The Physician and Sportsmedicine

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A Complete Approach to Groin Pain

Vincent J. Lacroix MD

To cite this article: Vincent J. Lacroix MD (2000) A Complete Approach to Groin Pain, The Physician and Sportsmedicine, 28:1, 66-86

To link to this article: http://dx.doi.org/10.3810/psm.2000.01.626

Published online: 19 Jun 2015.

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Download by: [University of Sheffield] Date: 05 November 2015, At: 17:45 AComplete Approach to Groin Pain

Vincent J. Lacroix, MD

IN BRIEF: Focused history questions and physical exam maneuvers are especially impor­ tant with groin pain because symptoms can arise from any of numerous causes, sports related or not. Questions for the patient should attempt to rule out systemic symptoms and clarify the pain pattern. Some of the most possible causes ofgroin pain include stress fracture of the femoral neck or pubic ramus, ~-Calve-Perthes disease, slipped capital femoral epiphysis, acetabular labral tears, iliopectineal bursitis, awlsion fracture, os­ teitis pubis, strain of the thigh muscles or rectus abdominis, inguinal hernia, ilioinguinal neuralgia, and the 'sports hernia.' Depending on the diagnosis, conservative treatment is often effective.

min injuries are a diagnostic and as in "I think I pulled my groin." It may refer to therapeutic challenge, even to the genitalia, as in "Doc, I got kicked in the the most skilled clinician. They groin." It can indicate hip pathology if it occurs are difficult to diagnose and treat in a child pointing to the anterior thigh while correctly because they involve a complex he or she is limping. Finally, it may refer to a regional anatomy that produces diffuse, insidi­ lower abdominal wall problem, as in "I have a ous symptoms and uncharacteristic presenta­ lump in my groin." tions; they involve coexisting multiple patholo­ Adding to the confusion caused by inaccu­ Downloaded by [University of Sheffield] at 17:45 05 November 2015 gies; and they are often described with in­ rate terminology, the groin is an anatomic area accurate terminology. of greatly overlapping nerve distributions. Back The term "groin injury" describes multiple pathology and intra-abdominal pathology may clinical conditions without clearly defining lo­ cause discomfort that radiates to the groin re­ cation or cause. Groin injury is to the lower ab­ gion, confusing the investigator as to the source domen and thigh what shin splints are to the ofthepain. leg. Webster's dictionary defines the groin as The list of causes that can result in groin "the fold or depression between belly and pain is therefore extensive, as Renstrom so elo­ thighs." Taber's dictionary equates it to "the in­ quently described in his landmark 1992 article.• guinal region." These include sport -specific injuries as well as "Groin'' is a confusing term at best, especial­ ailments more typical of the general popula­ ly when used in layperson's language. It can, as tion (table 1). Before getting to the sport-specif­ is usually the case, mean a thigh muscle strain, ic injuries, the examiner must eliminate the more general causes of groin pain. This task is For CME, see www.physsportsmed.com/ simple if we consider the anatomic sites that cme.htm beginning in February 2000 need to be evaluated through history and phys­ ical examination. They can be summarized by continued

66 Vol 28 • No. 1 • JanU8JY 2000 e 11111 PHYSICIAN AND IPORTIMIDICINI Photo: @ 2000. Lori Adamski Peek/Tony Stone Downloaded by [University of Sheffield] at 17:45 05 November 2015

THE PHYSICIAN AND SPORTSMEDICINE e Vol 28 • No. 1 • January 2000 67 groin pain continued

Athletes must be told that stress fractures of the femoral neck are serious injuries that can compromise their athletic careers. Return to play may take as long as 4 to 5 months in successful cases.

the mnemonic "How To Approach Groin Pain'' (see he or she reproduce the pain with exertion or with cer­ table 1). tain movements?

History Physical Examination The clinician confronted with the prospect of evalu­ The physical examination of the groin region (table ating a patient complaining of groin pain should always 2) should proceed through several deliberate steps to ask specific questions that screen for various pathologies, which are covered in Elicit systemic signs and symptoms. Does the detail below. patient have a fever, sweats, or chills (indicative of infection or neoplasm)? Has there been weight loss Hip and Pelvis Injuries (neoplasm)? What about urinary symptoms (dy­ Injuries to the hip and pelvis are some of the most suria, urgency, frequency, hematuria [possible signs common causes of groin pain. Some of the most com­ of sexually transmitted disease or urinary tract in­ mon in sports are described below. fection])? What about bowel symptoms (diarrhea, Femoral neck stress fracture. Occurring primarily mucus or blood in the stool [Crohn's disease, ulcera­ in endurance athletes (often in thin, amenorrheic tive colitis])? women), this important overuse injury occurs because Clarify the pain pattern. Is the pain acute or chron­ of a loss of shock absorption due to muscle fatigue. ic? Does the patient have pain at rest or at night (neo­ Other risk factors include training errors, inadequate plasm) or pain with exertion? What activities cause footwear, running on poor surfaces, and coxa vara (an­ the pain? What was the mechanism of injury (eg, a gular deformity of the hip). sudden turn while running)? Does the pain radiate (eg, Stress fractures of the femoral neck cause groin or to the back, hip, thigh, knee, scrotum, or perineum)? anterior thigh pain, often an ache, that is relieved with What alleviates the pain (eg, rest, nonsteroidal anti­ cessation of activity. Nighttime pain may be present in

Downloaded by [University of Sheffield] at 17:45 05 November 2015 inflammatory drugs [NSAIDs], acetaminophen, phys­ chronic cases. Examination reveals an antalgic gait iotherapy treatments)? and limitation of hip motion, especially internal rota­ Has there been a change in training regimen (an tion. Pain is reproduced at the extremes of hip rotation overload causing a stress fracture)? Is there associated and with axial compression. numbness (in what dermatomal pattern)? Has the pa­ Plain radiographs taken early in the injury continu­ tient had pain on coughing or sneezing, which in­ um may be negative. The tension (superior) side frac­ creases intra-abdominal pressure (hernia)? Can the ture may show periosteal callus or an overt fracture patient point to the pain? Is it localized or diffuse? Can line. The compression (inferior) side fracture may show sclerosis or a cortical break. A bone scan should be positive 2 to 8 days after symptoms appear. Further Dr Lacroix is director of the Primary Care Sports Medicine Fellowship imaging studies such as computed tomography (CT) Program in the Department of Family Medicine at McGill University in Montreal. or magnetic resonance imaging (MRD should be un­ Address correspondence to Vincent J. Lacroix, MD, McGill University dertaken early if clinical suspicion warrants it. Sport Medicine Clinic, 475 Pine Ave W, Montreal, QB, Canada H2W 1S4; Treatment is based on the type of fracture. If the e-mail to [email protected]. bone scan is positive but there is no visible fracture on continued

68 Vol 28 • No. 1 • January 2000 e THE PHYSICIAN AND SPORTSMEDICINE groin pain continued

TABLE 1. Dlffarantlal Diagnosis of Grain Pain, Using a 'How to Approach Grain Pain' Mnemonic

plain film, initial treatment will consist of modified How = Hip/pelvis bed rest. This will lead to non-weight bearing with To = Thigh Approach crutches and then pain-free weight bearing.' Cardio­ = Abdomen Groin = Genitalia vascular workouts should include cycling, swimming, Pain = Pain (referred) and water running. Some authors suggest weekly ra­ diographs to monitor bone healing. When a hip or Hip/Pelvis pelvis fracture occurs in an amenorrheic athlete, ad­ Stress fracture of the femoral neck* Pubic ramus fracture* dressing the hormonal, dietary, and psychological Osteitis pubis* needs of the patient is an essential part of any success­ Legg-Calve-Perthes disease· ful management plan. Slipped capital femoral epiphysis* Treatment for a nondisplaced fracture on the com­ Avulsion fracture about the pelvis* Snapping hip* pression side consists of bed rest until the patient is pain Acetabular labral tear* free, followed by progressive weight bearing. If there is Bursitis (iliopectineal,* trochanteric) no improvement in the healing of the fracture, the pa­ Avascular necrosis tient will likely require open reduction and internal fixa­ Osteoarthritis tion (ORIF). For a nondisplaced fracture on the tension Synovitis or capsulitis side, ORIF is the treatment of choice because of the high Thigh risk of displacement. A displaced fracture is considered Muscle strains an orthopedic emergency and requires ORIE Adductor longus* Athletes must be told that stress fractures of the Rectus femoris· Iliopsoas* femoral neck are serious injuries that can compromise Sartorius* their athletic careers. Return to play may take as long Gracilis* as 4 to 5 months in successful cases. Femoral hernia Legg-Calve-Perthes disease. This is a self-limiting, Lymphadenopathy noninflammatory condition that results in flattening Abdomen of the weight-bearing surface of the femoral head. It is Lower abdominal wall caused by disruption in the blood supply of the grow­ Strain of the rectus abdominis * ing femoral head (avascular necrosis) that is thought to Inguinal hernia* Ilioinguinal nerve entrapment* be due to antecedent trauma. Occurring usually in Sports hernia (hockey player's syndrome)* children 4 to 8 years of age, it causes pain in the groin, Abdominal organ conditions anterior thigh, or knee. For this reason, any athlete Abdominal aortic aneurysm younger than 12 years old presenting with knee pain Appendicitis

Downloaded by [University of Sheffield] at 17:45 05 November 2015 should have a thorough hip examination. Diverticulosis, diverticulitis Inflammatory bowel disease Legg-Calve-Perthes disease is associated with a Pelvic inflammatory disease painful limp that worsens with activity and is relieved Ovarian cyst by rest. On examination, hip motion reproduces the Ectopic pregnancy pain, and the patient typically has a loss of internal ro­ Genitalia tation. Chronically, a flexion and adduction contrac­ Prostatitis ture may develop. Plain radiographs show an in­ Epididymitis creased density of the femoral epiphysis and an Hydrocele/varicocele irregular, mottled appearance of the femoral head, Testicular torsion Testicular neoplasm sometimes associated with a subchondral fracture. Urinary tract infection The primary goal of treatment is containment of the femoral head within the acetabulum. Conservative Pain (referred) measures include rest, NSAlDs, traction, and the use of Herniated disk an abduction orthosis. Osteotomy of the femur or Renal lithiasis Spondyloarthropathy pelvis has been described in recalcitrant cases. Return continued *Common sports-related musculoskeletal cause.

THE PHYSICIAN AND SPORTSMEDICINE e Vol 28 • No. 1 • Januruy 2000 73 groin pain continued

TABLE 2. Physical Examination of the Inguinal Raglan

Patient's Position Procedure Details

Standing Observe posture. gait, limp, • Have the patient point to the area of pain and the pattern of radiation alignment, muscle wasting, • Have the patient reproduce painful movements ability to sit and stand up

Examine the low back: active ROM Forward flexion, side bending, extension

Examine the hip: active ROM Trendelenburg's sign (hip adductor strength), ability to squat and duck walk

Examine for hernia Palpate the inguinal region (have the patient cough or strain down)

Supine Examine the abdomen • Palpate for abdominal aortic aneurysm, pain, rebound, guarding, hernia, pulses, nodes • Test for costovertebral angle tenderness (renal punch) • When appropriate, perform a rectal exam to palpate the prostate and rule out occult blood

Examine male genitalia Palpate for a testicular mass, varicocele, or tender epididymis

Pelvic exam in women, • Look for purulent vaginal discharge of pelvic inflammatory disease if appropriate and bluish cervix of pregnancy (ectopic) • Palpate for tender cervix or adnexa. ovarian mass

Examine low back, sciatic Perform straight-leg raise test. test for Lasegue's sign and Bragard's nerve roots sign (dorsiflexion of ankle)

Examine hip motion • Evaluate flexion, external rotation. internal rotation, abduction, adduction, joint play, quadrant tests • Perform passive straight-leg raise. Thomas. and rectus femoris stretch tests

Palpate pelvic structures Palpate symphysis, pubic rami, iliac crests, adductor insertions, AS IS, PSIS, ischial tuberosities

Examine sacroiliac joints Perform Patrick's (FABERE) test Downloaded by [University of Sheffield] at 17:45 05 November 2015 Look for leg-length discrepancy Verify grossly and determine true length by measuring from AS IS to lateral malleoli

Prone Examine hip motion • Evaluate extension as well as internal and external rotation • Perform Ely's and femoral nerve stretch test

Side lying Examine iliotibial band Perform Ober's test

Sitting Evaluate muscle strength Test hip flexion (L-2, L-3), hip extension (L-5, S-1, S-2), abduction (L-4, L-5, S-1), adduction (L-3, L-4)

Test reflexes Assess patellar tendon (L -4)

Test sensation Assess lower abdomen (T-12), groin (L-1), medial thigh (L-2), anterior quadriceps (L-3)

ROM = range of motion; AS IS =anterior superior iliac spine; PSIS = posterior superior iliac spine

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to full activities is permitted when the femoral head tient stands on one leg, pain in the weight-bearing hip demonstrates reossification on radiographs.' or weakness of the ipsilateral gluteus medius results in Slipped capital femoral epiphysis. This progressive a downward pelvic tilt on the contralateral side). or sudden posteroinferior slip of the femoral head at Plain radiographs should include anteroposterior, the epiphysis is the most common hip disorder in ado­ lateral, and frog lateral views, which may show widen­ lescents. It most commonly affects 10- to 15-year-old ing of the epiphyseal line and the degree of slip: Grade boys who are tall and have recently undergone rapid 1 is less than one-third the width of the femoral head, growth, or who are obese and have delayed secondary grade 2 is one-third to half the width, and grade 3 is sex characteristics. While the cause of slipped capital more than half the width.' A rule of thumb on plain femoral epiphysis is unclear, the mechanically weak radiographs is that the superior line of the femoral wne of the epiphysis separates between the hypertro­ neck fails to transect the overhanging ossified epiph­ phying and calcifYing cells at a time of imbalance in ysis (figure 1). sex and growth hormones. Treatment consists of surgical fixation in situ with Slipped capital femoral epiphysis causes insidious threaded pins, with a possible osteotomy. There is a groin, hip, thigh, or knee pain (see caution in previous high incidence of avascular necrosis associated with section about knee pain in those w1der 12). On exami­ preoperative manipulation in chronic cases (more nation, the patient has painful limitation of hip mo­ than 3 weeks). After pinning, activity follows pain tol­ tion, with associated psoas spasm. The hip is often erance; a slow return to sports activity usually begins at held in flexion, with a resulting antalgic or gluteus about 6 weeks. medius lurch (Trendelenburg gait). External rotation Acetabular labral tears. A high index of suspicion is with passive hip flexion results in limited internal rota­ required to diagnose this uncommon cause of me­ tion and a measurable true leg-length discrepancy. chanical hip pain. The athlete may experience a feeling Trendelenburg's sign is usually positive (when the pa- of giving way or a sharp catching pain in the groin that continued

Figure 1 b: Staff enhancement Downloaded by [University of Sheffield] at 17:45 05 November 2015

FIGURE 1. Radiographic findings with slipped capital femoral epiphysis (a). Generally with this condition, a line drawn on and paralleling the superior aspect of the femoral neck fails to transect the epiphysis (b). In healthy patients, such a line transects the epiphysis (b, inset).

Figure 1 reprinted with permission from Greenspan A Orthopaedic Radiology. A Practical Approach. ed 2 Philadelphia. Lippincott-Raven. 1997

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Figures 2-5: Mary AJbury-Noyes radiates into the anterior thigh, especially with a rotation of the hip while arising from a seated position. On examination, a palpable and audible snapping may be elicited with extension and internal rotation of the hip. Arthrography, MR1, and arthroscopy can be used to confirm the diagnosis. Conserva­ tive management with NSAIDs and physio­ therapy is usually successful, although ar­ throscopic or open operative excision may be necessary in recalcitrant cases. Snapping hip syndrome. This syndrome refers to conditions about the hip that cause an audible or palpable "snapping." The cause can be intra-articular or extra-articular. The most common cause involves the snapping of the iliotibial band or the tensor fascia lata over the greater trochanter of the femur (ex­ ternal snapping). FIGURE 2. In patients who have groin pain, physical examination may reveal Less commonly, the iliopsoas tendon may ecchymosis and palpable tenderness at specific bony sites, most commonly, the snap as it slides over the iliopectineal emi­ anterior superior iliac spine, where the sartorius muscle attaches; the anterior inferior iliac spine, where the rectus femoris muscle attaches; and the ischial nence, or the iliofemoral ligament may slide tuberosities, where the hamstring muscles attach. Plain radiographs may reveal an over the femoral head (internal snapping). avulsion fracture at one of these sites, particularly in adolescent athletes. Other causes may include the long head of biceps femoris gliding over the ischial tuber- osity and intra-articular pathology such as subluxation stretching. With recalcitrant cases, operative excision of the hip or the presence ofloose bodies.z.' of the offending bursa has been described, but only as 2 The athlete may describe associated pain, crepita­ a final resort ,3 tion, and local warmth, but performance is rarely im­ Avulsion fractures about the hip. Avulsion frac­ paired. Physical examination focuses on localizing the tures occur more commonly in skeletally immature source of the click and associated discomfort athletes than in adults because young patients' ten­ Treatment consists of modified activity, correcting dons are stronger than their cartilaginous growth cen­ Downloaded by [University of Sheffield] at 17:45 05 November 2015 muscle imbalance and tightness of the involved struc­ ters. The same stress that causes a muscle strain in an tures (eg. the iliotibial band or tensor fascia lata), and adult can cause an avulsion fracture in an adolescent correcting biomechanical malalignments using orthoses These fractures occur at the secondary growth centers, whenever appropriate, as with a leg-length discrepancy. or apophyses, which become separated from the un­ Corticosteroid injections are appropriate if bursal causes derlying bone. The fractures do not become widely dis­ can be identified. Surgery is rarely recommended. placed because of the surrounding thick periosteum.z.' Iliopectineal bursitis. This disabling condition The mechanism of injury is a sudden, violent mus­ usually causes anterior hip pain that can be severe cle contraction or excessive repetitive action across the enough to cause a limp. The symptoms are relieved apophysis. Hip avulsion fractures are common in by flexion and external rotation of the hip. The pain young sprinters, soccer players, and jumpers. Patients may be related to snapping of the iliopsoas tendon typically describe local pain and swelling after an ex­ over the iliopectineal eminence. Stretching of the ilio­ treme effort and report no external trauma psoas tendon by hip extension will usually worsen Physical examination reveals ecchymosis and pal­ 2 the discornfort. ,3 pable tenderness at specific bony sites (figure 2), most Treatment consists of rest, NSAIDs, and iliopsoas commonly, the anterior superior iliac spine, where the continued

THE PHYSICIAN AND SPORTSMEDICINE e Vol 28 • No. 1 • January 2000 81 groin pain continued

Patients who have osteitis pubis rarely describe pain as originating from the ------symphysis. Instead, pain appears to emanate from the perineal, inguinal, or thigh region. On exam, however, the pubic symphysis is usually tender to palpation.

sartorius muscle attaches, the anterior inferior iliac Osteitis pubis. This inflammatory lesion of the spine, where the rectus femoris muscle attaches, and bone adjacent to the symphysis pubis is thought to be the ischial tuberosities, where the hamstring muscles due to mechanical strain from trauma, excessive twist­ attach. Plain radiographs will reveal the avulsion frac­ ing and turning in sports such as soccer, or repetitive ture. It is useful to compare the injured side with the shear stress from excessive side-to-side motion (as in contralateral side. runners with a crossover arm swing). It is common in Treatment involves rest-paying particular atten­ ice hockey, soccer, and distance running. It is also tion to avoid stretching the involved muscle-icing, common in exercising pregnant women and women and analgesics. Patients progress from gentle active in the postpartum period because of the particular in­ and passive range-of-motion exercises to resistance stability of this joint after birth. exercises. Stretching exercises and sport -specific exer­ Pain is rarely described by the injured athlete as cises are the final steps toward return to competition. originating from the symphysis. Instead, pain appears Most patients can be treated nonoperatively. although to emanate from the perineal, inguinal, or thigh re­ some authors recommend surgery for severely dis­ gions. On examination, however, the pubic symphysis placed fragments in rare cases. is usually tender to palpation, and the pain can be re­ Pubic ramus stress fracture. Stress fractures of the produced by passive abduction and active resisted ad­ pubic ramus occur mostly in distance runners and duction of the thigh. joggers. Differences in gait between the sexes, as well Radiographic changes may not be visible for 2 to 3 as osteoporosis in the female athlete triad, may ac­ weeks. Common bone changes are symmetric resorp­ count for a higher incidence in females. Traction forces tion of the medial ends of the pubic bones, widening produced by the muscles attaching to the pelvis have of the symphysis, and rarefaction or sclerosis along the been implicated as possible etiologic factors. pubic rami. Pain in the inguinal, perineal, or adductor region is Bone scintigraphy. typically showing increased up­

Downloaded by [University of Sheffield] at 17:45 05 November 2015 the usual presenting symptom. On examination, there take unilaterally or bilaterally at the pubic bones, is ef­ is no sign of limitation of hip motion, although an an­ fective in making an early diagnosis. talgic gait is common. Exquisite tenderness over the Treatment initially includes relative rest, icing, and affected pubic ramus is also common. The positive NSAIDs, followed by stretching and strengthening exer­ standing sign (frank pain or an inability to stand un­ cises of the adductors. During relative rest, patients supported on the affected leg) is pathognomonic of maintain fitness with cycling and swimming. Patients pubic ramus stress fracture. typically return to play after 8 to 12 weeks, although this Plain radiographs may not show a fracture until condition is often chronic and recurrent. If symptoms several weeks after the injury. Bone scan is necessary persist, local corticosteroid injections may be attempted. for early diagnosis. Because the main differential diagnosis is osteomy­ Treatment consists of cessation of running activi­ elitis, especially in patients having undergone a previ­ ties. Cardiovascular fitness can be maintained by per­ ous surgical procedure to the pelvic region, corticoste­ forming non-weight-bearing activities such as swim­ roid injections should be preceded by blood tests aimed ming and cycling. Most athletes will show complete at ruling out leukocytosis. That being said, in contrast to union of bone at 3 to 5 months.' osteomyelitis, osteitis pubis is usually bilateral, has no

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The mechanisms of injury to the adductor longus include acute injury-such as a powerful abduction stress during simultaneous adduction of the leg when performing a cutting movement-or overuse, such as repetitive abduction of the free leg in the skating stride. With a sudden change of direction that occurs with sharp cutting movements, a forceful eccentric contrac­ tion of the muscle occurs instead of a concentric con­ traction, causing the strain. While a forceful muscle contraction in an adult may cause a strain in the mus­ cle-tendon unit, the same action in an immature ath­ lete may cause an avulsion fracture. • An acute strain will cause pain that feels like a sud­ den stab in the groin area. If the injured athlete tries to continue the activity, the intense pain will recur. There may be swelling and bruising localized to the origin of the adductor longus tendon or at the musculotendi­ nous junction. Overall, the patient has the classic mus­ culotendinous injury triad: (1) tenderness to palpa­ tion, (2) pain with resisted movement (in this case, adduction), and (3) pain with passive stretching (in this case, abduction). Imaging procedures are usually unnecessary in simple strains, although images may be obtained to FIGURE 3. Among the musculotendinous injuries of the thigh rule out more severe injuries such as avulsion frac­ that can cause groin pain, adductor longus muscle injuries are tures. Ultrasound, though operator dependent, is a most common. Any injury to the iliopsoas, rectus femoris, cost -effective method to confirm muscle tears. sartorius, or gracilis muscle can also produce groin pain. Treatment of acute groin injuries begins with rest from aggravating activities for 1 to 2 weeks. Icing. com­ pression shorts, and NSAIDs provide symptomatic re­ sequestrum, and yields a negative culture.• lief. Physiotherapy should begin as soon as pain allows Surgery, in the form of arthrodesis and debride­ and should initially include isometric contractions Downloaded by [University of Sheffield] at 17:45 05 November 2015 ment, has been described for cases unresponsive to without resistance, followed by isometric contractions conservative therapy. 1 against resistance, the limit being pain. After the initial phase of inflammation has subsid­ Thigh Muscle Strains ed, athletes can begin a stretching program. Heat in­ Muscle injuries can result from a variety of causes creases the extensibility of the collagen in tendons and including poor flexibility, uncoordination, inade­ muscles and will be beneficial for the remainder of re­ quate warm-up, muscle strength imbalance, muscle habilitation. Maintenance of cardiovascular fitness weakness, fatigue, electrolyte imbalance, poor sports with aerobic exercises that do not exacerbate the pain technique, and increased age.' Some of the most should be greatly encouraged. Preventive training and common thigh strains are of the adductor longus, the correction of predisposing factors (eg, intrinsic rectus femoris, and iliopsoas. muscle tightness, muscle strength imbalances, or Adductor longus strain. While the adductor longus, muscle weakness) should be included in a complete adductor magnus, adductor brevis, and pectineal rehabilitation program. muscles are all adductors of the hip (figure 3), of these Rectus femoris strain. The rectus femoris is heavily the adductor longus is most often injured in sports. 1 activated and commonly overused during running, continued

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jumping, bicycling, and skating.' Originating just entiate from an intra-abdominal process such as ap­ above the acetabulum and inserting as the patellar pendicitis. A key diagnostic clue is localized tender­ tendon at the tibial tuberosity (figure 3), the rectus ness that is accentuated when the patient contracts femoris flexes the hip and extends the knee. the muscle and decreases with muscle relaxation. The pain from a rectus femoris strain may be felt Conservative treatment as outlined for injuries of from the area anterior to the acetabulum and may radi­ the adductor longus should be used. In chronic, recal­ ate to the thigh and inguinal area. Pain can be repro­ citrant cases, such as significant tears, surgical repair duced by resisted hip flexion or resisted knee extension. may be necessary. Conservative treatment as outlined for injuries of Inguinal hernia. Hernias are common enough that the adductor longus should be used. The risk of myosi­ every patient suffering from groin pain should be ex­ tis ossificans is increased in cases of significant muscle amined to eliminate this possibility. An inguinal hernia hemorrhage. Initial bleeding leads to formation of a he­ is located above and medial to the pubic tubercle. A matoma, which later calcifies within the substance of femoral hernia, more common in female patients, is the muscle, restricting its flexibility.' Keeping the mus­ below and lateral to the pubic tubercle. cle in a lengthened position can help decrease further The most common type of hernia is a direct in­ bleeding and subsequent heterotopic bone formation. guinal hernia, which appears as a diffuse bulge at the Wrapping the affected area with ice and an elastic ban­ internal ring. in the medial part of the inguinal canal. dage, with the knee in maximum flexion, is optimal An indirect inguinal hernia is congenital in origin and therapy in the first 24 hours. Some authors believe that is caused by a failure of the processus vaginalis to NSAIDs should be avoided in the first 48 hours. close. It therefore appears at the external ring and may Iliopsoas strain. Strain of this strong hip flexor extend into the scrotum. In contrast to what some au­ commonly occurs in weight lifting. uphill running. and thors have called "groin disruptions" or in contrast to sit-ups. the "sports hernia'' described below, inguinal hernias Tenderness associated with this strain is difficult to result from a weakness or tear of the posterior wall of palpate, since the iliopsoas muscle inserts at the lesser the inguinal canal (transversus abdominis)."4 trochanter of the femur. If the site is to be successfully In most cases, activities that significantly increase palpated, palpation will be done bimanually over the intra-abdominal pressure or may involve repeated Val­ medial aspect of the femur. Pain can be elicited by salva's maneuvers, such as weight lifting. cause or ex­ having the patient flex the hip 90° and then try to flex it acerbate the hernia While the pain might initially oc­ further against resistance or by passive stretching with cur only after activity, it typically will increase in hyperextension at the hip. frequency to the point of occurring during activity and Conservative treatment as outlined for injuries of even with simple trunk and hip movements. The pain

Downloaded by [University of Sheffield] at 17:45 05 November 2015 the adductor longus should be used. will often radiate into the proximal thigh or the scro­ tum in males. Lower Abdominal Wall Injuries Examination for both types of hernia involves in­ The chief lower abdominal wall injuries in active vaginating the scrotal skin along the spermatic cord patients include rectus abdominis strain, inguinal her­ using the index finger in males or direct palpation in nia, ilioinguinal neuralgia, and conditions called females. A palpable mass may or may not be detected. "sports hernia" and "hockey player's syndrome." Maneuvers to increase intra-abdominal pressure, such Strain of the rectus abdominis. The rectus abdomi­ as coughing or tensing the abdominal musculature, nis muscle originates on the pubic bone, very close to may produce a cough impulse (a sign of hernia), or the origin of the adductor longus. Strain in this muscle may make a mass more prominent. is usually caused by overloading, as in weight lifting or Inguinal hernias should be surgically repaired not doing sit-ups. Pain is localized at the origin and is re­ only to relieve pain and discomfort, but also to prevent produced by elevating the legs and/ or the head with incarceration, obstruction, and infarction of the bowel. the patient supine. Dioinguinal neuralgia. The ilioinguinal nerve origi­ A rectus abdominis strain can be difficult to differ- nates from the Ll-2 nerve roots and is similar in course

84 Vol 28 • No. 1 • January 2000 e Tile PHYSICIAN AND SI'ORTSM5DICINE groin pain continued

Figure 6: Courtesy of Vincent J. Lacroix. MD. Steff recreation

FIGURE 4. Direct trauma, intense abdominal muscle training, or inflammatory conditions can lead to entrapment of the ilioinguinal nerve, which innervates the lowest portions of the transversus abdominis and internal oblique muscles and the skin overlying the inguinal ligament. The nerve transmits sensation from the base of the penis, scrotum (or labium major), and part of the medial thigh. Patients describe a burning or shooting pain in FIGURE 5. Typical sites of pain in the 'sports hernia,' 'hockey these areas; hip hyperextension may exacerbate it. Treatment player's syndrome,' and other conditions that cause pain in usually consists of injecting anesthetics and/or corticosteroids. the same general anatomic region.

and function to the intercostal nerves (figure 4). It in­ acerbated by hyperextension of the hip. Tenderness

Downloaded by [University of Sheffield] at 17:45 05 November 2015 nervates the lowest portions of the transversus abdo­ may be localized near the anterior superior iliac spine minis and internal oblique muscles, as well as the skin where the ilioinguinal nerve pierces the fascia. The di­ overlying the inguinal ligament. agnosis can be confirmed by a blockade of the nerve It transmits sensation from the base of the penis and with local anesthetics. scrotum (or labium major) along with part of the medial Treatment consists of repeated infiltrations at the thigh. Direct trauma, intense abdominal muscle train­ confirmed site with anesthetics and/or corticoste­ ing, or inflammatory conditions can lead to entrapment roids. Nerve ablation may be indicated in severe cases. of this nerve as it passes through or close to the abdomi­ Sports hernia. Athletes in fast-moving sports that nal muscle layers. Ilioinguinal nerve entrapment is a involve twisting and turning-like soccer and ice well-established cause of chronic inguinal pain in pa­ hockey-may be at particular risk of a disruption in tients who have had lower abdominal surgery (eg, ap­ the area of the inguinal canal. This injury, often called a pendectomy or inguinal herniorrhaphy).' "sports hernia," usually involves the posterior wall of Patients will describe a burning or shooting pain in the inguinal canal and can appear as a tear of the the distribution of the nerve. light-touch sensation in transversus abdominis muscle or as a disruption to the the inguinal area may be altered, and pain may be ex- conjoined tendon, which is the tendon of insertion of continued

THB PHYSICIAN AND IPORTSMBDICINB e Vol 28 • No. 1 • January 2000 85 groin pain continued

both the internal oblique and transversus abdominis oblique aponeurosis, associated with inguinal nerve muscles." A sports hernia may; however, involve the in­ entrapment. The pain is muscular in nature, of gradual ternal oblique muscle and external oblique aponeuro­ onset, and exacerbated by ipsilateral hip extension sis of the internal inguinal wall/ It differs from the and contralateral torso rotation. Interestingly; it occurs more common inguinal hernia in that it does not in­ almost exclusively on the side opposite the player's volve a clinically detectable hernia. forehand shot. It is felt mostly during the propulsive A sports hernia typically produces unilateral groin phase of skating (the first few strides) and during the pain during exercise (figure 5). In chronic cases, how­ slap-shot motion. Inherent abdominal wall weakness, ever, the patient may have symptoms during activities musculoskeletal fatigue, and poorly adapted equip­ of daily living. Onset of pain is usually insidious but ment probably all contribute to this overuse injury of may occur suddenly in some cases. It is typically local­ the lower abdominal wall. ized to the conjoined tendon but can involve the in­ Physical examination reveals no overt signs of her­ guinal canal laterally. Sudden movements often exac­ nia, although palpation of the superficial inguinal ring erbate the pain. may reproduce the pain. Conventional imaging mo­ Examination for the sports hernia is generally done dalities such as bone scan, ultrasound, cr, and MR1 all by inverting the scrotal skin with a finger and palpating fail to reveal the defect. Surgical exploration is current­ for pain over the conjoined tendon, pubic tubercle, ly the only method to confirm the diagnosis. and rnidinguinal region. The pain may be exacerbated Surgical treatment involves restoring normal anato­ by sit-ups. Radiographs are important to rule out other my by repairing the external oblique aponeurosis. injuries. Neurectomy of the ilioinguinal nerve is also performed. Treatment is generally surgical. Rehabilitation in­ The patient is advised to refrain from skating or other cludes 6 to 8 weeks of pelvic strength, stability, and types of violent twisting and turning motions for 4 flexibility exercises and avoidance of sudden, sharp weeks postoperatively and is then gradually returned to movements. full activity over the next 6 to 8 weeks. Physiotherapy, Hockey player's syndrome. A subset of the sports pool therapy; stationary cycling, and controlled weight hernia has been called "hockey player's syndrome." training are the mainstays of rehabilitation. 5 Since 1989, elite ice hockey players have been referred to our center for an atypical lower abdominal pain Broad Differential, Focused Treatment syndrome (figure 5) that resembles but does not clear­ Injuries located within the anatomical area de­ ly correspond to previously described entities. In 1998, scribed as the "groin'' require astute history-taking and colleagues and I published a report5 on 11 of these pro­ physical-exam skills. Once a careful diagnosis is made, fessional hockey players, a small subset of the 50 or tailored management-often involving conservative

Downloaded by [University of Sheffield] at 17:45 05 November 2015 more patients who have now been treated for this con­ measures-will help patients return to full activity as dition at our institution. quickly as possible. Judicious use of appropriate diag­ This hockey player's syndrome-also referred to as nostic imaging studies may help focus the large differ­ the "slap-shot gut" -involves a tear of the external ential diagnosis of these injuries. AiM

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86 Vol 28 • No. 1 • January 2000 e THE PHYSICIAN AND SPORTSMEDICINE