Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management
Kristian Thorborg, Michael P Reiman, Adam Weir, Joanne L Kemp, Andreas Serner, Andrea B Mosler, Per HÖlmich
Synopsis: Groin pain is common in athletes who participate in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there has been little agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade, the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance; and management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.
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Groin pain is common in athletes participating in multidirectional sports. It is especially prevalent in the various football codes and in ice hockey, which involve repetitive and forceful hip movements, such as those that occur during high-intensity kicking, skating, and direction change.22,62,104 Traditionally, groin pain has been considered difficult to understand, diagnose, and manage.33
A lack of detailed scientific understanding concerning the underlying pathology of pain originating from the pubic symphysis, adjacent bone, and many surrounding musculotendinous attachments has caused controversies and disagreements concerning diagnoses and terminology.94
Furthermore, current improvements in understanding hip joint pathologies causing groin pain in athletes have made the clinical examination and classification of groin pain more complex and comprehensive, sometimes resulting in an ambiguous diagnostic work-up process.94
Until recently, a lack of agreement regarding terminology, definitions, or classification of groin pain in athletes85,94,105 has led to poor communication and research interpretation between clinicians. However, during the past decade, the field has evolved and an evidence-based understanding is now emerging.33,94 Numerous groups around the world are working together to create clear terminology, provide information on the diagnostic accuracy of relevant clinical examination and imaging techniques, and improve the assessment of impairment, function, and performance to optimize management of athletes with groin pain.
The aim of this paper was to synthesize recent advances in the clinical examination, diagnostic imaging, and testing of athletes with groin pain. Furthermore, we describe how information from reliable and valid clinical examination, diagnostic imaging, and testing of impairment, function, and performance can guide current evidence-based management of athletes with groin pain.
The clinical framework suggested in this commentary (FIGURE 1) is based on consensus between experts31,105 and reliable and valid investigations where available.9,36,58,83,86,92,98
Clinical Examination
History
Groin pain is generally more common in male athletes,62,104 but some specific injuries, such as stress fractures in and around the pelvic ring, are more common in female athletes.23
In young, skeletally immature athletes, the pelvic apophyses are vulnerable to injury.74
High-load activities, such as kicking and sprinting, may result in avulsion fractures, with the anterior inferior and superior iliac spines being the 2 most frequently injured locations.72,81
Additionally, as the pubic symphysis is the last part of the human skeleton to mature, pubic apophysitis should be considered in the differential diagnosis of hip and groin pain in athletes as they age into their early twenties.74
Adolescent athletes are also at increased risk of hip-related problems if they have a previous history of slipped capital femoral epiphysis,18 Legg-Calvé-Perthes disease,55 or acetabular dysplasia.
Hip-related groin pain is more likely to occur in mature athletes starting in their early twenties,16,45 and hip joint osteoarthritis (OA) as a cause of groin pain should also be considered in older athletes.16
Types of Sports and Injuries
Due to the high number of athletes competing in multidirectional sports, such as football, many athletes with either acute strains or overuse injuries related to the groin region are seen in clinical practice. Acute strains often occur at the musculotendinous junction, specifically of the adductor longus, rectus femoris, and iliopsoas muscles.87,88
Acute adductor longus and rectus femoris injuries may also involve tendinous rupture/avulsion, primarily at the proximal insertions (FIGURE 2).87,88
In contrast to strains, groin overuse injuries more often involve bone and tendons and their insertions, and rarely involve the rectus femoris.34
Acute adductor muscle injuries usually occur during kicking and change of direction.84
In comparison, acute rectus femoris injuries primarily occur during kicking and sprinting, whereas acute iliacus and psoas major injuries mainly occur with movement requiring change of direction.88
Runners and dancers can also present with groin pain, often due to overuse. Hip flexor injuries, hip joint pain, and stress fractures are the most common injuries seen in these individuals,8,43,47,66 and, like most other overuse injuries, these are more often related to repetitive and accumulated overload.
Screening for Serious Pathology Causing Groin Pain
Evidence supporting diagnostically accurate red flag signs and symptoms in the groin region is limited21 and inconsistent across current practice guidelines.48
Still, clinicians must be aware of abdominal and pelvic organ disorders mimicking musculoskeletal-related groin pain.15 A history of cancer, such as prostate cancer in men, breast cancer in women, or cancer in any reproductive organs, is a potential red flag, as it is associated with metastases in the hip and groin region.32 Other red flags of concern are history of trauma, fever, unexplained weight loss, painful urination, night pain, and prolonged corticosteroid use.29,51,100
Serious pathology causing groin pain includes avascular necrosis, femoral neck fracture, or femoral shaft stress fracture. Information on screening for avascular necrosis is limited, but it has been suggested that having normal hip range of motion (ROM) is helpful in ruling out this condition.42 The patella-pubic percussion test (sensitivity, 95%; negative likelihood ratio = 0.07) and fulcrum test (sensitivity, 88%; negative likelihood ratio = 0.92) provide good to limited clinical utility to help rule out femoral neck fractures and femoral shaft stress fractures, respectively.68
If there is suspicion of serious underlying pathology, specific imaging should always be performed. Plain radiographs are a good primary examination to detect neoplasms in the skeleton. Even in seemingly healthy athletes, this should be considered for unexplained or long-standing groin pain not improving with treatment. If a stress fracture is considered, radiographs are frequently negative, especially in the early stages, and therefore cannot be used to rule out these injuries.17,47 (Katso jatko linkistä: Huomaa, että inguinaalisten kiputilojen etiologiassa on myös reisiluun tilat ja lonkka nivel mainittu ja jatkoseuraamuksissa on alaraajan funktio vaikeutunut. DOHA luokitus selvitetään erikseen artikkelissa)
TABLE Classification System of Groin Pain in Athletes
| Nomenclature | Symptoms | Definition | More Likely if Patient Presents With |
|---|---|---|---|
| Adductor-related groin pain† | Pain around the insertion of the adductor longus tendon at the pubic bone. Pain may radiate distally along the medial thigh | Adductor tenderness and pain on resisted adduction testing | Pain on adductor stretching |
| Iliopsoas-related groin pain† | Pain in the anterior part of the proximal thigh, more laterally located than adductor-related groin pain | Iliopsoas tenderness (either suprainguinal or infrainguinal) | Pain reproduced with resisted hip flexion and/or pain with hip flexor stretching |
| Inguinal-related groin pain† | Pain in the inguinal region that worsens with activity. If pain is severe, often inguinal pain occurs when coughing or sneezing or sitting up in bed | Pain in the inguinal canal and inguinal canal tenderness, or pain with Valsalva maneuver, coughing, and/or sneezing. No palpable inguinal hernia found, including on invagination of the scrotum to palpate the inguinal canal | Pain reproduced with resisted abdominal muscle testing |
| Pubic-related groin pain† | Pain in the region of the symphysis joint and the immediately adjacent bone | Local tenderness of the pubic symphysis and the immediately adjacent bone | No particular resistance test, but more likely if pain is reproduced by resisted abdominal and hip adductor testing |
| Hip-related groin pain† | Clinical suspicion that the hip joint is the source of groin pain, either through history or clinical examination | Mechanical symptoms present, such as catching, locking, clicking, or giving way | |
| FAI syndrome‡ | Motion- or position-related pain in the hip or groin. Pain may also be felt in the back, buttock, or thigh. Patients may also describe clicking, catching, locking, stiffness, restricted range of motion, or giving way | Motion-related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings. Cam and/or pincer morphology must be present on imaging | Limited range of hip motion, typically restricted internal rotation, and evidence of labral and/or chondral damage on imaging |
| Other† | Clinical suspicion if symptoms cannot be easily classified into any of the commonly defined clinical entities | Any other orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological, or surgical condition causing pain in the groin region |
REFERENCES: 1-109
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Journal of orthopaedic et Sports Physical Therapy. Vol.48, Number 4, April 2018, 239- 249
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