short overview of some of my previous experience/work with hip and groin injuries.

1. Sporting Hip
and Groin IST
By Darren Finnegan 14/8/12

2. Objectives
• Provide an overview of anatomy and
biomechanics of groin/hip injuries.
• Introduce a concise and thorough
method of diagnosis and
rehabilitation of groin/ hip injuries
• Help understand the diverse injuries
that occur in this complex anatomical
region.

3. Anatomy & Biomechanics
• Muscle imbalance
• Movement restriction
• Fascial slings
• Open vs. closed chain
function of adductors

4. Anatomy Quiz
Partner up!

6. Subjective Assessment
• Acute vs. insidious
• Mechanism
• Red flags
• Aggs/ Eases
• Investigations
• Athletes goals
• Occupation
• Training program
• VAS
• Referral pattern

7. Subjective Ax
• Training volume/intensity
• PMH- previous surgery or injury, medical conditions
• Sport level, technical requirements of sport, changes in
footwear/ environment
• Other joints- LX,SIJ, knee, scrotal pain

8. Objective Assessment
• AROM/PROM
• Fabers
• Quadrant
• Labral
• Cough Impulse
• Squeeze test
• Thomas +/- neural component
• Resisted sit up
• Passive abduction

9. Objective Ax
• Functional tests- hopping,
SLS, SKB, COD, alignment
• Palpation- Rectus
abdominus, Pubis
symphysis, Iliopsoas
• Neural- Obturator,
ilioinguinal, genitofemoral
• Invagination of inguinal ring
• Area A (in orange) genitofemoral nerve;
area B (in green) ilioinguinal nerve; arrow C
(in red with blue outline) shows the
direction and location for cremasteric reflex.

10. Abdominal related pathology
• Intra abdominal-
appendicitis, UTI, gynae
issues, rheumatological
(AS), gout
• Osteitis pubis
• Pubic bone stress syndrome
• ‘Hockey groin’
• Rectus abdominus
tendinopathy
• Inguinal hernia

11. Athletic Pubalgia
• Athletic Pubalgia
• 1/deep pain in groin/abdo
area
• 2/pain agg sprinting,
cutting, kicking, eased by
rest
• 3/Palpable tenderness
over pubic ramus, rec
femoris and/or conjoined
tendon
• 4/Pain on resist add 0,45
+/- 90deg hip flexion
• 5/Pain on resisted sit up

12. Athletic Pubalgia
• Local overload - Pubic bone stress – adductors –
iliopsoas -Posterior ingunial wall deficency - gilmores
/hockey players groin/ external oblique aponeurosis tear
• Definiton- Caudill(2008) phenomena of chronic activtiy
related groin pain unresponsive to conservative MX
and significantly improves with surgery.
• Surgical- Bissini repair- transversalis sewing together,
+/- mesh +/- nerve dehiscence

13. Adductor related pathology
• Trochanteric bursitis
• Gluteus medius
tendinopathy
• Snapping hip
• Rectus femoris strain
• Obturator neuropathy
• Iliopsoas strain/ bursitis/
tendinitis
• Adductor strain/
tendinopathy

14. Hip related pathology
• Femoro-acetabular
impingement
• (Sahrman,2002)
• Primary cause of labral
tears
• CAM
• PINCER
• Stress #- NOF, pubic
ramus, acetabulum
• Synovitis
• Labral
• Chondral lesion
• LX/SIJ referred
• Avulsion apophysitis-
ASIS, AIIS
• Perthes
• Slipped capital femoral
epiphysis

15. Labral Tears
• Extrinsic vs Intrinsic
factors (+/- FAI)
• Pain in anterior inguinal,
thigh and/ or buttocks
region
• AROM/ PROM painful
EOR
• Audible
clicking/catching/ locking
• Snapping Jt line/ ITB
• MRa
• +ve Impingement,
Fabers, Mccarthy
http://www.aafp.org/afp/991015ap/168
7.html

16. Rehabilitation
• 8-12 weeks (continue with rehab for up to1 year)
• Avoid NSAIDs
• Criteria for return to sport/ running-
• a/brisk walking pain free
• b/Thomas test + resist hip flexion pain free
• c/Nil crossover sign
• d/Minimal adductor guarding
• Manual therapy/ Acupuncture/ Soft tissue work
• Home exercise program
• Additional- compression shorts, pelvic belt
• Cycling
• (Brukner and Kahn, 2007)

17. Rehabilitation
• Progression of adductor exercises-  Core
setting
 add squeeze short then long lever
 with sit up
 with Russian twist ¼
 bridging
 plank
 plank with add/abd using friction free surface
standing as above
Other factors to consider????

18. Rehabilitation
kneeling pelvic tilts
 wall squat with pelvic tilt  sumo squat
lunge with reciprocal arm movement
 straight line running
 Change of direction --> sport specific training

19. Take home message
• Any questions?

20. References• Binningsely, D. (2003). Tear of the Acetabular Labrum in an Elite Athlete. British
Journal of Sports Medicine.37 p 84-88.
• http://www.mayoclinic.com/health/hip-labral tear/DS00920/DSECTION=symptoms
• http://www.sportsinjurybulletin.com/archive/acetabular-labrum-tears
• J. C. McCarthy, B. Busconi. Canadian Journal of Surgery. Hip Disease in Young
Adults. Ottawa: Feb 1995. Vol. 38, Iss. 1, p. S13-7 (5 pp.)
• http://www.isakos.com/innovations/soccer.aspx
• Holmlich, Urhskou, Ullnits (1999) Effectiveness of active physical training as
treatment for long standing adductor realted groin pain in athletes- RCT, The Lancet,
353, pp.439-443.
• Quinn, A (2010) Hip and groin pain_ physiotherapy and rehabilitation issues,
the open sports medicine journal, 4, pp.93-107.
• Bizzinni, M (2012) the groin area_ the bermuda triangle of sprots medicine, british
journal of sports medicine, 45.
• Caudill, P, Nyland, J, Smith,C (2008) Sports hernia a systematic literature review,
british journal of sports medicine, 42, pp.954-964.
• Internation Olympic committee World conference: prevention of injury in sport,
http://www.ioc-preventionconference.org/OnLPMonaco.php, Monaco.
Symposium 16 Session B.

21. References
• Brukner and Kahn (2007) clinical sports medicine, 3rd
edition, McGraw hill, pp.405-424.
• Sahrman,S (2002) diagnosis and treatment of movement
impairment syndromes, Mosby, pp.121-144.
• Gibbons SGT (1999) A review of the anatomy,
physiology and function of psoas major: A new model of
stability. Proceedings of: The Tragic Hip: Trouble in the
Lower Quadrant. 11th Annual National Orthopaedic,
Symposium. Halifax, Canada. Nov 6-7.
• Moore, J (2011) Pre-habbing and rehabbing the
sporting groin, the gilmore groin and hernia
symposium,RSM,.