treatment of groin injuries - ioc 2021
TRANSCRIPT
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Treatment of groin injuries
Per Hölmich
Sports Orthopedic Research Center – Copenhagen (SORC-C)
Department of Orthopedic Surgery
Copenhagen University Hospital Hvidovre, Denmark
&
IOC Research Center Copenhagen Research Center for Injury Prevention and Protection of Athlete Health
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The epidemiology
- elite and non-elite football players
• 64% (63%) adductor-related
• 10% (8%) iliopsoas-related
• 4% (4%) inguinal-related
• 5% (4%) hip-related
14% of all time-loss injuries
Werner et al; BJSM 2009 & 2018
• 51% adductor-related
• 30% iliopsoas-related
• 19 % inguinal-related
Hölmich et al; BJSM 2013
Clinical diagnosis
Acute injuries
66% - Adductor
25% - Iliopsoas
23% - Rectus Femoris
10% - Abdominal
6% - Sartorius
Andreas Serner et al,
AJSM 2015
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Isometric adductor test
Photos courtesy of UEFA Football doctor education program
The best squeeze test to
identify pain related to the
adductor longus
Lovell G et al
Drew M et al
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Palpation of the adductor origin
Photos courtesy of UEFA Football doctor education program
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Treatment of longstanding
adductor-related groin pain
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Treatment of longstanding
adductor-related groin pain
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Hölmich et al, The Lancet 1999
Exercise program for adductor related groin pain
– training period 8 to 12 weeks
h.theapp.mobi/adductorprotocol
Created by Roald Otten
Multimodal treatment RCT
Weir et al; Man Ther 2011
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Important aspects of the program
• Lots of repetitions
• 3 times a week, 1½ hour duration,8-12 weeks
• No pain provoking/exacerbating activities
• Running allowed after 6 weeks (no pain)
• Good results achieved in 4 months
Hölmich et al, The Lancet 1999
h.theapp.mobi/adductorprotocol
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Adductor tenotomy (unsystematic review)
• Five Level 4 studies with great variety in study
design
• Excellent result in 54% - 75%
• Poor results in 8% - 17 %
• Complications 5% - 34%
Active exercise program (Lancet 1999)
• Excellent 79%
• Poor 3%
• Complications 0
h.theapp.mobi/adductorprotocol
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8-12 year follow up
Hölmich et al; AJSM 2011
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Inguinal-related groin pain - Treatment
• No evidence-based non-surgical treatment
programmes
• The general principles of the treatment programme
used for adductor-related injuries can be used…
- strengthening muscles, training balance &
coordination around the pelvis…
• ..Including a particular focus on specific abdominal
muscle exercises
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Strengthening the abdominals
Sundstrup E et al., 2012
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Inguinal-related groin pain -
treatment
• With long-standing exercise resistant inguinal-
related groin pain, surgery is an option
• The basic principles of the surgical procedure and
the post-operative regime are identical to those for
manifest hernias – open or endoscopic - apart from
the fact that there is no hernia sac to invert or
remove
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Iliopsoas-related groin pain
- Treatment
• No evidence-based rehabilitation programmes
• The general principles of the treatment programme
used for adductor-related injuries can be used…
- strengthening muscles, training balance &
coordination around the pelvis…
• …Including a particular focus on specific exercises
for the hip flexor muscles
• Start with isometric and gentle eccentric exercises
• Continue with heavy slow resistance training
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Strength training of hip flexors – a RCT17% strength increase in 6 weeks
Thorborg et al., KSSTA 2015
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Iliopsoas-related groin pain
- Treatment
• No evidence-based rehabilitation programmes
• The general principles of the treatment programme
used for adductor-related injuries can be used…
• …Including a particular focus on specific exercises
for the hip flexor muscles
• Start with isometric and gentle eccentric exercises
• Continue with heavy slow resistance training
• If it is too painful to do the strength training
program ultrasound guided cortisone injections
can be helpful
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Iliopsoas-related groin pain
- Treatment
• No evidence-based rehabilitation programmes
• The general principles of the treatment programme
used for adductor-related injuries can be used…
• …Including a particular focus on specific exercises
for the hip flexor muscles
• Start with isometric and gentle eccentric exercises
• Continue with heavy slow resistance training
• Return to play in three to six weeks
• Almost never indication for:
Arthroscopic partial iliopsoas tenotomy in athletes
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Copenhagen Hip and Groin Outcome Score
- HAGOS
Thorborg, Hölmich et al; 2011 BJSM
• HAGOS is a profile score
• Consists of 6 subscales/scores
• Measuring specific dimensions
and constructs relevant to the
effects of hip/groin impairment
Has been translated into multiple
languages www.koos.nu
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AJSM 2018
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Methods
Hip arthroscopy for femoroacetabular
impingement syndrome in preceding 6 months to
6 years
Cam resection +
labral surgery
18-30 years old at time of surgery
Danish Hip Arthroscopy Registry
Ishøi et al
AJSM 2018
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Return to preinjury sport and HAGOS
Ishøi et al
AJSM 2018
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Return to sport following hip arthroscopy
for femoroacetabular impingement
syndrome
89,0%
49,0%
21,0%
74,0%
57,1%
16,9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any sport Preinjury sport Same/optimalperformance
Wörner et al., 2018 BJSM(N=127)
Ishøi et al., Accepted AJSM(N=189)
Combined
N=316
Ishøi et al
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• Groin and hip pain during previous season and at
beginning of current season registered
• HAGOS score at beginning of current season
• Half of the players report pain in the hip and/or groin
during the previous football season
• The football players with the longest duration of pain
in previous season displayed the lowest HAGOS
scores in the beginning of the new season
…..The groin pain carries over to next season
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Recommendation
• Use the off-season to focus on treatment and
recovery rather than simply resting
• Examine the athletes at the end of the season
• Use the off-season to improve any muscular deficits
found - combined with sports specific training
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The between-group difference for EHAD
strength increase was 13% -
(p=0.044)
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The Copenhagen 5-second squeeze
5-second isometric hip-adduction contraction
with extended legs in the supine position
Hölmich et al., 2004
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A simple idea
How much
pain
0-10?
Thomee, 1997
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Correlation between HAGOS and pain with
The Copenhagen 5-Second Squeeze n=668 football
players
Thorborg K, Hölmich P et al; BJSM 2017
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…..and help you decide to give
green or red light for your
soccer-player
Thorborg K, Hölmich P et al; BJSM 2017
The Copenhagen 5-second squeeze
is strongly related to hip- and groin
sporting-function…
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Prevention of groin injuries- a joined research project with
Oslo and Copenhagen IOC Research Centres
A cluster RCT
The preventive effect of an
Adductor Strengthening
Program on groin problems in
Norwegian male football players
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Copenhagen Adduction
Serner et al; BJSM 2013
Ishøi et al; SJMSS 2015
Significant increase in
eccentric strength
(35.8%)
after 8 weeks training
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RCT using the Copenhagen
Adduction as a single exercise
interventionLevel 1 Level 2 Level 3
WeekWeekly
sessionsSet per side Repetitions per side
1 2 1 3-5
2 3 1 3-5
3-4 3 1 7-10
5-6 3 1 12-15
In
season1 1 12-15
Joar Harøy et al
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76% gradual onset
37% time loss
Majority in the dominant leg
2500 groin problems reported
Joar Harøy et al
632 players from 34
teams
OSTRC Overuse Injury
Questionnaire (Clarsen et al. 2013)
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All groin problems
Mean difference in prevalence: 7.8%
Joar Harøy et al
41% lower injury risk(OR 0.59, p=0.008)
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Summary
• Use sufficient exercise stimulation and….time!
- Take another look at the old 1999 Lancet
study – it still works
• Restore the associated pelvic muscular deficits
• Restore the demands and skills needed to participate in sport – including endurance
• Monitor the groin and hip status with HAGOS
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Summary
• Use the off season break to avoid continued and
new groin injuries
• Use the Copenhagen 5-Second Squeeze
and HAGOS to monitor players on a regular
basis
• Use the Copenhagen Adduction exercise for
prevention
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Thank you