Iliopsoas and Adductor Related Groin Pain Introduction Tendinopathies of the Hip and Pelvis Represent a Large Burden on Both the Sporting and Ageing Populations

Home , Adductor longus muscle, Iliacus muscle, Iliopectineal bursa, Iliopsoas, Pyramidalis muscle

UNDERSTANDING TENDINOPATHIES OF THE HIP & PELVIS BOOK FOUR: Iliopsoas and Adductor Related Groin Pain Introduction Tendinopathies of the hip and pelvis represent a large burden on both the sporting and ageing populations. Growing evidence is shaping contemporary conservative management of tendinopathy.

This e-book series aims to provide readers with guidance towards a deeper understanding of tendinopathies of the hip and pelvis and more effective clinical management based on an emerging evidence base derived from scientific studies on structure and mechanobiological mechanisms, risk factors, impairments and the available information on effects of intervention.

Book 4 of this series explores two common groin pain clinical entities, adductor- related and iliopsoas-related groin pain. The adductor and iliopsoas tendons play a key role in these clinical entities, either as a pain source or a mechanism by which forces transferred by the tendon to adjacent structures results in pain or injury. A review of impact and prevalence, clinical presentation and local anatomy prepares the reader for the detailed analysis in the following chapters. Data available for pathology, pathoaetiology, impairments and diagnostic utility of clinical tests will be examined. The available scientific evidence and 25 years of clinical experience are combined to provide clinically relevant and readily applicable information.

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This book is suitable for anyone involved For more information in management of tendinopathies of the hip and pelvis or prescription of email [email protected] exercise in at-risk groups – such as the phone (07) 3342 4284 athletic population or perimenopausal web dralisongrimaldi.com women. The content assumes readers have a basic knowledge of anatomy and muscle function in this region.

PAGE 2 OF 88 Copyright Alison Grimaldi 2018 BOOK CONTENTS

Chapter 1 IMPACT AND PREVALENCE ...... 4

Chapter 2 CLINICAL PRESENTATION...... 8

Chapter 3 REVIEW OF LOCAL ANATOMY...... 12

Chapter 4 PATHOLOGY & TERMINOLOGY...... 22

Chapter 5 PATHO-AETIOLOGY ...... 28

Chapter 6 IMPAIRMENTS...... 40

Chapter 7 DIAGNOSIS...... 50

Chapter 8 MANAGEMENT...... 59

CONCLUSION ...... 73

REFERENCE LIST...... 75

PREVALENCE Groin Injury in Sport Gender Bias Prevalence of ARGP & IRGP

IMPACT Severity of Injury & Time Loss Recurrence Impact on Sporting Success Impact on Club Impact of surgical interventions for IRGP

PAGE 4 OF 88 Copyright Alison Grimaldi 2018 Prevalence of Groin Pain & Injury

Groin pain is common in athletes, particularly entity was iliopsoas related groin pain, with within the football codes and ice hockey this entity the secondary or tertiary source (Eckard et al. 2017, Orchard 2015) and may in 55% of athletes. In the runners assessed, have substantial impacts on both individual iliopsoas-related groin pain was the most and team performance. Injury surveillance common primary clinical entity (Holmich et data collected over 21 years in the Australian al. 2007). Football League (AFL), indicated that groin injury was the second most common injury Painful snapping or impingement of the sustained in this sport and the second iliopsoas tendon has also been documented most common reason for missed matches, in the literature. Anterior or internal snapping after hamstring injury (Orchard et al. 2013). is common in the dance population (Winston Similarly, in professional football (soccer), et al. 2007). Within a population of 653 injured groin injuries are the second most common dancers, the incidence of iliopsoas ‘syndrome’ musculotendinous injury (Walden et al. 2005), (pain, weakness, snapping) was 9.2% in with hip and groin injuries accounting for 12- female dancers and 3.2% in male dancers. 16% of all injuries across seven seasons of The highest incidence was in student dancers European professional football (Werner et al. (14%), followed by amateur dancers (7.5%), 2009). One in every five football players in the with professional dancers having the lowest Qatar professional football league experienced incidence (4.6%) (Laible et al. 2013). a groin injury each season (Mosler et al. 2017). Groin injury and particularly adductor injury, is Hip and groin pain associated with impingement also more prevalent in males compared with of the iliopsoas tendon against the underlying females playing the same sports (Eckard et joint structures has been a topic of much al. 2017, Orchard 2015, Walden et al. 2015). investigation and remediation in recent years. Iliopsoas impingement or tendinopathy has There are many differing reports and opinions been diagnosed in association with labral regarding the most common sources of groin pathology and femoroacetabular impingement pain. This will be addressed more fully in the (FAI) and reported as a cause of ongoing hip pathology section. Across the literature, the pain post hip arthroscopy and arthroplasty most prevalent clinical entity associated with (Domb et al. 2011, Mardones et al. 2016, groin pain is adductor-related groin pain, with Philippon et al. 2011). A 4% prevalence of painful some reporting this entity responsible for 60- Iliopsoas tendinopathy and impingement has 70% of all groin pain in athletes (Holmich et al. been reported following total hip arthroplasty 2007, Taylor et al. 2017). Iliopsoas-related groin (Henderson & Lachiewicz 2012). pain is usually rated as the second or third most common cause and is often diagnosed as a second entity where multiple pain sources exist (Holmich et al. 2007, 2014, Mosler et al. 2017, Taylor et al. 2017, Werner et al 2009). Holmich (2007) assessed 207 athletes with long standing groin pain to determine their primary, secondary and tertiary pain sources. In 36% of these athletes the primary clinical

Groin pain reduces an athlete’s ability Iliopsoas tendon conditions secondary to to accelerate, decelerate and change snapping hip or associated with underlying joint direction while running, impacting on sports pathology or prosthetic implant, may result in participation and performance.There is a wide substantial pain and disability. Brandenburg et spectrum of severity and associated impact, al. (2016) reported that patients with painful varying from mild symptoms lasting 7 days or anterior snapping hip associated with FAI less, to more severe injuries lasting for longer or chondrolabral damage, may progress to than 28 days with career altering potential. surgical release of the iliopsoas tendon if Moderate and severe injuries account for unresponsive to conservative management. 60 - 75% of groin injury in football (lasting Post surgery, the patients in this study were from 8 days to more than 28 days) (Holmich left with a 25% loss of Iliopsoas volume et al. 2014, Mosler et al. 2017). and a 19% reduction in seated hip flexion strength at a mean of 21 months post surgery. Groin injury also has a propensity for Unfortunately, no patient rated outcome recurrence, with 25% of injured AFL players measures were available to correlate these experiencing recurrent or ongoing problems changes with functional impact, however as following the initial injury (Orchard et al. 2013). the average age for patients in this study was Subsequent injuries also tend to keep the athlete between 30 and 35 years, such significant out of sport for longer. In one large study of losses of muscle size and strength are likely professional footballers, an initial groin injury to impact on function, muscle balance within kept an athlete out of sport for an average of the hip flexor synergy and even on muscular 14 days, while reinjuries resulted in an average protection of the underlying joint. 23-day absence (Werner et al. 2009). Arthroscopic release of the iliopsoas tendon The impact on a club can be substantial with increases the risk of hip joint instability and groin pain resulting in a median loss of 85 days even dislocation post arthroscopic surgery (IDR 35-215) per season for each football club (Austin et al. 2014, Sansone et al. 2013, Yeung (Mosler et al. 2017). Days out of training and et al. 2016). Considering the potential long competition has been shown to have a direct term negative impact of surgical iliopsoas impact on performance and achievement. release, early identification and effective Drew et al. (2017) found strong evidence for conservative management strategies are an association between availability of team required. members and risk of failure - the less availability for training and competition, the higher the risk of failure. Similarly, lower injury burden and higher match availability have been associated with increased points per match and higher final football league ranking (Haggland et al. 2013). Player injuries also place a significant financial burden on individual athletes or professional clubs responsible for rehabilitation.

PAGE 6 OF 88 Copyright Alison Grimaldi 2018 Most common Groin injury in football codes most common in and ice hockey male athletes

2nd most Groin Pain ARGP most common injury in Prevalence common clinical football codes entity in athletes

IRGP 2nd -3rd IRGP most most common common entity in clinical entity in runners athletes

Figure 1: Prevalence of groin pain. ARGP: Adductor-Related Groin Pain; IRGP: Iliopsoas-Related Groin Pain

CLINICAL ENTITIES MODEL Adductor-Related Groin Pain Iliopsoas-Related Groin Pain Inguinal-Related Groin Pain Pubic Related Groin Pain

ADDUCTOR-RELATED GROIN PAIN Area of Pain Painful Postures & Activities History

ILIOPSOAS-RELATED GROIN PAIN Area of Pain Painful Postures & Activities History

PAGE 8 OF 88 Copyright Alison Grimaldi 2018 Clinical Entities Model Defined Clinical Entities for Groin Pain (Figure 2) One of the most significant impediments for 1. Adductor-related groin pain clinicians and researchers working with groin Definition: pain, has been the lack of a common language. Adductor tenderness AND pain on resisted A review of groin pain management in 2015 adduction testing. highlighted the disparity in terminology, with 33 different diagnostic terms for groin pain used 2. Iliopsoas-related groin pain across 72 studies (Weir et al. 2015). This issue Definition: has made it very difficult to compare study Iliopsoas tenderness AND pain on resisted hip results and for clinicians to communicate flexion AND/OR pain on hip flexor stretching. without misinterpretation. 3. Inguinal related groin pain To address this issue, 24 international experts Definition: from 14 countries agreed on a classification Pain in the inguinal canal region AND tenderness system for groin pain (The Doha Agreement, of the inguinal canal AND no palpable inguinal Weir et al. 2015), adopting and developing a hernia. Pain on resistance of the abdominal clinical entities approach first suggested by muscles OR on Valsalva/cough/sneeze. Holmich et al. (2007). This approach seeks to describe distinct clinical presentations 4. Pubic-related groin pain without determination of the exact underlying Definition: pathological structure or pain source, around Tenderness of the pubic symphysis and which there is still inadequate consensus. With immediately adjacent bone. a consistent clinical diagnosis, imaging and surgical studies may be able to identify the most common pathologies associated with each clinical entity.

The Doha system has three major divisions: 1. Defined clinical entities for groin pain 2. Hip-related groin pain 3. Other causes of groin pain (e.g. Referred pain from lumbar spine, stress INRGP fracture, tumours, intra-abdominal and IRGP gynaecological conditions) PRGP ARGP

Figure 2: Clinical Entities for Groin Pain. ARGP: Adductor-Related Groin Pain; IRGP: Iliopsoas-Related Groin Pain; INRGP:Inguinal- Related Groin Pain; PRGP: Pubic-Related Groin Pain

Copyright Alison Grimaldi 2018 PAGE 9 OF 88 Painful Postures & Activities For the purposes of this book, we will Following an acute adductor injury, pain may be focus on the two most common groin experienced during many normal daily activities pain entities, adductor-related and such as walking, standing on one leg, turning or changing direction while weightbearing on iliopsoas-related groin pain. In both the injured leg, lifting the leg to dress or move cases the tendon is implicated in a in and out of the car, coughing or sneezing. significant proportion of presentations, Symptoms will vary with injury severity.

but not all. More detail regarding With milder, subacute or chronic adductor specific pathologies will be provided related groin pain, there is usually little to no in Chapter 4. pain at rest and during normal activities of daily living. The primary issues are with higher load or dynamic tasks such as running, particularly acceleration, deceleration and direction change, Adductor-Related kicking, hopping, bounding, deep split lunges or side lunges. The athlete may be able to Groin Pain participate in sport but full speed and function is hampered by pain or a lack of power.

Area of Pain History Adductor-related groin pain is most commonly experienced within the proximal Onset of pain may either be acute or of 1/3 of the adductor muscle region and/or gradual onset. When acute, the most common at the adductor origin. With long standing mechanisms of injury described include kicking, pain, the symptomatic region is often less change of direction, reaching or stretching, precise and may spread further across the running or sprinting, jumping, tackling or sliding pubic symphysis and into the lower abdomen, (Serner et al. 2017a). Patients complaining inguinal and contralateral adductor region. of pain of gradual onset may be unable to This reflects a multiple entity presentation. identify a single precipitating event, but may report increasing difficulty with these types of activities - pain, stiffness or loss of range, reduced performance. Pain and stiffness at the beginning of activity may ease as the athlete warms up. As the condition progresses, the symptoms remain throughout the activity and may persist or worsen after activity.

The clinician should also aim to identify potential contributing factors in the patient history which may include previous injury, a change in loading and general health factors.

PAGE 10 OF 88 Copyright Alison Grimaldi 2018 Iliopsoas-Related Painful Postures & Activities

Groin Pain Pain related to the iliopsoas is generally experienced either during actions that load the hip flexor complex into flexion or stretch the tissues into extension. For runners with Area of Pain iliopsoas-related pain, the problem is most evident through late stance and early swing Iliopsoas-related groin pain is located more phase of running. The runner may complain that anteriorly over the iliopsoas muscle, lateral to the hip tightens up anteriorly during their run, the adductors and across the hip joint in the mid-inguinal region. It may extend into the lower resulting in pain and/or limitation of stride length. abdomen and distally a short distance into the Symptoms tend to increase with distance and proximal thigh, usually described as a deep speed of running, particularly with longer stride discomfort or tightness as the muscle runs lengths. Iliopsoas-related pain may also occur in posteriorly to insert on the lesser trochanter. walkers, again evident particularly in late stance and early swing and with longer stride lengths and higher speeds.

For more severe situations, such as after acute injury or iliopsoas impingement post hip arthroplasty, significant pain may occur during hip flexion tasks such as walking upstairs, dressing or lifting the leg in and out of bed or the car.

History

Iliopsoas-related groin pain may also be either acute or more insidious in onset. Acute onset in one study was associated with kicking, sprinting, tackling and sliding.Interestingly, the most common mechanism of injury was changing direction (Serner et al. 2017b).

Other Symptoms Onset of symptoms may also be associated with a change in activity, previous surgery Patients with Iliopsoas-related groin pain may (e.g. arthroscopy or total hip arthroplasty) or also complain of a snapping sensation at the general health factors. Don’t forget to ask about anterior hip often accompanied by an audible medication. Ciprofloxacin induced tendinopathy click. Snapping most commonly occurs while eccentrically lowering a flexed hip, particularly and rupture of iliopsoas tendons has been if externally rotated. This may occur when reported in the literature (Smith et al. 2016). dressing or extending a flexed hip such as in supine abdominal leg loading exercises. For dancers, the snap occurs most frequently during grand battement or passe´ developpe´ (actions that require high hip flexion and external rotation under long lever loads (knee extended or extending during the action).

THE ADDUCTOR COMPLEX Adductor Muscles Adductor Origins & Connections The Proximal Tendon of the Adductor Longus

THE ILIOPSOAS COMPLEX Muscles Anatomical Relationships of the Psoas Tendon Functional Anatomy

PAGE 12 OF 88 Copyright Alison Grimaldi 2018 The Hip Adductor Complex

The adductor synergists include the adductor The primary functions of adductor longus are longus, brevis and magnus, gracilis and pectineus hip adduction and hip flexion. Gait studies have (Figure 3). The short external rotators also have demonstrated that adductor longus is activated potential for a small secondary adductor in late stance and early - mid swing phases function due to their location medial to the hip (Lee & Hidler 2008, Green & Morris 1970, Perry joint centre (Gudena et al. 2015, Vaarbakken et 1992). This is consistent with a functional role al. 2015). The adductor longus sits anteriorly for adductor longus in assisting the primary hip and is the most commonly involved muscle in flexors to eccentrically control extension in the presentations of adductor-related groin pain. final stage of terminal stance and initiate hip flexion. Not surprisingly, adductor longus is also highly active during a kicking action (Charnock et al. 2009).

The adductors are thought to play an important role in global stability mechanisms of the pelvis, coupling with the abductors to provide mediolateral control. Adductor longus has been shown to be involved in postural balance mechanisms in both the coronal and sagittal planes (Henry, Fung & Horak 1998). . In addition, the adductor longus has strong connections across the pubic symphysis and into the abdominal wall, suggesting that this muscle is involved in the transfer of large forces between the lower limbs and trunk (Robinson et al 2007, Robertson et al 2009). P . AL AB Gracilis

Figure 3: The Hip Adductor Synergy: Adductor Longus (AL); Addductor Brevis (AB); Adductor Magnus (deeper/posterior), Pectineus (P) and Gracilis.

* *

Figure 4: The adductor origin and connections. Fibrous connections exist between: - the left and right adductor longus (AL) - the adductor longus and both ipsilateral and contralateral abdominals - the adductor longus and rectus abdominis (RA) tendons and the pubic symphysis capsule and disc All conections flow through a fibrous aponeurotic plate sitting anterior to the pubic symphysis. Insert depicts the pyramidalis muscle (*).

PAGE 14 OF 88 Copyright Alison Grimaldi 2018 ADDUCTOR ORIGIN & CONNECTIONS

Detailed cadaveric and imaging studies have described a complex confluence of structures across the pubic symphysis. Robinson et al. (2007) revealed a continuity of fibrous tissue joining the adductor longus tendon and the rectus abdominis over the pubic symphysis. Both tendons also have connections directly * into the capsule of the symphysis pubis and even pass through the capsule to attach to the underlying disc and cartilage.

The adductor longus attaches not only to the ipsilateral rectus abdominis, but to the contralateral abdominal wall, and to the contralateral adductor longus, fibres passing through a fibrous aponeurotic plate that sits anterior to the pubic symphysis incorporating the pubic symphysis capsule and all tendinous attachments (Figure 4 & 5). Another small and sometimes inconstant muscle, the pyramidalis, contributes it’s tendinous fibres to this adductor- abdominal aponeurotic plate. Arising from the linea alba about half way between the umbilicus and the pubis, the muscle is thought to play some role in tensioning the rectus sheath and the linea alba (Natsis et al. 2016). Adductor brevis tendons sometimes, and the gracilis tendons occasionally, also have attachment to the fibrotic plate. Many large forces pass through this fibrous confluence.

Figure 5: Sagittal depiction of the confluence of the rectus abdominis (RA) and adductor longus (AL) tendons and the fibrous aponeurotic plate sitting anteriorly to the pubic symphysis. Pyramidalis *

The adductor longus inserts onto the pelvis One other earlier cadaveric study, with the via both a tendinous and a muscular insertion, largest sample size assessed a more equal although the contribution of each to the insertion distribution of males and females (Tuite et would appear quite variable, and is perhaps al. 1988). These authors did not provide a influenced by gender. percentage of tendon to muscle at the insertion but described a tendinous superficial portion, The main fibrous tendon sits superficially or with the deeper posterior portion of the insertion anteriorly at the insertion, while the deeper comprising of more muscular fibres. They noted part of the tendon may be more muscular. many anatomical variants, the most significant Strauss and colleagues (2007) in a dissection being that in 25% of their cadavers there was of 28 cadavers, reported that only 38% of the a significant increase in muscular contribution adductor longus attachment was tendinous, the to the lateral aspect of the insertion. This was remaining 62% comprised of muscle. Davis et al. twice as common in males. (2011) in a more recent study, reported similar cross sectional areas of the adductor longus From this information it would seem that attachment at the proximal origin, however they in females it is possible to have an almost found tendinous fibres comprising 94% of the completely tendinous enthesis, while in males attaching tissue. Davis et al. (2011) had a smaller there may be significant variability, with the sample size and interestingly a much larger muscular component comprising more than distribution of females in their sample, whereas 50% of the tendon insertion. Strauss et al.’s (2007) study was more heavily dominated by male samples (Table 1).

Dissection Male: Female CSA mm2 % of insertion tendinous Studies Specimens Strauss et al 2007 17:11 49.3 37.9

Davis et al 2011 3:7 56.6 93.9

Tuite et al 1998 18:19 Muscle on deep surface normal. Anatomic variant in 25% of specimens - increased muscle in lateral insertion. Twice as common in males.

Table 1: Summary of findings of dissection studies assessing adductor longus tendon of origin. CSA:Cross Sectional Area.

PAGE 16 OF 88 Copyright Alison Grimaldi 2018 On ultrasound, a much longer tendon of insertion is evident on the superficial or anterior aspect of the muscle (Figure 6). The deep surface is much more muscular almost all the way to the bone, but it does appear to have a short fibrous transition zone. This is consistent with the description and diagram provided by Orchard et al. (2004) in their surgical study on adductor tenotomy.

ALT AL Pubic Bone

Figure 6: Ultrasound of Adductor Longus Enthesis: Note the superficial tendon of adductor longus inserting into the pubis (outlined) and the short fibrous transition zone connecting the deep muscular component (arrowhead). AL:Adductor Longus; AB:Adductor Brevis; AM:Adductor Magnus; ADL:Adductor Longus Tendon.

If we look further at the specific nature in which From Robinson et al.’s (2007) work , we know the adductor longus attaches proximally into that the fibres that blend into the capsule may the pubic symphysis capsule, Robinson et al. continue through to the cartilage and bone. Davis (2007) describes two patterns of attachment: et al. (2011) reported that histological assessment 1. Both the superficial tendinous and the deeper confirmed that the adductor longus enthesis was muscular component attach to the capsule fibrocartilaginous in nature, reflecting adaptation (53% of specimens) to protect the tendon from excessive compression 2. The tendon attaches to the pubic tubercle and and the bone from shear force. the muscular attachment inserts predominantly into the capsular tissues (47% of specimens - more common in males).

From the attachment site, the adductor longus tendon lies superficially on the muscle and O generally extends distally 6-7cm on the medial side of the muscle and 1-2 cm on the lateral aspect, resulting in an oblique musculotendinous junction (Figure 7a). Davis and colleagues (2011) dissected the superficial muscle fibres away a. from the tendon along it’s entire length, to reveal lateral medial for the first time an intramuscular extension of the tendon (Figure 7b & c). They found the tendon AL extends on average 11-13cm in length or 20% or more of the femoral length. An intramuscular tendon may provide extra strength and stability for muscles involved in the transmission of large mechanical forces. The biceps femoris long anterior head similarly has an intramuscular tendon. b. O These junctions may fail under high load. Davis AL et al. (2011)suggests that pathology previously referred to as proximal adductor muscle strain may in fact be pathology of the intramuscular tendon, or a musculotendinous junction injury.

c. O anterior AL

Figure 7: Diagrammatic representation of adductor longus proximal tendon structure and variations. a.tendon from an anterior or superficial view. b & c. side view or profile of the tendon, with the tendon initially sitting superficial and then dropping within the muscle belly. b. depicting greater muscular insertion, more likely in males. c. depicting greater tendinous insertion, more likely in women. AL: Adductor Longus muscle belly; 0: Bony Origin of adductor longus

PAGE 18 OF 88 Copyright Alison Grimaldi 2018 The Iliopsoas Complex

The iliopsoas consists of two muscle bellies, and L1 and inserting into the pectineal line. It the iliacus and the psoas major (Figure 8). The also inserts heavily into the fascia iliaca that iliacus arises from the upper two thirds of the hammocks across the muscle bellies of the iliac fossa and the lateral edge of the proximal iliopsoas complex as they run through the pelvis sacrum, while the psoas major originates from (Neumann & Garcia 2015). T12-L5 lumbar vertebra and intervertebral discs. The medial fibres of the Iliacus and the psoas Iliocapsularis, often missing from text books, merge to form the iliopsoas tendon which inserts sits lateral to the iliacus muscle belly at the into the lesser trochanter. The lateral fibres of anterior hip. It originates from the inferior facet the iliacus attach onto the adjacent region of the of the anterior inferior iliac spine, below the anterior femur via a more muscular attachment. rectus femoris origin and inserts onto the femur adjacent to the lateral iliacus insertion (Walters The psoas minor, present in 40-60% of people, et al. 2014). sits anterior to the major, arising from T12

a. b. Pm Pm

PM PM IL IL FI

IC IC C

Figure 8: The Iliopsoas Complex: Psoas Major (PS), Psoas Minor (Pm) , Iliacus (IL) and Iliocapsularis (IC). a. Anatomy of the region. Pink shadow indicates fascia iliaca (FI), red crescent and arrowhead indicates Psoas Minor bony insertion. b. Closer view of tendinous insertions and iliocapsularis insertion onto capsule (C).

The psoas tendon sits directly adjacent to iliopsoas musculotendinous unit and the pelvic the iliopsoas bursa, capsule and labrum at brim and may extend proximally into the iliac the anterior hip (Figure 9). The iliopectineal fossa, and distally over the femoral head and bursa is the largest synovial bursa in humans, down to the lesser trochanter. It communicates measuring on average 5-7cm long, and 2-4cm with the hip joint in approximately 14% of adults. wide (Johnston et al 1998). It lies between the In normal imaging studies it is not usually visible but becomes evident if extended with fluid.

Anterior B *

FH FH A

Figure 9: Axial MRI and diagrammatic representation of the psoas tendon at the anterior hip. A:Acetabulum; FH:Femoral Head; *:Anterior acetabular labrum; B: Iliopectineal Bursa; Pink arrowhead indicating psoas tendon; Green line: Capsule .

PAGE 20 OF 88 Copyright Alison Grimaldi 2018 FUNCTIONAL ANATOMY Force couples around the pelvis Reflecting on how the iliopsoas works within muscular force couples around the pelvis (Figure The iliopsoas unit functions together as the 10), can provide direction regarding selection of primary hip flexor. It can also work in a reverse rehabilitative cues for exercise therapy. This may origin-insertion action to flex the trunk forward be particularly important when rehabilitating over the femur. Acting unilaterally, the psoas patients with painful snapping of the iliopsoas major may create some trunk lateral flexion. tendon. This will be discussed further in There has been some controversy regarding a subsequent chapters. small role for the iliopsoas in the axial plane. It appears that at least the fibres that insert into the lesser trochanter may have a small moment arm for lateral rotation. (Blankenbaker & Tuite 2008, Rajendran 1989).

In terms of stability function, the psoas major can provide an axial compression force to support the lumbar spine. EMG evidence also suggests

the psoas major muscle may be important Psoas Major Erector Spinae in maintaining the lumbar lordosis (Park et al. 2013). Fascicles of the psoas major may however vary their influence across the lumbar spine due to their positioning close to the axis of rotation. Small changes in spinal curvature may shift the resultant action of the psoas major

(Park et al. 2014). The iliopsoas tendon, the Rectus Abdominis iliacus muscle belly and the iliocapsularis with its capsular attachment, provide anterior support for the hip joint, particularly as the hip moves into extension (Lewis et al. 2009, Walters et al. 2014, Ward et al. 2000). Iliacus The psoas minor, although small and inconstant, has been suggested to play a role in mechanically stabilising the underlying iliopsoas. By influencing the tension in the iliac fascia, Neumann & Garceau (2015) propose that this muscle may influence stability of the iliopsoas tendon. Furthermore, this tension may prevent lifting of the iliopsoas muscle bellies within the pelvis as the hip moves into high ranges of hip flexion. Further research is required to provide support for these proposed functions. Figure 10: Sagittal representation of hip and pelvis. Iliacus and the erector spinae anteriorly rotate and rectus abdominis posteriorly rotates the pelvis on the femurs. The effect of the psoas major will vary depending on spinal posture.

TERMINOLOGY

ADDUCTOR RELATED GROIN PAIN Sites of Adductor Pathology Acute Groin Injury Long standing Adductor-Related Groin Pain

ILIOPSOAS RELATED GROIN PAIN Sites of Iliopsoas Pathology Acute Hip Flexor Injury Long standing Iliopsoas-Related Groin Pain

PAGE 22 OF 88 Copyright Alison Grimaldi 2018 Terminology The clinical As outlined in Chapter 2, the Doha consensus entities model has recommended the clinical entities model for diagnosis of groin pain, reflecting a recognisable does not however pattern of signs and symptoms, rather than a define underlying pathological entity (Weir et al. 2015). pathological processes The group recommended associated with these avoiding the following terms: presentations. Adductor tendinitis/ Is this important? An understanding of pathology tendinopathy and more importantly patho-aetiology, is usually Iliopsoas tendinitis/ considered one of the foundation stones for building effective strategies for management tendinopathy and prevention of musculoskeletal conditions. Athletic Groin Pain While psychosocial drivers of pain have become a large focus in contemporary rehabilitation and Athletic Pubalgia should be closely considered, it is important Osteitis Pubis that we do not lose sight of the importance of biological drivers. Lorimer Moseley at IFOMPT Biomechanical Groin Overload 2016 provided the following viewpoint: “…the Gilmore’s Groin biopsychosocial model rejects the biomedical model because the medical model is not Groin Disruption concerned with the person. But it does not reject the role of structural, biomechanical Hockey-Goalie Syndrome and functional disturbance of body tissue as Hockey Groin potentially powerful drivers of protection.”

Sportsman’s Groin The challenge now is to define what structural Sportsman’s Hernia and biomechanical issues may be related to pain and impairment associated with each of Sports Hernia the clinical entities outlined for groin pain. There are many papers describing different structural pathologies in those presenting with various previous diagnoses of groin pain. It is not yet The clinical entities model is a useful approach clear where each of these pathologies may fall that helps define an international language within the clinical entities model. with which researchers and clinicians can communicate more effectively.

Sites of Adductor Pathology

Investigation of groin pain in the adductor region reports variable areas of injury or Of the proximal adductor tendon injuries, three pathology. Damage may occur in the proximal quarters of these acute injuries were avulsions. enthesis or tendon of the adductor longus, the The authors suggest that the high prevalence musculotendinous junction and the muscle belly of avulsions may be a reflection of the study itself (Atkinson et al. 2010, Schilders et al. 2009, location at a hospital, where those presenting 2007; Shortt et al. 2008; Orchard et al. 2004; Zoga to a hospital for assistance may have more et al. 2008; Kalebo et al. 1992, Gabbe et al. 2010). severe injuries. Damage may also extend into the aponeurotic connection between the adductor origin and the Although this study excluded patients with rectus abdominis insertion, sometimes referred gradual onset or exacerbation of ongoing to as the pubic aponeurosis (Falvey et al. 2016). pain, tendon rupture usually reflects some A recent editorial highlighted the issue with pre-existing underlying weakening of tendon inconsistency in radiological terminology used structure. While histopathological studies in in the groin region. They suggested that global groin pain are scarce, Ippolito and Postacchini agreement on imaging terminology, together (1981) did examine a sample from an adductor with the clinical entities agreement regarding longus tendon that ruptured from its enthesis. clinical diagnoses would represent a significant They demonstrated thickening of the proximal advance in the field (Weir et al. 2017). fibrocartilage at the tendon insertion, implying that the fibrocartilaginous tissues had Acute Groin Injury extended beyond the normal transition zone, reducing the mechanical efficiency for tensile load and resulting in tendon rupture. Ruptured One recent prospective study of 111 acute onset Achilles tendons have also been shown to be adductor injuries in male athletes, reported structurally deficient and therefore at risk prior on the associated MRI findings (Serner et al. to rupture (Mafulli et al. 2011). 2017a). Adductor longus was most commonly injured (62/111), followed by adductor brevis (18/111) and pectineus (17/111), with a low injury frequency in obturator externus (9/111), gracilis (4/111) and adductor magnus (1/111). Injury within the adductor longus occurred in three locations - the proximal insertion (26%), the intramuscular musculotendinous junction of the proximal tendon (26%) and the musculotendinous junction of the distal tendon (37%). Intramuscular proximal tendon injury only occurred in one instance in this series.

PAGE 24 OF 88 Copyright Alison Grimaldi 2018 Long standing adductor-related For isolated adductor pathology, it would appear that the adductor longus tendon and it’s enthesis groin pain are common locations for pathology. Ultrasound papers have identified abnormality within the adductor tendon, such as hypoechoic areas Many differing pathologies have been and discontinuity of deeper tendon fibres See( reported in imaging and surgical studies for Figure 11) (Kälebo et al. 1981, Pesquer et al. 2015), long standing groin pain. However, often no consistent with tendon dysrepair or degenerative specific pathologic entity is identified or there change (Cook & Purdam 2009). Adductor is no correlation attempted between specific tendon pathologies may extend into the pubic physical assessment or clinical diagnoses and aponeurotic plate and coexist with multiple other imaging or surgical findings. A recent review groin pathologies and clinical entities. of 73 surgical studies has demonstrated that for 463 of 570 patients undergoing surgery for adductor-related pathology, the specific nature of the pathology was not provided. For the remaining 107 patients, adductor tendon pathology was noted in 84, tendon rupture or avulsion in 7 and a ‘strain’ in 16 patients.

ALT AL Pubic Bone AB

Figure 11: Longitudinal ultrasound of proximal adductor longus tendon. Abnormal hypoechoic area within the deep aspect of the tendon, indicated between pink arrowheads. AL:Adductor Longus; AB:Adductor Brevis; AM:Adductor Magnus; ADL:Adductor Longus Tendon.

Sites of Iliopsoas & Related or sprinting, iliopsoas was most commonly Pathology injured during change of direction.

Investigation of groin pain in the iliopsoas region The final piece of potentially relevant reports variable areas of injury or pathology. information from this study was that iliopsoas Iliopsoas pathology has been reported at the injuries primarily occurred in isolation. There proximal tendon, the musculotendinous junction, were no situtations where an iliopsoas injury the muscle belly and the iliopsoas bursa (Bui co-existed with an adductor injury. A previous et al. 2008, Johnston et al. 1998). Hip-related study from the same lead author had found groin pain associated with labral pathology and the combination of clinically diagnosed iliopsoas-related groin pain may also co-exist adductor and iliopsoas related injury to be and share a common aetiological mechanism the most common groin injury combination (Alpert et al 2009, Domb et al 2011). (Serner et al. 2015). On the basis of this more recent imaging information and a related paper that showed hip flexor clinical tests to Acute Hip Flexor Injury have poor accuracy, Serner et al. (2017b) now suggest that acute hip flexor-adductor injury combinations are unlikely to occur. Serner and colleagues published a companion paper on acute hip flexor injuries from their recent prospective study of MRI pathologies associated with acute onset groin pain (Serner et al. 2017a). Of the 33 hip flexor pathologies detected in male athletes, 16 were located in the rectus femoris, 12 in the iliacus, 7 in psoas major, 4 in sartorius and 1 within the tensor fascia lata.

While rectus femoris injuries predominantly occured at the proximal tendons, acute iliacus and psoas major injuries were mainly observed at the musculotendinous junction, with only two tendinous injuries. There was only one isolated psoas major injury, iliopsoas injuries usually occuring as an isolated iliacus injury or a combined iliacus-psoas major injury.

The most common mechanism of injury for rectus femoris and iliopsoas was also quite distinct in this series. While the rectus femoris was most likely to be injured when kicking

PAGE 26 OF 88 Copyright Alison Grimaldi 2018 Long standing iliopsoas-related Tendon pathology may be associated with impingement against prominent bone in those groin pain with femoroacetabular impingement or a prominent acetabular component following total hip arthroplasty (Chalmers et al. 2017). Imaging and surgical visualisation of local structures in those with long standing Iliopsoas- related groin pain has provided information on associated pathologies. There is consistent reporting in the literature of the presence of iliopsoas tendinopathy, with or without associated bursal thickening in the underlying iliopectineal bursa (Anderson 2016, Blankenbaker & Tuite 2008, Chalmers et al. 2017, Domb et al. 2011, Hain et al. 2013, Yen et al. 2015). This may occur in conjunction with painful snapping of 12 the iliopsoas tendon or impingement against underlying structures.

Iliopsoas impingement is now a well recognised cause of iliopsoas-related groin pain. Labral pathology has been noted at the 3 o’clock, direct 9 3 anterior region, immediately adjacent to the iliopsoas tendon (Figure 12). Labral injuries such as those associated with femoro-acetabular impingement occur most commonly in the anterosuperior or superior regions from the 6 11.30-2pm position. Labral pathology at the 3 o’clock position has been noted to range from frank tears, mucoid degeneration and an inflamed appearance without a tear. Pathology in this region is now thought to be caused by impingement of the overlying iliopsoas tendon (Alpert et al 2009, Domb et al 2011). The adjacent tendon on arthroscopic inspection is also noted to be red and inflammed with variable amounts of scarring which may bind the tendon down to Figure 12: Clockface orientation for indicating region the underlying capsule (Domb et al 2011). Tendon of chondrolabral pathology. 3 O’Clock is direct anterior. pathology and impingement can also occur in the context of femoroacetabular impingement and following total hip arthroplasty.

WORKLOADS & INJURY

ARGP - MECHANICAL FACTORS Compressive & Tensile Loads Loads in Sport

IRGP - MECHANICAL FACTORS Compressive & Tensile Loads The Effect of Posture & Function The Impact of Structure Anterior Snapping Hip

PAGE 28 OF 88 Copyright Alison Grimaldi 2018 Various models have been developed to help understand the aetiology of injury in athletes, with the ultimate motivation of enhancing injury prevention. Bahr and Krosshaug’s (2005) model outlines intrinsic factors that predispose an athlete to injury, extrinsic factors that then increase susceptibility and an inciting event that finally results in injury. Intrinsic factors encompass age, sex, body composition, previous history of injury or instability, physical fitness including muscle strength and flexibility, anatomy, skill level and psychological factors. Extrinsic risk factors may include sports factors (coaching, rules, referees), protective equipment, sports equipment (e.g. shoes) and environmental conditions (e.g. weather, playing surface). The final injury may be incited by a playing situation, player or opponent behaviour, gross biomechanical loads applied to the whole body or local biomechanical loads applied across a specific tissue. For pain of more gradual onset, there may not be a single definable inciting event, but a gradual accumulation of adverse loading. Workloads, while not addressed specifically in this model, have the potential to influence both extrinsic and intrinsic risk factors for injury (Windt & Gabbett 2017). This chapter will initially discuss workloads and then focus on intrinsic factors associated with physical fitness and biomechanical loads that may incite pain or injury.

Workloads & Injury 2. ’Workloads which induce high levels of negative changes to modifiable internal risk Windt and Gabbett’s (2017) recently updated factors (ie, ‘fatigue’) increase injury risk.’ Workload—Injury Aetiology Model explores how workloads may influence injury risk. They believe Fatigue from training at a level to which the that are three primary mechanisms: individual cannot adequately adapt , may result in both physical and psychological fatigue and 1. ’High workloads increase exposure, thereby subsequent increases in injury risk. Fatigue increasing injury risk.’ may compromise both neuromotor control and tissue resilience. The more time an individual spends in an at-risk sporting environment, the more opportunity 3. ’Workloads that maximise positive adaptations there is for injury. The same is likely to hold while minimising fatiguing effects will help make true for other situations of occupational and athletes more robust to injury.’ recreational risk.

Copyright Alison Grimaldi 2018 PAGE 29 OF 88 Total Workloads Consistent with this paradox, lower levels of pre-season sports-specific training has been Workload has traditionally been assessed by shown to be a significant risk factor for groin considering total, absolute workload over a injury in sport (Whittaker et al. 2015). defined period. There is evidence to suggest that total workload significantly influences injury risk. Gabbett (2010) devised an injury prediction model that demonstrated that elite Rugby players that exceeded a defined weekly workload threshold were 70 times more likely What we Know About to sustain a soft-tissue injury. Adequate workload however is essential to achieve Workload adequate skills and physical conditioning. By this mechanism, low workloads can also increase injury risk. INJURY RISK INCREASED BY: Acute vs Chronic Workload Total Workload: Workload monitoring then moved to assessing acute:chronic workload ratios that compare the Too much & too little workload over the last week (acute workload) against the workload over the preceding four weeks (chronic workload). Spikes in activity Acute vs Chronic Workload: where the acute:chronic ratio exceeds 1.5 has (Last week:4 weeks before) been shown to significantly increase injury risk (Hulin et al. 2014, Gabbett et al. 2016). > 1.5 Chronic Workload: Workload-Injury Paradox Too little The most recent investigations have revealed the workload-injury paradox, where higher chronic workloads do not predispose but SO ATHLETES SHOULD: in fact protect an athlete from injury. This Stay within advised is contingent on appropriate acute:chronic workload ratios. High acute:chronic workload volumes for the sport ratios together with high chronic workloads result in high injury risk, however high chronic workload with a moderate acute:chronic Avoid spikes in activity workload ratio (0.85–1.35) returns a very Increase by 10% / week low injury risk (Hulin et al . 2016). Statistics from rugby league have shown that the risk of sustaining an in-season injury were Put in the hard work in decreased by 17% for every 10 preseason training sessions that players completed the preseason (Windt et al. 2017).

PAGE 30 OF 88 Copyright Alison Grimaldi 2018 Mechanical Loads Adductor-Related Groin Pain

Compressive & Tensile Loads These positions will also result in tensile loads Both compression and tensile loading may across the tendons, the musculotendinous play a role in the development of the various junction and the aponeurotic connections across pathological entities involved in groin pain. In the anterior pubis (Figure 13). Combinations of Book 1 of this series, the adaptations engendered large range, high speed and high repetition by compression have been discussed. The of such movements will represent the most scant histological evidence that is available provocative combinations of compressive and relating to adductor pathology does reflect tensile loading. such adaptations to compression (Ippolito & Postacchini 1981). Cook & Purdam (2012) suggest that positions of hip extension and abduction will result in compressive loading of the adductor longus and rectus abdominis tendons as they wrap around the pubic ramus.

Compression AL

Tension

Figure 13: Compression and tension of the adductor longus (AL) and rectus abdominis (RA) tendons and the pubic aponeurosis as the hip moves into extension.

The high prevalence of adductor related groin pain in kicking sports may be associated with the specific challenges kicking presents for the adductor longus. Charnock et al. (2009) have analysed the action of the adductor longus during a soccer instep kick. They found that at the end of the wind up phase, when the hip was in maximal extension, the adductor longus was at its maximum rate of lengthening and maximum activation.

As the leg starts to move forward the path is into flexion and abduction so that maximum length of adductor longus occurred at 65% of the swing phase, at peak abduction (Charnock et al. 2009). The kicking action will therefore involve significant compressive loading at the adductor longus enthesis, both in wind up and swing phase. There will also be high tensile loads transmitted across the adductor-abdominal aponeurosis, and the pubic symphysis. For the adductor longus musculotendinous complex, the rapid, forceful stretch-shortening cycle will be challenging, particularly under conditions of high repetition and fatigue.

Rapid and forceful hip extension and abduction also occurs in many other sports such as ballet, gymnastics, and change of direction sports such as hockey, baseball and all the football codes. The tendon is exposed to compression and the muscle and musculotendinous junction to high velocity eccentric lengthening.

PAGE 32 OF 88 Copyright Alison Grimaldi 2018 highest values for compression were recorded Mechanical Loads over the femoral head, but this was range specific. Maximum pressure was recorded Iliopsoas-Related Groin Pain over the femoral head at 0° of flexion. Pressure on the femoral head reduced as the hip flexed and contact was lost between the head of the Compressive & Tensile Loads femur and the tendon at about 15° of flexion. From an extended hip position and into early As for other tendinopathies, excessive flexion, it is the head of the femur rather than compression and particularly combinations of the pelvic brim, that acts as the pulley for the compression and tension may have adverse psoas tendon. Yoshio et al. (2002) reported that effects on iliopsoas tendon health. At the anterior the tendon acts to stabilise the femoral head, hip, these loads may also adversely influence any creating a posterosuperior force. As the tendon underlying tissues such as the bursa, capsule lifts off the femoral head, above 15° of flexion, and acetabular labrum. Compression of the the pulley mechanism is transferred to the pelvic iliopsoas tendon and underlying structures will brim. The tendon then lifts off the pelvis around occur as the tendon wraps around the pelvic 60° so that in the higher ranges of hip flexion brim and then the head of the femur on its course there is minimal or no bony contact with the to the lesser trochanter. tendon (Figure 14).

Yoshio et al. (2002) performed a detailed cadaveric study on the psoas major, measuring pressure beneath the tendon at multiple sites along the length of the tendon, and through 0° to 90° of hip flexion. Across all bony sites, the Above 60° No bony contact 15-60°Hip flexion Pulley transferred to pelvic brim after loss of contact with HOF

0-15°Hip flexion Maximum pressure HOF HOF acts as pulley Tendon stabilises HOF Posterosuperior force

Figure 14: Psoas tendon bony contact and compression through range. Based on Yoshio et al (2002). HOF: Head of Femur

Copyright Alison Grimaldi 2018 PAGE 33 OF 88 Yoshio et al. (2002) only studied the 0-90° the joint forces significantly increased. There range of motion. It is logical to assume that would appear to be a delicate balance here the compressive loading will continue to between the provision of adequate stability increase from 0° into hip extension, so that while avoiding excessive compression. maximal compression will occur in maximal hip extension. In hip extension, the iliopsoas The Effect of Posture is thought to provide an important restraint against anterior translation of the head of Risk of excessive compressive loading of the femur (Retchford et al. 2013). During gait, the iliopsoas and related structures is likely to iliopsoas is also highly active at end stance increase with exposure to sustained, repetitive phase, presumably supporting the femoral and/or loaded hip extension. The ‘sway’ type head and storing energy for the subsequent posture is characterized by posterior pelvic tilt swing phase (Andersson et al. 1997). Through and anterior translation of the pelvis relative end stance and early swing phase of walking to the base of support (Kendall et al. 2005), and particularly running, the iliopsoas complex both resulting in relative hip extension (Figure will undergo a high energy storage and release 15). Those favouring a sway posture usually process and exposure to high compressive present with increased length in the anterior and tensile loads. soft tissues. While there is less passive tension of the longer iliopsoas, higher anterior loads Lewis and colleagues (2009) have also may be associated with the higher ranges of demonstrated through modelling that the hip extension employed. Those with a more highest anterior hip joint loads occur in lordotic posture will generally have a shorter extension, and that the iliopsoas appears to iliopsoas, presumably then reaching higher be involved in controlling this loading. When levels of compression in lower ranges of hip the iliopsoas was weakened in the model, extension.

a. b.

Figure 15: Posture type. a. Sway, demonstrating anterior translation of the pelvis relative to the base of support, and resultant hip extension. b. Lordotic, demonstrating increased relative anterior pelvic tilt and resultant hip flexion.

PAGE 34 OF 88 Copyright Alison Grimaldi 2018 Iliopsoas Loads During Dynamic Function

Although it is often postulated that static posture has little relevance for dynamic function, those with a sway type posture certainly appear to retain their tendency towards excessive hip extension during gait. This may have relevance for both tendon and joint loads, as even a 2º increase in hip extension has been shown to increase anterior hip joint loads by 20% of bodyweight (Lewis et al. 2007, 2010). High ranges of hip extension during gait and other function may significantly increase anterior tendon and joint Psoas Major loading (Figure 16). A combination of tightness of the iliopsoas complex, as might occur with a more lordotic posture, and moderate to high ranges of dynamic hip extension will also result in high anterior loads.

Power walking or running with a long stride Compression length, which is common in those with low * cadence, will increase the range and time spent in hip extension. It is a common clinical scenario to record a history of a patient who Tension has recently taken up power walking and subsequently developed iliopsoas-related groin pain. Those involved in ballet, gymnastics and martial arts use larger ranges of extension regularly, often sustained, repetitive and/or at high speed, which may contribute to their higher incidence of iliopsoas-related groin pain. Figure 16: Compression and tension of the iliopsoas as the hip moves into extension. The iliopsoas tendon will During a soccer or football kick, high sling around the femoral head and impinge against the compressive loads will be created as the hip acetabular labrum, capsule and iliopectineal bursa. reaches 20° or more of extension at the end *: Iliacus. of the wind-up phase (Charnock et al. 2009). This usually occurs under high velocity, and with strong hip flexor activity, working first eccentrically as the hip reaches final stages of extension, and then concentrically to bring the thigh powerfully into flexion.

Other factors may also increase the prominence of the femoral head and therefore predisposition to problematic compressive loading. Acetabular dysplasia and/or inadequate capsuloligamentous stability anteriorly may allow greater anterior translation of the femoral head, particularly in hip extension and if the dynamic stability mechanisms are inadequate.

Increased prominence of the head neck junction secondary to femoroacetabular impingement (cam lesion), perthes or slipped capital femoral epiphysis, or due to osteophytosis associated with hip osteoarthritis may also increase the risks of compression of the iliopsoas tendon (Mardones et al. 2016). Iliopsoas impingement against a prominent acetabular component following total hip arthroplasty is also now a well recognised cause of post-arthroplasty iliopsoas- related groin pain (Henderson & Lachiewicz 2012). The orientation of the cup is a key feature and to address the issue successfully, sometimes surgical reorientation of the cup is required. Osteophytosis around the acetabular cup post arthroplasty may also cause issues Figure 17: Impingement of the iliopsoas tendon against with compression or friction of the adjacent the acetabular cup and/or osteophytes may occur post tendon and bursa (Figure 17). total hip arthroplasty.

PAGE 36 OF 88 Copyright Alison Grimaldi 2018 Anterior or Internal Snapping Hip Traditional theories - what and why

Some patients with iliopsoas-related groin pain There is still a lack of complete certainty present with snapping of the iliopsoas tendon, regarding what the tendon is snapping over which may or may not be painful during the and why it occurs. The most common theories action. The relevance of the snap is unclear, are that the tendon snaps either over the head of as many people exhibit a snap of the iliopsoas the femur or the iliopectineal eminence, although tendon in the absence of hip pain, particularly the evidence for either is not strong (Anderson in the dance population (Winston et al. 2007). & Keene 2008, Ilizaliturri et al. 2009, Contreras It is thought that pain may develop from the et al. 2010). These theories suggest that as the repetitive snapping and friction of the tendon hip flexes, abducts and externally rotates, the against the underlying structures. It is also iliopsoas tendon may slide laterally. As the hip possible that painful pathology develops initially is lowered back down into extension, the snap secondary to excessive use of compressive, hip is thought to occur as the tendon snaps back extended postures and once painful, the snap over the head of the femur or the iliopectineal may also become symptomatic. eminence. Snapping of the tendon over a paralabral cyst and snapping of two portions of a bifid tendon over one another have been demonstrated but are uncommon causes (Deslandes et al. 2008).

Copyright Alison Grimaldi 2018 PAGE 37 OF 88 Theories as to why the snap occurs are variable. New insights Bony morphological issues such as excessive prominence of the iliopectineal eminence have In recent years, a novel theory has emerged been suggested. By far the most common around what is causing the snap, also providing assumption however, is that the underlying new insights into potential underlying drivers. cause is tightness of the iliopsoas, with all The range of motion in which iliopsoas snapping subsequent conservative and surgical measures occurs is usually around 45-60° of hip flexion. aimed at lengthening or releasing this structure. Based on Yoshio et al.’s work (2002), the tendon Despite this, evidence for tightness does not would not be expected to be in contact with feature in the literature. the femoral head through this range. There is contact however with the pelvic brim in this Reports of conservative management of range. Deslandes et al. (2008) and Winston et iliopsoas snapping have also failed to produce al. (2007) have both described a mechanism evidence of iliopsoas tightness in this population. whereby the psoas tendon lifts away from the Keskula et al. (1999) in a single case study of pelvic brim during hip flexion, embedding itself painful snapping hip, reported normal length of into the iliacus muscle belly, trapping a portion the hip flexors and pain at end of range extension, of the muscle belly beneath the tendon. On and yet the basis of the subsequent treatment lowering of the hip into extension, the psoas was stretching. Johnston et al. (1998) reports a tendon snaps around the iliacus and down onto clinical impression of tightness in patients with the pelvic brim (Figure 18). iliopsoas syndrome, with or without snapping, but no evidence is provided. Recent publications Deslandes et al. (2008) reported this finding on reference older publications, leaving the whole dynamic ultrasound assessment, in 14 of their evidence base resting on an assumption. 18 patients with snapping hip. These authors state that they never witnessed the iliopsoas Much more research in this area is required tendon move across the iliopectineal eminence, to clarify comparative hip flexor length in a the tendon always staying lateral to this bony population with painful snapping hip. It is prominence. They also state that although the well documented that dancers have a higher iliopectineal eminence is a commonly stated incidence of snapping hip and they fall usually site of tendon impingement, no-one has ever within the most mobile end of the spectrum. published evidence of such impingement. Clinically, those presenting with painful iliopsoas Recent studies have not provided this evidence snapping do appear to be much more commonly either, all referring to earlier narrative papers. hypermobile than hypomobile. Further research Back in 1990, Jacobsen and Allen also reported is extremely important as mobile patients that they had never been able to observe the undergoing a stretching protocol or surgical tendon cross the iliopectineal eminence, even iliopsoas release may be at risk of joint instability at far extremes of movement. and even dislocation (Sansone et al. 2013).

PAGE 38 OF 88 Copyright Alison Grimaldi 2018 IL-Lateral

DMB

Pelvic Brim

Figure 18: Axial ultrasound at the level of the superior pubic ramus. During hip flexion, abduction, external rotation, the psoas tendon (outlined in pink dots) lifts, rolls over and embeds itself on top of the deep medial bundle of the iliacus (DMB). On descent into hip extension, the tendon snaps back around the iliacus and down onto the pelvic brim. IL-Lateral: Lateral bundle of the iliacus.

So why would the psoas tendon snap over the iliacus muscle in some individuals? Deslandes et al. (2008) revert to the tight muscle hypothesis as the explanation for their new snapping mechanism. They hypothesise that the iliacus may be bulky, poorly compressible and confined within a tight fascia.

This is purely hypothesis however, and it could be equally plausible that the iliacus muscle may be inhibited with poor ability to stabilise or resist invasion by the psoas tendon. The deep medial bundle of the iliacus is most likely to have a stabilising action on the psoas tendon. Delayed activation or atrophy of this bundle may result in a relatively less stable psoas tendon. Much further research is required to confirm impairments and provide a sound evidence base for management.

DEFICITS ASSOCIATED WITH ARGP Muscle Strength Muscle Recruitment (EMG) Range of Motion

DEFICITS ASSOCIATED WITH IRGP The Evidence Clinical Impression

PAGE 40 OF 88 Copyright Alison Grimaldi 2018 adductor squeeze test could be a useful early Impairments screening tool. Various versions of the adductor squeeze test are now being used as a screening Adductor-Related Groin Pain tool in team sports, and may provide an early indication that load transference across the pelvis is becoming impaired. At present, the research on impairments associated with groin pain has not been A meta-analysis of all the available pooled data consistently divided into that associated with for the adductor squeeze test, demonstrated each of the clinical entities. The following strong evidence with a large effect size, that information therefore, will contain data that is those with hip/groin pain have reduced adductor primarily related to symptoms in the adductor strength on this test (Mosler et al. 2015). region but may contain subject groups that have varying local pathologies and multiple Adductor:Abductor Strength Ratio entity diagnoses e.g. adductor related, pubic- related, iliopsoas-related groin pain. Further The ratio between adductor and abductor strength research regarding impairments associated has also been assessed both prospectively and with specific entitites is required, but the in painful cohorts. In uninjured ice hockey players information currently available will provide Tyler et al. (2001) reported adductor strength the clinician with awareness of potential to be 95% of abductor strength. In elite male impairments. As is standard clinical practice, soccer players, Thorborg et al. (2011) showed each patient’s specific impairments should be the adductors were a little stronger than the addressed on an individual basis. abductors and Kemp et al. (2012) assessing a non-elite active population reported adductors to be just under 90% of abductor strength (Table 2). Hip Adductor Muscle Strength Tyler et al.’s (2001) prospective study found that Hip adductor weakness has been shown to players whose adductor strength was less than be both a risk factor for developing groin pain 80% of abductor strength were 17 times more (Whittaker et al. 2015) and an impairment in those likely to sustain an injury at the adductor origin with adductor-related groin pain (Kloskowska et during the subsequent ice hockey season. The al. 2016, Mosler et al. 2015). Tyler et al. (2001) results of this study led to recommendations completed a prospective study of male ice from the authors that adductor strength should hockey players. Eccentric hip adductor strength, return to at least 90% of abductor strength, and measured in sidelying, was found to be 18% lower symmetry in strength between sides should in ice hockey players who went on to sustain be within 10% before return to sport after a an adductor injury in the subsequent season. groin injury. Crow et al. (2010) prospectively screened Australian Football League players each week to evaluate adductor strength with the 45° squeeze test - knees bent 90° and feet on the bed. They reported that players who developed groin pain during the season had tested, on average, around 11% weaker in the week of reporting, and 5 % weaker in the week prior to pain onset. They concluded that adductor weakness precedes onset of pain and that the

Copyright Alison Grimaldi 2018 PAGE 41 OF 88 Relative Strengths Study Ratio as a Percentage Tyler et al. 2011 Abd:Add 1.05 Adductor strength 95% of Ice hockey players abductor strength Thorborg et al. 2011 Abd:Add 0.95 Adductor strength 105% Male soccer players of abductor strength

Kemp et al. 2012 Abd:Add 1.13 Adductor strength 88% of Non elite, active abductor strength

Table 2: Hip Abductor:Adductor Ratios in Painfree Populations

In Thorborg et al.’s (2011) study of 86 elite soccer reflective of protective inhibition. Crow et al. players who were uninjured at the time of testing, (2010) reported reductions in strength prior to 10 players experienced pain during adductor pain onset, although it is possible the central strength testing, reducing their adductor nervous system was already protective of a strength to 80% of their abductor strength. subclinical issue. After application of a pelvic Eight out of 10 of these subjects who had pain belt, Mens et al. (2006) recorded significant on testing had experienced hip and/or groin increases in adductor squeeze strength in pain in the previous year. The residual pain and athletes with groin pain. The authors suggested weakness may reflect inadequate rehabilitation the pain and weakness on adductor loading and help explain the high recurrence rates of may be secondary to failed load transfer across adductor injury. the pelvis. Application of a pelvic belt has been shown to have many and varied effects on Sixty-nine percent of Thorborg et al.’s (2011) muscle recruitment around the lumbopelvic group of soccer players had experienced hip, and hip region (Arumugam et al. 2012). The and/or groin pain in the previous year, and yet effects of a pelvic belt on adductor strength those who were non-painful on testing were may have some local mechanical effect or the stronger in their adductors than their abductors effect may be purely neuromotor. (Table 2). It is unclear why, but perhaps the majority of players focussed on adductor strengthening Together, the information tells us that those resulting in a slight supercompensation. with groin pain have consistent weakness in adduction strength and that this weakness may precede symptoms. It does not tell us if the adductors are atrophied or whether the Reasons for Reduced Strength? weakness is in fact an indication of failed load Surprisingly, despite the number of studies transfer across the anterior pelvis, or inhibition examining adductor strength, there does to protect failed or failing local soft tissues. not appear to have been any exploration of concurrent changes in adductor muscle size or quality. It is unclear then if adductor weakness is underpinned by adductor atrophy. Certainly in the presence of pain, weakness may be

PAGE 42 OF 88 Copyright Alison Grimaldi 2018 Hip Adductor EMG difficulty relaxing their adductor longus in low load postures and tasks - often referred to as Information from EMG studies, although limited, ‘adductor guarding’. This adductor behaviour may provide further insight into adductor may contribute to range restrictions in Bent impairments associated with groin pain. Lovell Knee Fall Out, that have been demonstrated in et al. (2012) looked at adductor EMG levels during those with groin pain (Mosler et al. 2015). six clinical tests, including bilateral squeeze tests and unilateral strength tests, all involving The evidence base here lacks the depth and maximum adductor force production. In those quality of information available for other hip who had sustained a previous groin injury, conditions. As discussed in Book 2, EMG studies adductor longus recruitment was significantly for those with painful gluteal tendinopathy have reduced and yet players were not painful at the revealed excess activity and a lack of normal time of testing. Lovell et al. (2012) concluded precision and variability in gluteal muscle that motor control deficits persist after groin recruitment during gait, a relatively low load task injury, even after successful return to sport. (Allison et al. 2017, Ganderton et al. 2017). The pattern is one of excessive co-contraction rather In a lower load functional task involving than the finesse of a more variable ‘load sharing standing and lifting one hip to 90 degrees - load sparing’ pattern. Adductor guarding may flexion, Morrissey et al. (2012) reported that reflect a similar recruitment issue. gluteus medius EMG was reduced and adductor longus EMG relatively increased in those with chronic groin pain. Clinically, patients with adductor-related groin pain do appear to have

What does this all mean for rehabilitation and exercise selection? xer ad Fun E cis o c ch e L ti i o h s h Reduced ? n CLINICAL IMPLICATION g W

Adductor

Strength &

Focus: Adductor Strengthening EMG Upregulate AL Activity ???

d Fun a ct Exerci o io h s L ic e n h s w Increased CLINICAL IMPLICATION ?

o W

Adductor EMG

Focus: Calm Adductor Longus

Downregulate AL Activity

Figure 19: What are the clinical implications of adductor electromyography (EMG)studies? AL:Adductor Longus

Copyright Alison Grimaldi 2018 PAGE 43 OF 88 Clinical Implications This apparent discrepancy can perhaps be explained as a motor control deficit where the adductor longus has both low load and Reduced adductor strength and lower levels high load dysfunction (Figure 20). Both are likely of adductor longus recruitment have been to be protective in nature – the guarding to reported under maximal loading conditions for prevent end range movements that may those with groin pain. It is therefore tempting place high passive loads across the anterior to conclude that our primary aims should be pelvic structures and the apparent high load to strengthen the adductors and increase weakness, a cortical inhibition reflecting an their recruitment by choosing exercises that unwillingness of the neuro-motor system to encourage high levels of EMG. However, there place maximal active load across potentially would appear to be a discrepancy when you at-risk structures. also consider information from low load tests such as standing hip flexion and bent knee fall out. For those with groin pain, these tests have demonstrated relatively greater levels of adductor EMG and an inability to completely relax into a bent knee fall out position (Figure 19). This information would therefore suggest that we should be teaching those with groin pain to relax their adductors and choose exercises that encourage reduction of adductor longus recruitment.

High load dysfunction t en m it Inadequate ability to ru n c ai re p maximally recruit l a in o m r % recruitment r G o N

Inadequate

ability to turn off % effort Low load dysfunction Figure 20: Graphical representation of co-existing high load and low load dysfunction in Adductor Longus recruitment.

PAGE 44 OF 88 Copyright Alison Grimaldi 2018 Trunk Muscle Impairments an active straight leg raise task (Cowan et al. 2004). Jansen et al. (2010) found resting muscle Can trunk muscle function predict groin injury? thickness of transversus abdominis in athletes In a small cohort of Australian Football League with long standing adductor-related groin pain players, one study found that the ability to draw was reduced, but thickness during active tasks in the abdominal corset was not predictive of such as an active straight leg raise or a squeeze hip, groin or thigh injuries (Hides et al. 2011). test was not. However, preseason size of multifidus at L3-5 was smaller in those who developed more Isokinetic dynamometry has revealed severe hip, thigh or groin injuries that resulted significantly lower concentric back extensor in missing four or more training sessions. Half and eccentric abdominal strength and a higher of the injuries sustained were groin injuries. The concentric abdominal:back extensor ratio in authors suggest that smaller multifidus muscles those with groin pain (Osteitis Pubis) compared may negatively effect neuromuscular control of with painfree controls (Mohammad et al. 2014). the lumbar lordosis and efficient distribution of Much research is required to clarify impairments forces between the lumbopelvic region and the for each of the clinical groin pain entities. lower limbs. They did however concede that the results would need to be replicated in a larger The information to date however indicates cohort to improve confidence in this measure a relationship exists between trunk muscle as a risk factor for hip, groin and thigh injury. function and groin pain and suggests that assessment and rehabilitation of trunk muscle Cross-sectional studies have also looked at impairments would be warranted in both abdominal muscle size and function in those prevention and management of groin pain. with long standing groin pain. One fine wire EMG study of Australian Football League players with long standing groin pain, demonstrated a delay in transversus abdominis onset during

Copyright Alison Grimaldi 2018 PAGE 45 OF 88 Hip Flexor Strength in Taylor et al’s athletes with groin pain, when more than one clinical entity was diagnosed, Limited evidence exists for changes in hip iliopsoas-related pain was recorded in almost flexor strength in the presence of groin pain. 70% of cases (Taylor et al. 2017). It is highly One study that assessed hip muscle strength unlikely however, that imaging studies would in subjects with long standing groin pain confirm iliopsoas pathology in all of these (osteitis pubis), found that the only significant athletes. The evidence suggests that clinical difference was higher strength in isometric tests used to diagnose iliopsoas-related groin hip flexion and a higher flexor:extensor ratio in pain are poor indicators of iliopsoas pathology those with groin pain compared with controls (Serner et al. 2016). (Mohammad et al. 2014). In contrast, a group of male soccer players diagnosed with the clinical What then does a diagnosis of iliopsoas-related entity - adductor-related groin pain, showed no groin pain tell us? Groin pain on resisted hip change in hip flexor strength compared with a flexion or passive hip extension may simply painfree control group. These varying results emanate from the adductor longus with its may reflect differences in presentations of significant hip flexor function. the groups assessed (pubic-related groin pain versus adductor-related groin pain) or the quality At a minimum, the high of each study (low quality versus high quality (Kloskowska et al.2016)). prevalence of signs on hip flexor testing suggest Hip Flexor-Adductor Relationships that those with groin pain

Adductor longus and Tensor Fascia Lata commonly have some form (TFL) are both known to provide secondary of hip flexor dysfunction and assistance to iliopsoas during hip flexion. Lewis difficulty transferring load and colleagues (2009), using a sophisicated modelling system, demonstrated that if the across the hip and pelvis in iliopsoas was weakened within the model, there the sagittal plane. would be a subsequent increase in secondary muscle contribution from TFL and the adductor longus muscle during a hip flexion task. Clinically, Further research is required to clearly this is a common scenario in both hip and characterise the impairments associated groin pain presentations - increases in TFL with a clinical entity diagnosis of iliopsoas- and adductor longus activation during a hip related groin pain and the implications for flexion task, associated with iliopsoas atrophy clinical practice. At this point, positive signs on or recruitment delay evident on ultrasound. active hip flexion and/or passive hip extension indicate that the clinician should undertake a The clinical diagnoses of adductor-related and detailed assessment of hip flexor function and iliopsoas-related groin pain commonly co-exist address any impairments as part of the overall (Holmich et al. 2007, Taylor et al 2007). While management plan. adductor-related groin pain is the most common primary entity, iliopsoas-related groin pain is the most common secondary entity when more than one clinical entity is diagnosed. Among football players in Holmich et al’s cohort (2007), 60% were diagnosed with iliopsoas- related pain as a secondary clinical entity. Similarly,

PAGE 46 OF 88 Copyright Alison Grimaldi 2018 Range of Hip Motion decreased bilateral, total hip external rotation (sum of both legs) (Kloskowska et al. 2016). A recent systematic review and meta-analysis has determined that hip abduction flexibility A recent report of pre-season screening data is not a risk factor for developing groin pain for two professional soccer clubs found no (Kloskowska et al. 2016). There is however, association between current groin pain and moderate-strong evidence from two meta- hip range of motion (Tak et al. 2016). They did analyses that reduced range on the bent knee however find that players who had a history of fall-out test is associated with groin pain in hip or groin injury in the previous season and athletes (Kloskowska et al .2016, Mosler et al. players that scored lowest on the HAGOS (Hip 2015). As discussed previously, a reduction and Groin Outcome Score) had a lower range in bent knee fall-out range may reflect a of hip internal rotation and total rotation range. protective upregulation of adductor longus These associations remained regardless of the activity. Stretching of the adductors may be presence of a cam deformity. provocative and is generally not recommended in the management of groin pain. With active Although limitation of hip range does not appear exercise and resolution of symptoms, adductor to be a significant risk factor for the development length has been shown to return without passive of groin injury (Whittaker et al. 2015), soccer/ stretching (Holmich et al. 1999). football players, particularly professional or senior athletes exhibit reduced range of motion Limitations of hip rotation range have a compared with the general active population complex relationship with groin pain. Significant (Manning & Hudson 2009). This may reflect discrepency exists in the literature, with some adaptive changes in both bone (Agricola et studies finding restriction in one or more aspects al. 2012) and soft tissues surrounding the of hip rotation range in those with groin pain joint (Manning & Hudson et al 2009), likely and others reporting no correlation. Positions of associated with the particular loading scenarios testing, inadequate study numbers and varying encountered in this sport. diagnoses may influence results. Co-existing femoroacetabular impingement, prevalent in football populations (Nepple et al. 2012, Weir et al. 2011), may influence hip rotation range, particularly at 90° of hip flexion.

One meta-analysis of previous study results for athletes with groin pain, found strong evidence for reduction of hip internal rotation range in prone (neutral hip flexion/extension) and moderate evidence for reduction of internal range in supine (90° hip flexion) (Mosler et al. 2015). In addition, they reported that hip external rotation range in neutral hip flexion/extension did not differentiate athletes with and without groin pain, but there was limited evidence of reduced external rotation at 90° hip flexion. Another meta-analysis reported no significant links between reduced hip internal rotation range or unilateral hip external rotation range and presence of groin pain, but strong evidence of

The Evidence There is a high need for evidence regarding Studies on groin pain in athletes have not impairments in those with iliopsoas-related specifically assessed impairments associated hip and groin pain. There is currently no with isolated iliopsoas-related groin pain. Where evidence base for conservative management this clinical entity co-exists with another of the of these conditions. The evidence for surgical groin pain entities, many of the impairments management is based purely on assumption discussed above may exist. and results of previous surgery.

Turning to the literature on primary iliopsoas related diagnoses, unfortunately very little evidence of any level exists as to the physical deficits associated with these conditions. In a study of 49 dancers with painful snapping of the iliopsoas tendon (referred to as Iliopsoas Syndrome), physical examination results refer to weakness on resisted isometric hip flexion (90°) in external rotation, although no clinical or instrumented measures of strength were recorded (Laible et al. 2013). Pain and/or tightness on passive iliopsoas stretching was also noted but no measures were performed or indications provided regarding their definition of tightness.

This is reflective of the low quality of evidence available for iliopsoas impairments. While papers on management of anterior snapping hip or iliopsoas impingement refer to tightness of the iliopsoas, no length testing studies are available. Reference is made occasionally to hip flexor weakness, and yet no strength testing studies are available for any pre-operative condition. Residual muscle atrophy and hip flexor weakness has been demonstrated for patients on average 21 months post surgical iliopsoas release (Brandenburg et al. 2016). No preoperative data is available however, so the study provides no insight into the influence of the original condition on muscle strength and size, only the influence of the subsequent surgery.

PAGE 48 OF 88 Copyright Alison Grimaldi 2018 Clinical Impression

In the absence of sound scientific evidence, Length of the iliopsoas should be formally the clinician is reliant on his or her clinical assessed in the Modified Thomas Test assessment and reasoning skills. The clinician position. The clinician should not assume treating patients with iliopsoas-related hip that the iliopsoas is short, even in the case and groin pain should assess each individual of restricted functional hip extension such as for impairments within the hip flexor synergy reduced stride length in gait. Patients with and around the whole lumbopelvic region. painful conditions of the iiopsoas will often Clinically, these patients often present with antalgically avoid positions of hip extension inadequate lumbopelvic control and deficits due to provocative compressive loads in such in trunk and/or gluteal muscle function. postures. If this has been a long term strategy, they may well be shortened on length testing, Snapping of the iliopsoas tendon is often but many patients remain long and flexible into associated with movement patterns where hip extension. The particular presentation will the pelvis is moved into a position of relative influence management approach. Stretching posterior pelvic tilt. For example, snapping is in either situation is not recommended due common in floor-based pilates classes where to potentially adverse loads being transferred participants may be encouraged to flatten their to a painful iliopsoas tendon, bursa, capsule back onto the floor for abdominal-hip flexor or labrum. loading exercises. Similarly, young dancers with snapping hip have often been encouraged to use an excessive amount of ‘tail-tuck’ or posterior pelvic tilt.

As discussed in the functional anatomy of the iliopsoas, the ilacus will be recruited during anterior pelvic tilt/lumbar extension, while the psoas may have either a flexing or extending effect on the lumbar spine and its activation is less likely to be delayed by a posterior pelvic tilt. If a posterior pelvic tilt is employed prior to a hip flexion task, it is possible that iliacus activation may be delayed enough to allow the psoas tendon to rise and embed itself in the iliacus muscle belly. As observed by Deslandes et al. (2008), a snapping may then occur on hip extension as the tendon snaps around the ilacus and back down onto the pelvic brim. Both motor control and strength deficits with respect to active hip flexion and control of the pelvis, particularly in the sagittal plane, may be present and require attention in the management process.

DIAGNOSTIC TESTS FOR ARGP Adductor Squeeze Tests Outer Range Adductor Stretch & Resistance Palpation Diagnostic Utility of Clinical Tests

DIAGNOSTIC TESTS FOR IRGP Resisted Hip Flexion Outer Range Hip Flexor Stretch & Resistance Palpation Anterior Snapping Hip Test Diagnostic Utility of Clinical Tests

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PAGE 50 OF 88 Copyright Alison Grimaldi 2018 While the Doha agreement (Weir et al. 2015) outlined definitions of the various clinicial entities associated with groin pain, the exact technique of physical examination was not discussed. There is no published consensus as yet on how the diagnostic tests should be performed and a limited amount of information on diagnostic accuracy of the various tests for predicting pathologies associated with a diagnosis of groin pain.

Diagnostic Tests For Adductor-Related Groin Pain

Adductor Squeeze Tests

Various methods of adductor squeeze testing have been described. The most commonly used squeeze tests are performed at 90°, 45° and 0° of hip flexion, with the 0° position either in neutral hip abduction/adduction or in a position of some abduction with the testers forearm positioned between the ankles (Figure 21). Highest adductor longus EMG has been recorded in the ‘hips-45° position’, with high EMG (Lovell et al. 2012) and greatest adductor force production in the ‘hips -0° position’ (Light & Thorborg 2016, Lovell et al. 2012). With the hips at 0°, there will also be more compression of the adductor longus tendon against the underlying pubic bone, which may be useful from a pain provocation perspective.

Figure 21: Squeeze Tests: 90°, 45°, 0°hip flexion, and 0° with slight abduction

and Resistance Tenderness on palpation of the adductors is the other criterion for diagnosis of adductor-related Adductor stretch and adductor resistance in groin pain. Palpation is performed along the a position of stretch (Figure 22) is also used for proximal adductor muscle bellies, through the assessment of groin pain (Serner et al. 2016, adductor longus tendon and importantly onto 2018a). Theoretically, this position should provide the bony tendon origin or enthesis, just below provocative combinations of compressive and the pubic tubercle (Figure 23). In the differential tensile loads. diagnosis, palpation would also continue through to the pubic bone, pubic symphysis, rectus abdominis insertion and the inguinal and iliopsoas regions.

Figure 22: Outer range adductor stretch and resistance

Figure 23: Palpation of adductor longus (AL). Follow up along the tendon to the insertion just below the pubic tubercle (*).

PAGE 52 OF 88 Copyright Alison Grimaldi 2018 DIAGNOSTIC UTILITY: a painful structure (Drew et al. 2014). Positive squeeze tests increase the likelihood of the What do these tests tell us? Do they presence of pubic bone marrow oedema on help us determine the painful or MRI (Verrall et al. 2005, Falvey et al. 2016), but not necessarily pathology of the adductor pathological structure? origin. One recent study found no correlation between adductor pathology and results of adductor squeeze tests. The authors Acute Groin Injury: suggest that pain elicited during a squeeze test represents more global distress of the The tests available are most valuable for structures of the anterior pubic area, including diagnosis of acute groin injury. Palpation both soft tissues (adductor, rectus abdominis is most useful for ruling out acute injury of and obliques) and bony structures (pubic bone, the adductors. One study reported negative symphysis pubis) (Falvey et al. 2016). predictive values of 91% and the best negative likelihood ratio of 0.08 (Serner et al. 2016). The Their findings indicate that for long standing negative predictive value suggests that if a groin pain, squeeze tests are sensitive to the patient does not have adductor tenderness, presence of groin pain in athletes but are not there is a 91% chance that there will be no specific to any particular pathology in the sign of adductor injury on MRI. A negative region. This is not surprising considering likelihood ratio of less than 0.1 indicates that the extensive connections of the adductor this test, when negative, will create a large and longus across the pubic region and into the often conclusive decrease in the likelihood of lower abdomen. As discussed in the previous a positive MRI. impairments section, pain and weakness on adductor loading is not necessarily an Three physical tests were shown to be indication of adductor weakness or even most useful for ruling in adductor injury. adductor pathology, but highlights an inability When positive, squeeze test at 0° hip flexion or reluctance of the neuromotor system to (forearm between ankles), resisted outer transfer load across the anterior pelvis. range adduction and passive adductor stretch showed positive predictive values of 80–81% The addition of palpation to an assessment of (probability of an adductor lesion on MRI) and long standing groin pain, assists in excluding the best positive likelihood ratios (3.04 - 3.30, local pathology of the adductor origin and representing a small increase in the likelihood pubic aponeurosis (Falvey et al. 2016). A of presence of an adductor injury on MRI) negative likelihood ratio of 0.22 for pubic (Serner et al. 2016). aponeurosis pathology and 0.11 for adductor pathology suggests that local palpation of Long Standing Groin Pain: those structures, when negative, is the best method of excluding these pathologies. Current clinical tests are unfortunately much less useful for diagnosing the source of long standing groin pain. A systematic review of imaging and clinical tests for the diagnosis of long standing groin pain in athletes concluded that while clinicians can be confident in the reliability of common clinical tests, most tests may be more useful as clinical tools for monitoring progress, than in the diagnosis of

Copyright Alison Grimaldi 2018 PAGE 53 OF 88 The positive predictive value for adductor achilles tendinopathy however, indicated that palpation however was quite poor. If a patient these conditions are predominantly local pain with long standing groin pain is tender on states, related to loading of tendons and without palpation of the adductor origin, there is only significant features of central sensitisation a 23.9% chance that they have pathology of (Plinsinga et al. 2018). the adductor origin. The positive likelihood ratio of 1.8 was the highest for any test for adductor pathology, but still only represents a minimal increase in the likelihood of adductor pathology being present if the patient is tender Diagnostic tests on local palpation. for long standing

A number of factors may underpin the difficulties groin pain are poor in determining the meaning of a positive clinical predictors of specific test when examining a patient with long standing groin pain. Firstly, multiple entities pathologies but are and pathologies may coexist, particularly in situations of ongoing or recurrent groin useful indicators of the pain. Secondly, with any test involving active ability of an individual resistance or stretch across the pubic region, force will be transferred widely due to the to transfer mechanical extensive anatomical connections, potentially producing pain in any number of pathological load across the structures. Thirdly, pain may be referred by local anterior pelvis. structures to adjacent regions. Drew et al. (2017) reported that experimental pain from injection of hypertonic saline into the adductor longus tendon referred into the lower abdominal region The Doha agreement requires the presence in 33% of cases. of adductor tenderness AND pain on resisted adduction testing, for the diagnosis of adductor Central mechanisms may also lead to spread -related groin pain. For acute groin injury, the of pain. Primary mechanical hyperalgesia evidence would largely support this approach. over the adductor longus tendon has recently For long standing groin pain, the diagnosis been reported in Australian football players should be used purely as a clinical diagnosis with groin pain, regardless of which clinical with the understanding that a positive diagnosis entitity diagnosis they received (Drew et al. has fairly poor predictive value with respect to 2016). Further studies using more extensive the presence of underlying pathology. quantitative sensory measures are required to determine the role of central mechanisms in long standing groin pain. One study using quantitative sensory testing (QST) in patients with chronic patellar tendinopathy reported significant signs of central sensitiation (van Wilgen et al. 2013). The results of a more recent study using QST in subjects with patellar and

PAGE 54 OF 88 Copyright Alison Grimaldi 2018 Diagnostic Tests For Iliopsoas-Related Groin Pain

Resisted Hip Flexion

Common hip flexion resisted tests include resisted isometric straight leg raise and resisted isometric hip flexion at 90° (Figure 24). As a diagnostic test, hip flexion at 90° is usually assessed in supine but may also be assessed in sitting, particularly if dynomometry is used to assess maximum force production or force production to first point of pain.

Outer Range Hip Flexor Stretch & Resistance

Hip flexor stretch is most commonly applied in the Modified Thomas Test position (Figure 25). A stretch applied into hip extension will not only load the iliopsoas but all the hip flexors, including the anterior adductors, and the whole Figure 24: Resisted hip flexion in Straight Leg Raise pubic region. This test will also apply torsional and 90° hip flexion load across the entire pelvic ring. The patient should be encouraged to point with one finger to the area or areas of pain reproduction. For iliopsoas-related pain, symptoms familiar to the patient should be reproduced in the iliopsoas region, usually in the mid-inguinal area. Pain in this region may also indicate isolated or co-existing joint pathology.

The addition of active resistance to a position of stretch should increase the provocative nature of the test, due to the combination of high tensile and compressive loads. The patient is asked to resist a hip extending force in this position. Again, there are many Figure 25: Outer range hip flexor stretch and resistance structures that will be loaded by this test, so in Modified Thomas Test the patient should be as specific as possible as to the location and nature of symptoms.

Copyright Alison Grimaldi 2018 PAGE 55 OF 88 Provocative combinations of hip extension and the iliopsoas complex medial to the anterior resisted hip flexion can also be applied in more superior iliac spine. Palpation in the latter case is functional tasks such as a long striding gait necessarily through the abdominal wall, which is or in a half kneeling hip flexor stretch position likely to reduce the specificity of any information (Figure 26). arising from this test. The psoas and iliopsoas tendons are not directly palpable at the anterior hip due to their location deep to the muscle belly. See Figure 27 below for anatomy.

IP P TFL AL S Figure 26: Outer range hip flexor stretch and resistance RF in half kneeling hip flexor stretch position. Resistance is self-applied by isometrically pulling the back knee in an anterior direction.

Palpation

Palpation will allow access to the iliacus muscle belly at the anterior hip (mid-inguinal region) and b

TFL RF Iliacus FA IC *

HOF

Figure 27: Anatomy of anterior hip. a.The iliopsoas sits between the femoral pulse medially and the sartorius laterally. The femoral pulse separates the hip flexor group from the adductor group. TFL: Tensor Fascia Lata; IP: Iliopsoas; P:Pectineus; AL:Adductor Longus; S:Sartorius; RF: Rectus Femoris b. Note the relationships and the position of the psoas tendon (*) in this panoramic transverse ultrasound image at the level of the head of the femur (HOF). IC:Iliocapsularis; FA: Femoral Artery.

PAGE 56 OF 88 Copyright Alison Grimaldi 2018 Anterior Snapping Hip Test

The snapping hip test is not a pain provocation test, although pain is occasionally reproduced. The primary aim of the test is to confirm if the source of the anterior snap is the iliopsoas tendon. The hip is flexed, abducted and externally rotated, and then eccentrically lowered back to the bed, effectively internally rotating and adducting while extending the hip (Figure 28). The test is active, not passive and the examiner should palpate across the anterior hip. The hypothesis is that the tendon is initially preset to a position lateral to the femoral head and iliopectineal eminence. On lowering, the tendon is thought to snap medially over the femoral head or iliopectial eminence. As discussed in Chapter 5, new theories suggest that the tendon may be snapping over a bundle of iliacus fibres and down onto the pelvic brim.

Figure 28: Anterior Snapping Hip Test. Photos demonstrate test positions in hip flexion and then as the hip is extended. The lower diagrammatic models demonstrate the proposed theory for movement of the psoas tendon from lateral to medial across the femoral head or iliopectineal eminence.

Copyright Alison Grimaldi 2018 PAGE 57 OF 88 DIAGNOSTIC UTILITY: What do these tests tell us? Do they Straight Leg Raise, with or without a positive help us determine the painful or snapping hip test (Daivajna et al. 2014, Domb et al. 2011, Nakano et al .2017). It has also been pathological structure? noted that the iliopsoas will be impinged by the FADIR (Flexion, Adduction, Internal Rotation) test (Nakano et al. 2017), commonly used for Acute Hip Flexor Injury: the assessment of intra-articular pathology. This is likely one reason why this test does As for acute adductor injuries, palpation is not hold strong diagnostic properties for most useful as a negative predictive test, where diagnosing symptomatic intra-articular lack of tenderness suggests a low likelihood pathology (Reiman et al. 2015). of acute hip flexor injury in athletes (Serner et al. 2018b). A positive palpation however is no better than chance at predicting a hip flexor injury on MRI (Positive Predictive Value 53%) (Serner et al. 2018b). The authors reported that all hip flexor resistance or stretch tests had Is it apparent that there poor capacity to predict hip flexor injury.Based are significant deficits in on this finding, they suggested that use of the clinical criteria outlined by the Doha agreement the literature with regard to for ‘iliopsoas-related groin pain’ may lead to iliopsoas-related groin pain inaccurate classification of acute injuries in and associated disorders. this area. Their recommendation was that imaging would be required to clarify injury Research is required to location in acute hip flexor injuries. provide evidence around impairments and the value Long Standing Iliopsoas-Related of diagnostic tests, with Groin Pain: important implications for management approaches. The current literature fails to provide evidence Assessment and regarding diagnostic utility of clinical tests management strategies used to assess non-traumatic or long-standing iliopsoas-related groin pain. The large majority for these conditions are of papers referencing iliopsoas as a pain currently based on low level source are surgical papers related to anterior evidence, predominantly snapping hip or iliopsoas impingement. Any discussion of clinical tests is of a narrative case studies and expert nature, accompanied in most cases by imaging opinion. and often confirmed at the time of surgery.

Assessment of iliopsoas impingement and snapping includes a history of pain on active hip flexion with or without snapping and objective signs of focal tenderness at the anterior hip, pain on resisted hip flexion/

PAGE 58 OF 88 Copyright Alison Grimaldi 2018 CHAPTER EIGHT MANAGEMENT

LOAD MANAGEMENT RAMP Protocol Specific Loading Advice Standing Posture Advice Sitting Posture Advice Activity Advice

EXERCISE Low Load Isometrics Graduated Strengthening Dynamic Progressions

Copyright Alison Grimaldi 2018 PAGE 59 OF 88 A recent systematic review of the literature LOAD MANAGEMENT regarding outcomes of physical therapy versus surgical outcomes for groin pain found that evidence was of poor quality overall, with high risk of bias, particularly in surgical studies (King et al. 2015). A review of Management of groin pain in an athletic exercise interventions for groin pain reported population will necessarily involve management that although there was strong evidence of training and competition loads. Minimising from Level 4 studies that exercise therapy exposure to specific adverse loading scenario’s was beneficial as a treatment for groin pain, that involve high tensile and or compressive there are a limited amount of studies with loads across the region, will be an important low risk of bias. Exercise interventions were consideration for all patients with groin pain of also found to be generally poorly described, musculoskeletal origin. making evaluation and reproduction difficult (Charlton et al. 2017).

General Load Management Advice In broad terms, conservative General load management advice can be approaches to managing groin pain summarised into the mnemonic RAMP. in athletes involve: 1. Load management, aiming to Rest from Aggravating Activities minimise exposure to provocative loads and graduate activity levels appropriately and Activity Pyramid 2. A graduated exercise programme. Monitor Response to Activity

Progress Gradually

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PAGE 60 OF 88 Copyright Alison Grimaldi 2018 They have used the adductor squeeze test at 0° with the examiners forearm between the ankles, holding for 5 seconds (Figure 28). REST FROM AGGRAVATING ACTIVITIES R Numeric pain ratings from players with groin The most provocative activities will be those injury were recorded during this test, and then that place high load across the groin region: divided according to anticipated risk of further - Change of direction activity injury: - High speed running, particularly acceleration Pain score 0 - 2: Safe and deceleration Pain score 3 - 5: Acceptable - High impact, particularly single leg e.g. Pain score 6 -10: High risk hopping, bounding - Activities that involve high range of motion These pain scores correlated well with into hip extension and abduction, particularly HAGOS (Hip and Groin Outcome Score) with high speed or force e.g. kicking, stretching. Sport scores. Those with a pain score of 6-10 had the worst (lowest) HAGOS score With acute onset groin injury, the decision (median score below 50) reflecting high pain to rest is often easier. With long standing and severe disability. Change in pain on the groin pain, the decision regarding whether squeeze test over time also correlated with an athlete should be participating or not, change in HAGOS scores, indicating the test can sometimes be more difficult. The is responsive to change over time and reflects Copenhagen group have recently published change in pain and disability as measured an easy to use test with decision making by the HAGOS (Sport). Decisions still need guidelines (Thorborg et al. 2017). to be made, but the test provides a quick screening tool. The Copenhagen 5s Squeeze Test and Traffic Light Approach (Thorborg et al. 2017)

6-10 STOP Stop Activity

3-5 ATTENTION Modify Activity

0-2 GO Return to Activity

UNDER DIRECTION OF A HEALTH PROFESSIONAL

Figure 28: The Copenhagen 5s Squeeze Test and Traffic Light Approach (Thorborg et al. 2017) STOP: Rest from training and competition ATTENTION: Review by Health Professional to determine appropriate activity modification Player may be able to continue a modified activity schedule with provocative activities removed. GO: Return to Activity: Review by a Health Professional to determine level of participation

Copyright Alison Grimaldi 2018 PAGE 61 OF 88 A ACTIVITY PYRAMID Athletes should be provided with clear direction as to what activities they may participate in, as appropriate for their level of pain and disability (Figure 29). The Copenhagen 5 second squeeeze and the HAGOS questionnaire can assist in staging an athlete. Readiness for each activity should be determined by a health professional on an individual basis, however the pyramid below provides some general guidelines regarding activity progression. Pain of more than 2/10 during and after an activity should be avoided.

FOR THOSE ON GREEN LEVEL: Kicking - Increase volume/distance Change of direction - faster, sharper, unpredictable Higher Impact - Jump, Hop, Bound Straight line run - increase speed & volume Sport Specific Rehabilitation FOR THOSE ON YELLOW LEVEL: Ball skills - dribbling, low volume/distance kick Progress to slow predictable change of direction Work on landing control Straight line run - intervals, controlled speed Swim with kick, continue upper body work Rehabilitation - Strength, High Level Motor Control

FOR THOSE ON RED LEVEL: Water based activity - Swim no kick, painfree water-run *Dependent on pain during & after activity & after during pain on *Dependent Walk - If painfree, on flat, short stride length Upper Body - Arm ergo, gym with modifications Rehabilitation Program - Pain Relief, Motor Control

Figure 29: Activity Pyramid - providing some general guidelines for activities that may be appropriate on red, yellow and green levels. Guidance by a Health Professional is required.

PAGE 62 OF 88 Copyright Alison Grimaldi 2018 M MONITOR RESPONSE TO ACTIVITY When any new activity is introduced or an activity is progressed (e.g. increase volume, speed, task complexity), the response to activity should be monitored to provide an indication of whether the athlete is coping with the load or requires further load modification. The Copenhagen 5 second squeeze test can be performed immediately after an activity, that evening and the next day. An athlete can even perform the test independently to check their immediate response to activity. Any increase in pain during or within 24 hours of activity indicates an athlete did not cope with that activity and load should be modified. Any increases in pain levels on a week to week basis, indicate that overall load is too high.

P PROGRESS GRADUALLY Overall load or activity progression should remain within a 10% window from week to week. An acute:chronic workload ratio of 1.5 or more will significantly increase injury risk. Consider activity scheduling and appropriate rest and recovery. Higher-load days should be followed by lighter-load recovery days. Avoid consecutive days of high loading or potentially provocative activities.

Specific loading advice additionally considers Stand with feet hip width apart and particular postures or tasks that may impose grow gently tall, but avoid muscle excess amounts of compression and tension across the groin region in both sport and ‘gripping’. Aim to use minimal activities of daily living. muscle effort to achieve a relaxed upright posture. Avoid swaying the Adductor - Related Groin Pain pelvis forward or translating the

In general, patients with adductor-related groin shoulders back behind the hips. pain should minimise sustained, loaded, rapid, or repetitive hip extension and hip abduction, particularly with eccentric activity of the adductor longus. High load hip adduction and flexion will also be provocative in the early stages. Those with co-existing pubic aponeurosis or pubic-related injuries may also not tolerate high rotational loads.

Iliopsoas - Related Groin Pain

Patients with iliopsoas-related hip and groin pain should minimise sustained, loaded, rapid, or repetitive hip extension. The application of active flexion loading will be dependent on symptoms during and following loading. In addition, tasks that may cause the psoas tendon to snap or friction across the anterior hip should be minimised. For example, supine abdominal-leg loading exercises should be avoided or modified if snapping is occurring. Dancers with groin pain should avoid the particular actions that induce snapping. It has also been recommended that ‘clams’ or ‘clamshell exercises’ be avoided following hip arthroscopy due to provocation of the iliopsoas tendon as it rubs across the anterior hip (Phillipon et al. 2011). It would be prudent to also avoid this exercise in non-surgical patients.

PAGE 64 OF 88 Copyright Alison Grimaldi 2018 Sitting Posture Advice Stretching Advice

Sitting in low chairs or car seats can provoke Adductor-related groin pain: Avoid iliopsoas-related pain due to impingement of the tendon against the underlying joint in stretching into hip extension and positions of high hip flexion. abduction Iliopsoas-related groin pain: Avoid Avoiding low chairs and using a stretching into hip extension wedge cushion in sitting and in the car can be helpful.

Some patients with adductor or iliopsoas- related pain may find that, particularly when driving, they have discomfort associated with difficulty relaxing their adductors and flexors.

Wedging rolled towels or a small pillow under the outer thighs can allow the muscles to relax .

NOT FOR REPRODUCTION WITHOUT PERMISSION

Copyright Alison Grimaldi 2018 PAGE 65 OF 88 across the anterior hip. Similarly stride length Activity Advice should be considered in adductor-related groin pain due to loads imposed on the adductor enthesis and associated structures. Walking/running modifications - Reduce stride length * Hip Extension/Abduction during - Reduce speed Rehabilitation Exercises - Reduce impact force - Reduce volume Sustained, loaded, rapid or repetitive hip extension (and hip abduction for adductor- * Often patients with iliopsoas-related groin pain related groin pain) should also be minimised in have developed pain after taking up long striding exercise therapy, particularly in the early stages ‘power walking’ or walking with a taller partner of rehabilitation. or friend. Long strides and particularly at speed will impart high compressive and tensile loads

PAGE 66 OF 88 Copyright Alison Grimaldi 2018 EXERCISE

The adductor magnus will be loaded within Load management advice and a graduated a gluteal strengthening program. Those with exercise program aim to reduce pain and facilitate both adductor and iliopsoas-related groin graduated return to painfree function. Evidence pain often present clinically with deficits in is very poor with respect to physical impairments gluteal function. As frontal plane loading for associated with groin pain. One thing is clear the adductors is most provocative, this will be - for adductor-related groin pain, low strength introduced in the final stage of rehabilitation, measures are evident on adductor strength as required. testing. What is unclear is the mechanism that drives the weakness. The mechanism is likely to have important implications for management Low Load Isometrics & approach. The most common approach is Motor Control to assume weakness = atrophy, with a major early and ongoing focus then on loading the Low load isometric exercise potentially provides adductor musculature. As discussed in Chapter benefits via a number of mechanisms: 6, pain and weakness on adductor loading is not necessarily an indication of isolated adductor 1. Analgesic response muscle weakness or even adductor pathology, (Hoeger Bement et al. 2008, Kosek & Kholm but highlights an inability or reluctance of the 1995, Kosek & Lundberg 2003, Rio et al. 2015). neuromotor system to transfer load across the anterior pelvis. An alternative approach 2. Neuroplastic effect then is to reduce loading across the adductor Provides improvements in motor control and connections and optimise load transfer across may assist with reduction of ‘guarding’ and the pelvis (Falvey et al. 2016, Mens et al. 2006). excessive co-contraction stategies. (Boudreau et al. 2010, Rio et al. 2015, Tsao et al. 2010). A recent paper describing a more contemporary model of rehabilitation reported that their 3. Local mechanotransduction participants demonstrated a significant (see Khan & Scott 2009 for review) improvement in adductor strength in the These mechanisms have been discussed in absence of any isolated adductor strengthening detail in Book 2. during rehabilitation (King et al. 2018).

The following information outlines an approach, of first reducing pain and optimising motor control and then gradually reloading the lumbo-pelvic-hip musculature, without early, targeted frontal plane adductor strengthening. Trunk muscle function is important for both adductor and iliopsoas-related groin pain, to optimise lumbopelvic control and provide a more stable base for function of the hip musculature. A graduated hip flexor program is usually also important for both conditions. The anterior adductors will be loaded less provocatively in a graduated hip flexor loading program than early frontal plane exercise.

Copyright Alison Grimaldi 2018 PAGE 67 OF 88 Isometrics for Trunk & Pelvic Floor Isometrics for the Hip Flexors Musculature

There may be either downregulation or Hip flexor isometric training can be performed in upregulation of the trunk and pelvic floor supported supine, as for the trunk musculature. musculature in patients with groin pain. For In patients with groin pain there is often early and those who have excessive muscle recruitment excessive recruitment of either the anterolateral even in low load postures or tasks, the value hip flexors (TFL, Sartorius, Rectus Femoris) of isometrics initially may be in learning again or the adductor longus. Retraining early how to relax the muscle and recruit in a more recruitment of the iliacus and co-ordination with precise manner. trunk musculature is useful for both iliopsoas and adductor-related groin pain. A belt around Low load abdominal (abdominal draw-in the thighs can assist in relaxing the adductors. manoeuvre) contractions and pelvic floor recruitment/relaxation training can be performed in supine, sidelying or upright postures. Real time ultrasound is an excellent tool for biofeedback and enhancing fine motor control (Whittaker & Preparation for lift Stokes 2011). A belt around the knees may be - hip flexion used in supine if there is background activity in the adductors.

Isometrics for the Hip Adductors

Isometrics for the hip adductors should be low load and painfree. Co-ordination training with the trunk muscles may be required to optimise function and eliminate pain. Ball squeezing recruits high amounts of adductor activity (Serner et al. 2014) and may be provocative. Multifidus training (isometric trunk extension/ Ensure complete adductor muscle relaxation ‘prepare’ to anteriorly pelvic tilt) is also enhanced between contractions. by the use of real time ultrasound and is most commonly performed in prone or sitting.

Preparation for lift - hip adduction

PAGE 68 OF 88 Copyright Alison Grimaldi 2018 Graduated Loading Program

Graduated loading includes components of both movement patterning or motor control training and low velocity, high load strengthening, before progressing to more dynamic function and sports specific loading. Unlike isolated tendinopathy, adductor and iliopsoas-related groin pain are often accompanied by other associated High sitting hip flexion symptomatic pathologies. A loading program should consider the effect of that load, not just on the target musculotendinous structure, but on adjacent and connected structures.

The following exercises represent some examples and principles rather than an all- inclusive set of exercises.

HIP FLEXOR & ABDOMINAL LOADING Standing hip flexion

Optimise lumbopelvic control Avoid early posterior pelvic tilt Avoid excessive anterior pelvic tilt Early iliacus recruitment Avoid snapping

Resisted hip flexion - forward lean

Supine hip flexor-abs loading

Resisted hip flexion - standing

Eccentric lean backs for Curl & Plank variations hip flexor lengthening

Copyright Alison Grimaldi 2018 PAGE 69 OF 88 BRIDGING PROGRESSIONS FUNCTIONAL LOADING PROGRESSIONS Maintain neutral spine Ensure good gluteal recruitment Attention to lumbopelvic control Maintain pelvis level Ensure good gluteal recruitment May require belt initially to allow Start with low range adductor muscle relaxation - aim to decrease excessive adductor muscle contribution

Double Leg Double Leg

Offset Offset

Single Leg Stance

Single Leg - Short Lever

Single Leg Squat

Single Leg - Long Lever Add external challenge e.g. metronome pacing, extra pacing, perturbation metronome load, .. externalAdd challenge e.g.

Add external load Step Up

PAGE 70 OF 88 Copyright Alison Grimaldi 2018 FRONTAL PLANE ABDUCTOR LOADING FRONTAL/AXIAL PLANE ADDUCTOR LOADING Attention to relative muscle recruitment Trunk position alters recruitment Once pain has settled & good strength Start small range, avoid end range abduction is achieved in other planes, add frontal plane adductor loading, if a strength Monitor response to loading deficit persists. Start low range, load and volume Monitor response to loading

Bent Knee Fall Outs Concentric-Eccentric or Eccentric Only Low load sidestep

Spring resisted bilateral abduction Spring resisted bilateral adductor loading (Upright skating) Lighter springs will load adductors rather than abductors

Spring resisted bilateral abduction (Skating in squat)

Band resisted adductor loading

Copyright Alison Grimaldi 2018 PAGE 71 OF 88 DYNAMIC PROGRESSIONS Progress to tasks specific Maintain attention to lumbopelvic control to the patients recreational, Optimise control of trunk centre of mass sporting or occupational Introduce gradually Monitor response to loading requirements

‘A’ Drills Landing control

Agility Ladder - Hip Flexor Drills

Lateral propulsion and landing control

Agility Ladder - Lateral Drills

Hip flexor wall/park drills

Change of Direction Drills

PAGE 72 OF 88 Copyright Alison Grimaldi 2018 iteria for progression ffset, then hold add time ecruitment pattern target muscles of o control motor optimal thenimproves, hold increase time & reduce reps r x 30 second holds, add arm/leg perturbations, then build continue to maximum 2 mins hold time to then further if 15, challenge required, add complexity & further range e.g. perform beginning on from ball large extended position. Drop initially, reps 3 x 15 to then again build sittinghigh or standing in forward lean, add external standing; then to progress control,load once can motor optimal & no pain reps, RPE <7 3 x 15 achieve during Drop or after reps exercise. 3 x 15. to then again build initially, - prioritise Initially onset and optimal - maintain hold Progress able time to as - endurance hold until reps Build to - 5 x 30 around second Maintain holds - Add isometric once appropriate has - For planks, once can perform 3 - For curls, repetitions progress 3 x to - For flexion, hip start may supine, in Cr

No pain during or after pecifics 3x/week once external load applied 7/10 building to once external3/10, load applied Sets/Reps: reps 5 – 10 1 – 2 sets of Speed/Hold: - 30secs hold 10 Ramp slowly, Frequency: Performed bd minimum, 5 times up to Load: load,Low 20-30% MVC, RPE ≈ 3/10 Pain: Sets/Reps: 6 – 15reps 3 sets of Speed: Slow: 3 secs each movement phase Holds: For maximum 2 mins planks – build to Frequency: Curls/planks 3 x week. Eccentrics daily. flexionHip control, x daily motor for – 1-2 Load: Curls/planks – bodyweight; RPE 3-5, flexionHip – leg load only initially; RPE MVC, 60 RPE ≈ 6-8/10Build to -70% Pain: Pain ≤2/10 during or after exercise. S

otor Control Guidelines muscle/s repetitions eg TFL,musculature Sartorius, Rectus Femoris, Oblique abdominals, lumbar erector spinae longus (apart from isometrics) & brevis adductor Develop perform: ability to - target controlled activation of ramp of slow, - controlled & complete relaxation between - without significant/earlysuperficialof activation - the adductor relaxation of maintaining while - respiration maintaining while - without the abdominal bracing wall or of bulging Develop ability to: - perform action without abdominal bracing or breath holding - between reps muscles offset appropriately variations 1.Curls - load without abdominals abdominal bulging wall - perform controlled movement, phasic just not pulses - flexion share throughout whole spine 2. variations Plank - lumbopelvic- control of maintain position hip significant, neutral a relatively in avoiding zone, observable more plane than e.g. deviations any in flexion/extension, hip lumbar of mild 5° loss of flexion/ either into pelvic tilt lordosis/anterior posterior pelvic or tilt increased extension/anterior pelvic tilt 3. flexion Hip variations - lumbopelvic not hip, around move region - neutral lumbopelvic maintain position above as - sagittal pure in limb lower plane. move M

Isometrics: adductors 1.Hip + Address deficits identified in other groups: 2.Deep hip flexors – iliopsoas & iliocapsularis 3. Abdominals - TA 4. floor Pelvic 5. Multifidus deep hip (+/- abductors & external rotators if deficits identified) Graduated Loading Abdominals and hip flexors: 1. Curl variations 2. variations Plank 3. flexion Hip variations able Guidelines 2: for exercise prescription. Transversus Abdominis; TA: fascia lata; TFL:Tensor reps: repetitions; secs: seconds; MVC: Maximal voluntary contraction; RPE: Rate of Exercise perceived exertion, where rest 0 = maximal = and 10 exertion; bd: twice daily; x: times. T

Copyright Alison Grimaldi 2018 PAGE 73 OF 88 recruitment pattern target muscles of external load once motor optimal reps, RPE <7 control, can 3 x 15 achieve during& no Drop pain or after exercise. 3 x 15. to then again build initially, reps leg bridge, (double tasks double leg asymmetrical bilateral tasks to squat), bridge, offset(offset squat/lunge), leg bridge, leg single (single tasks to ups) step leg squats, standing, single and then tolerated base as increase functional for and required needs living tolerated well is above) addressed bent – full knee fall-out range and no stiffness adductor resting remains squeezeaggravation, test negative, squeeze strength does not regress, and bent knee out remains fall full range. - Add isometric once appropriate has difficulty- Progress add/increaseor symmetrical from- Progress bilateral - Begin asymmetrical with tasks a small Coronal plane loading added only after during- no pain normal activities daily of painfree is - squeeze test - sagittal and axial plane loading (as - low-load dysfunction been has reps/load- Progress no if pain Criteria for progression

during or after exercise after or during more consistent with an individual’s needs. functional external load applied MVC, RPE ≈ 6-8/10-70% MVC, RPE ≈ 6-8/10-70% tolerated as Sets/Reps: 6 – 15reps 3 sets of Speed: Slow: 3 secs each movement phase Holds: build holdMay time rather than reps if Frequency: control, x daily motor for 3x/week1-2 once Load: Bodyweight initially; RPE 3-5/10 Once external load applied, 60 build to Pain: ≤2/10 Sets/Reps: 6 – 15reps 3 sets of Speed: Slow: 3 secs each movement phase Frequency: 3x/week Load: with load, light RPE 3-5/10 Test strengthIf 60 remains inadequate, build to exercise Pain: after Pain or ≤2/10 during Specifics

musculature rather than thigh musculature rather than thigh musculature musculature e.g. in hip extension, gluteus maximus rather than hamstrings or adductors. during actions hip performingplanes while primary plane hip excessive avoid e.g. movement adduction performing while or rotation sagittal flexion/extension plane hip task Develop ability to: actions- drive hip with uniarticular hip lumbopelvic required - maintain posture - control femoropelvic position secondary in Develop ability to: especially sagittal in load appropriately, - share and axial actions plane early hip i.e and dominant the adductors theseactivation in of planes may flexor/extensor/rotator hip inadequate indicate function adductors overload in of and result lumbopelvic required - maintain during posture adductor loading coronal plane loading adductor and - tolerate overcome inhibition during load high challenge Motor Control Guidelines

Graduated Loading andHip trunk extensors, hip and abductors rotators: 1.Bridging progressions 2. Functional loading progressions – lunges, squats, step ups, deadlifts Plane Frontal 3. Loading Abductor Graduated Loading Adductors:Hip able 2 continued: Guidelines for exercise prescription. Transversus Abdominis; TA: fascia lata; TFL:Tensor reps: repetitions; secs: seconds; MVC: Maximal voluntary contraction; Exercise RPE: Rate of perceived exertion, where rest 0 = maximal = and 10 exertion; bd: twice daily; x: times. T

PAGE 74 OF 88 Copyright Alison Grimaldi 2018 CONCLUSION

Where are we on our path to improving diagnosis, management and monitoring of those with groin pain?

There have been some significant advances published a successful case series that showed in the groin pain arena. There is a high volume good rates of recovery for ARGP, without isolated of data now available on prevalence of groin adductor strengthening (King 2018). In the injury in athletes, primarily in the football codes. presence of a pubic aponeurosis injury, high The Doha agreement has been a large step load adductor strengthening, especially in the forward in establishment of a common language frontal plane, may place potentially injurious for clinicians and researchers. These entities shearing loads across the already damaged however must be regarding as descriptions of aponeurotic plate. clinical presentations, rather than an indication of particular pathologies. Ball squeezing engenders high adductor recruitment (Serner et al. 2014). If the only Further research is required to attempt to agenda is to reach more than 40% of a maximum clarify what pathologies are associated with voluntary contraction to address a strength each clinical diagnosis. This may be challenging deficit, this may be the only consideration. considering the co-existence of multiple However, a positive adductor squeeze appears pathologies on imaging, and inherent difficulties most predictive of pubic bone marrow oedema in determining which of these is symptomatic in (Verrall et al. 2005, Falvey et al. 2016), indicative each individual. An understanding of underlying of bony overload. While pubic bone marrow pathologies and how specific loading scenarios oedema occurs in painfree athletes, it is a sign may effect these pathologies is likely to be of overload and in the presence of pain, may an important consideration in optimising be an indication to reduce bony load. Forceful, management, particularly of long standing groin bilateral adductor contraction is likely to place pain and recurrent injuries. The high incidence high compressive loads across the pubic of re-injury suggests that a rehabilitation model symphysis and this should be considered focussed on adductor strengthening may not in the development of an exercise strategy. adequately address underlying mechanisms. Clinically, adductor strength often returns A purely impairment-based model does not without any targeted frontal plane adductor necessarily consider underlying pathologies strengthening, again questioning what we and mechanisms. For example, the underlying can interpret from these tests alone. Do they driver of weakness on adductor testing is simply indicate an inability or reluctance of the unclear. Falvey et al. (2016) have suggested neuromotor system to transfer load across the that a primary focus on adductor strengthening anterior pelvis? If so, our search for strategies may be misdirected and serve to lengthen the to optimise pelvic load transfer is critical. rehabilitation process. This group has since

Copyright Alison Grimaldi 2018 PAGE 75 OF 88 Health professionals and researchers clearly incorrect and management programs working within the football arena have done built on this assumption may be misdirected an excellent job in moving forward aspects and potentially injurious to the patient. Hip such as load monitoring and the influence of flexor stretching is unlikely to be positive for general athletic loads on injury risk.Screening any patients with iliopsoas-related pain and and injury prevention continues to be a focus, pathology, due to the high loads imposed although relatively few injury risks have been on the tendon, bursa, capsule and labrum conclusively identitifed, particularly factors that in end-range hip extension. Active eccentric can be modified. Further reseach and a deeper lengthening techniques that avoid moving into understanding of impairments may in the future flow through to improvements in screening and end range, hold potential for more effective and prevention programs. safe lengthening. Avoiding the need for surgical release of the iliopsoas is an excellent outcome The Copenhagen group has provided clinicians for any patient facing such surgery and the risk with some excellent tools that can be simply of long term negative sequelae. applied in the clinical setting - the HAGOS questionnaire and the Copenhagen 5 second While a long journey of adductor squeeze. These tools allow clinicians to screen for early signs of dysfunction, provide discovery around groin an athlete with guidance with respect to sports pain and tendinopathy lays participation and a mechanism to monitor before us, these are exciting response to load during rehabilitation and on returning to sport. times with high interest in the area and an increasing For iliopsoas-related hip and groin pain, the volume of research building evidence base is unfortunately in its infancy. each year. Clinicians should Management approaches appear to be based ensure they continue to primarily on assumption, with no physical impairment studies available. A view that keep their knowledge and iliopsoas tightness is the cause for all issues skills updated to provide related to the iliopsoas, dominates the surgical their patients with optimal and narrative clinical literature. Yet, there is physical and psychosocial no evidence of this. Iliopsoas-related issues commonly occur in hypermobile individuals, outcomes. where excessive rather than restricted mobility is most likely a primary underlying driver for abnormal loading and injury.

Patients with increased anterior pelvic tilt and restricted hip flexor length represent an important subgroup of those who present with anterior hip and groin pain. However, an assumption that this represents all patient presentations is

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Copyright Alison Grimaldi 2018 PAGE 87 OF 88 With over 25 years of clinical experience, Alison is Principal Physiotherapist at Physiotec Physiotherapy in Brisbane, Australia and an Adjunct Research Fellow in the School of Health & Rehabilitation Sciences, University of Queensland. Alison has a special interest in movement, muscle dysfunction and optimising musculoskeletal loads and is a committed lifelong learner.

Alison completed a Bachelor of Physiotherapy at the University of Queensland in 1990, a Masters of Sports Physiotherapy in 1997, and her Doctorate in Philosophy in the Field of Physiotherapy (PhD) in 2008. Her PhD studies were concerned with improving our understanding of hip muscle function and the relationship with hip joint pathology and weightbearing stimulus. Alison continues to be passionate about extending our understanding of why we develop problems around the hip and pelvis, and what we can do to most effectively prevent and manage these problems. She has ongoing involvement in research studies investigating lateral hip pain, proximal hamstring tendinopathy, groin pain and function of the deep hip flexors and rotators.

It is one of Alison’s core beliefs that research should be relevant to clinical practice and helping the patients we treat every day, and that physiotherapists in the community should have access to this valuable information to allow them to transfer this knowledge into clinical practice as quickly as possible. To this end, Alison continues to publish, present and provide practical workshops for other health professionals. Alison has published many peer-reviewed papers in scientific journals, has contributed detailed information freely accessible via podcasts by PhysioEdge (itunes) and the British Journal of Sports Medicine (SoundCloud), and has recently contributed to 3 leading physiotherapy and sports medicine text books. She has presented her research and clinical teachings in Australia, New Zealand, England, Ireland, Scotland, Wales, Singapore, HongKong, the Netherlands, France, Belgium, the Unites States of America, Canada and the United Arab Emirates.

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