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[Case Studies] From the pitch to the clinic: a groin injury case study with Dr Stacey Hardin

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In this episode with Dr Stacey Hardin, we explore an interesting case study of a 25 year old soccer player who sustained a groin injury during match play. We cover:

  • Subjective history
  • On-field examination 
  • Differential diagnosis within this body area
  • Objective history
  • Surgical vs conservative management 
  • Role of MRI in the management of this injury
  • Role of multidisciplinary management

👉🏻 Learn more about Physio Network’s Case Studies here - https://physio.network/casestudy-hardin

Dr Stacey Hardin is a physical therapist and athletic trainer based in the United States. She has worked in elite soccer for over 10 years and currently works as the Director of Medical for Bay FC. In addition to her work in professional soccer, Hardin is actively involved in applied research and education.

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Our host is @James_Armstrong_Physio from Physio Network

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SPEAKER_02:

Welcome to Case Studies from the Physio Network. Today, we're going to be talking through a really interesting case study with Dr. Stacey Hardin. This is a groin pain case study of an athlete that Stacey herself treated. And we're going to be talking through the subjective history, the objective history, differential diagnosis, the plan and everything. And this is going to be really surprising things in here that you're going to find really interesting and some shocking timeframes that you probably wouldn't expect to be possible But as we go through in case study, you'll see that actually maybe they are, maybe there's a lot we can do. Stacey is a physical therapist and athletic trainer based in the US, and she's worked in elite soccer for over 10 years, currently as director of medical and performance for Bay FC. And as well as this, she also is involved in applied research and education. As always, there's loads for you to take away in this. You're going to really enjoy this episode and this case study. I'm James Armstrong, and this is Case Studies. Stacey, welcome back to the podcast. Really excited to be going through a case study today with you. So welcome. It's really good to have you back on.

SPEAKER_01:

Thanks, James. Really Good to see you.

SPEAKER_02:

Brilliant. So as I just mentioned, we're going to today take a different tact to the podcast and talk through a really interesting case study. We're going to be going through everything from subjective history to differential diagnosis to the things that went well to some of the things that could have gone better and some really important clinical takeaways I think will probably come out of the whole thing on this. So without any time wasted, let's go straight into this, Stacey. Talk us through your your case study, starting with subjective.

SPEAKER_01:

Amazing. Thank you. Yeah, this is one of my favorite cases of all times because it really ties together the science, the human portion of it. How do we make decisions? And then just carrying it all the way through to return to play. So thank you for having me on. We're going to talk about a 25-year-old professional male soccer player today. So prior to this injury, he had about a 90% availability rate during his career, his four-year career. So a shorter career up to that point, but relatively healthy. So he sustained a right groin injury during a match. He's a midfielder, so a player was trying to advance past him. He lunged and missed a tackle. But during that lunge, he forced that leg into a hyperflex position at the hip and knee and then went into some hip adduction and external rotation. No contact. It looked like there could have been contact, but we reviewed the video and there wasn't. But he immediately went to the ground. He said he felt a pop in his groin. And he was in pain. The interesting part with him with an on-field evaluation, he actually declined it. It was towards the end of the first half. So he waved everyone off. No, no, no. One of those on-field evaluations and said, I'm going to keep going. I'll make it. So he actually played 18 more minutes until he sat down on the field and said, yeah, I actually can't make it anymore. And at that point he was removed from the match. So obviously when somebody says to you, hey, I felt a pop, that makes you think of a few different things. He was pointing up into his groin, abdominal region. So with the mechanism and where he was pointing, we were considering an acute adductor-related injury. We obviously have to consider the other musculature that's in the area. So maybe it was the hip flexor involved and maybe the abdominals coming down. And then of course, keeping in mind intraarticular pathology, as we know, the muscles are rolling over or are superficial to the hip joint. So it could have happened inside the hip joint as well? Or did he have something underlying there that maybe was exacerbated? Those are really the things that we were thinking about as we started to put together our differential diagnosis and then moved into our actual evaluation after that.

SPEAKER_02:

Brilliant. So on the note of differential diagnosis, at this point, listeners are probably starting to formulate some differentials. I hope everyone listening is starting to think what you think might be going on. And at this point, stay Stacey, did you have anything clearly standing at your mind, depending on how you are as a clinician, but how were you at that point?

SPEAKER_01:

Yeah, it's really tough when you work in a specialty because you see a mechanism that most likely results in an injury and then you're like, oh, that's what it is. But I guess that's the point of the differential is to make sure you're not missing anything. But it seemed like a very classic groin injury. What we didn't know until we got on the field was that subjective report of feeling a pop, which is really important versus more of that report of maybe it's pulled or I felt a tear or kind of it move apart. That pop is usually can be more suggestive of something more significant. So that obviously put the word avulsion into my mind. I said, okay, is this, you know, an avulsion and maybe an avulsion fracture? He was a little bit younger, about 25 years old, but not out of the realm of possibility. So really started to think groin injury, pop, avulsion, that was really where the majority of our energy was thinking about.

SPEAKER_02:

Brilliant. So you've got a bit of a working hypothesis, working diagnosis there, You're then going to, I suppose, work into the objective assessment in seeing to prove yourself wrong or if there's other things going on. So let's move into that then subjectively. So objectively, where did we go from here?

SPEAKER_01:

Yeah. So right away, looking at the area, he didn't have any acute signs of injury. So he didn't have any big swelling. He didn't have any of that big like dipping that you may see. He didn't have any ecchymosis. But again, we're talking about a matter of about 25 minutes from injury to physical So we know a lot of those things can take a little bit longer to develop. So observation was unremarkable. But then on his examination, starting out with palpation, he did have a palpable divot off of the bony attachment and into the tendon of his adductor longus muscle. So that was pretty cool. Like when you could actually feel that, oh boy, okay, all right, we have the pop, we can feel a divot. And then there was this ball of increased tissue density off. off of the end of the divot. So you're starting to think, okay, has the tendon retracted a little bit? Is that what's actually going on? When we started to move through our range of motion testing, moving him out into end range abduction, he reported some increased tension, but not particularly painful. She said, yeah, it feels like the end of a stretch, something's going on. Abduction was the only one that there was somewhat relevant findings for. The rest, he moved through pretty freely, didn't report or any pain with and had near full range of motion. So that was surprising. Then we started to go into some manually resisted tests. That became even more confusing because with the exception of trying to have him deduct and flex his hip past midline, he wasn't able to initiate that movement and he wasn't able to resist manual resistance. But with the exception of that, he was able to, again, we're talking about manual resistance, not measuring what the dynamometer or something else but when you're trying to rule out an avulsion versus not manual resistance can be appropriate as that first pass through all of his regular short lever and long lever a deduction he was able to resist with he said about a four out of ten pain he wasn't wincing he wasn't rolling away from you all the things that people in pain typically do i think when you originally think of an avulsion it's hey this isn't going to be able to work at all but we know one of the cool parts about the groin as a whole complex is there's a lot of redundancy built in. So it's not just one muscle. So he did a great job of having the rest of his muscles help out during that testing. We did a couple special tests just to, again, try to rule out intraarticular pathology, fader test. That was unremarkable for reproduction of the symptoms he was having right now. And then he didn't have any tenderness or pain or any issues resisting with abdominal testing. We were pretty confident that we were cued in on that adductor longus. So looking to figure out next steps and really with that report of the pop and the palpable divot, say, you know, an MRI is indicated at this time because that may change his course of treatment if there is an avulsion. So he had an MRI that next morning. There was an avulsion of the adductor longus tendon and about two centimeters of retraction. Our clinical exam getting matched with the that additional piece of imaging.

SPEAKER_02:

Okay. Out of interest, Stacey, so you're honing in on the adductor longus there. And I know there's lots of talk about in terms of specifics and how we can be specific in certain areas. Can you talk us through sort of a bit more about what made you rule out other adductors and how you were kind of honing in on adductor longus outside of other things?

SPEAKER_01:

Yeah. So part of it, we know that's most commonly injured in footballers and soccer players. So that's one piece. The second piece was it kind of has that ropey nature to it. It's kind of thicker to palpate that band that comes down. But then really looking at a long lever squeeze between the malleoli, kind of that five-second squeeze test that you can really bias the adductor longus with. So those three put together said, okay, I think this is the primary muscle that's involved. It's also extremely relevant to footballers. Then we said, okay, maybe there may be accessory involvement of the other smaller adductor muscles, but we would have expected if there was something adductor magnus, we would have expected more potentially on that, the adduction extension or adduction flexion piece. So trying to get a little bit more specific with each test that we were doing.

SPEAKER_00:

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SPEAKER_02:

You've mentioned obviously the luxury of having MRI in the setting that you're in. Taking ourselves out of that setting, there'll be people listening to this who maybe don't have that ability to go straight for MRI. They'd have to go through a workup if they wanted that. How essential is that MRI and in this case, do you feel?

SPEAKER_01:

I think it was just more for confirmation. We have our subjective report. We have our clinical exam and an objective finding, including that palpable divot. We have impairment-based testing that shows some changes. So all of those to me say, okay, this is more than just a tension-related injury, maybe musculotendinous junction or mid-belly, something more significant. Then I think you could watch it clinically and say, okay, do we get some ecchymosis? Do we get any other signs of acute injury? that we would typically see. So you can continue to watch it clinically. But then the big question and the question that this player had was, is this case surgical? So we really consulted with our hip specialists, but really looking into the literature, it's really limited to case studies in professional and semi-professional footballers. There are some good cases coming out of the National Football League as well on how they're treated, but traditionally they have been surgical. But a lot of the more recent case is they're non-surgical and they're just showing a quicker return to play without long-term impairments or detriment to performance long-term. So that got us thinking and at least had the conversation of we have this injury, we have two ways that potentially it could be treated. And then that really opened up with the player a conversation of how do we want to approach this.

SPEAKER_02:

Absolutely. So where did you go from here? What was the conversation with the player and how did that go?

SPEAKER_01:

The return to play process is really complex, as you know. So I like to use a framework. I use kind of a modified version of the start framework, mainly just to organize. And that makes it, I think, a little bit easier to communicate to stakeholders. So this case was pretty interesting because this player, we had acquired part of the way through the season. So he wasn't even with us the full season. He was honoring out a contract from the previous team. So he was only slated to be with our team through the end of the year. He was traditionally more in a sub role. So he wasn't one of the starting or players who were consistently there. So he really wanted to try a non-surgical approach. This was towards the end of the season. He wanted to come back to try to be available for playoffs because he felt like that would have given him a better chance of having his contract renewed. And that's one thing that I always think about with the people I'm working with is we have a And really put it in a way that they understand, because these aren't insignificant things. And especially when other factors are playing into it, it may be easy to say, like, yeah, I just want to, I want to play, I want to play, I want to play. But I've had a number of athletes come back and say, I really wish somebody would have told me this when I was 18 or 25. But I was confident with him specifically that he really did understand that he was taking a risk, not necessarily by attempting non-surgical interventions. because we have a group of case studies that show up that it's possible, but more so with this one, the accelerated timeframe that he wanted to try to achieve to get back to play.

SPEAKER_02:

And what was that timeframe, Stacey? Because this is a good one.

SPEAKER_01:

Yeah, yeah, 25 days between the injury and postseason. And then we also had a player away on personal leave in his same position. So he really saw the possibility that he would be a starter in the postseason and he thought that would lock down his contract moving forward.

SPEAKER_02:

So really, really important. What were your thoughts around that timescale initially? Where did your head go immediately when you heard that kind of timeframe?

SPEAKER_01:

Yeah, immediately. I was like, no way. That's really aggressive. We talk about tissue healing and the phases of healing and it's like we're not there in 25 days. But again, that's where really diving into literature was helpful and talking to several different specialists and even physios internationally who actually wrote a couple of these case studies I reached out to and said, how'd you get to do this? What can you tell me? So I really appreciate just the collaborative nature of our profession. But initially it was, we will try our best, but I don't know.

SPEAKER_02:

So what was the plan? What do we do, Stacey? Or not we, what did you do? What did you do with the plan? No,

SPEAKER_01:

it was a we, and that's another great point is it is a multidisciplinary, interdisciplinary team. So it is a we. So we came up with a plan. And I think that's the first thing that this case highlights is you have to have a plan. People talk about it hypothetically, but put the plan in down on paper. That for us included what our very specific criteria to advance were and what we wanted to very closely monitor because we knew that this was going to be a more aggressive timeline. We set out our plan, we involve all of our stakeholders, and then we actually serially tested quite a bit with our strength using our force frame. We had our power assessments on our force plates. We looked at his functional progression, external loading with GPS, his wellness score and how he was reporting, he was responding back. So we had a number of different criteria that we used and evaluated daily to make sure that we weren't putting him in unsafe positions as we were advancing. The success of this case is we did it. So we achieved the goal that was set out. The player did play and played for the remaining two games of the postseason. And I think what's really important is we knew we had a shorter time frame. It was going to be a couple weeks that he would be playing after that and then the season would be completely over. He was committed to rehabbing fully during the off-season. So that's really important. But he also didn't have re-injury within 24 months. So two years after that, he had re-injured his hip and groin complex, the whole thing.

SPEAKER_02:

Stacey, another question. I mean, you had the MRI results. Do you think things might have changed if you had a greater retraction of the avulsion?

SPEAKER_01:

That's a really good question. Yeah, we talked about that. And then we talked about how, obviously, physical activity could cause more retraction. like a strong contraction, pulled it down almost. And so we talked about, is there a number cutoff that your surgeon was suggesting, hey, if we go past five centimeters, then it's less likely to heal on its own. We talked about that. And then we actually did do two other MRIs during that, his return to play, which isn't something we typically do. And that is one of the realities of pro sport that you can do that. The first one actually showed a three centimeter retraction. So it showed actually one centimeter more retraction. And so that guided a little bit of how aggressive we would be initially with his adductor longus specific exercises. But then the second one showed a less than one centimeter. So it showed some really beautiful scarring. So we felt that we were moving in the right direction after that. And

SPEAKER_02:

did it make you less aggressive with concentric strengthening based rehab?

SPEAKER_01:

Yeah. That's when we got back and looked at some of the EMG studies that look at exercises that specifically isolate the adductor muscles and the adductor longus and said, okay, these are probably ones that we're at least not going to attempt kind of our one rep mix. We're going to keep those a little bit lower than we normally would because we know that might cause a little bit more retraction.

SPEAKER_02:

Brilliant. It's a really good case. It highlights what's possible with certain individuals and that conversation that is really important and the planning. What are some of the key takeaways, Stacey? You think for people who might find themselves in a similar situation with an avulsion of the adductor longus, for instance, if that's what people are finding themselves in with patients, what are some of your key takeaways with management of this and things that you've learned?

SPEAKER_01:

I think the word avulsion can be really scary. And depending on population you're working with, there is an indication for shutting people down. But there's a lot you can do that is not detrimental to that area. So really understanding the role that the adductor longus plays in lumbar pelvic stability. Dr. Enda King does a lot of incredible work in intersegmental control. And so looking at some of his work to say, all right, if I'm not doing an isolated intervention at the adductor longus or really specifically specifically trying to target the adductor group, what else can I do that will still be beneficial to this type of rehab? And that's where Endocaine's work is absolutely remarkable. Brilliant.

SPEAKER_02:

Stacey, this has been fantastic. I mean, it's fascinating, actually. And I think it's always good, isn't it, as clinicians to hear each other's experiences with these sorts of things that we don't often see that often, but they're good to highlight some good clinical practice and how we can do things that we maybe wouldn't have thought we could do before, which is really useful. So thank you so much for your time today, Stacey. It's been really interesting.

SPEAKER_01:

Thanks for having me.