Chronic groin pain in athletes Charl Carstens CLL 705 September 2012.
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Transcript of Chronic groin pain in athletes Charl Carstens CLL 705 September 2012.
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Chronic groin pain in athletes
Charl Carstens
CLL 705
September 2012
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OVERVIEW
1. Case Presentation
2. Clinical Progress
3. Special Investigations
4. Treatment
5. Introduction
6. Summary
7. Discussion
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Case Presentation
26 year Male rugby player- hooker
C/O: Pain left supra inguinal area
(illiopsoas)
Conservative treatment 1/12
Surgeon referral
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Clinical Progress
Re-injured- acute pain left groin X-ray- NAD Ultrasound- ?Partial tear or
tendinopathy adductor
brevis
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Progress Cont.
Treatment 9/52 Rest/Rehab:
Core stabilizers, hip muscle
activation and strengthening
Slipped – pain left groin again
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Re- Evaluation
Tender Proximal adductors
Adductor squeeze test- Extension & 90° Hip flexion - adductor longus
FABER (+)
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Special Investigations
MRI: Partial avulsion enthesis left pectineus and adductor brevis anterior at inferior attachment of symphysis pubis.
Oedema medially in both muscles.
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Surgical Treatment
5 months post injury
Surgery: Extensive tendinopathy of Adductor longus – unilateral tenotomy
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Summary
1. Clinical
Chronic groin injury
2. Personal
Professional rugby player
3. Contextual
Pressure from club RTP
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Introduction
Non-specific exercise related groin pain
Osteitis Pubis/Athletic PubalgiaAdductor tendinopathy(enthesopathy)Iliopsoas dysfunctionSportsman’s hernia/sports herniaGilmore’s groin
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Discussion
4 Groin Entities
A. Adductor- related
B. Iliopsoas- related
C. Abdominal wall- related
D. Pubic bone stress –
related(Brukner & Khan 2012)
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4 Groin Entities
Anatomy:
- Adductor Longus & Rectus
Abdominus directly linked
- Indirectly to Transversus
Abdominus & Internal Oblique via
Rectus Abdominus sheath
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Pubic Joint
1. Anatomy- 2 Pubic symphyseal bones
- 3 Muscle Compartments
Anterior: Abdom, Quads, Sartorius,
Iliopsoas + Pectineus
Medial: 3 Adductors, Gracillis +
Obturator externus
Posterior: Hamstrings +Part Add Magnus
(Meyers et al 2012)
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Adductor Longus Related
Enthesopathy rather tendinopathy
Conservative treatment- soft tissue treatment, core stability program & strengthening local muscle groups
If all else fails- cut
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Treatment Cont.
Partial tenotomy – transferring load from superficial to deep part
(Orchard J.W et al 2004) ?RTP after 4-6 weeks
(Brukner & Khan 2012)
Complete Tenotomy
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Treatment Cont.
Unilateral Adductor tenotomy return to pre-injury level of sport:
1. Atkinson et al 2010 - 54%
2. Akermark et al 1992 – 62%
3. Robertson et al 2011 – 68%
Advocated 10 – 12 weeks rehabilitation
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Treatment Cont.
Bilateral Adductor tenotomy return to pre-injury level of sport or higher:
Maffuli et al 2012 – 76% with 16 weeks rehabilitation
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References
1. Brukner P., Khan K., et al, 2012. Brukner & Khan’s Clinical Sports Medicine. 4th ed. Australia: Mcgraw-Hill Australia. 342-389.
2. Akermark C. and Johansson C. 1992. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med. 20:640-643.
3. Atkinson H.D., Johal P., Falworth M.S., et al 2010. Adductor tenotomy: its role in the management of sports related chronic groin pain. Arch Orthop Trauma Surg. 130(8): 965-70.
4. Hackney R.G. 2012. Groin pain in athletes. Othop & Trauma 26(1): 25-32.
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References Cont.
5. Maffuli N., Loppini M., Longo U.G., et al. 2012. Bilateral Mini-Invasive Adductor Tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes. Am J Sports Med. 40(8): 1880-86.
6. Meyers W.C., Yoo E., Devon O.N., et al 2012. Understanding “Sports Hernia”(Athletic Pubalgia): The Anatomic and Pathophysiological Basis for Abdominal and Groin Pain in Athletes. Oper Tech Sports Med. 20: 33-45.
7. Orchard J.W., Cook J.L. and Halpin N. 2004. Stress-shielding as a cause of insertional tendinopathy: the operative technique of limited adductor tenotomy supports the theory. J Sci Med Sport. 7(4): 424-8.
8. Robertson I.J., Curran C., McCaffrey N., et al 2011. Adductor tenopathy in the management of groin pain in athletes. Int J Sports Med. 32(1): 45-48.