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“GILMORES GROIN” The First 30 Years. ( plus one ! ) R.S.M. 15 Sept 2011.

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Presentation on theme: "“GILMORES GROIN” The First 30 Years. ( plus one ! ) R.S.M. 15 Sept 2011."— Presentation transcript:

1 “GILMORES GROIN” The First 30 Years. ( plus one ! ) R.S.M. 15 Sept 2011

2

3 5% ALL SPORTS INJURIES AFFECT GROIN

4 PATIENT’S REFERRED with GROIN PAIN 1980 - 2010 TOTAL7738 MALE7479(97%) FEMALE259(3%)

5 INCIDENCE OF OPERATION 1980 - 2010 Referred 7738 pts Ops 4466 pts 58% (1% Female)

6 OTHER SPORTS BasketballFencing HandballEquestrian Gaelic footballMartial Arts American FootballDancers HurlingGymnasts WaterpoloKick Boxing Ice HockeySkiing & Snowboarding

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8 DIRECT TRAUMA FALL FALL KICK KICK PUNCH PUNCH IMPACT IMPACT SQUEEZE SQUEEZE

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10 GILMORE’S GROIN FIRST PATIENT 1980 PATHOLOGY & SURGICAL TREATMENT Apparent after Successful Management Apparent after Successful Managementof 3 Professional Footballers Unable to Play For over 15 weeks

11 CASE 1D.M. 27 FULL BACK: TOTTENHAM HOTSPUR FC PRESENTED: 28.08.80 SYMPTOMS: 17 WEEKS GROIN PAIN AFTER EVERSION INJURY LAST GAME: 17 WEEKS PAIN INCREASED: SPRINTING KICKING TWISTING & TURNING COUGHINGSNEEZING

12 CASE 1 D.M. PHYSICAL SIGNS INSPECTION:N.A.D. –NO SWELLING PALPATION:N.A.D. – NO LUMP NO HERNIA PALPATION VIA SCROTUM: -RIGHT SUPERFICIAL INGUINAL RING DILATED -COUGH IMPULSE -TENDER INSERTION OF FINGER  PAIN COMPARED TO OPPOSITE SIDE

13 CASE 1D.M. PREVIOUS INVESTIGATIONS: 3 ORTHOPAEDIC OPINIONS X-RAY CT SCAN U/S SCAN GILMORE: Fourth Opinion PREVIOUS TREATMENT: COMPLETE REST PHYSIOTHERAPYMANIPULATION LOCAL STEROIDS

14 CASE 2.G.S Tertiary Opinion MF : ABERDEEN & SCOTLAND PRESENTED:16.3.81 GROIN PAIN R > L SYMPTOMS:15 WEEKS : Following Over Stretching Eversion Injury LAST GAME:15 WEEKS (30.12.80) PAIN  TROTTING SUDDEN MOVEMENT KICKINGCOUGHINGSNEEZING ONLY ABLE TO WALK

15 CASE 2 – GS PHYSICAL SIGNS INSPECTION:No Swelling PALPATION:No Lump No Hernia PALPATION VIA SCROTUM -DILATED R S.I.R. - READILY ADMITTED FINGER -COUGH IMPULSE -FINGER IN R S.I.R.  TENDERNESS PAIN

16 My Conclusion after History & Examination My Conclusion after History & Examination Torn Groin Muscles & or Tendons Probably External Oblique Muscle Conjoined Tendon

17 ACTUAL PATHOLOGY Found at Operation ACTUAL PATHOLOGY Found at Operation TORN EXTERNAL OBLIQUE ====DILATED SUPERFICIAL INGUINAL RING TORN CONJOINED TENDON CONJOINED TENDON } DEHISCENCE } DEHISCENCE INGUINAL LIGAMENT

18 D. M. Post Operatively Training Fully at 3 weeksTraining Fully at 3 weeks Spurs Team at 5 weeksSpurs Team at 5 weeks

19 Post Operatively Training with Aberdeen 3 wks In Scotland Squad 7 wks

20 GILMORE’S GROIN GROIN DISRUPTION SPORTSMEN GROIN (Sportsmen Hernia:Wrong as NO HERNIA )

21 GROIN DISRUPTION TYPICAL PATIENT YOUNG MALEYOUNG MALE ACTIVE SPORTSMENACTIVE SPORTSMEN RARE OVER 45RARE OVER 45 RARE IN FEMALES (1%)RARE IN FEMALES (1%)

22 GROIN DISRUPTION MUSCULO – TENDINOUS INJURYMUSCULO – TENDINOUS INJURY ALL LAYERS GROINALL LAYERS GROIN INGUINAL + ADDUCTOR (40%)INGUINAL + ADDUCTOR (40%) “MUSCLE DISLOCATION”“MUSCLE DISLOCATION”

23 Only 1% Operative Cases Female Only 1% Operative Cases Female

24 GROIN DISRUPTION (GILMORE’S GROIN) 31 YEARS 1980 - 2010

25 PATIENT REFERRAL RELATED TO SPORT 1980 - 2010 CASES% ASSOCIATION FOOTBALL432356 RUGBY UNION & LEAGUE7319 ATHLETES3725 RACQUET GAMES2984 CRICKET1752 HOCKEY1522 OTHER SPORTS91212 NO SPORT77510 ____________________________________________________ TOTAL7738100

26 OPERATIONS 1980 - 2010 TOTAL 4466 MALE4423 (99%) FEMALE43(1%)

27 INCIDENCE OF OPERATION RELATED TO SPORT 1980 - 2010 CASESOPN% ASSOCIATION FOOTBALL **4323298169 RUGBY UNION + LEAGUE ** 73146864 CRICKET** 17511868 ATHLETES37215139 RACQUET GAMES29810134 HOCKEY1528858 OTHER SPORTS91230734 NO SPORT77525232 __________________________________________________________ TOTAL7738 4466 58

28 INCIDENCE OF OPERATIONS ASSOCIATION FOOTBALL 1980 - 2010 TOTALOPN% PROFESSIONAL1546127582 SEMI PRO.755 53871 AMATEUR2022116857 _______________________________________________ TOTAL4323298169

29 PROFESSIONAL FOOTBALLERS 1980 - 2010 CASES 1546 OPERATIONS1275 (82%)

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31 ENGLISH FOOTBALL LEAGUE CLUBS 92 CLUBS PATIENTS REFERRED BY 91

32

33 AETIOLOGY:MUSCLE IMBALANCE ( Recurrent Microtrauma ) 1. STRONG HIP FLEXORS PULL PELVIS DOWN (QUADS) (QUADS) 2.TILTED PELVIS STRETCH ABDO MUSCLES 3. STRETCHED ABDO MUSCLES BECOME WEAK (OBLIQUES) FAIL TO STABILIZE PELVIS (OBLIQUES) FAIL TO STABILIZE PELVIS 4. OVERUSE RECURRENT TEARS GROIN DISRUPTION GROIN DISRUPTION 5. MALE > FEMALE (99%)

34 ARSENAL F.C.: GILMORE’S GROIN OPERATIONP.A. 1986 – 1996 (GRAHAM)333 1997 – 2007 (WENGER)101 Gary Lewin 2007

35 ONSET OF SYMPTOMS INSIDIOUS72% SPECIFIC INJURY28% OVERSTRETCHING OVERSTRETCHING MISKICKING MISKICKING ABDUCTION ABDUCTION EVERSION EVERSION

36

37 SYMPTOMS DURING EXERCISE PAIN IN GROIN INCREASES WITH RUNNINGSTRIDINGSPRINTING SUDDEN MOVEMENT TWISTING & TURNING SIDE STEPPING JUMPING DEAD BALL KICKING LONG BALL KICKING

38 SYMPTOMS AFTER EXERCISE PAIN IN GROIN INCREASES WITH TURNING IN BED GETTING OUT OF BED GETTING OUT OF CAR SIT UPS COUGHINGSNEEZING SUDDEN MOVEMENT STIFF & SORE

39

40

41 EXAMINATION

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43

44 GROIN DISRUPTION: PHYSICAL SIGNS (ALL ELICITED VIA SCROTUM) S.I.R:DILATED (+/-) COUGH IMPULSE TENDER (PALPABLE TEAR) TENDERNESS:MAY BE EXQUISITE DIMINISHES WITH REST

45 INVESTIGATIONS

46 STORK VIEWS (FLAMINGO)

47 MRI in Groin Disruption MRI Poor in Abdomen Resolution insufficient for subtle changes But Inguinal ligament – clearly visible GapsDefects Significant Disruption Gross Scar Tissue MRI Good in Pelvis & Thigh Osteitis pubis HIP Pathology Adductor Tears Also visible clearly seen David Connell 2009

48 Ultrasound in Groin Disruption State of Art Ultrasound Equipment – required Subtle changes in Inguinal ligament Conjoined Tendon Conjoined Tendon Dynamic assessment – Essential Abdominal straining Sonopalpation Tender over Inguinal Canal Bulging Post. Wall Bulging Post. Wall maybe seen David Connell 2009

49 INDICATIONS FOR SURGERY PROFESSIONALANDAMATEUR FAILED CONSERVATIVE TREATMENT

50 INDICATION FOR SURGERY: PROFESSIONALS GAME INHIBITED TRAINING INHIBITED  LOSS OF SPEED  LOSS OF SPEED LOSS OF FITNESS

51 INDICATION FOR SURGERY: AMATEURS SYMPTOMS AFFECT EVERYDAY LIFE LOSS OF SPORT AFFECTS QUALITY OF LIFE

52 Principle Groin Disruption Surgery Groin Reconstruction Normal Anatomy – RestoredNormal Anatomy – Restored Each layer & Each Injury– RepairedEach layer & Each Injury– Repaired A Layer of Permanent Suture – Essential A Layer of Permanent Suture – Essential 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)

53 GROIN DISRUPTION & ADDUCTOR TEAR PRESENT IN 40%

54

55 GROIN DISRUPTION & ADDUCTOR TEAR TREATMENT MODERATE or ACUTE : REPAIR DISRUPTION + INTENSIVE ADDUCTOR PHYSIO SEVERE or CHRONIC : REPAIR DISRUPTION + ADDUCTOR TENOTOMY (18%)

56 RESULT : GROIN RECONSTRUTION SUCCESSFUL 97% AVERAGE RETURN TO PROFESSIONAL FOOTBALL 4 WEEKS 1220 OUT OF 1258 PLAYERS RANGE 3 - 7 WEEKS

57 Recurrent Groin Disruption SAME SIDE: True Recurrence3% Unoperated Side : 10% C/o Pain within 10 Years Recognize the Symptoms & Request Operation (knowing it will cure the Symptoms

58 INTERNATIONAL SOCCER FOOTBALLERS 1980 - 2010 ENGLAND59 SCOTLAND34 NORTHERN IRELAND18 EIRE16 WALES15 OTHER115 OTHER115___257

59 OTHER SOCCER INTERNATIONALS 1980 -2010 UAE38 QATAR21 KUWAIT7 NORWAY 5 AUSTRALIA 4 JAMAICA 4 COLUMBIA 3 PORTUGAL 3 ARGENTINA 2 DENMARK 2 FINLAND 2 HOLLAND 2 ICELAND 2 NEW ZEALAND2 USA 2 BRAZIL1 CROATIA 1 CZECH REPUBLIC 1 EGYPT1 FRANCE1 GERMANY 1 HONG KONG1 HUNGARY1 IVORY COAST1 LATVIA 1 NIGERIA 1 RUSSIA 1 SLOVAKIA 1 SWEDEN 1 TRINIDAD1 ZAIRE 1 ____________________________ TOTAL 115

60

61

62 RUGBY UNION 1980 - 2010 REF.OPN. Op % 631393 (44 I NT)62

63 RUGBY SYMPTOMS BACKS Sprinting Twisting and Turning Accelerating Striding out Side Stepping Dead Ball Kicking

64 RUGBY SYMPTOMS FORWARDS Sprinting Twisting and Turning Striding out Up after a tackle Jumping

65 R.U. INTERNATIONALS: POSITION 44 PLAYERS BACKS FORWARDS ½ BACKS 12 FRONT ROW 8 CENTRES 9 SECOND ROW 2 WING/F.B 5 BACK ROW 8 Total: 26(60%) 18(40%)

66 RUGBY LEAGUE 1980 - 2010 REF.OPN.% 9575 (17 INT)79

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68

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70 CRICKET 1980 - 2010 REF. OPN. % 175 118 (23 INT) 68 175 118 (23 INT) 68

71 INTERNATIONAL CRICKETERS 1988 - 2010 FAST BOWLER13 BATSMAN 6 ALL ROUNDER4 TOTAL23

72 SYMPTOMS IN CRICKETERS PAIN IN GROIN (Specific injury :unusual) FAST BOWLERS: LOOSE PACE PAIN in Groin Drag > Landing BATSMAN:RUNNING BETWEEN WICKETS TWISTING & TURNING FIELDERS:SUDDEN MOVEMENT PUSHING OFF STRIDING OUT DIVING 20/20 Games:INCREASED INCIDENCE

73

74 SYMPTOMS IN ATHLETICS PAIN IN GROIN MIDDLE & LONG DISTANCE RUNNERS HURDLERS TRIATHLETES SPRINTERS (UNUSUAL) PAIN INCREASES: WITH DISTANCE SPRINTING AT END OF RACE LOSS OF SPEED: REDUCED TIMES LOSS OF ENDURANCE: SLOW RECOVERY

75 ATHLETES 1980 - 2010 REF. OPN.% 372 151 (24 INT)40

76

77 SYMPTOMS IN FIELD HOCKEY PAIN IN GROIN ELITE PLAYERS FREQUENT GAMES ON ASTROTURF SPRINTING TWISTING & TURNING LOSS OF SPEED (CORNER SPECIALISTS)

78 FIELD HOCKEY 1980 - 2010 REF. OPN.% 152 88 (15 INT)58

79 RACQUET GAMES PLAYERS 1980 – 2010 1980 – 2010 REF. OPN. % 298 101 (3 INT) 34

80 ALL OTHER SPORTS Including Keep Fit 1980 - 2010 REF.OPN.% 912307 (26 INT)34

81

82 GOLF

83 FENCING

84 HURLING

85 GAELIC FOOTBALL

86 GYMANASTS

87 LACROSSE

88 MARTIAL ARTSMARTIAL ARTS KICK BOXINGKICK BOXING

89 WATERPOLOWATERPOLO

90 WEIGHT LIFTINGWEIGHT LIFTING STRONGMENSTRONGMEN

91 SKIINGSKIING SNOW BOARDINGSNOW BOARDING

92

93 INTERNATIONALS 1980-2010 SOCCER 257 RUGBY UNION 44 ATHLETES24 CRICKET22 RUGBY LEAGUE17 HOCKEY15 HANDBALL 4 RACQUET GAMES 4 SKIING2 BASKETBALL 2 FENCING 2 LACROSSE 2 MARTIAL ARTS 3 ICE HOCKEY2 GYMNASTICS 1 WATERPOLO 1 ROWING1 "STRONGMAN" 1 WEIGHT LIFTING 1 _______________________ TOTAL407

94 NO SPORT 1980 - 2010 REF.OPN.% 775252 33 BUILDERS. GARDENERS. DIY. POLICE and PORN STARS

95 SPORTSWOMEN

96

97 GILMORE’S GROIN IN WOMEN: DIAGNOSIS DIFFICULT:NO SCROTUM BASED ON:HISTORY TENDER S.I.R. GROIN PAIN WITH RESISTED HIP FLEXION ELEVATION FROM SUPINE POSITION  GRIMACE

98 FEMALES 1980 - 2010 REF.OPN.% 25943 (5 INT ) 17 25943 (5 INT ) 17

99 DANCERS

100 SCEPTICISM

101 31 Years No Groin Disruption Patient Complained of Swelling

102 Groin Disruption/Gilmore’s Groin Significantly different to Hernia Inguinal InguinalFemoralObturator Only similarity: SITE SYMPTONS & PATHOLOGY

103 DEPENDS ON ACCURATE DIAGNOSIS OfPATHOLOGY CORRECT SURGERY of ALL CONDITIONS CORRECT SURGERY of ALL CONDITIONS

104 Groin Disruption/Gilmore’s Groin Groin Disruption/Gilmore’s Groin Significantly different to Hernia Significantly different to Hernia REPAIR using Hernia Mesh Technique REPAIR using Hernia Mesh Technique Open or Laparoscopic Methods Open or Laparoscopic Methods Usually FAILS Usually FAILS PATHOLOGY PATHOLOGY

105 FUTURE

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107 Mr Simon Marsh Surgical Director 108 MARSH MODIFICATION For GROIN RECONSRUCTION

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109

110 Thank You.

111


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