- Title
- Beyond the pathoanatomical explanation of long-standing groin pain in athletes
- Creator
- Drew, Michael Keith
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2017
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Introduction: Groin pain in athletes can be a debilitating condition which can affect the individual experiencing the pain as well as the team they are associated with. Many publications have explored pathoanatomical explanations of groin pain yet little is known about sensory processing and its role in the pathogenesis and treatment of groin pain. This thesis examined quantitative sensory testing in controlled, experimental conditions and in Australian football players experiencing groin pain. Methods: Study populations: Two study populations were utilised in this thesis. To investigate the role that pain in the groin has on the diagnostic criteria, healthy active males were recruited from a university setting. The second population was constituted by professional and semi-professional Australia football players who had current groin pain and matched healthy controls recruited from the same clubs. Clinical assessments: Six common clinical assessments were evaluated under experimental pain conditions. These tests were bilateral adduction in 0°, 45° and 90° of hip flexion, resisted abdominal crunch, and oblique crunches in both directions. A positive result was defined as an increase in pain levels experienced during or immediately following contraction of the involved muscles. A negative finding was no change in the level of pain experienced. Electrodes were placed on the adductor longus, rectus femoris, tensor fascia latae and external obliques bilaterally to investigate the electromyography (EMG) activity of diagnostic tests to understand the differing diagnostic capacities. Quantitative sensory testing: Pressure pain thresholds were evaluated on the adductor longus, pubic bone, rectus femoris, tibialis anterior to investigate the mechanical sensitivity of the lower limb under experimental and clinical pain conditions. Pain distribution: To investigate the pain referral patterns of the adductor longus, body charts were utilised under experimental pain conditions. Patient-reported outcome measures: The Copenhagen Hip and Groin Outcome Score (HAGOS) was employed to investigate the symptoms and disability associated with groin pain in the study populations. Other measures: The McGill Pain Questionnaire was utilised to capture the descriptions of experimental pain in the groin. Statistical methods: Diagnostic statistics such as sensitivity, specificity and likelihood ratios (LR) were utilised to evaluate the clinical tests. Receiver Operator Characteristic (ROC) curves were determined with the ‘Jack-knife method’ comparisons of non-parametric variances of the diagnostic capacities of the clinical tests. Repeated measurements were utilised throughout the thesis. These were analysed using repeated-measures analysis of variances or mixed-effect linear models (restricted estimates maximum likelihood (REML) models) where ANOVA modelling failed the assumptions of the test or when inappropriate for the study design. For binary outcomes, mixed-effect logistical regression was utilised. Principal Component Analyses (PCA) were utilised to understand the responses to the HAGOS questionnaire in the clinical pain studies. Results: Under experimental pain conditions, adduction at 0° had the greatest positive likelihood ratio (+LR=2.8, 95%CI: 1.09–7.32) with 45° (-LR=0.0, 95%CI: 0.00–1.90) and 90° (-LR=0.0, 95%CI: 0.00–0.94) having the lowest negative LR. A local pain distribution was observed in the majority of subjects (>80%) with a proximal pain referral to the lower abdominal region in 33% (AL) and 7% (RF) of participants. Compared with baseline, PPTs at the ipsilateral and contralateral AL tendon did not increase significantly (P<0.05) after hypertonic saline. Experimental pain did not alter the EMG amplitude in individual groin or trunk muscles during provocation tests when forces were matched with baseline. In Australian football players, the point prevalence of groin pain in the pre-season was 21.9% with a career prevalence of 44.8%. Adductor-related groin pain was the most prevalent classification in the pre-season period. Hyperalgesia was observed in the adductor longus tendon site in athletes with current groin pain (OR=16.27, 95%CI 1.86 to 142.02). The ROC area under the curve of the regression model was fair (AUC=0.76, 95%CI 0.54 to 0.83). Participants with current groin pain showed lower Physical Function of Daily Living (PFDL) and Physical Function in Sport and Recreation (PFSR) subscale scores (p<0.05, ES: 0.77 and 0.90 respectively). Any groin pain (current or historical) lowered the Pain and Quality of Life (QOL) subscale scores (p<0.05, ES: 0.38 and 0.72 respectively). Factor analysis showed 8 significant factors with one main factor identified (Eigenvalue=18.02, Proportion=0.49). Conclusion: This series of studies indicates that the 0° hip adduction test resisted at the ankles optimises the diagnostic procedure without compromising diagnostic capacity to identify experimental groin pain. No statistically significant changes were observed in the EMG; however, a clinically significant decrease in the adductor longus was observed during experimental pain. The majority of participants reported the adductor longus pain distribution to be local yet a minority also perceived pain superiorly into the lower abdominal region. This may explain why abdominal pain concomitantly exists with groin pain in clinical situations. Hyperalgesia was observed in Australian football athletes with current groin pain highlighting that alterations in mechanical sensitivity exist in clinical groin pain. This thesis highlights that pain itself in the region can alter the diagnostic criteria and changes in the sensation can occur in clinical cases. The implications are that management of pain in the groin should consider all potential pain mechanisms and should not be limited to purely biomedical pathoanatomical models of diagnosis and treatment paradigms.
- Subject
- PhD; groin; pain; adductor; athlete
- Identifier
- http://hdl.handle.net/1959.13/1337746
- Identifier
- uon:27895
- Rights
- Copyright 2017 Michael Keith Drew
- Language
- eng
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