Hip and groin pain is one of the more common problems we see in athletes and may result from an acute injury or from chronic, repetitive trauma. It is responsible for significant problems of pain and mobility, which leads to time away from training and competition, and may result in a career-ending injury. The anatomic and biomechanical causes for hip and groin injuries are among the most complex and controversial in the musculoskeletal system. This makes clinical differentiation and subsequent management difficult because of the considerable overlap of symptoms and signs.
Doctors have long known that the diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to either the front of the hip and groin, the rear hip and buttock, or the side hip. The pain at the front of the hip and groin pain is commonly associated with osteoarthritis and hip labral tears. Rear hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome.
As stated above, groin pain is often a confusion and frustrating area for the patient and physician to treat. With a complicated matrix of connective soft tissue and weave of muscles, tendons, ligaments and nerves, the hip/groin area certainly presents a challenge to the patient in chronic pain.
There are dozens of possible reasons for groin pain, routine physician and other diagnostic tests can rule out many causes that do not involve musculoskeletal injury. These include kidney stones, infections, swollen lymph nodes, abdominal aortic aneurysm, and many other diagnosis. Surgeons are often warned in the medical literature to make sure that they rule out groin pain before you operate on the hip.
As chronic pain specialists, our practice specializes in pain caused injury – degenerative conditions such as arthritis, and the strains and strains of overuse in heavy work and sports related activity.
There are many reasons pain may resonate in the groin area including herniated disc or pinched nerve in the spine. The heavy ligaments of the pelvis including the the iliolumbar ligament which connect the spine to the pelvis and help form the pelvic girdle may be injured or “loose,” causing excessive and irritating movement in the groin.
Pain may be referred into the groin from the connecting fascia, (commonly fasciitis) that covers the hip muscle. In our practice we have seen patients with the common causes and the less common causes of hip pain. One thing that they hold in common is that they cannot get relief and that they cannot return to their work or sport. Another thing they hold in common is that to get the relief they seek they need a thorough physical examination.
Typically, when someone contacts me about groin pain, they have realized that it is not just groin pain that is the problem.
Many people will tell me that they developed groin pain after a long period of back problems, especially the low back. As their back pain worsened, they went on to physical therapy where their glute muscles were identified as being tight. Of course, the person tells me this would explain the problem they have with muscle spasms. As the glute problems were identified, their groin pain developed and so did their abdominal wall pains. Suddenly, their back pain problem became a sports hernia too. By the time this person has reached out to me, they have been to the physical therapist, the chiropractor, their general practitioner and their orthopedist. Maybe a few orthopedists.
Sometimes I will get an email about tender or strained groin that came as a result of wearing a walking boot during Achilles tendon repair recovery. The boot having disrupted the person’s normal gait to the point of creating new pains. Despite this, this person will relate to me that it took a few health care providers to make the connection between altered gait and development of groin pain.
Complexity of hip – groin – back pain diagnosis
A study from the University of Toronto (1) had this to say about this complexity: “The anatomic and biomechanical causes for hip and groin injuries are among the most complex and controversial in the musculoskeletal system. This makes clinical differentiation and subsequent management difficult because of the considerable overlap of symptoms and signs.”
Further, German researchers wrote: (2) “The differential diagnosis of hip and groin pain with respect to the high frequency of referred pain from the lumbar spine, lower abdomen, and pelvis is demanding. A systematic approach to the hip and groin area is important to identify the origin of pain. Both the history and quality of symptoms and the physical exam are the basics of the diagnostic algorithm.”
In other words, quality physical examination, identification of pain causing generators, detailed discussion with patient is what researchers recommend for making a good diagnosis.
So it is clear, the diagnosis of hip pain is broad and presents a diagnostic challenge. Patients often express that their hip pain is localized to either the front of the hip and groin, the rear hip and buttock, or the side hip.
“The differential diagnosis of hip pain is broad, presenting a diagnostic challenge”
A paper from the University of Wisconsin in the journal the American Family Physician (3) found gave an even more detailed look at the complexity of the hip-spine-groin problem.
“The differential diagnosis of hip pain is broad, presenting a diagnostic challenge. Patients often express that their hip pain is localized to one of three anatomic regions: the anterior hip and groin, the posterior hip and buttock, or the lateral hip.
Anterior hip and groin pain is commonly associated with intra-articular pathology, such as osteoarthritis and hip labral tears. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication. Lateral hip pain occurs with greater trochanteric pain syndrome.
Groin pain from the spine?
A study in the medical journal Spine (4) suggested that patients with groin pain that do not respond to conventional treatments, may have their groin pain coming from their spine. Here is what these researchers wrote:
“We selected 5 patients with groin pain alone for investigation. The patients suffered from groin pain and showed disc degeneration only at 1 level (L4-L5 or L5-S1) on magnetic resonance imaging. Patients did not show any hip joint abnormality on radiography or magnetic resonance imaging. To prove that their groin pain originated in degenerated intervertebral discs, we evaluated changes in groin pain after infiltration of lidocaine into hip joints and examined pain provocation on discography, pain relief by anesthetic disc block, and finally anterior lumbar interbody fusion surgery.” In our office spinal fusion, especially for the athlete would be consider the very, very last resort.”
Don’t do a hip surgery until undiagnosed groin injury is explored
In The Journal of the American Academy of Orthopaedic Surgeons,(5) the wrong diagnosis and the wrong treatment, surgery is explored in relation to hip and groin pain. Here is what these surgeons wrote:
“Groin pain is often related to hip pathology. As a result, groin pain is a clinical complaint encountered by orthopaedic surgeons. Approximately one in four persons will develop symptomatic hip arthritis before age 85 years. Groin injuries account for approximately 1 in 20 athletic injuries, and groin pain accounts for 1 in 10 patient visits to sports medicine centers. Many athletes with chronic groin pain have multiple coexisting pathologies spanning several disciplines. In treating these patients, the orthopaedic surgeon must consider both musculoskeletal groin disorders and non-orthopaedic conditions that can present as groin pain.”
Osteitis Pubis – Athletic pubalgia – A high clinical suspicion should exist when evaluating soccer, rugby, or football players and distance runners who present with complaints of groin pain
A paper published in the Current sports medicine reports (6) describes Osteitis pubis as “a painful overuse injury of the pubic symphysis and the parasymphyseal bone that typically is found in athletes whose sports involve kicking, rapid accelerations, decelerations, and abrupt directional changes. Athletes most commonly present with a complaint of anterior and/or medial groin pain but also can present with lower abdominal, adductor, inguinal, perineal, and/or scrotal pain. Symptoms can be severe and can limit participation in sport until treatment is instituted. A high clinical suspicion should exist when evaluating soccer, rugby, or football players and distance runners who present with complaints of groin pain.”
Groin, Hip, and Pelvic Injections
Many people contact my office looking for treatment options and they know we do PRP and Stem Cell Injections.
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
Here is a recent case history from Canadian doctors (7) who treated a professional hockey player with recurrent groin pain after an acute episode. The patient received a clinical diagnosis of inguinal disruption (sports hernia). Imaging revealed a tear in the rectus abdominis (better known as the “abs.”) Management included two platelet-rich plasma (PRP) injections to the injured tissue, and subsequent manual therapy and exercise. The patient returned to his prior level of performance in 3.5 weeks.
Researchers described a case report (8) where a novel approach to the treatment of distal rectus abdominis tendinopathies with ultrasound-guided needle tenotomy and platelet-rich plasma (PRP) injection was performed. After injection, the patient returned to pain-free play at his previous level of intensity. This suggests that PRP may be a useful treatment for this diagnosis.
Probably no other athletes do more damage to their pelvic hip region than elite rugby and soccer player. Most times chronic pain in the region is the cause to the end of these athlete’s careers. In a long term study researchers (9) showed that treating the problematic areas with Prolotherapy (a simple dextrose solution) returned a remarkable 66 or 72 players back to the game.
Adductor tendinopathy and Athletic pubalgia
A 2016 study (10) examined the effectiveness of PRP in treating adductor tendinopathy and athletic pubalgia (Sports related groin pain).
“Adductor tendinopathy typically presents with groin pain and is often seen in soccer players due to the frequency of running and cutting movements involved in this sport. Athletic pubalgia is a more general term involving groin pain, often in athletes, with adductor tendinopathy being a frequent concomitant pathology in these patients. Good outcomes have been shown following adductor tenotomy with and without hernioplasty, though PRP provides a non-operative treatment option for this pathology.
Adductor longus tendinopathy is a common indication for PRP treatment. (One study) performed a retrospective case series of 408 consecutive patients treated by a single ultrasound-guided PRP injection for tendinopathy of upper (medial and lateral epicondylar tendons, i.e. golfer’s and tennis elbow, respectively) and lower (patellar, Achilles, hamstring, adductor longus, and peroneal tendons) limbs. Patients with hamstring and adductor longus tendinopathy demonstrated significantly improved (pain and function scores) scores at 6 weeks and a mean 20.2 months following injection.”
In some cases of advanced deterioration we also employ Stem Cells if the athlete wishes to reduce the number of treatments or accelerate healing. Stem Cells are drawn from the patient and then reintroduced into significantly damaged areas.
There is not much research specific to stem cell injections into the groin area. As the injections are trying to stabilize the groin, pelvic, hip region by strengthening tendons, general research into stem cells effectiveness in treating tendon disorders can be helpful in showing how stem cell therapy can work. Please see may article Stem cells for tendinopathy
References:
1 McSweeney SE, Naraghi A, Salonen D, Theodoropoulos J, White LM. Hip and groin pain in the professional athlete. Canadian Association of Radiologists Journal. 2012 May;63(2):87-99.
2 Holmich P, Dienst M. Differential diagnosis of hip and groin pain. Symptoms and technique for physical examination. Orthopade. 2006 Jan;35(1):8, 10-5.
3 Wilson JJ, Furukawa M. Evaluation of the patient with hip pain. American family physician. 2014 Jan 1;89(1):27-34.
4 Oikawa Y et al. Lumbar disc degeneration induces persistent groin pain. Spine (Phila Pa 1976). 2012 Jan 15;37(2):114-8. doi: 10.1097/BRS.0b013e318210e6b5.
5 Suarez JC, Ely EE, Mutnal AB, Figueroa NM, Klika AK, Patel PD, Barsoum WK. Comprehensive approach to the evaluation of groin pain.J Am Acad Orthop Surg. 2013 Sep;21(9):558-70. doi: 10.5435/JAAOS-21-09-558.
6 Beatty T. Groin Pain Osteitis pubis in athletes. Curr Sports Med Rep. 2012 Mar-Apr;11(2):96-8.
7 St-Onge E, MacIntyre IG, Galea AM. Multidisciplinary approach to non-surgical management of inguinal disruption in a professional hockey player treated with platelet-rich plasma, manual therapy and exercise: a case report. The Journal of the Canadian Chiropractic Association. 2015;59(4):390-397.
8 Scholten PM, Massimi S, Dahmen N, Diamond J, Wyss J. Successful treatment of athletic pubalgia in a lacrosse player with ultrasound-guided needle tenotomy and platelet-rich plasma injection: a case report. PM R. 2015 Jan;7(1):79-83. doi: 10.1016/j.pmrj.2014.08.943. Epub 2014 Aug 16.
9 Topol GA, Reeves KD: Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am J Phys Med Rehabil 2008;87
10 Kraeutler MJ, Garabekyan T, Mei-Dan O. The use of platelet-rich plasma to augment conservative and surgical treatment of hip and pelvic disorders. Muscles, ligaments and tendons journal. 2016 Jul;6(3):410. — 1976