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This case study explores the diagnosis, treatment, and rehabilitation of chronic groin pain in a professional rugby player, highlighting the importance of special investigations and surgical intervention.
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Chronic groin pain in athletes Charl Carstens CLL 705 September 2012
OVERVIEW • Case Presentation • Clinical Progress • Special Investigations • Treatment • Introduction • Summary • Discussion
Case Presentation • 26 year Male rugby player- hooker • C/O: Pain left supra inguinal area (illiopsoas) Conservative treatment 1/12 Surgeon referral
Clinical Progress • Re-injured- acute pain left groin • X-ray- NAD • Ultrasound- ?Partial tear or tendinopathy adductor brevis
Progress Cont. • Treatment 9/52 Rest/Rehab: Core stabilizers, hip muscle activation and strengthening • Slipped – pain left groin again
Re- Evaluation • Tender Proximal adductors • Adductor squeeze test- Extension & 90° Hip flexion - adductor longus • FABER (+)
Special Investigations • MRI: Partial avulsion enthesis left pectineus and adductor brevis anterior at inferior attachment of symphysis pubis. Oedema medially in both muscles.
Surgical Treatment • 5 months post injury • Surgery: Extensive tendinopathy of Adductor longus – unilateral tenotomy
Summary • Clinical Chronic groin injury • Personal Professional rugby player • Contextual Pressure from club RTP
Introduction Non-specific exercise related groin pain • Osteitis Pubis/Athletic Pubalgia • Adductor tendinopathy(enthesopathy) • Iliopsoas dysfunction • Sportsman’s hernia/sports hernia • Gilmore’s groin
Discussion • 4 Groin Entities A. Adductor- related B. Iliopsoas- related C. Abdominal wall- related D. Pubic bone stress – related (Brukner & Khan 2012)
4 Groin Entities • Anatomy: - Adductor Longus & Rectus Abdominus directly linked - Indirectly to Transversus Abdominus & Internal Oblique via Rectus Abdominus sheath
Pubic Joint • Anatomy- 2 Pubic symphyseal bones - 3 Muscle Compartments Anterior: Abdom, Quads, Sartorius, Iliopsoas + Pectineus Medial: 3 Adductors, Gracillis + Obturator externus Posterior: Hamstrings +Part Add Magnus (Meyers et al 2012)
Adductor Longus Related • Enthesopathy rather tendinopathy • Conservative treatment- soft tissue treatment, core stability program & strengthening local muscle groups • If all else fails- cut
Treatment Cont. • Partial tenotomy – transferring load from superficial to deep part (Orchard J.W et al 2004) • ?RTP after 4-6 weeks (Brukner & Khan 2012) • Complete Tenotomy
Treatment Cont. • Unilateral Adductor tenotomy return to pre-injury level of sport: • Atkinson et al 2010 - 54% • Akermark et al 1992 – 62% • Robertson et al 2011 – 68% Advocated 10 – 12 weeks rehabilitation
Treatment Cont. • Bilateral Adductor tenotomy return to pre-injury level of sport or higher: • Maffuli et al 2012 – 76% with 16 weeks rehabilitation
References • Brukner P., Khan K., et al, 2012. Brukner & Khan’s Clinical Sports Medicine. 4th ed. Australia: Mcgraw-Hill Australia. 342-389. • Akermark C. and Johansson C. 1992. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med. 20:640-643. • Atkinson H.D., Johal P., Falworth M.S., et al 2010. Adductor tenotomy: its role in the management of sports related chronic groin pain. Arch Orthop Trauma Surg. 130(8): 965-70. • Hackney R.G. 2012. Groin pain in athletes. Othop & Trauma 26(1): 25-32.
References Cont. • Maffuli N., Loppini M., Longo U.G., et al. 2012. Bilateral Mini-Invasive Adductor Tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes. Am J Sports Med. 40(8): 1880-86. • Meyers W.C., Yoo E., Devon O.N., et al 2012. Understanding “Sports Hernia”(Athletic Pubalgia): The Anatomic and Pathophysiological Basis for Abdominal and Groin Pain in Athletes. Oper Tech Sports Med. 20: 33-45. • Orchard J.W., Cook J.L. and Halpin N. 2004. Stress-shielding as a cause of insertional tendinopathy: the operative technique of limited adductor tenotomy supports the theory. J Sci Med Sport. 7(4): 424-8. • Robertson I.J., Curran C., McCaffrey N., et al 2011. Adductor tenopathy in the management of groin pain in athletes. Int J Sports Med. 32(1): 45-48.