CoreMuscleInjuries

R.RobertFranks,D.O.,FAOASMDirectorofConcussionProgram

SportsMedicineRothmanInsBtute

AssociateProfessorFamilyMedicineThomasJeffersonUniversityPhiladelphia,Pennsylvania

PleaseDONOTCallThemSportsHernias

IntroducBon

•  Philadelphiaathleteswithcoremuscleinjuries– Eagles’DonovanMcNabb

– Eagles’ZachErtz– Eagles’KevinCurBs– Flyers’DannyBriere

IntroducBon

•  Incidentofgroinpainis5to7%ofallsportsinjuries

•  Mostcommoninsoccer,iceandfieldhockey,tennisandAustralianRulesFootball

•  SomestudieshaveaVributedincreaseddiagnosistomoreaggressiveathleBcplaybutotherstudieshavecitedgreaterawarenessofcoremuscleinjuriesbyCerBfiedAthleBcTrainersandSportsMedicinePhysicians

IntroducBon

•  Oneofleastunderstood,inadequatelydefinedandpoorlyresearchedaffecBonsofallsportsmedicineinjuries

•  CoremuscleinjuriesareactuallyseveraldifferentcondiBonslumpedtogetherunderonecommonmedicalterminology

•  Canbeacute,chronic,oracuteonchronicvariety

•  Foundmorecommonlyinmalethanfemaleathletes

DifferenBalDiagnosis

•  Adductorstrain•  OsteiBsPubis•  IliopsoasStrains/BursiBs•  StressFractures•  AvulsionFractures•  HipPathology–LabralTear,FAI,SnappingHip•  NerveCompression

Anatomy

•  BonyPelvis–  Ilium

–  Ischium– Pubis– Sacrum/Coccyx

Anatomy

Anatomy

•  So\Tissue– FibrousaVachmentofpubicsymphysis

– FibrocarBlagearBculardiscbetweenpubicboneswithaVachedligaments

– Mostimportantisthearcuateligamentattheanterior,inferiormarginofthejointaVachingtothesymphysiscapsule,bothpubictuberclesandprovidingasuperficialaVachmentforregionaltendon/musclecomplex

Anatomy

•  So\Tissue– RightandLe\RectusAbdominis/AdductorAponeuroses• MeetatmidlinepubicsymphysiscontainingverBcalrapheformingadensemidlinepubicplate

Anatomy

•  So\Tissue– AdductorMuscles

•  PecBneus–Anterior•  AdductorBrevis,Gracilis,andAdductorMagnus-Posterior

Anatomy

•  So\Tissue–  InguinalRing

•  Lateraltoaponeuroses– ExternalObliqueblendingwithlateralmarginofRectusAbdominusformingExternalObliqueAponeuroses–superficialtoinguinalcanalandcephaladandlateraltoring

Anatomy

AnatomicalBalance

•  RectusAbdominiscreatesposteriortension•  AdductorscreateinferoanteriortensionwithcorerotaBonandextension

•  ThisopposiBonalongwithaponeurosisneededforanteriorpelvicstability

•  DisrupBonofthisbalanceleadstocoremuscleinstabilityandcoremuscleinjury

Anatomy

Pathogenesis

•  Groininjuriesusuallyoccurfromthefollowing:– Overuse–  Increasedshearingacrossthehemipelvis– Lumbopelvicandlowerextremitymusclestrengthendurance,extensibility,andcoordinaBonimbalance

– LossofdynamicabdominalwallrotaBonalstability– Lossofcongenitalinguinalwallweakness– Overallcoreweakness

MostCommonCauses

•  Hipadductorstrain/tearwithpalpablepainatpubicboneaVachmentandresistedhipadducBon

•  Iliopsoasstrain/tearwithpalpablepainofmuscleatlowerlateralabdomenorjustdistaltoinguinalligament.Paino\enwithcrunchorresistedcrunch.Canbeco-morbidThomasTestpain

•  Rectusabdominisstrain/tearwithpalpablepainatdistaltendonoronaVachmentatpubicboneandpainwithresistedsitup

MostCommonCauses

PhysicalExaminaBonFindings

•  NOdetectableinguinalhernia•  Inguinalcanaltenderness•  Dilatedsuperficialinguinalring•  Pubictubercletenderness•  Hipadductororigintenderness

PhysicalExaminaBonFindings

•  KeyphysicalfindingmaybepubictubercletendernessandinguinalfloortearthatcanpossiblybepalpatedcreaBngpaininsidetheexternalinguinalring– PainmyradiatetotesBcleorlaterallytoupperthigh

– Aggravatedbysuddenmovement,Valsalva,sexualacBvity,resistedsitup,orhipadducBon

Imaging

•  TradiBonalX-rayviewsinclude:– APPelvis– APandlateralofaffectedhip

•  X-rayscanyieldchangesassociatedwith:– FAI– OA– OsBBsPubis– AvulsionFracture

Imaging

•  TradiBonalultrasoundisusefulmodalitytodiagnoseINGUINALHERNIA

•  CTiso\enusedtodiagnoseINGUINALHERNIA

•  MSKUltrasoundidenBfiestendonopathiesandtendon/muscletearsbutincompleteinlookingatinflammatoryanddegeneraBvebonyprocesses

Imaging

•  MRIofAthleBcPubalgiaseries– 1.5Teslaunitwithphasedarray,mulBchannelcoilgivesbestimaging

MRIofAthleBcPubalgiaSeries

•  Sequencesincludethefollowing:– EnBrebonypelvisincludinghighresoluBonsequencesoverthepubicsymphysis

– Standardcoronal,sagiValandaxialplanes,butalsocoronalobliqueimagingplanefromanteriormarginoftheiliaccrestformingasagiVallocalizersequence(alongthearcuatelineofthepelvis)neededtoseetherectusabdominus/adductorlongusaponeurosisanditsaVachmentatpubictubercle

MRIofAthleBcPubalgiaSeries

•  Sequencesincludethefollowing:– Largefieldofviewsequencefromumbilicustomidthigh

– Smallerfieldofviewsequencesfocusedonpubicsymphysisextendingthroughthepubicramibilaterally

MRIofAthleBcPubalgiaSeries

Treatment

•  ConservaBve:– Rest–  Ice– NSAIDs– DisconBnuaBonofoffendingacBvity

Treatment

•  ConservaBve:– PhysicalTherapy

• ModaliBesthatmayassistinrecoveryinclude–  E-sBm

–  DeepBssuemassage

–  AcBveReleaseTherapy–  GrastonTechnique–  Iontophoresis

Treatment

•  ConservaBve:– PhysicalTherapy

•  Focusedprogressivehipadductorstretchingandstrengtheningexercisesaswellasextensivecoremusclestrengthening

•  Exercisetoimprovestrength,endurance,coordinaBonandappropriatehipandabdominalmusclebalanceaswellascorestability–  AbducBon,adducBon,flexionandextensionexercises–  Sit-ups– Wobbleboard–  Slidingboard–  FiVerexercises

Treatment

•  ConservaBve:– OMT

•  Focusedtreatmentonhip/pelvisando\ensacrum/SIjoint

– PhysicalTherapy•  Returntosportsisgenerallya\er8-12weeksoftreatmentwithathletepainfreeinPTandwithexerBontherapy

•  Athletemustbeabletosuccessfullypasssport-specificacBvity–cuingandsmoothdirecBonalchangearecriBcal

Treatment

•  ConservaBve:– CorBcosteroidInjecBon

•  UsuallydoneatinserBonofrectusabdominisoradductorlongustendonsusuallyatpubictubercle

– ProlotherapyInjecBon•  Sclerosingagentinjectedatoneofthefollowingsites:

–  AdductoraVachments

–  Conjoinedtendonatpelvicrim

–  Pubicsymphysis

Treatment

•  Surgical– ExploraBonandrepairconsideredwhenrestandnonsurgicaltreatmenthasbeenaVemptedUNLESS•  TruepathologyelicitedonMRIandconservaBvetreatmentwouldnotbeconducivetoahighlevelathlete–i.e.competedisrupBonofpubicplateinicehockeyplayer

Treatment

•  Surgical– Openorlaparoscopicapproachescanprovidegoodresults

– Mostrepairsaddressrepairofabdominalmuscles,adductormuscles,orboth,orfascianeartheinguinalligament.

– Repairsthatdonotaddressesforcescausingpathologyareo\enunsuccessful

– Whetheropenorlaparoscopic,repairratesvaryfrom63to95%

Treatment

•  Surgical– Laparoscopicrepairusuallyassociatedwithquickerreturntosports•  Trainingat4weeks•  FullacBvityat6weeks

Treatment

•  Post-SurgicalRehabilitaBon– GooddatalackingforreturntoacBvityfollowingsurgery

– SomephysiciansdonotdoPTa\ersurgery

Treatment

•  Post-SurgicalRehabilitaBon– PTpost-surgicalgenerallyconsistsofthefollowing:•  Avoidanceofsharp,sudden,cuingmovements

•  Lowerextremityinflexibility,weakness,andlackofcoordinaBoniscorrected

•  Runningstraightaheadatday21•  SprinBngwithoutcuingatweek3•  FullacBvitya\erlaparoscopicrepairin6to8weeks•  FullacBvitya\eropenrepairatapproximately18weeks

References

•  Caudill,P,EtAl.“SportsHernias:ASystemicLiteratureReview.”BrJSportsMed.42:954-964.July2008.

•  Kachingwe,AF,Grech,S.“ProposedAlgorithmfortheManagementofAthletesWithAthleBcPubalgia(SportsHernia):ACaseSeries.”JournalofOrthopaedicandSportsPhysicalTherapy.38:768-781.December2008.

•  Larson,CM.“SportsHernia/AthleBcPubalgia:EvaluaBonandManagement.”SportsHealth.6:139-144.January2013.

•  Morelli,V.,EtAl.“GroinInjuriesinAthletes.”AmericanFamilyPhysician,64:1405-1414.2001.

•  Mullens,FE,Zoga,AC,EtAl.“ReviewofMRITechniqueandImagingFindingsinAthleBcPubalgiaandtheSportsHernia.”EuropeanJournalofRadiology,81:3780-92

PhotoReferences

•  1.FromAntenatalCareModule–AnatomyoftheFemalePelvis

•  2.Fromwww.rebalancetoronto.com

•  3.UMEMEducaBonalPearls–UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine

•  4.FromSportsHealth:sph.sagepub.com

•  5.Fromwww.radsource.us