Ep 177: Diagnosing and managing inguinal-related groin pain, with Willem Heijboer

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality

[00:00:09] research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal

[00:00:15] of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.

[00:00:22] Today I'm handing over the JOSPT Insights reigns to some of the world's leading

[00:00:27] clinician researchers in the field of hip morphology and hip pain. At JOSPT we're really proud to

[00:00:33] work with the YAHIRA Collaborative to advance research and clinical practice for young people

[00:00:38] with hip pain. Over the coming months you're going to hear more about what's new in the

[00:00:43] research and understanding of hip pain, including how it develops and how to best

[00:00:48] treat it, all geared towards helping you best help the patients and athletes you

[00:00:53] work with. Dr Joshua Heary, Sports Physiotherapist and Research Fellow at La Trobe University in Melbourne

[00:01:00] has the hosting duties today. Josh is talking with Willem Hyba, Sports Physiotherapist and

[00:01:05] Clinical Epidemiologist working at the Amsterdam University Medical Centre about

[00:01:10] Willem's clinical and research work in diagnosing and managing long-standing

[00:01:14] groin pain in athletes. Today Josh and Willem focus on inguinal related groin pain.

[00:01:21] You'll learn what it is, how to approach diagnosis and whether surgery or active rehabilitation

[00:01:26] is the best option for treatment. Don't forget to check out the show notes today for links

[00:01:31] to the research that Willem mentions. And you'll find loads more information in the

[00:01:36] show notes about an upcoming webinar mini-series that JOSPT and the YAHIRA

[00:01:41] Collaborative are hosting with La Trobe University. In these webinars you'll hear

[00:01:46] more from experienced clinician researchers including doctors Josh Heary, Joe Kemp,

[00:01:51] Kate Yockelson and Mike Ryman. Lindsay Plass and Luke Kearney who both have lived

[00:01:57] experience of hip pain limiting their sporting careers will join the webinars to

[00:02:02] bring that important athlete perspective. Okay here's today's episode.

[00:02:07] Hi Willem welcome to the podcast. Hi Josh thanks for the invitation. A really nice

[00:02:12] place to start is if you can maybe tell our listeners what is inguinal related groin pain?

[00:02:19] Ingenal related groin pain refers to groin pain in the inguinal canal area that

[00:02:23] worsens on exercise without the presence of an actual inguinal hernia and this term was introduced

[00:02:28] in the DELA agreement classification system that subclassified long-standing groin pain into

[00:02:32] four different entities of groin pain. A doctor, inguinal, ellipsoas and pubic related

[00:02:37] groin pain and inguinal related groin pain can be present as an isolated problem but

[00:02:40] especially in long-standing groin pain multiple entities can also coexist.

[00:02:45] Another term for the same condition that is currently often used is inguinal disruption

[00:02:49] which is a recommended term from the British hernia society's position statement

[00:02:53] and then we also have the commonly used older term for the same problem sports hernia

[00:02:58] and I think this term is still often used in sports medicine but the use of this term

[00:03:02] has actually been discouraged by both the DELA agreement classification system

[00:03:06] and the British hernia society position statement since an actual inguinal hernia is not present

[00:03:11] with this condition. I'm sure I speak for many of the listeners that work and see patients on a

[00:03:17] daily basis. This condition is obviously really complex and difficult to diagnose so

[00:03:24] everything that you know what makes it such a complex injury for us as clinicians to manage

[00:03:28] and diagnose. The main reason probably is that we don't have a thorough gold standard for

[00:03:33] the diagnosis so we don't have any imaging or clinical examination tests that can make you

[00:03:37] 100% certain on the diagnosis and there are several anatomical structures in close proximity

[00:03:42] in this area that may cause symptoms. So the inguinal canal runs through the anterior

[00:03:47] abdominal wall just above the inguinal ligament with a deep and a superficial ring. Some nerves

[00:03:52] run through it such as the ilio-inguinal nerve and in men we have the large perimetic

[00:03:56] cord running through the inguinal canal while in women this is the round ligament of

[00:04:01] the uterus. This differing anatomy is suggested to be one of the reasons why

[00:04:05] inguinal related joint pain is much more prevalent in men than in women so approximately

[00:04:10] 9 in every 10 cases can expect it to be in men and lastly we as clinicians and researchers

[00:04:16] made it complex ourselves as well due to the terminology problem that we introduced in this

[00:04:20] area. So in a delvie study performed by Anduin Wehr and colleagues prior to the DOA agreement

[00:04:25] meeting 23 international groin experts were presented with a clinical case of an athlete

[00:04:30] with pain in the inguinal region and they were asked to share their most likely diagnosis

[00:04:35] and the 23 groin experts provided 22 different diagnostic terms. I think this indicated need for

[00:04:41] more uniform terminology to improve communications between healthcare providers and patients and

[00:04:46] also for a better interpretation of research findings. You mentioned earlier that there's

[00:04:52] obviously a lot of the anatomical structures in the groin area obviously lying close proximity

[00:04:58] and is an unorthen hyperlap. Do we know what is I suppose simplistically the cause of inguinal

[00:05:06] related groin pain or what structures are involved? Unfortunately we don't we often don't know the

[00:05:11] exact source of pain there are a lot of different theories presented in the literature on the pathology

[00:05:15] of inguinal related groin pain. We recently published an editorial that was led by

[00:05:19] Zarkavukovich one of the world leading groin surgeons in this area presenting these

[00:05:23] different theories. The most theories are based on two main ideas or a combination of these two

[00:05:29] first nerve irritation for example due to bulging of the posterior wall causing compression or

[00:05:34] entrapment of the nerves and secondly musculoskeletal pathology such as aponorotic tears or an

[00:05:40] inguinal ligament and tisopathy. Based on current evidence we don't know if these potential

[00:05:45] causes or subclassifications require different management so that's why we currently

[00:05:49] still recommend the use of the umbrella term inguinal related groin pain.

[00:05:53] And from your experience treating these patients with them do you think it's possible that we can

[00:05:58] differentiate between say a patient that may have a nerve component or nerve compression versus

[00:06:03] the patient with more musculoskeletal pathology? I think we don't have the evidence yet to

[00:06:10] do that so sometimes for nerve related issues and diagnostic injections can be informed by

[00:06:16] physicians that may differentiate between these issues but I think we don't have the

[00:06:21] evidence to truly differentiate between these issues. So we have a patient in front of us

[00:06:27] that presents with groin pain how do we diagnose inguinal related groin pain in this patient?

[00:06:33] Yeah so I think that the classification of inguinal related groin pain is mainly clinically

[00:06:37] so based on history taking and clinical examination it often presents with a with

[00:06:42] a gradual onset of groin pain in the lower abdominal area sometimes also radiating

[00:06:46] through the inner fire scrotum in men. Initially athletes are often able to play with their pain

[00:06:51] unless symptoms are too severe that it limits their performance and in more severe cases

[00:06:56] I think athletes often also report pain during coughing or sneezing or sitting up in bed.

[00:07:01] Then with clinical examination it should include abdominal palpation including spoto

[00:07:05] and vagination in men where palpation pain could reproduce a recognizable injury pain

[00:07:11] and the DOA agreement states that inguinal related groin pain is also more likely when

[00:07:14] athletes report pain in the inguinal canal area during a resisted abdominal testing.

[00:07:19] We found in recent study that we perform that approximately half of the patients classified

[00:07:24] with inguinal related groin pain also report pain during resisted abdominal testing so these

[00:07:29] tests may often be negative and I think it's also important to emphasize that

[00:07:33] scrotum and vagination is not something that is common practice in a lot of vision

[00:07:36] therapy clinics and we recently published an inter-examiner reliability study where we also

[00:07:41] looked at the prevalence of positive tests in inguinal related groin pain but when you're not

[00:07:45] performing scrotum and vagination you can still catch nine in every ten cases of inguinal related

[00:07:50] groin pain by history taking abdominal resistance testing and trans-abdominal

[00:07:54] palpation testing where palpation pain is often present at the cranio-lateral border

[00:07:59] of the pubic tubercle at the assertions of the inguinal ligament and the conjoined tendon.

[00:08:04] But on the other hand you will potentially miss one in every ten cases when you're not performing

[00:08:08] scrotum and vagination but I think when endowed as a visual therapist it's always helpful

[00:08:14] to consult an experienced sports medicine physician or a groinsurer and surgeon in Zaria.

[00:08:19] What are the treatment options that we have available for the athlete with

[00:08:23] inguinal related groin pain? I think the main treatment options basically are surgical

[00:08:28] treatment or conservative management. The current literature is heavily focused on surgical treatment

[00:08:34] which often includes reinforcement of the posterior wall by an open suture repairer or

[00:08:38] an escapricen reinforcement with a mesh. The only two randomized controlled trials to date

[00:08:45] compared surgical versus conservative management one from X-Fronted Colleagues in 2001

[00:08:50] and one from Piana and colleagues in 2011 and they both found better clinical outcomes for

[00:08:55] surgical treatment versus exercise-based management at three months and one year follow-up.

[00:09:00] So this last study by Piana and colleagues found that 90% of surgically treated patients

[00:09:05] returned to sports successfully as three months follow-up versus only 25% in the conservative

[00:09:10] management arm and a one-year follow-up approximately half of the conservatively treated patients

[00:09:16] returned pain-free to sports. But based on current evidence surgery leads to better

[00:09:21] clinical outcomes than conservative management but every surgery has its risk of course so

[00:09:26] current clinical practice often starts primarily with conservative management of approximately

[00:09:31] three months to see if symptoms improve but this timing is often context dependent I think.

[00:09:36] But I think a multidisciplinary assessment of these cases and shared decision making are key.

[00:09:41] What does that look like if we think about the components of a rehabilitation program

[00:09:44] for an athlete with inguinal related groin pain? If we first look at the evidence again

[00:09:49] there's really a lack of researchers already mentioned so only one randomized control trial

[00:09:54] from Egypt in 2019 compared two different conservative treatment groups for inguinal related

[00:09:59] groin pain. One group receiving only passive interventions including heat packs, friction

[00:10:03] massages, mobilization techniques and stretching exercises and a second group that also received

[00:10:09] this passive pair of these but in addition also an active rehabilitation program with a main

[00:10:15] focus on strengthening the abdominal muscles and the hip. So this study found much better

[00:10:21] clinical outcomes for active treatment in addition to passive treatment with 65 percent

[00:10:26] pain-free return to play after two months compared to only 15 percent in a passive therapy group.

[00:10:31] These results were more promising than the previously mentioned Piana study and Lerdos

[00:10:36] and an exercise based intervention is probably superior compared to only passive interventions.

[00:10:42] So there are obviously different exercise options for example to target the lower abdominal muscles.

[00:10:47] I personally prefer exercises that patients can also perform and progress easily at home.

[00:10:53] So for example the leg lowers and windshield wiper exercise can be started with a low load

[00:10:57] by working in a shorter range of motion with the knees flexed and patients can easily

[00:11:01] progress the load based on symptoms or symptom response by working in a larger range of

[00:11:07] motion and by readily extending the knees more and more during the exercises.

[00:11:12] Generally I think that conservative management follows more or less the same basic tender

[00:11:17] rehab approach so with education, load management and progressive exercise based therapy

[00:11:23] where you can progress from isometric to isotonic to more explosive and sport specific tasks.

[00:11:29] You mentioned the hip strengthening is an important part of the rehabilitation program.

[00:11:35] Are there particular muscles you think are really critical or key muscle groups that we focus on in

[00:11:40] our exercise based approaches for ingonal related groin pain? We see in clinic and also from research

[00:11:47] that ingonal related groin pain often co-exist with adductor related groin pain as well.

[00:11:53] So we know that the aduncto lungus has an interconnection with the erector's abdominis

[00:11:57] so these lower abdominals and the adductor lungus after interconnect and work synergistically.

[00:12:03] So I think there definitely should be a main focus on the lower abdominal muscles and also the

[00:12:08] hip adapters and the hip flexors. If we look at the studies that looked at conservative management

[00:12:13] they took it more broadly and also worked on the hip adductors and gluteal muscles.

[00:12:19] But I think focus should be on the lower abdominal muscles and for the hip,

[00:12:23] especially the hip adapters and the hip flexors.

[00:12:26] Right that's really a really nice summary of a conservative based treatment approach.

[00:12:29] Thanks Willem.

[00:12:31] You're welcome.

[00:12:32] Willem, what are your key take-homes for our listeners today?

[00:12:35] The classification in the related groin pain can normally be made clinically based on history

[00:12:40] but patient pain verification tests or recognizable injury pain should be reported

[00:12:45] and abdominal resistance testing. Primary treatment should include a progressive exercise

[00:12:50] based treatment with a main focus on strengthening the lower abdominal and the hip muscles.

[00:12:55] You can tell patients that approximately 5 to 6 in every 10 cases can recover without

[00:12:59] surgery based on current evidence but surgery can be very helpful if conservative management

[00:13:04] fails. And additionally I think it's also important to emphasize that this is typically a

[00:13:09] long-standing pain condition and I've been mainly discussing the biomedical evidence

[00:13:14] but it's obviously also important to address psychosocial factors and have a person-centered

[00:13:18] approach in clinical decision making.

[00:13:21] Right Willem, thanks for a really comprehensive podcast today.

[00:13:25] Thanks Josh, thanks for having me.

[00:13:27] Thanks for listening to this episode of JO-SPT Insights.

[00:13:34] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your

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