Mark Wotherspoon - The Gilmore Groin & Hernia Clinic
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Transcript Mark Wotherspoon - The Gilmore Groin & Hernia Clinic
Dr Mark Wotherspoon
MB BS, DipSportsMed(Lond), FFSEM
Consultant in Sports and Exercise Medicine
Introduction
Groin injury is common
Large differential diagnosis
Seen in sports with kicking/sprinting/change
direction
i.e football/rugby/hockey
Complex anatomy
No consensus on pathology/pathophysiology or
management
Pubalgia
Pain arising from local structures in the pubic
area
2-5% of sporting injuries
5-7% football injuries
Chronic and debilitating condition
Prolonged recovery period
Difficult to assess clinically
Poorly imaged/interpreted
On-going debate/research
Reflects chronic stress in pubic region
resulting in breakdown in a variety of ways
Similar to “Shin Splints”
Causes of Pubalgia
Bone
Musculotendinous
Pubic: osteitis pubis
Nonpubic: pelvic stress fractures
Joint
Pubic: pubic instability/disc
degeneration
Nonpubic: hip joint/SIJ/Lumbar
spine
Pubic: adductor tendinopathy/rectus abdom
inguinal canal pathology
conjoint tendinopathy
Nonpubic: iliopsoas dysfunction
rectus femoris injury
Nerve Entrapment
Ilio-inguinal Nerve/Obturator Nerve
Genito-urinary
Prostatitis/salpingitis/epididymitis
Other
Hernias/tumours(osteiod osteoma)
Infection/seronegative spondarthropathy
Main Causes
Sportsmans surgical groin/Abdominal related groin
pain
Pubic Bone stress Response
Chronic Adductor Tendinopathy/Adductor Related
Groin Pain
Hip related groin pain
Risk Factors
Previous groin pain
Level of sport
Number of training sessions
Flexibility
Muscle imbalance
Poor core stability / functional movement
Reduced hip ROM especially internal rotation
Symptoms
Pain in groin
Worse with twisting,sprinting,kicking
Stiff/sore after sport
Non specific loss of power / speed
Radiates into upper thighs,perineum,testicles
Unilateral/bilateral
Coughing/sneezing
Turning over in bed/getting out of a car
Insidious onset and often play with it
Sit-ups
Exclude the hip
Signs
Exclude the hip, SIJ’s and back
Localisation of pain
Resisted single and bilateral SLR
Resisted sit up
Adductor squeeze in all ranges
Adductor signs
Sites of tenderness
Modified Thomas test/ crossover sign
Exclude psoas
Burden of evidence
Investigations
X-ray +/- stork views
Bone scan
CT scan / CT spect
MRI / MR arthrogram
Herniography
Ultrasound
Diagnostic LA injection into hip
Hip arthroscopy
Abdominal Related Groin Pain
Abdominal symptoms
Pain with cough and sneeze
Tenderness over conjoint tendon at pubic tubercle
Tender/dilated superficial inguinal ring
Number of different surgical theories/operations
? Rx with belt
Abdominal Related Groin Pain
Munich Approach
David Connell’s radio-ablation
Gilmore’s technique
David Lloyd’s tenotomy
Munich Approach
Swelling in stretched / weak posterior inguinal
canal wall
Identified digitally or via ultrasound
Transversalis fascia dilates widening Hasselbach’s
triangle
With abdominal muscle contraction swelling
increases
Compression of genital branch of genitofemoral
nerve (dull pain radiating around pubic region)
Tension on rectus abdominis insertion at pubic
tubercle (pubalgia)
Munich Approach
No mesh
Laparoscopic
Genital branch of genitofemoral nerve indentified
and if necessary partially excised
Reduction in tension of rectus abdominis at pubic
bone by special suture repair
Repair of weak posterior wall of inguinal canal
with sutures
Local anaesthetic
Munich Approach
Day case surgery
Jogging / cycling at 2 days
Sprinting / change of direction at 3-4 days
Full training 5-6 days
Back to sport at 6-7 days
1,100 operations per year
7% of which are elite athletes
99% successful
Pulsed Radiofrequency
Assumption is that inguinal related groin pain is nerve
entrapment/irritation around inguinal ligament
Under LA
Along inguinal ligament past genitofemoral nerve and
ilioinguinal nerve
Pulsed radiofrequency stuns the nerves for 9 months.
Rest 2 days after and start rehab
Laparoscopic Inguinal Ligament
Tenotomy
Laparoscopic
Acute/chronic injury of inguinal ligament at pubic
tubercle
Tatty scarred inguinal ligament at insertion into
pubic tubercle with holes and ruptures
Sutures if previous surgery
Mesh to re-inforce posterior wall of inguinal canal
and change pressure onto mesh rather than
inguinal ligament
Divide inguinal ligament and scar tissue
Inguinal Ligament Tenolysis
Aggressive rehab with stretches
No sutures so safe
Train at 1 week
Full training at 2 weeks
Return to play at 4 weeks
400 operations
Few failures
David Lloyd’s Main Criteria
Unilateral pain
Abdominal related groin pain
Pain radiates < 5cm from superior pubic tubercle
Tender superior pubic tubercle
Pain with cough/sneeze
Pain reproduced by resisted sit ups/Valsalva manoevre
Prognosis
Good outcome if 4 main criteria present
Low success if pain radiates > 5 cm from superior
pubic tubercle especially if laterally
Abdominal Related Groin Pain – is
it a continuum ?
Munich Approach
David Connell’s radio-ablation
Gilmore’s technique
David Lloyd’s tenotomy
Pubic Bone Stress Response
Repetitive minor trauma leads to painful non
infectious/stress related lesion at pubic symphysis
and local muscle insertions/origins
Men more than women
Maximum tenderness at or adjacent to symphysis
Stress reactions at adductor tubercle and pubic
tubercles
Shearing forces across symphysis
Rare as primary problem / asymptomatic finding
Investigations
X-ray - if early nothing
sclerosis, erosions, widening of symphysis,
periosteal reactions, moth eaten
Bone scan - hot
MRI stress reactions and marrow oedema,fluid in
symphysis etc
Treatment
Modified rest/prevent shearing
Rehabilitation/flexibility
NSAID’s to reduce inflammation
U/S guided cortisone injections
Usually 2-3 months
Can last 3-6 months
Graded return to sport
Bisphosphonates
Chronic Adductor tendinopathy
Easy diagnosis with pain resisted contraction,local
tenderness adductor tubercle and pain and
resisted stretch
Usually adductor longus
Insertion into pubic tubercle +symphysis ie blends
in not one insertion site
U/S and MRI confirm diagnosis
Local physio Rx, ? U/S guided cortisone, ? Dry
needling and autologous blood / PRP
Adductor tenotomy
Graded rehabilitation programme
Iliopsoas Related Groin Pain
Pain on stretch – Thomas’s test
Pain on resisted hip flexion at 90
Tender on palpation
Snapping hip(hip flexion/abduction and extend)
Psoas bursae – one deep to psoas can become
symptomatic (one anterior to hip like Baker’s cyst in
knee)
Iliopsoas Related Groin Pain
U/S or MRI
Local physio Rx / rehab
U/S guided injection
Summary
Spectrum of same problem
Conditions can co-exist
Prevention best treatment/Pre-hab
All need rehabilitation as main stay of Rx
MRI Ix of choice
4-6 wks rehab/Rx and re-asses/pick off what is left
Multidisciplinary Team/Groin clinic
Summary
Exclude other pathology eg hip/back
History particularly coughing/sneezing/turning in bed
Examination chronic adductor + pubic symphysis
tendernes
Choose patients for surgery + surgeon + when
New developments
Groin Pain
assessment
Ix with MRI +/- US
Rehab 4-6 wks
review
PBS response
Iv pamidronate/calcitonin
Chronic adductor
Autologous blood
If improving C/T
Sportsman’s hernia
surgery
C/T rehab
Psoas dysfunction
us guided inj