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Diagnosis And Medical Management Of chronic Groin pain

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Presentation on theme: "Diagnosis And Medical Management Of chronic Groin pain"— Presentation transcript:

1 Diagnosis And Medical Management Of chronic Groin pain
Dr Mark Wotherspoon MB BS, DipSportsMed(Lond), FFSEM Consultant in Sports and Exercise Medicine

2 Introduction Groin injury is common Large differential diagnosis
Seen in sports with kicking/sprinting/change direction i.e football/rugby/hockey Complex anatomy No consensus on pathology/pathophysiology or management

3 Pubalgia Pain arising from local structures in the pubic area
2-5% of sporting injuries 5-7% football injuries Chronic and debilitating condition Prolonged recovery period Difficult to assess clinically Poorly imaged/interpreted On-going debate/research Reflects chronic stress in pubic region resulting in breakdown in a variety of ways Similar to “Shin Splints”

4 Causes of Pubalgia Bone Pubic: osteitis pubis Joint
Nonpubic: pelvic stress fractures Joint Pubic: pubic instability/disc degeneration Nonpubic: hip joint/SIJ/Lumbar spine Musculotendinous Pubic: adductor tendinopathy/rectus abdominis inguinal canal pathology conjoint tendinopathy Nonpubic: iliopsoas dysfunction rectus femoris injury Nerve Entrapment Ilio-inguinal Nerve/Obturator Nerve Genito-urinary Prostatitis/salpingitis/epididymitis Other Hernias/tumours(osteiod osteoma) Infection/seronegative spondarthropathy

5 Main Causes Sportsmans surgical groin/Abdominal related groin pain
Pubic Bone stress Response Chronic Adductor Tendinopathy/Adductor Related Groin Pain Hip related groin pain

6 Risk Factors Previous groin pain Level of sport
Number of training sessions Flexibility Muscle imbalance Poor core stability / functional movement Reduced hip ROM especially internal rotation

7 Symptoms Pain in groin Worse with twisting,sprinting,kicking
Stiff/sore after sport Non specific loss of power / speed Radiates into upper thighs,perineum,testicles Unilateral/bilateral Coughing/sneezing Turning over in bed/getting out of a car Insidious onset and often play with it Sit-ups Exclude the hip

8 Signs Exclude the hip, SIJ’s and back Localisation of pain
Resisted single and bilateral SLR Resisted sit up Adductor squeeze in all ranges Adductor signs Sites of tenderness Modified Thomas test/ crossover sign Exclude psoas Burden of evidence

9 Investigations X-ray +/- stork views Bone scan CT scan / CT spect
MRI / MR arthrogram Herniography Ultrasound Diagnostic LA injection into hip Hip arthroscopy

10 Abdominal Related Groin Pain
Abdominal symptoms Pain with cough and sneeze Tenderness over conjoint tendon at pubic tubercle Tender/dilated superficial inguinal ring Number of different surgical theories/operations ? Rx with belt

11 Abdominal Related Groin Pain
Munich Approach David Connell’s radio-ablation Gilmore’s technique David Lloyd’s tenotomy

12 Munich Approach Swelling in stretched / weak posterior inguinal canal wall Identified digitally or via ultrasound Transversalis fascia dilates widening Hasselbach’s triangle With abdominal muscle contraction swelling increases Compression of genital branch of genitofemoral nerve (dull pain radiating around pubic region) Tension on rectus abdominis insertion at pubic tubercle (pubalgia)

13 Munich Approach No mesh Laparoscopic
Genital branch of genitofemoral nerve indentified and if necessary partially excised Reduction in tension of rectus abdominis at pubic bone by special suture repair Repair of weak posterior wall of inguinal canal with sutures Local anaesthetic

14 Munich Approach Day case surgery Jogging / cycling at 2 days
Sprinting / change of direction at 3-4 days Full training 5-6 days Back to sport at 6-7 days 1,100 operations per year 7% of which are elite athletes 99% successful

15 Pulsed Radiofrequency
Assumption is that inguinal related groin pain is nerve entrapment/irritation around inguinal ligament Under LA Along inguinal ligament past genitofemoral nerve and ilioinguinal nerve Pulsed radiofrequency stuns the nerves for 9 months. Rest 2 days after and start rehab

16 Laparoscopic Inguinal Ligament Tenotomy
Acute/chronic injury of inguinal ligament at pubic tubercle Tatty scarred inguinal ligament at insertion into pubic tubercle with holes and ruptures Sutures if previous surgery Mesh to re-inforce posterior wall of inguinal canal and change pressure onto mesh rather than inguinal ligament Divide inguinal ligament and scar tissue

17 Inguinal Ligament Tenolysis
Aggressive rehab with stretches No sutures so safe Train at 1 week Full training at 2 weeks Return to play at 4 weeks 400 operations Few failures

18 David Lloyd’s Main Criteria
Unilateral pain Abdominal related groin pain Pain radiates < 5cm from superior pubic tubercle Tender superior pubic tubercle Pain with cough/sneeze Pain reproduced by resisted sit ups/Valsalva manoevre

19 Prognosis Good outcome if 4 main criteria present
Low success if pain radiates > 5 cm from superior pubic tubercle especially if laterally

20 Abdominal Related Groin Pain – is it a continuum ?
Munich Approach David Connell’s radio-ablation Gilmore’s technique David Lloyd’s tenotomy

21 Pubic Bone Stress Response
Repetitive minor trauma leads to painful non infectious/stress related lesion at pubic symphysis and local muscle insertions/origins Men more than women Maximum tenderness at or adjacent to symphysis Stress reactions at adductor tubercle and pubic tubercles Shearing forces across symphysis Rare as primary problem / asymptomatic finding

22 Investigations X-ray - if early nothing
sclerosis, erosions, widening of symphysis, periosteal reactions, moth eaten Bone scan - hot MRI stress reactions and marrow oedema,fluid in symphysis etc

23 Treatment Modified rest/prevent shearing Rehabilitation/flexibility
NSAID’s to reduce inflammation U/S guided cortisone injections Usually 2-3 months Can last 3-6 months Graded return to sport Bisphosphonates

24 Chronic Adductor tendinopathy
Easy diagnosis with pain resisted contraction,local tenderness adductor tubercle and pain and resisted stretch Usually adductor longus Insertion into pubic tubercle +symphysis ie blends in not one insertion site U/S and MRI confirm diagnosis Local physio Rx, ? U/S guided cortisone, ? Dry needling and autologous blood / PRP Adductor tenotomy Graded rehabilitation programme

25 Iliopsoas Related Groin Pain
Pain on stretch – Thomas’s test Pain on resisted hip flexion at 90 Tender on palpation Snapping hip(hip flexion/abduction and extend) Psoas bursae – one deep to psoas can become symptomatic (one anterior to hip like Baker’s cyst in knee)

26 Iliopsoas Related Groin Pain
U/S or MRI Local physio Rx / rehab U/S guided injection

27 Summary Spectrum of same problem Conditions can co-exist
Prevention best treatment/Pre-hab All need rehabilitation as main stay of Rx MRI Ix of choice 4-6 wks rehab/Rx and re-asses/pick off what is left Multidisciplinary Team/Groin clinic

28 Summary Exclude other pathology eg hip/back
History particularly coughing/sneezing/turning in bed Examination chronic adductor + pubic symphysis tendernes Choose patients for surgery + surgeon + when New developments

29 Iv pamidronate/calcitonin
Groin Pain assessment Ix with MRI +/- US Rehab 4-6 wks If improving C/T review PBS response Iv pamidronate/calcitonin Chronic adductor Autologous blood Sportsman’s hernia surgery Psoas dysfunction us guided inj C/T rehab

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