why gilmore’s groin is not a hernia 16.06.2011
TRANSCRIPT
WHY GILMORE’S GROIN WHY GILMORE’S GROIN IS IS
NOT A HERNIANOT A HERNIA
16.06.201116.06.2011
GILMORE’S GROINGILMORE’S GROIN
SPORTSMEN GROINSPORTSMEN GROIN
GROIN DISRUPTION GROIN DISRUPTION
ATHLETIC PUBALGIAATHLETIC PUBALGIA(Sportsmen hernia NO!)(Sportsmen hernia NO!)
CASE 1CASE 1 D.M. 27D.M. 27
FULL BACK:FULL BACK: TOTTENHAM HOTSPUR FCTOTTENHAM HOTSPUR FC
PRESENTED:PRESENTED: 28.08.8028.08.80
SYMPTOMS:SYMPTOMS: 17 WEEKS GROIN PAIN17 WEEKS GROIN PAIN
AFTER EVERSION INJURYAFTER EVERSION INJURY
LAST GAME:LAST GAME: 17 WEEKS17 WEEKS
PAIN INCREASED:PAIN INCREASED: SPRINTINGSPRINTING
KICKINGKICKINGTWISTING & TURNINGTWISTING & TURNINGCOUGHINGCOUGHINGSNEEZINGSNEEZING
CASE 1CASE 1 D.M.D.M.
PREVIOUS INVESTIGATIONS:PREVIOUS INVESTIGATIONS:
3 ORTHOPAEDIC OPINIONS3 ORTHOPAEDIC OPINIONSX-RAYX-RAYCT SCANCT SCANU/S SCANU/S SCAN
PREVIOUS TREATMENT:PREVIOUS TREATMENT:
COMPLETE RESTCOMPLETE RESTPHYSIOTHERAPYPHYSIOTHERAPYMANIPULATIONMANIPULATIONLOCAL STEROIDSLOCAL STEROIDS
CASE 1 D.M. PHYSICAL SIGNSCASE 1 D.M. PHYSICAL SIGNS
INSPECTION:INSPECTION: N.A.D. –NO SWELLINGN.A.D. –NO SWELLING
PALPATION:PALPATION: N.A.D. – NO LUMPN.A.D. – NO LUMP
PALPATION VIA SCROTUM:PALPATION VIA SCROTUM:-- RIGHT SUPERFICIAL INGUINAL RIGHT SUPERFICIAL INGUINAL
RING DILATEDRING DILATED
-- COUGH IMPULSECOUGH IMPULSE
-- TENDERTENDER
INSERTION OF FINGER PAIN COMPARED TO OPPOSITE SIDEINSERTION OF FINGER PAIN COMPARED TO OPPOSITE SIDE
Presented 16.03.81(Eversion / Overstretching Injury)
15 wks Groin Pain but No Lump Prevented Training /Play
Post Op: Training with Aberdeen 3 wks In Scotland Squad 7 wks
GROIN DISRUPTION GROIN DISRUPTION TYPICAL PATIENTTYPICAL PATIENT
• YOUNG MALEYOUNG MALE
• ACTIVE SPORTSMENACTIVE SPORTSMEN
• RARE OVER 45RARE OVER 45
• RARE IN FEMALES (1%)RARE IN FEMALES (1%)
GROIN DISRUPTIONGROIN DISRUPTION
• MUSCULO – TENDINOUS INJURYMUSCULO – TENDINOUS INJURY
• ALL LAYERS GROINALL LAYERS GROIN
• INGUINAL + (ADDUCTOR 40%)INGUINAL + (ADDUCTOR 40%)
• ““MUSCLE DISLOCATION”MUSCLE DISLOCATION”
ONSET OF SYMPTOMSONSET OF SYMPTOMS
INSIDIOUSINSIDIOUS 72%72%
SPECIFIC INJURYSPECIFIC INJURY 28%28%
OVERSTRETCHINGOVERSTRETCHING MISKICKINGMISKICKING ABDUCTIONABDUCTION EVERSION EVERSION
PATIENT’S REFERRED with PATIENT’S REFERRED with GROIN PAINGROIN PAIN
1980 - 20101980 - 2010
TOTALTOTAL 77387738
MALEMALE 74797479 (9(977%)%)
FEMALEFEMALE 259259 ((33%)%)
INCIDENCE OF OPERATIONINCIDENCE OF OPERATION1980 - 20101980 - 2010
Referred
7738 pts
Ops
4466 pts
58%
C
1980-20101980-2010
Over 31 years 7479 SporsmenOver 31 years 7479 Sporsmen
referred with “Groin Pain”referred with “Groin Pain”
Many have returned with other complaintsMany have returned with other complaints
including Haemorrhoids and skin lesionsincluding Haemorrhoids and skin lesions
But ONLY 1 with HERNIA But ONLY 1 with HERNIA
INTERNATIONALS 1980-2010INTERNATIONALS 1980-2010SOCCER SOCCER 257257
RUGBY UNION RUGBY UNION 4444
ATHLETESATHLETES 2424
CRICKETCRICKET 2222
RUGBY LEAGUERUGBY LEAGUE 1717
HOCKEYHOCKEY 1515
HANDBALLHANDBALL 4 4
RACQUET GAMESRACQUET GAMES 44
SKIINGSKIING 22
BASKETBALLBASKETBALL 2 2
FENCING FENCING 2 2LACROSSELACROSSE 2 2MARTIAL ARTS MARTIAL ARTS 3 3ICE HOCKEYICE HOCKEY 22GYMNASTICSGYMNASTICS 1 1WATERPOLOWATERPOLO 1 1ROWINGROWING 11"STRONGMAN" "STRONGMAN" 1 1WEIGHT LIFTING WEIGHT LIFTING 1 1
______________________________________________
TOTALTOTAL 407407
SYMPTOMS DURING EXERCISESYMPTOMS DURING EXERCISE
PAIN IN GROIN INCREASES WITHPAIN IN GROIN INCREASES WITH
RUNNINGRUNNINGSTRIDINGSTRIDINGSPRINTINGSPRINTINGSUDDEN MOVEMENTSUDDEN MOVEMENTTWISTING & TURNINGTWISTING & TURNINGSIDE STEPPINGSIDE STEPPINGJUMPINGJUMPINGDEAD BALL KICKINGDEAD BALL KICKINGLONG BALL KICKINGLONG BALL KICKING
(BUT NO SWELLING)(BUT NO SWELLING)
SYMPTOMS AFTER EXERCISESYMPTOMS AFTER EXERCISE
PAIN IN GROIN INCREASES WITHPAIN IN GROIN INCREASES WITH
TURNING IN BEDTURNING IN BED
GETTING OUT OF BEDGETTING OUT OF BED
GETTING OUT OF CARGETTING OUT OF CAR
SIT UPSSIT UPS
COUGHINGCOUGHING
SNEEZINGSNEEZING
SUDDEN MOVEMENTSUDDEN MOVEMENT
STIFF & SORE
MRI in Groin DisruptionMRI in Groin Disruption
MRI Poor in AbdomenMRI Poor in Abdomen
Resolution insufficient for subtle changesResolution insufficient for subtle changesBut Inguinal ligament – clearly visibleBut Inguinal ligament – clearly visible HerniaHernia
Gross Scar TissueGross Scar TissueDefects / GapsDefects / GapsSignificant DisruptionSignificant Disruption
MRI Good in Pelvis & ThighMRI Good in Pelvis & ThighAdductor TearAdductor TearOsteitis pubisOsteitis pubisHIP PathologyHIP Pathology
Also visible
clearly seen
David Connell 2009
Ultrasound in Groin DisruptionUltrasound in Groin Disruption
State of Art Ultrasound Equipment – requiredState of Art Ultrasound Equipment – required
Subtle changes in Inguinal ligamentSubtle changes in Inguinal ligament
Conjoined TendonConjoined Tendon
Dynamic assessment – EssentialDynamic assessment – Essential
Abdominal strainingAbdominal straining
SonopalpationSonopalpation
Tender over Inguinal CanalTender over Inguinal Canal
Bulging Post. WallBulging Post. Wall
HERNIA: Shows Clearly as Peritoneal Sac or ProtrusionHERNIA: Shows Clearly as Peritoneal Sac or Protrusion
maybe seen
David Connell 2009
31 Years No Groin 31 Years No Groin PatientPatient
Complained of Complained of SwellingSwelling
INDICATIONS FOR SURGERYINDICATIONS FOR SURGERYGroin DisruptionGroin Disruption
PROFESSIONALPROFESSIONAL
ANDAND
AMATEURAMATEUR
FAILED CONSERVATIVE FAILED CONSERVATIVE TREATMENTTREATMENT
INDICATION FOR INDICATION FOR SURGERY: SURGERY:
PROFESSIONALSPROFESSIONALS
GAME INHIBITEDGAME INHIBITED
TRAINING INHIBITEDTRAINING INHIBITED
LOSS OF LOSS OF SPEEDSPEED
LOSS OF LOSS OF FITNESSFITNESS
INDICATION INDICATION FOR SURGERY: FOR SURGERY:
AMATEURSAMATEURS
SYMPTOMS AFFECTSYMPTOMS AFFECT
EVERYDAY LIFEEVERYDAY LIFE
LOSS OF SPORT AFFECTS LOSS OF SPORT AFFECTS QUALITY OF LIFEQUALITY OF LIFE
GROIN DISRUPTION: PATHOLOGYGROIN DISRUPTION: PATHOLOGYFound at OperationFound at Operation
TORN EXTERNAL OBLIQUE ====TORN EXTERNAL OBLIQUE ==== DILATED DILATED SUPERFICIAL SUPERFICIAL INGUINAL RINGINGUINAL RING
TORN CONJOINED TENDONTORN CONJOINED TENDON
CONJOINED TENDONCONJOINED TENDON
}} DEHISCENCEDEHISCENCEINGUINAL LIGAMENTINGUINAL LIGAMENT
( 40% also have Adductor Pathology)( 40% also have Adductor Pathology)
Groin Disruption SurgeryGroin Disruption SurgeryGroin ReconstructionGroin Reconstruction
• Normal Anatomy - RestoredNormal Anatomy - Restored• Each layer – RepairedEach layer – Repaired• Each Injury- RepairedEach Injury- Repaired• Permanent Suture – EssentialPermanent Suture – Essential• Nylon Darn / Ethilon DarnNylon Darn / Ethilon Darn
• Preferable to Absorbable Sutures (Don’t Last)Preferable to Absorbable Sutures (Don’t Last)• Preferable to Mesh (May Restrict Mobility)Preferable to Mesh (May Restrict Mobility)
CONJOINED TENDON REPAIR
TRASVERSALIS FASCIA PLICATED with O Vicryl
TENSION FREE NYLON DARN
(CONJ. TENDON to ING. LIG)
EXT OBLIQUE REPAIR
(NEW S.I.R)
GROIN DISRUPTIONGROIN DISRUPTION& ADDUCTOR TEAR& ADDUCTOR TEAR
PRESENT IN 40%PRESENT IN 40%
HALF REQUIREHALF REQUIRE
ADDUCTOR TENOTOMYADDUCTOR TENOTOMY
D
No evidence of increased incidence of No evidence of increased incidence of
Hernia in Sportsmen Hernia in Sportsmen
Groin Disruption/Gilmore’s GroinGroin Disruption/Gilmore’s Groin
Neither Hernia or Pre HerniaNeither Hernia or Pre Hernia
Terminology HERNIA: IncorrectTerminology HERNIA: Incorrect
HERNIA IN SPORTSMENHERNIA IN SPORTSMEN
B
QUOTEQUOTE
““Jerry Jerry I had your “Groin” in 74,I had your “Groin” in 74,
As did my colleague Alan MulleryAs did my colleague Alan Mullery
We both had to rest for monthsWe both had to rest for months
There was no other treatment then”There was no other treatment then”
Terry Venables 2006Terry Venables 2006
E
A Protrusion of a Viscus beyond A Protrusion of a Viscus beyond
it’s normal confinesit’s normal confines
HERNIAHERNIA
HERNIA (2% MALES IN UK)HERNIA (2% MALES IN UK)
INGUINAL 73%INGUINAL 73%
FEMORAL 17%FEMORAL 17%
(Bailey & Love )(Bailey & Love )
INGUINAL – DIRECTINGUINAL – DIRECT INDIRECT INDIRECT
FEMORALFEMORAL
OBTURATOROBTURATOR
GROIN HERNIAGROIN HERNIA
H
INDIRECT INGUINAL HERNIAINDIRECT INGUINAL HERNIAPRESENTATIONPRESENTATION
Usually young malesUsually young males
Swelling only occurs with Swelling only occurs with
standing/strainingstanding/straining
Swelling can be difficult to reduce Swelling can be difficult to reduce
If swelling persists - PainIf swelling persists - Pain
Swelling which when present Swelling which when present causes pain or discomfort causes pain or discomfort
Irreducible swellingIrreducible swelling
StrangulationStrangulation
HERNIA: INDICATION HERNIA: INDICATION FOR SURGERYFOR SURGERY
INDIRECT INGUINAL INDIRECT INGUINAL HERNIA OPERATIONHERNIA OPERATION
Herniotomy (Excise Indirect Sac)Herniotomy (Excise Indirect Sac)
Reconstitute Inguinal canalReconstitute Inguinal canal
(Repair only necessary if post wall defect)(Repair only necessary if post wall defect)
I
DIRECT INGUINAL HERNIADIRECT INGUINAL HERNIA
Protrusion of Viscus throughProtrusion of Viscus through
Post Inguinal Canal WallPost Inguinal Canal Wall
Due to defect in Post WallDue to defect in Post Wall
J
Swelling readily appearsSwelling readily appears
with Coughing or Standing with Coughing or Standing
Swelling reduces when lying down Swelling reduces when lying down
Patient often complains of discomfort with Patient often complains of discomfort with
Standing e.g. cocktail parties or window shoppingStanding e.g. cocktail parties or window shopping
(Sport rarely Restricted)(Sport rarely Restricted)
DIRECT INGUINAL HERNIA DIRECT INGUINAL HERNIA PRESENTATIONPRESENTATION
K
Reduce Peritoneal SacReduce Peritoneal Sac
Insert MeshInsert Mesh
Close Ext Oblique & SkinClose Ext Oblique & Skin
DIRECT INGUINAL DIRECT INGUINAL HERNIA OPERATIONHERNIA OPERATION
Protrusion through Femoral CanalProtrusion through Femoral Canal
Swelling: Below and lateral to pubic tubercle Swelling: Below and lateral to pubic tubercle
i.e. Upper thighi.e. Upper thigh
FEMORAL HERNIAFEMORAL HERNIA
Reduce Sac contentsReduce Sac contents
Excise SacExcise Sac
Suture Lacunar to Inguinal ligamentSuture Lacunar to Inguinal ligament
FEMORAL HERNIA OPERATIONFEMORAL HERNIA OPERATION
Groin Disruption/Gilmore’s GroinGroin Disruption/Gilmore’s Groin
Significantly different to HerniaSignificantly different to Hernia
InguinalInguinal
FemoralFemoral
ObturatorObturator
Only similarity: SITEOnly similarity: SITE
SYMPTOMS & PATHOLOGYSYMPTOMS & PATHOLOGY
DEPENDS ON DEPENDS ON
ACCURATE DIAGNOSIS ACCURATE DIAGNOSIS OfOf
PATHOLOGY PATHOLOGY
CORRECT SURGICAL TREATMENTCORRECT SURGICAL TREATMENT ALWAYS ALWAYS
Groin Disruption/Gilmore’s GroinGroin Disruption/Gilmore’s GroinSignificantly different to HerniaSignificantly different to Hernia
REPAIR using Hernia Mesh TechniqueREPAIR using Hernia Mesh Technique Open or Laparoscopic Open or Laparoscopic Usually FAILSUsually FAILS
PATHOLOGYPATHOLOGY in in
F
““I have had the mesh repair I have had the mesh repair
But I can still feel a tear behind the meshBut I can still feel a tear behind the mesh
My symptoms have not improved”My symptoms have not improved”
P.W P.W Patient 2009Patient 2009
8% our Operations in 8% our Operations in Patients with Previous Groin Patients with Previous Groin
RepairRepair
A
““General Surgeons in this area either General Surgeons in this area either
do not recognise Gilmore’s Groin ordo not recognise Gilmore’s Groin or
They treat it as a Hernia They treat it as a Hernia
with mesh repair, which fails”with mesh repair, which fails”
Johnny MorrisJohnny MorrisSports Medicine PhysicianSports Medicine PhysicianHampshire 2011Hampshire 2011
QUOTEQUOTE
F
DOES NOT CUREDOES NOT CUREOFTEN COMPLICATESOFTEN COMPLICATESSIGNIFICANT DELAY in RECOVERYSIGNIFICANT DELAY in RECOVERY ororRESULTS IN FAILURERESULTS IN FAILURE
Conclusion:Wrong DiagnosisConclusion:Wrong DiagnosisResulting in Wrong OperationResulting in Wrong Operation
Patients with Groin ProblemsPatients with Groin ProblemsDeserve aDeserve a
GROIN SURGEONGROIN SURGEON
16.06.201116.06.2011