340])...Davis et al BJSM 2012 Aspetar & Arthroscopic Center Amager Muscle, tendons and aponeuroses...

12-06-2013

1

Differential diagnosis in athletes with

groin and hip pain

Per Hölmich

Sports Groin Pain Center

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

&

The Copenhagen Groin and Hip Research Center

Arthroscopic Center Amager

University of Copenhagen, Denmark

Aspetar & Arthroscopic Center Amager

Muscles reated to groin and hip

• Adductor longus/brevis

• Adductor magnus

• Gracilis

• Pectineus

• Iliopsoas

• Sartorius

• Rectus femoris

• Tensor Fascia Latae

• Gluteus medius, minimus

• Gluteus maximus

• Piriformis and other external

rotators

• Hamstrings


Codon, Am J Surg 1996Gibbon, The Lancet 1999Robinson et al; Skeletal Radiol. 2004Davis et al BJSM 2012


Muscle, tendons and aponeuroses


The anatomy of groin injuries- from a sports hernia point of view

Muschaweck describes the abdominal wall

biomechanically as -

a matrix of tension bands that

attach to the pubic bone & the

muscle and fascia layers form a

‘‘slide bearing’’

- which is essential for an athlete’s mobility, including running, sprinting,

jumping, and upper body rotation

Minnich et al

AJSM 2011

Aspetar & Arthroscopic Center Amager Aspetar & Arthroscopic Center Amager

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…greater trochanteric pain syndrome (GTPS) is

being advertised as a clinical entity that includes a number of disorders of the lateral peritrochanteric space of the hip, including

trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip)

Athletic knee syndrome….

Athletic pubalgia….????


Clinical entities for groin injuries

Very few diagnosis of the groin are clearly

established yet –

A systematic clinical approach to groin and hip pain in athletes was suggested in

2007 based on the relation of the pain to the anatomy

Utilising a number of specific and reliable tests –to identify a diagnostic pattern

leading to clinical entities

Hölmich et al BJSM 2004 & Hölmich BJSM 2007


”Clinical Entity”

• The symptoms and clinical findings are related to a specific anatomical structure:

• Iliopsoas related groin pain

• Adductor related groin pain

• Inguinal related groin pain

Hölmich BJSM 2007


The clinical entity approach has since been

implemented by several other authors

Ekstrand, Hägglund, Walden - UEFA-studies

AJSM, BJSM, SJMSS 2007-13

UEFA Football Doctor Education Programme 2013

Robinson P et al; Skeletal Radiol. 2004

Lovell G et al; CJSM 2006

Schilders et al; JBJS Am. 2007

Atkinson HD et al; Arch Orthop Trauma Surg 2009

Weir A et al BJSM 2009

Malliaras P et al BJSM 2009

Hanna C et al, JSMS 2010

Schilders et al AJSM 2013


998 soccer players followed for 1 season • 58 groin injuries – all examined systematically

with the standardised technique

• 51% adductor-related

• 30% iliopsoas related

• 19 % inguinal related

• 68% in the dominant leg

• The duration of having both adductor- and inguinal-related injury is

4.56 times longer

• 24% had more than one clinical entity

• 39% had a traumatic onset of the groin injury

Hölmich et al (unpublished data)


Further studies needed to develop the

clinical entity approach to groin injuries

• Combining the imaging and

the clinical entities

• Investigating the acute groin

entities

• Biomechanical evaluation

• Differentiating the clinical

entities into specific diagnosis


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The known pain

• The patient should be asked, whether the pain inflicted by

the test is the pain, that usually is bothering the patient (the

known pain)

or “just” something that

happens because of an uncomfortable test


Iliopsoas - related

• Location of pain

– Lower abdomen

– Proximal on anterior thigh

– Antero-medial groin

– Low back pain/fatigue

• Complaints

– Sitting in a deep chair for longer periods

– Climbing stairs

– Biking with click-shoes (uphill)

– Long runs

– Coughing, sneezing, sprinting


Iliopsoas - related• Clinical findings

– Decreased strength (flexed hip, isometric

test) plus sometimes pain or discomfort

– Pain with stretching during Thomas test

– Pain when palpating the psoas

• At the level of SIAS

• Just below the inguinal ligament

• At the lesser trochanter

- Positive skin fold test

- Pain when compressing/folding/twisting


Isometric iliopsoas testThorborg K, Petersen J, Magnusson P, Hölmich P; SJMSS, 2009


Iliopsoas - related• Clinical findings

– Decreased strength (flexed hip, isometric test)

plus sometimes pain or discomfort









Thomas test – passive stretching

Hölmich et al BJSM 2004


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Iliopsoas - related

• Clinical findings











Palpation of Iliopsoas

Hölmich et al BJSM 2004


Iliopsoas-related





– , pelvic tilt








Squeezing the iliopsoas…

Impingement test for the hip:

flexion, adduction and internal rotation…

Several structures are impinged in the

process

This test is not specific for FAI

It is important to be able to differentiate

what structures are causing the pain

P.Hölmich & M.Dienst, Der Orthopaede 2006

A.Weir, R.de Vos, M.Moen, P.Hölmich and J.L.Tol BJSM 2011


Lesser Trochanter


Runner - groin pain during 1½ yearIliopsoas tendinosis – spindle shape


12-06-2013

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Adductor-related


- Medially deep in the groin

- Sometimes radiating to the

medial thigh or deep behind the

scrotum

- Rarely pain at the tendon itself

• Complaints

- Pain during fast turns, sprinting,

slippery surface, kicking, tackling

- Long runs – fatigue

- Coughing & sneezing

- “Standing on one leg putting on socks”


Adductor-related


- Decreased adduction strength

- Pain with adduction against resistance

- Tenderness on the origin of the

adductors(longus) at the pubic bone

- Pain on stretching the adductors

- Rarely tightness of the adductors


Isometric adductor test

Hölmich et al; BJSM 2004

Assessment of the adductor longus may be a primary focus

of clinical examination…. & EMG and force data suggest thatexamination in this position may be clinically important

Lovell G et al; Phys Ther Sport 2011


Adductor-related• Clinical findings








Palpation of the adductor origin



Adductor-related• Clinical findings








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ROM and stretch of adductors



Adductor longus

Sonographic pathology


Inguinal-related


- Low abdominal in the area of

the inguinal canal

- Radiating across the pubis

- Radiating to the groin and genitals

• Complaints

- Activities including the abdominal muscles

- Pain during fast turns, sprinting, slippery surface,

kicking, tackling

- Coughing & sneezing

- “Standing on one leg putting on socks”


Inguinal-related


- Tender conjoined tendon at insertion

(sometimes also tender rectus abdominis

tendon insertion)

- Tender conjoined tendon when palpating

through the scrotum

- Tender external opening of inguinal canal when

palpating through the scrotum

- Soft posterior wall/small dilation of the external

opening

- Decreased strength of the abdominal muscles

especially the oblique plus sometimes pain


Palpation of the conjoined tendon


Inguinal-related• Clinical findings

- Tender conjoint tendon at insertion


tendon insertion)

- Tender conjoint tendon when palpating

through the scrotum




opening




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Palpation of the inguinal canal -

with the patient standing


Inguinal-related


- Tender conjoint tendon at insertion


tendon insertion)

- Tender conjoint tendon when palpating

through the scrotum




opening




Isometric test of abdominal muscles


Incipient hernia – soft posterior wall


The specificity of a test

Patrick’s FABERE test

• Hip joint

• Adductor muscles

• SI-joint

• Lumbar spine

• …and?


Interrater reliability of hip tests

(Martin and Sekiya, JOPST 2008)


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Clinical examination of the hip joint

Hölmich & Dienst, Der Orthopaede

2006;35(1) 8-15


Impingement test


Apprehension testPosterior impingement test – same position but the

hip is internally rotated


Isometric test - m.Gluteus mediusThe most effective position to test GM is

the side lying abduction in neutral or internal rotationRoald Otten et al (submitted)


Log roll test

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12-06-2013

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Tests pointing to a possible hip artroscopy

• Positive hip impingement test (flexion,

adduction and internal rotation)

• Positive log-rolling test

• Positiv apprehension test

• Positive injection test (US-guided)

and/or

• Pathologic findings at MR-A / MR-3T


Thank you


340])...Davis et al BJSM 2012 Aspetar & Arthroscopic Center Amager Muscle, tendons and aponeuroses...

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