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07/05/2018
1
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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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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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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Dynamic with eccentric emphasis MANAGEMENT
• Progress slowly
• Use clinical indicators
• Progress to functional
activities
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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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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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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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41
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