pre-habbing & rehabbing the sporting groin · pre / rehab should include: 1. establish...
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Pre-habbing & Re-habbingThe Sporting Groin
- Early to End Stages
James MooreConsultant Physio RFU & UKA
The Gilmore Groin and Hernia Clinic Symposium RSM, Sept 2011
Diagnostic Flow chart
Pt presents with Abdominal related groin pain
Do they have any Hip symptoms or PE signs? - Image the Hip
Do they have any PJ symptoms or PE signs? - Image the PJ
Do they have any abdominal symptoms or PE Signs? - Image the Abdominals
Treat the Hip, PJ and abdominals for 2-6 weeks
Re-assess for change - two types of patients
Abdominal symptoms & Physical signs are settling
Function has improved, able to do more, Pain no change
Sporting movement - Sprinting
Sporting movement - Kicking
Muscles – Trunk flexors
Grays et al 1994
Inguinal canal
Netter 1994
Transverse Abdominal Fascia
Abdominal inguinal ring (deep inguinal ring)
Conjoint Tendon
Superficial Inguinal Ring
• Roof
– Internal oblique
– Transversus abdominis
• Floor
– Inguinal ligament
– Lacunar ligament
• Anterior Wall
– External oblique aponeurosis
– Internal oblique aponeurosis
• Posterior wall
– Transversalis fascia
– Conjoint tendon
Inguinal canal
Inguinal ligament
Pubic symphysis
Tensile forces Shear forces
Adductor longus enthesis (FC)
Functional sling work in planes
Overlapping clinical entities
Holmich 2007
The blind men and the elephant...
Sportsman’s groin
Adductor dysfunction
Bone stress injury
The blind men and the elephant...
Pubic joint injury!
Abdominal
Adductor Hip joint
Restoring the arches
Snooks 2008
Bassini’s Repair 1884
Pre / Re - Habbing decisions
• Isolation or functional load?
• Inner vs. outer range?
• Isometric vs. concentric vs. eccentric?
• Resisting an extension torque or producing a flexion mvt?
• Sagittal vs. Coronal vs. Transverse?
• Produce vs. resist rotation / coronal?
• Perturbations?
• Max force vs. sub-maximal?
• Time under tension?
• Tensile load?
Trunk stiffness vs core stability
Trunk stiffness - Rotation
Monitoring progress
1. Pain or “stiffness” next morning
2. Squeeze test
–Compare with baseline
3. Pubic symphysis stress tests
4. Adductor muscle tone
–Bent knee fall outs
Hogan 2003
GROIN PROFILE
DAY (DATE)
0 DEG0 DEG 60 DEG60 DEG 90 DEG90 DEG SLING SPECIFICSLING SPECIFIC STRESS HIP IRHIP IR VAS (SQ) KICKS GPS DATAGPS DATAGPS DATA
P1 MAX P1 MAX P1 MAX AOS PHE LEFT RIGHT 0-100 TOTAL >40% TRAINING EFFECT
BASELINE
20.2.11
21.2.11
POST
22.2.11
22.2.11
POST
23.2.11
24.2.11
POST
25.2.11
POST
26.2.11
1/2 TIME
POST
27.2.11
1.3.11
1.3.11 (PM)
2.3.11
280 260 250
180 200 180 200 200 200 180 120 -ve 5 15 20 20
120 180 140 190 160 200 190 120 -ve 0 15 30
60 120 80 140 80 140 NA NA -ve 15 15 50 40
100 140 120 160 120 160 180 120 -ve 0 15 40
120 180 140 180 120 180 NA NA -ve 15 15 30 0 4.5K 1.5K 3.5
120 160 140 180 140 160 NA NA -ve 15 15 30
100 160 120 160 100 180 180 180 -ve 15 15 30
130 190 130 160 170 180 180 180 -ve 5 5 30 0 3.2 840m 2.8
120 160 130 180 120 180 NA NA -ve NA NA 40
120 170 150 160 180 220 180 140 -ve 5 5 30 12 2.0 480.0 2.0
120 160 140 160 160 180 NA NA -ve 5 5 40
160 200 180 190 150 190 180 170 -ve 5 5 30
160 180 180 180 120 150 NA NA -ve NA NA 30
120 160 160 180 100 140 NA NA -ve 10 10 50
100 160 130 150 140 170 NA NA -ve 10 10 40
140 160 150 200 140 200 NA NA -ve 10 10 30
140 200 200 220 170 230 NA NA -ve 15 15 30
200 230 200 230 200 220 NA NA -ve 5 5 20
0
75
150
225
300
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
280
200180
120140
180160 160
190
160170
160
200180
160 160 160
200
230
180
120
60
100120 120
100
130120 120 120
160 160
120100
140 140
200
SQUEEZE: 0 DEGREES
P1 Max
0
65
130
195
260
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
260
200190
140
160
180 180
160 160
180
160 160
190180 180
150
200
220230
180
140
80
120
140 140
120130 130
150140
180 180
160
130
150
200 200
SQUEEZE: 60 DEGREES
60 Deg P1 Max
0
63
125
188
250
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
250
200 200
140
160
180
160
180 180 180
220
180190
150140
170
200
230220
200
160
80
120 120
140
100
170
120
180
160150
120
100
140 140
170
200
SQUEEZE: 90 DEGREES
90 DEG P1 Max
0
25
50
75
100
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
VAS
VAS (SQ) 0-100
GROIN PROFILE
DAY (DATE)
0 DEG0 DEG 60 DEG60 DEG 90 DEG90 DEG SLING SPECIFICSLING SPECIFIC STRESS HIP IRHIP IR VAS (SQ) KICKS GPS DATAGPS DATAGPS DATA
P1 MAX P1 MAX P1 MAX AOS PHE LEFT RIGHT 0-100 TOTAL >40% TRAINING EFFECT
BASELINE
20.2.11
21.2.11
POST
22.2.11
22.2.11
POST
23.2.11
24.2.11
POST
25.2.11
POST
26.2.11
1/2 TIME
POST
27.2.11
1.3.11
1.3.11 (PM)
2.3.11
280 260 250
180 200 180 200 200 200 180 120 -ve 5 15 20 20
120 180 140 190 160 200 190 120 -ve 0 15 30
60 120 80 140 80 140 NA NA -ve 15 15 50 40
100 140 120 160 120 160 180 120 -ve 0 15 40
120 180 140 180 120 180 NA NA -ve 15 15 30 0 4.5K 1.5K 3.5
120 160 140 180 140 160 NA NA -ve 15 15 30
100 160 120 160 100 180 180 180 -ve 15 15 30
130 190 130 160 170 180 180 180 -ve 5 5 30 0 3.2 840m 2.8
120 160 130 180 120 180 NA NA -ve NA NA 40
120 170 150 160 180 220 180 140 -ve 5 5 30 12 2.0 480.0 2.0
120 160 140 160 160 180 NA NA -ve 5 5 40
160 200 180 190 150 190 180 170 -ve 5 5 30
160 180 180 180 120 150 NA NA -ve NA NA 30
120 160 160 180 100 140 NA NA -ve 10 10 50
100 160 130 150 140 170 NA NA -ve 10 10 40
140 160 150 200 140 200 NA NA -ve 10 10 30
140 200 200 220 170 230 NA NA -ve 15 15 30
200 230 200 230 200 220 NA NA -ve 5 5 20
0
75
150
225
300
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
280
200180
120140
180160 160
190
160170
160
200180
160 160 160
200
230
180
120
60
100120 120
100
130120 120 120
160 160
120100
140 140
200
SQUEEZE: 0 DEGREES
P1 Max
0
65
130
195
260
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
260
200190
140160
180 180160 160
180160 160
190180 180
150
200220
230
180
140
80
120140 140
120130 130
150140
180 180160
130150
200 200
SQUEEZE: 60 DEGREES
60 Deg P1 Max
0
63
125
188
250
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
250
200 200
140
160
180
160
180 180 180
220
180190
150140
170
200
230220
200
160
80
120 120
140
100
170
120
180
160150
120
100
140 140
170
200
SQUEEZE: 90 DEGREES
90 DEG P1 Max
0
25
50
75
100
BASELINE 20.2.11 21.2.11 POST 22.2.11 22.2.11 POST 23.2.11 24.2.11 POST 25.2.11 POST 26.2.11 1/2 TIME POST 27.2.11 1.3.11 1.3.11 (PM) 2.3.11
VAS
VAS (SQ) 0-100
Pre / Rehab should include:
1. Establish benchmark
2. Early loading for tissue regulation and pain reduction
3. Progress to dynamic loading - Stress / strain / elastic
4. Integrate dynamic loading - speed
5. Balance the hip & pelvis - Total hip strength
6. Progression based on obj functional & clinical markers
7. Re-evaluate every 2 weeks
8. Time frame to consider surgery
Summary