Sporting Hip and Groin IST

By Darren Finnegan 14/8/12

Objectives• Provide an overview of anatomy

and biomechanics of groin/hip

injuries.

• Introduce a concise and

thorough method of diagnosis

and rehabilitation of groin/ hip

injuries

• Help understand the diverse

injuries that occur in this complex

anatomical region.

Anatomy & Biomechanics• Muscle imbalance

• Movement restriction

• Fascial slings

• Open vs. closed chain

function of adductors

Anatomy Quiz

Partner up!

Subjective Assessment• Acute vs. insidious

• Mechanism

• Red flags

• Aggs/ Eases

• Investigations

• Athletes goals

• Occupation

• Training program

• VAS

• Referral pattern

Subjective Ax• Training volume/intensity

• PMH- previous surgery or injury, medical conditions

• Sport level, technical requirements of sport,

changes in footwear/ environment

• Other joints- LX,SIJ, knee, scrotal pain

Objective Assessment

• AROM/PROM

• Fabers

• Quadrant

• Labral

• Cough Impulse

• Squeeze test

• Thomas +/- neural

component

• Resisted sit up

• Passive abduction

Objective Ax• Functional tests- hopping,

SLS, SKB, COD, alignment

• Palpation- Rectus

abdominus, Pubis

symphysis, Iliopsoas

• Neural- Obturator,

ilioinguinal, genitofemoral

• Invagination of inguinal

ring

• Area A (in orange) genitofemoral

nerve; area B (in green) ilioinguinal

nerve; arrow C (in red with blue outline)

shows the direction and location for

cremasteric reflex.

Abdominal related pathology• Intra abdominal-

appendicitis, UTI, gynae

issues, rheumatological

(AS), gout

• Osteitis pubis

• Pubic bone stress

syndrome

• ‘Hockey groin’

• Rectus abdominus

tendinopathy

• Inguinal hernia

Athletic Pubalgia• Athletic Pubalgia

• 1/deep pain in

groin/abdo area

• 2/pain agg sprinting,

cutting, kicking, eased

by rest

• 3/Palpable tenderness

over pubic ramus, rec

femoris and/or

conjoined tendon

• 4/Pain on resist add 0,45

+/- 90deg hip flexion

• 5/Pain on resisted sit up

Athletic Pubalgia• Local overload - Pubic bone stress – adductors –

iliopsoas -Posterior ingunial wall deficency -

gilmores /hockey players groin/ external oblique

aponeurosis tear

• Definiton- Caudill(2008) phenomena of chronic

activtiy related groin pain unresponsive to

conservative MX and significantly improves with

surgery.

• Surgical- Bissini repair- transversalis sewing together,

+/- mesh +/- nerve dehiscence

Adductor related pathology• Trochanteric bursitis

• Gluteus medius

tendinopathy

• Snapping hip

• Rectus femoris strain

• Obturator neuropathy

• Iliopsoas strain/ bursitis/

tendinitis

• Adductor strain/

tendinopathy

Hip related pathology• Femoro-acetabular

impingement

• (Sahrman,2002)

• Primary cause of labral

tears

• CAM

• PINCER

• Stress #- NOF, pubic

ramus, acetabulum

• Synovitis

• Labral

• Chondral lesion

• LX/SIJ referred

• Avulsion apophysitis-

ASIS, AIIS

• Perthes

• Slipped capital femoral

epiphysis

Labral Tears• Extrinsic vs Intrinsic

factors (+/- FAI)

• Pain in anterior inguinal, thigh and/ or buttocks region

• AROM/ PROM painful EOR

• Audible clicking/catching/ locking

• Snapping Jt line/ ITB

• MRa

• +ve Impingement, Fabers, Mccarthyhttp://www.aafp.org/afp/991015ap/168

7.html

Rehabilitation• 8-12 weeks (continue with rehab for up to1 year)

• Avoid NSAIDs

• Criteria for return to sport/ running-

• a/brisk walking pain free

• b/Thomas test + resist hip flexion pain free

• c/Nil crossover sign

• d/Minimal adductor guarding

• Manual therapy/ Acupuncture/ Soft tissue work

• Home exercise program

• Additional- compression shorts, pelvic belt

• Cycling

• (Brukner and Kahn, 2007)

Rehabilitation

• Progression of adductor exercises- Core setting

add squeeze short then long lever

with sit up

with Russian twist ¼

bridging

plank

plank with add/abd using friction free surface

standing as above

Other factors to consider????

Rehabilitationkneeling pelvic tilts

wall squat with pelvic tilt sumo squat

lunge with reciprocal arm movement

straight line running

Change of direction --> sport specific training

Take home message

• Any questions?

References• Binningsely, D. (2003). Tear of the Acetabular Labrum in an Elite Athlete. British

Journal of Sports Medicine.37 p 84-88.

• http://www.mayoclinic.com/health/hip-labral tear/DS00920/DSECTION=symptoms

• http://www.sportsinjurybulletin.com/archive/acetabular-labrum-tears

• J. C. McCarthy, B. Busconi. Canadian Journal of Surgery. Hip Disease in Young Adults. Ottawa: Feb 1995. Vol. 38, Iss. 1, p. S13-7 (5 pp.)

• http://www.isakos.com/innovations/soccer.aspx

• Holmlich, Urhskou, Ullnits (1999) Effectiveness of active physical training as treatment for long standing adductor realted groin pain in athletes- RCT, The Lancet, 353, pp.439-443.

• Quinn, A (2010) Hip and groin pain_ physiotherapy and rehabilitation issues,

the open sports medicine journal, 4, pp.93-107.

• Bizzinni, M (2012) the groin area_ the bermuda triangle of sprots medicine, british journal of sports medicine, 45.

• Caudill, P, Nyland, J, Smith,C (2008) Sports hernia a systematic literature review, british journal of sports medicine, 42, pp.954-964.

• Internation Olympic committee World conference: prevention of injury in sport, http://www.ioc-preventionconference.org/OnLPMonaco.php, Monaco. Symposium 16 Session B.

References• Brukner and Kahn (2007) clinical sports medicine, 3rd

edition, McGraw hill, pp.405-424.

• Sahrman,S (2002) diagnosis and treatment of

movement impairment syndromes, Mosby, pp.121-

144.

• Gibbons SGT (1999) A review of the anatomy,

physiology and function of psoas major: A new

model of stability. Proceedings of: The Tragic Hip:

Trouble in the Lower Quadrant. 11th Annual

National Orthopaedic, Symposium. Halifax,

Canada. Nov 6-7.

• Moore, J (2011) Pre-habbing and rehabbing the

sporting groin, the gilmore groin and hernia

symposium,RSM,.