Diagnosis

Last week I went in London to see a consultant in London about my groin injury, which has all but sidelined me for the last 5 months. It was worrying at the start, as after his initial examination he thought I had a hernia. However, subsequent tests proved otherwise, which would explain why the not few people that have seen me over the last few months have not been able to pin down a diagnosis. I ended up being evaluated over the course of an hour; I understand the appointments are usually 20-35 mins long, so I’m appreciative of the extra time the doctor spent with me.  The headline diagnosis is Right sided rectus abdominis and inguinal ligament injury.

An extract from the report is as follows:

On examination today your single legged balance and single legged stability were poor with a positive trendelenburg test on both sides. Certainly, in your eyes-closed balance the muscle activation of your lower limb was unstable with some over-active peronei and underactive Tibialis posterior. Your hip range of motion on the left was normal with a full active range of motion and a negative FABER and FADIR test. On the right side we were able to reproduce your pain a little on end range flexion and you were tight in right extension although, again, internal and external rotation were normal, FABER and FADIR were negative and these did not reproduce your symptoms. I could find no abnormality in your knees and your foot and ankle range of motion was normal with good power in flexion, extension, inversion and eversion. With respect to your adductors on the left side there was no adductor tenderness or weakness, the pubic tubercle was normal with no inguinal ligament irritation, and the left rectus abdominis and left rectus femoris were normal. On the right side you were tender over the insertion of rectus abdominis into the pubic tubercle but not tender over adductor longus at its insertion. However, the tenderness did extend up the inguinal ligament and there was some irritation over reproducing Tinel's sign over the ilioinguinal nerve. Resisted sit up and resisted rotational oblique sit up reproduced your pain which was not relieved by pressure over the ilioinguinal nerve. Your sacroiliac joints were stiff but not irritable mainly on the left and your lumbar lordosis was flattened but slump test and straight leg raise were negative.

In summary, I think the underlying precipitating factor here is your proximal core and gluteal functional

stability and I think this is the mainstay of our initial treatment. We certainly need to review your orthoses at some point but I think we can do that here at Pure, in terms of a temporary heel raise and deeper heel cup prior to having a formal orthotic review when your pain and symptoms settle down. We need to work on core, transversus and the abdominal insertion at the same time as working on your proximal gluteal control of your hip stability, and I think you are booking in with our Physiotherapist over the next couple of days to make progress with this. We discussed the possibility of a diagnostic local anaesthetic injection over the ilioinguinal nerve and if things fail to progress over the next two weeks that would certainly be my next step.

I had the opportunity to review your MRI films with you and these are really rather unremarkable but confirm the presence of some free fluid around the rectus abdominis insertion. I have not specifically looked at the ilioinguinal nerve or, indeed, the inguinal canal and it is difficult to comment further on these. I am delighted you decided to consult at Pure Sports Medicine and I hope we will be able to rapidly provide you an effective rehabilitation programme and map your rehab back to full distance running over the next four to six months.

So, that’s the verdict. There’s no mention of the micro tear diagnosed by the radiographer from my MRI. So, I hope that is the case and that the non-surgical approach is the right one. He did mention that footballers would typically just take the surgery straight away in an effort to be back playing in 4-6 weeks. However, I’m more interested with addressing the underlying biomechanics and taking a longer time to rehab. This diagnosis effectively writes off the rest of the year, which I had more or less assumed would be the case anyway. I can write off to the end of the year, but would have to be back training after Christmas to build up for an attempt at the Gobi in June, given I would be starting from square 1.  If the physio doesn't work, and I need surgery as well afterwards, then the Gobi could be out.  My orthotics have worn out too, and the doctor only saw the pair I walk in. The ones I run in are in a very sorry state indeed. He mentions getting a change to the prescription, and getting a deeper heel cup, so I’ll have to see about getting that arranged. My first physio appmt is tomorrow. I’m looking forward to starting but if I’m honest I think I’m pessimistic about the outcome of physio intervention alone. I guess I just fail to understand how doing glut and core strength is going to stop my chronic rectus abdmonis and ligament pain. I suspect I’ll end up having the ultrasound guided injection at best, but at worst am still suspicious that I’ll end up having surgery. If anyone thinks they can explain to me how that will cure the pain, then I’d love to know.

The doctor told me than no amount of rest was ever going to cure this problem, and I’d have to have phsyio, to walking, to running, so I assume that means no running. I’ll find out tomorrow, and maybe go for one short farewell run beforehand, in case that is going to be what’s prescribed.

I’ll let you know how I get on. Have a good week.