Multifactorial Determinants of Running Injury Locations in 550 Injured Recreational Runners

PURPOSE

Despite the health benefits of running, the prevalence of running-related injuries (RRI) remains high. The underlying risk factors between these injuries are still not well understood. Therefore, the aim of this study was to compare biomechanical, anthropometric, and demographic injury risk factors between different locations in injured recreational runners.

METHODS

In this retrospective case-control analysis, 550 injured runners (49.6% female) with a medically diagnosed RRI were included. All runners had undergone an instrumented treadmill analysis to determine habitual footstrike pattern, vertical instantaneous load rate, peak vertical ground reaction force (vGRF) and cadence. Injuries were classified by location according to a recent consensus statement. A logistic regression model was used to determine the association between the biomechanical parameters and RRI locations. Because injuries can be associated with age, sex, and body mass index, these variables were also entered into the logistic regression.

RESULTS

Strike pattern and peak vGRF were the only biomechanical variable distinguishing an injury from the group of injuries. A midfoot strike differentiated Achilles tendon injuries (odds ratio [OR], 2.27; 90% confidence interval [CI], 1.17-4.41) and a forefoot strike distinguished posterior lower leg injuries (OR, 2.59; 90% CI, 1.50-4.47) from the rest of the injured group. Peak vGRF was weakly associated with hip injuries (OR, 1.14; 90% CI, 1.05-1.24). Female sex was associated with injuries to the lower leg (OR, 2.65; 90% CI, 1.45-4.87) and hip/groin (OR, 2.22; 90% CI, 1.43-3.45). Male sex was associated with Achilles tendon injuries (OR, 1.923; 90% CI, 1.094-3.378).

CONCLUSIONS

Sex, foot strike pattern, and vGRF were the only factors that distinguished specific injury locations from the remaining injury locations.

Three-dimensional visualization and measurement of myopectineal orifice in non-inguinal hernia patients

PURPOSE

The myopectineal orifice (MPO) is a weak area at lower part of the anterior abdominal wall that directly determines the mesh size required in inguinal hernia repair. However, MPO data have mainly been acquired from measurements of cadavers or anesthetized patients. Furthermore, there are very few reports on the measurement of the MPO in Chinese patients. The present study aimed to use three-dimensional visualization technology to measure the MPO in live non-anesthetized Chinese patients, and to use this information to indicate the appropriate mesh size required for inguinal hernia repair.

METHODS

In this study, we used the parameters of the MPO and the pelvis that were measured in 40 patients with peripheral arterial disease of the lower limb arteries (80 inguinal regions) using Medraw software (Image Medraw Technology Co., Ltd., China).

RESULTS

The result showed that the average width and height of the MPO were 5.71 ± 0.99 cm and 4.96 ± 0.69 cm, respectively (5.22 ± 0.77 cm and 5.13 ± 0.63 cm in males, and 6.20 ± 0.95 cm and 4.80 ± 0.71 cm in females). The average projected area of the MPO was 16.06 ± 4.37 cm² on the left, and 15.61 ± 4.10 cm² on the right (P > 0.05).

CONCLUSION

Three-dimensional visualization was used to measure the area, width, and height of the MPO in living non-anesthetized Chinese patients. MPO area was correlated with age, but not with pelvic parameters.

[Footballer's hip]

Although complaints and injuries in the knee and ankle joints are very prevalent in football, the hip has so far been given very little attention. Complaints in this area are often attributed to pathological changes in the inguinal region. However, intraarticular differential diagnoses are often not taken into consideration. This article gives an overview of possible hip pathology in footballers, as well as its diagnosis and treatment.

Calcific tendinopathy of the direct head of rectus femoris: a rare cause of groin pain treated with ultrasound guided percutaneous irrigation

Groin pain can be caused by a myriad of pathologies. Abnormalities of the rectus femoris are a very rare cause of groin pain; calcific tendinopathy of the direct head is particularly so, with only two case reports in the literature. We report the first case of calcific tendinopathy of the direct head of the rectus femoris that was treated effectively with ultrasound-guided percutaneous irrigation of calcific tendinopathy (USPICT). The anatomy of the rectus femoris and the technique for US-PICT of the rectus femoris are also described.

Groin Pain in Athletes: A Review of Diagnosis and Management

INTRODUCTION

Groin pain is a common symptom in athletes, particularly in sports requiring sudden changes in speed and direction and those involving kicking. Despite a high prevalence of groin pain in this patient cohort, the diagnosis and management of the underlying pathological processes remains a challenge for surgeons and radiologists alike.

AIM

The aim of this paper is to review the imaging findings and management of the common pathological processes which produce groin pain in athletes.

MATERIALS AND METHODS

The anatomy of the groin region will be defined as a basis for further discussion. The common pathological processes underlying groin pain such as adductor dysfunction, rectus abdominus injury, osteitis pubis, and femuro-acetabular impingement will then be reviewed and correlating radiological imaging findings presented. Current management options will also be considered.

CONCLUSION

This paper will aid surgeons and radiologists in navigating the challenging diagnostic and management dilemma of groin pain in athletes.

Pubic inguinal pain syndrome: the so-called sports hernia

The "sportsman's hernia" commonly presents as a painful groin in those sports that involve kicking and twisting movements while running, particularly in rugby, football, soccer, and ice hockey players. Moreover, sportsman's hernia can be encountered even in normally physically active people. The pain experienced is recognized at the common point of origin of the rectus abdominis muscle and the adductor longus tendon on the pubic bone and the insertion of the inguinal ligament on the pubic bone. It is accepted that this chronic pain caused by abdominal wall weakness or injury occurs without a palpable hernia. We proposed the new name "pubic inguinal pain syndrome." In the period between January 2006 and November 2013 all patients afferent in our ambulatory clinic for chronic groin pain without a clinically evident hernia were assessed with medical history, physical examination, dynamic ultrasound, and pelvic and lumbar MRI. All patients were proposed for a conservative treatment and then, if it was not effective, for a surgical treatment. Our etiopathogenetic theory is based on three factors: (1) the compression of the three nerves of the inguinal region, (2) the imbalance in strength of adductor and abdominal wall muscles caused by the hypertrophy and stiffness of the insertion of rectus muscle and adductor longus muscle, and (3) the partial weakness of the posterior wall. Our surgical procedure includes the release of all three nerves of the region, the correction of the imbalance in strength with the partial tenotomy of the rectus and adductor longus muscles, and the repair of the partial weakness of the posterior wall with a lightweight mesh. This treatment reported excellent results with complete relief of symptoms after resumption of physical activity in all cases.

Groin pain and hip range of motion is different in Indigenous compared to non-indigenous young Australian football players

OBJECTIVES

Hip and groin pain are common problems in Australian football. Although indigenous (I) players are at greater risk of soft tissue injury than their non-indigenous (non-I) counterparts, Aboriginal descent has not previously been identified as a risk factor for hip and groin injury. The aim of this study was to investigate if hip and groin screening tests would demonstrate differences between indigenous and non-indigenous junior elite AF players.

DESIGN

Cross-sectional study.

METHOD

Two hundred and seventy elite junior Australian football players were screened using five hip and groin musculoskeletal tests.

RESULTS

Thirty-three players (12%) were indigenous. Differences were demonstrated between the two groups for right prone hip internal rotation (I X = 27.60 ± 9.16, non-I X = 33.39 ± 8.88, p < 0.001) and left prone hip internal rotation (I X = 25.83 ± 10.25, non-I X = 31.36 ± 8.75, p < 0.001), pressure on squeeze test with knees at 90° (I X = 165.71 ± 40.32, non-I X = 188.17 ± 62.32, p = 0.001) and pressure on squeeze tests with knees at 0° (I X = 172.57 ± 35.98, non-I X = 202.57 ± 49.14, p = 0.049), and pain provocation during squeeze test with knees at 90° (I X = 3.19 ± 2.26, non-I X = 1.03 ± 1.78, p > 0.001).

CONCLUSIONS

The indigenous players displayed less range of passive hip internal rotation with the hip in neutral, reduced adductor squeeze force and higher levels of groin pain with the squeeze test at 90°. The differences observed between indigenous and non-indigenous players suggest indigenous players are at greater risk of hip and groin injuries in Australian football.

[Groin pain in athletes]

Groin pain is a common problem in athletes who engage in sports involving accelerations, decelerations and sudden direction changes. It is still a frustrating pathology which has significant overlap and multiple problems coexist frequently. The pathogeny remains unclear, but the hypothesis that imbalances between abdominal muscles and adductors exist, has a certain success. Some anatomic and biomechanic factors may play a role in this pathology. A good clinical examination is an important part of the diagnosis and imaging may be helpful to eliminate other causes of groin pain that wouldn't be mechanic. The conservative treatment is long and difficult and must be focused on functional strengthening and core stabilisation.

Hip pain - a focus on the sporting population

BACKGROUND

Patients complaining of 'hip' or 'groin' pain can present a diagnostic and therapeutic challenge for practitioners not only in primary care, but also those in specialist practice.

OBJECTIVE

This article outlines common patterns of groin and lateral hip pain, and provides a targeted clinical approach to treatment or referral.

DISCUSSION

Common causes of chronic groin pain include osteitis pubis, incipient hernia, adductor tendinopathy and intrinsic hip pathology. Tendinopathy of the hip abductor muscles is a common cause of lateral hip pain. While a careful history and targeted examination is essential, the frequently nonspecific findings add to the challenge of managing this group of patients. Treatment remains focused on relative rest, although other, more active modalities are discussed. Advances in hip arthroscopy have lead to further improvement in our understanding, diagnosis and treatment of intrinsic hip pathology.

Successful endoscopic treatment of chronic groin pain in athletes

BACKGROUND

Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem.

METHODS

From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 +/- 4.5 years; range, 17-36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement.

RESULTS

Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation.

CONCLUSIONS

A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Pain related sexual dysfunction after inguinal herniorrhaphy

To determine the incidence of pain related sexual dysfunction 1 year after inguinal herniorrhaphy and to assess the impact pain has on sexual function. In contrast to the well-described about 10% risk of chronic wound related pain after inguinal herniorrhaphy, chronic genital pain, dysejaculation, and sexual dysfunction have only been described sporadically. The aim was therefore to describe these symptoms in a questionnaire study. A nationwide detailed questionnaire study in September 2004 of pain related sexual dysfunction in all men aged 18-40 years undergoing inguinal herniorrhaphy between October 2002 and June 2003 (n=1015) based upon the nationwide Danish Hernia Database collaboration. The response rate was 68.4%. Combined frequent and moderate or severe pain from the previous hernia site during activity was reported by 187 patients (18.4%). Pain during sexual activity was reported by 224 patients (22.1%), of which 68 (6.7%) had moderate or severe pain occurring every third time or more. Genital or ejaculatory pain was found in 125 patients (12.3%), and 28 (2.8%) patients reported that the pain impaired their sexual activity to a moderate or severe degree. Pain during sexual activity and subsequent sexual dysfunction represent a clinically significant problem in about 3% of younger male patients with a previous inguinal herniorrhaphy. Intraoperative nerve damage and disposition to other chronic pain conditions are among the most likely pathogenic factors.

Spontaneous fecal fistula: a rare presentation of inguinal hernia

A 25 years old young man presented with the right scrotal and supra-pubic fecal fistulae due to the spontaneous bursting of a congenital inguinal hernia. This hernia remained obstructed and strangulated for about ten days before getting ruptured. Resection and end to end anastomosis of involved ileum was done. The literature search could reveal only five such cases in pediatric age group and this complication is considered to be much rarer among the adult population. This case report is being presented here in view of the extreme rarity of this complication in the adult age group.

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome

BACKGROUND

Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation.

HYPOTHESIS

Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season.

RESULTS

Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not.

CONCLUSION

Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.

Topical negative pressure therapy. A very useful new method to treat severe infected vascular approaches in the groin

AIM

The treatment of infected vascular surgery sites is challenging. Negative pressure applied uniformly to the entire wound surface has been shown to allow granulation tissue formation and to promote healing of acute and chronic wounds.

METHODS

We used the Vacuum-Assisted Closure (VAC, Kinetic Concepts Incorporated, San Antonio, Texas, USA) system in 4 patients with severe groin wound infection after emergency surgery on the femoral artery.

RESULTS

In all 4 patients, general health improved and the wound changed rapidly from a large infected cavity to a minor lesion readily covered using a simple surgical technique.

CONCLUSION

This study establishes VAC as a very valuable tool for managing severe complications of groin vascular surgery sites even in patients with obesity and/or diabetes mellitus.

A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain

To the best of our knowledge, this prospective study is the first to investigate the prevalence of acetabular labrum tears in athletes presenting with groin pain. Eighteen athletes who presented to our sports clinic with groin pain, underwent clinical assessment and magnetic resonance arthrography (MRa) to detect presence or absence of acetabular labrum tears. Ethical committee approval and informed consent was obtained from each patient. In four out of these eighteen athletes (22%) the MRa demonstrated the presence of acetabular labrum tear. Three of them underwent arthroscopic debridement of their acetabular labrum tears and returned to their sporting activities within 8 months. Clicking sensation of the hip was a sensitive (100%) and specific (85%) clinical symptom to predict labral tears. The internal rotation-flexion-axial compression manoeuvre was sensitive (75%) but not specific (43%). The Thomas test was neither sensitive nor specific. The conclusion of the study is that acetabular labrum tears can be a common cause of groin pain in athletes. Sports clinicians managing athletes with groin pain have to be well aware of the condition.

Femoral incision morbidity following endovascular aortic aneurysm repair

Currently available aortic stent-grafts require bilateral femoral incisions for device deployment. The incidence of morbidity (infection, lymphatic complications, breakdown) of vertical, infrainguinal incisions used in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) was assessed, and the natural history of asymptomatic groin fluid collections following such procedures was determined. Between June 1999 and February 2001, 77 consecutive patients underwent EVAR for AAAs utilizing bilateral vertical femoral incisions. Fifty-nine (77%) bifurcated stent-grafts (BSGs), and 18 (23%) aortouniiliac (AUI) devices, with femorofemoral bypass were performed. Patients returned at 2 weeks, 1 month, and 6 months for physical examination, and 1 month and 6 months for abdominal and pelvic computed tomography (CT) scans. The presence of fluid collections was determined from the dictation report of the attending radiologist. Data are reported as (n) mean +/-SE. Patient characteristics were compared using Fisher's exact test; p<0.05 considered significant. There were 72 males and 5 females, age 75 +/-6.4 years and aneurysm size (77) 5.6 +/-0.8 cm. There were no cases of wound breakdown or lymph fistula. Wound infections occurred in 3/150 incisions (2%), 2/34 AUI incisions (6%), and 1/116 BSG incisions (0.86%). There was no statistical difference (p=0.13) between graft types (BSG vs AUI). All infections were diagnosed clinically before the 1-month CT scan, treated without operative intervention or hospitalization, and resolved. There was a significant decrease in the BSG group and overall in asymptomatic wound fluid collections from 1 to 6 months postoperatively. At 1 and 6 months, respectively, the BSG group had 17 (14.6%) and 3 (2.6%) fluid collections out of 116 incisions (p=0.003); the AUI group had 6 (17.6%) and 1 (2.9%) fluid collection(s) out of 34 incisions (p=0.13); and overall 23 (15.3%) and 4 (2.6%) out of 150 incisions (p=0.004). The present study demonstrates that bilateral vertical femoral incisions used in EVAR have a wound infection rate of 2.0%. Infections are usually detected and treated clinically and empirically without the need for hospitalization or surgery. Asymptomatic groin wound fluid collections resolve significantly within 6 months without intervention. Therefore, surgical femoral artery exposure adds little morbidity to the endovascular repair of abdominal aortic aneurysms.

Case of a non-pulsatile groin swelling

We report a case of a non-pulsatile groin swelling in a 38 years old male drug addict without the typical clinical signs of an aneurysm. Ultrasound revealed a left femoral artery pseudo-aneurysm. He was surgically treated and the vessels were ligated without revascularisation.

Electrophysiological analysis of pudendal neuropathy following traction

Pudendal neuropathy is an unusual but important complication of orthopedic surgical procedures involving traction on the fracture table. We describe the clinical and electrophysiological features in six patients presenting with perineal sensory disorders and sexual dysfunction following surgical repair of femoral fracture, hip dislocation, or intra-articular foreign body, in which the traction table was used. All underwent electrophysiological recordings: bulbocavernosus muscle electromyography (EMG), measurements of the bulbocavernosus reflex latencies (BCRLs), somatosensory evoked potentials of the pudendal nerve (SEPPNs), sensory conduction velocity of the dorsal nerve of the penis (SCVDNP), and pudendal nerve terminal motor latencies (PNTMLs). Signs of denervation localized to the territory of the pudendal nerve were found in 3 patients, normal BCRL in 6, abnormal SEPPNs in 4, and abnormal SCVDNPs and PNTMLs in all cases. The outcome at 2-year follow-up was good, except in one patient with initially unrecordable PNTML. Perineal electrophysiological examination can thus confirm the pudendal neuropathy and give prognostic information.

Pelvis and sacral dysfunction in sports and exercise

Pelvic and sacral dysfunctions resulting from sports-related injuries are unusual. A simple groin pull, however, can prohibit an athlete from participating in sports activities for an extended period of time. Pelvic floor dysfunctions can be particularly impairing for women athletes, and are rarely discussed in sports literature. This article reviews the anatomy, biomechanics, common injury patterns, and treatment options for athletic injuries related to the pelvis.

The sports hernia: a cause of chronic groin pain

The management of chronic pain in sportsmen and women requires consideration of a wide differential diagnosis. A syndrome caused by a distension of the posterior inguinal wall is described, effectively an early direct inguinal hernia. The diagnosis can be made from certain aspects of the history and examination, which are described. The results of surgical repair to the posterior inguinal wall are excellent. The procedure was carried out on 14 sportsmen and one woman. There is an 87% return to full sporting activity, with a follow-up of 18 months to 5 years. The remaining 13% were improved by the repair. Many of the athletes had received other treatments without success. The sports hernia should be high on the list of differential diagnoses in chronic groin pain.