Diagnosis A nd 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

2. 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

3. 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”

4. 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

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

6. 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

7. 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

8. Signs • 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

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

10. 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

11. Abdominal Related Groin Pain • Munich Approach • David Connell’s radio-ablation • Gilmore’s technique • David Lloyd’s tenotomy

12. Munich Approach • Swelling in stretched / weak posterior inguinal canal wall • Identified digitally or via ultrasound • Transversalis fascia dilates widening Hasselbach’s 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. Abdominal Related Groin Pain – is it a continuum ? • Munich Approach • David Connell’s radio-ablation • Gilmore’s technique • David Lloyd’s tenotomy

21. 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

22. 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

23. Treatment • 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

24. 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

25. 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 knee)

26. Iliopsoas Related Groin Pain • U/S or MRI • Local physio Rx / rehab • U/S guided injection

27. 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

28. 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

29. 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 Sportsman’s hernia surgery Psoas dysfunction us guided inj C/T rehab