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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.