|Year : 2015 | Volume
| Issue : 1 | Page : 3-8
Groin pain in athletes: Differential diagnosis, assessment, and management
Abdulaziz Z Alomar
Department of Orthopaedic Surgery, King Saud University, Medical College, Riyadh, Saudi Arabia
|Date of Web Publication||19-Jan-2015|
Abdulaziz Z Alomar
Department of Orthopaedic Surgery, King Khalid University Hospital, Medical College, King Saud University, Riyadh
Groin pain in athletes is a common problem in sports medicine, accounting for 10% of all visits to sports medicine centers. Furthermore, groin injuries have been estimated to account for up to 6% of all athletic injuries, with the prevalence in sports such as football as high as
12-16%. However, despite the prevalence of this condition, its diagnosis and treatment remain a challenging problem for the sports medicine physician, and the injury is a frustrating one for the athlete. Chronic groin pain in particular can be difficult to diagnose, treat, and rehabilitate, and is responsible for a large proportion of time lost from sport and work for the athlete. A complicating component in the treatment of this condition is an extensive differential diagnosis and overlap in symptoms between possible diagnoses. Typically, groin pain develops in male and female athletes who participate in sports involving kicking, rapid accelerations and decelerations, and sudden changes of direction. The aim of this article is to briefly review the most common musculoskeletal conditions that cause groin pain in athletes and to discuss their diagnosis and management.
الآلم في منطقة الأُربية هو مشكلة شائعة في الطب الرياضي وتشكل 10% من مجموع الزيارات إلي مراكز الطب الرياضي .
وأيضا فإن إصابات منطقة الأربية قدرت بأنها تشكل 6% من جميع إصابات الأربية مع كثرة هذه الإصابات في بعض الرياضات مثل كرة القدم بحيث تشكل 12-16% .
ورغم شيوع هذه الإصابات فإن تشخيصها وعلاجها تمثل تحديا لأطباء الطب الرياضي , كما أن الإصابة تمثل إحباطا للرياضيين .
إن ألم الأربية المزمن بشكل خاص هو صعب التشخيص والعلاج وإعادة التأهل و يشغل حيزا كبيرا من الوقت الذي يضيع من الرياضة والعمل بالنسبة للرياضي .
وعادة يتطور ألم الأربية عند الرياضيين سواءً ذكور أو إناث الذين يشاركون في رياضات تتطلب الركض , وتسارع وتباطؤ سريع مع تغير مفاجئ في الوضعية .
إن الهدف من هذا المقال هو مراجعة مختصرة لأكثر الحالات العضلية الهيكلية شيوعا التي يمكن أن تسبب ألم في الأربية عند الرياضيين مع مناقشة طرق التشخيص والعلاج .
Keywords: Athletes, groin pain, hip pain
|How to cite this article:|
Alomar AZ. Groin pain in athletes: Differential diagnosis, assessment, and management. Saudi J Sports Med 2015;15:3-8
| Introduction|| |
Groin pain in an athlete refers to discomfort in the anterior area of the lower abdomen, the inguinal regions, the area of the adductors, and the upper anterior thigh and hip. Groin pain is a common finding in athletes, accounting for 10% of all visits to sports medicine centers, , and its prevalence is estimated to be 5-28% of all sport injuries.  Moreover, sports-related injuries of the hip and groin region occur in 5-9% of high-school athletes. ,, In adult soccer players, hip and groin injuries account for 12-16% of all injuries. 
Sports-related injuries to the hip and groin region occur most commonly in athletes participating in sports involving side-to-side cutting, quick accelerations and decelerations, and sudden directional changes. The onset is more commonly gradual but can also be acute. Groin pain can originate from bones, joints, bursae, muscles, tendons, fascial structures, and nerves. In addition, the spectrum of conditions that can cause groin pain include not only musculoskeletal conditions but also urological and general surgery concerns. Therefore, a team approach with many different specialties is usually the best one in the treatment and rehabilitation of the athlete, particularly for enabling the athlete to return to the sport.
Although groin pain in athletes occurs at a high prevalence, the cause of this condition can be difficult for sports medicine physicians to elucidate because of the complex local anatomy of the affected area and the multitude of differential diagnoses. The diagnosis is often frustrating for both the athlete and physician, and remains unclear in ~30% of cases.  A factor complicating the diagnosis is that a large number of hip and groin injuries have multiple components or coexisting injuries.  In particular, it has been estimated that 27-90% of athletes with chronic groin pain have multiple coexisting pathologies requiring expertise that span several disciplines. , These coexisting injuries are thought to arise because of the close proximity of anatomical elements in the region, predisposing one insult to naturally involve adjacent structures. Indeed, it is common for one injury to be properly diagnosed and improve with treatment while a concomitant injury is entirely undiagnosed and untreated, leaving both the athlete and physician frustrated in the absence of proper monitoring and re-evaluation.  Hence, the treating physician must consider both musculoskeletal groin disorders and non-musculoskeletal conditions that can present as groin pain. More specifically, diagnosis and management requires an understanding of pelvic anatomy and mechanics, thorough review of the patient history, careful physical examination, and judicious use of imaging studies.
Acute groin pain is fairly common in sports-related activities and usually relates to a musculoskeletal etiology. This condition is particularly common in sports that require sharp cutting movements, as in kicking and running sports, especially soccer. Relative to acute groin pain, chronic groin pain represents the more difficult diagnostic challenge and can be related to a non-musculoskeletal etiology. Athletes will present with ongoing complaints that may have been present for months to years. Determining the exact cause of the pain in these athletes can prove quite elusive because of the number of diagnostic possibilities [Table 1] and [Table 2]. Complete discussion of each entity is beyond the scope of this article. Instead, this review will focus on only the most common musculoskeletal causes of acute and chronic groin pain in athletes, namely, adductors strain, osteitis pubis, sports hernia, and femoroacetabular impingement (FAI). The diagnosis and management of these musculoskeletal causes will also be discussed.
Adductor strain or tendinopathy
The most common cause of acute groin pain is strains of the adductor muscles (adductor longus, magnus, and brevis; gracilis; pectineus; and obturator externus).  Among soccer players, the incidence of abductor muscle strains has been reported to range from 10% to 18%.  Strains commonly result from sudden eccentric loading, and the most frequently affected muscle is the adductor longus. ,, Clinically, the patient presents with pain in the inner thigh and tenderness along the muscle belly, tendon, or insertion. The pain is exacerbated by adduction against resistance. ,,,
A decrease in abductor range of motion or strength is associated with an increased incidence of adductor strains.  Although the diagnosis is usually made clinically, magnetic resonance imaging (MRI) can be used to confirm the diagnosis in uncertain cases. In cases of acute injury, an increase in the muscle signal intensity has been observed in hemorrhagic areas, and this signal intensity has been shown to have a high correlation with patient symptoms.  MRI can also yield prognostic information about muscle tears. Of note, tears involving >50% of the cross-sectional area, tissue fluid collection, or deep muscle tears might indicate more severe injury and a more prolonged recovery. The location of the tear also has important therapeutic and prognostic implications.  An acute tear at the musculotendinous junction, which has a relatively robust blood supply, allows a relatively aggressive approach to rehabilitative treatment. In contrast, an acute partial tear at the less vascularized tendinous insertion necessitates a period of rest before pain-free physical therapy becomes possible.  In chronic cases, MRI can also document traction periostitis or stress fracture. 
In cases involving strains of the abductor muscles, athletes might recall an acute strain or present with chronic overuse tendinopathy. Acute adductor strains can be treated by rest, ice, and in some cases short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). The subsequent physical therapy should be directed at restoring range of motion and prevention of atrophy. Finally, the athlete should focus on regaining strength, flexibility, and endurance. , Rehabilitation typically takes 4-8 weeks, and the athlete may return to the sport when he/she has achieved a full painless range of motion and an adductor strength of least 70% relative to the contralateral side. 
Chronic adductor muscle-related groin pain can be due to non-inflammatory tendinopathy or to an incompletely rehabilitated acute injury resulting in chronic recurrent strains. The treatment protocols for chronic adductor strains are similar to those for acute strains but require a protracted (8- to 12-week) time period to achieve desired results. ,, Isometric strength training followed by isotonic and eccentric strength training in a closed kinetic chain mode is the primary approach in the treatment of this condition. Notably, stretching is of little importance in these treatment protocols. Within this context, an active muscular training program has been found to be more effective and to result in significantly better outcomes than passive physical therapy and other physical modalities in returning chronic groin patients to sport.  Athletes who have failed to respond to at least 6 months of conservative treatment for chronic adductor longus strains may benefit from surgical tenotomy. However, this procedure may be considered only if other causes of groin pain have been excluded. Tenotomy of the adductor longus tendon has been described as surgical procedure for chronic adductor muscle-related groin pain. ,
Sports hernia (also known as athletic pubalgia, sportsman hernia, or hockey hernia) is a common sports-related groin injury. However, it is not a true hernia but an occult hernia caused by a weakness or tear in the posterior inguinal wall leading to a condition of chronic groin pain. , Sports hernias comprise a spectrum of pathologies that include attenuation or tearing of the transversalis fascia or conjoined tendon, abnormalities at the insertion of the rectus abdominis muscle, avulsion of part of the internal oblique muscle fibers at the pubic tubercle, tearing within the internal oblique musculature, or abnormalities in the external oblique muscle and aponeurosis. ,,
The reported incidence of sports hernia ranges from 10% to 13% in soccer players, and the condition is caused by stress and pivot forces placed on this area.  Sports hernia is one of the more difficult diagnoses to make when evaluating a patient with groin pain because it is poorly understood, not well defined, and difficult to evaluate by physical examination and imaging modalities.  Moreover, the etiology and optimal treatment of this condition remain somewhat controversial.
Patients with sports hernia typically present with insidious, unilateral, deep groin pain that is exacerbated by sudden movements, acceleration, twisting, turning, or kicking and can be provoked by coughing and sneezing. The pain is typically localized to the conjoined tendon but may involve the inguinal canal laterally. A key discriminator for sports hernia is pain that disappears completely with inactivity but reappears on resumption of activity. ,,,, The physical examination of a patient with a sports hernia will reveal no detectable inguinal hernia. , Instead, the most common physical findings include local tenderness over the conjoined tendon, pubic tubercle, and mid-inguinal region; a tender, dilated superficial inguinal ring; and tenderness of the posterior wall of the inguinal canal. ,, Pain with a resisted sit-up and resisted hip adduction are other common findings on examination.  Athletes typically report the inability to achieve a satisfactory level of play. 
The findings of most imaging studies for patients with this condition are normal. Accordingly, imaging is useful primarily for ruling out alternative diagnoses.  Sports hernia is treated initially with nonsurgical modalities, including anti-inflammatory medications, deep massage, heat or ice, and prolonged rest followed by a gradual return to activity.  Surgical exploration and repair should be considered if a nonsurgical treatment of 6-8 weeks has failed and a thorough review of the patient history and careful physical examination have allowed other potential sources of the pain to be excluded. ,, Surgical repair of the weak posterior inguinal wall with conventional or laparoscopic techniques can lead to excellent results, usually with success rates of 80% to 97%. ,,,
As a more recently recognized common cause of groin pain in athletes, FAI likely represents the most common mechanism leading to the development of early cartilage and labral damage in the non-dysplastic hip.  FAI can be caused by cam impingement (abnormal sphericity of the femoral head), rim impingement (an excessive anterolateral acetabular bony prominence), or a combination of these pathologies.  FAI has been associated with injuries such as labral tears, chondral delamination, and secondary osteoarthrosis. ,, The severe impact that this condition can have on athletes is important to note. FAI can lead to significant career-ending pain, loss of range-of-motion, and disruption to athletic performance and activities of daily living, together with severe limitations in sporting activities, particularly high-demand sports involving sharp cutting movements or sprinting. ,
Cam-type impingement is most often observed in young male athletes,  and occurs with flexion and internal rotation of the hip joint, which forces the prominent femoral head-neck junction into contact with the anterolateral aspect of the acetabular chondrolabral junction. Repeated impingement results in increased shear and direct impact forces, with subsequent intrasubstance labral tears, chondrolabral separation, chondral delamination, and intrasubstance labral ossification.  In contrast, rim impingement more commonly occurs in middle-aged female athletes.  Rim impingement results from increased anterolateral acetabular overcoverage leading to a similar reduction in the functional hip flexion arc and subsequent impingement on the anterolateral femoral head-neck junction.
The typical patient with FAI reports groin pain with insidious onset that may be preceded by minor trauma, although many patients do not report the occurrence of any specific precipitating factor.  Groin pain in patients with FAI can be exacerbated by functional activities of the hip, including standing from a sitting position, climbing stairs, extensive ambulation, or athletic participation. Mechanical symptoms, including clicking, popping, and catching with hip motion, may also occur. ,, In patients with FAI, the pain exhibited on internal rotation in flexion results from the abutment and impingement of the femoral neck against the acetabular labrum. Accordingly, it can be postulated that FAI will be most common in sports in which this mechanism is utilized, including hockey, tennis, martial arts, weight lifting, soccer, and horse riding. 
A focused physical examination should assess range of motion, strength, and stability of the involved hip and the contralateral asymptomatic extremity. A finding of limited internal rotation with the hip flexed to 90° is particularly important. An impingement test should be conducted using passive hip hyperflexion, adduction, and internal rotation, which recreate the most common pathologic position of FAI. The test is positive if the maneuver elicits pain identical to that experienced with FAI.  The diagnostic evaluation of potential FAI in an athlete should include an anteroposterior view of the pelvis and a Dunn lateral view of the affected hip. These radiographs allow evaluation of the acetabular version and identification of the crossover sign, in which the superolateral border of the anterior wall of the acetabulum can be observed intersecting or crossing over the inferiomedial border of the posterior wall. Moreover, the Dunn view allows improved evaluation of the femoral head-neck geometry and identification of cam-type lesions.  Further, MRI with or without gadolinium contrast can allow the accurate delineation of the periarticular soft-tissue structures of the affected hip, including the femoral and acetabular chondral surface, labrum, capsule, and surrounding extra-articular tendinous insertions.  Computed tomography with three-dimensional reconstruction and femoral version analysis can provide a more detailed analysis of the proximal femoral and acetabular geometry.  A fluoroscopically guided, intra-articular, analgesic and steroid injection can be used as a diagnostic and therapeutic tool in addition to the patient's history and physical examination.
Treatment of FAI involves an initial trial of non-operative measures that include oral NSAIDs, physical therapy, and intra-articular analgesic/steroidal injections.  Nonsurgical management is often ineffective in patients with an identifiable pathology because patients with FAI typically have a mechanical pathology.  However, because of the typically high activity level and athletic ambitions of these patients, such treatment usually fails to control the symptoms. Furthermore, continued FAI leads to progression of the destructive process and advancement of labral and chondral lesions; therefore, early intervention with surgery for preventing the progression of arthritis is the preferred treatment option for these patients. 
The operative treatment of symptomatic FAI should primarily address all contributory mechanical factors to the symptomatic impingement and secondarily address the resultant intraarticular pathology. Surgical treatment includes acetabuloplasty, femoral head osteoplasty, chondroplasty, labral resection, and repair through both open and arthroscopic approaches. 
As a common source of groin pain, osteitis pubis presents with pain and tenderness involving the pubic symphysis, adjacent rami, and tendinous attachments, and can radiate to the inner thigh or lower abdomen.  Osteitis pubis occurs commonly in distance runners and soccer players, and has been found to be the most common cause of chronic groin pain in some sports medicine clinics. , The most likely mechanism of this condition is repetitive stress from increased shearing forces across the pubic symphysis resulting in symphysis inflammation or even joint disruption.  In particular, repetitive adductor pull on the symphysis has been proposed as one of the etiologic mechanisms. Therefore, distinguishing osteitis pubis from adductor strains can be difficult since the origin of the adductors is in close proximity to the symphysis. ,
The primary symptom of osteitis pubis is usually the gradual onset of exercise-induced pain in the lower abdomen and medial thighs, and can be exacerbated by activities producing shearing of the pubis, such as rapid accelerations, cutting, pivoting, or kicking.  Physical examination usually reveals tenderness over the pubic symphysis and pain on passive stretch and active contraction of the adductors. , Pain can be reproduced with palpation as well as resisted hip adduction with the hip and knee in 90° of flexion. ,, Osteitis pubis can also be evaluated radiographically and often presents with erosions, sclerosis or lysis, and widening of the pubic symphysis on an anteroposterior pelvic radiograph. However, some adult athletes with no osteitis pubis symptoms may have plain-film radiographic changes characteristic of osteitis pubis.  MRI typically shows marrow edema in the pubic bones early in the course of the condition and low signal on T1- and T2-weighted images as the disease progresses.  However, because these MRI findings are also frequently found in asymptomatic athletes, their significance remains uncertain, and the diagnosis should not be based on MRI alone.  Bone scan in patients who have osteitis pubis may demonstrate diffuse increased uptake in the area of the pubic symphysis; however, some athletes who have classic clinical symptoms fail to show abnormal uptake, and thus clinicians are helped only by a positive scan. 
Since the majority of cases are self-limiting, conservative treatment is typically the first-line treatment, which can include NSAIDs, heat treatment, compression shorts, and rehabilitative physiotherapy, with a particular focus on core muscle stability. Some series advocate intra-symphysial corticosteroid injection, with or without a local anesthetic. However, the use of injections remains controversial because of concerns regarding symphysis loosening. , In addition, only limited evidence is available to support their use in the treatment of osteitis pubis. In the literature, studies with a low level of evidence (levels 3 and 4) but no randomized controlled trials have been conducted to evaluate the efficacy and safety of injections. Because of the overall limited nature of the evidence, very few conclusions can be drawn with respect to the best treatment for these patients. Surgical intervention is reserved for symptoms refractory to conservative management. Options include curettage of the pubic symphysis, polypropylene mesh placement into the preperitoneal retropubic space wedge resection, and pubic symphysis fusion. 
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[Table 1], [Table 2]