Conjoint Tendon

[Russo]

Can anyone give me some information regarding conjoint tendon repairs??

[hhh]

The sports hernia is a contraversial diagnosis in sports medicine circles. The term sports hernia refers to a specturm of injuries principally involving the conjoined tendon, inguinal ligament, fascia transversalis and the internal and external oblique musculs. It is known is that athletes participating in sports which require high agility and change of direction skills (eg. soocer, afl and ice/field hockey) are more susceptible to groin injuries, and often a spectrum of conditions may be present which can cloud definitive diagnosis of sports hernia (eg. osteitis pubis, adductor tendonopathy etc).

Because of the difficulty in diagnosis and the lack of objective findings available following physical examination, it is hard to provide definitive details on management of the sports hernia. Most physicians will agree that a period of conservative management should be trialled before a surgical option is considered. However, this opinion is not universal, as some authors suggest that conservative management is rarely effective and if sports hernia is the sole diagnosis, surgical measures should be considered at an early stage. However, a conundrum exists as previously mentioned, sole diagnosis is a vexed issue. Success following surgery has been positive, although a lack of literature and randomization of surgical procedures should be considered when interpretating results.

Please find two links regarding surgical technique, which are subtle variations of regualation hernia repair that invovle separating some of the anatomical attachments and reattaching them.
Gilmore OJ: Gilmore's groin. Sportsmed Soft Tissue Trauma 1992;3(3):12-14
Williams P, Foster ME: 'Gilmore's groin'--or is it? Br J Sports Med 1995;29(3):206-208

Rehabilitation is a progressive procedure that should occur immediately following surgery. It is imperative to take into considerating the immobilization required for effective scar tissue maturation. Hence, procedures can be applied adjacent to the region initially. The target should be on lumbo-pelvic flexibility and stabilization exercises initially (especially the adductor group). Beliefs exist that transverus abdominus activation deficiency predisposes adductor related injuries which should be included in rehabilitation protocols. This is followed by specific strengthening exercises to the adductor and lumbopelvic muscles and a progression of aerobic exercise from walking, to jogging, and straight line sprinting. Most authors believe that exercises progression should be closed to open chain exercises. The challenge in rehabilitation is incorporating more functional and sports specific challenges and demands, noteably change in direction and agility based exercises. Again these procedures need to be progressed from walking to full pace and must be completed before full return to activity is allowed.

It is important to balance strength and muscle length across the pubic symphysis (particularly adductor group v abdominals). The majority of people will experience tight adductors and weak abdominals. Comparisons need to be made between the adductors (medial) and lateral structures on each leg also.

Management should also attempt to identify any etiological non local factors. This may include subtalar pronation, genu valgum, leg length inequality etc etc which will aid in preventing recurrence of injury.

Let me know if you require more specific protocols and procedures.

[Russo]

Thanks for your reply.

If you have specific protocols and procedures I would appreciate them. Would you prefer to post here or send via email.

[hhh]

Actually I try not to give out 'specific' protocols to patients as I firmly believe that care has to be individualised. This is particularly for this type of injury which is not something you see every day. If you look at the evidence, personalised rehabilitation programs give superior results to generalised one. This is where the skill of the practitioner comes into play. You can teach a monkey to give the same treatment and the same rehabilitation programs to everyone once a diagnosis is made (which will get results).

Some advice Karel Lewit, a physician, internationally renowned neurologist and professor with Charles University, Prague, Czech Republic passed on to me - "he who looks at the site of pain is often lost". Traditional biomedical thinking has led to an overemphasis on structural pathology and an "underemphasis" on functional pathology. Try to identify the key primary weaknesses in the locomotor system and address them, as well as providing symptomatic relief. As I mentioned in the first email, the key locomotor dysfunctions relevant to the presenting diagnosis could be any of the listed biomechanical factors. Such key dysfunctions are not limited to articular restrictions, but can include problems with the fascia, or even muscles.

Having said this clinical (and anecdotal) experience will come into play.

Sorry if this hasn't been helpful!