Hip and Groin Flashcards
Football
Prevalence 12-16%
Account for 11-16% of all FB injuries
hockey
20 GI/100 players/year
Increasing rate of 1.32/100 players/year
3rd most common injury
8% of all injuries
Australian football
GI incidence failed to decrease since 2002
Prevalence 2nd highest after H/S
Highest recurrence rate
Rugby
3.29/1000 player hours (training)
0.1/1000 player hours (match)
101/25 absence days (training/match)
Ranked 4th most severe injuries
23% risk of sustaining GI in RB
history
Gilmore’s groin
Hockey’s groin
Sportsman’s hernia
Adductor-related groin pain
Hip joint anatomy
V stable and robust
Subject to high loads through many movements
Joint supported by v powerful muscles
Functionally, muscles act like slings- abdominal muscles connected to adductor muscles
Contributor factors- Load
Complex loading through pelvis/groin region
Sudden dynamic changes of load in sports specific movements
Lack of functional training for changing load
Contributing factors- other
Age
Lack of adequate training- less training hours in pre-season is a RF
Other injuries
Lack of proper conditioning
Hamstring + adductor muscles injuries seem to be well correlated
Hip anatomy recab
Multiple muscle attachments
Potentially natural deficits in abdo wall e.g. hernias
Hip biomechanics
Important biomechanical associations
Spine, pelvis, hip etc all meet at pubic symphysis
Central –> lateral loading distribution
Muscle (im)balance
Groin triangle- Superiorly
Pubic Symphysis
Abdo Wall
Hernias
Groin triangle- Medial
Adductor muscles
Groin triangle- Within
Iliopsoas
Rectus Femoris
Nerves
Groin triangle- Lateral
Femoral acetabular joint
Tensor fascia lata
Hip joint
Pubic tubercle- adductor tendon enthesopathy
Insidious onset, warms up with onset
Guarding on passive abduction, weakness
Pubic clock 6-8
Pubic tubercle- rectus abdominis enthesopathy
Well localised to insertion, acute or insidious onset
Pain from resisted sit up
Pubic clock 12
Pubic tubercle- pubic bone stress injury
Non-specific diminished athletic performance, loss of propulsive power
Bone tenderness predominates
Diagnosis of exclusion
Medial to triangle- Adductor/gracilis enthesopathy
Insidious onset Diminished performance Warms up Proximal adductor pain, at enthesis Guarding, weakness
Medial to triangle- Adductor longus pathology at musculotendinous junction
Acute onset, worse during exercise
Pain in proximal adductor
(2-4cm distal to enthesis), guarding, weakness
Medial to triangle- Pubic bone stress injury
Pain primarily at pubis radiating to proximal thigh
Bone tenderness
Lack of point muscular tenderness
Superior to base- rectus abdominis tendinopathy
Well localised to insertion, acute or insidious onset
Pain from resisted sit-up
Pubic clock 12
Lateral to triangle- Impingement/labral pathology, femoro-acetabular joint
Mechanical signs
Clicking in joint and/or catching
Impingement test
Lateral to triangle- Osteoarthritis/chondral damage, femoro-acetabular joint
History of traumatic/congenital insult
Older age group
Persistent lateral hip pain worse on lying on affected side
Limited ROM
Pain on weight bearing
Pain on transition between lying/standing
Lateral to triangle- Iliotibial band friction syndrome
External snapping and/or lateral knee pain
Re-create snapping
Ober’s test
Within- Iliopsoas syndrome
Pain above and below inguinal ligament- associated snapping at hip joint
Thomas test, modified
Adductor related pathologies
Palpation + resisted adduction
Iliopsoas related pathologies
Palpation + resisted flexion OR extension stretch
Inguinal related pathologies
Palpation
Pubic related pthologies
Palpation
Hip related pathologies
Passive ROM (PROM) Flexion adduction internal rotation (FADIR) Flexion abduction external rotation (FABER)
Neural
Ilioinguinal nerve
Genitofemoral
True hernia
Cough sign
Pelvis sign
Warning signs of acute pathology
Morning pain + stiffness
Feeling of warmth and fullness
Swelling
Acute hip
Majority of studies using 4-6 weeks
Sharp, obvious pain in groin
Big haemorrhage
Instant loss of balance and performance
What injuries account for majority of acute groin injuries
Adductor injuries
What other injuries common for acute
Proximal rectus femoris and iliopsoas
More than — injuries showed no imaging signs of acute injuries
1 in 5
Clinically diagnosed adductor injuries often confirmed on
Imaging
Iliopsoas + rectus femoris injuries showed
a different radiological injury location in more than 1/3 of cases
Acute - 0-48 hours
RICE
Gentle stretching to P1
Active pain-free ex
Phys mod (TENS, laser)
Acute- after 1st 48 hours
Gradually increase stretching
Gradually increase strengthening (act abd/add, add/flex against resistance, stabilizing exs)
Functional strengthening
Sport-specific skills
Movement patterns
Groin/hip pain usually multi-structural, multi-planar and multi-directional
A number of research without stringent inclusion/exclusion criteria found strong associations
Still high incidence, still high recurrence, still no reliable treatment strategy
Treatment
- Active rehab with manual elements
- Including mainly the adductor and abdominal muscle
- Regardless of evidence, not all discovered elements are present in exercise programmes
- Common: abdominal, adductor work
- Missing: sport specific rehab, other muscle groups (adductors? Hip ROM?)
Prehab groin
Adductors + trunk flexors + glutes
Functional work
Hip pathologies
Labral tears
FAI (morphology, not pathology)
Hip pathologies- treatment
o Usual patient: M/F, active (loading activities) professional
o Treatment: usually good and quick improvement (to the point) with intense gluteal exercises (off-loading) and temporary avoiding painful activities
o Some further improvement (usually including increase of strength and stability)
o Recovery either plateaus, or go back to square 1 with going back to sports
o Loading management
o Injection
o Surgery
