WHY GILMORE’S GROIN WHY GILMORE’S GROIN IS IS

NOT A HERNIANOT A HERNIA

16.06.201116.06.2011

GILMORE’S GROINGILMORE’S GROIN

SPORTSMEN GROINSPORTSMEN GROIN

GROIN DISRUPTION GROIN DISRUPTION

ATHLETIC PUBALGIAATHLETIC PUBALGIA(Sportsmen hernia NO!)(Sportsmen hernia NO!)

CASE 1CASE 1 D.M. 27D.M. 27

FULL BACK:FULL BACK: TOTTENHAM HOTSPUR FCTOTTENHAM HOTSPUR FC

PRESENTED:PRESENTED: 28.08.8028.08.80

SYMPTOMS:SYMPTOMS: 17 WEEKS GROIN PAIN17 WEEKS GROIN PAIN

AFTER EVERSION INJURYAFTER EVERSION INJURY

LAST GAME:LAST GAME: 17 WEEKS17 WEEKS

PAIN INCREASED:PAIN INCREASED: SPRINTINGSPRINTING

KICKINGKICKINGTWISTING & TURNINGTWISTING & TURNINGCOUGHINGCOUGHINGSNEEZINGSNEEZING

CASE 1CASE 1 D.M.D.M.

PREVIOUS INVESTIGATIONS:PREVIOUS INVESTIGATIONS:

3 ORTHOPAEDIC OPINIONS3 ORTHOPAEDIC OPINIONSX-RAYX-RAYCT SCANCT SCANU/S SCANU/S SCAN

PREVIOUS TREATMENT:PREVIOUS TREATMENT:

COMPLETE RESTCOMPLETE RESTPHYSIOTHERAPYPHYSIOTHERAPYMANIPULATIONMANIPULATIONLOCAL STEROIDSLOCAL STEROIDS

CASE 1 D.M. PHYSICAL SIGNSCASE 1 D.M. PHYSICAL SIGNS

INSPECTION:INSPECTION: N.A.D. –NO SWELLINGN.A.D. –NO SWELLING

PALPATION:PALPATION: N.A.D. – NO LUMPN.A.D. – NO LUMP

PALPATION VIA SCROTUM:PALPATION VIA SCROTUM:-- RIGHT SUPERFICIAL INGUINAL RIGHT SUPERFICIAL INGUINAL

RING DILATEDRING DILATED

-- COUGH IMPULSECOUGH IMPULSE

-- TENDERTENDER

INSERTION OF FINGER PAIN COMPARED TO OPPOSITE SIDEINSERTION OF FINGER PAIN COMPARED TO OPPOSITE SIDE

Presented 16.03.81(Eversion / Overstretching Injury)

15 wks Groin Pain but No Lump Prevented Training /Play

Post Op: Training with Aberdeen 3 wks In Scotland Squad 7 wks

GROIN DISRUPTION GROIN DISRUPTION TYPICAL PATIENTTYPICAL PATIENT

• YOUNG MALEYOUNG MALE

• ACTIVE SPORTSMENACTIVE SPORTSMEN

• RARE OVER 45RARE OVER 45

• RARE IN FEMALES (1%)RARE IN FEMALES (1%)

GROIN DISRUPTIONGROIN DISRUPTION

• MUSCULO – TENDINOUS INJURYMUSCULO – TENDINOUS INJURY

• ALL LAYERS GROINALL LAYERS GROIN

• INGUINAL + (ADDUCTOR 40%)INGUINAL + (ADDUCTOR 40%)

• ““MUSCLE DISLOCATION”MUSCLE DISLOCATION”

ONSET OF SYMPTOMSONSET OF SYMPTOMS

INSIDIOUSINSIDIOUS 72%72%

SPECIFIC INJURYSPECIFIC INJURY 28%28%

OVERSTRETCHINGOVERSTRETCHING MISKICKINGMISKICKING ABDUCTIONABDUCTION EVERSION EVERSION

PATIENT’S REFERRED with PATIENT’S REFERRED with GROIN PAINGROIN PAIN

1980 - 20101980 - 2010

TOTALTOTAL 77387738

MALEMALE 74797479 (9(977%)%)

FEMALEFEMALE 259259 ((33%)%)

INCIDENCE OF OPERATIONINCIDENCE OF OPERATION1980 - 20101980 - 2010

Referred

7738 pts

Ops

4466 pts

58%

C

1980-20101980-2010

Over 31 years 7479 SporsmenOver 31 years 7479 Sporsmen

referred with “Groin Pain”referred with “Groin Pain”

Many have returned with other complaintsMany have returned with other complaints

including Haemorrhoids and skin lesionsincluding Haemorrhoids and skin lesions

But ONLY 1 with HERNIA But ONLY 1 with HERNIA

INTERNATIONALS 1980-2010INTERNATIONALS 1980-2010SOCCER SOCCER 257257

RUGBY UNION RUGBY UNION 4444

ATHLETESATHLETES 2424

CRICKETCRICKET 2222

RUGBY LEAGUERUGBY LEAGUE 1717

HOCKEYHOCKEY 1515

HANDBALLHANDBALL 4 4

RACQUET GAMESRACQUET GAMES 44

SKIINGSKIING 22

BASKETBALLBASKETBALL 2 2

FENCING FENCING 2 2LACROSSELACROSSE 2 2MARTIAL ARTS MARTIAL ARTS 3 3ICE HOCKEYICE HOCKEY 22GYMNASTICSGYMNASTICS 1 1WATERPOLOWATERPOLO 1 1ROWINGROWING 11"STRONGMAN" "STRONGMAN" 1 1WEIGHT LIFTING WEIGHT LIFTING 1 1

______________________________________________

TOTALTOTAL 407407

SYMPTOMS DURING EXERCISESYMPTOMS DURING EXERCISE

PAIN IN GROIN INCREASES WITHPAIN IN GROIN INCREASES WITH

RUNNINGRUNNINGSTRIDINGSTRIDINGSPRINTINGSPRINTINGSUDDEN MOVEMENTSUDDEN MOVEMENTTWISTING & TURNINGTWISTING & TURNINGSIDE STEPPINGSIDE STEPPINGJUMPINGJUMPINGDEAD BALL KICKINGDEAD BALL KICKINGLONG BALL KICKINGLONG BALL KICKING

(BUT NO SWELLING)(BUT NO SWELLING)

SYMPTOMS AFTER EXERCISESYMPTOMS AFTER EXERCISE

PAIN IN GROIN INCREASES WITHPAIN IN GROIN INCREASES WITH

TURNING IN BEDTURNING IN BED

GETTING OUT OF BEDGETTING OUT OF BED

GETTING OUT OF CARGETTING OUT OF CAR

SIT UPSSIT UPS

COUGHINGCOUGHING

SNEEZINGSNEEZING

SUDDEN MOVEMENTSUDDEN MOVEMENT

STIFF & SORE

MRI in Groin DisruptionMRI in Groin Disruption

MRI Poor in AbdomenMRI Poor in Abdomen

Resolution insufficient for subtle changesResolution insufficient for subtle changesBut Inguinal ligament – clearly visibleBut Inguinal ligament – clearly visible HerniaHernia

Gross Scar TissueGross Scar TissueDefects / GapsDefects / GapsSignificant DisruptionSignificant Disruption

MRI Good in Pelvis & ThighMRI Good in Pelvis & ThighAdductor TearAdductor TearOsteitis pubisOsteitis pubisHIP PathologyHIP Pathology

Also visible

clearly seen

David Connell 2009

Ultrasound in Groin DisruptionUltrasound in Groin Disruption

State of Art Ultrasound Equipment – requiredState of Art Ultrasound Equipment – required

Subtle changes in Inguinal ligamentSubtle changes in Inguinal ligament

Conjoined TendonConjoined Tendon

Dynamic assessment – EssentialDynamic assessment – Essential

Abdominal strainingAbdominal straining

SonopalpationSonopalpation

Tender over Inguinal CanalTender over Inguinal Canal

Bulging Post. WallBulging Post. Wall

HERNIA: Shows Clearly as Peritoneal Sac or ProtrusionHERNIA: Shows Clearly as Peritoneal Sac or Protrusion

maybe seen

David Connell 2009

31 Years No Groin 31 Years No Groin PatientPatient

Complained of Complained of SwellingSwelling

INDICATIONS FOR SURGERYINDICATIONS FOR SURGERYGroin DisruptionGroin Disruption

PROFESSIONALPROFESSIONAL

ANDAND

AMATEURAMATEUR

FAILED CONSERVATIVE FAILED CONSERVATIVE TREATMENTTREATMENT

INDICATION FOR INDICATION FOR SURGERY: SURGERY:

PROFESSIONALSPROFESSIONALS

GAME INHIBITEDGAME INHIBITED

TRAINING INHIBITEDTRAINING INHIBITED

LOSS OF LOSS OF SPEEDSPEED

LOSS OF LOSS OF FITNESSFITNESS

INDICATION INDICATION FOR SURGERY: FOR SURGERY:

AMATEURSAMATEURS

SYMPTOMS AFFECTSYMPTOMS AFFECT

EVERYDAY LIFEEVERYDAY LIFE

LOSS OF SPORT AFFECTS LOSS OF SPORT AFFECTS QUALITY OF LIFEQUALITY OF LIFE

GROIN DISRUPTION: PATHOLOGYGROIN DISRUPTION: PATHOLOGYFound at OperationFound at Operation

TORN EXTERNAL OBLIQUE ====TORN EXTERNAL OBLIQUE ==== DILATED DILATED SUPERFICIAL SUPERFICIAL INGUINAL RINGINGUINAL RING

TORN CONJOINED TENDONTORN CONJOINED TENDON

CONJOINED TENDONCONJOINED TENDON

}} DEHISCENCEDEHISCENCEINGUINAL LIGAMENTINGUINAL LIGAMENT

( 40% also have Adductor Pathology)( 40% also have Adductor Pathology)

Groin Disruption SurgeryGroin Disruption SurgeryGroin ReconstructionGroin Reconstruction

• Normal Anatomy - RestoredNormal Anatomy - Restored• Each layer – RepairedEach layer – Repaired• Each Injury- RepairedEach Injury- Repaired• Permanent Suture – EssentialPermanent Suture – Essential• Nylon Darn / Ethilon DarnNylon Darn / Ethilon Darn

• Preferable to Absorbable Sutures (Don’t Last)Preferable to Absorbable Sutures (Don’t Last)• Preferable to Mesh (May Restrict Mobility)Preferable to Mesh (May Restrict Mobility)

CONJOINED TENDON REPAIR

TRASVERSALIS FASCIA PLICATED with O Vicryl

TENSION FREE NYLON DARN

(CONJ. TENDON to ING. LIG)

EXT OBLIQUE REPAIR

(NEW S.I.R)

GROIN DISRUPTIONGROIN DISRUPTION& ADDUCTOR TEAR& ADDUCTOR TEAR

PRESENT IN 40%PRESENT IN 40%

HALF REQUIREHALF REQUIRE

ADDUCTOR TENOTOMYADDUCTOR TENOTOMY

D

No evidence of increased incidence of No evidence of increased incidence of

Hernia in Sportsmen Hernia in Sportsmen

Groin Disruption/Gilmore’s GroinGroin Disruption/Gilmore’s Groin

Neither Hernia or Pre HerniaNeither Hernia or Pre Hernia

Terminology HERNIA: IncorrectTerminology HERNIA: Incorrect

HERNIA IN SPORTSMENHERNIA IN SPORTSMEN

B

QUOTEQUOTE

““Jerry Jerry I had your “Groin” in 74,I had your “Groin” in 74,

As did my colleague Alan MulleryAs did my colleague Alan Mullery

We both had to rest for monthsWe both had to rest for months

There was no other treatment then”There was no other treatment then”

Terry Venables 2006Terry Venables 2006

E

A Protrusion of a Viscus beyond A Protrusion of a Viscus beyond

it’s normal confinesit’s normal confines

HERNIAHERNIA

HERNIA (2% MALES IN UK)HERNIA (2% MALES IN UK)

INGUINAL 73%INGUINAL 73%

FEMORAL 17%FEMORAL 17%

(Bailey & Love )(Bailey & Love )

INGUINAL – DIRECTINGUINAL – DIRECT INDIRECT INDIRECT

FEMORALFEMORAL

OBTURATOROBTURATOR

GROIN HERNIAGROIN HERNIA

H

INDIRECT INGUINAL HERNIAINDIRECT INGUINAL HERNIAPRESENTATIONPRESENTATION

Usually young malesUsually young males

Swelling only occurs with Swelling only occurs with

standing/strainingstanding/straining

Swelling can be difficult to reduce Swelling can be difficult to reduce

If swelling persists - PainIf swelling persists - Pain

Swelling which when present Swelling which when present causes pain or discomfort causes pain or discomfort

Irreducible swellingIrreducible swelling

StrangulationStrangulation

HERNIA: INDICATION HERNIA: INDICATION FOR SURGERYFOR SURGERY

INDIRECT INGUINAL INDIRECT INGUINAL HERNIA OPERATIONHERNIA OPERATION

Herniotomy (Excise Indirect Sac)Herniotomy (Excise Indirect Sac)

Reconstitute Inguinal canalReconstitute Inguinal canal

(Repair only necessary if post wall defect)(Repair only necessary if post wall defect)

I

DIRECT INGUINAL HERNIADIRECT INGUINAL HERNIA

Protrusion of Viscus throughProtrusion of Viscus through

Post Inguinal Canal WallPost Inguinal Canal Wall

Due to defect in Post WallDue to defect in Post Wall

J

Swelling readily appearsSwelling readily appears

with Coughing or Standing with Coughing or Standing

Swelling reduces when lying down Swelling reduces when lying down

Patient often complains of discomfort with Patient often complains of discomfort with

Standing e.g. cocktail parties or window shoppingStanding e.g. cocktail parties or window shopping

(Sport rarely Restricted)(Sport rarely Restricted)

DIRECT INGUINAL HERNIA DIRECT INGUINAL HERNIA PRESENTATIONPRESENTATION

K

Reduce Peritoneal SacReduce Peritoneal Sac

Insert MeshInsert Mesh

Close Ext Oblique & SkinClose Ext Oblique & Skin

DIRECT INGUINAL DIRECT INGUINAL HERNIA OPERATIONHERNIA OPERATION

Protrusion through Femoral CanalProtrusion through Femoral Canal

Swelling: Below and lateral to pubic tubercle Swelling: Below and lateral to pubic tubercle

i.e. Upper thighi.e. Upper thigh

FEMORAL HERNIAFEMORAL HERNIA

Reduce Sac contentsReduce Sac contents

Excise SacExcise Sac

Suture Lacunar to Inguinal ligamentSuture Lacunar to Inguinal ligament

FEMORAL HERNIA OPERATIONFEMORAL HERNIA OPERATION

Groin Disruption/Gilmore’s GroinGroin Disruption/Gilmore’s Groin

Significantly different to HerniaSignificantly different to Hernia

InguinalInguinal

FemoralFemoral

ObturatorObturator

Only similarity: SITEOnly similarity: SITE

SYMPTOMS & PATHOLOGYSYMPTOMS & PATHOLOGY

DEPENDS ON DEPENDS ON

ACCURATE DIAGNOSIS ACCURATE DIAGNOSIS OfOf

PATHOLOGY PATHOLOGY

CORRECT SURGICAL TREATMENTCORRECT SURGICAL TREATMENT ALWAYS ALWAYS

Groin Disruption/Gilmore’s GroinGroin Disruption/Gilmore’s GroinSignificantly different to HerniaSignificantly different to Hernia

REPAIR using Hernia Mesh TechniqueREPAIR using Hernia Mesh Technique Open or Laparoscopic Open or Laparoscopic Usually FAILSUsually FAILS

PATHOLOGYPATHOLOGY in in

F

““I have had the mesh repair I have had the mesh repair

But I can still feel a tear behind the meshBut I can still feel a tear behind the mesh

My symptoms have not improved”My symptoms have not improved”

P.W P.W Patient 2009Patient 2009

8% our Operations in 8% our Operations in Patients with Previous Groin Patients with Previous Groin

RepairRepair

A

““General Surgeons in this area either General Surgeons in this area either

do not recognise Gilmore’s Groin ordo not recognise Gilmore’s Groin or

They treat it as a Hernia They treat it as a Hernia

with mesh repair, which fails”with mesh repair, which fails”

Johnny MorrisJohnny MorrisSports Medicine PhysicianSports Medicine PhysicianHampshire 2011Hampshire 2011

QUOTEQUOTE

F

DOES NOT CUREDOES NOT CUREOFTEN COMPLICATESOFTEN COMPLICATESSIGNIFICANT DELAY in RECOVERYSIGNIFICANT DELAY in RECOVERY ororRESULTS IN FAILURERESULTS IN FAILURE

Conclusion:Wrong DiagnosisConclusion:Wrong DiagnosisResulting in Wrong OperationResulting in Wrong Operation

Patients with Groin ProblemsPatients with Groin ProblemsDeserve aDeserve a

GROIN SURGEONGROIN SURGEON

16.06.201116.06.2011