The Sporting Hip and Groin
The Sporting Hip and GroinCPD Course Review Tony TomposU21s Physiotherapist Wigan Athletic FC
Anatomy of the Hip and GroinPelvisStable base for spine and lower limbs to functionWeightbearing and propulsive forces are transmitted during gaitInstability 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 JointBest example of a ball and socket joint in the human bodyStability 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 painThe 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 SymphysisFibrocartilage disk = Shock absorberReinforced by ligaments: Superior Pubic, Arcurate, Interpubic, Inferior and Posterior Pubic ligaments.Little to no movement at all: Vertical motion = 2mm, Rotary movement = 10.
Hip AdductorsAdductors 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 JointBeyond 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 SIJs 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 ArteriesKinking 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 painLumbar spine may refer in to the groinUsually L1, L2 due to dermatomal patternNeed 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 typicallyCongenital hip dysplasia is seen in infancy aged 3-12Legg Calve-Perthes Disease more common in boys aged 3-12Elderly women more prone to osteoperotic NOF fractureAggs and Eases:Hip Joint Movements: Climbing up down stairs/in and out of car. Driving or sitting for long periodsAbdominal 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 FemorisTwisting - may indicate adductor pathologySit 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 SymptomsUsing Falvey et als 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 ClockFalvey 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 AthletesA 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 AthletesDefined clinical entities for groin painAdductor related groin painIlliopsoas related groin painInguinal related groin painPubic related groin painHip Related Groin PainOther causes of Groin pain in athletes
Clinical entities for Groin PainAdductor Related Groin Pain - Adductor Tenderness AND pain on resisted adduction testingIlliopsoas Related Groin Pain - Pain on resisted Hip Flexion AND/OR pain on stretching the hip flexorsInguinal 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/SneezePubic Related Groin Pain - Local tenderness of the pubic symphysis and the immediately adjacent bone.
Hip Related Groin PainThe 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, FABERs and FADIRs 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 athletesA 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 athletesThe 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, Gilmores 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, 2015Bradshaw et al, 2008
Results of Hip and Groin AssesmentsHolmich, 2007
Bradshaw et al, 2008
Falvey et al, 2015
Other findings from Hip and Groin AssesmentsHolmich, 2007
Bradshaw et al 2008
Falvey et al, 2015
Adductor Muscle InjuryCommon 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:Bony AvulsionAvulsion Fibrocartilage (Enthesis)Tear at the M-T Junction (Schilders, 2007).
Adductor Muscle InjuryAdductor 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 resumpti