Diagnosis And Medical Management Of chronic Groin pain Dr Mark Wotherspoon MB BS, DipSportsMed(Lond), FFSEM Consultant in Sports and Exercise Medicine

Introduction Groin injury is common Large differential diagnosis Seen in sports with kicking/sprinting/change direction i.e football/rugby/hockey Complex anatomy No consensus on pathology/pathophysiology or management

Pubalgia Pain arising from local structures in the pubic area 2-5% of sporting injuries 5-7% football injuries Chronic and debilitating condition Prolonged recovery period Difficult to assess clinically Poorly imaged/interpreted On-going debate/research Reflects chronic stress in pubic region resulting in breakdown in a variety of ways Similar to “Shin Splints”

Causes of Pubalgia Bone Pubic: osteitis pubis Joint Nonpubic: pelvic stress fractures Joint Pubic: pubic instability/disc degeneration Nonpubic: hip joint/SIJ/Lumbar spine Musculotendinous Pubic: adductor tendinopathy/rectus abdominis inguinal canal pathology conjoint tendinopathy Nonpubic: iliopsoas dysfunction rectus femoris injury Nerve Entrapment Ilio-inguinal Nerve/Obturator Nerve Genito-urinary Prostatitis/salpingitis/epididymitis Other Hernias/tumours(osteiod osteoma) Infection/seronegative spondarthropathy

Main Causes Sportsmans surgical groin/Abdominal related groin pain Pubic Bone stress Response Chronic Adductor Tendinopathy/Adductor Related Groin Pain Hip related groin pain

Risk Factors Previous groin pain Level of sport Number of training sessions Flexibility Muscle imbalance Poor core stability / functional movement Reduced hip ROM especially internal rotation

Symptoms Pain in groin Worse with twisting,sprinting,kicking Stiff/sore after sport Non specific loss of power / speed Radiates into upper thighs,perineum,testicles Unilateral/bilateral Coughing/sneezing Turning over in bed/getting out of a car Insidious onset and often play with it Sit-ups Exclude the hip

Signs Exclude the hip, SIJ’s and back Localisation of pain Resisted single and bilateral SLR Resisted sit up Adductor squeeze in all ranges Adductor signs Sites of tenderness Modified Thomas test/ crossover sign Exclude psoas Burden of evidence

Investigations X-ray +/- stork views Bone scan CT scan / CT spect MRI / MR arthrogram Herniography Ultrasound Diagnostic LA injection into hip Hip arthroscopy

Abdominal Related Groin Pain Abdominal symptoms Pain with cough and sneeze Tenderness over conjoint tendon at pubic tubercle Tender/dilated superficial inguinal ring Number of different surgical theories/operations ? Rx with belt

Abdominal Related Groin Pain Munich Approach David Connell’s radio-ablation Gilmore’s technique David Lloyd’s tenotomy

Munich Approach Swelling in stretched / weak posterior inguinal canal wall Identified digitally or via ultrasound Transversalis fascia dilates widening Hasselbach’s triangle With abdominal muscle contraction swelling increases Compression of genital branch of genitofemoral nerve (dull pain radiating around pubic region) Tension on rectus abdominis insertion at pubic tubercle (pubalgia)

Munich Approach No mesh Laparoscopic Genital branch of genitofemoral nerve indentified and if necessary partially excised Reduction in tension of rectus abdominis at pubic bone by special suture repair Repair of weak posterior wall of inguinal canal with sutures Local anaesthetic

Munich Approach Day case surgery Jogging / cycling at 2 days Sprinting / change of direction at 3-4 days Full training 5-6 days Back to sport at 6-7 days 1,100 operations per year 7% of which are elite athletes 99% successful

Pulsed Radiofrequency Assumption is that inguinal related groin pain is nerve entrapment/irritation around inguinal ligament Under LA Along inguinal ligament past genitofemoral nerve and ilioinguinal nerve Pulsed radiofrequency stuns the nerves for 9 months. Rest 2 days after and start rehab

Laparoscopic Inguinal Ligament Tenotomy Acute/chronic injury of inguinal ligament at pubic tubercle Tatty scarred inguinal ligament at insertion into pubic tubercle with holes and ruptures Sutures if previous surgery Mesh to re-inforce posterior wall of inguinal canal and change pressure onto mesh rather than inguinal ligament Divide inguinal ligament and scar tissue

Inguinal Ligament Tenolysis Aggressive rehab with stretches No sutures so safe Train at 1 week Full training at 2 weeks Return to play at 4 weeks 400 operations Few failures

David Lloyd’s Main Criteria Unilateral pain Abdominal related groin pain Pain radiates < 5cm from superior pubic tubercle Tender superior pubic tubercle Pain with cough/sneeze Pain reproduced by resisted sit ups/Valsalva manoevre

Prognosis Good outcome if 4 main criteria present Low success if pain radiates > 5 cm from superior pubic tubercle especially if laterally

Abdominal Related Groin Pain – is it a continuum ? Munich Approach David Connell’s radio-ablation Gilmore’s technique David Lloyd’s tenotomy

Pubic Bone Stress Response Repetitive minor trauma leads to painful non infectious/stress related lesion at pubic symphysis and local muscle insertions/origins Men more than women Maximum tenderness at or adjacent to symphysis Stress reactions at adductor tubercle and pubic tubercles Shearing forces across symphysis Rare as primary problem / asymptomatic finding

Investigations X-ray - if early nothing sclerosis, erosions, widening of symphysis, periosteal reactions, moth eaten Bone scan - hot MRI stress reactions and marrow oedema,fluid in symphysis etc

Treatment Modified rest/prevent shearing Rehabilitation/flexibility NSAID’s to reduce inflammation U/S guided cortisone injections Usually 2-3 months Can last 3-6 months Graded return to sport Bisphosphonates

Chronic Adductor tendinopathy Easy diagnosis with pain resisted contraction,local tenderness adductor tubercle and pain and resisted stretch Usually adductor longus Insertion into pubic tubercle +symphysis ie blends in not one insertion site U/S and MRI confirm diagnosis Local physio Rx, ? U/S guided cortisone, ? Dry needling and autologous blood / PRP Adductor tenotomy Graded rehabilitation programme

Iliopsoas Related Groin Pain Pain on stretch – Thomas’s test Pain on resisted hip flexion at 90 Tender on palpation Snapping hip(hip flexion/abduction and extend) Psoas bursae – one deep to psoas can become symptomatic (one anterior to hip like Baker’s cyst in knee)

Iliopsoas Related Groin Pain U/S or MRI Local physio Rx / rehab U/S guided injection

Summary Spectrum of same problem Conditions can co-exist Prevention best treatment/Pre-hab All need rehabilitation as main stay of Rx MRI Ix of choice 4-6 wks rehab/Rx and re-asses/pick off what is left Multidisciplinary Team/Groin clinic

Summary Exclude other pathology eg hip/back History particularly coughing/sneezing/turning in bed Examination chronic adductor + pubic symphysis tendernes Choose patients for surgery + surgeon + when New developments

Iv pamidronate/calcitonin Groin Pain assessment Ix with MRI +/- US Rehab 4-6 wks If improving C/T review PBS response Iv pamidronate/calcitonin Chronic adductor Autologous blood Sportsman’s hernia surgery Psoas dysfunction us guided inj C/T rehab