\u00a0![\"\"](\"https:\/\/blogs.bmj.com\/bjsm\/files\/2012\/04\/groin.jpg\")
<\/p>\n
What is Groin Pain? <\/strong><\/h3>\nUndergraduate training often fails to emphasise the two joints in the pelvis \u2013 \u00a0\u00a0the hip joint and also the pubic symphysis are at the centre of many movements. (2) \u00a0As a clinician, try to assess how the patient\u2019s functional movement influences both the hip and the pubic symphysis. What causes pain and where?\u00a0 Try to understand the entire kinetic chain with its related function to the pelvis \/ groin \/ hip. Then perform relevant clinical tests as well as sports-specific functional tests.<\/p>\n
The cause of groin pain<\/strong> is a \u2018million dollar question\u2019\u2026….<\/p>\nThe diagnosis<\/strong> is mostly by exclusion not inclusion. Osteitis Pubis (OP) diagnosis is no longer an accepted term. This may be a normal response to overload and may lead to bone stress reaction, and then possibly joint and disc degeneration. Increased signal of bone marrow oedema may be a precursor to the development of groin pain. It may or may not correlate with clinical symptoms. (3) As a clinician, consider prevention and reducing load when there are early groin pain symptoms or radiological changes (MRI) of excess load.<\/p>\nAnd what of the Adductor muscles?<\/strong> (4)<\/p>\nIn <\/strong>soccer players with groin pathology, adductor dysfunction is a more frequent MRI finding than \u201costeitis pubis\u201d. Both entities are mechanically related and frequently coexist.<\/p>\nSpecific strengthening of all Adductor muscles is one of the<\/strong> main goals<\/strong> for preventing and managing groin \/ hip pathologies.<\/strong><\/p>\nHowever, one must not be single minded and should take into account<\/strong>\u00a0other structures\u00a0<\/strong>including Ligamentum Teres tears (5), Ilio Psoas (6), Greater Trochanter (7), Rectus Abdominus (8), Pelvic floor muscles (9) and Gluteus muscle function (10).<\/p>\nThen consider\u00a0Radiologists<\/strong> with their preferred way of imaging.<\/p>\nAlthough radiological investigations are important, most studies tend to agree that experienced clinical judgment<\/strong> remains a critical element in the diagnostic pathway. (11)<\/p>\nA few groin \/ hip tests<\/strong> have been well documented and are valuable for diagnosis<\/strong>. (12)<\/p>\nWhat about the treatment options?<\/strong><\/p>\nThere is consensus in the literature that non- surgical treatment should always be applied before surgery is considered. However, the time span differs in the studies.<\/p>\n
The rehabilitation protocols<\/strong> show gradual progression based on objective functional and clinical markers over a reasonable time frame.<\/p>\nIn my experience, it is of value to always have pre-season specific baseline tests (Musculo-Skeletal evaluation).<\/p>\n
The rehabilitation can take anything from 3 \u2013 12 weeks depending on the actual diagnosis e.g. if it is an overload problem, one would \u201cactively rest\u201d the athlete until they are able to fully function symptom free in their respective sport.<\/p>\n
One should address the local strength first, followed by functional strength with the entire global perspective taken into account.<\/p>\n
Reassessment criteria to judge progress and assess next level of activity with objective markers are essential in order to increase the rehabilitation appropriately.<\/p>\n
Of course, at an elite sports level, one is mostly not given this time-frame to do conservative rehabilitation!<\/p>\n
Post-operative rehabilitation<\/strong> programmes varies from 10 days \u2013 12 weeks.<\/p>\nThis depends on the type of surgery, the specific demands \u00a0and\u2026\u2026\u2026the very different requirements of the Surgeon involved!<\/p>\n
And surgery:<\/strong><\/p>\n\u2022 \u00a0 No consensus as to an ideal operating technique<\/p>\n
\u2022 \u00a0 Serial patient outcome measurements are needed to base intervention success on\u00a0factors other than return to sports activity.<\/p>\n
\u2022 Operate on asymptomatic side, as it has been suggested that 40% progress to\u00a0bilateral?<\/p>\n
There is also on-going controversy regarding the prevalence of a True Hernia, with many different surgical implications. (13)<\/strong><\/p>\n <\/p>\n
Then on to the discussion regarding hips<\/strong>…….<\/p>\nThe prevalence of radiographic hip abnormalities in elite soccer players is considerable. (15)<\/p>\n
One must identify the relationship between these radiographic abnormalities and the clinically symptomatic pathologies.<\/p>\n
A battery of tests should be utilised to improve the accuracy of the clinical reasoning.<\/p>\n
Hip joint restriction often precedes the development of chronic groin injury and may be a risk factor for this condition.<\/p>\n
One must also remember that the Acetabular Labrum and Ilio-Femoral Ligament are vital for normal hip mechanics and excessive removal of either in surgery can be detrimental. \u00a0(16)<\/p>\n
As our understanding of FAI and chondral injuries and their causes grows, future efforts will focus on prevention.<\/strong><\/p>\nFuture research is required to determine the extent to which physio intervention<\/strong> aimed at improving hip kinematics would be effective in treating individuals with labral injuries<\/p>\n <\/p>\n
CONCLUSION<\/strong><\/p>\n\u2022\u00a0\u00a0 The challenge lies between ascertaining the Anatomical diagnosis vs. Pathological diagnosis vs. Functional diagnosis \u2013 the interaction of the three will influence prognosis and management, whereas identification of one alone will give a bias in one direction.<\/p>\n
<\/p>\n
SOLUTION?<\/strong><\/p>\n\u2022\u00a0\u00a0\u00a0\u00a0 In spite of minimal EBM, it seems the most pertinent point is that many of the groin \/hip pathologies can be averted by thorough and specific pre-habilitation,\u00a0<\/strong>bearing in mind the entire kinetic chain and addressing total function around the\u00a0pelvis above and below.<\/p>\n
The diagnosis<\/strong> is mostly by exclusion not inclusion. Osteitis Pubis (OP) diagnosis is no longer an accepted term. This may be a normal response to overload and may lead to bone stress reaction, and then possibly joint and disc degeneration. Increased signal of bone marrow oedema may be a precursor to the development of groin pain. It may or may not correlate with clinical symptoms. (3) As a clinician, consider prevention and reducing load when there are early groin pain symptoms or radiological changes (MRI) of excess load.<\/p>\n And what of the Adductor muscles?<\/strong> (4)<\/p>\n In <\/strong>soccer players with groin pathology, adductor dysfunction is a more frequent MRI finding than \u201costeitis pubis\u201d. Both entities are mechanically related and frequently coexist.<\/p>\n Specific strengthening of all Adductor muscles is one of the<\/strong> main goals<\/strong> for preventing and managing groin \/ hip pathologies.<\/strong><\/p>\n However, one must not be single minded and should take into account<\/strong>\u00a0other structures\u00a0<\/strong>including Ligamentum Teres tears (5), Ilio Psoas (6), Greater Trochanter (7), Rectus Abdominus (8), Pelvic floor muscles (9) and Gluteus muscle function (10).<\/p>\n Then consider\u00a0Radiologists<\/strong> with their preferred way of imaging.<\/p>\n Although radiological investigations are important, most studies tend to agree that experienced clinical judgment<\/strong> remains a critical element in the diagnostic pathway. (11)<\/p>\n A few groin \/ hip tests<\/strong> have been well documented and are valuable for diagnosis<\/strong>. (12)<\/p>\n What about the treatment options?<\/strong><\/p>\n There is consensus in the literature that non- surgical treatment should always be applied before surgery is considered. However, the time span differs in the studies.<\/p>\n The rehabilitation protocols<\/strong> show gradual progression based on objective functional and clinical markers over a reasonable time frame.<\/p>\n In my experience, it is of value to always have pre-season specific baseline tests (Musculo-Skeletal evaluation).<\/p>\n The rehabilitation can take anything from 3 \u2013 12 weeks depending on the actual diagnosis e.g. if it is an overload problem, one would \u201cactively rest\u201d the athlete until they are able to fully function symptom free in their respective sport.<\/p>\n One should address the local strength first, followed by functional strength with the entire global perspective taken into account.<\/p>\n Reassessment criteria to judge progress and assess next level of activity with objective markers are essential in order to increase the rehabilitation appropriately.<\/p>\n Of course, at an elite sports level, one is mostly not given this time-frame to do conservative rehabilitation!<\/p>\n Post-operative rehabilitation<\/strong> programmes varies from 10 days \u2013 12 weeks.<\/p>\n This depends on the type of surgery, the specific demands \u00a0and\u2026\u2026\u2026the very different requirements of the Surgeon involved!<\/p>\n And surgery:<\/strong><\/p>\n \u2022 \u00a0 No consensus as to an ideal operating technique<\/p>\n \u2022 \u00a0 Serial patient outcome measurements are needed to base intervention success on\u00a0factors other than return to sports activity.<\/p>\n \u2022 Operate on asymptomatic side, as it has been suggested that 40% progress to\u00a0bilateral?<\/p>\n There is also on-going controversy regarding the prevalence of a True Hernia, with many different surgical implications. (13)<\/strong><\/p>\n <\/p>\n Then on to the discussion regarding hips<\/strong>…….<\/p>\n The prevalence of radiographic hip abnormalities in elite soccer players is considerable. (15)<\/p>\n One must identify the relationship between these radiographic abnormalities and the clinically symptomatic pathologies.<\/p>\n A battery of tests should be utilised to improve the accuracy of the clinical reasoning.<\/p>\n Hip joint restriction often precedes the development of chronic groin injury and may be a risk factor for this condition.<\/p>\n One must also remember that the Acetabular Labrum and Ilio-Femoral Ligament are vital for normal hip mechanics and excessive removal of either in surgery can be detrimental. \u00a0(16)<\/p>\n As our understanding of FAI and chondral injuries and their causes grows, future efforts will focus on prevention.<\/strong><\/p>\n Future research is required to determine the extent to which physio intervention<\/strong> aimed at improving hip kinematics would be effective in treating individuals with labral injuries<\/p>\n <\/p>\n CONCLUSION<\/strong><\/p>\n \u2022\u00a0\u00a0 The challenge lies between ascertaining the Anatomical diagnosis vs. Pathological diagnosis vs. Functional diagnosis \u2013 the interaction of the three will influence prognosis and management, whereas identification of one alone will give a bias in one direction.<\/p>\n <\/p>\n SOLUTION?<\/strong><\/p>\n \u2022\u00a0\u00a0\u00a0\u00a0 In spite of minimal EBM, it seems the most pertinent point is that many of the groin \/hip pathologies can be averted by thorough and specific pre-habilitation,\u00a0<\/strong>bearing in mind the entire kinetic chain and addressing total function around the\u00a0pelvis above and below.<\/p>\n