GP sports medicine specialist Dr Emma Lunan offers advice on some common hip and groin injuries that can be caused by exercise
Hip and groin pain are common in athletes and active individuals of varying ages. Because the anatomy in the area is complex, pathology in the hip and groin can present a diagnostic challenge.1 Causes are multifactorial and there can be significant overlap in symptoms and signs. A detailed history eliciting precipitant, provoking and relieving factors, along with a thorough clinical examination is required. It is also useful to have an awareness of the biomechanical demands of certain sports. It is important to exclude other potential causes, which include gynaecological, gastrointestinal and urological issues, inguinal and femoral hernias and osteoarthritis (OA).
Case 1. Groin strain
A 25-year-old male recreational footballer attends with a history of sudden onset left groin pain that came on after a slide tackle in a five-a-side match the previous evening. He didn’t feel it was serious enough to attend A&E but is struggling with discomfort and wondering when he can play again.
A ‘groin strain’, also referred to as a ‘groin pull’, is very common in young active males and is essentially a stretch or tear of the groin or lower abdominal muscles. An adductor strain is the commonest presentation, with the adductor longus muscle most frequently injured, but strains can occur anywhere in the adductor complex.
Strains can also affect the hip flexors and lower abdominal muscles.2 Diagnosis can be challenging and many athletes will play through mild strains. It is important to remember that groin strains can be debilitating and inappropriate treatment can lead to chronic issues.
Key history
Acute groin strains are common in explosive, multidirectional sports such as football, rugby and hockey. Patients report a sudden onset of pain in the groin or medial thigh while performing a specific movement such as over-stretching in a tackle. The patient may report a ‘pop’ or ‘snap’ and the dominant leg is more frequently injured. The mechanism of injury is usually secondary to strong eccentric contraction of the adductors while the hip is in external rotation and abduction. Risk factors include prior injury, age, adductor weakness, sporting experience level and biomechanical issues.
Examination
In anyone presenting with groin pain, a good understanding of the regional anatomy is necessary to aid clinical diagnosis. Ensure the patient is adequately exposed for the examination. On inspection there may or may not be bruising in the medial thigh area. On palpation there is often tenderness along the adductor complex or over the inferior pubic ramus. Patients with adductor strains may exhibit reduced strength with resisted testing and a positive squeeze test.
Adductors also act as hip flexors so the patient may have a positive modified Thomas test, which is commonly used to assess problems with hip flexion.3 In this test, the patient sits at the edge of the couch, with legs hanging freely, then lies back, flexing and pulling one knee back to the chest using both arms. If the opposing leg lifts from the couch this indicates tightness in the hip flexor. It is essential to also examine the hip joint, inguinal and lower abdominal regions.
Management
In the acute setting, groin strains should be managed with protection, optimal loading, ice, compression and elevation (POLICE) along with simple analgesics as required. Patients can be reassured that most groin strains are managed conservatively with activity modification, early mobilisation and that they generally recover within one to two weeks. In most cases imaging is not required.
Depending on the grade of injury (see box 1), patient factors and sporting level, physiotherapy may help with specific strengthening and biomechanical assessment. If a patient is not progressing or recovering within a reasonable time frame it is worth excluding all relevant differential diagnoses and referring to a sports medicine specialist (if available) or orthopaedic surgeon.
Box 1 Classification of muscle injuries
Methods of classification are based on pain, muscle damage and functional loss:
Grade 1 Mild, minimal damage to muscle fibres, no loss of strength or function
Grade 2 Moderate, partial or incomplete tears, moderate loss of strength
Grade 3 Severe, compete tear or rupture, significant loss of strength or function
Case 2. Femoroacetabular impingement (FAI)
A 20-year-old female hockey player presents describing a three-month history of right groin pain, worse after training sessions and associated with clicking. She cannot recall any specific injury and has no significant past medical or family history of note. She is concerned as she has an important tournament coming up.
FAI syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents premature contact between the proximal femur and the acetabulum.4 This can cause progressive hip pain and lead to labral damage and chondral defects. In the longer term, FAI is associated with the development of hip OA.
FAI occurs when anatomical changes in either the femoral head and neck or acetabulum cause a bony block to free movement at the joint at a certain range of motion.5 Two distinct bony morphologies are described. Cam impingement is characterised by excess bony development over the femoral head and neck, thus limiting the amount of hip flexion. Pincer impingement involves excess bony development of the superior acetabular lip, increasing acetabular socket depth and restricting the normal hip range of motion.
Both lesions are commonly found in asymptomatic individuals. However, cam lesions are more commonly found in males, pincer in females.6 Cam lesions are associated with an increased risk of labral tear and subsequent OA.7
Typical presentation
Hip joint pathology should be considered when dealing with groin pain. FAI frequently affects active adolescents and young adults, although it may affect older groups. Sports such as dancing, tennis, golf and football, involving repetitive hip movement beyond the normal range of motion, increase the risk. Pain with FAI is primarily reported in the hip or groin, but may also be felt in the lower back, lateral hip, buttock and knee.
Pain is most commonly related to activity, but can occur after sitting for long periods in sedentary individuals. The character of pain can be stabbing and severe after turning or twisting or can also be described as a dull ache.
History should focus on the onset of symptoms along with other commonly reported issues such as clicking, catching, giving way and stiffness. Other risk factors include genetic predisposition to developmental hip pathology and biomechanical issues.
Examination
The patient may limp. On inspection patients report groin pain and often demonstrate the ‘C sign’, whereby the location of pain is demonstrated by gripping the lateral hip between thumb and index finger. Hip flexion may be reduced and painful.
A positive flexion adduction internal rotation (FADDIR) test of the hip joint is sensitive for intra-articular pathology but not specific for FAI. To perform this test, the patient should lie supine with the hip and knee flexed to 90˚. The hip should be adducted with combined internal rotation. A positive test may elicit a sharp pain, catching or a block to rotation.8
Management
If FAI is suspected, advice should be given on pain relief and activity modification. Physiotherapy may help correct biomechanical abnormalities and achieve targeted strengthening. Pelvic X-rays should be requested, to identify abnormal morphology and exclude other pathologies such as early OA, avascular necrosis, fracture or other bony pathology. If symptomatic, refer for an orthopaedic review. Magnetic resonance arthrogram is the imaging modality of choice for detecting labral tears or chondral damage. Surgery may be required depending on symptom level, age, comorbidities and hip joint pathology. Radiologically guided local anaesthetic injections into the joint can relieve pain.
Case 3. Inguinal disruption
A 29-year-old male crossfit athlete attends your clinic reporting a six-month history of worsening groin pain. He denies any discrete injury, but feels the symptoms are getting worse over time, with stiffness and pain the day after exercise and when getting out of his car. He is tender in his groin area, but has not noticed any swelling or lumps.
Inguinal disruption is a common cause of chronic groin pain in active individuals. It is a multifactorial overuse injury, in which sudden twisting and turning movements cause muscular tearing or strain in the inguino-pelvic region. This leads to weakness in the musculature and increasing pain and symptoms over time. The term inguinal disruption was agreed by British Hernia Society due to confusion with previous terminology.9 Inguinal disruption has also been referred to as Gilmores groin, athletic pubalgia, incipient hernia, pubic inguinal pain syndrome and pubic symphysitis as well as sportman’s hernia, which is misleading as there is no true hernia.
Key history
Inguinal disruption is a condition most commonly seen in young male athletes, occurring frequently in sports such as cricket, athletics, football and rugby.10 The majority of affected athletes report an insidious onset of activity-related pain which is often described as deep, dull or diffuse. There is often involvement of various regional nerves leading to referred pain into the scrotum or perineum. Manoeuvres that place excess forces across the groin and inguinal region, and increasing intra-abdominal pressure such as coughing, sneezing and core work also provoke pain. There is often stiffness and discomfort in the days following exercise, which may be worse when rising from a low position, for example getting out of a car or bed.
Examination
On inspection of the groin, a visible hernia or lump will be absent in cases of inguinal disruption.
Often a tender and enlarged superficial inguinal ring is found and can be palpated by invagination through the scrotum, reproducing the pain. There may also be a palpable defect in the fibres of external oblique fascia.
The British Hernia Society advises that three out of five clinical signs should be present for diagnosis:10
• Pinpoint tenderness over the pubic tubercle (insertion of conjoint tendon).
• Palpable tenderness deep inguinal ring.
• Pain and or dilatation of superficial ring with no palpable hernia.
• Pain at the origin of adductor longus.
• Dull diffuse pain in the groin, often radiating to the perineum, inner thigh or across the midline.
Management
If symptoms are minimal, a conservative approach including analgesia, activity modification and referral to physiotherapy for core and abdominal muscle strengthening is usually first line.11 If the athlete presents with significant symptoms and loss of function, refer to a groin surgeon; these may be orthopaedic or general surgeons. A variety of imaging techniques can be employed. Plain radiographs are useful to exclude intra-articular pathology. MRI is most commonly used to assess groin pain and will help exclude other injuries such as osteitis pubis and adductor tears. If available, stress ultrasonography to provide a dynamic assessment of the abdominal wall during manoeuvres that increase intra-abdominal pressure is helpful. Local anaesthetic injection of the inguinal canal can be used as a diagnostic and therapeutic tool. Various surgical methods are purported to work, based on those for manifest hernias (but without a hernial sac).
Dr Emma Lunan is a GPSI in musculoskeletal medicine in Kilmarnock and honorary lecturer in sports and exercise medicine at the University of Glasgow
References
1. Weir A, Brukner P, Delahunt E et al. Doha agreement meeting on terminology and definitions in groin pain in athletes Br J Sports Med 2015;49:768-74
2. Tyler T, Silvers H, Gerhardt M et al. Groin injuries in sports medicine. Sports Health 2010;2:231-6
3. Physiopedia. Modified Thomas Test. tinyurl.com/Mod-Thomas-test
4. Ganz R, Parvizi J, Beck M et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;417:112–20
5. Griffin D, Dickenson E, O’Donnell J et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement. Br J Sports Med 2016;50:1169-76
6. Dijkstra H, Ardern C, Serner A et al. Primary cam morphology; bump, burden or bog-standard? A concept analysis Br J Sports Med 2021;55:1212-21
7. van Klij P, Heerey J, Waarsing J et al. The prevalence of CAM and pincer morphology and its association with development of hip osteoarthritis. J Orthop Sports Phys Ther 2018;48:230-8
8. Physiopedia. FADDIR test. tinyurl.com/FADDIR-test
9. Sheen A, Stephenson B, Lloyd D et al. Treatment of the sportsman’s groin: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014;48:1079-87
10. Anderson K, Strickland S, Warren R. Hip and groin injuries in athletes. Am J Sports Med; 29:521–33
11. Sheen A, Iqbal Z. Contemporary management of ‘inguinal disruption’ in the sportsman’s groin. BMC Sports Sci Med Rehabil 2014;6:39
