What a Pain in the Groin!

 

I watch a lot of hockey….like A LOT of hockey.  It seems like every offseason there are at least a handful of players having surgery for femoral acetabular impingement (FAI), “hernia” repairs and/or abdominal “tears.”

Whenever there is a huge increase in certain procedures, I’m always a little suspect whether it’s just the latest trendy thing to be done or truly necessary.  In June of 2018, the Journal of Orthopedic Sports Physical Therapy even dedicated their whole issue to FAI occurrence and treatment. 

It was an interesting issue that didn’t just address FAI, but a large number of complex groin pain.  I realized much is the same as it was 20 years ago, but the understanding of the concurrent injury has improved.

What’s In A Name? 

Complex and difficult to treat groin pain has gone by a lot of names over the years. Gilmore’s Groin, Sports Hernia, Core Muscle Injury, Athletic Pubalgia.  All these different terms complicate literature searches and lead to poorly defined anatomy definitions.

It is now agreed upon to leave the term “hernia” behind because the injury usually involves the various structures that compromise the pubic and abdominal aponeurosis, but rarely a deficiency of the posterior wall. 

The literature also doesn’t agree whether surgical intervention or conservative treatment is best. These patients may seek you out for pain management or while waiting for a diagnosis.

Who’s At Risk?

Males are at higher risk than females due to the narrow pubic arch angle.  As well as athletes that involve high frequency of deceleration and acceleration particularly with cutting/pivoting such as ice hockey, soccer, rugby, and our military personnel.

71% can relate the pain to a reproducible, specific activity that usually involves hyperextension of the trunk and hip hyperabduction.  And there is a high incident with a co-existing FAI. Athletes with limited ROM due to FAI will rely more on trunk extension and the pivot point of the pubic symphysis perhaps making them more at risk to develop tears of the aponeurosis. Repetitive pelvic motion against a fixed extremity with decreased range due to CAM or Pincer lesions may result in rectus abdominus sheath and oblique muscle fiber injuries (Strosberg et al 2016). Studies have shown if the athlete has their abdominal/groin tear repaired, but not FAI, only 25% return to sport.

However, if both are repaired 89% return to sport (Larson et al 2014).

What Do I Need To Look For? 

We are not going to diagnosis an athlete with FAI or athletic pubalgia.

But what if our athlete comes to us with groin pain and we aren’t sure if it’s something muscular to treat? 

What makes this diagnosis difficult is there is no great test or exam that is specific for these injuries.  And studies have shown that there are potentially 17 different structure that can be involved!  Common Hallmark Signs include:

• Deep going or lower abdominal pain
• Pain exacerbated by very specific sports activity that is relieved by rest
• Palpable tenderness over a conjoined tendon or rectus abdominus insertion near pubic tubercle
• Pain with resisted abdominal curl up
• Pain with resisted hip abduction at 0, 45 and 90 degrees of hip flexion

And of course, if your patient isn’t responding to treatment, it’s always time to investigate further.

To Treat Or Not To Treat?  

Most guidelines agree to always treat conservatively.

However, only 27% of athletes return long term to sport with conservative treatment.

Also, the length of a conservative treatment trial is somewhat controversial and inconsistent.  Nature of injury, level of performance of the athlete and length of time before return to pre-injury play all need to be considered when deciding how long to have a trial of conservative treatment.

I think back to my college athletic training days and I realize there were quite a few “sports hernia” surgeries being done.  So maybe this isn’t a new trend after all! However, it’s always good to remind myself of signs and symptoms and anatomy so we all make sure we are treating our patients effectively. It will, of course, be crucial for you to do your own assessment and use your critical thinking on how to progress with treatment, along with how to manage it as a conservative treatment as recommended. But at least after this hockey season is done, I’ll have my own answers as to how necessary the treatments on my favourtie players are.

 

References:

Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding Athletic Pubalgia: A Review. Rhode Island Medical Journal (2013)[serial online]. October 4, 2016;99(10):31-35.

Copperthite K. Athletic Pubalgia, Part 1: Anatomy and Diagnosis. Athletic Therapy Today[serial online]. September 2010;15(5):4-

Harris-Hayes M, Steger-May K, van Dillen LR, Schootman M, Salsich GB, Czuppon S, Clohisy JC, Commean PK, Hillen TJ, Sahrmann SA, Mueller MJ. Reduced Hip Adduction Is Associated With Improved Function After Movement-Pattern Training in Young People With Chronic Hip Joint Pain.  J Orthop Sports Phys Ther. 2018 Apr;48(4):316-324. doi: 10.2519/jospt.2018.7810. Epub 2018 Mar 16.

Heerey J, Risberg MA, Magnus J, Moksnes H, Ødegaard T, Crossley K, Kemp JL.  Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol for the HIP ARThroscopy International Randomized Controlled Trial.  J Orthop Sports Phys Ther. 2018 Apr;48(4):336-342. doi:10.2519/jospt.2018.8002.

Hopkins J, Brown W, Lee C. Sports Hernia: Definition, Evaluation, and Treatment. JBJS Reviews[serial online]. September 2017;5(9):e6

Larson CM. Sports Hernia/Athletic Pubalgia: Evaluation and Management. Sports Health. 2014;6(2):139-144. doi: 10.1177/1941738114523557

Munegato D, Bigoni M, Gridavilla G, Olmi S, Cesana G, Zatti G. Sports hernia and femoroacetabular impingement in athletes: A systematic review. World Journal Of Clinical Cases[serial online]. September 16, 2015;3(9):823-8

Strosberg D, Ellis T, Renton D. The Role of Femoroacetabular Impingement in Core Muscle Injury/Athletic Pubalgia: Diagnosis and Management. Frontiers In Surgery[serial online]. February 12, 2016;3:6.

Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, HÖlmich P.  Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management.  J Orthop Sports Phys Ther. 2018 Apr;48(4):239-249. doi: 10.2519/jospt.2018.7850. Epub 2018 Ma

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