Transcript Talk I did - Sports Clinic NQ

No right or wrong. Provoking thought!
• Massive regional bias.
• Australian East Coast– diagnosis of sports hernia is quite common.
• In Adelaide I was with a group of AFL doctors who had not made the
diagnosis in years. Was told “There is no such thing. It is all FAI,
adductor tendinopathy and pubic bone marrow oedema.”
• Iliopsoas related pain is a diagnosis I had rarely made at all.
Publications stating that it is the primary clinical entity in 36% and
clinically meaningful in 58% of hip / groin presentations!
No right or wrong. Provoking thought!
• Doha agreement Groin pain.
• 23 world experts were sent two case studies and were asked for their
clinical impression. Principle diagnosis
• Case 1 “Six adductor-related groin pain, 6 adductor tendinopathy, 4
adductor enthesiopathy, 2 femoro-acetabular impingement (FAI), 1
adductor tendinitis, 1 adductor strain, 1 pubic bone stress injury, 1 pubic
bone fibrocartilage separation and 1 chronic low grade capsular/enthesis
stress.”
• Case 2 “Nine inguinal-related groin pain, 3 sports hernia, 2 incipient
hernia, 2 inguinal disruption, 1 Gilmore’s groin, 1 pubic bone fibrocartilage
separation, 1 inguinal canal aponeurosis strain, 1 ilioinguinal disruption, 1
enthesopathy inguinal ligament, 1 posterior wall weakness, 1 core muscle
injury and 1 hip chondral surface damage”
• Agreement for secondary diagnosis was even worse.
Case 1
History
• 20 year old Australian rules football player. No PMHx. NKDA. No
medications. No history of drug use.
• Presents with a 3 month history of insidious onset crescendo groin
pain. When localising the pain he puts his open hand on his right
groin.
What extra history is needed
What extra history is needed
• Red flags? Is this definitely a musculoskeletal injury? Could it be infection
or neoplasm? Must never miss these! Well established for back pain but
weight loss, night pain, diaphoresis, fevers would constitute red flags for
hip pain.
Inflammatory vs mechanical? Is it possible that there is a rheumatological
component? Ankylosing spondylitis, inflammatory arthropathy. Post
infection. Ask about night pain. Pain progress over a 24 hour period and
response to activity.
Nature of symptoms? Need to know the exact nature of the pain. Ask
about exact location of the pain. Point to it with one finger. Duration. What
it feels like. Exacerbations with coughing and sneezing. Activities and
movements that provoke symptoms. Relieving factors. Response to activity.
Extra history
• No night pain, weight loss or fevers. Gets an ache in the morning but
not classic morning pain and stiffness. Pain is worse with activity.
• Deep squats hurt. Has pain and difficulty with some mobility and
agility drills. Always tight in the hips. Difficulty with some stretches.
Long cross body kicks hurt a lot. When asked to localise the site of
maximal pain with one finger he points to the hip joint.
What would you look for on exam?
What would you look for on exam?
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Gait.
Single leg weight bearing.
Lumbar spine range.
LLD.
Hip range of motion and power.
Hip impingement signs.
Sites of tenderness.
Palpate for hernia / inguinal tenderness.
Squeeze test.
Resisted sit up.
Active tests hop, single leg squat etc
Exam findings
• Normal lumbar spine range. Normal gait. No loss of hip control in
single leg stance. Good power for all muscle groups. Mild pain with
squeeze. Minimal discomfort with resisted hip flexion and sit up.
Decreased internal rotation. FADIR positive for pain and reduced
range. It does reproduce his exact symptom and he localises the pain
from the test to the hip joint. FABER was positive for decreased range
but had minimal discomfort. Pubic symphysis was tender but not
reproducing the presenting pain. Adductor origin palpation is tender
but not reproducing the same pain.
What investigations if any would you order?
What investigations would you order?
• First line
• XR pelvis, hip views, flamingo views, dunn view
• First line and very useful especially for late presentations in the clinic.
What investigations would you order?
• First line
• “But Xrays don’t show anything?!?!?!!?”
A
B
C
D
E
F
H
I
Can get lots of info from xrays!
• A, B, C, D – AP pelvis and Dunn views. Small CAM lesion / bump /
subchondral change suggestive of FAI in professional football player
• E – Significant CAM lesions, ? Pincer lesions. Severe FAI.
• F – Pubic symphysis degenerative change
• G – Pubic growth plates. In right clinical context could be suggestive
of apophysitis in a 21 year old!!!
• H – Normal pubic symphysis in adolescent.
• I – Normal pubic symphysis, bilateral CAM lesions worse on the left
and left sided hamstring origin enthesis change, hypertrophic
adductor insertions.
What investigations would you order?
• Second line
• MRI / MRA
What investigations would you order?
• Second line
• MRI / MRA
• 3 tesla MRI supposedly equivalent to MRA although dependent upon the
radiologist / surgeon / person making the interpretation. Hotly debated.
Regional bias. Teaching is different in different parts of the country.
• Best test is probably 3T MRA
• Acceptable test is likely 1.5 MRA or 3T MRI
• If young patient / needle phobia / imperfect skin -> risk of infection then 3T
MRI is probably the way to go.
• In Townsville the 3T machine is at JCU QXR. It is not rebatable even with
specialist referral.
What investigations would you order?
• Second line
• MRI / MRA
• MRI/MRA hip can have incidental findings which can act as red
herrings!
The
problem
with
most
tests !
The
problem
with MRI!
What investigations would you order?
• Second line
• MRI / MRA
• Silvis AJSM High Prevalence of Pelvic and Hip Magnetic Resonance
Imaging Findings in Asymptomatic Collegiate and Professional Hockey
Players found 77% of asymptomatic hockey players had pathology in
the hip or adductors. 36% had adductor related imaging
abnormalities and 64% had hip pathology. Clearly many players had
both. Another study found that 39% of asymptomatic people aged
26 had labral tears and 7% had non labral hip pathology ie bone,
ligamentum teres or chondral surface.
What investigations would you order?
• Second line
• MRI / MRA
• Need judicious ordering of higher level imaging.
• Ensure clinical correlation before discussing surgery!
Imaging findings
Imaging findings
• MRI shows cam lesion and associated small degenerative labral tear.
Pubic bone marrow oedema. Adductor tendinopathy changes.
Imaging findings
• MRI shows cam lesion and associated small degenerative labral tear.
Pubic bone marrow oedema. Adductor tendinopathy changes.
• All of these findings are potentially seen in the normal asymptomatic
athletic population!
• What correlates clinically?
What is your clinical impression?
What could you do if you were still unsure of
the source of the pathology?
What could you do if you were still unsure of
the source of the pathology?
• Could consider local anaesthetic injection.
• Excellent correlation
• How to do it
• Perform provocative testing.
• Local anaesthetic injection.
• Repeat provocative testing. If pain free then there is a good chance
that the tissue injected is the source of the pain. Best studied for the
hip joint but can be done for soft tissues. Can diffuse between tissues
though so be careful. Should have rapid and dramatic relief.
FAI
What management would you recommend?
• Movement education – squat depth and positions to avoid
• Advice re stretching – stretch what can be stretched don’t
jam bones together and expect flexibility to improve. Know
the difference between the impingement sensation and a
stretch.
• Advice re loading / load management
• Physiotherapy – strength, range, hip / lumbo-pelvic stability.
• Extensive trial +++
What management would you recommend?
• Get on top of it early!
Decreased
lumbopelvic
stability
Decreased
lumbopelvic
stability
= potential for
low back pain
Increased adductor
muscle tone
Increased adductor
muscle tone = risk
of adductor
tendinopathy
Increased pubic stress
Increased pubic stress
= increased risk of
osteitis pubis
Increased rectus
abdominus tone
Increased rectus
abdominus tone
= increased risk of
abdo pain + ? Sports
hernia
Short / tight iliopsoas
Short / tight iliopsoas
Hip / groin dysfunction
Tightening
iliopsoas
 Rectus
abdominus
tone
 adductor
tone
HIGH
RUNNING
VOLUME
L spine / SIJ
dysfunction
Limited hip IR
ROM (hip joint)
Hip / groin
dysfunction
Lumbopelvic
stability
PAIN
OVERLOAD
DYSFUNCTION
TIGHTNESS
WEAKNESS
• Squat depth and squat technique
• https://www.youtube.com/watch?v=PkQb2LJtLgo
What management would you recommend?
• Hip scope if all conservative measures have been exhausted
• What indications for hip scope?
• Scopes treat mechanical symptoms and often pain. No good proof
that they decrease degeneration in the future.
• Recent patient. Young man with max 90 deg of flexion and could only
achieve that with negative internal rotation. Bony block – cant squat
to the toilet. <- good candidate for surgery.
What management would you recommend?
• Drugs and injections
• Can be used to palliate symptoms early but chronic use should be
discouraged.
• Avoid if not needed.
• Better off managing load than taking NSAIDs
What management would you recommend?
Take home points!
• History and examination very important.
• Loss of internal rotation + positive FADIR is suspicious of FAI.
• Imaging can be tricky. Sensitive but not specific.
• Load management in crucial
• May need to talk to coaches / trainers about stretching and
technique. Some old school trainers may assume that they are ‘soft’
and try to push them in to impingement positions thinking it can be
stretched out.
• Get on to it early. If left too long can be a problem.
Readings
• http://www.sportsclinicnq.com.au/assets/long-standing-groin-pain-in-athletes-falls-into-three-primary-patterns-a-clinical-entity-approach.pdf
• http://www.sportsclinicnq.com.au/assets/doha-agreement-meeting-on-terminologyand-de%EF%AC%81nitions-in-groin-pain-in-athletes.pdf
• http://www.sportsclinicnq.com.au/assets/return-to-sport-after-hip-surgery-forfemoroacetabular-impingement-a-systematic-review.pdf
• http://www.sportsclinicnq.com.au/assets/what-is-the-relationship-between-groin-painin-athletes-and-femoroacetabular-impingement.pdf
• http://www.ncbi.nlm.nih.gov/pubmed/22069031
• http://www.ncbi.nlm.nih.gov/pubmed/9546460
• http://www.ncbi.nlm.nih.gov/pubmed/21663719
• https://www.youtube.com/watch?v=PkQb2LJtLgo
• http://www.sportsclinicnq.com.au/development
Case 2
History
• 17 year old cricket player presents with a one month history of axial
back pain radiating in to his buttock but not further. Has been playing
cricket in the last couple of weeks but hasn’t been doing a lot.
What extra history is needed
• Red flags
• Yellow flags
• Inflammatory vs mechanical
• Nature of symptoms
• Acute on chronic work load (Significant increase in injury 3-6 weeks
post abnormal elevation in high intensity load.)
• Type of activity – stress fractures common in fast bowlers but not so
common for other players.
Extra history
• Fast bowler
• One month ago got asked to fill in for the 19s team as well as his 17s
team. He bowled 60 overs which is triple what he would normally do.
• Worse on the left
• Worse with leaning backwards
Exam findings
Extension combined with rotation provoke left sided pain.
Single leg weight bearing on the left combined with extension is
painful.
Palpation over the area is painful.
What investigations if any would you order?
What investigations if any would you order?
• Xray
• Previously gold standard was combination CT and bone scan.
• High dose radiation
• Should be avoided in young adults and children where possible.
• Now MRI is good enough with newer imaging sequences.
Scan type
Ionising radiation dose
Equivalent time of natural
background radiation
Increased risk of cancer
X-Ray of extremity
0.001mSv
3 hours
Essentially zero or 1/1,000,000
Bone Density
0.001mSv
3 hours
Essentially zero or 1/1,000,000
X-Ray of spine or pelvis
1.5mSv
6 months
1/100,000
CT Brain
2-4mSv
8 -16months
1/10,000-1/1000
CT spine (cervical or
lumbar)
6mSv
2 years
1/10,000-1/1000
Bone Scan
6mSv
2 years
1/10,000-1/1000
CT Abdomen / Pelvis
10-20 mSv
3-7 years
1/1000 to 1/500
MRI
0
0
Zero
Ultrasound
0
0
Zero
Investigation findings
Is this worth worrying about?
• Lumbar stress fractures in cricketers need to be considered high risk
like jones, 2nd MT, navicular etc.
• 12 weeks no bowling or rapid extension / rotation activity.
• Aim for return to sport at 16-20 weeks.
• Must be pain free to return to graded return to activity with no pain
prior to return to sport.
• MRI is useful and can avoid radiation doses associated with SPECT ,
bone scan, CT.
• Peter Brukner and Alex Kountouris feel that spondylolisthesis is
incompatible with elite cricket.
Spondylolisthesis is
better tolerated in other
sports. This is a scan of
an NRL player. Cricket
Australia medical team
feel that this is never
seen in fast bowlers.
They do not survive to
become elite.
MRI problems
• Sometimes too sensitive.
• Telling a 17 year old (and his worried parents) that they have a
degenerative spine can do more harm than good.
Take home points!
• Lumbar stress fractures in cricket players should be considered high
risk similar to navicular and jones fractures.
• Lumbar stress fractures need early diagnosis and swift and complete
avoidance from sport.
• This is not something that is safe to push through.
• Personally I have probably not been rigid enough with these
recommendations previously.
Case 3
History
• 20 year old previously well female presents with a two week history
of severe increasing anterior hip pain. Changed life style 18 months
ago. Lost 15kgs in the last 18 months. Now training for a marathon.
Pain in anterior hip.
What extra history is needed?
What extra history is needed
• Red flags
• Yellow flags
• Inflammatory vs mechanical
• Nature of symptoms
• Training history
• Menstrual history
• Diet / food intake
• Approach to food / food psychology
• Appearance issues
Extra history
• Last year weighed 63kgs.
• Entered a weight loss gym challenge and lost 10kgs in 8 weeks.
• Has since lost another 5kgs.
• Now 48kgs
• Training for a marathon.
• Increasing running distance sensibly. Running 60ks/week at present.
• Menarche 14 years of age irregular initially. Always very skinny.
• Gained weight in late teens and menses normalised.
• Hasn’t had a period for 3 months.
Exam findings
Antalgic gait
Unable to hop
Generally irritable hip
Tender anterior joint
You elected not to try the tuning fork - stethoscope test
What investigations if any would you order?
• XR
• MRI given age of patient / could consider bone scan if older
• Bloods including endocrine and nutritional status
• Consider BMD
Investigation findings
A – Superior - Distraction / traction / tension – HIGH RISK – Strict NWB
B – Inferior - Compression - PWB 6/52, FWB but no running 6/52, Graded return to run
C – Complete / displaced - urgent surgery
RED-S vs FAT
• RED-S is broader more encompassing term.
• Ultimately an argument of nomenclature.
• Main benefit IMO - Can avoid using the diagnosis of FAT with a young
woman who has an eating disorder.
What management would you recommend?
•
•
•
•
•
Multidisciplinary approach extremely important.
If FAT / RED-S / eating disorder
Dietician – minimum appropriate referral
Psychologist – strongly consider
Endocrinologist - consider
• Running biomechanics review
• Start slow strength, posture, control work early. As soon as tolerating / pain free.
• Slow, careful, graded return to activity.
Take home points!
• Must ask about training history
• Must ask questions including menstrual history that may seem
unrelated and awkward to a young woman or refer to someone who
she would be comfortable with.
• If suspicious of RED-S / Female must be referred on
Readings
• http://bjsm.bmj.com/content/48/7/491.full.pdf+html
• http://bjsm.bmj.com/content/early/2015/04/17/bjsports-2015094873.full.pdf+html