1

Helen Millson

(M.Phil Sports Physio; M.C.S.P)

Groin / Hips in the Youth

SA Physio Congress Aug 2015

Athletes should be considered skeletally immature until at

least their 21st birthday. (Sailly et al., BJSM. 2015)

Secondary ossification centres of the pelvis, including the

pubic apophysis, appear during puberty and fuse between the

ages of 15 and 25 years

Background

We believe now that CAM deformities develop around

12-13 years old (Agricola and Kemp – Aspetar 2014).

What is Youth?

12 – 25 years

2. Anatomy

7. Surgery

8. Conservative Rx/ Rehab

5. Tests

4. Hips Overview / Solution ??!

1. Differential Diagnosis - Adult / Youth

6. Radiological Imaging

3. Biomechanics

Content

Lack of specific clinical tests

Co-existence of multiple pathologies

Lack of agreement of diagnostic criteria

Werner et al., BJSM 2009;Choi et al., BJSM 2011;

Non-specific nature of the signs and symptoms

.

Davis et al. Br J Sports Med 2012; Branci et al. Br J Sports Med 2013

Holmich, BJSM Aug 2013: Incidence and clinical presentation of groin injuries in sub-elite male soccer”

Thorborg and Holmich:BJSM 2013. “Advancing Hip and Groin injury management: from eminence to evidence.”

Background General

The Bermuda Triangle of Sports Medicine

(Bezzini BJSM 2011)

Arnason et al AJSM 2004; Holmich et al; Scan J Sp Med 2010; Engebretsen et al., AJSM 2010;

Holmich et al, BJSM 2013: 24% had more than one clinical entity

Up to 70% of male soccer players experience hip and or

groin pain during one season. (Hanna et al., J Sci Med Sport. 2010)1. Differential diagnosis

2

Background

Differential diagnosis

Hip Joint

Clinical examination based classification system

Other causes

Differential diagnosis

Findings of multiple abnormal clinical entities tempt one to

speculate that one clinical entity likely precedes other

developing entities

Adult

Background

YouthBackground

YouthBackground

YouthBackground

3

Kicking and twisting movements.

These actions place strain on fascial and musculo -skeletal structures

that are fixed to a number of bony anatomical points in close proximity.

2. Anatomy Anatomy

Hip Joint and Pubic joint

“Anatomic basis for Evaluation of Abdominal and Groin pain in Athletes.” Meyer et al 2005; Thorborg and Holmich BJSM 2013

Anatomy in Theory

Holmlich P, BJSM 2007; Holmlich et al., BJSM Aug 2013 Robinson et al., 2006; Davis et al.,BJSM 2011; Brukner and Kahn 2012

Anatomy in Reality

Pubic Symphysis

Rectus Abdominis

Common Adductor

Anatomy in Theory

The Groin Triangle

Falvey et al., BJSM 2009;

Anatomy in Reality

4

Adductor muscles

O Conner 2004; Robinson et al., 2004; 2007; Schilders et al., 2007; Schilders et al 2009; Prof Ernest Schilders, 2012Davis et al (2012) Br J Sports Med.; Norton-

Old et al. Clin Anat 2013; Incidence and clinical presentation of groin injuries in sub-elite male soccer (Per Hölmich et al., BJSM Aug 2013)

;

Prime Mover and Stabiliser

Normative adductor squeeze test values in elite junior rugby union players. Coughlan et al., Clin J Sports Med 2014

RA

AD

Robinson et al., AJR Am J Roentgenol 2007; Prof W Meyer, 2011; Norton-Old et al., Clin Anat 2013; Murphy et al., Skelet Radiolog 2013

Biomechanics

Comment: Adductor muscles Author

Player was 17 TIMES more likely to get Adductor muscle strain, if

Adductor strength was <80% of Abductor strength

Tyler et al 2001;

O’Connor 2004

Squeeze test was significantly weaker (20%) in players with

longstanding groin pain

Malliaras et al 2009

AL risk of strain injury during transition from hip ext to hip flex, probably

because of the high eccentric load on the kicking leg during the swing

phase.

Charnock et al., Sports

Biomech 2009

Add : Abductor Ratio was 24% lower in groin pain athletes Thorborg et al 2010

Inguinal ligament release not a Rx for Adductor strain, although

adductor symptoms do improve after a release

David Lloyd, 2009

Reduced hip adductor muscle strength preceded the onset of groin

pain and was further reduced at the time of the onset of groin pain

Crow et al., 2010

Weak adductor muscles are an intrinsic risk factor for groin injuries Engebretsen et al., 2010

Adductor Longus dysfunction may result in instability and ant

subluxation of the symphysis.

Connell, Presentation 2011

Importance of Eccentric strength adaptations in hip adductors. Thorborg et al., BJSM 2011

Adductor-related groin injury was the most common clinical

presentation of groin injuries in male soccer players and the cause of

long injury time, especially when combined with abdominal-related

injury

Per Hölmich et al., BJSM

Aug 2013

Many studies show importance of Adductor muscles

Study Author

New insights into the proximal tendons of adductor

longus, adductor brevis and gracilis.

Davis et al., BJSM 2012

Normative Adductor Squeeze Test Values in Elite

Junior Rugby Union Players.

Coughlan et al.,

Clinical Journal of Sport Medicine 2014

Adductor longus activation during common hip

exercises.

Delmore et al., Journal of Sport Rehabilitation,

2014

Acute and sub-acute effects of repetitive kicking on

hip adduction torque in injury-free elite youth soccer players.

Jensen, J., et al. Journal of Sports Sciences.

2014.

EMG evaluation of hip adduction exercises for soccer

players: implications for exercise selection in prevention and treatment of groin injuries.

Serner et al. BJSM 2014

Importance of Adductor muscles

Adductor strength may be an important objective

outcome for Prevention, Rehabilitation and to

assess RTP readiness.

Cunningham et al., 2007; Crow et alJ Sci Med Sport 2010; Engebretsen et al., AJSM 2010

Adults

Youth

Overuse.

Diagnosis of Acute Groin injuries. Serner et al., AJSM 2015

Other areasGroin Pain:

Zoga et al, Radiol. 2008; Jansen et al., J of Ortopaedic and Sp Phys Th. 2009; Graham et al., BJSM 2010; Hides et al., (Psoas and QL).

BJSM 2010; Connell 2011; Blomberg et al. BJSM 2011; Dr Ruth Lovegraven-Jones 2011; Brukner and Kahn 2012; Murphy et al., Skelet

Radiolog 2013; Whitaker et al., J of Orthopaedic and Sp Phys Th. 2013; Youdas et al., J of Sp Rehab. 2014; Philipon et al. AJSM 2014.

Pelvic Floor

5

- Numerous similarities to ACL.

Ligamentum Teres

Shetty, 2007; Barkados and Villar.,J Bone Jt Surg. 2009;Botser et al., AJSM 2011.; Domb et al.Arthroscopy 2013;

Amenabar and O Donnell Hip Int 2013; de SAD et al., Arthroscopy 2014; van Arkel et al., Bone Joint J. 2015

N.B. The Functional Lines

Symphysis Pubis joint / “Osteitis Pubis”

Verral et al., BJSM 2001; Paajanen et al., AJSM 2008; Hechtman et al., Sports Health, 2010; Becker et al. J Anat 2010; Treatment of osteitis pubis

and osteomyelitis of the pubic symphysis in athletes: a systematic review. Choi et al.BJSM 2011; Branci et al.BJSM; Campbell et al (2013) Semin

Musculoskelet Radiol 2013.

Adult Youth

Isokinetic imbalance of hip muscles in soccer players with osteitis pubis Mohammed et al., J of Sp Sci 2014

NB

Youth

Overload

Pain

Overload Tightness

Dysfunction Weakness

Pubic bone

overload

P Brukner FA Presentation Sep 2013

Pubic JointYouth 3. Hips: Anatomy

6

- Hip joint = 56%

- Add related = 33%

- PBSI = 28%

- IP = 12%

- Abdominal wall related = 11%

Holmich BJSM 2007; Bradshaw et al., BJSM 2008; Holmich and Bradshaw 2012;

Groin Pain

A common pattern was a co-existence of hip joint pathology,

PBSI and Add-related groin pain.

Hip Joint Pathology as a leading cause of Groin Pain in the Sporting population. Rankin et al AJSM 2015

Angle of torsion alters:

1. Functional role of hip muscles

Estimation of the hip joint centre in human motion analysis: A systematic review Hans Kainz.

Clinical Biomechanics 2015

Screening

Hips: Youth

Hip Morphology

Assymetric Hip Rotation in Professional baseball pitchers.

McCulloch et al., Orthop J Sp Med 2014

The gymnasts' hip and groin: an MRI study in asymptomatic elite athletes.

Papavasiliou et al., Skeletal Radiol .2014:

Correlation of clinical and MRI findings in elite female ballet dancers.

Duthon et al., Arthroscopy. 2013

Caution

YouthAdultsHips: Youth

Adaptation?

N.B.

Maintain / Improve hip ROM

????????

7

Damien Griffin: Aspetar Conference Nov 2014:

Intrinsic and extrinsic factors contributing to hip joint stress

Youth Adult

NB

Biomechanics

Anatomy

Normal = 10 degrees

Posture

Biomechanics

The effect of Pelvic Tilt on Radiographic Markers of Acetabular Coverage. Henebry and Gaskill, AJSM 2013.The effect of hip angle on anterior hip joint force during gait. Lewis and Sahrmann. Gait Posture 2010

Adults Youth

Screening

Walking in greater hip extension may result in greater anterior hip joint force = Ant Hip pain

A 10 degree increase in anterior pelvic tilt,

resulted in a significant loss of 6-9 degrees of hip

internal rotation and increase in FAI.

Effect on other joints

Donnelly et al.,School of Sp Science, Exc and Health. Australia 2014; Prior et al., Sp Science Medicine and

Rehab . 2014; Improvements in hip muscle performance result in increased use of the hip extensors and abductors during a landing task. Stearns and Powers AJSM 2014

Biomechanics

Anatomical Anatomy vs Functional Anatomy

8

Take Home Message: Anatomy

Prof Meyers Bullet point, Groin Hip Handbook

Youth

Understand the role the hip / groin plays in a combination

of movement patterns and dysfunctions.

Anatomy

Groin and Hips

Youth:

Groin / Hip

Background

Meindl et al. A revised method of age determination using the os pubis, with a review and tests of accuracy of other current methods

of pubic symphyseal aging. Am J Phys Anthropol 1985; Froholdt A, Olsen OE, Bahr R. Low risk of injuries among children playing

organized soccer a prospective cohort study. Am J Sports Med 2009; Sailly et al. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. BJSM, 2015;

“Some athletes are immature… skeletally”

Drew MK. BJSM 2015

Underage athletes have been shown to pose approximately

double the risk of adults in an Australian Rules football

population.

Maturation is related to age, gender, race and the environment,

with injury rates increasing throughout the adolescent period.

7 – 18 years

Spending hours ++ in organised sports

Specialise in a single sport

65% were overuse injuries

Risk factors

PHV – Peak height velocity

Youth

9

Youth

Major Factors:

3) Avulsion injury

4) CAM Deformity (“FAI”)

2) Epiphyseal injuries

1) Overload

Groin / Hip

Mechanisms of overuse injury

In the skeletally immature athlete, the tissues

most vulnerable to injury are the cartilaginous

growth centers, the physes and apophyses,

which account for 15% of all youth sports

injuries

1) Overload

L/Spine

SIJ Dysfunction

Weak Adductors /

Increased Adductor tone

Decreased

Lumbo-pelvic stability

Increased RA tone Limited Hip ROM ?

Ilio-Psoas

Dysfunction

Pubic Bone overload

What is the mechanism of injury?

Brukner and Kahn. Clinical Sports Medicine 2012 / Presentation 2013

Pubic Bone overload

Screening

Prevention

The importance of documenting training and

competition workloads of football.

The Relationship Between Workloads, Physical Performance,

Injury and Illness in Adolescent Male Football Players

Gabbett et al., Sportsmed 2015

The Relationship Between Workloads, Physical Performance, Injury and Illness in Adolescent Male

Football Players. Gabbett et al., Sportsmed 2015

Unfused growth centre is structurally the weakest link

in the bone-tendon-muscle unit

Pill et al.,Managing and preventing overuse injuries in young athletes. J Musculoskel Med 2003;Pubic apophysitis:

a previously undescribed clinical entity of groin pain in athletes. Sailly et al., BJSM June 2015

2) Epiphyseal injuries

10

Sudden forceful contraction of the MTU during sport - kicking, running, or changing direction.

3) Avulsion injury

Avulsion fractures are most common in the pelvis and

lower extremities.

Apophyseal avulsion fractures of the pelvis in adolescent competitive athletes are most common in soccer and

gymnastics. The lesions are usually the consequence of sudden and forceful muscle-tendon contractions during sport activities.

Pubis

At origin of the Adductors and RA

Secondary to microtrauma or repeated traction with

excessive rotation of the body

Avulsion injury

Sailly et al., BJSM June 2015

RA

AD

Sailly et al., BJSM June 2015

Pubis

AIIS

Avulsion fracture

.

Avulsion fracture of the lesser trochanter: an unusual cause of hip pain in an adolescent.Vazquez et al.,CJEM 2013

Lesser Trochanter

Greater Trochanter

An adolescent athlete with groin pain Thing et al., BMJ 2014

11

Iliac Crest

Aponeurotic insertion of IO, EO and TA

Sudden torsion of the body eg Tennis, Soccer

Apophysis of iliac crest starts to ossify at 15yrs and

fuses at 18 yrs

Ischial Tuberosity

Excessive eccentric contraction of Hamstrings.

Intense sport load – sprinting, gym, dance.

Bannerjee and McClean. Curr Rev MS Med. 2011; Agricola et al. 2013; Chaudry and Olufemi, “The Aetiology of FAI: What we know and

what we don’t” Sports Health Feb 2014;

4) CAM Deformity (“FAI”)

We believe now that CAM deformities develop around 12-13

years old (Agricola and Kemp – Aspetar 2014).

CAM

ER and flexion increase weight bearing through the femoral

neck and lateral femoral head, around the growth plate,

“FAI” prevalence in general population is 15%,

while in male athletes it can be as high as 75%

Correlation of clinical and magnetic resonance imaging findings in hips of elite female ballet dancers.

Duthon et al. Arthroscopy 2013,

Aspetar - Oct 2014

Prof Damian Griffin

12

Prof Griffin:

FAI morphology does not mean symptomatology

but more likely in athletes because of

- Loads

- Hip positions

BalletGymnastics

Ice skating

Extreme hip motion in professional ballet dancers: dynamic and morphological evaluation based on magnetic resonance

imaging.Kolo et al., Skeletal Radiol 2013; Tramer et al., Ice Hockey Goaltender. Sportshealth 2015; FAI in Elite Ice Hockey

Goaltenders Etiological Implications of On-Ice Hip Mechanics. Whiteside et al., AJSM 2015

Ice Hockey

The formation of a cam deformity may therefore be a result of

structural adaptation to high-impact sporting activities during

growth, when the skeleton is highly sensitive to mechanical

loading.

Especially 12 – 13years (Agricola and Kemp 2013; Correlation of clinical and magnetic resonance imaging findings in hips of elite

female ballet dancers.Duthon et al., Arthroscopy.2013; A Cam Deformity Is Gradually Acquired During Skeletal Maturation in

Adolescent and Young Male Soccer Players A Prospective Study With Minimum 2-Year Follow-up. Agricola et al., AJSM 2014

Overcoverage Pincer might even be protective effect

on development ??

Can the Alpha Angle Assessment of Cam Impingement Predict Acetabular

Cartilage Delamination? Beaule´et al Clinical Orthop related Research 2012

Igor Tak et al., BJSM 2015 Youth

Instability, Impingement, or Combinations or both

Correlation of clinical and MRI findings in hips of elite female ballet dancers. Duthon et al. Arthroscopy 2013; Gupta et al.,

Osteoplasty for FAI. AJSM Aug 2014; FAI: Defining the condition and its role in the pathophysiology in OA. Sankar et al., J Am

Acad Orthop Surg., 2013; The Hyperflexible Hip: Managing Hip Pain in the Dancer and Gymnast . Weber et al June 2015 Sports

Health

Pathologic changes seen on MRI were symptomatic in less

than two thirds of the dancers.

13

Kemp et al BJSM 2014Yuan et al., AJSM 2013

HOW and WHY the patho-anatomy of FAI leads to future hip

injuries in some patients?

? Impact on incidence of OA

Further research is required

NB:Can the Alpha Angle Assessment of Cam Impingement Predict Acetabular

Cartilage Delamination? Beaul et al BJSM 2012

Screening hips in asymptomatic patients to detect the

hip at risk of future pathological changes secondary to

impingement during high risk activities

More Specific research required!

Surgery???

Prevention of the formation of a cam deformity might

be possible by adjusting the type, duration or frequency of

loads that are applied to the hip during skeletal growth.

Igor Tak et al., BJSM 2015

Siebenrock et al. Prevalence of cam-type deformity and hip pain in elite ice hockey players before and after the end of growth. AJSM 2013; Agricola et al. Cam impingement of the hip: a risk factor for hip osteoarthritis. Nat Rev Rheumatol 2013

N.B.

We should now seriously start to consider activity

modification for children in this stage of development

Agricola and Kemp BJSM 2014

What can we do?

Author

JournalArticle Comments

Agricola AJSM2012

The Development of CAM type deformity in adolescent and young male soccer players

CAM type deformities were recognisable and present in from the

age of 13 years and were more prevalent in soccer players than

their non athletic peers. Influenced by high impact sport

Sankar et al.,J Am AcadOrthop Surg., 2013

FAI: Defining the condition and its role in the pathophysiology in OA

Long term follow ups and more studies required to determine the

relationship between type and severity of intra articular damage

and the longer term risk of developing clinically significant hip

OA.

Siebenrock et al., AJSM 2013

Growth Prevalence of Cam-Type Deformity and Hip Pain in Elite Ice Hockey Players Before and After the End of Growth

The data suggest that playing ice hockey at an elite level during

childhood is associated with an increased risk for cam-type

deformity and hip pain after physeal closure.

Gupta et al., AJSM 2014

Does the Femoral CAM lesion Regrow after Osteoplasty for FAI

No recurrence of CAM deformity at 2 years after femoral neck osteoplasty

Tramer et al.,Sportshealth 2015

Ice Hockey Goaltender after treatment for FAI impingement

- Surgical treatment of symptomatic FAI = P relief and improved kinematics

- ? Improved kinematics enhance longevity of native hip and alter progression of OA changes with asymptomatic FAI deformity

Nepple et al.,

AJSM., 2015What is the Association between sports participation and the development of Proximal CAM Deformity?

Risk of Hip OA in males participating in high impact sports may be due to underlying CAM type FAI and continued high levels of exercise

Many studies on CAM deformity

Author

JournalArticle Comments

Yuan et al., AJSM 2013

Decreased ROM is associated with Structural Hip deformity in Asymptomatic Adolescent athletes.

8% of asymptomatic teenagers had limited Internal Rotation.

68% had radiographic findings of FAI. 2/3rds asymptomatic

Roels et al., 2014

Mechanical Factors explain development of CAM-type Deformity

Specific loading patterns seem to stimulate the development of

CAM type deformity. Reveals mechanobiological mechanisms that

trigger the development of CAM type deformity. Prevention!

Nepple et

al., AJSM

2015

What is the Association between sports participation and the development of Proximal CAM Deformity?

Risk of Hip OA in males participating in high impact sports may be due to underlying CAM type FAI and continued high levels of exercise

14

Non-Sports-Related Pathologies

Consider / Exclude

- Slipped capital femoral epiphysis (SCFE),

- Legg–Calvè–Perthes disease (LCPD),

- Benign and malignant bone and soft tissue tumors

- Juvenile idiopathic arthritis (JIA).

Youth

NB

HIP: Other pathologies

Refer!!

Hypermobility

Youth

Study Author Comment

Overuse injuries of

the hip in adolescents.

Zambelli et al., Rev

Med Suisse 2010

NB

The concept of overload is explained as the inability of the hip to ensure its centricity during activities

that could lead to the occurrence of any

degenerative disorders.

Children with hip pain

should be seen by a specialist.

Hjort et al.,

Ugeskr Laeger. 2013

SCFE is typically seen in overweight boys, but may also

occur in normal-weight teenage girls. Early image diagnostic assessment of both hips is crucial, since slip

severity and consequently the risk of disabling

complications are strongly correlated to late diagnosis.

Hip pathology in

the adolescent athlete.

Frank et al.,

J Am Acad OrthopSurg. 2013

Advances in diagnostic and therapeutic interventions.

Assessment and

treatment of hip pain in the adolescent athlete.

Giordano et al.,

Pediatr Clin North Am. 2014

Over past 20 years, improvements in imaging

modalities and technical innovations have led to greater diagnostic insights and creative new treatment

strategies.

Hip Joint Pathology as a

leading cause of Groin Pain in the sporting

population

Rankin et al., AJSM

2015

Hip joint pain is most common clinical entity and is most

likely related to FAI, labral tears and OA

Ongoing studies re Hip pathologies

Management

1. Significant Tests

2. Investigations

3. Conservative Management

REFER!!

Groin / Hips

Groin /Hip Tests References

TrendelenburgVerral et al. 2001/04.; Hogan, 2003/06; Youdas et al., 2007;

Lequesne et al., Arthrit Rh2008; Kendall et al.,Clin J Sp Med. 2012

Holmlich et al., BJSM, 2004; Ellenbecker et al AJSM 2007

Wanget al., 2006;Martin and Sekiya, J Orthop Sp Phys Ther, 2008;

Malliaras et al., BJSM 2009; Ferber et al., J Ath Training. 2010

Nussbamer et al., 2010; Fulcher et al. 2010; James Moore, 2011

Thorborg et al 2010;Thorborg et al., BJSM 2011;

Magee,Orth Phys Ass 2008; Thorborg et al, AJSM 2010; 2011,

2012; Burgess et al., Man Th 2011

Delahunt et al.,Man Th 2011; Tijssen et al., Arthroscopy 2012;

Ferber et al., J Ath Tr., 2010; 2012;Thomas Byrd 2012;

Reiman et al., BJSM. 2012 ; Aprato et al., AJSM 2012

Hanna et al., 2012; Kendall et al.,Clin J Sport Med, 2013

Holmlich BJSM 2013 Thorburg et al., Knee Surg Sports Traumatol Arthrosc., 2013

Thorborg and Holmlich, BJSM, 2013

Gowda et al., Physical Therapy in Sport, 2013

Serner et al,. BJSM 2013; Tourville et al., Sports Health 2013

LLD

Obers test (Modified)

Thomas test

Fabers test

Leg roll

Internal Rot test (Craig’s)

Quadrant test

Donatelli Drop Test

C sign

HOOS, HOS and the HAGOS

Questionnaire

Harris Hip Score

Bent Knee fallout test

Impingement test

Glut strengthening / sequence

Research ++

Groin /Hip Tests References

Steps toward the validation of the

Trendelenburg test: the effect of experimentally reduced hip abductor muscle

function on frontal plane mechanics

Kendall, K. D., et al. (2013).Clinical Journal of Sport Medicine :

Journal of the Canadian Academy of Sport Med.

Manske, R. and Reiman, M. (2013). Sports Health.

Coughlan, G. F., et al. (2014). Clinical Journal of Sport Medicine

:Journal of the Canadian Academy of Sport Medicine

Drew, M. K., Osmotherly, P. G. and Chiarelli, P. E. (2014).

Physical Therapy in Sport.

Gowda, A. L., et al. (2014). Physical Therapy in Sport : Journal

of the Association of Chartered Physiotherapists in Sports

Medicine.

Nevin, F. and Delahunt, E. (2014). J of Science and Medicine in

Sport / Sports Medicine Australia

Reiman, M. P., et al. (2014). BJSM

Thomee, R., et al. (2014). Knee Surgery, Sports Traumatology,

Arthroscopy : Official Journal of the ESSKA.

Thorborg, K., et al. (2014).BJSM.

Tong, T. K., Wu, S. and Nie, J. (2014). Phys Th in Sport : J of

the Association of Chartered Physiotherapists in Sports

Medicine.

Functional performance testing for power

and return to sports.

Normative Adductor Squeeze Test Values in

Elite Junior Rugby Union Players.

Imaging and clinical tests for the diagnosis of

long-standing groin pain in athletes. A

systematic review.

Gluteus medius strengthening and the use of

the Donatelli Drop Leg Test in the athlete.

Adductor squeeze test values and hip joint

range of motion in Gaelic football athletes with longstanding groin pain.

Diagnostic accuracy of clinical tests for the

diagnosis of hip FAI impingement / labral tear: a systematic review with meta-analysis.

Cross-cultural adaptation to Swedish and

validation of the Copenhagen Hip and Groin Outcome Score (HAGOS) for pain, symptoms

and physical function in patients with hip and

groin disability due to FAI.

Copenhagen hip and groin outcome score

(HAGOS) in male soccer: reference values for

hip and groin injury-free players.

Sport-specific endurance plank test for

evaluation of global core muscle function.

Research ++

15

Further research is required when assessing the clinical

usefulness of these tests

Summary: Tests

A battery of tests should be performed

Special Tests in MS Examination.” Paul Hattam and Alison Smeatham 2010

Physical examination tests for hip dysfunction and injury. Reiman et al., BJSM 2015

2. Investigations

• X-ray

• Bone scan

• CT scan / CT spect

• MRI / MR arthrogram

• Herniography

• Ultrasound

• Diagnostic LA injection into hip

• Hip arthroscopy

Investigations

Dr Richard de Villers 2012.Otto Chan; Prof William Meyers, 2012; Bullet points Groin Hip HandbookGerhardt et al 2012; Radiological findings in symphyseal and ARGP in athletes: a critical review of the

literature. Branci et al.,BJSM 2013; Branci et al., BJSM 2013; Register et al., AJSM 2012; Serner Aspetar 2014

Lovell 2006: “Moderate to severe in 61% asymptomatic players”; Verrall 2008; Lischuk et al., Imaging. 2010; .Marchie et al., 2011; Godinho,

Sportsmed update 2012; Bullet points Groin Hip Handbook: Otto Chan 2012; Prof Meyers, 2012; Dr Richard de Villiers 2012; Register et al.,

AJSM 2012; Palisch et al., Clin Sports Med 2013; Khan et al., Magn Reson Imaging Clin N Am 2013; Branci et al., BJSM 2013

Need trials where clinical entities are correlated with

systemic investigation.

How much bone stress is normal?????

Radiological Imaging

72% of male elite soccer athletes demonstrated some

evidence of radiographic abnormality (Gerhardt et al 2012)

Experienced clinical judgement remains a critical

element in the diagnostic pathway.

3. Conservative Management

16

Cricket

Peak Vertical GRF is approx. 5x bowler’s BW at front foot strike

Physiotherapy / Rehab

Know your sport !!

Symptoms

DysfunctionPathology

Role of the physio

The recognition and evaluation of patterns of compensatory injury in patients with Mechanical Hip pain.

Hammoud et al, Sports Health, 2014

Conservative Management

Screening: Tyler TF et al.. AJSM 29(2), 2001; Thorborg K et al. M imbalance. AJSM 2011; Hides J et al. Screening the lumbopelvic muscles for a relationship to injury of the quadriceps, hamstrings, and adductor muscles among elite Australian Football League players. JOSPT. 2011; Emery et al. Med Sci 2001 – Experience; Chalmers et al. The relationship between pre-season fitness testing and injury in elite junior Australian football players. J Sci Med Sport. 2013; T Tyler Aspetar Conf 2014

Know the Risk factors: Screening

Jackie Whittaker PhD, BScPT, FCAMPT

Aspetar

Screening: Tyler TF et al. The association of hip strength and flexibility with the incidence of adductor strains in professional ice hockey players.

AJSM 29(2), 2001; Thorborg K et al. M imbalance. AJSM 2011; Hides J et al. Screening the lumbopelvic muscles for a relationship to injury of the

quadriceps, hamstrings, and adductor muscles among elite Australian Football League players. JOSPT. 2011

Tailor exercises for the individual patient.

Soooooooo:

Look for movement dysfunction patterns

and compensatory muscle patterning.

Off load the Pubic Joint.

Implications

for clinical

practice

Screen.

Local and Global

Brukner and Kahn 2012

N.B.

Identify and reduce the sources of increased load on the pelvis

17

Rehab Adductor Muscles

Pointers Neuromotor Control

Sahrmann, 2002; Buurke et al., 2004; Hiemstra et al.,2004; Wingert et al., Arch Phys Med Rehabil. 2013; Larkin et al., Clinical Orthop and

Rel Research. Hip resurfacing cf THA. 2013; Response: Girard Clin Orthop Relat Res 2013; Sugimoto et al J Str and Cond. 2014;

Proprioception

Pointers

Monitor Progress – ongoing – throughout season

Pointers

Summary – Conservative Rx

Minimise pre-existing risk factors and compensatory

strategies

Understand Anatomy vs Functional Anatomy

Gradual progression based on objective functional

and clinical markers

Prevention

Groin and Hips - Overview

Youth…………..

Solution ???

Developmental changes in puberty should be

carefully monitored to reduce the risk of injury.

Load management is key and must be monitored

Dr Adam Weir

18

Well researched studies are needed

with Practical outcome

Prevention of Groin/ Hip problems

Any Questions?