Diagnosis And Medical Management Of chronic Groin pain

1
Diagnosis And Medical Management Of chronic Groin
pain

• Dr Mark Wotherspoon
• MB BS, DipSportsMed(Lond), FFSEM
• Consultant in Sports and Exercise Medicine

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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

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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
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Causes of Pubalgia
Bone Pubic osteitis pubis 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
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Main Causes

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

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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

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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

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Signs

• Exclude the hip, SIJs 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

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Investigations

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

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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

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Abdominal Related Groin Pain

• Munich Approach
• David Connells radio-ablation
• Gilmores technique
• David Lloyds tenotomy

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Munich Approach

• Swelling in stretched / weak posterior inguinal
  canal wall
• Identified digitally or via ultrasound
• Transversalis fascia dilates widening
  Hasselbachs 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)

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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

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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

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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

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Laparoscopic Inguinal Ligament Tenotomy

• Laparoscopic
• 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

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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

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David Lloyds Main Criteria

• Unilateral pain
• Abdominal related groin pain
• Pain radiates lt 5cm from superior pubic tubercle
• Tender superior pubic tubercle
• Pain with cough/sneeze
• Pain reproduced by resisted sit ups/Valsalva
  manoevre

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Prognosis

• Good outcome if 4 main criteria present
• Low success if pain radiates gt 5 cm from superior
  pubic tubercle especially if laterally

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Abdominal Related Groin Pain is it a continuum ?

• Munich Approach
• David Connells radio-ablation
• Gilmores technique
• David Lloyds tenotomy

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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

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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

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Treatment

• Modified rest/prevent shearing
• Rehabilitation/flexibility
• NSAIDs to reduce inflammation
• U/S guided cortisone injections
• Usually 2-3 months
• Can last 3-6 months
• Graded return to sport
• Bisphosphonates

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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

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Iliopsoas Related Groin Pain

• Pain on stretch Thomass 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 Bakers
  cyst in knee)

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Iliopsoas Related Groin Pain

• U/S or MRI
• Local physio Rx / rehab
• U/S guided injection

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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

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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

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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
Sportsmans hernia surgery
Psoas dysfunction us guided inj
C/T rehab