Groin Pain Non-Surgical Treatments & Rehabilitation

“A “A “A “A Sports Physician’s Perspective”Sports Physician’s Perspective”Sports Physician’s Perspective”Sports Physician’s Perspective”

Dr Ralph Rogers MD PhD MBAFACN FECSS FACSM FFSEM

Sports & Musculoskeletal Physician

London Orthopaedic Clinic30 Devonshire Street

London

Princess Grace Hospital

Terminology (the condition very much misunderstood)

� Athletic Pubalgia

� Chronic Symphysis syndrome

� Groin Pull

� Sports Hernia

� Hockey player’s syndrome

� Gilmore’s Gilmore

Sports Physician’s 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 twistingin 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 treatmentPain Resistant to conservative treatmentPain Resistant to conservative treatmentPain 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 inflammation3. Fluid, bone or tissue deformity4. Weakened muscles.

� Movements hip

� Diagnostic tests will not identify ”Disruption”, used to rule outother 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)

PRPPRP

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 processhealing 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 separateseparate from red from red

and white blood cellsand white blood cells

�� Growth Factors and other Growth Factors and other

molecules within the plasma layer molecules within the plasma layer

modulate healingmodulate healing

Platelet ActivationPlatelet Activation

Unactivated platelets

Activated platelets

Releases growth factors Releases growth factors

and other cytokines from and other cytokines from

αα--granulesgranules

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 3rd 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 RehabilitationGeneral Principles

� Research in this area is sparse

� Protocol is very open

� Listen to your body;

if you are having pain stop

Post Op RehabilitationGeneral 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 microcirculationJonker 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