A course Review from James Moore's Sporting Hip and Groin Course - February 2016 (Highly Recommend!). Following my attendance of the course, i performed my own research on 'The Sporting Hip and Groin' and incorporated this into the course review which I presented to the Sports Science and Medicine staff at Wigan Athletic FC. Further references available upon request.

1. The Sporting Hip and
Groin
CPD Course Review
Tony Tompos
U21s Physiotherapist Wigan Athletic FC

2. Anatomy of the Hip and
Groin
Pelvis
• Stable base for spine and lower
limbs to function
• Weightbearing and propulsive
forces are transmitted during gait
• Instability or pain at one point has
a direct effect on another (polo
mint)
• The pelvis is designed primarily for
load transfer and is therfore
inherently stable (Snijders et al,
1993)

3. Hip Joint
• Best example of a ball and socket joint in the
human body
• Stability of the joint provided by bony
configuration; specifically the depth of the joint
augmented by the labrum and strong capsular
ligaments (Griffin, 2001).
• Labrum contains free nerve endings which has
the potential to be a source of pain
• The Labrum creates a suction effect on the
femoral head, generating a negative
atmopheric pressure, enhancing the stability of
the joint.
• The joint capsule is re-inforced by ligaments
(ILF is the strongest ligament in the body)and
is thickest and strongest superiorly where it is
under most loads during stance and gait.
• Weakest posteriorly.

4. Pubic Symphysis
• Fibrocartilage disk = Shock
absorber
• Reinforced by ligaments:
Superior Pubic, Arcurate,
Interpubic, Inferior and
Posterior Pubic ligaments.
• Little to no movement at all:
Vertical motion = 2mm, Rotary
movement = <1.5°

5. Muscles
Trunk Flexors
• Rectus abdominus together
with Internal and External
Obliques produce trunk flexion
when the pelvis is fixed.
• Lateral Flexion of the trunk is
produced by the lateral fibres of
EO and ipsilateral IO.
• Rotation is produced by EO
and contralateral IO.

6. Hip Extensors
• The greatest hip extensor is the
Gluteus Maximus.
• The adductor magnus (Ischial
portion) is the strongest hip
extensor in hip flexion (Moore,
2016)
• Hamstrings contribute to hip
extension, though this is not
their main function
• Piriformis and glute med also
play a role in extension

7. Hip Flexors
• The Illiopsoas and Rectus
Femoris are the major hip
flexors of the hip.
• Evidence sugegsts Illiospas
initiates Hip flexion in a hip
extended position and then RF
and momentum take over.

8. Abductors of the
Hip
• The TFL assists in abduction, though
the major abductor of the hip are Glute
Max and Min.
• Glute Med is the primary stabiliser of
the the hip in standing.
• There is succesive recruitment of the
abdutor muscles dependant on pelvic
tilt..
• When the COM is behind the joint axis
(Posterior Tilt), TFL is the dominant
abductor. Optimal function of the
Gluteus Medius is at 10° anterior tilt.
Glute Max alongside Piriformis laterally
stabilise the hip when the pelvis is tilted
more than >10°.

9. Hip Adductors
• Adductors of the hip are divided
in to 2 groups:
• Anterior Group: Pectineus.
Brevis, Longus, Magnus &
Gracilis.
• Posterior Group: Glute Max,
Quadratus Femoris, Obturator
externus, and hamstrings.
• Adductor Longus; Aids Hip
Flexion, Co-Contracts during
stance phase and decellerates
hip extension eccentrically.

10. Sacroilliac Joint
• Beyond scope of this presentation.
• BUT….
• The SIJ has very little movement in
non-weight bearing (average 2.5°,
range 0-4°) (Jacob & Kissling 1995)
• There is strong evidence that intra-
articular displacements within the
SIJ’s do not occur (Tullberg et al,
1993).
• A clinical diagnosis of SIJ pain can
be made by 3/5 positive SIJ pain
provocation tests (Laslett, 2005)

11. Pelvic Arteries
• Kinking and endofibrosis of the
iliac arteries are uncommon and
poorly recognized conditions
affecting young endurance
athletes (Peach et al, 2012).
• Despite having no cardiovascular
risk factors, highly trained young
athletes (Usually cycling) have
been found to have localized flow
limitation within the iliac arteries.
Vessel stenosis was often caused
by endofibrosis – a pathological
thickening of the vessel intima –
or kinking of the iliac artery
(Peach et al, 2012).

12. Pelvic nerves and referred
pain
• Lumbar spine may refer in to
the groin
• Usually L1, L2 due to
dermatomal pattern
• Need to rule out Lumbar Spine
when assesing Hip and Groin

13. Subjective AssesmentAssesment should be systematic ascertaining the relationship between primary and secondary conditions
and the source of pain versus the source of dysfunction.
• Presenting complaint: Listen closely to pick up on structures involved; joint v muscle v nerve. E.G Vague, deep, dull ache
may be more syonymous with joint injury. Where as a sharp pin point pain brought on by specific movement may be indicative
of a muscular problem.
• Age of Patient:
• OA hip >45 years typically
• Congenital hip dysplasia is seen in infancy aged 3-12
• Legg Calve-Perthes Disease more common in boys aged 3-12
• Elderly women more prone to osteoperotic NOF fracture
• Aggs and Eases:
• Hip Joint Movements: Climbing up down stairs/in and out of car. Driving or sitting for long periods
• Abdominal work/coughing may indicate hernia type pain.
• Pain that becomes worse with exercise may suggest stress fracture, bursitis, muscle tear.
• Movements which patient feels are weak or abnormal:
• Kicking - may be related to Illiopsoas / Rectus Femoris
• Twisting - may indicate adductor pathology
• Sit Ups - may indicate rectus abdominus / hernia pathology

14. Superior border of the Triangle: Corresponds to the position of the
inguinal ligament, a thickening of the external oblique muscle. Rectus
abdominus insertions, internal oblique, external oblique, transverse
abdominus insertion and aponeurosis, inguinal canal, inguinal ring,
illiolinguinal, illiopogastric and genital branch of the genitofemoral nerve,
conjoint tendon of illiopsoas and visceral contents.
Subjective Assesment -
Location of Symptoms
Using Falvey et al’s Patho-anatomical approach
to the diagnosis of groin pain (2009), clinicians
can use the location of patients pain as a guide to
consider different groin pathology.
Within the Triangle: Conjoint tendon of the
illiopsoas muscle, rectus femoris muscle, femoral
canal.
Lateral Border of the Triangle: Femoro-
acetabular joint, trochanteric bursa, TFL, and ITB.
Although the FA Joint is within the triangle,
pathology of the joint is usually referred to as the
greater trochanter.
Medial Border of the Triangle: Lie the
adductor muscles from superficial to deep
- adductor longus, gracilis, adductor
brevis, adductor magnus. AL and Gracilis
tendons most commonly affected and line
in a continuous site of origin along the
body of the pubis.

15. The Pubic Clock
• Falvey et al describe the use of
a ‘pubic clock’ to define areas
of tenderness of the pubic
tubercle due to the amount of
structures which converge at
this point. Using the pubic
clock, the clinician can ‘walk
their finger’ around the tubercle
assigning tender points to each
part of the clock face to the
relevant attachment (Falvey,
2009).

16. Terminology and definition of
groin pain in Athletes
• A recent consensus statement was
produced by 24 experts in 2015
which looked to define standard
terminology related to groin pain
along with accompanying definitions
(Weir et al, 2015).
• The reason for this consensus
statement was because in a recent
systematic review on the treatment
of groin pain in athletes, 33 different
diagnostic terms were used in 72
different studies (Semer et al, 2015).

17. Terminology of Groin Pain in
Athletes
• Defined clinical entities for groin
pain
1. Adductor related groin pain
2. Illiopsoas related groin pain
3. Inguinal related groin pain
4. Pubic related groin pain
• Hip Related Groin Pain
• Other causes of Groin pain in
athletes

18. Clinical entities for Groin
Pain
• Adductor Related Groin Pain -
Adductor Tenderness AND pain on
resisted adduction testing
• Illiopsoas Related Groin Pain - Pain
on resisted Hip Flexion AND/OR pain
on stretching the hip flexors
• Inguinal Related Groin Pain - Pain
located in the inguinal canal AND
tenderness of the inguinal canal. More
likely if pain is aggravated with
resistance testing of the abdominal
muscles OR Valsalva/Cough/Sneeze
• Pubic Related Groin Pain - Local
tenderness of the pubic symphysis and
the immediately adjacent bone.

19. Hip Related Groin Pain
• The hip joint should always be considered as a source of possible
groin pain (Weir et al, 2015)
• History should focus on the onset, nature and location of the pain
and mechanical symptoms such as catching, locking, or giving way
as these are highly sensitive for ruling out hip pathology (Mosler et
al, 2007).
• Tests including passive hip range of motion, FABER’s and FADIR’s
can be used to rule out hip pathology if -ve, but no special tests are
specific enough to rule in hip pathology (Weir et al, 2015).
• If unable to rule out hip pathology due to a positive special test,
then there should be a high index of suspicion for injury to the
labrum, articular cartilage or FAI (Weir et al, 2015).

20. Other conditions causing
Groin pain in athletes
• A high index of suspicion is
needed to appreciate other
sources of groin pain which
may arise from non-MSK
sources including
neurological, rheumatological,
urological, gastrointestinal,
dermatological, oncological
and surgical. Appropriate
additional investgations or
referral are critical for
identifying these other causes
(Weir et al, 2015).

21. Recomendations of terms to avoid
using in groin pain with athletes
• The team of experts from the Doha
agreement (2015) agreed on terms
that should not be used when
describing groin pain to their athletes.
• The terms that the group chose not
to recomend were: Adductor and
Illiopsoas tendinnitis or tendinopathy,
athletic groin pain, athletic pubalgia,
biomechanical groin overload,
Gilmore’s groin, groin disruption,
Hockey-Goalie syndrome, Hockey
groin, osteitis pubis, sports groin,
sportsmans groin, sports hernia,
sportsmans hernia (Weir et al, 2015)

22. Evidence Based Assesment
of Hip and Groin pain
Holmich, 2007
Falvey et al, 2015
Bradshaw et al, 2008

23. Results of Hip and Groin
Assesments
Holmich, 2007
Bradshaw et al, 2008
Falvey et al, 2015

24. Other findings from Hip and
Groin Assesments
Holmich, 2007 Bradshaw et al 2008 Falvey et al, 2015

25. Adductor Muscle Injury
• Common in sports with sudden changes of direction (Hockey, soccer, rugby etc),
Adductor Longus being the most involved.
• Adductor Longus (70%), Magnus (15%), Other (Gracilis, Pectinius, Brevis = 15%)
(Lovell, 2001)
• There may be local tenderness, pain on passive abduction, pain on resisted
adduction or combined flexion/adduction (Moore, 2016)
• Types of Adductor injury include:
1. Bony Avulsion
2. Avulsion Fibrocartilage (Enthesis)
3. Tear at the M-T Junction (Schilders, 2007).

26. Adductor Muscle Injury
• Adductor Tendinopathy may be a primary or a
secondary condition of an acute adductor
muscle injury.
• Clinically this presents as proximal groin pain
which tends to subside with a warm up and
decrease with gentle activities but may progress
with increasing stress.
• If untreated this may progress to persist during
activity and has the potential to limit activity with
pain migrating to the contralateral groin or to the
suprapubic region.
• Emphasis in rehab is the early introduction of
eccentric strengthening. Twice daily eccentric
training may stimulate new tenocyte production
in the target tissues. There may be an initial
increase in symptoms for the first 2-4 weeks and
it may take up to 12-14 weeks before the tissues
are ready for resumption of sporting activities
(Moore, 2016)
Cook & Purdham, 2012

27. Adductor Muscle Injury
• A recent Cadaveric study found
that the proximal anatomy of the
adductor muscles are more
complex than previously described.
• Davis et al found that n=20/20
cadavers had a fusion between the
tendons of Adductor Longus and
Rectus Abdominus (2012).
• Proximal fusion between the
tendons of Adductor Brevis and
Gracilis were also found in n=16/16
patients (Davis et al, 2012).

28. Adductor Muscle Injury
• The same study by Davis also found
a significant difference between the
vascularity of the proximal tendons of
the adductors (2012).
• AL and AB enthesis were significantly
less vascular near the enthesis, a
factor which may predispose the
capacity or rate of tendon repair in AL
and AB (Davis, 2012).
• AL Mid-tendon was also significantly
less vascular compared to AB and
gracilis, which again suggest an
apparant ‘weak spot’ in this area
(Davis, 2012)

29. Illiopsoas Related Groin Pain
• Illiopsoas-Related pain is localised in the
anterior part of the proximal thigh (within the
triangle) sometimes radiating down the anterior
thigh (Holmich, 2012).
• When attempting to discriminate between intra
and extra-articular pathology using FADIR’s
test, consider that the muscle will be folded
(flexion), twisted (adduction) and pulled (internal
rotation) (Holmich, 2012).
• Illiopsoas related groin pain may be diagnosed
with:
1. Pain when palpating the muscle through the
lower abdominal wall
2. Pain on passive stretching of the muscle using
the thomas test position
3. Pain and/or weakness on loading in during hip
flexion at 90° (Holmich, 2012).

30. Inguinal Related groin Pain
• Inguinal related groin pain is experienced ‘deep’ in
the groin, slightly more proximal than adductor
related pain (Superior to the triangle) (Holmich,
2012).
• The pain may radiate along the inguinal ligament,
the perineum, rectus abdominus, adductors and
also the opposite side. Increased intra-abdominal
pressure such as coughing, sneezing or the valsalva
manouevre usually cause increased pain (Homich,
2012).
• Clinical signs include:
1. Pain location in the inguinal canal AND tenderness
of the inguninal canal
2. Pain is aggravated with restance testing of the
abdominal muscles OR on Valsalva/cough/sneeze
3. No palpable inguinal hernia is present (Weir et al,
2015).

31. Pubic Related Groin Pain
• Local tenderness of the pubic
symphysis and the adjacent bone
(Weir et al, 2015)
• Examination may display:
1. Excuisite tenderness over the pubic
bone
2. Adductor muscle guarding on ‘Fall
out test’
3. Pain/loss of power on ‘Squeeze
Test’
4. Positive ‘Pubis Symphysis Stress
Tests’

32. Pubic Related Groin Pain
Best thought of as a stress reaction/degeneration of
the pubic bone characterised by pain, BMO and
degeneration of the pubic symphysis (Moore, 2016)
Consider ‘tug of
war’ between RA
and AL
aponeusosis
Repetetive micro-trauma may
accelerate degeneration of the
articular disk.
Ligamentus injury
to the ligaments of
the symphysis
may lead to
instability within
the joint

33. Pubic Related Groin Pain
• Pubic Symphysis Stress test
1. Passive Hip Extension
2. Passive Hip ABDuction in Extension
3. Resisted hip ADDuction in hip
extension and ABDuction
4. Resisted hip flexion in hip extension
• Squeeze Test
• 45°,0°, 90° hip flexion (200-
240mmHG). Measure P1 and Max
and able to work out % of
strength/load tolerance

34. Hip Joint Related Groin Pain
- Imaging the Hip Joint
• When to image?
1. Diagnosis uncertain AND will affect management decisions
2. Diagnosis obvious, but EXTENT of injury is unclear (will affect
management)
• Options:
• Plain X-Ray (Weightbearing and then supine)
• Bone Scan
• MRI/MRa (MRa offers greater specificity for Labral pathology(75-
95%) (Edmonds, 2003)
• CT Scan (3D CT)
• Ultrasound
Consider that imaging modalities of the hip offer high sensitivity,
but relatively low specificity. E.G MRI/CT unable to detect partial
thickness defects (1cm), Osteochondral loose bodies, small labral
tears. Arthoscopy therfore is a useful investigation for diagnosis
(Villar et al, 1995)

35. Hip Joint Pathology
• Joint Space Pathology - Cysts,
synovitis
• Chondral loose body
• Osteochondral defect
• Ligamentum Teres Tears
• Acetabular Labral Tears
• Osteoarthritis
Diagnosis Pre-2000 Post-2000
OA 38% 8%
Labral
Tear
19% 63%
Chondral
Lesions
16% 3%
Lig. Teres
Tears
5% 11%
Synovitis 4% 3%
Loose
Bodies
4% 6%
Other 14% 6%

36. Labral Injury
• History
1. Rarely a history of trauma
2. Repetetive joint stress in flexion
+/- IR
3. Pain located over anterior thigh
4. Clicking and catching (highly
sensitive descriptions)
5. Grasp C-Sign
6. Flexion and rotation activities
aggravate pain

37. Femoro-acetabular
Impingement
• FAI is a concept describing the early and painful
contact of morphological changes of the hip joint,
both on the acetbular and femoral head sides
• These changes can lead to symptoms of hip and
groin pain, limited range of motion with chondral,
labral and bony lesions (Anderson et al, 2012)
• Pincer impingement involves the acetabular side
of the joint where there is excessive coverage of
the acetabulum.
• Cam impingement involves the femoral side of the
joint where the head is associated with bony
excrescences and is aspheric (The aspheric head
jams in to the acetabulum) (Anderson et al, 2012)
• Awareness of the Mixed type of Cam-Pincer
impingement is important as types often occur
together.

38. Hip Dysplasia
• Dysplasia of the hip encompasses a
wide specturm of hip abnormaility,
ranging from a shallow acetabulum to
a completely dislocated ‘high riding’
hip (Beltran, 2013)
• On plain x-ray, dysplasia of the hip
may be diagnosed using the ‘centre
edge angle’.
• CE angle < 25° suggests hip dysplasia
and likely to have instability
• Normal CE angle is 25-40°
• CE angle > 40° suggests Pincer lesion

39. Hip related pain in the
adolescent
• Any child <15 years old must
have an x-ray on first episode
of pelvic bone pain to rule out
osteosarcoma.
• One of the most common
causes of bone cancer in
children aged 10-25.

40. Hip related pain in the
adolescent
Traction Apophysitis
• Excessive muscle pull on
immature bone
• Will always resolve, but can
take much longer than a
muscle strain
• May progress to avulsion
fractures
• Most common sites are AIIS,
ASIS and Ischial Tuberosity
(Moore, 2016).

41. Slipped Upper Femoral
Epiphysis
• Typically occurs in 12-15 year old boys
(overweight) (4:1)
• During growth spurts, there is a widening of the
physis and the axis of the physis moves from
being horizontal to more oblique. As this
occurs, shear forces across the growth plate
increase (Knipe et al, 2016)
• Most common symptom is limp
• Affected leg shortened and externally rotated
• Reduced Hip flexion and IR
• X-Ray - Lateral frog leg as slip is posterior
(Bomer et al, 2014).
• An acute sudden slip is a surgical emergency!
• Usually presents as a gradual slip

42. Legg-Calve-Perthes Disease
• Idiopathic avascular necrosis of the
growing femoral epihpysis
• Boys affected 5x more than girls
between ages of 2-18 with a peak
around 5-6 years old (Dillman et al,
2009)
• Commonly presents as pain
around the hip and groin with or
without a limp
• Prognosis isinfluenced by the
percentage of femoral head
involvement and degree of
deformity

43. Principles of Management
• Adductor longus, magnus, rectus
abdominus,internal obliques and illiopsoas all
have the potential to contribute to stability and
force transmission in the groin
• If groin pain results from an imbalance of forces
through the sympyshis pubis of the above
musculature, then a management approach
directed at only one tissue may be inneffective
(SINI, 2011)
• One of the primary factors in the rehabilitaion of
groin pain is modification of training load,
without which it is often impossible to effectively
address key mechanical dysfunctions (SINI,
2011)
• The focus of rehabilitation should be directed at
re-establishing efficient load transfer across the
pubic region by addressing joint mobility, muscle
extesibility and gloabl muscle strength (SINI,
2011).

44. The first 48 hours
• Avoid use of NSAID’s
• Utilise Game Ready for Ice and
Compression (Herringbone
Compression using short stretch
bandage causing high dynamic
pressure)
• Early movement useful but avoid
stretching
• Avoid direct tissue work
• Avoid excessive travel
• EIS - no stretching or massage for 96
hours

45. Principles of
Management
• Identify plane of movement of
weakness (Saggital, Coronal,
Transverse)
• Train movement not muscles
• Consider function (Twisting,
turning, stepping, kicking,
accelerating, sprinting)
• Focus on TOTAL hip strength
including Add/Abductors,
Extensors and hip flexors
• Consider Add:Abd for both
dominant and non dominant sides

46. Manual Therapy
• Hip mobilisations
• Dry Needling
• Adductor Origin Stripping
• TFL/Glute TrP Release
• Illiopsoas Release
• Joint Capsule Release (PA
Mobs in Prone Fabers)

47. Rehabilitation Protocols
Holmich, 1999
Hogan, 2006
Weir et al, 2010

48. Additional Exercises
• Lateral Lunge 3x12 each side, build
from BW to 20kg
• Single leg barbell high step ups
• Squeeze and Bridge @ 0°,30°, 60° &
90° (6s holds x4)
• Adductor Magnus Bridge Matrix.
Feet elevated with hips flexed 110°
(20reps), 90°, (12 reps), 30° single
leg lowers (8 reps)
• Sumo Squat with gym ball
• Hip Adduction Theraband (Jensen,
2012)
• Dissociation exercises - Deadbugs/Bird
Dogs: Continuous abdominal loading 2-
4mins using SL & DL loading
• Plank Matrix - Reverse on elbows (30s), L &
R Side (30s each) (foot over for IO
recruitment), Table top (30s), front plank
(1min) = 3mins
• Swiss ball push backs, swissball half pike,
swiss ball full pike.
• Lower abdominal Routine: Lay on bench
with hands above head. SL reach below
paralel (5 reps), DL reach to 45° (5 repsx6s
holds), DL hips to 0° feet off floor (5 reps).
• Hip Flexion from Extension with theraband
(Thorborg, 2016).

49. Rehab for Pubic Bone Stress
• Enhancing bone mass for pubic bone stress
injuries can be achieved by talioring the
rehabilitation programme
• Burr et al found that loading bone 4x
throughout the day via high amplitude, low
volume perturbations with 90 reps produced
the most bone growth (2002).
• An increase in bone mineral content and
bone mineral density were found when
compared to loading with different
parameters (Burr et al, 2002)
• For patients suffering with bone stress
injuries it may be beneficial to use high
amplitude, low volume, non linear forces
such as hopping 4xper day for 90 reps with
2-3 hours rest inbetween (Moore, 2016)

50. 5 Key Re-Assesment Signs
• Pain during exercise
• Pain +/- ‘stiffness’ next morning
• Squeeze test - Compare with
baseline
• Pubic Symphysis Stress Tests
(Passive Hip Ext and Abd,
Resisted Flex and Add)
• Adductor Muscle Tone
(BKFO’s, Passive Abduction
ROM

51. Prevention of Hip and Groin
Injuries
• No single test can effectively identify
those at risk of developming groin pain,
although there are several clinical
findings that when combined can help
highlight those at risk (SINI, 2011)
• Like most other injuries, previous groin
history of groin pain is linked to an
increased risk of groin pain (SINI, 2011)
• A recent updated systematic review
found that the most common risk factors
for groin pain were related to age, Hip
ROM, Hip adductor strength, previous
groin injury and lower levels of sports
specific training were associated with
increased risk of groin pain (Whittaker et
al, 2015).

52. Prevention of Hip and Groin
Injuries

53. Prevention of Hip and Groin
Injuries
• Delahunt et al found that a commercially
available sphygmomanometer is a reliable
device for measuring adductor squeeze test
values (2011).
• This paper showed that the interrater
reliability of a BP cuff in assesing squeeze
values is excellent and that 45° of hip flexion
produced maximal scores during testing
compared to 0° and 90° (Delahunt, 2011).
• Crow et al found that squeeze scores were
reduced by 10% 1 week preceeding groin
injury in elite AFL players (2008).
• As a result, it is reasonable to suggest that
weekly monitoring of adductor strength within
a squad could identify those at risk of
breakdown and allow early modification of
activity (SINI, 2011).

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