The Sporting Hip and Groin
CPD Course Review Tony Tompos
U21s Physiotherapist Wigan Athletic FC
Anatomy of the Hip and Groin
Pelvis• Stable base for spine and
lower limbs to function• Weightbearing and propulsive
forces are transmitted during gait
• Instability or pain at one point has a direct effect on another (polo mint)
• The pelvis is designed primarily for load transfer and is therfore inherently stable (Snijders et al, 1993)
Hip Joint• Best example of a ball and socket joint in
the human body• Stability of the joint provided by bony
configuration; specifically the depth of the joint augmented by the labrum and strong capsular ligaments (Griffin, 2001).
• Labrum contains free nerve endings which has the potential to be a source of pain
• The Labrum creates a suction effect on the femoral head, generating a negative atmopheric pressure, enhancing the stability of the joint.
• The joint capsule is re-inforced by ligaments (ILF is the strongest ligament in the body)and is thickest and strongest superiorly where it is under most loads during stance and gait.
• Weakest posteriorly.
Pubic Symphysis• Fibrocartilage disk = Shock
absorber• Reinforced by ligaments:
Superior Pubic, Arcurate, Interpubic, Inferior and Posterior Pubic ligaments.
• Little to no movement at all: Vertical motion = 2mm, Rotary movement = <1.5°
MusclesTrunk Flexors
• Rectus abdominus together with Internal and External Obliques produce trunk flexion when the pelvis is fixed.
• Lateral Flexion of the trunk is produced by the lateral fibres of EO and ipsilateral IO.
• Rotation is produced by EO and contralateral IO.
Hip Extensors• The greatest hip extensor is
the Gluteus Maximus.
• The adductor magnus (Ischial portion) is the strongest hip extensor in hip flexion (Moore, 2016)
• Hamstrings contribute to hip extension, though this is not their main function
• Piriformis and glute med also play a role in extension
Hip Flexors
• The Illiopsoas and Rectus Femoris are the major hip flexors of the hip.
• Evidence sugegsts Illiospas initiates Hip flexion in a hip extended position and then RF and momentum take over.
Abductors of the Hip
• The TFL assists in abduction, though the major abductor of the hip are Glute Max and Min.
• Glute Med is the primary stabiliser of the the hip in standing.
• There is succesive recruitment of the abdutor muscles dependant on pelvic tilt..
• When the COM is behind the joint axis (Posterior Tilt), TFL is the dominant abductor. Optimal function of the Gluteus Medius is at 10° anterior tilt. Glute Max alongside Piriformis laterally stabilise the hip when the pelvis is tilted more than >10°.
Hip Adductors• Adductors of the hip are
divided in to 2 groups:• Anterior Group: Pectineus.
Brevis, Longus, Magnus & Gracilis.
• Posterior Group: Glute Max, Quadratus Femoris, Obturator externus, and hamstrings.
• Adductor Longus; Aids Hip Flexion, Co-Contracts during stance phase and decellerates hip extension eccentrically.
Sacroilliac Joint• Beyond scope of this
presentation.• BUT….• The SIJ has very little movement
in non-weight bearing (average 2.5°, range 0-4°) (Jacob & Kissling 1995)
• There is strong evidence that intra-articular displacements within the SIJ’s do not occur (Tullberg et al, 1993).
• A clinical diagnosis of SIJ pain can be made by 3/5 positive SIJ pain provocation tests (Laslett, 2005)
Pelvic Arteries• Kinking and endofibrosis of the
iliac arteries are uncommon and poorly recognized conditions affecting young endurance athletes (Peach et al, 2012).
• Despite having no cardiovascular risk factors, highly trained young athletes (Usually cycling) have been found to have localized flow limitation within the iliac arteries. Vessel stenosis was often caused by endofibrosis – a pathological thickening of the vessel intima – or kinking of the iliac artery (Peach et al, 2012).
Pelvic nerves and referred pain
• Lumbar spine may refer in to the groin
• Usually L1, L2 due to dermatomal pattern
• Need to rule out Lumbar Spine when assesing Hip and Groin
Subjective AssesmentAssesment should be systematic ascertaining the relationship between primary and secondary conditions
and the source of pain versus the source of dysfunction.
• Presenting complaint: Listen closely to pick up on structures involved; joint v muscle v nerve. E.G Vague, deep, dull ache may be more syonymous with joint injury. Where as a sharp pin point pain brought on by specific movement may be indicative of a muscular problem.
• Age of Patient:
• OA hip >45 years typically• Congenital hip dysplasia is seen in infancy aged 3-12• Legg Calve-Perthes Disease more common in boys aged 3-12• Elderly women more prone to osteoperotic NOF fracture• Aggs and Eases:
• Hip Joint Movements: Climbing up down stairs/in and out of car. Driving or sitting for long periods• Abdominal work/coughing may indicate hernia type pain.• Pain that becomes worse with exercise may suggest stress fracture, bursitis, muscle tear.• Movements which patient feels are weak or abnormal:
• Kicking - may be related to Illiopsoas / Rectus Femoris• Twisting - may indicate adductor pathology• Sit Ups - may indicate rectus abdominus / hernia pathology
Superior border of the Triangle: Corresponds to the position of the inguinal ligament, a thickening of the external oblique muscle. Rectus abdominus insertions, internal oblique, external oblique, transverse abdominus insertion and aponeurosis, inguinal canal, inguinal ring, illiolinguinal, illiopogastric and genital branch of the genitofemoral nerve, conjoint tendon of illiopsoas and visceral contents.
Subjective Assesment - Location of Symptoms
• Using Falvey et al’s Patho-anatomical approach to the diagnosis of groin pain (2009), clinicians can use the location of patients pain as a guide to consider different groin pathology.
• Within the Triangle: Conjoint tendon of the illiopsoas muscle, rectus femoris muscle, femoral canal.
• Lateral Border of the Triangle: Femoro-acetabular joint, trochanteric bursa, TFL, and ITB. Although the FA Joint is within the triangle, pathology of the joint is usually referred to as the greater trochanter.
Medial Border of the Triangle: Lie the adductor muscles from superficial to deep - adductor longus, gracilis, adductor brevis, adductor magnus. AL and Gracilis tendons most commonly affected and line in a continuous site of origin along the body of the pubis.
The Pubic Clock• Falvey et al describe the
use of a ‘pubic clock’ to define areas of tenderness of the pubic tubercle due to the amount of structures which converge at this point. Using the pubic clock, the clinician can ‘walk their finger’ around the tubercle assigning tender points to each part of the clock face to the relevant attachment (Falvey, 2009).
Terminology and definition of groin pain in
Athletes• A recent consensus statement was produced by 24 experts in 2015 which looked to define standard terminology related to groin pain along with accompanying definitions (Weir et al, 2015).
• The reason for this consensus statement was because in a recent systematic review on the treatment of groin pain in athletes, 33 different diagnostic terms were used in 72 different studies (Semer et al, 2015).
Terminology of Groin Pain in Athletes
• Defined clinical entities for groin pain
1. Adductor related groin pain
2. Illiopsoas related groin pain
3. Inguinal related groin pain
4. Pubic related groin pain• Hip Related Groin Pain• Other causes of Groin pain
in athletes
Clinical entities for Groin Pain
• Adductor Related Groin Pain - Adductor Tenderness AND pain on resisted adduction testing
• Illiopsoas Related Groin Pain - Pain on resisted Hip Flexion AND/OR pain on stretching the hip flexors
• Inguinal Related Groin Pain - Pain located in the inguinal canal AND tenderness of the inguinal canal. More likely if pain is aggravated with resistance testing of the abdominal muscles OR Valsalva/Cough/Sneeze
• Pubic Related Groin Pain - Local tenderness of the pubic symphysis and the immediately adjacent bone.
Hip Related Groin Pain• The hip joint should always be considered as a source of
possible groin pain (Weir et al, 2015)• History should focus on the onset, nature and location of
the pain and mechanical symptoms such as catching, locking, or giving way as these are highly sensitive for ruling out hip pathology (Mosler et al, 2007).
• Tests including passive hip range of motion, FABER’s and FADIR’s can be used to rule out hip pathology if -ve, but no special tests are specific enough to rule in hip pathology (Weir et al, 2015).
• If unable to rule out hip pathology due to a positive special test, then there should be a high index of suspicion for injury to the labrum, articular cartilage or FAI (Weir et al, 2015).
Other conditions causing Groin pain in athletes
• A high index of suspicion is needed to appreciate other sources of groin pain which may arise from non-MSK sources including neurological, rheumatological, urological, gastrointestinal, dermatological, oncological and surgical. Appropriate additional investgations or referral are critical for identifying these other causes (Weir et al, 2015).
Recomendations of terms to avoid using in groin pain with
athletes• The team of experts from the
Doha agreement (2015) agreed on terms that should not be used when describing groin pain to their athletes.
• The terms that the group chose not to recomend were: Adductor and Illiopsoas tendinnitis or tendinopathy, athletic groin pain, athletic pubalgia, biomechanical groin overload, Gilmore’s groin, groin disruption, Hockey-Goalie syndrome, Hockey groin, osteitis pubis, sports groin, sportsmans groin, sports hernia, sportsmans hernia (Weir et al, 2015)
Evidence Based Assesment of Hip and
Groin pain
Holmich, 2007Falvey et al, 2015
Bradshaw et al, 2008
Results of Hip and Groin Assesments
Holmich, 2007
Bradshaw et al, 2008
Falvey et al, 2015
Other findings from Hip and Groin Assesments
Holmich, 2007 Bradshaw et al 2008 Falvey et al, 2015
Adductor Muscle Injury
• Common in sports with sudden changes of direction (Hockey, soccer, rugby etc), Adductor Longus being the most involved.
• Adductor Longus (70%), Magnus (15%), Other (Gracilis, Pectinius, Brevis = 15%) (Lovell, 2001)
• There may be local tenderness, pain on passive abduction, pain on resisted adduction or combined flexion/adduction (Moore, 2016)
• Types of Adductor injury include:
1. Bony Avulsion
2. Avulsion Fibrocartilage (Enthesis)
3. Tear at the M-T Junction (Schilders, 2007).
Adductor Muscle Injury• Adductor Tendinopathy may be a primary
or a secondary condition of an acute adductor muscle injury.
• Clinically this presents as proximal groin pain which tends to subside with a warm up and decrease with gentle activities but may progress with increasing stress.
• If untreated this may progress to persist during activity and has the potential to limit activity with pain migrating to the contralateral groin or to the suprapubic region.
• Emphasis in rehab is the early introduction of eccentric strengthening. Twice daily eccentric training may stimulate new tenocyte production in the target tissues. There may be an initial increase in symptoms for the first 2-4 weeks and it may take up to 12-14 weeks before the tissues are ready for resumption of sporting activities (Moore, 2016)
Cook & Purdham, 2012
Adductor Muscle Injury
• A recent Cadaveric study found that the proximal anatomy of the adductor muscles are more complex than previously described.
• Davis et al found that n=20/20 cadavers had a fusion between the tendons of Adductor Longus and Rectus Abdominus (2012).
• Proximal fusion between the tendons of Adductor Brevis and Gracilis were also found in n=16/16 patients (Davis et al, 2012).
Adductor Muscle Injury
• The same study by Davis also found a significant difference between the vascularity of the proximal tendons of the adductors (2012).
• AL and AB enthesis were significantly less vascular near the enthesis, a factor which may predispose the capacity or rate of tendon repair in AL and AB (Davis, 2012).
• AL Mid-tendon was also significantly less vascular compared to AB and gracilis, which again suggest an apparant ‘weak spot’ in this area (Davis, 2012)
Illiopsoas Related Groin Pain
• Illiopsoas-Related pain is localised in the anterior part of the proximal thigh (within the triangle) sometimes radiating down the anterior thigh (Holmich, 2012).
• When attempting to discriminate between intra and extra-articular pathology using FADIR’s test, consider that the muscle will be folded (flexion), twisted (adduction) and pulled (internal rotation) (Holmich, 2012).
• Illiopsoas related groin pain may be diagnosed with:
1. Pain when palpating the muscle through the lower abdominal wall
2. Pain on passive stretching of the muscle using the thomas test position
3. Pain and/or weakness on loading in during hip flexion at 90° (Holmich, 2012).
Inguinal Related groin Pain
• Inguinal related groin pain is experienced ‘deep’ in the groin, slightly more proximal than adductor related pain (Superior to the triangle) (Holmich, 2012).
• The pain may radiate along the inguinal ligament, the perineum, rectus abdominus, adductors and also the opposite side. Increased intra-abdominal pressure such as coughing, sneezing or the valsalva manouevre usually cause increased pain (Homich, 2012).
• Clinical signs include:
1. Pain location in the inguinal canal AND tenderness of the inguninal canal
2. Pain is aggravated with restance testing of the abdominal muscles OR on Valsalva/cough/sneeze
3. No palpable inguinal hernia is present (Weir et al, 2015).
Pubic Related Groin Pain
• Local tenderness of the pubic symphysis and the adjacent bone (Weir et al, 2015)
• Examination may display:
1. Excuisite tenderness over the pubic bone
2. Adductor muscle guarding on ‘Fall out test’
3. Pain/loss of power on ‘Squeeze Test’
4. Positive ‘Pubis Symphysis Stress Tests’
Pubic Related Groin PainBest thought of as a stress
reaction/degeneration of the pubic bone characterised by pain, BMO and degeneration of the pubic symphysis (Moore, 2016)
Consider ‘tug of war’
between RA and AL
aponeusosis
Repetetive micro-trauma may accelerate degeneration of
the articular disk.
Ligamentus injury to the
ligaments of the symphysis may
lead to instability within
the joint
Pubic Related Groin Pain
• Pubic Symphysis Stress test
1. Passive Hip Extension
2. Passive Hip ABDuction in Extension
3. Resisted hip ADDuction in hip extension and ABDuction
4. Resisted hip flexion in hip extension
• Squeeze Test
• 45°,0°, 90° hip flexion (200-240mmHG). Measure P1 and Max and able to work out % of strength/load tolerance
Hip Joint Related Groin Pain - Imaging the Hip
Joint• When to image?
1. Diagnosis uncertain AND will affect management decisions
2. Diagnosis obvious, but EXTENT of injury is unclear (will affect management)
• Options:• Plain X-Ray (Weightbearing and then supine)• Bone Scan• MRI/MRa (MRa offers greater specificity for Labral
pathology(75-95%) (Edmonds, 2003)• CT Scan (3D CT)• Ultrasound
Consider that imaging modalities of the hip offer high sensitivity, but relatively low specificity. E.G MRI/CT unable to detect partial thickness defects (1cm), Osteochondral loose bodies, small labral tears. Arthoscopy therfore is a useful investigation for diagnosis (Villar et al, 1995)
Hip Joint Pathology• Joint Space Pathology -
Cysts, synovitis
• Chondral loose body
• Osteochondral defect
• Ligamentum Teres Tears
• Acetabular Labral Tears
• Osteoarthritis
Diagnosis Pre-2000 Post-
2000OA 38% 8%
Labral Tear 19% 63%
Chondral Lesions 16% 3%
Lig. Teres Tears 5% 11%
Synovitis 4% 3%Loose Bodies 4% 6%
Other 14% 6%
Labral Injury• History
1. Rarely a history of trauma
2. Repetetive joint stress in flexion +/- IR
3. Pain located over anterior thigh
4. Clicking and catching (highly sensitive descriptions)
5. Grasp C-Sign
6. Flexion and rotation activities aggravate pain
Femoro-acetabular Impingement
• FAI is a concept describing the early and painful contact of morphological changes of the hip joint, both on the acetbular and femoral head sides
• These changes can lead to symptoms of hip and groin pain, limited range of motion with chondral, labral and bony lesions (Anderson et al, 2012)
• Pincer impingement involves the acetabular side of the joint where there is excessive coverage of the acetabulum.
• Cam impingement involves the femoral side of the joint where the head is associated with bony excrescences and is aspheric (The aspheric head jams in to the acetabulum) (Anderson et al, 2012)
• Awareness of the Mixed type of Cam-Pincer impingement is important as types often occur together.
Hip Dysplasia• Dysplasia of the hip encompasses
a wide specturm of hip abnormaility, ranging from a shallow acetabulum to a completely dislocated ‘high riding’ hip (Beltran, 2013)
• On plain x-ray, dysplasia of the hip may be diagnosed using the ‘centre edge angle’.
• CE angle < 25° suggests hip dysplasia and likely to have instability
• Normal CE angle is 25-40°• CE angle > 40° suggests Pincer
lesion
Hip related pain in the adolescent
• Any child <15 years old must have an x-ray on first episode of pelvic bone pain to rule out osteosarcoma.
• One of the most common causes of bone cancer in children aged 10-25.
Hip related pain in the adolescent
Traction Apophysitis
• Excessive muscle pull on immature bone
• Will always resolve, but can take much longer than a muscle strain
• May progress to avulsion fractures
• Most common sites are AIIS, ASIS and Ischial Tuberosity (Moore, 2016).
Slipped Upper Femoral Epiphysis
• Typically occurs in 12-15 year old boys (overweight) (4:1)
• During growth spurts, there is a widening of the physis and the axis of the physis moves from being horizontal to more oblique. As this occurs, shear forces across the growth plate increase (Knipe et al, 2016)
• Most common symptom is limp• Affected leg shortened and externally
rotated• Reduced Hip flexion and IR• X-Ray - Lateral frog leg as slip is posterior
(Bomer et al, 2014).• An acute sudden slip is a surgical
emergency!• Usually presents as a gradual slip
Legg-Calve-Perthes Disease
• Idiopathic avascular necrosis of the growing femoral epihpysis
• Boys affected 5x more than girls between ages of 2-18 with a peak around 5-6 years old (Dillman et al, 2009)
• Commonly presents as pain around the hip and groin with or without a limp
• Prognosis isinfluenced by the percentage of femoral head involvement and degree of deformity
Principles of Management
• Adductor longus, magnus, rectus abdominus,internal obliques and illiopsoas all have the potential to contribute to stability and force transmission in the groin
• If groin pain results from an imbalance of forces through the sympyshis pubis of the above musculature, then a management approach directed at only one tissue may be inneffective (SINI, 2011)
• One of the primary factors in the rehabilitaion of groin pain is modification of training load, without which it is often impossible to effectively address key mechanical dysfunctions (SINI, 2011)
• The focus of rehabilitation should be directed at re-establishing efficient load transfer across the pubic region by addressing joint mobility, muscle extesibility and gloabl muscle strength (SINI, 2011).
The first 48 hours• Avoid use of NSAID’s• Utilise Game Ready for Ice and
Compression (Herringbone Compression using short stretch bandage causing high dynamic pressure)
• Early movement useful but avoid stretching
• Avoid direct tissue work• Avoid excessive travel• EIS - no stretching or massage
for 96 hours
Principles of Management• Identify plane of movement of
weakness (Saggital, Coronal, Transverse)
• Train movement not muscles• Consider function (Twisting,
turning, stepping, kicking, accelerating, sprinting)
• Focus on TOTAL hip strength including Add/Abductors, Extensors and hip flexors
• Consider Add:Abd for both dominant and non dominant sides
Manual Therapy• Hip mobilisations
• Dry Needling
• Adductor Origin Stripping
• TFL/Glute TrP Release
• Illiopsoas Release• Joint Capsule Release (PA
Mobs in Prone Fabers)
Rehabilitation Protocols
Holmich, 1999
Hogan, 2006
Weir et al, 2010
Additional Exercises• Lateral Lunge 3x12 each side,
build from BW to 20kg• Single leg barbell high step ups• Squeeze and Bridge @ 0°,30°,
60° & 90° (6s holds x4)• Adductor Magnus Bridge Matrix.
Feet elevated with hips flexed 110° (20reps), 90°, (12 reps), 30° single leg lowers (8 reps)
• Sumo Squat with gym ball• Hip Adduction Theraband
(Jensen, 2012)
• Dissociation exercises - Deadbugs/Bird Dogs: Continuous abdominal loading 2-4mins using SL & DL loading
• Plank Matrix - Reverse on elbows (30s), L & R Side (30s each) (foot over for IO recruitment), Table top (30s), front plank (1min) = 3mins
• Swiss ball push backs, swissball half pike, swiss ball full pike.
• Lower abdominal Routine: Lay on bench with hands above head. SL reach below paralel (5 reps), DL reach to 45° (5 repsx6s holds), DL hips to 0° feet off floor (5 reps).
• Hip Flexion from Extension with theraband (Thorborg, 2016).
Rehab for Pubic Bone Stress
• Enhancing bone mass for pubic bone stress injuries can be achieved by talioring the rehabilitation programme
• Burr et al found that loading bone 4x throughout the day via high amplitude, low volume perturbations with 90 reps produced the most bone growth (2002).
• An increase in bone mineral content and bone mineral density were found when compared to loading with different parameters (Burr et al, 2002)
• For patients suffering with bone stress injuries it may be beneficial to use high amplitude, low volume, non linear forces such as hopping 4xper day for 90 reps with 2-3 hours rest inbetween (Moore, 2016)
5 Key Re-Assesment Signs
• Pain during exercise• Pain +/- ‘stiffness’ next
morning• Squeeze test - Compare
with baseline• Pubic Symphysis Stress
Tests (Passive Hip Ext and Abd, Resisted Flex and Add)
• Adductor Muscle Tone (BKFO’s, Passive Abduction ROM
Prevention of Hip and Groin Injuries
• No single test can effectively identify those at risk of developming groin pain, although there are several clinical findings that when combined can help highlight those at risk (SINI, 2011)
• Like most other injuries, previous groin history of groin pain is linked to an increased risk of groin pain (SINI, 2011)
• A recent updated systematic review found that the most common risk factors for groin pain were related to age, Hip ROM, Hip adductor strength, previous groin injury and lower levels of sports specific training were associated with increased risk of groin pain (Whittaker et al, 2015).
Prevention of Hip and Groin Injuries
Prevention of Hip and Groin Injuries
• Delahunt et al found that a commercially available sphygmomanometer is a reliable device for measuring adductor squeeze test values (2011).
• This paper showed that the interrater reliability of a BP cuff in assesing squeeze values is excellent and that 45° of hip flexion produced maximal scores during testing compared to 0° and 90° (Delahunt, 2011).
• Crow et al found that squeeze scores were reduced by 10% 1 week preceeding groin injury in elite AFL players (2008).
• As a result, it is reasonable to suggest that weekly monitoring of adductor strength within a squad could identify those at risk of breakdown and allow early modification of activity (SINI, 2011).
ReferencesFalvey EC, King E, Kinsella S, Franklyn-Miller A (2016) Athletic Groin Pain (Part 1): A prospective anatomical diagnosis of 382 patients - clinical findings, MRI findings and patient-reported outcome measures at baselin. Br J Sports Med 2016; 50;423-430
King E, Ward J, Small L, Falvey E, et al. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes Br J Sports Med 2015;49:1447–51.
Hölmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med 2007;41:247–52
Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med 2008;42:851–4.
Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomisedtrial. Lancet 1999;353:439–43.
Weir A, Jansen JA, van de Port IG, et al. Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial.Man Ther 2011;16:148–54.
Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med
Hölmich P, Hölmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med 2004;38:446–51.
Delahunt E, McEntee BL, Kennelly C, et al. Intrarater reliability of the adductor squeeze test in Gaelic games athletes. J Athl Train 2011;46:241–5.
Thorborg K, Serner A, Petersen J, et al. Hip adduction and abduction strength profiles in elite soccer players: implications for clinical evaluation of hip adductor muscle recovery after injury. Am J Sports Med 2011;39:121–6.2009;43:213–20.
Weir A, Brukner P, Delahunt E et al (2015) Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49:768-774
Peach G,Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchcliffe RJ (2011) Endofibrosis and Kinking of the Illiac Arteries in Athletes: A systematic Review. European Journal of Vascular and Endovascular Surgery 43 (2012) 208e217
Laslett M (2005) Evidence based diagnosis and treatment of the pain ful sacroilliac joint. The journal of Manipulative therapy, Vol 16, Number 3
Recommended
