Hip/Groin Anatomy
March 18, 2021
Sural Nerve Entrapment
April 23, 2021

Groin pain in Athletes (Non-hip joint)

Groin Pain in Athletes (Non-hip joint)

Description:

There are many terms that are used to label non-hip joint groin pain in athletes, including but not limited to athletic pubalgia, sports hernia, and adductor tendinopathy (see table 1 for a more comprehensive list of terms). The 2015 Doha Agreement provided a consensus of 3 classification categories: (1) defined clinical entities (adductor-related, inguinal-related, iliopsoas-related, and pubic-related), (2) hip-related groin pain, and (3) other causes of groin pain, including a true inguinal hernia and non-musculoskeletal (MSK) conditions. (Weir et al. 2015) The use of these terms is increasing within the literature, while terms such as athletic pubalgia and sports hernia are being slowly phased out.

 

Table 1 – Athletic Groin Pain terms in Literature (Serner et al. 2015, Omar et al. 2008, Sheen et al. 2017))

 

Adductor pain/tendonitis Adductor tear, avulsion, herniation of muscle fibers through myofascial membrane
Athletic Groin Injury Undifferentiated
Athletic Pubalgia/pubalgia Undifferentiated
Gilmore Groin Inguinal ligament injury/disruption
Hockey groin syndrome/ Hockey goalie baseball pitcher syndrome Adductor tear, avulsion, herniation of muscle fibers through mysofascial membrane, fascial tear of external oblique
Incipient Hernia Undifferentiated, groin pain with activity
Inguinal ligament/canal syndrome Sprain, tear of inguinal ligament or of posterior wall or conjoint tendon
Groin Disruption Undifferentiated, or could infer inguinal ligament injury
Osteitis Pubis Degenerative changes of pubic symphysis (osteophytes, subchondral cysts, +- boney edema)
Pubic bone stress injury Bone Marrow Edema (BME) seen on MRI
Pubic Inguinal Pain Syndrome Undifferentiated, groin pain with activity
Sports Hernia Undifferentiated, groin pain with activity
Sportsman Hernia Undifferentiated, groin pain with activity
Sportsman Groin Undifferentiated, groin pain with activity

Figure 1 – Diagram of 2015 DOHA agreement consensus on groin pain classification (Weir et al. 2015)

 

The relationships between the abdominal wall, hip joint, sacroiliac joint, adductors, and pubic symphysis are complex. A significant force imbalance between the abdominal musculature and adductors causes fascial microtrauma. Classification helps identify and communicate where the microtrauma is located. For example, inguinal-related groin pain presents with pain and tenderness localized to the inguinal canal as a result of microtrauma to the posterior inguinal canal, with or without nerve compression, and Iliopsoas-related groin pain is a result of microtrauma to the iliopsoas, etc. 

 

Hip pathology typically causes restricted range of motion (ROM). To achieve sufficient ROM for sport, there is a compensatory stretching of the surrounding musculature, which predisposes these tissues to developing microtrauma and force imbalances . The treatment of intra-articular hip pathology varies from that of extra-articular pathology, and thus hip-related groin pain is categorized separately.

 

Underlying pathology for non-hip groin pain: It is clear from the literature that there is significant heterogeneity in pathology from a relatively small anatomical area. (see table 2).  However a 2020 JAMA Surgery review paper summarized the following pathologic origins of groin pain syndromes:  Inguinal canal, Rectus abdominus and Adductor longus, pubic symphysis and finally inguinal neuralgias.   These neuralgias can occur secondary to true hernias, disruption of the tranversalis fascia leading to increased pressure on the nerves, or due to scar tissue entrapment.

 

Table 2 – Sources of pain in Athletic groin pain (non-hip) [Intra-abdominal sources excluded]

Bone Soft tissue Nerve
Pubic bone (BME/stress #) Rectus Abdominis Genitofemoral nerve
Pubic symphysis Pubic aponeurosis/pubic ligament/Aponeurotic plate Iliohypogastric nerve
Osteomas of ischium/pubis Inguinal ligament sprain/tear Ilioinguinal Nerve
Septic osteomyelitis of pubic symphysis Conjoint tendon Obturator nerve
Adductor tendon
Psoas tendon/bursa
Inguinal ring disruption
Hematoma (rectus abdominis, iliopsoas)
Pectineus

 

One important anatomical point is the area of the pubis that acts as a hub for insertions and origins of rectus abdominis, adductor longus, the inguinal ligament and conjoint tendon (see Figure 1 where purple meets blue).  This portion of the pubis is directly lateral to the pubic symphysis.  

One study, by Falvey et al.in 2016, of 382 male patients with athletic groin pain, mainly gaelic footballers, found that bone marrow edema was present in 68 % of athletes and the pubic aponeurosis was abnormal on 52.6% of MRIs. Nearly a ⅓ of patients had 3 or more findings on MRI. 

The pubic aponeurosis, has been further recognized to contain a pubic ligament complex by Shiclder et al. 2017.  The ligament is positioned horizontal and midline with communications with the pyramidalis tendons, adductor tendons and external oblique aponeurosis, just superficial to rectus abdominis.

 

Part of the goal of assessment of groin pain – is to rule out various diagnoses through systematic assessment and examination to narrow the differential.   The heterogeneity even within non-hip joint pain athletic groin pain is highly suggestive of a multifocal cause to groin pain. 


Figure 3 – Pubic aponeurosis/aponeurotic plate in relation to rectus abdominis and adductor longus

 

Figure 4 – dermatome mapping of Iliohypogastric, ilioinguinal, and genitofemoral

 

Important factors on History:

Location of pain (see Figure 5): Pain should be focused around 2 (medial 1/3rd), 3, 4, and/or 5 

Nature of pain:

  1. Activity-related: worse with twisting, sprinting, changing direction.
  2. a) Dull ache, pulling pain (more likely soft tissue-related)
  1. b) burning, tingling, sharp, shooting (more likely due to nerve impingement or neuralgia). 

History of prior abdominal surgery esp. hernia/sport hernia surgery with mesh: Increases risk of a nerve entrapment.

 

Differential diagnosis:

Non-Hip:  Hernias (direct, indirect, femoral, spigelian, obturator) genitofemoral nerve impingement, iliohypogastric nerve impingement, ilioinguinal nerve impingement, obturator nerve impingment, kidney stones, osteitis pubis, psoas bursitis, pubic stress fracture, inguinal ligament sprain/tear, intra-pelvic pathology, intra-abdominal pathology, rectus sheath hematoma,  testicular pathology.

Hip: Femoral acetabular impingement, labral tear, osteoarthritis, avascular necrosis femoral head, osteomyelitis, septic arthritis, snapping hip syndromes

 

Examination:

A 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.

 

Table 3 – Examination for undifferentiated musculoskeletal groin pain in athletes

 

Area of interest Examination Interpretation of findings Imaging
Hip Range of motion, log roll, FADIR, FABER, scour +ve testing reduces probability of athlete having non-hip groin-related pain, especially if remainder negative Xray: (AP pelvis, Dunn view, lateral)

MRI Hip: Groin pain protocol will comment on hip pathology)

Hip Flexors, Psoas (4 and between 1 and 4) Direct palpation over anterior hip AIIS, Thomas test, AROM 

Psoas stretch and Rectus femoris: stretch and activation v. resistance

+ve testing in keeping with psoas or rectus femoris related pain, especially if remainder negative Xray: AP pelvis if concern for avulsion fracture

US: hip/groin (hip flexors on requisition)

MRI: Either hip or groin pain protocol

Inguinal Ligament and conjoint tendon Direct palpation US: hernia
MRI: groin pain protocol – with and without valsalva
Pubic symphysis (3,6) and Pubic bone Direct palpation for reproduction of patient’s pain Xray AP pelvis

CT Pelvis

MRI groin pain protocol – with and without valsalva (+ve cleft sign)

Rectus Abdominis  Palpation of the distal rectus femoris and its insertion for pain.

A dynamic version includes either a head and leg lift or a sit-up with localized pain in area 5 (see Fig 5), along with amplification with palpation of the area 

US

Dynamic Ultrasound for Sport hernia – to assess inguinal ring and conjoint tendon

MRI groin pain protocol

Adductor Longus Tendon Swelling, tender to palpation, pain with stretch, pain with activation US

MRI groin pain protocol

Hernia testing Palpation with valsalva for indirect and direct hernias -ve testing essential for a diagnosis of athletic groin pain US abdomen (inguinal hernias)

Dynamic abdominal US – to assess inguinal ring and conjoint tendon

MRI groin pain protocol – obturator hernia

Nerves Can be referred for US or CT guided nerve blocks – see Figure 4 US abdomen

MRI groin pain protocol

MR neurography

Figure 5 – Surface anatomy for groin-related pain examination

 

Investigations:

  • Xray
    • AP Pelvis, lateral hip and Dunn views
  • Abdominal US 
    • This is mainly to rule out the presence of other hernias
  • Dynamic US for sport hernia 
    • Positive finding is the bulging anteriorly of the posterior inguinal wall (transversis abdominalis) with the patient performing valsalva. 
  • CT scan 
    • Assesses hips and pubic symphysis with some capability for assessing soft tissue scarring
  • MRI Groin pain protocol 
    • Assesses hip, psoas, proximal rectus femoris, inguinal ligament, and the pubic rami and symphysis.
  • MR neurography 
    • Can be used to identify impingement of iliohypogastric, ilioinguinal, and genitofemoral nerves

 

Assessment:  The bottom line is narrowing down the differential diagnosis as this will aid in guiding treatment as well as with prognostication. We recommend localizing the area of pain into following categories:

  1. Inguinal
  2. Rectus Abdominis/Pubic bone
  3. Adductor Longus

 

Plan:

 

Prognosis:

Estimating prognosis can be difficult given the heterogeneity of the issue.  A review of return to play reported by both surgical and rehabilitative methods ranged from 2 weeks up to almost 30 weeks (King et al. 2015).  For pubic-related pain, rehabilitation recovery was significantly faster than surgical by ~12 weeks. However, little difference was noted between surgical and rehabilitative treatments for abdominal-located or adductor-located pain and return to play.  The mean return to play was 13 weeks across all studies in a 2015 systematic review. (King et al. 2015). It should be noted, from experience, that age is a predictor of prognosis, with younger patients in their 20’s recovering faster than patients over 40.  A prospective trial, by Paajanen et al. in 2011, following 60 athletes found that 53% of the non-operative group still had symptoms at 1 year, despite 2 months of physio, +/- corticosteroid and/or oral anti-inflammatories.  However, other studies have suggested shorter periods (references).   The presence of bone marrow edema or “osteitis pubis” on MRI typically results in longer (>3 months) times to return to sport. (Jardi et al. 2014).

 

Conservative:

Protocols may differ based on underlying pathology.  Common themes include hip range of motion and mobility training along with increasing lumbopelvic control. 

Abdominal-related pain – 4 week protection phase from increased and forceful tension. Slow gradual activation of these muscles over next 4-6 weeks. Along with hip ROM and core mobility training.  Generally a period of 4 weeks has been recommended before resuming explosive/agility maneuvers.

Adductor-related pain – avoiding aggravating activities, and gradual progression of strengthening. The program should also focus on hip range of motion and core mobility training. 

Inguinal-related pain – 4 week protection phase from increased and forceful tension. Slow gradual activation of these muscles over next 4-6 weeks. The program should also focus on hip range of motion and core mobility training. 

Pubic-related pain: 4 week protection phase from increased and forceful tension. Slow gradual activation of these muscles over next 4-6 weeks.  The program should also focus on hip range of motion and core mobility training. Four weeks of no pain is generally recommended before resuming explosive/agility maneuvers. (Jardi et. al. 2014)

 

Injections: Adjunct therapies described have included NSAIDs, and injections (corticosteroids and platelet rich plasma) into pubic symphysis, or rectus abdominus muscles.

 

Radiofrequency ablation/denervation:

If there is nerve-like symptom description in the history or the pain transects inguinal, pubic and/or adductor areas, then there has been some promise shown in the use of both nerve blocks for treatment.  These can generally be helpful as a diagnosis tool in non-hip groin pain in athletes.  Radiofrequency ablation of the ilioinguinal nerve demonstrated improvement in a study of 36 patients when compared to bupivacaine with triamcinolone.  (Comin et al. 2013).  We have a case of iliohypogastric nerve RFA in a professional football player that was able to resume full training without pain after 4 months of discomfort.  Many of the surgical techniques report including an neurectomy of the inguinal sensory nerves. (Zuckerbraun et al. 2020).

 

Surgical:

There are multiple different surgical interventions  which can involve any of the following: fixation of transversus abdominus to inguinal ligament, mesh insertion (total extraperitoneal mesh placement), aponeurotic plate fixation back to periosteum with inguinal floor repair, adductor tenotomy/lengthening, rectus abdominis repair and neurectomy of associated nerves.

Adductor tenotomy alone is generally reserved for patients that report adductor localized pain. Robertson et al. 2011, reported 71% of athletes returning to their pre-injury level of sport after chronic adductor pain.  The series included 109 male athletes that had chronic adductor pain with a mean of 15 months at time of operation) despite conservative management.   

Laparoscopic mesh for posterior wall was used frequently.   In 2 different studies, one of 35 and the other 131 patients,respectively.  The authors found that 97%  of patients returned to prior sporting level within 3 weeks. (Genitsaris et al. 2004, Susmallion et al. 2004).

Another option is open repair, one study of 128 patients with a minimal repair technique (posterior wall repair with decompression of genital branch of genitofemoral nerve) reported 84% returned to pre-injury level of sport at 4 weeks.(Mushaweck et al., 2010) 

 

Complications include: bruising, bleeding, hematomas, infection, and dysthesias (Meyers et al. 2008).

 

Criteria for referral for Laparoscopic Repair for Sport hernia (Inguinal-related groin pain in athlete in absence of a true hernia):

 

  1. History features that must be present (must have all three):

1) Athletic Injury – overuse/gradual onset;

2) Worse with twisting, sprinting, change of directions, and mechanical provocation;

3) Pain greater than 6 months ( > 6 weeks if professional/elite athlete).

  1. Examination features that must be present (must have both):

1) Pain over inguinal ligaments and location of external and internal rings;

2) Absence of true inguinal hernia.

  1. Imaging features that must be present (must have both):

1) Ultrasound – demonstrating no true inguinal hernia;

2) MRI groin pain protocol – Negative for other causes of groin pain.

 

It should be noted that despite promising results with surgical interventions, geographical availability can be quite limited.

 

Author:  Dr. Jordan Anderson, MD CCFP PGY3 and Dr. Neil Dilworth (April 4, 2021 – PR AF MC updated May 5, 2021)


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