James allen

21 – 22 May 2016

“Tackling the Hip and Groin” A football and functional dilemma

Rehabilitation strategies in tackling the hip & groin in field sports: from theory to practice James Allen. M.Sc, B.Sc, MISCP National Team Physiotherapist, IRFU

Rehabilitation strategies in tackling the hip & groin in field sports: from theory to practice Strategy 3: Strategy Strategy 1: Injury 2: Practical Rehabilitation Prevention Application

Strategy 1: Injury Prevention

Injury Prevention & Prediction: Literature update

VanTiggelen et al, 2008 “Effective prevention of sports injuries: a model integrating efficacy, efficiency, compliance and risk-taking behaviour�. Br J Sports Med. 42:648-652

Audit

Screening

Injury Prevention

Injury surveillance

Exercise prescription

The sequence of prevention of Sports Injuries. Van Mechelen 1992

Injury Prevention

Efficacy = scientifically proven use systematic reviews of interventions relating to prevention efficacy limitation: no conclusive evidence…….yet?!!!! eg: normative values sparse; isometric strength ratios; ‘core’ ????

Efficiency = cost-benefit analysis of introducing the measure costs: staff, time, equipment, setting up protocols benefits: ? Fewer injuries, improved performance, better preparedness Risk Homeostasis Theory (Wilde G J S Inj Prev 1998;4:89-91)

Compliance & Risk-taking Behaviour success of intervention dependent on athlete’s compliance to protocol Introduce a measure → athlete will internalise specific learning processes → affect adoption/success Risk factors: behaviour & organisational environment Process factors: attitudes/beliefs & social norms/culture Behavioural modification best integrated into skills training, not through dictatorial means

Injury Prevention

Injury Prevention

Strategy 2: Rehabilitation

•

Efficacy – what do we know?

• Many differential diagnoses with varied symptomatology Holmich, 2007 {football n=137}: 1. Adductor-related pain (69%); 2. Iliopsoas-related pain (26%); 3. RA-related pain (11% - secondary) Omar et al, 2008: Injury to RA or Add.L tendon predisposes opposing tendon to injury

Associated with / resultant from abnormal forces around the pelvis Mechanism: Hyper-abduction Deceleration Loaded Rotation

Rehab

Evidence-based Sports Medicine 2002, Ch 20

Only a small % are: • chronic • recurrent • irritable • ‘grumbly’ • require surgery

Rehab

Majority of injuries are: • Acute • Short-lived • Respond well to conservative measures

Holmich et al, 1999:

TENS

Stretches

DTF

Laser

SP: n = 29

Compared active training (AT) to standard physiotherapy (SP) AT: n=30.

Strengthening of adductors, abs, hip flexors & core Balance exercises, sliding board, low back extns Cross-country ski machine Results: AT: 23/30 (77%) returned after average of 15 sessions SP: 4/29 (14%) returned after an average of 14 sessions Follow-up: 8-12 yrs; soccer players; n=39 AT n=20: Excellent 55%; Good 35%; Fair 10%; Poor 0% SP n=19: Excellent 16%; Good 58%; Fair 16%; Poor 10%

Rehab

Return to training (x2)

Jog 50%

Injury onset

Fn.

Power

Strength Endurance

Flexibility / R.O.M

B.

C.

D.

E.

Planning

A.

Phase 3 Week 5-6

Phase 2 Week 3-4

Rehab

Phase 1 Week 1-2

Skeletal

SLR, PKB

Phasic muscles Gluteals, hamstrings, Quads, Calves, Qls, Lats

T-L fascia S+R +/- rotation

Rehab

Obturators, Gemelli, TFL, Pectineus, Gracilis

Deep int. & ext. rotators

FABER (BKFO) / modified Thomas‘ test Iliopsoas activity

Neural mobility

Neuromuscular

A. Flexibility & R.O.M

Spinal symmetry Lordosis, T.Sp rotn, Scoliosis

Lumbopelvic movt. Fwd flex, Squat

Hemipelvic movt.

Alt. Hip flexn

Hip Joint mechanics Flexn, Int/Ext rotn., Extn.

LL mechanics Genu varus/valgus, Tib rotn, rearfoot pro/supination

Tonic Muscles

B. Endurance

Gluteus medius/minimus Clams, WB contralateral twists, 'T' exercises

Lower Abdominals Alt. Cycle, Lower AB crunch/press

Lat. Gastroc. & Adductors Lateral step-up → high knee holds

Erector Spinae Swiss ball Cobras +/- rotation

Rehab

Rehab

Strategy 3: Practical Application

Practical Application

Do we correctly apply this info?

Efficacy – what do we know?

• Mostly soft tissue injuries • Problematic cases involve tendons of RA & Add.L….”pubic instability” O2 consumption x 7.5 < skeletal muscle => sustained loading without ischaemia/necrosis

Tenoblasts → tenocytes: collagen & ECM synthesis in response to exercise = ↑ strength, stiffness, weight & CSA. Repetitive loading = sheath inflammation +/degeneration of body.

Repair/remodelling ↔ tenocyte activity Sharma & Maffulli 2006

Tendon rehab Include a progressive eccentric strengthening component. (Silbernagel combined/HSR protocols)

Do static isometric exercises/tests adequately replicate the injury mechanisms involved in dynamic sports?

Are these exercises: specific? of adequate intensity? of adequate velocity?

Do these exercises: Include the ability to progressively load or symptomatically deload?

Include a weight-bearing element?

Include a proprioceptive component?

Address the Ipsilateral stability/Contralateral mobility function?

Practical Application

C. Strength

Medical Exercise Therapy Graded pain-free exercise to restore function

Uses exercise (& specific equipment) to effect anatomical structures Phase 1: de-load injured tissue restore functional movement Phase 2: increase load/movement velocity increase strength/function En-TreeM determines: Position, velocity, force, power & work

Practical Application

Practical Application

Practical Application

Practical Application

En-TreeM groin device offers: • Controlled ROM

• Progressive loading/deloading 0-54kg • Weight-bearing rehab

• Ipsilateral stability/contralateral mobility • Core co-contraction

• Measures of concentric & eccentric force, velocity, power, work done, fatigue index

Does this system meet our criteria?

Efficacy: fulfils tenets of • Specificity • Intensity • Duration • load Efficiency: • STG£3000 • 1 person operator • self-records

D. Power & E. Function

Kinetic Chain 1. DLS (Ref: 'The Outer Unit' by Paul Chek)

Practical Application

Kinetic Chain 2. AOS

Practical Application

Kinetic Chain 3. POS

Practical Application

Kinetic Chain 4. LS

Practical Application

Summary

A framework exists to aid in the planning / co-ordinating of all rehabilitation programs: • Is it applicable?

• Have I considered all aspects to make my intervention effective?

Rehabilitation: • Is it specific?

• Of the correct intensity?

• Measurable?

• Progressive?

• Has velocity/power been addressed?

Practical applications: • Do I know why I’m using certain exercises?

• Does the athlete understand?

• Is the athlete compliant?

• Is this intervention going to lead to a behavioural change?

Conclusions • Hip/groin pain is a complex & multifactorial clinical entity

• Acute muscle strain injuries account for the majority of cases

• Recognise contributory factors and act directly upon them

• Rehab for lingering conditions should aim to restore functional patterns • 50/50 chance of successful rehab with chronic conditions

22.05.16. 11:45am

james.allen@irfu.ie