Groin pain in athletes

Abstract

Groin pain in athletes is not infrequently a cause of frustration and aggravation to both doctor and patient. Complaints in the groin region can prove difficult to diagnose, particularly when they are of a chronic nature. These injuries are seen more commonly in sports that require specific use (or overuse) of the proximal musculature of the thigh and lower abdominal muscles. Some of the more common sports would be soccer, skiing, hurdling, and hockey. The differential diagnosis can cover a rather broad area of possibilities. Most common groin injuries are soft-tissue injuries, such as muscular strains, tendinitis, or contusions. More difficult areas to pinpoint are such entities as osteitis pubis, nerve entrapment, the so-called "sports hernia," or avulsion fractures, to name but a few. The evaluation of such patients includes a familiarity with the sport and possible mechanism of injury (i.e., taking a careful history), meticulous physical examination of the groin, abdomen, hips, spine, and lower extremities. Diagnostic examinations may or may not prove helpful in formulating a final diagnosis. Some patients may be required to undergo procedures, such as laparoscopic evaluation of the region to obtain adequate information that allows a proper diagnosis and treatment plan. This article describes many of the possible causes of groin pain in athletes. The list is quite lengthy, and only the more common problems will be discussed in detail.

Proposed Algorithm for the Management of Athletes With Athletic Pubalgia (Sports Hernia): A Case Series

“…22,39,40,80 Some patients may complain of referred pain along the adductor longus tendon(s) with forceful or resisted hip adduction, 22,58,66 and most report point tenderness over the superior-lateral pubis. 48,51 Occasionally, patients with athletic pubalgia report groin pain with sneezing and coughing, 22,40,48,51,80 and males may report testicular pain. 40,51,58,80 Prospective validation studies of athletes undergoing surgical repair of a sports hernia, along with examination findings of 3 of the participants in this case series who subsequently underwent repair, reveal a cluster of 5 signs and symptoms to be the most indicative of a sports hernia: (1) a subjective complaint of deep groin/ lower abdominal pain, (2) pain that is exacerbated with sport-specific activities such as sprinting, kicking, cutting, and/or sit-ups and is relieved with rest, (3) palpable tenderness over the pubic ramus at the insertion of the rectus abdominis and/or conjoined tendon, (4) pain with resisted hip adduction at 0°, 45°, and/or 90° of hip flexion, and (5) pain with resisted abdominal curl-up.…”

“…79 Many diagnoses (snapping hip syndrome, hip subluxation/dislocation, acetabular labral tears, and bursitis) were immediately ruled out due to the absence of various signs and symptoms. 5,59,62,63 Others were omitted based on a negative radiograph or MRI report (avulsion fracture, proximal hip fracture, stress fracture) 5,51,53,[61][62][63]73 or based on the absence of neurological signs and symptoms (lumbar radiculopathy, pudendal/genitofemoral neuropathy, obturator nerve entrapment, ilioinguinal neuralgia). 5,51,62,63,73 Inguinal hernia was ruled out, as there was no palpable hernia.…”

“…5,59,62,63 Others were omitted based on a negative radiograph or MRI report (avulsion fracture, proximal hip fracture, stress fracture) 5,51,53,[61][62][63]73 or based on the absence of neurological signs and symptoms (lumbar radiculopathy, pudendal/genitofemoral neuropathy, obturator nerve entrapment, ilioinguinal neuralgia). 5,51,62,63,73 Inguinal hernia was ruled out, as there was no palpable hernia. Other diagnoses (rectus femoris strain, symphyseal instability) 5,52 might have been concomitantly present in some of the athletes, but the investigators believed they were chronic secondary dysfunctions.…”

Pubic inguinal pain syndrome: the so-called sports hernia

“…Gullmo refers that pain in these circumstances may be caused by a distension of peritoneum or stretching of the ilioinguinal nerve [2-4, 14, 15]. There has been recent interest in neurogenic groin pain: Lovell et al have studied the clinical presentation of inguinal neuralgia in a series of athletes with groin pain [1,3,4,15,16]. Obturator neuropathy has been described in a series of 32 patients, but the nerve entrapments in the inguinal region include those of the genitofemoral and ilioinguinal nerves, which cause local pain and neurological dysfunction [1-3, 17, 18].…”

“…The history must include questions directed at referred lumbar abnormalities, including back pain, radiculopathy and sensory disturbances [1,2,6,16,[22][23][24]27]. Night pain and persistence of pain at the rest may indicate the presence of a neoplasm.…”