Physio Network

#17 - Hip and groin pain with Dr. Andrea Mosler

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On today's episode we explore hip pathologies and definitions around CAM morphology, pincer and FAI with Dr. Andrea Mosler. We covered the diagnosis, signs and symptoms of each and what to do about them. We also explored what the literature is showing us around reducing groin pain for athletes by implementing strengthening protocols.

Dr. Andrea Mosler is a specialist sports physiotherapist and research fellow at La Trobe University. She completed her PhD on risk factors for hip/groin pain in professional male football players. 

Want to dive deeper into this topic? Andrea has done a brilliant Masterclass with on us 'groin pain in athletes'. You can watch here whole class now with our 7-day free trial: https://www.physio-network.com/masterclass/groin-pain-in-athletes/ 

Our host is Michael Rizk from Physio Network and iMoveU: https://cutt.ly/ojJEMZs

👏 Become a better physiotherapist with online education from world-leading experts:

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SPEAKER_01:

We

SPEAKER_00:

have some pretty good evidence now that implementing a very simple exercise program for the Copenhagen abduction exercise into pre-season and then continuing throughout the season has an effect of reducing the incidence of groin pain by about 40%.

SPEAKER_01:

Growing pain is a really common presentation in the clinic amongst weekend warriors and elite athletes alike. And sometimes it can be difficult to find the source of that pain. Today we had Dr. Andrea Mosler, who's a specialist sports physiotherapist. She's also a research fellow at La Trobe University. And she did a wonderful job going through the definitions and the categorizations for different types of growing pain. We then finished on some solutions and the effect that strengthening can have on growing pain. My name is Welcome, Andrea. Thank you for joining us.

SPEAKER_00:

Thanks, Michael. It's really fantastic to have this opportunity to speak to physios about a topic I'm really passionate about.

SPEAKER_01:

Awesome. We're going to talk about chem morphology. Tell me, what does it mean? What is it?

SPEAKER_00:

All right, camorphology. Well, it's a little bit of a buzzword at the moment, and we're actually trying to differentiate between primary camorphology and secondary camorphology. So camorphology is really a cartilage or bony prominence or a bump of varying sizes at the femoral head-neck junction. The most important thing about camorphology is that it changes the head of the femur from a spherical one to an aspherical one, so one that is no longer round. And we're wanting to differentiate between primary camorphology, which seems to occur as a result of load, and secondary camorphology, which occurs as a result of a previous condition. So something along the lines of flipped upper femoral epiphysis, Percy's disease, or even secondary to acetabular dysplasia can create this mushrooming effect of the femur, which appears like a camorphology, but it's a secondary camorphology.

SPEAKER_01:

Okay, we've got primary and secondary. And What's tipping you off to those? Probably the history there, right?

SPEAKER_00:

Yeah, the history and generally primary cam morphology is seen in athletes of particularly high impact sports. So it seems like there's something about having a lot of impact loading, particularly impact loading involving some rotations. which during maturation, that seems to increase the prevalence of having a primary CAM morphology. At the moment, we don't know exactly what those sort of loading patterns, but it does seem that athletes have a higher prevalence of CAM morphology than non-athletes.

SPEAKER_01:

And should we make the distinction here with FAI while we're teasing out the definitions?

SPEAKER_00:

Oh, thank you, Mike. This is one of my pet topics to discuss. So camorphology is really just describing this bump or this bony prominence of the femoral head-neck junction and this aspherical head. And as I mentioned before, we see this in athletic populations at a prevalence of around 60 to 90%. So depending on the study, it's actually more common to have a camorphology in your hip than not. But femoracetabular impingement syndrome is a very specific condition. And we had the Warwick Agreement, which was published in 2016. And with the Warwick Agreement, we had the definition of femoris etabler impingement syndrome really clearly defined. And that is you need to have hip-related symptoms. Otherwise, you do not have femoris etabler impingement syndrome. So you need to have the symptoms of hip-related pain. You need to have some clinical signs, so either a positive flexion adduction internal rotation test or reduced hip internal rotation range of motion, so some sort of clinical signs, and you need the bony morphology. So if you only have the bony morphology, as in the bump, and you have no pain, you cannot have femoracetabular impingement syndrome. So that is what we call CAM morphology. So the bump on its own without symptoms is CAM morphology.

SPEAKER_01:

Okay. And I'm going back to anatomy at uni. Where does the pincer sit into all of this?

SPEAKER_00:

Okay, so pincer morphology is when you have an overcoverage of the acetabulum. And similarly to can morphology, you can have a pincer morphology with absolutely no symptoms at all and it just sits there rather benign. Or you may have changes to the joint as a result of the pincer morphology where you're getting this compression and impingement, which then leads to femoracetabular impingement syndrome.

SPEAKER_01:

So if you're an athlete, you're likely to have, more likely to have one of those morphologies and you may or may not have FAI.

SPEAKER_00:

Well, saying that, pins morphology is actually not very common. although it does depend on your definition. And we don't have clear definitions of pincer morphology at the moment. But if you look at it as defined purely by the lateral center edge angle or the angle of Weiberg, which only looks at the overcoverage of the acetabulum on the femur from a lateral perspective, if you use that definition, pincer morphology really is very uncommon, only around 3% of hits in professional male football players.

SPEAKER_01:

And what's the research telling us at the moment about this? You mentioned the Warwick Agreement. Where are we at with FAI?

SPEAKER_00:

Yeah, so thanks for asking that, Michael. Yeah, it's really a massively growing field at the moment, and we have some really exciting new data and new projects which are going to elucidate a lot more information for the clinician about camorphology and femoral scapular impingement syndrome. So as I mentioned before, we do see this higher prevalence of camorphology in athletes compared to not athletes. And as a consequence of that, we do see a lot of athletes that have groin pain have an associated camorphology. But it's because they're an athlete probably and may not be related to their groin pain because we also see this high prevalence of camorphology in asymptomatic hips. And if you look at the prevalence of camouflage in asymptomatic hits, it's actually very similar to those of symptomatic hits. So we have this fantastic prospective cohort occurring at the moment down at La Trobe where it's called the Project Force. And we have 55 males and females without hip and groin pain and 184 males and females with hip and groin pain. And they're all football players, both the round ball and Australian rules football. And what we found was that the prevalence of camorphology was almost exactly the same, whether you looked at it as a continuous, the alpha and was a continuous variable or whether you looked at it as a camphology, yes, no, between those that had groin pain and those that didn't have groin pain. So the size and prevalence of camphology was really similar in these two groups. And we also found that there was no association between camphology and patient reported outcome measures. So even the amount of pain was not related to the size of the camphology. And this also follows other research that comes out of Netherlands that camphology is modifier to the relationship between range of motion and hip and groin pain. So it's really unclear what the relationship is between camphology and groin pain at the moment. And in my own PhD work, we didn't find that camphology was a risk factor for groin pain in professional male football players in Qatar. So yeah, it's really unclear what the relationship is between camphology and groin pain. Certainly once you You have that triad of symptoms of camphorology, the pain in the hip or pain emanating from the hip and the clinical signs and maybe loss of range of motion. It seems like when you have that classic femicidal impingement syndrome, it can be quite disastrous for young athletes. But in fact, that is quite rare. So

SPEAKER_01:

it's not really a predictor. And we're probably seeing that in other areas as far as structural changes. What do we do now? Have you uncovered any other predictors and how does this change what we do?

SPEAKER_00:

Yeah, great question. So when it comes to groin pain, the biggest predictor of future groin injury is previous groin injury. So just like a lot of our musculoskeletal injuries that we see in athletes, we need to look after those that have had the same injury before. And as we know, groin pain has such a high prevalence in athletic populations. It's one of the injuries that has the highest incidence and the highest recurrence. So we need to make sure that we're monitoring those players that have had previous groin injuries in the next season. Now, the other thing that's being found with groin pain, because a doctor-related groin pain is the most common clinical entity of groin pain that we see in athletes. We have some pretty good evidence now that implementing a very simple exercise program called the Copenhagen Adduction Exercise into pre-season and then continuing throughout the season has an effect of reducing the incidence of groin pain by about 40%. So I think that's a really clear message of putting something like a Copenhagen Adduction Exercise or some form of adduction strengthening into pre-season and throughout the season for your sporting teams.

SPEAKER_01:

We like certainty, don't we? So it's really nice to get some research, bring those kind of numbers. That feels comforting to know as a therapist for me.

SPEAKER_00:

Yeah, we're doing well with prevention of groin pain and this literature really has evolved in the last three to four years. So we're understanding much more about the burden of groin pain, the difference between time loss injuries and non-time loss injuries and how that's affecting our athletes. And with some of the data that's come from Australia, from Spain, from Qatar and from Denmark and Norway, we're really learning much more and how to prevent and manage groin pain. But we still have quite a lot of uncertainty is with hip-related pain. And we know that the sequelae of something like Femur Acetabular Impingement Syndrome is really quite a nasty sequelae. And we just have to watch what's happened with Andy Murray to see that, that you can go down this path of joint destruction and requiring an early hip replacement. So we really need to pick those nasty FAI Can you speak more to that process

SPEAKER_01:

and what happens in that breakdown?

SPEAKER_00:

Yeah, so some of the impairments that we see with these athletes is changes in trunk control. So it's really important to look at really carefully good function of the abdominals and the control of the pelvis. So trunk endurance in particular has been associated with poor functioning in the hip. And then generally strength around the hip has been shown to correlate with symptoms, in particular strength of adduction. So it seems to be really, really important to have good function of the adductors to have a good, healthy hip. And that's a little bit contrary to what we're taught as undergrads, I think, where we think it's all about abduction strength. But in fact, it's about both. And particularly, abduction seems to be the one that correlates with better function and reduced pain on patient-reported outcome measures. Now, the other impairment that's been associated with symptoms in pharyngeal tubular impingement syndrome is things like the star excursion test. So it's clear that we need to work on control and proprioception around the hip as well as pure strength. And what we've found with recent systematic review is that we really need to be looking at giving a minimum of three months of good targeted strengthening program before we sort of give up on conservative management. So give some time. It takes time to have a change in these motor patterns and for there to be a real change in muscle strength. So it seems like three months is that kind of magic amount of time that we need to give for conservative management of these sort of conditions. And I'll just take you, Michael, through to the recent consensus papers that were published in British Journal of Sports Medicine. We had a consensus meeting in Zurich at the end of 2018. And there was four papers that were published from that consensus meeting. And one of them is on physiotherapists led rehabilitation for hip related pain. And a lot of the data that I'm quoting in terms of the restoration following FAIS is all nicely included in that paper.

SPEAKER_01:

That is an awesome resource. And I've got some tips here. So I'm looking at Copenhagen. I'm looking at at least three months. I'm looking at a doctor strength and trunk control. But for you, what has really changed in the treatment of this space?

SPEAKER_00:

I guess for me, it's really this clarity behind what is the condition that we're dealing with. So the Doha Agreement Meeting Consensus was published at the end of 2014. So for me, this categorisation into the four clinical entities of adductor-related groin pain, psoas-related groin pain, pubic-related groin pain and inguinal-related groin pain, and then the two additional categories of hip-related groin pain and then medical causes has really helped clarify what we're dealing with. So by categorizing into those categories, it just simplifies the management process. And the hip-related groin pain has also been further classified into femoris etabler impingement syndrome, hip dysplasia and or instability, and then other soft tissue conditions such as labral tears, ligament and serious tears with the outer bony morphological variant. So by having these different classifications, it really allows us as clinicians to target and direct our management and also consider our prognosis. So when no longer sort of swimming in the dark with all of this groin pain, which can seem so complicated. So for me, that's really the big change in terms of understanding and managing this area of the body.

SPEAKER_01:

So we definitely want to go and look at those papers and those consensus. I feel like that categorization can really stop us spending one to two months barking up the wrong tree, which can be everything for an athlete. Andrea, where can we find out more about you And you were mentioning some of these blogs from Latrobe where some really good work is coming out of. Could you point us to those?

SPEAKER_00:

Yeah, so the first one is just our blog. So that's semrc.blogs.latrobe.edu.au. That's really a culmination of all of the work that we're doing at Latrobe. We have a big team of amazingly talented researchers and clinicians. And there's been a lot of work being done in knee pain, particularly post ACL reconstruction, and obviously hip and groin pain. And we're doing a lot of work with women in sport now. And we have a lot of work a new project about to start in community women's football which i'm involved in and really proud of and if you want to find out more about that specific project please go to hersport.latrobe.edu.au

SPEAKER_01:

that is amazing thank you so much for your time and sharing your wisdom andrea

SPEAKER_00:

my pleasure thanks mike