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CoreMuscleInjuries
R.RobertFranks,D.O.,FAOASMDirectorofConcussionProgram
SportsMedicineRothmanInsBtute
AssociateProfessorFamilyMedicineThomasJeffersonUniversityPhiladelphia,Pennsylvania
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PleaseDONOTCallThemSportsHernias
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IntroducBon
• Philadelphiaathleteswithcoremuscleinjuries– Eagles’DonovanMcNabb
– Eagles’ZachErtz– Eagles’KevinCurBs– Flyers’DannyBriere
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IntroducBon
• Incidentofgroinpainis5to7%ofallsportsinjuries
• Mostcommoninsoccer,iceandfieldhockey,tennisandAustralianRulesFootball
• SomestudieshaveaVributedincreaseddiagnosistomoreaggressiveathleBcplaybutotherstudieshavecitedgreaterawarenessofcoremuscleinjuriesbyCerBfiedAthleBcTrainersandSportsMedicinePhysicians
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IntroducBon
• Oneofleastunderstood,inadequatelydefinedandpoorlyresearchedaffecBonsofallsportsmedicineinjuries
• CoremuscleinjuriesareactuallyseveraldifferentcondiBonslumpedtogetherunderonecommonmedicalterminology
• Canbeacute,chronic,oracuteonchronicvariety
• Foundmorecommonlyinmalethanfemaleathletes
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DifferenBalDiagnosis
• Adductorstrain• OsteiBsPubis• IliopsoasStrains/BursiBs• StressFractures• AvulsionFractures• HipPathology–LabralTear,FAI,SnappingHip• NerveCompression
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Anatomy
• BonyPelvis– Ilium
– Ischium– Pubis– Sacrum/Coccyx
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Anatomy
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Anatomy
• So\Tissue– FibrousaVachmentofpubicsymphysis
– FibrocarBlagearBculardiscbetweenpubicboneswithaVachedligaments
– Mostimportantisthearcuateligamentattheanterior,inferiormarginofthejointaVachingtothesymphysiscapsule,bothpubictuberclesandprovidingasuperficialaVachmentforregionaltendon/musclecomplex
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Anatomy
• So\Tissue– RightandLe\RectusAbdominis/AdductorAponeuroses• MeetatmidlinepubicsymphysiscontainingverBcalrapheformingadensemidlinepubicplate
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Anatomy
• So\Tissue– AdductorMuscles
• PecBneus–Anterior• AdductorBrevis,Gracilis,andAdductorMagnus-Posterior
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Anatomy
• So\Tissue– InguinalRing
• Lateraltoaponeuroses– ExternalObliqueblendingwithlateralmarginofRectusAbdominusformingExternalObliqueAponeuroses–superficialtoinguinalcanalandcephaladandlateraltoring
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Anatomy
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AnatomicalBalance
• RectusAbdominiscreatesposteriortension• AdductorscreateinferoanteriortensionwithcorerotaBonandextension
• ThisopposiBonalongwithaponeurosisneededforanteriorpelvicstability
• DisrupBonofthisbalanceleadstocoremuscleinstabilityandcoremuscleinjury
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Anatomy
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Pathogenesis
• Groininjuriesusuallyoccurfromthefollowing:– Overuse– Increasedshearingacrossthehemipelvis– Lumbopelvicandlowerextremitymusclestrengthendurance,extensibility,andcoordinaBonimbalance
– LossofdynamicabdominalwallrotaBonalstability– Lossofcongenitalinguinalwallweakness– Overallcoreweakness
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MostCommonCauses
• Hipadductorstrain/tearwithpalpablepainatpubicboneaVachmentandresistedhipadducBon
• Iliopsoasstrain/tearwithpalpablepainofmuscleatlowerlateralabdomenorjustdistaltoinguinalligament.Paino\enwithcrunchorresistedcrunch.Canbeco-morbidThomasTestpain
• Rectusabdominisstrain/tearwithpalpablepainatdistaltendonoronaVachmentatpubicboneandpainwithresistedsitup
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MostCommonCauses
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PhysicalExaminaBonFindings
• NOdetectableinguinalhernia• Inguinalcanaltenderness• Dilatedsuperficialinguinalring• Pubictubercletenderness• Hipadductororigintenderness
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PhysicalExaminaBonFindings
• KeyphysicalfindingmaybepubictubercletendernessandinguinalfloortearthatcanpossiblybepalpatedcreaBngpaininsidetheexternalinguinalring– PainmyradiatetotesBcleorlaterallytoupperthigh
– Aggravatedbysuddenmovement,Valsalva,sexualacBvity,resistedsitup,orhipadducBon
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Imaging
• TradiBonalX-rayviewsinclude:– APPelvis– APandlateralofaffectedhip
• X-rayscanyieldchangesassociatedwith:– FAI– OA– OsBBsPubis– AvulsionFracture
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Imaging
• TradiBonalultrasoundisusefulmodalitytodiagnoseINGUINALHERNIA
• CTiso\enusedtodiagnoseINGUINALHERNIA
• MSKUltrasoundidenBfiestendonopathiesandtendon/muscletearsbutincompleteinlookingatinflammatoryanddegeneraBvebonyprocesses
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Imaging
• MRIofAthleBcPubalgiaseries– 1.5Teslaunitwithphasedarray,mulBchannelcoilgivesbestimaging
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MRIofAthleBcPubalgiaSeries
• Sequencesincludethefollowing:– EnBrebonypelvisincludinghighresoluBonsequencesoverthepubicsymphysis
– Standardcoronal,sagiValandaxialplanes,butalsocoronalobliqueimagingplanefromanteriormarginoftheiliaccrestformingasagiVallocalizersequence(alongthearcuatelineofthepelvis)neededtoseetherectusabdominus/adductorlongusaponeurosisanditsaVachmentatpubictubercle
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MRIofAthleBcPubalgiaSeries
• Sequencesincludethefollowing:– Largefieldofviewsequencefromumbilicustomidthigh
– Smallerfieldofviewsequencesfocusedonpubicsymphysisextendingthroughthepubicramibilaterally
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MRIofAthleBcPubalgiaSeries
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Treatment
• ConservaBve:– Rest– Ice– NSAIDs– DisconBnuaBonofoffendingacBvity
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Treatment
• ConservaBve:– PhysicalTherapy
• ModaliBesthatmayassistinrecoveryinclude– E-sBm
– DeepBssuemassage
– AcBveReleaseTherapy– GrastonTechnique– Iontophoresis
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Treatment
• ConservaBve:– PhysicalTherapy
• Focusedprogressivehipadductorstretchingandstrengtheningexercisesaswellasextensivecoremusclestrengthening
• Exercisetoimprovestrength,endurance,coordinaBonandappropriatehipandabdominalmusclebalanceaswellascorestability– AbducBon,adducBon,flexionandextensionexercises– Sit-ups– Wobbleboard– Slidingboard– FiVerexercises
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Treatment
• ConservaBve:– OMT
• Focusedtreatmentonhip/pelvisando\ensacrum/SIjoint
– PhysicalTherapy• Returntosportsisgenerallya\er8-12weeksoftreatmentwithathletepainfreeinPTandwithexerBontherapy
• Athletemustbeabletosuccessfullypasssport-specificacBvity–cuingandsmoothdirecBonalchangearecriBcal
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Treatment
• ConservaBve:– CorBcosteroidInjecBon
• UsuallydoneatinserBonofrectusabdominisoradductorlongustendonsusuallyatpubictubercle
– ProlotherapyInjecBon• Sclerosingagentinjectedatoneofthefollowingsites:
– AdductoraVachments
– Conjoinedtendonatpelvicrim
– Pubicsymphysis
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Treatment
• Surgical– ExploraBonandrepairconsideredwhenrestandnonsurgicaltreatmenthasbeenaVemptedUNLESS• TruepathologyelicitedonMRIandconservaBvetreatmentwouldnotbeconducivetoahighlevelathlete–i.e.competedisrupBonofpubicplateinicehockeyplayer
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Treatment
• Surgical– Openorlaparoscopicapproachescanprovidegoodresults
– Mostrepairsaddressrepairofabdominalmuscles,adductormuscles,orboth,orfascianeartheinguinalligament.
– Repairsthatdonotaddressesforcescausingpathologyareo\enunsuccessful
– Whetheropenorlaparoscopic,repairratesvaryfrom63to95%
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Treatment
• Surgical– Laparoscopicrepairusuallyassociatedwithquickerreturntosports• Trainingat4weeks• FullacBvityat6weeks
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Treatment
• Post-SurgicalRehabilitaBon– GooddatalackingforreturntoacBvityfollowingsurgery
– SomephysiciansdonotdoPTa\ersurgery
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Treatment
• Post-SurgicalRehabilitaBon– PTpost-surgicalgenerallyconsistsofthefollowing:• Avoidanceofsharp,sudden,cuingmovements
• Lowerextremityinflexibility,weakness,andlackofcoordinaBoniscorrected
• Runningstraightaheadatday21• SprinBngwithoutcuingatweek3• FullacBvitya\erlaparoscopicrepairin6to8weeks• FullacBvitya\eropenrepairatapproximately18weeks
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References
• Caudill,P,EtAl.“SportsHernias:ASystemicLiteratureReview.”BrJSportsMed.42:954-964.July2008.
• Kachingwe,AF,Grech,S.“ProposedAlgorithmfortheManagementofAthletesWithAthleBcPubalgia(SportsHernia):ACaseSeries.”JournalofOrthopaedicandSportsPhysicalTherapy.38:768-781.December2008.
• Larson,CM.“SportsHernia/AthleBcPubalgia:EvaluaBonandManagement.”SportsHealth.6:139-144.January2013.
• Morelli,V.,EtAl.“GroinInjuriesinAthletes.”AmericanFamilyPhysician,64:1405-1414.2001.
• Mullens,FE,Zoga,AC,EtAl.“ReviewofMRITechniqueandImagingFindingsinAthleBcPubalgiaandtheSportsHernia.”EuropeanJournalofRadiology,81:3780-92
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PhotoReferences
• 1.FromAntenatalCareModule–AnatomyoftheFemalePelvis
• 2.Fromwww.rebalancetoronto.com
• 3.UMEMEducaBonalPearls–UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine
• 4.FromSportsHealth:sph.sagepub.com
• 5.Fromwww.radsource.us