Groin Pain

Non-Surgical Treatments & Rehabilitation

A A A A Sports Physicians Perspective Sports Physicians Perspective Sports Physicians Perspective Sports Physicians Perspective
Dr Ralph Rogers MD PhD MBA
FACN FECSS FACSM FFSEM
Sports & Musculoskeletal Physician
London Orthopaedic Clinic
30 Devonshire Street
London
Princess Grace Hospital
Terminology
(the condition very much misunderstood)
Athletic Pubalgia
Chronic Symphysis syndrome
Groin Pull
Sports Hernia
Hockey players syndrome
Gilmores Gilmore
Sports Physicians Perspective
Mechanism of Injury
Complaints, History, Symptoms
Physical Examination
Diagnostic Tools
Differential Diagnosis
Referral
Treatments
Cases
Rehabilitation
Diagnosis of Groin Pain
requires an understanding requires an understanding requires an understanding requires an understanding
of the pelvic anatomy of the pelvic anatomy of the pelvic anatomy of the pelvic anatomy
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
With Opposing Forces
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
Disruption
Imbalance between weak
abdominal muscles in relation
to strong leg muscles
This is not the Answer
Strength & Conditioning Coaches
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
Sudden onset in Footballers
Pain Resistant to conservative treatment Pain Resistant to conservative treatment Pain Resistant to conservative treatment Pain Resistant to conservative treatment
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
running
cutting/twisting
forward flexion/sit-ups
side-stepping
coughing
sneezing
Symptoms Exacerbated
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.
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)
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.
Examination
Physical Exam
Palpable tenderness
conjoined tendon insertion
along inguinal canal
adductor longus origin & belly
Usually unilateral
May be bilateral
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
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
Diagnosis of Exclusion
Non Surgical Treatment
1996
10mg Depo-Medron
1.5 ml Lignocaine
1.5 ml Saline
2000
5-10mg Depo-Medron
Traumeel & other Biotheraputics
1.5 ml Lignocaine
2009
Platelet Rich Plasma (PRP)
Platelet Rich Plasma (PRP)
PRP PRP
Increased concentration of Increased concentration of
platelets and growth factors platelets and growth factors
which are associated with the which are associated with the
healing process healing process
What Does PRP Look Like? What Does PRP Look Like?
RBCs
Platelet-containing
plasma (PRP)
Soft centrifugation
Blood
5 min / 1500 rpm (350g)
What Exactly Is PRP? What Exactly Is PRP?
A system that concentrates A system that concentrates
platelets and growth factors within platelets and growth factors within
a plasma layer a plasma layer separate separate from red from red
and white blood cells and white blood cells
Growth Factors and other Growth Factors and other
molecules within the plasma layer molecules within the plasma layer
modulate healing modulate healing
Platelet Activation Platelet Activation
Unactivated platelets
Activated platelets
Releases growth factors Releases growth factors
and other cytokines from and other cytokines from
- -granules granules
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
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
Improvement - able to play 5 aside.
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
PRP
3 injections in 3 weeks
3 weeks after
Vas 1-2/10
Able to play football
So you decided the problem is surgical So you decided the problem is surgical So you decided the problem is surgical So you decided the problem is surgical
To Who To Who To Who To Who
Understand the surgery
Major Financial Implications
M
Rehabilitation
They tried to make me go to rehab, They tried to make me go to rehab, They tried to make me go to rehab, They tried to make me go to rehab,
....but I said no no no ....but I said no no no ....but I said no no no ....but I said no no no
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
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
General Principals
Core stretching especially of the operative site.
Core strengthening is slowly advanced as tolerated.
Note
Second 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 (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
Yes. Sex is OK
Week 2
Exercises consisting of:
Gentle Core strengthening
Gentle abdominal stretching
Treadmill running but still at a Progression of
core strengthening 25-30 min
Body weight movement such as
Lunges
Side lunges
Partial Squats
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)
M
Core strengthening and upper body
exercises
Abdominal crunches
Body weight movements progressed
into movements with weight
Lunges
Squats
Side lunges
Week 3
Week 3
55 meter sprints 65-75%
Add in tempo change of direction
Box drills
Figure 8
90 degree cutting drills
Week 3
Begin to incorporate position specific drills
and change of direction exercises
Add reactionary change of direction
movements
Week 4
Progress into football training activities
No limitations by the end of the week
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
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