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Groin Injuries in Athletes

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Groin Injuries in Athletes Groin Injuries in Athletes VINCENT MORELLI, M.D., Louisiana State University School of Medicine, New Orleans, Louisiana VICTORIA SMITH, M.D., Louisiana State University Health Sciences Center, Kenner, Louisiana Groin injuries comprise 2 to 5 percent of all sports injuries. Early diagnosis and proper treatment are important to prevent these injuries from becoming chronic and poten- tially career-limiting. Adductor strains and osteitis pubis are the most common muscu- loskeletal causes of groin pain in athletes. These two conditions are often difficult to distinguish. Other etiologies of groin pain include sports hernia, groin disruption, ilio- psoas bursitis, stress fractures, avulsion fractures, nerve compression and snapping hip syndrome. (Am Fam Physician 2001;64:1405-14.) he diagnosis of groin pain in unclear in approximately 30 percent of cases.4 athletes is difficult because the Factors that complicate the diagnosis include anatomy of the region is com- the complex anatomy of the region and the plex and because two or more frequent coexistence of two or more disor- injuries often coexist. Intra- ders. In one study5 of 21 patients with groin Tabdominal pathology, genitourinary abnor- pain, 19 patients were found to have two or malities, referred lumbosacral pain and hip more disorders. The investigators concluded joint disorders (e.g., arthritis, synovitis, avas- that groin pain in athletes is complex and can cular necrosis) must first be excluded. Once be difficult to evaluate even by experienced these conditions are ruled out, other muscu- physicians. loskeletal conditions involving the groin may The ability to visualize the anatomy of the be pursued (Table 1). groin area is important for both the physical Between 2 and 5 percent of all sports examination and the differential diagnosis. injuries occur in the groin area.1,2 These in- The anatomy of the groin region is illustrated juries are more prevalent in persons who par- in Figure 1. ticipate in sports such as ice hockey, fencing, handball, cross country skiing, hurdling and Adductor Strains high jumping, and may comprise as many as The most common cause of groin pain in 5 to 7 percent of all injuries in soccer players.3 athletes is probably adductor strain. This is The diagnosis is often frustrating for both the certainly true among soccer players: in this athlete and the physician, and remains sport, rates as high as 10 to 18 groin injuries per 100 players have been reported, and 62 percent of these have been diagnosed as 2,6 TABLE 1 adductor strains. Differential Diagnosis of Nonathletic Causes of Groin Pain These strains are usually easily diagnosed on physical examination with pain on palpa- tion of the involved muscle and pain on Intra-abdominal disorders (e.g., aneurysm, appendicitis, diverticulosis, 6 inflammatory bowel disease) adduction against resistance. They must, however, be distinguished from osteitis pubis Genitourinary abnormalities (e.g., urinary tract infection, lymphadenitis, prostatitis, scrotal and testicular abnormalities, gynecologic abnormalities, and “sports hernias,” which can present with nephrolithiasis) pain in similar locations. Referred lumbosacral pain (e.g., lumbar disc disease) Although the diagnosis is usually made clinically, radiographs can be helpful in ex- Hip joint disorders (e.g., Legg-Calvé-Perthes disease, synovitis, slipped femoral 6 capital epiphysis in younger patients and osteochondritis dissecans of femoral cluding fractures or avulsions. If the diagno- head, avascular necrosis of the femoral head, osteoarthritis, acetabular labral sis is in question, magnetic resonance imag- tears) ing (MRI) can be used to confirm muscle strain or tears, and partial and complete ten- OCTOBER 15, 2001 / VOLUME 64, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1405 don tears. Ultrasound is useful for diagnos- specializing in sports medicine believe that ing muscle and tendon tears, but not muscle these are important contributing factors.6 If strains.7 The most common site of strain is present, these abnormalities should be evalu- the musculotendinous junction of the ated and corrected if possible. adductor longus or gracilis. Complete avul- Second, what is the location of the tear? sions of these tendons also occur, but much This has important therapeutic and prognos- less frequently. tic implications. If an acute tear occurs at the Once the diagnosis of adductor strain has musculotendinous junction, a relatively ag- been established, three questions must be con- gressive approach to rehabilitative treatment sidered. First, are there biomechanical abnor- can be undertaken. When an acute partial malities that may predispose to injury? Foot tear occurs at the tendinous insertion of the and lower leg malalignment, muscular imbal- adductors into the pubic bone, a period of ances, leg length discrepancy, gait or sport- rest must be completed before pain-free phys- specific motion abnormalities can all theoret- ical therapy is possible.8 ically place abnormal loads on the adductors. Third, what is the chronicity of the symp- Although controlled clinical studies demon- toms? Athletes often do not recall an acute strating a causal relationship between biome- inciting incident and complain instead of chanical abnormalities and adductor strains pain of an insidious onset. These athletes are have not been conducted, many physicians difficult to treat because they remain able to play their sports (at least for a while) after a good warm-up and are not motivated to take time off and undergo proper rehabilitation. Although few controlled studies of the treatment of adductor strains exist in the lit- erature, most clinical experience dictates that acute treatment include physical therapy modalities (i.e., rest, ice, compression, eleva- tion) that help prevent further injury and inflammation. Following this, the goal of therapy should be restoration of range of motion and prevention of atrophy. Finally, the patient should regain strength, flexibility and endurance.6 When the athlete has regained at least 70 percent of his or her Adductor longus muscle strength and pain-free full range of motion, a return to sport may be allowed.9 This return . Pubic symphysis may take four to eight weeks following an . acute musculotendinous strain and up to six months for chronic strains.6,10 . One randomized trial of 68 athletes with Gracilis chronic adductor strain11 compared physical therapy (i.e., friction massage, stretching, Adductor brevis muscle transcutaneous electrical nerve stimulation, Adductor magnus muscle laser treatment) with active training exercise. A significantly greater number of participants ILLUSTRATIONS BY CHRISTY KRAMES (23 versus four in the physical therapy group) FIGURE 1. Bony pelvis with origin of adductor musculature. were able to return to their sport after an 1406 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 64, NUMBER 8 / OCTOBER 15, 2001 Groin Injuries eight- to 12-week active training program. Further studies may corroborate this initial Osteitis pubis occurs commonly in soccer players and investigation, and active training methods distance runners and is a frequent cause of groin pain. may be the future in treating acute and chronic adductor strains. Nonsteroidal anti- inflammatory drugs (NSAIDs) and steroid injections have been mentioned in the treat- pubis. However, it is plausible that such ment of these conditions, but their efficacy is abnormalities could place the pelvis in the debatable and lacks support in the literature.6 path of excessive force. Patients with chronic adductor longus The clinical symptoms of osteitis pubis strains that have failed to respond to several include exercise-induced pain in the lower months of conservative treatment have been abdomen and medial thighs. Symptoms are shown to do well after surgical tenotomy and gradual in onset, slowly increasing in severity if should be referred to a sports medicine sur- activities are not curtailed. One review article20 geon for this consideration.12,13 Complete noted the following incidence of symptoms in tears of the tendinous insertion from the patients with documented osteitis pubis: bone, though rare, generally do better with adductor pain in 80 percent, pain around the surgical repair.9 pubic symphysis in 40 percent, lower abdomi- nal pain in 30 percent and hip pain in 12 per- Osteitis Pubis cent. Referred scrotal pain, which is said to be Osteitis pubis is characterized by pubic typical, was found in only 8 percent. symphysis pain and joint disruption.14 It On physical examination, tenderness over occurs commonly in distance runners and the pubic symphysis is usually present, and soccer players, and has been found in some lack of such tenderness usually excludes the sports medicine clinics to be the most com- diagnosis.3 Pain can often be provoked by mon cause of chronic groin pain.5 Osteitis active adduction if the distal symphysis is pubis may be difficult to distinguish from involved, or by sit-ups if the proximal portion adductor strains, and the two conditions may is involved. occur concomitantly in the same patient. Plain radiographs may show widening of Also, one must remember that osteomyelitis the pubic symphysis, irregular contour of of the pubic symphysis, although usually seen articular surfaces or periarticular sclerosis. following a surgical procedure around the However, in early or mild disease, radiographic pelvis, has been reported to occur sponta- findings may be normal.17 Plain films are also neously in athletes.15,16
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