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12-06-2013
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Differential diagnosis in athletes with
groin and hip pain
Per Hölmich
Sports Groin Pain Center
Aspetar Orthopaedic and Sports Medicine Hospital
Doha, Qatar
&
The Copenhagen Groin and Hip Research Center
Arthroscopic Center Amager
University of Copenhagen, Denmark
Aspetar & Arthroscopic Center Amager
Muscles reated to groin and hip
• Adductor longus/brevis
• Adductor magnus
• Gracilis
• Pectineus
• Iliopsoas
• Sartorius
• Rectus femoris
• Tensor Fascia Latae
• Gluteus medius, minimus
• Gluteus maximus
• Piriformis and other external
rotators
• Hamstrings
Aspetar & Arthroscopic Center Amager
Codon, Am J Surg 1996Gibbon, The Lancet 1999Robinson et al; Skeletal Radiol. 2004Davis et al BJSM 2012
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Muscle, tendons and aponeuroses
Aspetar & Arthroscopic Center Amager
The anatomy of groin injuries- from a sports hernia point of view
Muschaweck describes the abdominal wall
biomechanically as -
a matrix of tension bands that
attach to the pubic bone & the
muscle and fascia layers form a
‘‘slide bearing’’
- which is essential for an athlete’s mobility, including running, sprinting,
jumping, and upper body rotation
Minnich et al
AJSM 2011
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…greater trochanteric pain syndrome (GTPS) is
being advertised as a clinical entity that includes a number of disorders of the lateral peritrochanteric space of the hip, including
trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip)
Athletic knee syndrome….
Athletic pubalgia….????
Aspetar & Arthroscopic Center Amager
Clinical entities for groin injuries
Very few diagnosis of the groin are clearly
established yet –
A systematic clinical approach to groin and hip pain in athletes was suggested in
2007 based on the relation of the pain to the anatomy
Utilising a number of specific and reliable tests –to identify a diagnostic pattern
leading to clinical entities
Hölmich et al BJSM 2004 & Hölmich BJSM 2007
Aspetar & Arthroscopic Center Amager
”Clinical Entity”
• The symptoms and clinical findings are related to a specific anatomical structure:
• Iliopsoas related groin pain
• Adductor related groin pain
• Inguinal related groin pain
Hölmich BJSM 2007
Aspetar & Arthroscopic Center Amager
The clinical entity approach has since been
implemented by several other authors
Ekstrand, Hägglund, Walden - UEFA-studies
AJSM, BJSM, SJMSS 2007-13
UEFA Football Doctor Education Programme 2013
Robinson P et al; Skeletal Radiol. 2004
Lovell G et al; CJSM 2006
Schilders et al; JBJS Am. 2007
Atkinson HD et al; Arch Orthop Trauma Surg 2009
Weir A et al BJSM 2009
Malliaras P et al BJSM 2009
Hanna C et al, JSMS 2010
Schilders et al AJSM 2013
Aspetar & Arthroscopic Center Amager
998 soccer players followed for 1 season • 58 groin injuries – all examined systematically
with the standardised technique
• 51% adductor-related
• 30% iliopsoas related
• 19 % inguinal related
• 68% in the dominant leg
• The duration of having both adductor- and inguinal-related injury is
4.56 times longer
• 24% had more than one clinical entity
• 39% had a traumatic onset of the groin injury
Hölmich et al (unpublished data)
Aspetar & Arthroscopic Center Amager
Further studies needed to develop the
clinical entity approach to groin injuries
• Combining the imaging and
the clinical entities
• Investigating the acute groin
entities
• Biomechanical evaluation
• Differentiating the clinical
entities into specific diagnosis
Aspetar & Arthroscopic Center Amager
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12-06-2013
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The known pain
• The patient should be asked, whether the pain inflicted by
the test is the pain, that usually is bothering the patient (the
known pain)
or “just” something that
happens because of an uncomfortable test
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Iliopsoas - related
• Location of pain
– Lower abdomen
– Proximal on anterior thigh
– Antero-medial groin
– Low back pain/fatigue
• Complaints
– Sitting in a deep chair for longer periods
– Climbing stairs
– Biking with click-shoes (uphill)
– Long runs
– Coughing, sneezing, sprinting
Aspetar & Arthroscopic Center Amager
Iliopsoas - related• Clinical findings
– Decreased strength (flexed hip, isometric
test) plus sometimes pain or discomfort
– Pain with stretching during Thomas test
– Pain when palpating the psoas
• At the level of SIAS
• Just below the inguinal ligament
• At the lesser trochanter
- Positive skin fold test
- Pain when compressing/folding/twisting
Aspetar & Arthroscopic Center Amager
Isometric iliopsoas testThorborg K, Petersen J, Magnusson P, Hölmich P; SJMSS, 2009
Aspetar & Arthroscopic Center Amager
Iliopsoas - related• Clinical findings
– Decreased strength (flexed hip, isometric test)
plus sometimes pain or discomfort
– Pain with stretching during Thomas test
– Pain when palpating the psoas
• At the level of SIAS
• Just below the inguinal ligament
• At the lesser trochanter
- Positive skin fold test
- Pain when compressing/folding/twisting
Aspetar & Arthroscopic Center Amager
Thomas test – passive stretching
Hölmich et al BJSM 2004
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Iliopsoas - related
• Clinical findings
– Decreased strength (flexed hip, isometric
test) plus sometimes pain or discomfort
– Pain with stretching during Thomas test
– Pain when palpating the psoas
• At the level of SIAS
• Just below the inguinal ligament
• At the lesser trochanter
- Positive skin fold test
- Pain when compressing/folding/twisting
Aspetar & Arthroscopic Center Amager
Palpation of Iliopsoas
Hölmich et al BJSM 2004
Aspetar & Arthroscopic Center Amager
Iliopsoas-related
• Clinical findings
– Decreased strength (flexed hip, isometric
test) plus sometimes pain or discomfort
– Pain with stretching during Thomas test
– , pelvic tilt
– Pain when palpating the psoas
• At the level of SIAS
• Just below the inguinal ligament
• At the lesser trochanter
- Positive skin fold test
- Pain when compressing/folding/twisting
Aspetar & Arthroscopic Center Amager
Squeezing the iliopsoas…
Impingement test for the hip:
flexion, adduction and internal rotation…
Several structures are impinged in the
process
This test is not specific for FAI
It is important to be able to differentiate
what structures are causing the pain
P.Hölmich & M.Dienst, Der Orthopaede 2006
A.Weir, R.de Vos, M.Moen, P.Hölmich and J.L.Tol BJSM 2011
Aspetar & Arthroscopic Center Amager
Lesser Trochanter
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Runner - groin pain during 1½ yearIliopsoas tendinosis – spindle shape
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Adductor-related
• Location of pain
- Medially deep in the groin
- Sometimes radiating to the
medial thigh or deep behind the
scrotum
- Rarely pain at the tendon itself
• Complaints
- Pain during fast turns, sprinting,
slippery surface, kicking, tackling
- Long runs – fatigue
- Coughing & sneezing
- “Standing on one leg putting on socks”
Aspetar & Arthroscopic Center Amager
Adductor-related
• Clinical findings
- Decreased adduction strength
- Pain with adduction against resistance
- Tenderness on the origin of the
adductors(longus) at the pubic bone
- Pain on stretching the adductors
- Rarely tightness of the adductors
Aspetar & Arthroscopic Center Amager
Isometric adductor test
Hölmich et al; BJSM 2004
Assessment of the adductor longus may be a primary focus
of clinical examination…. & EMG and force data suggest thatexamination in this position may be clinically important
Lovell G et al; Phys Ther Sport 2011
Aspetar & Arthroscopic Center Amager
Adductor-related• Clinical findings
- Decreased adduction strength
- Pain with adduction against resistance
- Tenderness on the origin of the
adductors(longus) at the pubic bone
- Pain on stretching the adductors
- Rarely tightness of the adductors
Aspetar & Arthroscopic Center Amager
Palpation of the adductor origin
Hölmich et al; BJSM 2004
Aspetar & Arthroscopic Center Amager
Adductor-related• Clinical findings
- Decreased adduction strength
- Pain with adduction against resistance
- Tenderness on the origin of the
adductors(longus) at the pubic bone
- Pain on stretching the adductors
- Rarely tightness of the adductors
Aspetar & Arthroscopic Center Amager
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12-06-2013
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ROM and stretch of adductors
Hölmich et al; BJSM 2004
Aspetar & Arthroscopic Center Amager
Adductor longus
Sonographic pathology
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Inguinal-related
• Location of pain
- Low abdominal in the area of
the inguinal canal
- Radiating across the pubis
- Radiating to the groin and genitals
• Complaints
- Activities including the abdominal muscles
- Pain during fast turns, sprinting, slippery surface,
kicking, tackling
- Coughing & sneezing
- “Standing on one leg putting on socks”
Aspetar & Arthroscopic Center Amager
Inguinal-related
• Clinical findings
- Tender conjoined tendon at insertion
(sometimes also tender rectus abdominis
tendon insertion)
- Tender conjoined tendon when palpating
through the scrotum
- Tender external opening of inguinal canal when
palpating through the scrotum
- Soft posterior wall/small dilation of the external
opening
- Decreased strength of the abdominal muscles
especially the oblique plus sometimes pain
Aspetar & Arthroscopic Center Amager
Palpation of the conjoined tendon
Aspetar & Arthroscopic Center Amager
Inguinal-related• Clinical findings
- Tender conjoint tendon at insertion
(sometimes also tender rectus abdominis
tendon insertion)
- Tender conjoint tendon when palpating
through the scrotum
- Tender external opening of inguinal canal when
palpating through the scrotum
- Soft posterior wall/small dilation of the external
opening
- Decreased strength of the abdominal muscles
especially the oblique plus sometimes pain
Aspetar & Arthroscopic Center Amager
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12-06-2013
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Palpation of the inguinal canal -
with the patient standing
Aspetar & Arthroscopic Center Amager
Inguinal-related
• Clinical findings
- Tender conjoint tendon at insertion
(sometimes also tender rectus abdominis
tendon insertion)
- Tender conjoint tendon when palpating
through the scrotum
- Tender external opening of inguinal canal when
palpating through the scrotum
- Soft posterior wall/small dilation of the external
opening
- Decreased strength of the abdominal muscles
especially the oblique plus sometimes pain
Aspetar & Arthroscopic Center Amager
Isometric test of abdominal muscles
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Incipient hernia – soft posterior wall
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The specificity of a test
Patrick’s FABERE test
• Hip joint
• Adductor muscles
• SI-joint
• Lumbar spine
• …and?
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Interrater reliability of hip tests
(Martin and Sekiya, JOPST 2008)
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12-06-2013
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Clinical examination of the hip joint
Hölmich & Dienst, Der Orthopaede
2006;35(1) 8-15
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Impingement test
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Apprehension testPosterior impingement test – same position but the
hip is internally rotated
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Isometric test - m.Gluteus mediusThe most effective position to test GM is
the side lying abduction in neutral or internal rotationRoald Otten et al (submitted)
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Log roll test
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12-06-2013
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Tests pointing to a possible hip artroscopy
• Positive hip impingement test (flexion,
adduction and internal rotation)
• Positive log-rolling test
• Positiv apprehension test
• Positive injection test (US-guided)
and/or
• Pathologic findings at MR-A / MR-3T
Aspetar & Arthroscopic Center Amager
Thank you
Aspetar & Arthroscopic Center Amager