WHY GILMORE’S GROIN
IS
NOT A HERNIA
16.06.2011
GILMORE’S GROIN
SPORTSMEN GROIN
GROIN DISRUPTION
ATHLETIC PUBALGIA
(Sportsmen hernia NO!)
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.
PREVIOUS INVESTIGATIONS:
3 ORTHOPAEDIC OPINIONS
X-RAY
CT SCAN
U/S SCAN
PREVIOUS TREATMENT:
COMPLETE REST
PHYSIOTHERAPY
MANIPULATION
LOCAL STEROIDS
CASE 1 D.M. PHYSICAL SIGNS
INSPECTION:
N.A.D. –NO SWELLING
PALPATION:
N.A.D. – NO LUMP
PALPATION VIA SCROTUM:
RIGHT SUPERFICIAL INGUINAL
RING DILATED
-
COUGH IMPULSE
-
TENDER
INSERTION OF FINGER
PAIN COMPARED TO OPPOSITE SIDE
Presented 16.03.81
(Eversion / Overstretching Injury)
15 wks
Groin Pain but No Lump
Prevented Training /Play
Post Op: Training with Aberdeen
In Scotland Squad
3 wks
7 wks
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”
ONSET OF SYMPTOMS
INSIDIOUS
72%
SPECIFIC INJURY
28%
OVERSTRETCHING
MISKICKING
ABDUCTION
EVERSION
PATIENT’S REFERRED with
GROIN PAIN
1980 - 2010
TOTAL
7738
MALE
7479
(97%)
259
(3%)
FEMALE
INCIDENCE OF OPERATION
1980 - 2010
Referred
Ops
58%
7738 pts
4466 pts
1980-2010
Over 31 years 7479 Sporsmen
referred with “Groin Pain”
Many have returned with other complaints
including Haemorrhoids and skin lesions
But ONLY 1 with HERNIA
C
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
SYMPTOMS DURING EXERCISE
PAIN IN GROIN INCREASES WITH
RUNNING
STRIDING
SPRINTING
SUDDEN MOVEMENT
TWISTING & TURNING
SIDE STEPPING
JUMPING
DEAD BALL KICKING
LONG BALL KICKING
(BUT NO SWELLING)
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
MRI in Groin Disruption
MRI Poor in Abdomen
Resolution insufficient for subtle changes
But Inguinal ligament – clearly visible
Hernia
Gross Scar Tissue
Defects / Gaps
Significant Disruption
Also
visible
MRI Good in Pelvis & Thigh
Adductor Tear
clearly seen
Osteitis pubis
HIP Pathology
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
HERNIA: Shows Clearly as Peritoneal Sac or Protrusion
David Connell 2009
31 Years No Groin
Patient
Complained of
Swelling
INDICATIONS FOR SURGERY
Groin Disruption
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
GROIN DISRUPTION: PATHOLOGY
Found at Operation
TORN EXTERNAL OBLIQUE ====
DILATED SUPERFICIAL
INGUINAL RING
TORN CONJOINED TENDON
CONJOINED TENDON
}
DEHISCENCE
INGUINAL LIGAMENT
( 40% also have Adductor Pathology)
Groin Disruption Surgery
Groin Reconstruction
•
•
•
•
•
Normal Anatomy - Restored
Each layer – Repaired
Each Injury- Repaired
Permanent Suture – Essential
Nylon Darn / Ethilon Darn
• Preferable to Absorbable Sutures (Don’t Last)
• Preferable to Mesh (May Restrict Mobility)
CONJOINED TENDON REPAIR
TRASVERSALIS FASCIA PLICATED
with O Vicryl
TENSION FREE NYLON DARN
(CONJ. TENDON to ING. LIG)
EXT OBLIQUE REPAIR
(NEW S.I.R)
GROIN DISRUPTION
& ADDUCTOR TEAR
PRESENT IN 40%
HALF REQUIRE
ADDUCTOR TENOTOMY
HERNIA IN SPORTSMEN
No evidence of increased incidence of
Hernia in Sportsmen
Groin Disruption/Gilmore’s Groin
Neither Hernia or Pre Hernia
Terminology HERNIA: Incorrect
D
QUOTE
“Jerry I had your “Groin” in 74,
As did my colleague Alan Mullery
We both had to rest for months
There was no other treatment then”
Terry Venables 2006
B
HERNIA
A Protrusion of a Viscus beyond
it’s normal confines
E
HERNIA (2% MALES IN UK)
INGUINAL 73%
FEMORAL 17%
(Bailey & Love )
GROIN HERNIA
INGUINAL – DIRECT
INDIRECT
FEMORAL
OBTURATOR
INDIRECT INGUINAL HERNIA
PRESENTATION
Usually young males
Swelling only occurs with
standing/straining
Swelling can be difficult to reduce
If swelling persists - Pain
H
HERNIA: INDICATION
FOR SURGERY
Swelling which when present
causes pain or discomfort
Irreducible swelling
Strangulation
INDIRECT INGUINAL
HERNIA OPERATION
Herniotomy (Excise Indirect Sac)
Reconstitute Inguinal canal
(Repair only necessary if post wall defect)
DIRECT INGUINAL HERNIA
Protrusion of Viscus through
Post Inguinal Canal Wall
Due to defect in Post Wall
I
DIRECT INGUINAL HERNIA
PRESENTATION
Swelling readily appears
with Coughing or Standing
Swelling reduces when lying down
Patient often complains of discomfort with
Standing e.g. cocktail parties or window shopping
(Sport rarely Restricted)J
K
DIRECT INGUINAL
HERNIA OPERATION
Reduce Peritoneal Sac
Insert Mesh
Close Ext Oblique & Skin
FEMORAL HERNIA
Protrusion through Femoral Canal
Swelling: Below and lateral to pubic tubercle
i.e. Upper thigh
FEMORAL HERNIA OPERATION
Reduce Sac contents
Excise Sac
Suture Lacunar to Inguinal ligament
SYMPTOMS & PATHOLOGY
Groin Disruption/Gilmore’s Groin
Significantly different to Hernia
Inguinal
Femoral
Obturator
Only similarity: SITE
CORRECT SURGICAL TREATMENT
ALWAYS
DEPENDS ON
ACCURATE DIAGNOSIS
Of
PATHOLOGY
PATHOLOGY
in
Groin Disruption/Gilmore’s Groin
Significantly different to Hernia
REPAIR using Hernia Mesh Technique
Open or Laparoscopic
Usually FAILS
8% our Operations in
Patients with Previous Groin
Repair
“I have had the mesh repair
But I can still feel a tear behind the mesh
My symptoms have not improved”
P.W
Patient 2009
F
QUOTE
“General Surgeons in this area either
do not recognise Gilmore’s Groin or
They treat it as a Hernia
with mesh repair, which fails”
Johnny Morris
Sports Medicine Physician
A
Hampshire
2011
Conclusion:Wrong Diagnosis
Resulting in Wrong Operation
DOES NOT CURE
OFTEN COMPLICATES
SIGNIFICANT DELAY in RECOVERY
or
RESULTS IN FAILURE
F
Patients with Groin Problems
Deserve a
GROIN SURGEON
16.06.2011