groin pain / pubalgia in the athlete
TRANSCRIPT
1
Groin Pain / Pubalgia in the Athlete
Joanne BorgJoanne Borg--Stein, MDStein, MD
Spaulding Rehabilitation HospitalSpaulding Rehabilitation HospitalNewton Wellesley HospitalNewton Wellesley Hospital
Dept of PM&R, Harvard Medical SchoolDept of PM&R, Harvard Medical SchoolDirector, Sports Medicine FellowshipDirector, Sports Medicine FellowshipTeam Physician, Wellesley CollegeTeam Physician, Wellesley College
Goals of the Presentation
Systematic analysis and Systematic analysis and treatment of the athlete treatment of the athlete with groin / pelvic girdle with groin / pelvic girdle pain based onpain based onpain based onpain based on AnatomyAnatomy Clinical PresentationClinical Presentation Physical ExamPhysical Exam Patient managementPatient management
Anatomy
Tissue type = pain generatorMuscle TendonLigamentEnthesisEnthesisNerve BoneJoint
Referred painLumbarsacroiliacVisceral
DIDIER DROGBA
2
Anterior ligaments
Posterior ligaments
Anterior M lMuscles
3
PosteriorMuscles
MedialAdductor
4
Abdominal attachments to the Pelvis/Confluence with adductors
Dermatomes Around the Hip and Pelvis
Peripheral Nerves Around the Hip
5
Key elements of the Patient History
Onset of symptoms Acute vs gradual
Location of symptoms
Provocative factors Provocative factors Rotation
Stretch
With muscle activation
Lumbar/neurologic symptoms ***
Associated medical history *** GI, Gyn, GU, rheum, endocrine
Clinical Evaluation: Physical Exam: Lumbosacral
Overall: posture, facial expression, position Observation: gait, transitional movements, active tasks Inspection: curves, alignment, atrophy, symmetry Range of motion: flexion, extension, side-bend, rotation ***Palpation Palpation
Bony: spinous process, transverse process, ribs, trochanter, SI, iliac crest, iliac spine
Muscle: erector spinae, thoraco-lumbar fascia, quadratus, glutei, hip flexors
Careful neurologic examination. ***especially L5 reflex Special tests: one legged standing lumbar extension, Dynamic “athlete” testing: lunge, squat, step ups, clock
Physical Exam PelvisPhysical Exam Pelvis
Posterior: SI tests
Standing stork
Ganslen’s
Pelvic rock
Anterior/medialAnterior/medial
Pubic Pubic symphysissymphysis
Pubic Pubic ramirami
Adductor attachmentAdductor attachment
Hip flexor mechanismHip flexor mechanism Pelvic rock
SI compression
Posterior Pelvic Ligaments
Posterior muscle attachments
Lateral
Gluteal mechanism
Hip rotator cuff
Hip capsule
Intra-articular
Impingement/labral
instability
6
Physical Exam: Special Tests
ArticularArticular teststests
Impingement testsImpingement tests
McCarthy. If done actively, can screen for snapping hip. McCarthy. If done actively, can screen for snapping hip. Called the snapping hip testCalled the snapping hip test
FAIR: nonFAIR: non--specificspecific
Scour: add axial compressionScour: add axial compression
StinchfieldStinchfield or active SLR testor active SLR test
Log rollingLog rolling
Stability testStability test
Posterior and anterior glidePosterior and anterior glide
Muscle and tendon testsMuscle and tendon tests
Thomas test for hip flexor tightnessThomas test for hip flexor tightness
Rectus Rectus femorisfemoris
OberOber/modified/modified
Faber or Patrick test
Scour test
7
Stinchfield
FAIR test
Trendelenburg sign
8
Leg Length Testing
True Leg LengthTrue Leg Length
measure to medial malleolusmeasure to medial malleolus
measure to lateral malleolusmeasure to lateral malleolus
WeberWeber--Barstow ManeuverBarstow Maneuver WeberWeber Barstow ManeuverBarstow Maneuver
evaluates leg length evaluates leg length asymmetry by comparing asymmetry by comparing height of medial malleoli with height of medial malleoli with legs extendedlegs extended
Thomas Test
Tests for hip flexor Tests for hip flexor contracturecontracture
Mechanism:Mechanism: flatten lumbarflatten lumbar lordosislordosis flatten lumbar flatten lumbar lordosislordosis
flex hip against chestflex hip against chest
check for ability of the check for ability of the extended leg to lay flat extended leg to lay flat on the table.on the table.
Rectus Femoris Test
Method 1Method 1
over the edge of over the edge of examining table.examining table.
Knee should be Knee should be flexible to 90flexible to 90flexible to 90 flexible to 90 degreesdegrees
Method 2Method 2
Ely’s testEly’s test
prone positionprone position
on knee flexion, on knee flexion, check for ipsilateral check for ipsilateral hip flexionhip flexion
9
Ober’s Test
Assess for tensor Assess for tensor fasciae fasciae lataelatae ((iliotibialiliotibialband) contractureband) contracture
Can perform with knee:Can perform with knee: Can perform with knee: Can perform with knee:
flexed=greater stress flexed=greater stress on femoral nerveon femoral nerve
extended=greater extended=greater stretch on ITB.stretch on ITB.
Summary: Patient Evaluation
Summary: Patient Evaluation
1. History: mechanism of injury, sport and chronicity
2. Careful assessment for referred pain sources: gyn, GI, spine, neuro
3. Targeted functional assessment. Identify abnormal biomechanicsbiomechanics
4. Pelvic, buttock, hip, groin PE with focus on region of pain, identification of pain generators. Generate ddx.
5. Diagnostic imaging as needed and relevant
6. ***Bedside MSK ultrasound
7. ***Diagnostic/therapeutic injections
10
Summary: Treatment Options
Physical therapyPhysical therapy
Manual therapyManual therapy
RehabilitationRehabilitation
MedicationMedication
InjectionsInjections CorticosteroidCorticosteroid
ProlotherapyProlotherapy
PRPPRP
Trigger pointTrigger point Neuropathic painNeuropathic pain
NociceptiveNociceptive painpain
InflammationInflammation
Mood/sleepMood/sleep
gg pgg p
SurgerySurgery
HerniaHernia
HipHip
TendonTendon
BursaBursa
Cases
Case TL: bilateral athletic pubalgia with
“working out” 34 34 yoyo RH computer scientist and active cyclist/exerciser RH computer scientist and active cyclist/exerciser
presents with >6 presents with >6 mosmos h/o “athletic h/o “athletic pubalgiapubalgia”. Feels it ”. Feels it began after aggressive sit ups. PT of insufficient helpbegan after aggressive sit ups. PT of insufficient help
PMH notable for PMH notable for Hernia repair with meshHernia repair with mesh Hernia repair with meshHernia repair with mesh
L5 L5 radicularradicular pain (L) secondary to DDDpain (L) secondary to DDD
PE: Neuro wnl
Hernia scar well healed.
Pain with abdominal muscle activation and with palpation over superior pubic bone and adductor attachment
11
What to do next?
Treatment
ProlotherapyProlotherapy : patient request based on : patient request based on researchresearch 4 visits4 visits
Symptom resolutionSymptom resolution Symptom resolutionSymptom resolution
Additional core/ pelvic / abdominal/ hip Additional core/ pelvic / abdominal/ hip girdle strengtheninggirdle strengthening
Topol and Reeves. ArchPM&R. 2005
Athletic pubalgia or sports hernia
Most common in men with sports involving cutting, pivoting, kicking and sharp turns
May represent posterior inguinal wall weakening from shear forces applied through the pelvic attachments of the hip adductors and abdominal musclesthe hip adductors and abdominal muscles
Imaging useful to exclude other diagnoses
Physical therapy for hip and pelvic strengthening
Prolotherapy or PRP
Surgery: laparascopic and minimally invasive techniques
Caudhill et al. Sports Hernia: a systematic review. Br J Sports Med 2008Jansen et al. Treatment of longstanding groin pain in athletes Scandinavian J of Sports Med 2008
12
CASE : SL HPIHPI: 21: 21 yearyear--old Rold R--handed varsity handed varsity Wellesley College soccer player with Wellesley College soccer player with pelvidpelvid pain for 16 months: pain for 16 months: Localized to Localized to left sacroiliac area left sacroiliac area anterior , anterior ,
medial and posterior proximal thighmedial and posterior proximal thigh
StartedStarted during soccer game.during soccer game.
Rated 4Rated 4--5 out of 10 on VAS.5 out of 10 on VAS.
Worse with training, running.Worse with training, running.g gg g
Denies numbness, tingling, weakness, Denies numbness, tingling, weakness, bowel/bladder changes, fevers/sweats.bowel/bladder changes, fevers/sweats.
Ice, heat, ibuprofen, of temporary benefit.Ice, heat, ibuprofen, of temporary benefit.
CASE STUDY -SL
PMHPMH: : Pelvic girdle pain since age 20 Pelvic girdle pain since age 20
with increased soccer trainingwith increased soccer training Seasonal allergies Seasonal allergies
MedsMeds: : ZyrtecZyrtec, ibuprofen , ibuprofen prnprn, , tylenoltylenol prnprn, , FlexerilFlexeril prnprn
ROS, FH, ROS, FH, SocHSocH: non: non--contributory.contributory.
Previous Previous txtx: TFESI, S1 SNRB, : TFESI, S1 SNRB, facet and SI joint injections. facet and SI joint injections. PT, ATC, orthotics, OMTPT, ATC, orthotics, OMT
CASE STUDY - SL Physical ExaminationPhysical Examination: :
ROM: Lumbar flexion ROM mildly decreased.ROM: Lumbar flexion ROM mildly decreased. Hip ROM Hip ROM wnlwnl. . Increased lumbar Increased lumbar lordosislordosis
Sensation, reflexes, strength: Sensation, reflexes, strength: wnlwnl.. Negative FABER, Negative FABER, GaenslenGaenslen,, SI joint compression tests. ,, SI joint compression tests. Positive tenderness overPositive tenderness over left left iliolumbariliolumbar ligament and superior ligament and superior
t i ili li tt i ili li t ththposterior sacroiliac ligament posterior sacroiliac ligament enthesesentheses. .
13
SL: Imaging
CASE STUDY - SL
Differential Diagnosis: Differential Diagnosis: S1 radicular painS1 radicular pain Facet mediated painFacet mediated pain Discogenic pain Discogenic pain Iliolumbar and posterior sacroiliac ligament sprain and Iliolumbar and posterior sacroiliac ligament sprain and
enthesopathyenthesopathy
CASE STUDY - SL
TreatmentTreatment:: Physical therapy, ePhysical therapy, e--stim, stim,
osteopathic manipulative osteopathic manipulative treatment minimal benefit.treatment minimal benefit.
LeftLeft iliolumbar and sacroiliaciliolumbar and sacroiliac Left Left iliolumbar and sacroiliac iliolumbar and sacroiliac ligament steroid injection with ligament steroid injection with 100% relief for 2 months100% relief for 2 months
Season 2: treatment with platelet Season 2: treatment with platelet rich plasma injectionrich plasma injection
Return to training 10 daysReturn to training 10 days Return to play 3Return to play 3--6 weeks6 weeks
14
TENDON, LIGAMENT, ENTHESIS
Anatomy: Ligament and tendon attachments occur togetherAnatomy: Ligament and tendon attachments occur together
Netter 2001
COMMON ENTHESOPATHIES
Common Common enthesopathiesenthesopathies of of the spine/SI region: the spine/SI region: IliolumbarIliolumbar ligamentligamentIliolumbarIliolumbar ligamentligament Posterior sacroiliac Posterior sacroiliac
ligamentsligaments SacrotuberousSacrotuberous
ligamentligament GlutealGluteal tendonstendons Hip adductor Hip adductor
tendonstendons
Clinical Presentation of Tendinopathy or Enthesopathy
Trauma or repetitive or repetitive overload.overload.
Pseudoradicular symptomswith negative imaging, with negative imaging, EMG d/ lEMG d/ lEMG and/or poorly EMG and/or poorly responsive to spinal responsive to spinal injections.injections.
Prior shortPrior short--term response term response to local steroid injectionto local steroid injection
May have underlying May have underlying hypermobilityhypermobility postural postural dysfunction or mechanical dysfunction or mechanical overloadoverload
15
MECHANISMS OF INJURY
Repetitive trauma:Repetitive trauma: Each traumatic event Each traumatic event
damages tissue but is not damages tissue but is not enough to trigger the repair enough to trigger the repair process.process.
Thus, damage accumulates Thus, damage accumulates resulting in degeneration of resulting in degeneration of tissue, in this case tissue, in this case tendons, ligaments and tendons, ligaments and their enthesis their enthesis attachmentsattachments..
Neuromuscular control and “core
strength””
Dynamic Dynamic testingtestingtestingtesting SquatSquat
LungeLunge
Step upsStep ups
Unilateral Unilateral hophop
Case : Chronic back pain and stiffness non-responsive to prior treatment
37 yo software engineer, league soccer player and part time referee, presents with 2 year h/o non-relenting lower back/bilateral buttock, pelvic and groin pain
P i t t t i l d d Chi PT ib f Prior treatments included: Chiro, PT, ibuprofen (helped), epidural steroid injections for “discogenic LBP” (no sustained relief)
PMH: Crohn’s disease. Mild hypothyroidism euthyroid on synthroid
16
Case : Physical examination
Limited lumbar flexion
Decreased internal rotation of hips R>L.
Pain with pelvic rock test and ili isacroiliac compression
Minimal wrist / ankle synovitis
Neuro exam WNL.
Case : Spondyloarthropathy associated with inflammatory bowel disease
Case : Treatment
Rheumatology referral
TNF agent
Marked clinical improvement
17
Case: JP: 49 yo runner training for Boston marathon with Pelvis and gluteal pain
6 mos R gluteal, proximal posterior thigh pain.
2 week h/o incapacitating L inguinal pain. p
The gluteal and thigh pain has been insidious and slowly worsening as training regimen increases.
Pelvic pain is acute
Only PMH: small lumbar disc protrusion 20 years prior. No sequelae
Case: JP: 49 yo runner training for Boston marathon with Pelvis and gluteal pain
Physical exam General medical and neuro exam wnl
Mild pelvic obliquity. Mild restriction of lumbar flexion
Minimal L5 weakness.
Local pain to palpation and with resisted activation of hamstring and gluteal muscles. Tight TFL
Pain with resisted L hip adduction and tender over the pubic ramus
Case: JP: 49 yo runner training for Boston marathon with Pelvis and gluteal pain
MRI Edema in the L inferior pubic ramus, (near insertion of
obturator internus insertion without discrete fracture line
R greater trochanteric bursitis
Mild bilateral hip arthritis
Partial tears of R hamstring insertion at ischial tuberosity and gluteus minimus at the greater trochanteric insertion with bone marrow edema
18
Case: JP: 49 yo runner training for Boston marathon with Pelvis and gluteal pain
No discrete fracture
Low risk stress bone injury
M d ith l ti Managed with relative rest, cross training and prolotherapy
Able to complete marathon. Did walk small sections.
Insert pic of runner
Groin Pain / Pubalgia in the Athlete: Take Home Points
Etiology is diverse
Important to rule out visceral, inflammatory, hip, fracture and lumbar sources of pain
Careful evaluation and treatment of the hip Careful evaluation and treatment of the hip rotators, pelvic floor, adductors, abdominal attachments for enthesopathy/tendinopathy
Restoration of joint mobility, flexibility, muscle balance, strength, endurance is critical
Consider regenerative injection treatment for refractory cases
Thank you!!
Joanne Borg-Stein, MD