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