The groin/hip enigma in sports The hip in athletic groin 12.12.2017 ¢  The groin/hip enigma in sports

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  • The groin/hip enigma in sports

    The hip in athletic groin pain Onur Tetik MD

    Professor in Orthopedics and Traumatology

    KOC University School of Medicine & American Hospital

    Istanbul

    IOC ADVANCED TEAM PHYSICIAN COURSE ANTALYA, TURKEY

    27-29 NOVEMBER 2017

  • Introduction Groin: name

    Inguinal: adjective

    Junction between abdomen and leg

    Acute vs Chronic

    Trauma vs Overuse

    Intraarticular vs Extraarticular

    Orthopedic vs Nonorthopedic

    AGE Child

    Adolescent Adult (W/M)

    Old

  • Difficulties 1. Complex local anatomy with large soft tissue sleeve

    2. Complex biomechanics

    1. Biggest joint,

    2. Carry the body weight,

    3. 2nd biggest ROM

    3. Wide differential diagnosis

    4. Often diffuse, insidious symptoms with nonspecific

    presentation

    5. Often multiple diagnoses 27-90% (one triggers the other

    SIEVING

    Conservative Surgery

    TEAM APPROACH !

  • Incidence

    • Sports injuries: 2.5-5 % groin related

    • High school athletes 5-9 % USA

    • Any sports

    Sudden: Acceleration Deceleration, Hip Abd-Add, Rotational

    • Soccer, Rugby, Skiing, Skating, Horse riding

    • Ice hockey 10 %

    • Football 5 %

    • Muscle strain the most common

    • “Sports hip triad” labral tear, adductor strain, rectus

    abdominus strain

  • Hip pathology ??

    Think twice

    THINK LATERAL! • Inflammatory arthropathy

    • Infection,

    • Tumour

    • Lumbar spine

    • Metabolic bone disease

    • Nerve entrapment syndromes

    • Referred pain

    – Abdomen / Spine / Pelvic viscera etc etc…......

    48y, W Tennis Pain for 2 mos

  • A) EXTRA ARTICULAR

    B) PERIARTICULAR (BONY)

    C) INTRA ARTICULAR

    D) NON-ORTHOPEDIC /

    REFERRED

    Classification

    D) NON-ORTHOPEDIC

    (REFERRED/MEDICAL)

    • Lumbar / Sacral pathology

    • Gynecologic

    • Urologic

    • Testicular neoplasm,

    • Ureteral colic,

    • Prostatitis,

    • Epidydimitis,

    • Urethritis,

    • Hydro/Varicocele

    • GI

    • Hernia, (Inguinal, Femoral, Peritoneal)

    • Inflammatory bowel D

    • Aneurysm

    • Appendicitis

    • Neoplasms

  • Diagnostics

    • Radiography

    – Osteitis pubis

    – Stress fractures

    – Osteomiyelitis

    – SFCE

    – OA

    • Bone scan

    – Osteitis pubis

    – Stress fractures

    – Osteomiyelitis

    – SI

    – Tenoperiosteal lesions

    •US  injections

    –Muscle tears

    –Hematoma

    –Inguinal hernia

    –Bursitis

    •Nerve conduction

    –Neuropathies

    •Peritonel radyography

    •Herniography

    •CT

    •Bony pathologies

    •Surgical planning

    •MRI*

    Bone & soft tissue

    –AVN

    –Disc hernia

    –Ostetis pubis

  • A) Extraarticular 1. Muscle tendon unit strains* / “Pulled Groin”

    2. Athletic Pubalgia / Osteitis Pubis

    3. Snapping Hip

    4. Nerve entrapment syndromes

    5. Avulsion and apophyseal injuries

    6. Piriformis syndrome

    7. Ischiofemoral impingement syndrome

    8. Bursitis

    9. Trochanteric

    10.Hip and thigh contusions

    11.Limb length discrepancies

    12.Lymphatic problems

  • Muscle tendon unit problems

    Groin Pull = Strain

    • Adductor strain – Pectineus

    – Adductor brevis & Adductor longus

    – Gracilis & Adductor magnus

    • Iliopsoas insertion

    • Rectus femoris origin (ASİS)

    • Rectus abdominis

    • Sartorius

  • Adductors* • Soccer 10-18%

    – Abductor ROM limitation+ Adductor weakness

    – Lower extremity biomechanical problems

    – Hip musculature weakness

    • Adductor longus & gracilis MT junction

    • Preseason camps x 20 > Season

    • US + MRI

    16y boy, weightlifter

  • Tx

    • Chronic: ~6 mos +

    Active muscle strengthening better > Passive PT

    • Painless full ROM + 70% of strength = return to Sport

    • Early return to sport  recurrence + other pathologies

    • Prevention !!! (Adds = Min 80% of Abds)

  • Iliopsoas

    • Hip flex or hyperextension sports

    • Diagnosis 32-41 mos.!

    • Exam (extension test, supine 15o heel rise test)

    • Surgery rare

    – success 12/16

  • High hamstring strain

    Ischial tuberosity avulsion

    Conservative

    No surgery except

    Displacement>2cm ~Surgery

    Sartorius & Rectus femoris strains

    Tx  Conservative

    Scar tissue excision ? (after complete tears and painful scar formation)

  • Avulsion and Apophyseal injuries 17y, M Soccer 16y, M, Weight lifting

    SİAS 21-25y Ossification late Tuber ischii 20-30 y

    !

    Adolescent (14-17y) Hard training

    14-40% Avulsion fracture

  • Athletic Pubalgia / Osteitis Pubis

    • Over trained adolescent and prepubescent

    • Repetitive adductor pull shearing forces

    • Symptoms

    – Adductor pain occurred 80%

    – Pain around the pubic symphysis 40%

    – Lower abdominal pain 30%

    – Hip pain 12%

    – Referred scrotal pain 8%

    Widening Narrowing, OA

  • Osteitis Pubis Tx

    • Usually self-limited !

    • Xray (+) Asymptomatic soccer player 76%

    • Acute  PT + Medical (Oral Cs?)+ Manipulation

    • Injection? Acute period ~ – When?: Immediately vs 1.week

    – No sport for 1 week

    – ~Repeat: 2-3 weeks

    Recurrence rate 25%

    • More than a year to resolve

    (mean 9.6 mos)

    • Surgery:

    – Vertical instability

    – No response to conservativeTx

  • ‘Snapping Hip’ Syndrome

    INTERNAL

    • Labral tear

    • Loose bodies

    • Synovial chondramatosis

    • Osteochondramatosis

    • Hip subluxation

    EXTERNAL • Iliotibial band

    tensor fascia lata,

    gluteus medius tendon

    (external)

    • Psoas tendon – Ilio-pectineal eminentia

    – Anterior hip

    (internal)

    Not a diagnosis, Symptom 70% painless

  • Snapping iliotibial band

    • Repetitive activities

    • Iatrogenic

    • Prominent trochanter

    • Coxa vara

    • Reduced bi-iliac width

    • Tight IT band

  • Snapping iliopsoas tendon

    • 5-10% asymptomatic

    • Hip Flex+Abd+ER  neutral

    Surgery if needed Anterior / Inferior / Proximal/ Arthroscopic

    •MRI

    •Iliopsoas bursography

    •US

  • Nerve entrapment syndromes

  • Reasons

    1. Post surgical

    1. Appendectomy,

    2. Hernia repair

    3. Pfannen Steil incision: scar tissue or

    deep fascia impingement

    2. Blunt trauma

    3. Overstretching

    4. Compression

    • Nerve block: Dx & Tx

    • Plexitis, Neuritis

  • Piriformis syndrome

    • Never radiates down

    • Anatomic variations !

    • Hard to show

    • Stretching

    • Very rarely surgery

  • Ischiofemoral impingement syndrome

    • Lately popularized

    • Conservative Tx

    • Surgery  underlying causes

  • Bursitis

    • Overuse or Trauma

    • Conservative

    • Aspiration and injection (Serial)

    • Rarely surgery

  • Hip pointer hip bruise

    Iliac crest or Trochanter major

    and soft tissue contusions

    Tx Conservative

    Hematoma

    ! Myositis ossificans! Chronic bursitis

  • Lymphatic problems Drains

    • skin of the lower limb,

    • lower abdominal wall,

    • scrotum,

    • labia,

    • vagina,

    • anal canal

  • *Posterior abdominal wall abnormalities

    Sports hernias

    Groin disruptions

  • Sports hernia

    • Insidious-onset, gradually worsening, deep

    chronic groin pain

    • 1/3 trauma history (+)

    • No true hernia

    • Coughing and bearing down increases 10%

    • Post exercise and next morning pain

    • Resisted adduction 65% painful

  • Causes

    • Muscle imbalance with relatively strong adductors

    • Weak lower abdominal musculature

    • Increased shearing forces across the hemipelvis

    • Overuse

    • Genetically weakened inguinal wall

  • Sports hernia

    • Surgery for groin pain 30% documented sports hernias

    • PE hernia ~

    • Radiating pain 30%

    Inguinal ligament, perineum, rectus muscles

    • Imaging: MRI?

    • Nonoperative treatment unsuccessful

    • Surgery 90% success

  • Groin Disruption

    Pathology

    • Tears of

    – Transversalis fascia,

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