00:00:08:

00:00:29: Hello and welcome to a new episode of the Sports Physiotalk podcast.

00:00:35: The sports physio talk has been around since two thousand twenty-two and focuses on topics from the world of Sports Physiotherapy as well, relevant aspects.

00:00:44: From other areas of

00:00:46: sports.

00:00:47: this podcast gives you insights into daily clinical practice their rehab process And the realities of working with athletes both in a clinic and on the field.

00:00:58: I regularly invite experts to share knowledge experience and perspective on specific topics.

00:01:05: And that's exactly what we are doing today!

00:01:08: Todays episode is a special one, We're diving into real clinical case A case study of an athlete dealing with Crohn pain One the most complex and often misunderstood issues in sports physiotherapy.

00:01:23: For this conversation I'm joined by someone who truly stands out in this field.

00:01:28: Stefan Boda brings a unique combination of what I always describe as the three E's, evidence experience and expertise.

00:01:38: He doesn't just understand the science behind groin pain.

00:01:41: he translated into practical real-world clinical reasoning.

00:01:46: over the past years Stefan has developed a project called Focus Leister which was helped many clinicals better understand.

00:01:57: This project is also available in English, making it accessible to an international audience.

00:02:04: That's the reason why todays episode was recorded for the first time.

00:02:10: In this episode you will get a deep insight into how Stefan approaches cases like these from patient history to clinical examination and decision-making treatment strategies.

00:02:22: So, if you're working with athletes dealing with groin pain in your daily practice or simply want to sharpen your clinical reasoning this episode is definitely for you.

00:02:43: Yeah,

00:03:14: Stefan.

00:03:15: Great to have you here today.

00:03:16: we are talking about Crohn case but could you briefly introduce yourself in the beginning.

00:03:24: Well,

00:03:25: I thank you very much Chris for hosting me.

00:03:28: so just a quick intro about myself.

00:03:31: uh i was born and raised in vienna austria.

00:03:34: that's also where i completed my undergrad physio and then i did a master's in musculoskeletal and sports physiotherapy at university of south Australia in adelaide um and then worked for many years with the austrian national eye soccer team Austrian national football team, also at major tournaments such as the European Championships and the Isoco World Championships.

00:04:01: As you might have noticed i've got a huge interest in groin pain... ...I've kind of seen like more than five hundred cases now in the last fifteen years And today I want to walk you through case.

00:04:14: that's really good example how groin pin athletes is rarely just local muscle issue.

00:04:21: All right, so there that's a huge amount of cases you worked with and Are.

00:04:29: most of them are athletes or do we have also?

00:04:33: Not at least.

00:04:34: So but most of the time it's a common injury in athletes.

00:04:38: I think its And we're here in this sports physio talk.

00:04:41: So yeah It's more than The athlete thing.

00:04:45: Yeah,

00:04:45: so obviously it's more about active people.

00:04:49: So the majority of my patients would have been soccer players and ice hockey players because its very common in those codes.

00:04:58: However It can also happen to recreational athletes who just go for a run And maybe take it too hard on themselves Too far or too fast often.

00:05:11: Well, this is a common presentation in soccer rugby or ice hockey.

00:05:15: Today I want to present you a case about the handball player just because i believe there have been so many case studies done on addict-related groin pain in soccer players that it felt the right thing to do.

00:05:30: well she's a twenty two year old female hand ball player and saw her last when she was having groin pain since January, so she kept playing training and competing which led to recurring issues rather than one acute episode.

00:05:49: So it was like an insidious onset of her condition.

00:05:55: One important piece off the puzzle was injury history.

00:05:59: Back in twenty-twenty-one She had a major knee injury on the left side An ACL rupture Medial and lateral meniscus tears And an MCL All surgically repaired using a quadriceps graft.

00:06:14: She reported good recovery and didn't have any further symptoms or issues with playing handball, but as we'll see that history will become highly relevant.

00:06:27: Her symptoms profile she had pain in the right groin radiating into the medial thigh And occasionally to the pelvic floor region.

00:06:37: What stood out was that her symptoms were clearly low dependent and they were aggravated by stop-and-go movements especially in defensive play.

00:06:47: So handball players, she was a back court player... ...a tall woman.

00:06:53: but in handball when you play defense You have to do A LOT of stop & go movements In the short area like many quick and short steps a bit like basketball.

00:07:07: So, essentially all high demand situations involving deceleration and load transfer.

00:07:14: Interestingly gentle adductor work actually relieved her symptoms.

00:07:18: so we did some soft tissue work just to keep her playing which already suggests this isn't simply a case of download the tissue.

00:07:29: She had already been doing some rehab before she saw me.

00:07:33: This included physiotherapy, core strengthening and Copenhagen adducta exercises at around level two.

00:07:40: At that stage the goal was mainly to manage symptoms through the season with a planned break later in the year.

00:07:47: so we have like five weeks period initially where we knew We were looking into like a five week national team break where we considered to really go deeper and where would have been able.

00:08:04: To do some more advanced rehab, but what will come back today later?

00:08:09: Yeah um What would you say if your can?

00:08:14: is it possible toe play with a chrome pain In this case, you said that you have found a management to work around or with treatment techniques... ...to let her play till the season break.

00:08:37: Is it often that athletes who deal with chrome paint can play?

00:08:45: Or what's your...?

00:08:48: I think that's one of the unique things about groin pain and groin injuries.

00:08:52: While many other conditions such as ACL or muscle injuries tend to immediately ban you from competing, with a groin injury many athletes can compete.

00:09:05: however they might do so on lower level performance but since she managed well we monitored her squeeze values.

00:09:16: She didn't aggravate her pain Extremely, we decided to keep her playing because if you're a professional athlete that's what your meant.

00:09:25: To do and at this time It didn't look like the risk of further injury would have been very big.

00:09:32: Yeah That actually reminds me over case I had recently in my own clinical practice.

00:09:38: We were not talking about these early in German because we recorded the episode in German as well.

00:09:44: And it just came to my mind during the English recording, I treated a football player in the middle of season who developed pain and took the region that took the Magnus already doing.

00:09:59: the patient history was quite clear too me.

00:10:02: at issue was likely not just muscle itself being overloaded but that was probably something else contributing to the problem.

00:10:11: However, it is also obvious that the player needed to finish half of his season as they were competing for a championship.

00:10:21: So in this situation we made a concisious decision to manage the symptoms and use more passive approach, in this case trineetling of Dr Magnus which reduced the pain, cried effectively.

00:10:38: The player was able to continue playing but after about three weeks symptoms returned.

00:10:43: so we repeated this same approach and helped him get through the final weeks of end-to-season break.

00:10:50: Of course during season ended we addressed that issue in a more sustainable way focused on underlying cause greater than just the symptoms.

00:11:00: In German, you call it Opfer and Theta in English is

00:11:04: a culprit and victim?

00:11:05: Yes

00:11:06: I think as a physiotherapist sports physiotherapists You always have to assesses whatever this approach is accessible from health perspective And in these case It was quite an align with what you mentioned earlier Stefan that athletes can sometimes continue competing with a certain level of manageable pain.

00:11:26: So I think this really highlights that in sports physiotherapy, you often have to think a bit differently compared to more traditional clinical setting.

00:11:36: How was it?

00:11:37: In your case?

00:11:38: Well i think thats'a good example because especially when working in elite sport or in an elite environment, very often muscles get sore and they might impair you when playing but can still play.

00:11:53: And then it can help doing some passive treatment such as gentle soft tissue or dry kneeling because we do know that this can help matching patient expectations during some neuromodulation.

00:12:11: But I think it's really important not only to know the victim, in this case obviously Dr.

00:12:17: Longos' muscle for her was the victim which we'll get into a bit later.

00:12:22: but i was quite aware that there had to be a culprit like a main cause of problem.

00:12:29: so when we assessed her We were able to reproduce her symptoms quite consistently.

00:12:36: She has pain with active straight leg raise and a combined leg lift with the sit-up.

00:12:42: So when I pushed on both her injured leg, or right leg, and resisted to left shoulder such as diagonal sit up cross over body crunch she had typical pain of the right adductors but also in pubic bone from joint perspective.

00:13:03: the favor reproduced a familiar pinching sensation, but overall hip rotation and the Fadir test were all negative.

00:13:12: So I expected the discomfort on the Faber being due to her hypotonic adductolongous muscle.

00:13:22: And what really stood out was this squeeze test.

00:13:25: I tend to perform the squeeze test in various angles and when she brought up her legs into a ninety-ninety position, like hips flex till ninety and also knee.

00:13:37: But uh...when she squeezed together obviously had to use both her adductors and hip fluxes and abdominals.

00:13:45: that was their position which aggravated the symptoms the most, which led me to a hypothesis and clinical diagnosis that it was not only adducta-related groin pain such as she was being referred with from her GP but also pubic related groin pains.

00:14:03: So it is quite often with the DOE agreement many athletes fit more than one category so both adductor and abdominal And the pubic symphysis, when we did the ninety-ninety squeezes became like a central load and transfer point where she had to withstand detention from above the abdominal muscles.

00:14:28: And below the adductors so kind of the leg and the core muscles were fighting at tug of war with the bubic synthesis and the adductor being the victim When on palpation She also presented with an increased tone in adactolongous and all the other adacta muscles around the right side like pectinias, adactomagnus and erecticepdominis.

00:14:58: But now that's the important thing!

00:15:00: We also performed, when she was pain-free a long liver adductor strength testing because I already suspected that the adductors were just victim and not decalporate.

00:15:12: And we realized that her Adductor peak torque like Newton times meter divided by body weight where absolutely fine.

00:15:21: so she was strong enough but still Her right adduct always became hypertonic and painful bordering her when she was playing handball.

00:15:32: So that's, I think the beauty of this example is like the culprit and victim analogy.

00:15:39: so... The real turning point came when i asked her to present some tasks such as change of direction in the clinic.

00:15:49: but even when we did a simple forward launch.. ..I could observe there were clear valgus collabs on right side.

00:15:57: So, we just want to keep in mind that she had the ACL recon and this big ACL surgery on her left knee.

00:16:04: And she did a fantastic job with her physio and athletic coach on rehabbing the left side.

00:16:11: but for some reason when she put load onto your right foot such as change of direction or stepping forward decelerating... She collapsed into a knee valgus!

00:16:25: The thing is even though it was not the injured leg, It was highly relevant for her problems because when we corrected The right knee medial collapse like the right knee valgus Just by giving a resistance band pushing her right knee into a neutral position.

00:16:46: It got much better from the symptoms.

00:16:48: so We learned that despite the adductors were haphatonic They were strong enough.

00:16:54: There was a victim and they just could not handle the load that we're put under during change of direction or deceleration,

00:17:04: so the most relevant thing what you are finding with the knee collabs?

00:17:10: You would say And That's was the reason for your working diagnosis How did you approach to treatment and What Was Your starting point?

00:17:21: after all your clinical reasoning?

00:17:23: So, as I've said at the beginning we had a five to six week period where we just have to manage and monitor her throughout the season waiting for a five-week period of a national team break.

00:17:35: Where we could really get into that problem.

00:17:40: so it often happens things didn't go exactly to plan after or in the beginning off the National Team Break.

00:17:50: she became ill required antibiotics and ended up having time off anyway, just not in a structured way.

00:17:57: So we had to adapt!

00:17:59: And to be honest even if everything had gone to plan I would still have given her at least one full week completely off because i believe proper recovery is often underestimated... ...and will always need to keep in mind that we are dealing with human beings.

00:18:17: so the return-to-training phase in January & February We had to shift our focus because the plan was to work on the culprit, like re-educate and reload.

00:18:31: The whole thing in international team break didn't work.

00:18:35: so one key step is communication with a coach.

00:18:39: When we are using some reverse engineering such as what was the trigger for her culprit or problems, it obviously was a change of direction.

00:18:50: Most of groin pain athletes divide into kicking and shooting mechanism sprinting and changing directions being three main triggers for groin pains.

00:19:03: so in here case we could not eliminate this factor when she is playing Handball, because that's part of the game.

00:19:13: But as with most field sports they had quite an intense athletic session on Tuesday mornings usually where a lot of stop and go movements... A lot of defense play was required from her.

00:19:26: And what we did?

00:19:28: We involved the coaching staff.

00:19:34: She had to perform her rehab program doing some heavy loading exercises, some quite demanding ones for keeping her leg alignment perfect.

00:19:46: And instead of the athletic session she did all those work and it was fun with a coach because he was aware that she wants to do everything to get better.

00:19:58: She doesn't want to take it easy in practice.

00:20:01: so we had really good experience.

00:20:05: This is exactly where everything connects again because these were the situations that stressed their symptoms the most.

00:20:11: Rapid deceleration, valgus stress high load transfer.

00:20:17: so in this case even it didn't work at first place.

00:20:21: during a national team break on November we could kind of figure out with controlled exposure and some shifting from her training load to some more rehab exercises.

00:20:39: And again, that doctor was the victim but the movement pattern in this case the knee collapse was the culprit.

00:20:47: so it's like one of my key messages In past experience very often the groin is a victim not the culprit.

00:20:58: Would you say that these are one of the common mistakes clinicians can make, they just focus on the victim?

00:21:09: Yes.

00:21:10: Definitely.

00:21:11: And I think it's just a low hanging fruit to focus on the victim because obviously if your patient, If you're athlete is getting better with doing some menial work and some adduct exercises You attempted to thing are need to get him stronger or her?

00:21:27: Work on head actors but in my case Or in this cases what was a bit easier because these had already been done.

00:21:35: so i'm seeing many athletes as second opinion.

00:21:39: in many cases proper rehab has already been done, has unfortunately failed.

00:21:44: So I gotta say usually i don't tend to see the cases which have failed.

00:21:48: But I think it's always important if an athlete doesn't respond to the exercises, you give him in a way that he or she keeps coming back with the same problem.

00:22:00: You definitely want your whole diagnosis and consider whether there is a culprit as in her case like a shadow of past is around?

00:22:14: What's one key takeaway for this case?

00:22:18: ?

00:22:19: If you choose one.

00:22:22: Okay, if I just have to pick one i think of the problem first.

00:22:30: in her case reassess which movement gives it a most trouble and then later do it in your clinic until she fails.

00:22:40: so in that case when she did the forward lunges in this slowly uncontrolled manner she was fine.

00:22:46: but when we did it a bit faster, we used some reactive type of exercises.

00:22:53: She started failing and then also the symptoms started to flare up.

00:22:58: so I think that's the important thing.

00:23:00: if you suspect one mechanism You need your athlete to fail And It makes sense To use some reverse engineering.

00:23:09: Where can people find more about Your work?

00:23:14: I'm really glad that now i can tell i've launched TheGroenPhysio.com which is an educational platform for sports doctors and physiotherapists who just want to get a better, clearer understanding of groin-pinning athletes.

00:23:31: you can find me on www.TheGroennPhysia.com And also put together nice online course the Groen Playbook which is like a two-hour course, also using many case studies from my past experience and should help you to get better understanding on how your treat and manage groin injuries.

00:23:57: Stefan!

00:23:58: Your next step is big tournament.

00:24:02: You are working with the Austrian national team The Ice Hockey Team And they're starting their World Championship in Switzerland in the upcoming week now.

00:24:14: It's not that coming week or it is two weeks?

00:24:18: I'm really looking forward to this.

00:24:20: so we're gonna start tomorrow with last preparation camp In Carinthia, which is like a southern state of Austria With fantastic hockey culture.

00:24:30: So i am really looking for what to sold out rink in Klangfurt and then next week on Tuesday We are going fly off to Zurich where we're going to play the ice hockey world championships, facing some fantastic hockey nations such as the US and Finland.

00:24:50: And yeah I'm really looking forward to being back with The Hockey Team!

00:24:53: With the first match against Great Britain it actually feels quite fitting that this also became the first English episode of the Sports Fusion Talk so... Stefan, thanks a lot for your time and insights.

00:25:07: I appreciate that!

00:25:08: And

00:25:09: yeah...

00:25:10: Thank you very much for hosting Chris.

00:25:11: You're welcome.

00:25:13: That's it again with todays episode.

00:25:19: I hope you had fun watching this.

00:25:22: I'm looking forward to a like and subscription on the upcoming streaming platforms Spotify Apple Music & Co.

00:25:28: For questions, suggestions for today's episode or one of the previous ones you can write me an email at info.at-sportfysio-fortbildung.at.

00:25:40: I'm looking forward to seeing you next time!