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©Benoy Mathew 2016 www.function2fitness.co.uk/courses

Rehabilitation of Adductor-related & Iliopsoas-related Groin Pain

Benoy Mathew MSc, MCSP Extended Scope Practitioner

Twitter @function2fitnes [email protected]

Learning outcomes

•  Overview of Groin pain (Articular & Extra-articular)

•  Differential Diagnosis (Osteitis Pubis, Sports Hernia, FAI)

•  Adductor related Groin Pain •  Ilio-psoas related Groin Pain

(Risk factors, Clinical findings & Rehab)

Appraisal of Current Literature

10% - General Population 10-20% - Sporting Injuries 30% - May go undiagnosed (Picavet et al, 2003; Ekstrand et al, 1999; Leblanc et al, 2003)

Chronic Hip & Groin Pain


§ GroinPain(MSK&Non-MSKPainReferrals)§ DeepLocationoftheHipJoint§ Lumbo-Pelvic-HipComplex(LPHC)§ DirectInEluenceof22MusclesontheHip§ ConfusingterminologyinLiterature(Gilmoregroin,Sportshernia,OsteitisPubis,AthleticPubalgia)

Multipleclinicalentitiesarecommoninchronicgroinpain(63.6%)

(Falveyetal,2016)N=382patients

Differential Diagnosis Chronic Groin Pain

Intra- Articular Extra- Articular Referred Pain •  Femoro-acetabular

Impingement (FAI) •  Acetabular Labral tears

(ALT) •  Chondral lesions •  Osteoarthritis •  Hip Dysplasia (HD) •  Ligamentum Teres tears •  Hip Joint Instability /

Capsular Laxity

•  Adductor related Groin Pain •  Hip Flexor related Groin

Pain •  Gluteus Medius

tendinopathy & tears •  Rectus Abdominis Strain •  Pubic Groin Pain (Osteitis

Pubis) •  Snapping Hip Syndrome

(External & Internal) •  Atheltic Pubalgia (Sports

Hernia)

•  Lumbar Spine (Disc, Pars Injuries, Facet arthropathy) & SIJ

•  Lower abdominal (Gastrointestinal)

•  Pelvis (Genitourinary) •  Abdominal Muscle

Strains / Side Strain


1.  Defined Clinical Entities 2.  Hip Related Groin Pain 3.  Other causes of groin pain (Weir et al, 2015)

1. Defined Clinical Entities •  Adductor- related groin pain •  Iliopsoas - related groin pain •  Inguinal - related groin pain •  Pubic - related groin pain

•  Pectineus •  Brevis •  Longus •  Magnus •  Gracilis

Hip Adductors (5 Muscles) Peanut Butter Leaves Me Greasy

Unique Role – 4th Hamstring •  Proximal Attachment - Ischial

tuberosity •  Powerful Hip Extensor •  Assists in Post Pelvic Tilt


Role of Hip Adductors •  Not as prime movers, but in reflex response to

gait changes. •  Work Synergistically with abductors to provide

stabilisation of the pelvis •  Mainly active in bilateral stance •  Gracilis (2 joint muscle) - Medial Knee Stabiliser

(Neumann, 2009)

Larger than Hamstrings 22.5% of total LL Mass Combined Peak Forces > GMax

Acute Groin Injury

“Adductor injuries account for the majority of acute groin injuries. Ilio-psoas and

proximal rectus femoris injuries are also common”

Serner et al, (2015) n=110

VerycommoninMaleFootball!

N = 695 (all male) 49 % report Hip & Groin pain in one season (Thorborg et al, 2016)


Risk Factors ê Adductor Strength (10% difference)

ê Adductors / Abductors Ratio ê Hip External Rotation ROM ê Hamstrings Strength

(Kloskowska et al, 2016)

Weakness may precede pain onset by 2 weeks

Adductor Related Groin Pain (Localised medially in the groin)

•  Mainly Adductor Longus •  Pain on squeeze test •  Pain on passive stretching •  Pain on palpation •  Weakness is common

Clinical Tests


Clinical examination appears sufficient to diagnose acute adductor injuries

(Serner et al, 2016)

21% of athletes had negative

imaging (especially Iliopsoas &

Rectus Femoris)

Squeeze Test The adductor squeeze test was sensitive for athletic groin pain, but not specific to adductor pathology (Falvey et al, 2015)

Soft Tissue •  Adductors •  Rectus Abdominis •  Obliques

Bone •  Pubic bone •  Symphysis

6 degrees = Real Change in Muscle Flexibility (Cejudo et al, 2016)


Entrapment Neuropathies

§  Osteitis Pubis (Pubic BMO: 70 - 94%) §  Symphysis Joint (Deg Changes) §  Adductors Enthesis Pathology

(Male Footballers)

ChronicAdductorRelatedGroinPainCommonMRIFindings(Branci,2013)

Co-exis(ngPathologies•  Ostei&sPubis•  SportsHernia(Athle&cPubalgia)•  FAI


Osteitis Pubis (OP) DOHA Terminology (Pubic related groin pain)

•  Overuse Injury •  Kicking, Sprinting, COD •  Bone Stress Response •  Co-exist with Ch ARGP

Pain on Squeeze test

TOP- Symphysis Pubis MRI (Bone Marrow Oedema)

A Brevis A Longus Gracilis

Rectus Abdominis Levator Ani

Body Part Action Key Muscles

Trunk Stabilisation of rotation to the right

Abdominals, Psoas Major, Erector spinae, Spinal postural muscles

Right Hip

Extension GMax and Hams

Left Hip

External Rotation and Eccentric Extension

GMed, GMin, Hamstring, Adductor Magnus

Right Knee

Flexion Hamstrings and Popliteus

Left Knee

Eccentric extension Quadriceps

Right Ankle

Plantar flexion Plantar-flexors

The Football Kick

Inadequate Hip ROM (Extension or Rotation)

Excessive compensatory motion through the Pubic Symphysis


§  Not a Hernia §  Myo-tendinous Injury §  External Oblique tear, Disruption of Conjoined tendon (Weakness of Posterior abdominal wall)

AthleticPubalgia/SportsHernia

Abdominal Wall Related Groin Pain

Clinical Presentation -  Professional Male Football or Golf -  Supra-pubic pain, Fullness -  Burning Pain -  MRI can be normal -  Dynamic Ultrasound is useful

Extremely Rare in

Primary Care (Very Rare in

Women)


Prevalence of radiological signs of

FAI in long-standingadductorrelated

groinpainwas94%(Weiretal,2011)

N=34athletes

GroinPain>2months

APPelvicX-ray

“FAIisacriticaltopic,becauseitiscommon,incompletelyunderstood,but

certainlyassociatedwithpainandperhapsarthritisprogressioninsomepatients”

(Nardoetal,2015)


•  Hip Pain > 3 months •  Internal Rotation < 20° (In 90° of hip flexion) •  Radiological confirmation (CAM - Alpha< 60°, PINCHER - LCEA > 40°)

•  MRI (Labral or Chondral damage)

•  Diagnostic injection (Articular or Extra-articular)

•  No clinical evidence of inflammatory arthritis (no morning stiffness) (Nepple et al, 2013)

Dx of FAI Syndrome = Subj + Obj + Imaging

Hip Related Groin Pain •  Groin Pain •  Limping (7 times than LBP) •  Clicking, Catching &

Snapping •  Stiffness & Limited IR •  Sitting, Squatting, Socks

(Transition & Loaded Rotation Movements)

Management of Adductor Related Groin Pain


Phase 1 •  Reduce Pain •  Restore ROM •  Maintain aerobic fitness •  Adductor Strength

Phase 2 •  Progress Adductor Strength •  Address associated deficits •  Progress to global LL

Strengthening

Phase 3 •  Eccentric Hip Adductor •  Sports Specific Training •  Graded RTP

The mul&-modal program

resulted in a significantly

quickerreturntosports

(Weiretal,2010)VandenAkkerTechnique

RCT(N=26)12.8weeksVs17.3weeks

RCT (Holmich et al, 1999) •  Active Training Vs Passive Rx •  Graded Ex Programme (8-12 weeks) •  RTP (23 out of 29; 4 out of 30)


Best for Prevention of AGRP -  Copenhagen Adduction -  Hip Adduction with elastic band -  Hip Adductor machine (Serner et al, 2014)

35.7%increaseinEccentricHip

Adduc&onStrengthin8weeks

(Ishoietal,2015)

Initial Stage


Progression

Late Stage

Add/AbdStrengthRa(o17&mesmorelikelytosustainadductorsstrainif

adductorstrengthwaslessthan80%ofabductor

strength(Tyleretal,2001)

CorrectAssociatedDeficits•  Adductor/AbductorStrengthRa&o•  KneeFlexorStrength•  ROMDeficits(ExternalROM)


Hip Mobility Deficits Decreased Hip ROM is associated with more hip and groin related symptoms, independent of the presence of a cam deformity

(Tak et al, 2015)

•  Patients with CLBP had decreased hip extension and IR compared to healthy controls (Lee et al, 2015)

•  Hip rotation ROM was less in patients with CLBP who participate in rotational sports (Dillen et al, 2008)

Hip Mobility Drills


Self MWMs with bands may be beneficial, when used to augment

therapist induced MWMs Pilot RCT - (Walsh et al, 2016)

RTP Testing

•  Movement Screening •  Strength Ratio •  CV Fitness •  Performance Testing •  Psychological Readiness


Return to Play

•  Holmich et al (1999) •  Weir et al (2011) •  Weir et al (2011)

Supervised exercise programme 18.5 weeks

Home exercise programme 17.3 weeks

Multi-modal treatment 12.8 weeks

Athletesseekingtoreduce

demandonthehipadductors

maybenefitfromtheuseof

direc&onalcompressionshorts

(Chaudharietal,2008)

ApproachFullReturntoSports


Summary •  Clinical Diagnosis of Chronic Groin pain can be challenging •  Adductor related Groin Pain - Common cause of acute groin pain - Previous Injury & Adductor Strength (Key Risk Factors)

- Co-existing pathologies (OP, Sports hernia, FAI)

- Correct associated deficits (Strength ratio, ROM)

- Return to Play in Athletic Population (12 weeks to 18 weeks)

©BenoyMathew2016 www.func5on2fitness.co.uk/courses

Ilio-psoasRelatedGroinPain

Anatomy

PsoasMajor(Transverseprocesses,sidesofthebodiesanddiscsfromT12-L5)Iliacus(Inneraspectofiliacfossa,lipofiliaccrest)PsoasMajor(AnteriortoPsoasmajor,BodiesanddiscsofT12–L1topubis)Absentin40%ofcases

IliopsoasTendon(Usually2disEncttendons)

•  Maintendon(Psoas)(Originatesatlevelofinguinalligament,mostmedial)

•  Accessorytendon(Iliacus)(Medialfibresofiliacus,blendswithmaintendonoveralengthof6-8cm)


Ilio-psoasBursa

•  Dimensions(5-7cminlength;2-4cmwidth)

•  Communica5onwithhipcapsule

(15%ofpopulaEon)

•  PrimegeneratorofHipFlexion•  Stabiliserofthefemoralhead

(0-15degreesofHipFlexion)

•  StabilityoftheLumbarSpine•  UniqueDualFunc5onPM-t(LxExtension+HipFlexion)PM-v(TrunkFlexion+HipFlexion)(Yoshioetal,2002;Parketal,2013)

•  Primaryaimduringgaitisswingini5a5on•  ControlHipExtensionatendofstancephase


HipFlexorPower

“Mostprevalentlimi5ngfactorinsprintspeed,isnothipextension,butinadequatehipflexorpower”Dr.Stuart

McGill

IliopsoasSyndrome(Mul%plePathologies)

•  Acutelesion(usuallykickingorsprinEngrelated)ChronicLesions(>3months)

•  Iliopsoastendinopathy(+/-BursiEs)•  IliopsoasImpingement(Labraltears)•  Iliopsoasin‘internalsnappinghipsyndrome’

•  Post-opera5veover-use(PostTHRorHipArthroscopy)

Co-existwithIntra-arJcularHipPathology

Decreasedhipinternalrota5onandextensionresul5ngfromintra-ar5cularpathologyoXen leads to a shortened,painfuliliopsoastendon(Brophy&Prather,2014)


DD: Snapping Hip (Coxa Saltans) §  Internal - Iliopsoas §  External - IT Band or GMax Tendon Common - Dancers, Gymnasts, Yoga

Clinical Profile §  Young females §  Extreme Extension (eg. Dance)

Mechanism of Labral Tears •  Chronic Tight or Inflammed Iliopsoas •  Adherent to anterior capsulo-labral

complex •  Traction Phenomenon

(Tightness or Snapping-Tendinopathy-Tears)

All hips in this series had labruminjuryatthe3o’clockposi5on

(Dombetal,2011)


CaseSeries•  Mean5me=20months(2-96)•  Painfulac5vehipflexion•  PainfulandweakASLR

(O’Sullivanetal,2007)

ClinicalFindings•  Painandweaknesswithresistedhipflexion•  StretchPainduringThomastest•  Painonpalpa5onofPsoasabovetheinguinalligament(poorreliability)

•  Aggravatedby-Running(especiallyuphill)-Speedtraining

ManagementofIliopsoasTendinopathy(withoutco-exis5ngAr5cularHipPathology)


EarlyStage•  Educa5on•  Ac5vityModifica5on(NoSpeed)•  Op5misePelvicStability•  Isometrics

AvoidAggressiveStretching

EccentricPsoasMarch


EccentricExercisesToImproveFlexibility

(LengthenwithLoad)

BulgarianSplitSquat

Step-upandRaise

Resistance(CablesorBands)KneeTucksonGymballSlingBasedtraining


HSTgroupincreasedtheirhipflexionstrengthofthetrainedlegby17%(Thorborgetal,2015)–6weekstraining,3Emes/week

SpeedbasedTraining(WallDrive)

NotRespondingtoRehab

•  Ar5cularHippathology(eg,FAI,ALT)•  InflammatoryComponent(BursiEs)

Speed,onlyaTeradequateHipFlexorStrength&Pelviccontrol


Managementalgorithmofiliopsoastendinopathy(Garalaetal,2014)

Summary

•  Iliopsoas(KeyStabiliserofHipandLxSpine)•  IliopsoasSyndrome(MulEplePathologies)

•  Canco-existwithIntra-ar5cularHipPathology

Thank You! CPDCourses:www.func5on2fitnesss.co.uk/coursesTwieer:@func5on2fitnesEmail:[email protected]

Learning outcomes - Amazon S3 · The mul&-modal program resulted in a signiﬁcantly quicker return...

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