“GILMORES GROIN”
The First 30 Years.
( plus one ! )
R.S.M. 15 Sept 2011
5% ALL SPORTS INJURIES
AFFECT GROIN
PATIENT’S REFERRED with
GROIN PAIN
1980 - 2010
TOTAL
7738
MALE
7479
(97%)
259
(3%)
FEMALE
INCIDENCE OF OPERATION
1980 - 2010
Referred
Ops
58%
(1%
Female)
7738 pts
4466 pts
OTHER SPORTS
Basketball
Fencing
GROIN
PAIN
Handball
Equestrian
• MANY CAUSES
Gaelic football
Martial Arts
American
Football
Dancers
• ORTHOPAEDIC
Hurling
Gymnasts
• SOFT TISSUE INJURY
Waterpolo
Kick Boxing
Ice Hockey
Skiing & Snowboarding
• CO-EXISTENT PATHOLOGY
DIRECT TRAUMA
FALL
KICK
PUNCH
IMPACT
SQUEEZE
GILMORE’S GROIN
FIRST PATIENT
1980
PATHOLOGY & SURGICAL TREATMENT
Apparent after Successful Management
of
3 Professional Footballers Unable to Play
For over 15 weeks
CASE 1 D.M. 27
FULL BACK:
TOTTENHAM HOTSPUR FC
PRESENTED:
28.08.80
SYMPTOMS:
17 WEEKS GROIN PAIN
AFTER EVERSION INJURY
LAST GAME:
17 WEEKS
PAIN INCREASED: SPRINTING
KICKING
TWISTING & TURNING
COUGHING
SNEEZING
CASE 1 D.M. PHYSICAL SIGNS
INSPECTION:
N.A.D. –NO SWELLING
PALPATION:
N.A.D. – NO LUMP NO HERNIA
PALPATION VIA SCROTUM:
RIGHT SUPERFICIAL INGUINAL
RING DILATED
-
COUGH IMPULSE
-
TENDER
INSERTION OF FINGER
PAIN COMPARED TO OPPOSITE SIDE
CASE 1 D.M.
PREVIOUS INVESTIGATIONS:
3 ORTHOPAEDIC OPINIONS
X-RAY
CT SCAN
U/S SCAN
GILMORE: Fourth Opinion
PREVIOUS TREATMENT:
COMPLETE REST
PHYSIOTHERAPY
MANIPULATION
LOCAL STEROIDS
CASE 2 .G.S Tertiary Opinion
MF : ABERDEEN & SCOTLAND
PRESENTED: 16.3.81 GROIN PAIN R > L
SYMPTOMS: 15 WEEKS :
Following Over Stretching Eversion Injury
LAST GAME: 15 WEEKS (30.12.80)
PAIN
TROTTING
SUDDEN MOVEMENT
KICKING
COUGHING
SNEEZING
ONLY ABLE TO WALK
CASE 2 – GS
PHYSICAL SIGNS
INSPECTION:
No Swelling
PALPATION:
No Lump No Hernia
PALPATION VIA SCROTUM
- DILATED R S.I.R. - READILY ADMITTED FINGER
- COUGH IMPULSE
- FINGER IN R S.I.R.
TENDERNESS
PAIN
My Conclusion after History &
Examination
Torn Groin Muscles & or Tendons
Probably
External Oblique Muscle
Conjoined Tendon
ACTUAL PATHOLOGY
Found at Operation
TORN EXTERNAL OBLIQUE ====
DILATED SUPERFICIAL
INGUINAL RING
TORN CONJOINED TENDON
CONJOINED TENDON
}
INGUINAL LIGAMENT
DEHISCENCE
D. M. Post Operatively
• Training Fully at 3 weeks
• Spurs Team at 5 weeks
Post Operatively
Training with Aberdeen
3 wks
In Scotland Squad
7 wks
GILMORE’S GROIN
GROIN DISRUPTION
SPORTSMEN GROIN
(Sportsmen Hernia:Wrong
as NO HERNIA )
GROIN DISRUPTION
TYPICAL PATIENT
• YOUNG MALE
• ACTIVE SPORTSMEN
• RARE OVER 45
• RARE IN FEMALES (1%)
GROIN DISRUPTION
• MUSCULO – TENDINOUS INJURY
• ALL LAYERS GROIN
• INGUINAL + ADDUCTOR (40%)
• “MUSCLE DISLOCATION”
Only 1% Operative Cases Female
GROIN DISRUPTION
(GILMORE’S GROIN)
31 YEARS
1980 - 2010
PATIENT REFERRAL RELATED TO SPORT
1980 - 2010
CASES
%
ASSOCIATION FOOTBALL
4323
56
RUGBY UNION & LEAGUE
731
9
ATHLETES
372
5
RACQUET GAMES
298
4
CRICKET
175
2
HOCKEY
152
2
OTHER SPORTS
912
12
NO SPORT
775
10
____________________________________________________
TOTAL
7738
100
OPERATIONS
1980 - 2010
TOTAL
4466
MALE
4423
(99%)
43
(1%)
FEMALE
INCIDENCE OF OPERATION
RELATED TO SPORT
1980 - 2010
ASSOCIATION FOOTBALL **
RUGBY UNION + LEAGUE **
CRICKET**
CASES
OPN
%
4323
731
175
2981
468
118
69
64
68
ATHLETES
372
151
39
RACQUET GAMES
298
101
34
HOCKEY
152
88
58
OTHER SPORTS
912
307
34
NO SPORT
775
252
32
__________________________________________________________
TOTAL
7738
4466
58
INCIDENCE OF OPERATIONS
ASSOCIATION FOOTBALL 1980 - 2010
TOTAL
OPN
%
1546
1275
82
SEMI PRO.
755
538
71
AMATEUR
2022
1168
57
PROFESSIONAL
_______________________________________________
TOTAL
4323
2981
69
PROFESSIONAL FOOTBALLERS
1980 - 2010
CASES
1546
OPERATIONS
1275 (82%)
ENGLISH FOOTBALL LEAGUE
CLUBS
92 CLUBS
PATIENTS REFERRED BY 91
AETIOLOGY:MUSCLE IMBALANCE
( Recurrent Microtrauma )
1. STRONG HIP FLEXORS
(QUADS)
2.
TILTED PELVIS
PULL PELVIS DOWN
3. STRETCHED ABDO MUSCLES
(OBLIQUES)
BECOME WEAK
FAIL TO STABILIZE PELVIS
4. OVERUSE
RECURRENT TEARS
GROIN DISRUPTION
5. MALE > FEMALE (99%)
STRETCH ABDO MUSCLES
ARSENAL F.C.: GILMORE’S GROIN
OPERATION
P.A.
1986 – 1996 (GRAHAM)
33
3
1997 – 2007 (WENGER)
10
1
Gary Lewin 2007
ONSET OF SYMPTOMS
INSIDIOUS
72%
SPECIFIC INJURY
28%
OVERSTRETCHING
MISKICKING
ABDUCTION
EVERSION
SYMPTOMS DURING EXERCISE
PAIN IN GROIN INCREASES WITH
RUNNING
STRIDING
SPRINTING
SUDDEN MOVEMENT
TWISTING & TURNING
SIDE STEPPING
JUMPING
DEAD BALL KICKING
LONG BALL KICKING
SYMPTOMS AFTER EXERCISE
STIFF & SORE
PAIN IN GROIN INCREASES WITH
TURNING IN BED
GETTING OUT OF BED
GETTING OUT OF CAR
SIT UPS
COUGHING
SNEEZING
SUDDEN MOVEMENT
EXAMINATION
GROIN DISRUPTION:
PHYSICAL SIGNS
(ALL ELICITED VIA SCROTUM)
S.I.R:
DILATED (+/-)
COUGH IMPULSE
TENDER
(PALPABLE TEAR)
TENDERNESS:
MAY BE EXQUISITE
DIMINISHES WITH REST
INVESTIGATIONS
STORK VIEWS
(FLAMINGO)
MRI in Groin Disruption
MRI Poor in Abdomen
Resolution insufficient for subtle changes
But Inguinal ligament – clearly visible
Gaps
Defects
Significant Disruption
Gross Scar Tissue
Also
visible
MRI Good in Pelvis & Thigh
Osteitis pubis
HIP Pathology
Adductor Tears
clearly seen
David Connell 2009
Ultrasound in Groin Disruption
State of Art Ultrasound Equipment – required
Subtle changes in Inguinal ligament
Conjoined Tendon
maybe seen
Dynamic assessment – Essential
Abdominal straining
Sonopalpation
Tender over Inguinal Canal
Bulging Post. Wall
David Connell 2009
INDICATIONS FOR SURGERY
PROFESSIONAL
AND
AMATEUR
FAILED CONSERVATIVE
TREATMENT
INDICATION FOR
SURGERY:
PROFESSIONALS
GAME INHIBITED
TRAINING INHIBITED
LOSS OF SPEED
LOSS OF FITNESS
INDICATION
FOR SURGERY:
AMATEURS
SYMPTOMS AFFECT
EVERYDAY LIFE
LOSS OF SPORT AFFECTS
QUALITY OF LIFE
Principle Groin Disruption
Surgery
Groin Reconstruction
• Normal Anatomy – Restored
• Each layer & Each Injury– Repaired
•
A Layer of Permanent Suture – Essential
• Preferable to Absorbable Sutures (Don’t Last)
• Preferable to Mesh (May Restrict Mobility)
GROIN DISRUPTION
& ADDUCTOR TEAR
PRESENT IN 40%
GROIN DISRUPTION
& ADDUCTOR TEAR
TREATMENT
MODERATE or ACUTE : REPAIR DISRUPTION +
INTENSIVE ADDUCTOR PHYSIO
SEVERE or CHRONIC : REPAIR DISRUPTION +
ADDUCTOR TENOTOMY (18%)
RESULT : GROIN RECONSTRUTION
SUCCESSFUL
97%
AVERAGE RETURN TO PROFESSIONAL
FOOTBALL 4 WEEKS
1220 OUT OF 1258 PLAYERS
RANGE 3 - 7 WEEKS
Recurrent Groin Disruption
SAME SIDE: True Recurrence 3%
Unoperated Side : 10% C/o Pain within 10 Years
Recognize the Symptoms
&
Request Operation (knowing it will cure the Symptoms
INTERNATIONAL SOCCER
FOOTBALLERS
1980 - 2010
ENGLAND
SCOTLAND
NORTHERN IRELAND
EIRE
59
34
18
16
WALES
15
OTHER
115
___
257
OTHER SOCCER INTERNATIONALS
1980 -2010
UAE
QATAR
KUWAIT
NORWAY
AUSTRALIA
JAMAICA
COLUMBIA
PORTUGAL
ARGENTINA
DENMARK
FINLAND
HOLLAND
ICELAND
NEW ZEALAND
USA
38
21
7
5
4
4
3
3
2
2
2
2
2
2
BRAZIL
1
CROATIA
CZECH REPUBLIC
EGYPT
FRANCE
GERMANY
HONG KONG
HUNGARY
IVORY COAST
LATVIA
NIGERIA
RUSSIA
SLOVAKIA
SWEDEN
TRINIDAD
ZAIRE
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
____________________________
TOTAL
115
RUGBY UNION
1980 - 2010
REF.
OPN.
631
393 (44 I NT)
Op %
62
RUGBY SYMPTOMS
BACKS
Sprinting
Twisting and Turning
Accelerating
Striding out
Side Stepping
Dead Ball Kicking
RUGBY SYMPTOMS
FORWARDS
Sprinting
Twisting and Turning
Striding out
Up after a tackle
Jumping
R.U. INTERNATIONALS: POSITION
44 PLAYERS
BACKS
½ BACKS
CENTRES
WING/F.B
Total:
FORWARDS
12
9
5
26(60%)
FRONT ROW
SECOND ROW
BACK ROW
8
2
8
18(40%)
RUGBY LEAGUE
1980 - 2010
REF.
OPN.
%
95
75 (17 INT)
79
CRICKET
1980 - 2010
REF.
OPN.
175
118
%
(23 INT)
68
INTERNATIONAL CRICKETERS
1988 - 2010
FAST BOWLER
13
BATSMAN
6
ALL ROUNDER
4
TOTAL
23
SYMPTOMS IN CRICKETERS
PAIN IN GROIN
(Specific injury :unusual)
FAST BOWLERS: LOOSE PACE
PAIN in Groin Drag > Landing
BATSMAN:
RUNNING BETWEEN WICKETS
TWISTING & TURNING
FIELDERS:
SUDDEN MOVEMENT
PUSHING OFF
STRIDING OUT
DIVING
20/20 Games:
INCREASED INCIDENCE
SYMPTOMS IN ATHLETICS
PAIN IN GROIN
MIDDLE & LONG DISTANCE RUNNERS
HURDLERS
TRIATHLETES
SPRINTERS (UNUSUAL)
PAIN INCREASES:
WITH DISTANCE
SPRINTING AT END OF RACE
LOSS OF SPEED:
REDUCED TIMES
LOSS OF ENDURANCE:
SLOW RECOVERY
ATHLETES
1980 - 2010
REF.
OPN.
372
151
%
(24 INT)
40
SYMPTOMS IN FIELD HOCKEY
PAIN IN GROIN
ELITE PLAYERS
FREQUENT GAMES ON ASTROTURF
SPRINTING
TWISTING & TURNING
LOSS OF SPEED
(CORNER SPECIALISTS)
FIELD
HOCKEY
1980 - 2010
REF.
OPN.
%
152
88 (15 INT)
58
RACQUET GAMES
PLAYERS
1980 – 2010
REF.
OPN.
%
298
101 (3 INT)
34
ALL OTHER
SPORTS
Including Keep Fit
1980 - 2010
REF.
OPN.
%
912
307 (26 INT)
34
ICE HOCKEY
GOLF
FENCING
HURLING
GAELIC FOOTBALL
GYMANASTS
LACROSSE
• MARTIAL ARTS
• KICK BOXING
• WATERPOLO
• WEIGHT LIFTING
• STRONGMEN
• SKIING
• SNOW BOARDING
INTERNATIONALS 1980-2010
SOCCER
257
RUGBY UNION
44
ATHLETES
24
CRICKET
22
RUGBY LEAGUE
17
HOCKEY
15
HANDBALL
4
RACQUET GAMES 4
SKIING
2
BASKETBALL
2
FENCING
LACROSSE
MARTIAL ARTS
ICE HOCKEY
GYMNASTICS
WATERPOLO
ROWING
"STRONGMAN"
WEIGHT LIFTING
2
2
3
2
1
1
1
1
1
_______________________
TOTAL
407
NO SPORT
1980 - 2010
REF.
OPN.
%
775
252
33
BUILDERS. GARDENERS. DIY. POLICE and PORN
STARS
SPORTSWOMEN
GILMORE’S GROIN IN WOMEN:
DIAGNOSIS
DIFFICULT:
NO SCROTUM
BASED ON:
HISTORY
TENDER S.I.R.
GROIN PAIN WITH RESISTED HIP FLEXION
ELEVATION FROM SUPINE POSITION
GRIMACE
FEMALES
1980 - 2010
REF.
OPN.
%
259
43 (5 INT )
17
DANCERS
SCEPTICISM
31 Years No Groin
Disruption Patient
Complained of
Swelling
SYMPTONS & PATHOLOGY
Groin Disruption/Gilmore’s Groin
Significantly different to Hernia
Inguinal
Femoral
Obturator
Only similarity: SITE
CORRECT SURGERY
of ALL CONDITIONS
DEPENDS ON
ACCURATE DIAGNOSIS
Of
PATHOLOGY
PATHOLOGY
Groin Disruption/Gilmore’s Groin
Significantly different to Hernia
REPAIR using Hernia Mesh Technique
Open or Laparoscopic Methods
Usually FAILS
FUTURE
Mr Simon Marsh
Surgical Director
108
MARSH MODIFICATION
For
GROIN RECONSRUCTION
Thank You.