The Painful Groin: Introduction (03:02)
The American Medical Society for Sports Medicine brought internationally renowned experts known for their approaches to groin pain. Dr. Adam Weir will speak on the classification of Groin injuries. 24 individuals collaborated to create a unified definition and terminology.
Doha Agreement Meeting (03:59)
Doha sent out a Delphi method questionnaire to discover how physicians categorized and defined groin pain. Dr. Weir presents a case study and asks the audience members to diagnose.
What Is the Diagnosis? (02:14)
Sports physicians, physiotherapists, general and orthopedic surgeons, and radiologists used 18 different terms to diagnose the patient. Weir will present the outcome of the Doha Agreement meeting.
Clinical Examination-Based Classification (02:47)
Doha defined adductor, iliopsoal, inguinal, pubic related for groin pain in athletes. Dr. Weir will also touch upon hip-related and other causes. The techniques provided are based upon Per Holmich's 2004 paper.
Different Types of Groin Pain (04:04)
Dr. Weir reviews the definitions for adductor, iliopsoal, inguinal, and pubic related groin pain. If ROM, FABER, and FADIR tests do not reproduce pain, the hip is less likely to be the culprit. The June edition of the British Journal of Sports Medicine will include a large table of other potential causes.
Recommendations Against Terms (02:31)
The Doha agreement meeting advocated not using the following terms with regards to groin pain: adductor/iliopsoas, tendinitis, tendinopathy, athletic groin pain, athletic pubalgia, Gilmore's groin, groin disruption, hockey-goalie syndrome, hockey groin, osteitis pubis, sports groin, and sports hernia. Physicians wanted to create a common language to discuss injury.
Next Panelist (02:42)
Dr. Justin Rothmier introduces Dr. Jon Patricios who will give a talk on athletes returning to play after groin injuries. The presenter is a primary care sports physician and not an expert on groin injuries.
The Bermuda Triangle (02:40)
Physicians feel apprehension when trying to diagnose athletes with groin injuries. Dr. Patricios reviews how multiple pathologies run concurrently, the pain does not localize in the region, and terminology made it difficult for doctors to communicate.
Back to Basics (02:56)
Dr. Clive Noble believed most injuries were age dependent. Dr. Patricios emphasizes the need for conservative management protocol and the possibility that it may need to be repaired surgically. Possible causes of groin pain include tumors, hernias, metabolic issues, bursitis, ectopic pregnancy, irritable bowel syndrome, and referred pain.
Groin Pain (03:39)
Dr. Patricios commends Dr. Weir and the Doha meeting agreement for creating a concise definition. The inguinal area is one of the most complicated areas of anatomy in the human body. Three abdominal layers converge to create groin stability.
Pathology of Groin Pain (02:17)
Because athletes push through the pain, secondary sites decompensate. Dr. Patricios hypothesizes the mechanisms for injury includes overloading the posterior wall which causes instability and secondary trauma.
Multiple potential underlying causes include: adductor muscles causing a shearing force, hip flexors tilting forward, muscle imbalance, weak flexors, SI dysfunction, and lumbar pathology. Increased training, multiple changes of directions, jumping, and kicking can cause groin pain.
Conventional Treatment Methods (02:58)
Dr. Patricios emphasizes how physicians take a prehabilitation approach to groin injuries. Physiologists and exercise therapists recommend a combination of therapy and support after an injury occurs. Approximately 60% of groins will heal within 20 weeks.
Surgical Methods (03:41)
Athletes might succumb to surgery if they are diagnosed with split exterior aponeurosis, a compressed genital nerve, localized bulging, dilated transverse fascia, or enlarged Hasselbach triangle. Dr. Patricios no longer uses mesh because it causes adherence to tissues. The physician recommends that athletes return to sport when pain is no longer felt during exercise, but discomfort at the scar may last as long as six months.
Patricios Concludes (02:45)
Doha clarified that a multi-modal treatment plan is needed when addressing groin pain. Decisions on how to effectively treat patients depend on the age, caliber, the sport, and what stage of the season the athlete is in. Patricios discusses how to prevent injury and current gaps in research.
The Next Speaker (02:44)
Dr. Rothmier introduces Dr. Adam Zoga, a musculoskeletal radiologist, who will be speaking on imaging techniques for Athletic Pubalgia or Inguinal Disruption.
Cases of Athletic Pubalgia (03:19)
Dr. Zoga presents two cases of football players and the imaging techniques he implemented to effectively diagnose them. Three weeks after declining a surgical procedure, the patient further damages his groin. Physicians need to decide whether conventional or surgical treatments would be best.
What is "The Core?" (03:19)
The core contains the anterior and posterior muscles, hip joints, pubic symphysis, and aponeuroses in the groin. Phil Robinson and Andrew Granger published a high resolution image of the inguinal area. Dr. Zoga believes most groin injuries begin at the fibrocartilage plate.
Rectus Abdominis Adductor Aponeurosis Disruption (03:28)
While inguinal injury sounds appropriate, sports hernia is not an effective term. Dr. Zoga explains how cutting the rectus abdominis affects the other pubic bones and adductor damage can lead to hip instability. Ultrasound can be used to guide a dry needle tenotomy.
Another Case (04:13)
Studies show percutaneous therapy is helpful in calcific tendinosis of adductor longus. A good radiologist should MRI scan the entire groin area to ensure a correct diagnosis. Dr. Zoga describes his Thomas Jefferson University Hospital Athletic Pubalgia MR Protocol.
"Sport's Hernia" Treatment (02:46)
Mid-line groin injuries increase the risk of re-damaging. Dr. Zoga explains why using the term sports hernia is misleading. Surgeons in the radiologist's clinic tend to no longer use mesh to repair.
By predicting injuries, doctors can focus therapy on the concerning area and hopefully minimize potential damage. Dr. Zoga's team realized that football players tend to injure their groin on their open side and now require core strengthening exercises. The radiologist presents three more cases.
Next Presenter (04:09)
Dr. Rothmeir introduces Dr. Asheesh Bedi, an orthopedic surgeon, who will speak on femoral acetabular impingement and labral surgery. Labral tears occur because of bony mechanics. Using diagrams, the doctor discusses cam and pincer deformity.
Surgical Challenges (04:02)
Marc Philippon, Brian Kelly, and Chris Larson spoke on addressing the entire hip when performing surgical procedures arthroscopically. Mechanical causes of hip pain include cam and pincer lesions, femoral retroversion, femoral varus, and static overload.
Advances in Labral Arthroscopies (04:15)
Recent innovations include access to the joint, new instruments to reconstruct, radiofrequency ablation, and not needing to remove the labrum. Developers created software based upon 3-D CT technology to help guide surgeons.
Repairing the Labrum (04:55)
Anchor technology has become smaller, allowing surgeons to keep the labrum attached. In cases of profunda type deformities it is necessary to detach it arthroscopically. Brian Kelly taught Dr. Bedi how to perform a t-capsulotomy on a patient.
Pitfalls of Hip Arthroscopy (03:10)
Arthroscopic hip surgery carries an increased risk of arthritis. Surgeons must leave the operating room confident they restored the geometry of the joint. Joint space narrowing of less than two millimeters carries an increased risk of the repair failing.
Future of Arthroscopic Surgery (01:53)
Future innovations include T1 mapping to detect where cartilage moves in young athletes. Rehabilitation is essential to restoring soft tissues. Dr. Bedi summarizes and thanks the audience.
Q/A: Stability of Adductor Muscle? (01:53)
Dr. Patricios explains that adductor release is necessary surgically because the tendon needs to be stimulated to promote healing.
Q/A: Groin Pain and Hip Imaging (04:58)
Dr. Zoga explains that radiologist findings are diverse depending upon the readers and technician's skill levels. Dr. Bedi describes his procedure in diagnosing a labral tear. Experts describe how they only perform hip arthroscopies for diagnostic purposes rarely.
Credits: The Painful Groin (00:24)
Credits: The Painful Groin
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