groin injuries assessment and management

• Structured approach to groin pain definition: 

  Many soft tissue structures in the same region 

  Various definitions used between clinicians  

  Confusion with clients /patients 
• Types:

  Adductor groin pain 

  Iliopsoas groin pain 

  Inguinal groin pain 

  Pubic groin pain 

  Hip groin pain 

  Other groin pain 
• Who gets groin pain? 

  • Mainly in athletic populations: - particularly during multidirectional sports - repetitive and forceful hip movements e.g. kicking / skating  
  • Male athletes > female ice hockey and football codes (i.e. Australian / Gaelic football)  
  • Female pathologies: stress fractures, gynecological conditions, pelvic girdle pain  

   

  Risk factors: 

  • Previous groin injury  
  • Higher level of play  
  • Reduced hip adduction strength  
  • Lower level of sport specific training 
• Adductor related pain: 

   Symptoms: 

  Pain around adductor longus insertion tendon at the pubis.  

  Possible radiating pain down the medial thigh 

   

  Most likely presents with complaint of: 

  Pain on adductor stretching Intense, sudden pain with high force  

  Low intensifying pain with low repetitive force 

   

  The most common groin injury in sports  

  Kicking 29%  

  Reaching 24%  

  Change of direction 15%

  Jumping 12%   
• Adductor related pain: 

  Most athletes continue to play for months until it is unbearable to play 

  
  

  Clinical presentation:  

  Adductor tenderness on palpation and stretch   

  Pain on resisted adduction testing 

  
  

  Main impairments:  

  • Reduced capacity and strength: Abdominals, hip adductors and abductors  
  • Functional loss: Decreased playing performance and ability to change direction at speed, kick with force etc. 
• Pubic related pain:  

  Symptoms: 

  Pain around pubic symphasis  

   

  Most likely presents with complaint of: 

  Pain with resisted abdominal and hip adductor testing  

  No specific test 

    

  Common overuse injury  

  Weakness in the hip flexor and abdominals can result in excessive strain around the pubic symphysis 
• Pubic related pain:  

  Common population: 

  • Young athletes involved in pivoting, cutting, twisting  
  • Rapid acceleration and deceleration  
  • Adductor longus and rectus abdominis tendons under strain during young athlete growth spurts = microtrauma at the MTJ (muscular tendonous junction) 

  
  

  The pubic symphysis is the last structure of the human skeleton to mature – apophysitis (inflammation or strain around the area) should be considered as a differential in young athletes 

  Pubic pain can also occur during pregnancy due to an increase in ligament laxity 
• Iliopsoas related pain: 

   

  Symptoms: 

  Pain at the anterior proximal thigh.  

  More lateral than adductor-related pain 

   

  Most likely presents with complaint of: 

  Pain with resisted hip flexion or hip flexion stretches 

   

  Second most common injury in soccer.   

  Powerful hip flexor. Normally injured as a pair (46%), rather than an isolated muscle. 

  MOI (mechanism of injury) Similar to adductor longus, but with more focus on kicking/acceleration. 

  Sprinting uphill commonly reproduces pain 
• Iliopsoas related pain: 

   Clinical presentation: 

  • Iliopsoas tenderness on palpation   
  • Pain on resisted hip flexion 
  • Pain and tightness – Modified Thomas test 

   

  Main impairments:  

  • Reduced hip flexor strength  
  • Functional loss: Decreased playing performance and ability to change direction at speed, kick with force and acceleration loss. 

   
• Inguinal related pain: 

   

  Symptoms: 

  Inguinal pain worsening with activity.  

  Can occur with coughing, sneezing or sitting up in bed 

   

  Most likely presents with complaint of: 

  Pain with resisted abdominal or adductor testing 
• Inguinal related pain: 

   

  Inguinal Hernia: 

  • Can be caused by posterior abdominal wall weakness  
  • Results in bulging of the posterior abdominal structures compressing onto branches of the genitofemoral nerve 
  • Can be in sporting and non-sporting populations 

   

  Sportsman Hernia: 

  • Sharp groin soreness  
  • Overuse of the external obliques and transverse abdominus  
  • Causes shearing forces at the hemi pelvic region   
  • Common in sports involving: twisting, turning and kicking 
• Inguinal related pain: 

  Clinical presentation: 

  • Pain whilst palpating the inguinal canal 
  • Pain on a resisted sit up  
  • Pain with the Valsalva manoeuvre 
  • +/- palpation of present hernia  

   

  Key Impairments: As per adductor pain 
• Hip related pain: 

  80% of intraarticular hip pathologies can refer pain to the groin  

   

  Hip screening tests: 

  • Passive range of motion (are they in the normal values?)  
  • FADIR (90º flexion, adduction, internal rotation overpressure)  
  • FABER (flexion, abduction, external rotation overpressure) 
  • Positive test indicates further investigation on the hip 
• Other sources of groin pain: 

   

  Sources of referred pain: 

  Lumbar spine and Sacroiliac joints  

  Discogenic, facet joint or nerve pathologies  

   
• Avulsion and Apophysitis: 

  • Traction injury causing inflammation and stress at the growth areas of bone (apophyses) that have muscles attached to them.  
  • Often occurs in sporting adolescents 
  • MOI: 

    - Pull of groin muscles 

    - Growth spurts  

    - Repetitive overuse 

    -  +/- Avulsion fracture 
• Avulsion and Apophysitis: 

  Risk factors: 

  • Poor flexibility 
  • Repetitive overuse  

   

  Findings: 

  • Pain at the palpation of the pubic symphysis   
  • X-Ray/MRI needed to confirm presence of an avulsion fracture  

   

  Management:  

  • Reduce load and relative rest  
  • Gentle progressive stretching of affected muscle groups to aid in improving flexibility  
  • Avulsions can be managed conservatively OR surgically if more than 2.5cm from normal position 

   
• Red flags can include:  

  • A history of cancer: Metastases or cancer present in the prostate, breast or hip and groin region  
  • Infection: High fever, STI/UTI’s can cause groin pain  
  • Neurological: CES, Saddle anaesthesia, sexual dysfunction  
  • Fractures: Trauma or overuse 

   

  Not ideal to unnecessarily expose a patient’s genitals to radiation doses  

  Imaging can be used as a supportive to e.g. to rule out fractures if suspected  

  High risk of finding abnormal, but asymptomatic findings – may cause unnecessary fear in patients 
• Outcome measures:  

   

  Manual muscle testing: 

  • Dynamometer favoured over manual testing  
  • Dynamometer shown to identify deficits >20% strength in the adductor muscle groups 

   

  Copenhagen hip and groin outcome score (HAGOS): 

  • Valid and reliable for measuring the hip and groin pain   
  • Free, simple to use 
• Outcome measures:  

   

  Patient specific function scale (PSFS)  

  Visual analogue scale for pain, e.g.4/10 

   

  Management: 

  Individualised  

  Supervised rehabilitation / training has a higher success rate than passive modalities 

   

  Early stage - Pain management, pain free ROM, Isometrics, protective loading  

  Mid stage - Introduce eccentric loading, Copenhagen adductor protocol  

  Late stage - Sport specific rehab, acceleration/deceleration