Dear Guy

Firstly the hernia repair I take to be something like a 'Gilmores Groin',
has this been considered and ruled out ?

Also if an osteopathic treatment has been undertaked I also assume a decent
assessment and treatment via manipulation/MET etc of the SIJs and pubei have
been attempted. As a note I would be more surprised if asymetry and leg
length difficiency had not been found.

Suggestions Muscle balance; a good whole body assessment but with particular
relevance to the relationship between.
1 Transverse Abd and obliques over rectus fem, if you have not already done
so stop this lad doing sit ups.
2 Stabilising and moving adductors.
3 General pelvic to include Hams and gluts. IR and ERs of the hip and Lumbar
stabilisers.

Sometimes the exams are coincidences and can be referred pain, obturator
nerve can manifest as troublesome groins (slump with abd and lat hip
rotation ). Also look at interfaces particularly lower Tx and upper Lx. Hope
this helps   Regards Kevin

-----Original Message-----
From: [log in to unmask] <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 19 May 1999 19:17
Subject: Groin Pain


Dear All,

Further to our discussion on osteitis pubis and groin pain, I would
like to present the following account of a premier league soccer
player, midfielder, mid twenties, who developed a lower abdominal
injury, and the various steps taken to help him.

Unfortuneately all our treatments had only a limited and temporary
effect. Currently it is felt that we have no more conservative
solutions to offer him. We would like to discuss this case further
with anyone who has had experience of this condition and the pros and
cons of different treatment options.

Calendar of events:
February 1998: Gradual onset of right sided lower abdominal discomfort
descending to the pubic symphysis.
May 1998: Seen by both orthopaedic and general surgeon-inguinal
hernia ruled out. Analgesic injections to the area were used sparingly
prior to end of season games. At this stage rest thought to be most
important factor in gaining resolution.
July 1998: Six weeks of complete rest. Recurrence of symptoms after
two days of pre season training. Unable to cope with pain. MRI showed
right sided marrow oedema of the pubic symphysis. Ultrasound
examination suggested previous adductor shear injury. No pre hernia
complex was shown at this time. Degenerative changes were noted at
pubic symphysis. In addition "hyperostosis" was noted at the SI-joints.
At this stage further steroidal injections under ultrasound control
to the common adductor origin and symphyseal cavity were performed.
August 1998: A controlled stretching and exercise programme was
started.
October 1998: Small bi-lateral herniae were diagnosed by general
surgeon. These were repaired in November with mesh augmentation.
The rehab. programme was as per surgeons's instructions.
December 1998: Reviewed by surgeon following onset of pain right
lower abdominal region. Probable cause was the stretch of the mesh on
the rectus sheath.
Jan-February 99: Return to training and competition. Played three
first team matches but was unable to train afterwards due to lower
abdominal pain.
April 1999: Multidisciplinary case conference reviewed the patient
and pain management in particular. Diclophenac was the drug of choice
, used before during and after games. This regime required constant
reinforcement. Simultaneously the player underwent several sessions
of osteopathic treatment. Orthotists found some leg length
discrepancy but this was disputed by eminent orthopaedic surgeon. At
the time of writing orthotics were supplied but not used. Currently
the player is playing and has recovered some form. However should
this problem deteriorate again we fear that we may have to consider a
more aggressive approach. We were not able to find many references on
the long term results of operative treatments for this condition e.g.
simple subcutaneous adductor tenotomy and /or a rectus abdominus
tenotomy in combinatioin with a fascia plasty or a symphysis pubis
fusion with a bone graft and plate.

We would be grateful to anyone who could share their experiences of
operative or conservative treatment of this condition.
Please send your reply to the above mentioned address. I will compile
a summary of the replies and list them for further discussion
Individual respondents will be contacted in due course.


Guy Van Herp MSc, MCSP
Queen Margaret University College
Edinburgh



%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%