Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Tim Tyler MS, PT, ATC Extra-‐Articular Sources of Groin Pain
Transcript
Tim Tyler MS, PT, ATC Extra-‐Articular Sources of Groin Pain Presentation Goals Terminology Groin Pain Anatomy Evaluation Groin Pain Terminology Defined clinical entities: Adductor-‐related groin pain: Adductor tenderness AND pain on resisted adduction testing. Iliopsoas-‐related groin pain: Iliopsoas tenderness +more likely if pain on resisted hip flexion AND/OR pain on hip flexor stretching. Inguinal-‐related groin pain: Pain in inguinal canal region AND tenderness of the inguinal canal. No palpable inguinal hernia is present. More likely if aggravated with abdominal resistance OR Valsalva/cough/sneeze. Pubic-‐related groin pain: Local tenderness of the pubic symphysis and the immediately adjacent bone. No particular resistance tests to test specifically for pubic-‐related groin pain. Differential Diagnosis Abdominal strain Hip joint etiology Labral tear FAI Osteitis pubis Stress fracture Nerve compression syndrome Obturator nerve entrapment lateral femoral cutaneous nerve Sources of Groin Pain in Athletes Sports hernia (Inguinal-‐related groin pain) Athletic Pubalgia Adductor tear The Inguinal Canal Superior wall (roof): 2 Muscles: internal oblique Muscle transverse abdominus Muscle Anterior wall: 2 Aponeuroses: Aponeurosis of external oblique Aponeurosis of internal oblique Lower wall (floor): 2 Ligaments: inguinal Ligament· lacunar Ligament Posterior wall: 2Ts: Transversalis fascia conjoint Tendon Sports Hernia A weakened or deficient posterior wall of the inguinal canal Sports Hernia Signs & Symptoms 1 – A subjective complaint of deep groin/lower abdominal pain. 2 – The pain is exacerbated with increased exertion/explosive movements such as sprinting or cutting and is relieved with rest. 3-‐ Palpable tenderness over the pubic ramus at the insertion of the rectus abdominus and/or conjoined tendon. 4-‐ Pain with resisted hip adduction at 0, 45, and/or 90 degrees of hip flexion. Sports Hernia Physical Exam Rule out hernias Resisted sit-‐up—lower rectus pain Resisted adduction: adductor longus entheseal pain Palpate along rectus border to pubis, inguinal ligament, adductor attachment Palpate posterior wall defect New Research Klein D, Shah R, Maeder M, Zoland M. The Clinical Utility of Valsalva Imaging When Evaluating for Sports Hernia: Presented at the Society of Skeletal Radiology Annual Conference, San Diego California March, 2014. Maeder, M, Zoland, M and Klein D. Athletic Pubalgia and Other Findings in Patients Referred for MRI of Sport-‐Related Groin pain: With Surgical Correlation. Presented at Radiological Society of North America Scientific Assembly and Annual Meeting, Chicago, Illinois, December 2013. Maeder, M, Zoland, M and Klein D. Athletic Pubalgia and Other Findings in Patients Referred for MRI of Sport-‐Related Groin pain: Preliminary Findings. Lenox Hill Hospital Department of Orthopedic Surgery 19th Annual Orthopaedic Research Day Symposium, June 4, 2013. Same person, with and without valsalva; notice the protrusion on the right. Source of the Pain Given the location of the injury, nerve impingement is a definite possibility Athletic Pubalgia A more medial injury involving the attachments to the pubis: a detachment to some degree of the aponeurotic plate If enough force is generated, the common aponeurosis can begin to lift off the pubis Athletic Pubalgia Signs & Symptoms Pain after the activity, or the next day Rectus, lateral edge Pubic Tubercle Adductor Longus Athletic Pubalgia Physical Exam Pain lateral to the rectus muscle Rectus insertional pain with resisted sit-‐up Pain at the pubic tubercle Adductor tendon pain with resistance NO INGUINAL FLOOR DISRUPTION MRI has become an integral part in the diagnosis of Athletic pubalgia The injury may also involve both sides. Frequently we see the fluid layer progressing across the midline, suggesting a BILATERAL aponeurotic plate disruption Adductor Muscle Tear Adductor longus pathology can be such the main source of pain; partial or complete disruptions off the pubis can occur. Adductor Tear Signs & Symptoms 1 –Recollection of a specific incidence of the injury occurring. 2-‐ Tenderness at the origin of the adductor longus and/or the gracilis located at the inferior pubic ramus and pain increases with resisted adduction. 3-‐Pain with rapid adduction of the thigh. 4-‐Loss of hip abduction ROM occurs. Loss of function may be is present in the case of a severe tear. Adductor Tear Physical Exam Rule out all hernias Tenderness, swelling, and ecchymosis can be observed at the superior medial thigh. Sometimes, a defect in the muscle can be palpated. Pain is noted with resisted adduction and full passive abduction of the hip. TERIBLE TRIFECTOR Clinical Summary Sports hernia Defect of posterior wall of inguinal canal Palpation of defect, Valsava MRI Athletic pubalgia Pin point pain over pubic tubercle at rest MRI positive Adductor tear Pain at MTJ on contraction Pain on PROM at end range of ABD Take Home Messages There are many sources of groin pain. Overlapping conditions can exist. The inguinal canal has distinct boarders. A sports hernia is a disruption of Posterior Wall. MRI is useful in diagnosing a sports hernia. Thank You
