The Physician and Sportsmedicine ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20 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. Submit your article to this journal Article views: 2 View related articles Citing articles: 2 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipsm20 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.