Diploma of Remedial Massage Case studies Hip & Groin

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

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

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.

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

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

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

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

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

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.

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

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

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

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.

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

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.

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)

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

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.

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

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.

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