Chronic groin pain in athletes

Charl Carstens

CLL 705

September 2012

OVERVIEW

1. Case Presentation

2. Clinical Progress

3. Special Investigations

4. Treatment

5. Introduction

6. Summary

7. Discussion

Case Presentation

26 year Male rugby player- hooker

C/O: Pain left supra inguinal area

(illiopsoas)

Conservative treatment 1/12

Surgeon referral

Clinical Progress

Re-injured- acute pain left groin X-ray- NAD Ultrasound- ?Partial tear or

tendinopathy adductor

brevis

Progress Cont.

Treatment 9/52 Rest/Rehab:

Core stabilizers, hip muscle

activation and strengthening

Slipped – pain left groin again

Re- Evaluation

Tender Proximal adductors

Adductor squeeze test- Extension & 90° Hip flexion - adductor longus

FABER (+)

Special Investigations

MRI: Partial avulsion enthesis left pectineus and adductor brevis anterior at inferior attachment of symphysis pubis.

Oedema medially in both muscles.

Surgical Treatment

5 months post injury

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 PubalgiaAdductor tendinopathy(enthesopathy)Iliopsoas dysfunctionSportsman’s hernia/sports herniaGilmore’s groin

Discussion

4 Groin Entities

A. Adductor- related

B. Iliopsoas- related

C. Abdominal wall- related

D. Pubic bone stress –

related(Brukner & Khan 2012)

4 Groin Entities

Anatomy:

- Adductor Longus & Rectus

Abdominus directly linked

- Indirectly to Transversus

Abdominus & Internal Oblique via

Rectus Abdominus sheath

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)

Adductor Longus Related

Enthesopathy rather tendinopathy

Conservative treatment- soft tissue treatment, core stability program & strengthening local muscle groups

If all else fails- cut

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

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

Treatment Cont.

Bilateral Adductor tenotomy return to pre-injury level of sport or higher:

Maffuli et al 2012 – 76% with 16 weeks rehabilitation

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.

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.