Monday, February 28, 2011

ATSNJ Pubalgia workshop 2-27-11

The talk started off with Dr. Andrew Boyarski, a general sugeon from New Brunswick, NJ.  I really enjoyed this one:

Dr. Boyarski is skeptical of the US trend of using mesh to do these repairs, especially in young athletes.  He put it quite simply, that this technique destroys the continuity of the fascia and may promote nerve entrapments.  He described what he calls the normal "scissor down" effect of the fascia on the inguinal canal, which protects the area from injury.

He says although MRIs are beneficial in the differential diagnosis, they are too uni-dimensional to be of benefit in the diagnosis of an athletic hernia.  He prefers diagnostic ultrasound for this purpose.  He simply asks the athlete to cough, and looks for the "scissor down" effect on the ultrasound.  (Note: on the A.T. side of the evaluation, he says with a little practice this effect is palpable externally.  He says adductor tenderness varies, and is not a good indicator).

 He chooses to a version of the repair technique he learned from Dr. Ulrike Muschaweck, an orthopedist from Germany.  The surgery is done with a local anasthetic.  He asks the athlete to cough while he is staring directly at the canal to be sure the "scissor down" effect has been restored.  In this technique, the floor of the canal is reinforced with sutures and the athlete is usually back to competition in 6 weeks.  He was quick to emphasise the importance of the therapist on the prevention and rehabilitation side of the equation by way of a good "core" strengthening program.

Next up was orthopedist Charles Gatt

Dr. Gatt spoke of evaluation & treatment of pelvis/hip injuries in general.  Again the topic of diagnostic ultrasound came up. He uses a portable one to guide cortisone injections in the inflammatory phase, especially in hamstring injuries.  He cites research from Bergfeld to support this (readers take a look at this and let me know what you think) :

I asked him about FAI, as to whether he felt it was a nature or nurture thing.  He agreed with most researchers, that its the latter.

Russel Steves, PT, ATC spoke on the rehabilitation of athletic hernia:

Those with Dr. Boyarski's repair are up and doing light walking immediately, doing light stretching and exercise weeks 3 & 4, and are segueing back to competition the 5th & 6th!  While most of he protocol was pretty traditional, it was interesting he proposed the possibility of a functional protocol as being effective also.  He spoke of the need of the "muscles to be powerful in a lengthened position".  Sounds like Dr. Tiberio's "transformational zone" concept, no?  He also mentioned ART and Graston by name as being beneficial.
Finally Jennifer Lister A.T.C. spoke on using a Pilates based approach to pelvis/groin injury rehabilitation and prevention:


Brian Green said...

Interesting post...Dr. Muschaweck is a VERY busy gal this side of the Atlantic. I believe she is becoming known in American soccer circles...
Throw Muschaweck, Holmich, Verrall, and Renstrom in a room and they'll tell ya "groin pain" is caused by 4 different structures...go figure.
Regardless, the core and hip ROM, especially internal rotation, is crucial

Joe Przytula said...

...especially RELATIVE IR. And Pilates ain't going to fix it.

Jack Martin said...

Joe, our top 400 runner pulled up tonight running the 400 leg of DMR.
He has seen Dr. Bonsall about his left hamstring. Tonight it was his right hamstring. Any thoughts? Martin

Brian Green said...

When you say relative IR you mean similar to assessment of it for GH jt?

Joe Przytula said...

RR= the movement of the pelvis on the femur, rather than the femur on the pelvis. So if we're talking about about RELATIVE IR of the left femur, the pelvis would be ER on a fixed femur, or, that same femur would be moving through space (like kicking a ball), either internally or externally rotating, with the pelvis moving faster than the femur.

Sorry, but there is a lot of neuromuscular control going on there you ain't getting with Pilates.

Joe Przytula said...

Jack- In both hamstrings, where was the strain, i.e. "inside" or "outside", high or low? Bonsall is a great manual therapist, but Martin is the consummate complex systems practitioner.

Jack Martin said...

Joe, mid hamstring. My take is a cramping issue as he has had calf cramps this winter as well. Very frustrating. Our trainer is looking at him today. Martin

Joe Przytula said...

Jack- Sounds like that "posterior chain" (hate to use that term) may be over-taxed, hence the cramping. In particular, a circular leg pattern, as opposed to linear, could be the culprit. A forward torso lean could also produce that cramping issue. Rule that out first. If this is the case, popular "posterior chain" exercises may make it worse.