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Core Muscle Injuries - American Osteopathic Academy of Sports
CoreMuscleInjuries R.RobertFranks,D.O.,FAOASM DirectorofConcussionProgram SportsMedicine RothmanInsBtute AssociateProfessorFamilyMedicine ThomasJeffersonUniversity Philadelphia,Pennsylvania PleaseDONOTCallThemSports Hernias IntroducBon • Philadelphiaathleteswithcoremuscleinjuries – Eagles’DonovanMcNabb – Eagles’ZachErtz – Eagles’KevinCurBs – Flyers’DannyBriere IntroducBon • Incidentofgroinpainis5to7%ofallsports injuries • Mostcommoninsoccer,iceandfieldhockey, tennisandAustralianRulesFootball • SomestudieshaveaVributedincreased diagnosistomoreaggressiveathleBcplaybut otherstudieshavecitedgreaterawarenessof coremuscleinjuriesbyCerBfiedAthleBc TrainersandSportsMedicinePhysicians IntroducBon • Oneofleastunderstood,inadequatelydefined andpoorlyresearchedaffecBonsofallsports medicineinjuries • Coremuscleinjuriesareactuallyseveral differentcondiBonslumpedtogetherunder onecommonmedicalterminology • Canbeacute,chronic,oracuteonchronic variety • Foundmorecommonlyinmalethanfemale athletes DifferenBalDiagnosis • • • • • • • Adductorstrain OsteiBsPubis IliopsoasStrains/BursiBs StressFractures AvulsionFractures HipPathology–LabralTear,FAI,SnappingHip NerveCompression Anatomy • BonyPelvis – Ilium – Ischium – Pubis – Sacrum/Coccyx Anatomy Anatomy • So\Tissue – FibrousaVachmentofpubicsymphysis – FibrocarBlagearBculardiscbetweenpubicbones withaVachedligaments – Mostimportantisthearcuateligamentatthe anterior,inferiormarginofthejointaVachingto thesymphysiscapsule,bothpubictuberclesand providingasuperficialaVachmentforregional tendon/musclecomplex Anatomy • So\Tissue – RightandLe\RectusAbdominis/Adductor Aponeuroses • MeetatmidlinepubicsymphysiscontainingverBcal rapheformingadensemidlinepubicplate Anatomy • So\Tissue – AdductorMuscles • PecBneus–Anterior • AdductorBrevis,Gracilis,andAdductorMagnus- Posterior Anatomy • So\Tissue – InguinalRing • Lateraltoaponeuroses – ExternalObliqueblendingwithlateralmarginof RectusAbdominusformingExternalOblique Aponeuroses–superficialtoinguinalcanaland cephaladandlateraltoring Anatomy AnatomicalBalance • RectusAbdominiscreatesposteriortension • Adductorscreateinferoanteriortensionwith corerotaBonandextension • ThisopposiBonalongwithaponeurosis neededforanteriorpelvicstability • DisrupBonofthisbalanceleadstocoremuscle instabilityandcoremuscleinjury Anatomy Pathogenesis • Groininjuriesusuallyoccurfromthe following: – Overuse – Increasedshearingacrossthehemipelvis – Lumbopelvicandlowerextremitymusclestrength endurance,extensibility,andcoordinaBon imbalance – LossofdynamicabdominalwallrotaBonalstability – Lossofcongenitalinguinalwallweakness – Overallcoreweakness MostCommonCauses • Hipadductorstrain/tearwithpalpablepainat pubicboneaVachmentandresistedhip adducBon • Iliopsoasstrain/tearwithpalpablepainofmuscle atlowerlateralabdomenorjustdistaltoinguinal ligament.Paino\enwithcrunchorresisted crunch.Canbeco-morbidThomasTestpain • Rectusabdominisstrain/tearwithpalpablepain atdistaltendonoronaVachmentatpubicbone andpainwithresistedsitup MostCommonCauses PhysicalExaminaBonFindings • • • • • NOdetectableinguinalhernia Inguinalcanaltenderness Dilatedsuperficialinguinalring Pubictubercletenderness Hipadductororigintenderness PhysicalExaminaBonFindings • Keyphysicalfindingmaybepubictubercle tendernessandinguinalfloortearthatcan possiblybepalpatedcreaBngpaininsidethe externalinguinalring – PainmyradiatetotesBcleorlaterallytoupper thigh – Aggravatedbysuddenmovement,Valsalva,sexual acBvity,resistedsitup,orhipadducBon Imaging • TradiBonalX-rayviewsinclude: – APPelvis – APandlateralofaffectedhip • X-rayscanyieldchangesassociatedwith: – FAI – OA – OsBBsPubis – AvulsionFracture Imaging • TradiBonalultrasoundisusefulmodalityto diagnoseINGUINALHERNIA • CTiso\enusedtodiagnoseINGUINAL HERNIA • MSKUltrasoundidenBfiestendonopathies andtendon/muscletearsbutincompletein lookingatinflammatoryanddegeneraBve bonyprocesses Imaging • MRIofAthleBcPubalgiaseries – 1.5Teslaunitwithphasedarray,mulBchannelcoil givesbestimaging MRIofAthleBcPubalgiaSeries • Sequencesincludethefollowing: – EnBrebonypelvisincludinghighresoluBon sequencesoverthepubicsymphysis – Standardcoronal,sagiValandaxialplanes,but alsocoronalobliqueimagingplanefromanterior marginoftheiliaccrestformingasagiVallocalizer sequence(alongthearcuatelineofthepelvis) neededtoseetherectusabdominus/adductor longusaponeurosisanditsaVachmentatpubic tubercle MRIofAthleBcPubalgiaSeries • Sequencesincludethefollowing: – Largefieldofviewsequencefromumbilicusto midthigh – Smallerfieldofviewsequencesfocusedonpubic symphysisextendingthroughthepubicrami bilaterally MRIofAthleBcPubalgiaSeries Treatment • ConservaBve: – Rest – Ice – NSAIDs – DisconBnuaBonofoffendingacBvity Treatment • ConservaBve: – PhysicalTherapy • ModaliBesthatmayassistinrecoveryinclude – E-sBm – DeepBssuemassage – AcBveReleaseTherapy – GrastonTechnique – Iontophoresis Treatment • ConservaBve: – PhysicalTherapy • Focusedprogressivehipadductorstretchingand strengtheningexercisesaswellasextensivecore musclestrengthening • Exercisetoimprovestrength,endurance,coordinaBon andappropriatehipandabdominalmusclebalanceas wellascorestability – AbducBon,adducBon,flexionandextensionexercises – Sit-ups – Wobbleboard – Slidingboard – FiVerexercises Treatment • ConservaBve: – OMT • Focusedtreatmentonhip/pelvisando\ensacrum/SI joint – PhysicalTherapy • Returntosportsisgenerallya\er8-12weeksof treatmentwithathletepainfreeinPTandwith exerBontherapy • Athletemustbeabletosuccessfullypasssport-specific acBvity–cuingandsmoothdirecBonalchangeare criBcal Treatment • ConservaBve: – CorBcosteroidInjecBon • UsuallydoneatinserBonofrectusabdominisor adductorlongustendonsusuallyatpubictubercle – ProlotherapyInjecBon • Sclerosingagentinjectedatoneofthefollowingsites: – AdductoraVachments – Conjoinedtendonatpelvicrim – Pubicsymphysis Treatment • Surgical – ExploraBonandrepairconsideredwhenrestand nonsurgicaltreatmenthasbeenaVempted UNLESS • TruepathologyelicitedonMRIandconservaBve treatmentwouldnotbeconducivetoahighlevel athlete–i.e.competedisrupBonofpubicplateinice hockeyplayer Treatment • Surgical – Openorlaparoscopicapproachescanprovide goodresults – Mostrepairsaddressrepairofabdominalmuscles, adductormuscles,orboth,orfascianearthe inguinalligament. – Repairsthatdonotaddressesforcescausing pathologyareo\enunsuccessful – Whetheropenorlaparoscopic,repairratesvary from63to95% Treatment • Surgical – Laparoscopicrepairusuallyassociatedwith quickerreturntosports • Trainingat4weeks • FullacBvityat6weeks Treatment • Post-SurgicalRehabilitaBon – GooddatalackingforreturntoacBvityfollowing surgery – SomephysiciansdonotdoPTa\ersurgery Treatment • Post-SurgicalRehabilitaBon – PTpost-surgicalgenerallyconsistsofthe following: • Avoidanceofsharp,sudden,cuingmovements • Lowerextremityinflexibility,weakness,andlackof coordinaBoniscorrected • Runningstraightaheadatday21 • SprinBngwithoutcuingatweek3 • FullacBvitya\erlaparoscopicrepairin6to8weeks • FullacBvitya\eropenrepairatapproximately18 weeks References • Caudill,P,EtAl.“SportsHernias:ASystemicLiteratureReview.”BrJSportsMed. 42:954-964.July2008. • Kachingwe,AF,Grech,S.“ProposedAlgorithmfortheManagementofAthletes WithAthleBcPubalgia(SportsHernia):ACaseSeries.”JournalofOrthopaedicand SportsPhysicalTherapy.38:768-781.December2008. • Larson,CM.“SportsHernia/AthleBcPubalgia:EvaluaBonandManagement.” SportsHealth.6:139-144.January2013. • Morelli,V.,EtAl.“GroinInjuriesinAthletes.”AmericanFamilyPhysician,64: 1405-1414.2001. • Mullens,FE,Zoga,AC,EtAl.“ReviewofMRITechniqueandImagingFindingsin AthleBcPubalgiaandtheSportsHernia.”EuropeanJournalofRadiology,81: 3780-92 PhotoReferences • 1.FromAntenatalCareModule–AnatomyoftheFemalePelvis • 2.Fromwww.rebalancetoronto.com • 3.UMEMEducaBonalPearls–UniversityofMarylandSchoolofMedicine, DepartmentofEmergencyMedicine • 4.FromSportsHealth:sph.sagepub.com • 5.Fromwww.radsource.us
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