy

7 Complex Anatomy Note the relationship of the adductor longus and rectus & transverse abdominis

8 Mechanism of Injury A tremendous amount of torque or twisting in the midportion of the body With Opposing Forces

9 Core Muscles are Weaker than Leg Muscles Conjoined tendon pulls up and rotates the trunk and the adductor pulls down and rotates the upper leg These opposing forces cause disruption of the muscles at their insertion

10 Disruption Imbalance between weak abdominal muscles in relation to strong leg muscles

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12 This is not the Answer

13 Strength & Conditioning Coaches

14 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

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16 History Typically Insidious in Runners Sudden onset in Footballers Pain Resistant to conservative treatment

17 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

18 Symptoms Exacerbated running cutting/twisting forward flexion/sit-ups side-stepping coughing sneezing

19 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.

20 The Team Interorganizational Networking: A Comparative Study of Sports & Exercise Medical Services in English Professional Football Dr Ralph Rogers. MBA Dissertation (the approach must be systematic)

21 Physical Examination Team Approach Inspection Palpate the bones and soft tissue in and around your pelvis and groin area (symmetry), recognize differences and identify pain and tenderness. 1. Any abnormalities, 2. Mild or severe inflammation 3. Fluid, bone or tissue deformity 4. Weakened muscles. Movements hip Diagnostic tests will not identify Disruption, used to rule out other conditions that cause groin and abdominal pain.

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23 Examination

24 Physical Exam Palpable tenderness conjoined tendon insertion along inguinal canal adductor longus origin & belly Usually unilateral May be bilateral

25 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

26 No Palpable Hernia

27 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

28 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

29 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

30 Nerve Entrapment Ilioinguinal Nerve Direct Trauma or Intense Muscle Training Patient describes; Burning shooting pain to groin

31 Diagnosis of Exclusion

32 Non Surgical Treatment

33 mg Depo-Medron 1.5 ml Lignocaine 1.5 ml Saline

34 mg Depo-Medron Traumeel & other Biotheraputics 1.5 ml Lignocaine

35 2009 Platelet Rich Plasma (PRP)

36 Platelet Rich Plasma (PRP)

37 PRP Increased concentration of platelets and growth factors which are associated with the healing process

38 What Does PRP Look Like? Blood Soft centrifugation Platelet-containing plasma (PRP) 5 min / 1500 rpm (350g) RBCs

39 What Exactly Is PRP? A system that concentrates platelets and growth factors within a plasma layer separate from red and white blood cells Growth Factors and other molecules within the plasma layer modulate healing

40 Platelet Activation Releases growth factors and other cytokines from Unactivated platelets α-granules Activated platelets

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42 Case1 42yr old Manager, Keen Footballer 2004 slight twinge while kicking a football 2005 Seen by Sports Physician-steroid injection no benefit 2006 groin surgery some benefit 2007 different surgeon- exercise 2008 pain again in groin

43 Seen by a 3 rd surgeon MRI Surgery intact but Grade 2 tear at the musculo-tendionous origin of the right adductor longus muscle. Referred to me Clinically Classic MTJ Triad Palpation tenderness Pain with resisted adduction Pain with passive abduction 3 treatments in 1 month

44 Improvement - able to play 5 aside.

45 Case 2 27yr old IT Analysis, Keen Footballer Complex Hx bilateral groin surgery 7/12 Hx of rt groin pain has not played football Ultrasound guided injection insertion no improvement MRI partial tear to MTJ Referred to me VAS 8/10

46 PRP 3 injections in 3 weeks 3 weeks after Vas 1-2/10 Able to play football

47 So you decided the problem is surgical

48 To Who Understand the surgery

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50 Major Financial Implications

51 M

52 Rehabilitation They tried to make me go to rehab,...but I said no no no

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54 Post Op Rehabilitation General Principles Research in this area is sparse Protocol is very open Listen to your body; if you are having pain stop

55 Post Op Rehabilitation General Principles 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

56 General Principals Core stretching especially of the operative site. Core strengthening is slowly advanced as tolerated.

57 Note Second week Jog on a treadmill for 20 minutes per day. Treadmill there is less resistance and bars are available for balance.

58 Compression Garments

59 Compression Garments Considered Beneficial For Recovery Recognized action DOMS prevention By increasing microcirculation Jonker et al 2001

60 Week 1 (Relative Rest) Straight line physical activity only No lifting or activities that increase abdominal pressure End of the week some pool work No butterfly Walking forward and backward

61 Yes. Sex is OK

62 Week 2 Exercises consisting of: Gentle Core strengthening Gentle abdominal stretching Treadmill running but still at a Progression of core strengthening min Body weight movement such as Lunges Side lunges Partial Squats

63 Week 2 Stretching Hip extension, psoas, hip extension Pace increases on treadmill but still at a Progression of core strengthening Body weight movement such as Lunges Side lunges Some ball work - no shooting or long volleys (end of the week)

64 M

65 Week 3 Core strengthening and upper body exercises Abdominal crunches Body weight movements progressed into movements with weight Lunges Squats Side lunges

66 Week 3 55 meter sprints 65-75% Add in tempo change of direction Box drills Figure 8 90 degree cutting drills

67 Week 3 Begin to incorporate position specific drills and change of direction exercises Add reactionary change of direction movements

68 Week 4 Progress into football training activities No limitations by the end of the week

69 General Concepts to Rehabilitation Understand the surgery Demands of the sport Account for Whole body de-conditioning an athlete may have Athlete can tolerate activity level Do not rush return which may lead to other injuries

70 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

71 Thank You