Transcript ChronicGroinAthlete cc

Chronic groin pain in athletes
Charl Carstens
CLL 705
September 2012
OVERVIEW
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Case Presentation
Clinical Progress
Special Investigations
Treatment
Introduction
Summary
Discussion
Case Presentation
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26 year Male rugby player- hooker
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C/O: Pain left supra inguinal area
(illiopsoas)
Conservative treatment 1/12
Surgeon referral
Clinical Progress
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Re-injured- acute pain left groin
X-ray- NAD
Ultrasound- ?Partial tear or
tendinopathy adductor
brevis
Progress Cont.
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Treatment 9/52 Rest/Rehab:
Core stabilizers, hip muscle
activation and strengthening
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Slipped – pain left groin again
Re- Evaluation
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Tender Proximal adductors
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Adductor squeeze test- Extension &
90° Hip flexion - adductor longus
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FABER (+)
Special Investigations
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MRI: Partial avulsion enthesis left
pectineus and adductor brevis anterior
at inferior attachment of symphysis
pubis.
Oedema medially in both muscles.
Surgical Treatment
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5 months post injury
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Surgery: Extensive tendinopathy of
Adductor longus – unilateral tenotomy
Summary
1.
Clinical
Chronic groin injury
2.
Personal
Professional rugby player
3.
Contextual
Pressure from club RTP
Introduction
Non-specific exercise related groin pain
Osteitis
Pubis/Athletic Pubalgia
Adductor tendinopathy(enthesopathy)
Iliopsoas dysfunction
Sportsman’s hernia/sports hernia
Gilmore’s groin
Discussion
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4 Groin Entities
A. Adductor- related
B. Iliopsoas- related
C. Abdominal wall- related
D. Pubic bone stress –
related
(Brukner & Khan 2012)
4 Groin Entities
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Anatomy:
- Adductor Longus & Rectus
Abdominus directly linked
- Indirectly to Transversus
Abdominus & Internal Oblique via
Rectus Abdominus sheath
Pubic Joint
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)
1.
Adductor Longus Related
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Enthesopathy rather tendinopathy
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Conservative treatment- soft tissue
treatment, core stability program &
strengthening local muscle groups
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If all else fails- cut
Treatment Cont.
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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
Treatment Cont.
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Unilateral Adductor tenotomy return to
pre-injury level of sport:
Atkinson et al 2010 - 54%
Akermark et al 1992 – 62%
Robertson et al 2011 – 68%
Advocated 10 – 12 weeks rehabilitation
Treatment Cont.
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Bilateral Adductor tenotomy return to
pre-injury level of sport or higher:
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Maffuli et al 2012 – 76% with 16 weeks
rehabilitation
References
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Brukner P., Khan K., et al, 2012. Brukner & Khan’s Clinical
Sports Medicine. 4th ed. Australia: Mcgraw-Hill Australia.
342-389.
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.
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): 96570.
Hackney R.G. 2012. Groin pain in athletes. Othop & Trauma
26(1): 25-32.
References Cont.
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Maffuli N., Loppini M., Longo U.G., et al. 2012. Bilateral MiniInvasive Adductor Tenotomy for the management of chronic
unilateral adductor longus tendinopathy in athletes. Am J
Sports Med. 40(8): 1880-86.
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.
Orchard J.W., Cook J.L. and Halpin N. 2004. Stressshielding as a cause of insertional tendinopathy: the
operative technique of limited adductor tenotomy supports
the theory. J Sci Med Sport. 7(4): 424-8.
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.