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 • • • • • Athletic Pubalgia Chronic Symphysis Syndrome Groin Pull Sports Hernia Gilmore’s Groin Sports Physician Perspective • • • • • • • • • • 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 – – – – – – 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 • Inspection • Palpate the bones and soft tissue in and around your pelvis and groin area (symmetry), recognize differences and identify pain and tenderness. 1. 2. 3. 4. Any abnormalities, Mild or severe inflammation Fluid, bone or tissue deformity 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 •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: • • • • Asymmetry Imbalances Limitation Weakness The Idea • View Movement quality • Simple grading system Functional Movement Screen 7 Fundamental Movement Tests 1) 2) 3) 4) 5) 6) 7) 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?  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 Platelet Activation Releases growth factors and other cytokines from α-granules Unactivated platelets Activated platelets Case Study 42 year Old Male (Manager) • • • • • 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 • • • • • 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 • • • 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