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Athletic Groin Pain in Sport

Athletic Groin Pain in Sport

Posted 4 Dec '20

 

Athletic Groin Pain in Sport

Overview:

Groin pain in athletes that is not associated with the hip joint is often referred to by various terms, such as athletic pubalgia, sports hernia, and adductor tendinopathy. The 2015 Doha Agreement categorized this pain into three main groups: (1) defined clinical entities (adductor-related, inguinal-related, iliopsoas-related, and pubic-related), (2) hip-related groin pain, and (3) other causes like true inguinal hernias and non-musculoskeletal conditions (Weir et al., 2015). Terms like "athletic pubalgia" and "sports hernia" are being phased out in favour of more specific classifications. Groin Pain in Athletes (Non-Hip Joint)

Classification of Groin Pain:


The Anatomy of the Athletic Groin

The interactions among the abdominal wall, hip joint, sacroiliac joint, adductors, and pubic symphysis are intricate. A notable imbalance in forces between the abdominal muscles and adductors can lead to microtrauma in the fascia. Proper classification aids in pinpointing and conveying the location of this microtrauma. For instance, inguinal-related groin pain manifests as pain and tenderness concentrated around the inguinal canal, stemming from microtrauma to the posterior inguinal canal, which may or may not involve nerve compression. Similarly, iliopsoas-related groin pain arises from microtrauma to the iliopsoas muscle.

Hip pathologies often result in a limited range of motion (ROM). To attain adequate ROM for athletic activities, compensatory stretching of the surrounding muscles occurs, which makes these tissues more susceptible to microtrauma and force imbalances. The treatment approaches for intra-articular hip pathologies differ from those addressing extra-articular issues, thus necessitating a separate categorization for hip-related groin pain.

Regarding non-hip groin pain, literature indicates a significant diversity in pathology within a relatively small anatomical region. A 2020 review published in JAMA Surgery outlined several pathological origins of groin pain syndromes, including the inguinal canal, rectus abdominus, adductor longus, pubic symphysis, and inguinal neuralgia. These neuralgia may arise as a result of true hernias, disruption of the transversalis fascia that increases pressure on the nerves, or entrapment due to scar tissue.

Common diagnosis of the Groin




The Pubic Clock

An important anatomical feature of the pubis is its role as a central point for the attachments of various structures, including the rectus abdominis, adductor longus, inguinal ligament, and conjoint tendon . This region of the pubis is located just lateral to the pubic symphysis. A study by Falvey et al. (2016) involving 382 male athletes suffering from groin pain, primarily Gaelic football players, found that 68% had bone marrow edema, and 52.6% showed abnormalities in the pubic aponeurosis on MRI. Nearly one-third of the patients exhibited three or more findings on their MRI scans. Additionally, research by Schilders et al. (2017) identified a pubic ligament complex within the pubic aponeurosis. This ligament runs horizontally at the midline and connects with the pyramidalis and adductor tendons as well as the external oblique aponeurosis, lying just above the rectus abdominis. The goal of assessing groin pain is to systematically rule out different diagnoses and narrow down the differential through thorough examination. The wide variation in non-hip joint-related groin pain suggests that it likely has multiple contributing factors.


Examination:

At Offaly Physio & Performance Lab we use comprehensive examination for groin pain (inguinal-related, pubic-related, adductor-related and psoas-related) must involve examination to exclude intra-articular hip pain, inguinal, femoral, and spigelian hernias, as well as the pubic bone (superior and inferior ramus), pubic symphysis, and other soft-tissues injuries. Strength testing using force frames can be beneficial to ascertaining strength assymetries between sides.



When to Use Imaging?

Investigations:

  1. X-ray:
    Views include AP Pelvis, lateral hip, and Dunn views.
  2. Abdominal Ultrasound (US):
    Primarily used to rule out other hernias.
  3. Dynamic US for Sports Hernia:
    A positive finding is the bulging of the posterior inguinal wall (transversus abdominis) when the patient performs the Valsalva maneuver.
  4. CT Scan:
    Assesses the hips and pubic symphysis with some capacity to evaluate soft tissue scarring.
  5. MRI Groin Pain Protocol:
    Evaluates the hip, psoas, proximal rectus femoris, inguinal ligament, pubic rami, and symphysis.
  6. MR Neurography:
    Used to detect impingement of the iliohypogastric, ilioinguinal, and genitofemoral nerves.


Plan:

Prognosis:
Determining prognosis is challenging due to the variety of conditions. Return-to-play timelines vary significantly, ranging from 2 to 30 weeks, according to a 2015 review by King et al. For pubic-related pain, recovery with rehabilitation is notably faster than with surgery, with an approximate 12-week difference. For abdominal and adductor-related pain, no significant differences were observed between surgical and non-surgical treatments. Across all studies, the average return to play was 13 weeks. Age influences prognosis, with younger patients in their 20s recovering faster than those over 40. In a 2011 study by Paajanen et al., 53% of the non-operative group continued to have symptoms after one year, despite physiotherapy and anti-inflammatory treatments. The presence of bone marrow edema ("osteitis pubis") on MRI often leads to longer recovery periods, typically over three months.

Conservative Management:

Rehabilitation varies by the underlying pathology but often involves improving hip range of motion and lumbopelvic control.

  1. Abdominal-related pain:
    A 4-week protection phase from excessive tension is recommended, followed by 4-6 weeks of gradual muscle activation, focusing on hip range of motion and core mobility. Return to agility training should be avoided until at least 4 weeks without pain.
  2. Adductor-related pain:
    Avoid aggravating activities with a gradual strengthening program, emphasizing hip mobility and core strength.
  3. Inguinal-related pain:
    A 4-week protection phase similar to abdominal pain, with a gradual return to muscle activation and hip/core training.
  4. Pubic-related pain:
    The same 4-week protection phase applies, with a focus on controlled muscle activation. A minimum of four pain-free weeks is advised before resuming agility drills.


Injections:
Adjunct treatments include NSAIDs and injections (corticosteroids or platelet-rich plasma) into the pubic symphysis or rectus abdominis muscles.

Radiofrequency Ablation/Denervation:
In cases of nerve-like symptoms or pain spanning the inguinal, pubic, or adductor areas, nerve blocks may be useful both diagnostically and therapeutically. Radiofrequency ablation (RFA) of the ilioinguinal nerve has shown promise, with improvement in studies comparing it to local anesthetics. A notable case involved a professional football player achieving full recovery after iliohypogastric nerve RFA.

Surgical Management:
There are various surgical approaches, including the fixation of the transversus abdominis to the inguinal ligament, mesh insertion, adductor tenotomy, rectus abdominis repair, and nerve neurectomy.

  • Adductor tenotomy: Generally reserved for chronic, localized adductor pain. Robertson et al. (2011) reported a 71% return to pre-injury levels in athletes after chronic adductor pain surgery.
  • Laparoscopic mesh repair: Frequently used for posterior wall defects, with studies showing high success rates (97% return to sport within three weeks) in athletes.
  • Open repair: A technique involving posterior wall repair with decompression of the genital branch of the genitofemoral nerve. In one study, 84% of patients returned to their pre-injury activity level within four weeks.

Complications:
Common complications include bruising, bleeding, hematomas, infections, and nerve-related issues (dysthesias).


Criteria for Referral for Laparoscopic Repair for Sports Hernia:

History (All three must be present):

  1. Athletic injury with overuse or gradual onset.
  2. Symptoms worsened by twisting, sprinting, or directional changes.
  3. Pain persisting for over 6 months (or 6 weeks in elite athletes).

Examination (Both must be present):

  1. Pain over the inguinal ligaments and at the internal/external rings.
  2. No evidence of a true inguinal hernia.

Imaging (Both must be present):

  1. Ultrasound shows no true inguinal hernia.
  2. MRI Groin Pain Protocol negative for other causes.

Note:
Despite favorable surgical outcomes, access to such interventions may be geographically limited.

Thank you for reading this blog

If you would like to book an appointment to review your groin pain please feel free to do so www.offalyphysioandperformancelab.com/book-online

References

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