1. Diploma of Remedial Massage Case studies Hip & Groin

2. Hip & Groin injuries Common pathologies:
Hip arthritis (Osteoarthritis)
Hip flexor strains
Osteitis Pubis
Adductor Tendinopathy v’s Hamstring Origin Tendinopathy v’s ischiogluteal bursitis

3. Hip & Groin injuries Hip Arthritis / Osteoarthritis
Degenerative joint disease
Gradual eroding of the surfaces of the hip joint with subsequent inflammation. Eventual wearing down of the bone ends so the surfaces are no longer smooth and may have small bony processes called osteophytes
May occur following a specific injury or repetitive forces going through the hip beyond what it can withstand over a period of time.
Usually > 50 yo more common if overweight
Confirmed by Xray / Bone scan

4. Hip & Groin injuries Hip Arthritis / Osteoarthritis
Symptoms usually develop gradually over time. In patients with minor cases of hip arthritis, little or no symptoms may be present
As condition progresses, there may be increasing hip pain with weight bearing activity and joint stiffness – particularly after rest and first thing in the morning
Decreased hip flexibility, pain at night and grinding sensations during certain movements may also be experienced. Pain is typically felt in the buttock region and / or front of the hip and groin. Occasionally pain may be referred to the thigh or knee.

5. Hip & Groin injuries Hip Arthritis / Osteoarthritis
When pain unrelenting – surgery usually necessary
Interim Rx:
↓ aggravating activities,
Stretching / maintaining flexibility without pain
Non weight-bearing exercise
Pain relief - CSI
Massage / Myotherapy beneficially in recovery / rehab post surgery
See AAMT article re Mobility & Scar Tissue Rx

6. Hip & Groin injuries Osteitis Pubis
Often misdiagnosed and poorly understood
Some theories suggest that osteitis pubis begins as separate pathologies i.e. Adductor tendinopathy that are either not Rx’d early or miss managed

7. Assessment to determine pathology
Adductor Tendinopathy v’s Hamstring Origin Tendinopathy v’s ischiogluteal bursitis
Assessment to determine pathology
Timing of pain
Pain lessens during exercise, worsens after exercise, = inflammatory condition i.e. Tendinopathy
Pain progressively worsen with exercise = stress fracture, bursitis or muscle strain
Location of pain
Lx or buttock pain = possible referred pain i.e. Lx. Lx/Tx junction or SIJ

8. Assessment to determine pathology cont.
Adductor Tendinopathy v’s Hamstring Origin Tendinopathy v’s ischiogluteal bursitis
Assessment to determine pathology cont.
Identify movements aggravate pain i.e. Kicking = illiopsoas or rec fem; twisting or adduction = adductor; situps = abdominal or inguinal hernia
Special tests

9. Hip & Groin injuries Muscle strains:
Muscle Strains range from grade 1 to grade 3 and are classified as follows:
Grade 1 Tear: a small number of fibres are torn resulting in some pain, but allowing full function.
Grade 2 Tear: a significant number of fibres are torn with moderate loss of function.
Grade 3 Tear: all muscle fibres are ruptured resulting in major loss of function

10. Hip flexor strains Often associated with: overuse / miss-use,
Excessive hip flexion i.e. kicking, sprinting
postural dysfunction / excessive lordosis
usually a sudden sharp pain or pulling sensation in the front of the hip or groin at the time of injury
minor strains, pain minimal = cont activity.
severe cases = severe pain, muscle spasm, weakness, inability to continue activity unable to walk without limping.

11. Hip flexor strains Signs and symptoms
pain when lifting the knee towards the chest (especially against resistance) or during running, kicking or going upstairs.
pain or stiffness after these activities with rest, especially upon waking in the morning.
swelling, tenderness and bruising may also be present in the hip flexor muscles.
grade 3 tear a visible deformity in the muscle may be evident

12. Hip flexor strains Contributing factors to a hip flexor strain
muscle weakness - quads, hip flexors or gluteals
muscle tightness - hip flexors, quads, h/strings or gluteals
inappropriate training
inadequate warm up
joint stiffness (lower back, hip or knee)
poor biomechanics
poor posture
inadequate rehabilitation following a previous hip flexor injury
decreased fitness
fatigue
poor pelvic and core stability
neural tightness

13. Hip & Groin injuries Hip flexor strains Rx: ↓ aggravating activity
Stretching
MFT
Lx mobilisation

14. Adductor Tendinopathy v’s ischiogluteal bursistis
Adductor Tendinopathy = tissue damage and inflammation to the adductor tendon at its attachment to the pelvis resulting in groin pain
The ischiogluteal bursa lies between the hamstring tendon and the ischial tuberosity. This can become inflamed. It may exist in isolation or in conjunction with hamstring origin tendinopathy.
Clinically, it is almost impossible to differentiate between the two
Both present as pain aggravated by sitting or running, with local tenderness.

15. Adductor Tendinopathy
Adductor muscles are responsible for stabilising the pelvis and adducting the leg. They are particularly active during running (especially when changing direction) and kicking
usually an overuse injury, which commonly occurs due to repetitive or prolonged activities or rapid acceleration whilst running (particularly when changing direction) or when a footballer performs a long kick, also common in, hockey and athletics (particularly sprinters, hurdlers, and long jumpers) as well as in skiing, horse riding and gymnastics

16. Adductor Tendinopathy
Signs and symptoms:
Groin pain that develops gradually overtime
Pain on firmly touching the adductor tendon at its attachment
Pain may increase with resisted adduction (squeeze test)
In less severe cases, an ache or stiffness in the groin that increases with rest following activities requiring strong or repetitive contraction of the adductor muscles, may also warm up with activity in the initial stages of the condition.

17. Adductor Tendinopathy
Contributing factors to the development of adductor tendinopathy
Adductor, gluteals, hip flexors, hamstrings tightness
poor biomechanics
muscle weakness (especially of the groin, gluteals or core stabilisers)
inadequate rehabilitation following a previous adductor injury
inappropriate training or technique
change in training conditions or surfaces
poor posture inc poor foot posture (e.g. flat feet)

18. Adductor Tendinopathy
Contributing factors to the development of adductor tendinopathy cont.
inappropriate footwear
joint stiffness (particularly the lower back, hip and knee)
inadequate warm up
poor pelvic and core stability
neural tightness
muscle imbalances

19. Adductor Tendinopathy
Rx:
REST sufficiently from ANY activity that increases their pain until they are symptom free
Once pain-free a gradual return to activities provided no increase in groin symptoms
Massage / Myotherpay to ↓ pain ↑ ROM ALL hip / groin muscles / structures
Once chronic, possible Osteitis Pubis and healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.

20. Adductor Tendinopathy
Rx: / Management
hydrotherapy
activity modification advice
technique correction
anti-inflammatory advice
prescription of orthotics
devising and monitoring a return to sport or activity plan

21. Adductor Tendinopathy
Rx: / Management
Some do not improve adequately.
Referral to physiotherapist, or doctor
May require investigations X-ray, ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid injection
Podiatrist - prescription of orthotics
In very rare cases surgical intervention may be considered.

22. Treatment options Soft Tissue: DF; MFT; TP; MET/PNF…….
ST / joint mobilisation NOT MANIPULATION
Positioning
Active / Passive movement
Thermal – Heat / Ice
Strengthening / Stretching
Taping / Postural adjustment
Self Mx: Tx extension; spikey ball
Modification of activity