Steve wright pdf

Conference 2016

Steve Wright Senior First Team Physiotherapist Southampton FC

Screening hip & groin

Nick Grantham S & C Coach West Bromwich Albion FC

Matt Reeves First Team Sports Scientist Leicester City FC

Gym Based S&C Interventions

Matt Green First Team Sports Scientist West Bromwich Albion FC

Field Based S&C Interventions

Van Mechelen Model (1997) Applied to hip & groin injury

Epidemiology 10 to 15% of all football related injuries 23% of all muscle injuries in football Rugby, ARF, GAA, Hurling, Hockey, Cricket, Ice Hockey ‌.

Prevelent in FBS with HSR, CoD, Acc, Dec Screening MUST explore risk factors

6/9

5/5

Whittaker et al. 2015

2014

6 prospective and 1 retrospective cohort Overwhelmingly prev injury and strength biggest risk factors 4/6 studies With flexibility a potential risk factor – assessed variously

Largest Prospective Cohort

508 players, 31 teams, 61 injuries Injury – pain inside thigh or groin area resulting in time loss Multivarate analysis Prev hx groin inj 2 x higher risk Weak adductors 4x higher risk

2010

Agreement with others Verrall, 2007 Maliaris, 2009 Engebretsen, 2010 Crow et al., 2010 Freckleton et al 2013 Nevin & Delahunt 2014

Consider the Adductor Squeeze Test…?

Validity • • •

Decreased hip adductor strength precedes groin injury in some populations (Crow et al., 2010,Nevin & Delahunt 2014, anecdotal) Weak adductor muscles are an intrinsic risk factor for groin injuries (Engebretsen et al., 2010) Hip adductor strength is reduced by groin injury (Crow et al., 2010)

Reliability • • • • •

Delahunt & Nevin, 2011 Intra subject - good Intra and Inter tester same subject - good Inter subject???

Caution when comparing to squad averages in team sports

Add Squeeze more than a strength test form/force couple closure pelvis .

Passive compression of SIJ, increased adductor force 39%, decreased groin pain in 68%. (Mens, 2006) • SIJ compression increase Mm recruitment with stabilizing role (O’Sulivan 2002, Arumugam et al 2012) •

•

Lumbo pelvic link to groin pain Delayed onset & Latent firing patterns in Local stabilizing muscles in chronic groin subjects (Cowan et al. 2004, Comerford & Mottram, 2012…..)

Adductor Squeeze Test Squeeze demonstrates how able athlete is to transfer force across the anterior of pelvis Often ¯ in presence groin pain Not a strength test – see dynamometry & SL

Inner range inhibits some Add Muscles Internal Rotator contribution likely at 45 90

Consider Pelvis width, nuetral hips… 105mmHg

160mmHg

ROM testing Bubble inclinometer vs Videographic Vi Perform – time, cost, reliability

Where does that leave us?

Have we moved on in 10 years‌?

Balance of mobility and stability within lumbo pelvic hip seems important – anecdotal (Engebretsen, 2010, Thornborg, 2014, Falvey, 2015) Poor control of the hip and pelvis, and an abnormal distribution of forces in the region, are associated with AGP (Almeida 2013, Cowan 2004, Holmich 1999) Control of femoropelvic alignment, is integral to assessment of lower limb dysfunction (Falvey, 2015) Relative dearth of studies in this area

Southampton FC hip/groin interest!

Adductor, hip & ‘Inguinal’ Surgery at SFC (~50 players per season u18-1st Team) Season

DiagnosisH

Number

Age Ranges

2003/4

Inguinal Surgery

3

18-21

2004/5

FAI* Inguinal Surgery

1 4

21 19-23

2007/8

FAI*

3

17-34

2008/9

FAI* Inguinal Surgery

1 2

18 19-28

FAI* Inguinal Surgery

2 3

18-20 20-28

Age

Football

Local

Club

Schools Control Group

9

20

20

10

20

20

11

10

10

12

10

10

13

10

10

2010/11

14

10

10

2011/12

15

10

10

16

10

10

17

10

10

18

10

10

2009/10

2012/13 2013/14 2014/15 2015/16

Inguinal Surgery

1

27

Hip & Groin 3T MRI Screening : EliteResults Footballers u9-18’s

FAI on scan normal in footballers!

Kinetic Control Tests for Hip Trunk Dissociation

Mvt Faults • Hip/Trunk Flexion • ¯ Active hip Flex past 90 • ­ Hip Medial rotation?

Other common mvt dysfunction groin pain • Video removed – shows hip flex dysfunction and trunk on femur dissociation • Weakness above 90 deg ? Iliacus

Hip Flexion with neutral LPHC – Key test

Screen: Lumbopelvic Hip Stability with dissociation trunk femur

Lumbopelvic Hip Stability with dissociation

Step Further: evidence ÂŻ Hip control & Trunk dissociation in hip/groin pts

3D biomech analysis 360+ hip and groin pain subjects, SL Squat, Box drop, Cutting mechanics

Box Drop: Landing mechanics Screen for Knee injury risk?

OR Core competencies LPHC

Groin or Knee inj risk?

A – both!

Changes in cutting strategy post rehab Pre intervention ­ Abduction angle relative to pelvis ­ Trunk angle relative to femur ? Increasing shear & Adductor stress

Richter et al, 2015 unpublished

Lateral Movement - Pushers & Pullers

NB Video removed

Story so far…..

• •

Groin pain can be complex & multi factorial Represents a significant time loss in field sports

•

Screening should account for Previous history, ROM, strength

•

Emerging evidence that Predictable Hip dysfunction seen in groin pain: dissociation femur & trunk lumbopelvic hip stability

•

Early evidence from biomechanical analysis altered patterns of landing, cutting and change of direction are present in those with groin pain

Q. Where is the transfer of load going to fail…?

Tom Sturdy

Mo Gimpel Suzanne Scott

Dr Steve Baynes

Prev SFC Staff

Thankyou

Spare slides for Q’s

More than an adductor strength test form/force couple closure pelvis Form Closure & Alignment SIJ, lumbar, hip PICR hip Panjabi Neutral Zone

Force Closure Mm acting upon pelvis to create a corset Core Cylinder Pillar Strength Vleemings myofascial slings

Recurrant/chronic groin pain Fairly typical picture emerges

• Decreased Groin Squeeze

• Often Lack Internal Rotation hip • Poor Lumbar Extension Control • Anterior femoral head translation / lack of posterior glide • Predictable mvt dysfunction hip dominant tasks • IS THERE A COMMON DENOMINATOR…?

• Weak Inner range hip flexion……

Consider Local & Global Muscles & Path Instantaneous Centre of Rotation

Sahrmann, 2002, 2010

Psoas – hip flexor or LPHC stabilizer