Pre-habbing & Re-habbing The Sporting Groin - Early to End Stages James Moore Consultant 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
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Pre-habbing & Rehabbing the Sporting Groin · Pre / Rehab should include: 1. Establish benchmark 2. Early loading for tissue regulation and pain reduction 3. ... Pre-habbing & Rehabbing
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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