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Sports Hernia MAOP Annual Meeting
12/07/2013
Jeffrey P. Haggquist, DOMedical Director
QuistMD – Flexibility, Sports & Rehabilitation ClinicWashington, DC
Examine Rehabilitation Perspective on Sports Hernia
• Understand why term sports hernia is confusing
• Discriminate conditions with similar symptoms
• Outline a brief physical exam for surgical consideration of sports hernia
• Define core and global strength as they relate to pre‐hab and rehab of sports hernia
• Give rehabilitation protocols and management algorithm for sports hernia / groin pain
Sometimes the Etiology is Clear
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Etiology is Often Multifactoral
Functional Inguinal Canal
• Anterior Wall
• Posterior Wall
• Interior Structures
• Floor
(Campanelli; Moeller; Swan; Fon; Paajanen; Hackney; Akita; Ekberg; LeBlanc; Hoelmich; Lloyd)
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Sports Hernia (Redfined)
• Groin pain in athletes secondary to acquired “functional” inguinal canal injury with inguinal wall deficiency not sufficient to result in discrete hernia formation
Prevalence and Nature
• Common ‐ Groin pain found in 5‐28% of athletes (Preskitt 2011)
• Insidious onset(72%) (Gilmore 2011)
But Not Always Insidious
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Triad of Soft Tissue Injury
Haggquist 2013
Eccentric Muscle Contraction puts Greater Load Stress on Muscles
Hamstring Injury
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A Cascade of Events Through Kinetic Chain
5) Stretch strain ‐ abdominals
4) Unlevel pelvis ‐> torsional strain ‐ pubic symphysis
3) Contraction / tightness ‐ left adductors
Classic left anterior inferior chain pattern(From the Bottom up)
1) Collapsed foot arch
2) Internal rotation of lower limb
• Injured adductors can lead to osteitis pubis
• Osteitis pubis can lead to inhibition of the adductors
• Resulting unbalanced tensile stress promotes attenuation or tearing of the transversalis fascia and / or overlying musculature
(Moeller 2007; Swan 2007; Fon 2000; Kesek 2002; Van Der Donckt 2003; Polglase 1991)
Clinical Exam to Determine Need for Surgery
Dx of Exclusion
#1 ‐ Rule out other causes of groin pain• Genitourinary
• Intraabdominal
• Gynecological
• Hip / lumbar
• Other muscular strains and sprains
#2 ‐ Standard hernia exam**Careful bilateral scrotal and external inguinal ring palpation**
Preskitt 2012
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Grade Tenderness 0‐5 at Five Locations
#1 ‐ Pubic symphysis
#2 – Left & right adductor tendon
#3 – Left & right inguinal floor
Grade Response
0 no tenderness
1 very slight tenderness
2 mild but definite & reproducible tenderness
3 moderate tenderness (“Yes that hurts”)
4 severe tenderness (“Hey, that really hurts”)
5 pain is so severe that patient cannot tolerate palpationPreskitt 2012
Assess Osteitis Pubis (Percussion)
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Alternative Test Inguinal Floor
Surgical Decision
• In the absence of any other pathology
• + SURGERY– If tenderness or pain of ≥ 3/5 in the medial inguinal floor that is clearly dominant over ipsilateral adductor tenderness
• + REHABILITATION– If grade is ≤ 2 unilaterally or bilaterally
– If there is a clear dominance of adductor pathology and injury
Preskitt 2012
Diagnosis of Exclusion –Musculoskeletal
• COMMON DENOMINATOR = Anterior hip pain radiating to the groin– Isolated adductor /rectus / pubis injuries
– Hip injury / fracture
– Femoral Acatabular Impingement (FAI)
– Hip snapping syndrome (Iliopsoas Tendonitis)
– Labral tears
– Osteoarthritis
– OsteonecrosisMcSweeney 2012
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Isolated Adductor / Rectus / Pubic Injuries
Best evaluated by MRI
– sensitive (98%)
– specific (89‐100%)(Zoga 2008)
Hip Injury / Fracture
• Femoral neck stress fracture– Activity‐related anterior groin pain
– Relieved by rest
– Initially mild
– Worsens with therapy
• Gait assessment– Difficulty bearing weight on affected side = limp or antalgic gait
• X‐rays negative up to 4 weeks, MRI positive within 2 days
Femoral Acatabular Impingement (FAI)
• Insidious onset
• Pain with sports requiring hip internal rotation (hockey, tennis, golf, soccer…)
• Stepping out of a low‐seated car difficult
• FADDIR test
• X‐rays lateral and AP – Determines cam or pincer morphology
• MRI / MRA – Cartilage deterioration / labral tear
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FADDIR Test for Impingement
Hip Snapping Syndrome (Iliopsoas Tendonitis)
• FABER Test with Leg Extension
• Resisted Hip Flexion, Seated Position• Direct Palpation of Iliopsoas
Labral Tear
• Worsens with twisting motions, running, walking, sitting for long periods
• Clicking or catching
• X‐ray, MRA nearly 100% specific
C‐Sign
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Hip Osteoarthritis
• Progressive deep ache with loss of ROM
• Loss of hip internal rotation
• Confirmed with X‐ray
60° Normal 0‐5° Severe Restriction
Osteonecrosis
• Age 20‐50 years
• Trauma, steroids, ETOH, smoking, lupus, sickle cell, coagulopathy, scuba diving
• Deep intermittent ache
• PE
– Early – pain with extreme ROM
– Advanced – pain with limited ROM
• MRI
The Core Simplified: 4 Sides, a Roof & a Floor
Prehab & Rehab
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The Core in ActionFunctional conduit for the transfer of energybody’s upper half ⇄ lower half
Foundation for the stabilizationof posture and movement
Strengthening the Abs in Isolation Does Not a Strong Core Make
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The Forgotten Parts
• Would you buy a boxwithout a bottomor top?
– respiratory diaphragm
– pelvic floor m. (Kegel)
http://www.mayoclinic.com/health/kegel‐exercises‐for‐men/MY01402
http://www.mayoclinic.com/health/kegel‐exercises/WO00119
Posterior Chain
Primary Structures of Good Posture‐ Traps, Lats, Gluts
Central Feature ‐ Thoraco‐lumbar Fascia
Global Strength
• Obliques plug into the thoraco‐lumbar fascia laterally and, together with core, create a tension‐integrity system which stabilizes the pelvis
– Pelvis = key to all other stability in the body
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Stages of Rehabilitation
Reduce PainReduce Pain• Control inflammation & deliver manual therapy
Improve
Range of Motion
Improve
Range of Motion• Train Active Isolated Stretching
Re‐educate
Neuromuscular Pathways
Re‐educate
Neuromuscular Pathways• Optimize brain‐muscle pathways
Strengthen and Condition
Strengthen and Condition
Develop Functional
Training
Develop Functional
Training
•Return to Sport
Take Home Points
• Majority of groin pain correlated to instability across the pubis
• Usually combination injury / conditions can co‐exist
• Any type of biomechanical alteration of the core leads to instability across the pubis
• Therefore, pre‐habilitation and rehabilitation imperative to correct biomechanical imbalances, ie, potentially the root cause of most groin pain
Proposed Algorithm for ManagingSports Hernia
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Brown 2013
ReferencesAkita K, Niga S, Yamato Y, Muneta T, Sato T. (1999) Anatomic basis of chronic groin pain with special reference to sports hernia. Surg Radiol
Anat 21:1‐5.
Anderson K, Strickland S, Warren R. (2001) Hip and groin injuries in athletes. Am J Sports Med 29:521‐33.
Campanelli, G. (2010) Pubic inguinal pain syndrome: the so‐called sports hernia. Hernia 14;1‐4.
Caudill, P, Nyland J, Smith, C, et al. (2008) Sports hernias: a systematic literature review. Br J Sports Med 42:954‐964.
Ekberg O, Persson NH Abrahamsson PA, Westlin NE, Lilja B. (1988) Longstanding groin pain in athletes. A multidisciplinary approach. Sport Med 6:56‐61.
Fon LJ, Spence RA. (2000) Sportman’s hernia. Br J Surg 87:545‐552.
Frank, Rachel M., Mark A. Slabaugh, Robert C. Grumet, Charles A. Bush‐Joseph, Walter W. Virkus, Shane J. Nho. (2012) Hip pain in active patients: what you may be missing. Jour Fam Prac Vol 61, no 12: 736‐744.
Gilmore, Jerry. (2011) “Why Gilmore’s Groin is not a Hernia,” presentation to Gilmore Groin and Hernia Symposium.
Hackney RG. (1993) The sports hernia; a cause of chronic groin pain. Br J Sports Med 27:58‐62.
Hölmich P, Hölmich LR, Bjerg AM. (2004) Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med 6:56‐61.
Kavanagh EC, Koulouris G, Ford S, et al. (2006) MR imaging of groin pain in the athlete [review]. SeminMusculoskelet Radiol 10:197‐207
Kesek P, Ekberg O, Westlin N. (2002) Herniographic findings in athletes with unclear groin pain. Acta Radiol 43:603‐608.LeBlanc KE, LeBlanc KA. (2003) Groin pain in athletes. Hernia 7:68‐71.
Lloyd, David M. (2010) “The Inguinal Ligament Release Procedure: A New Concept – A New Procedure for Sportsman’s Groin,” presentation to Gilmore Groin and Hernia Symposium.
MacMahon PJ, Hogan BA, Shelly MJ, et al. (2009) Imaging of groin pain. Magn Reson Imaging Clin N Am 17:655‐66.
McSweeney, Sean E., Ali Naraghi, David Salonen, John Theodoropoulos, Lawrence M. White. (2012) Hip and groin pain in the professional athlete. Canadian Association of Radiologists Journal 63:87‐99.
References
Moeller JL. (2007) Sportsman’s hernia. Curr Sports Med Res 6:111‐114.
Moore, James. (2010) “Groin Pain In Sportsmen: The Physiotherapist’s Role,” to Gilmore Groin and Hernia Symposium.
Moore, James. (2011) “Pre‐habbing & Re‐habbing The Sporting Groin ‐ Early to End Stages, presentation to Gilmore Groin and Hernia Symposium.
Omar IM, Zoga AC, Kavanagh EC, et al. (2008) Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics 28:1415‐38.
Orchard, J, Read JW, Werrall GM, Slavotinek JP. (2000) Pathophysiology of chronic groin pain in the athlete. Intl SportMed J for FIMS;1(1).
Paajanen H, Syvähuoko I, Airo I. (2004) Totally extraperitoneal endoscopic (TEP) treatment of sportsman’s hernia. Surg Laparosc EndoscPercutan Tech 14:215‐218.
Polglase AL, Frydman GM, Farmer KC. (1991) Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust 155:674‐677.
Preskitt, John T. (2011) Sports hernia: the experience of Baylor University Medical Center at Dallas. Proc (Bayl Univ Med Cent) 24(2):89‐91.
Robinson P, White LM. (2005) The biomechanics and imaging of soccer injuries. Semin Musculoskelet Radiol 9:397‐420.
Rogers, Ralph. (2009) “Groin Pain, Non‐surgical Treatments & Rehabilitation, A Sports Physician’s Perspective,” presentation to Gilmore Groin and Hernia Symposium.
Swan KG Jr., Wolcott M. (2007) The athletic hernia: a systematic review. Clin Orthop Relat Res 455:78‐87.
Van Der Donckt K, Steenbrugge F, Van Den Abbeele K, Verdonck R, Verhelst M (2003) Bassini’s hernia repair and adductor longus tenotomy in the treatment of chronic groin pain in athletes. Acta Orthop Belg 69:35‐41.
Wang JHC. (2006) Mechanobiology of tendon. J of Biomech 39(9):1563‐82.
Zoga AC, Kavanagh EC, Omar IM, et al. (2008) Athletic pubalgia and the “sports hernia”: MR imaging findings. Radiology 247:797‐807.