Mark Wotherspoon - The Gilmore Groin & Hernia Clinic

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Transcript Mark Wotherspoon - The Gilmore Groin & Hernia Clinic

Dr Mark Wotherspoon
MB BS, DipSportsMed(Lond), FFSEM
Consultant in Sports and Exercise Medicine
Groin injury is common
Large differential diagnosis
Seen in sports with kicking/sprinting/change
i.e football/rugby/hockey
Complex anatomy
No consensus on pathology/pathophysiology or
Pain arising from local structures in the pubic
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”
Causes of Pubalgia
Pubic: osteitis pubis
Nonpubic: pelvic stress fractures
Pubic: pubic instability/disc
Nonpubic: hip joint/SIJ/Lumbar
Pubic: adductor tendinopathy/rectus abdom
inguinal canal pathology
conjoint tendinopathy
Nonpubic: iliopsoas dysfunction
rectus femoris injury
Nerve Entrapment
Ilio-inguinal Nerve/Obturator Nerve
Hernias/tumours(osteiod osteoma)
Infection/seronegative spondarthropathy
Main Causes
 Sportsmans surgical groin/Abdominal related groin
 Pubic Bone stress Response
 Chronic Adductor Tendinopathy/Adductor Related
Groin Pain
 Hip related groin pain
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
Pain in groin
Worse with twisting,sprinting,kicking
Stiff/sore after sport
Non specific loss of power / speed
Radiates into upper thighs,perineum,testicles
Turning over in bed/getting out of a car
Insidious onset and often play with it
Exclude the hip
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
 X-ray +/- stork views
 Bone scan
 CT scan / CT spect
 MRI / MR arthrogram
 Herniography
 Ultrasound
 Diagnostic LA injection into hip
 Hip arthroscopy
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
Abdominal Related Groin Pain
 Munich Approach
 David Connell’s radio-ablation
 Gilmore’s technique
 David Lloyd’s tenotomy
Munich Approach
 Swelling in stretched / weak posterior inguinal
canal wall
 Identified digitally or via ultrasound
 Transversalis fascia dilates widening Hasselbach’s
 With abdominal muscle contraction swelling
 Compression of genital branch of genitofemoral
nerve (dull pain radiating around pubic region)
 Tension on rectus abdominis insertion at pubic
tubercle (pubalgia)
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
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
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
Laparoscopic Inguinal Ligament
 Laparoscopic
 Acute/chronic injury of inguinal ligament at pubic
 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
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
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
 Good outcome if 4 main criteria present
 Low success if pain radiates > 5 cm from superior
pubic tubercle especially if laterally
Abdominal Related Groin Pain – is
it a continuum ?
 Munich Approach
 David Connell’s radio-ablation
 Gilmore’s technique
 David Lloyd’s tenotomy
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
 Shearing forces across symphysis
 Rare as primary problem / asymptomatic finding
 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
 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
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
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
Iliopsoas Related Groin Pain
 U/S or MRI
 Local physio Rx / rehab
 U/S guided injection
 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
 Exclude other pathology eg hip/back
 History particularly coughing/sneezing/turning in bed
 Examination chronic adductor + pubic symphysis
 Choose patients for surgery + surgeon + when
 New developments
Groin Pain
Ix with MRI +/- US
Rehab 4-6 wks
PBS response
Iv pamidronate/calcitonin
Chronic adductor
Autologous blood
If improving C/T
Sportsman’s hernia
C/T rehab
Psoas dysfunction
us guided inj