groin injuries are common but neglected in orthopaedics and sports injuries field as region is an enigma as too mant structures are present in a small space. the present PPT describes approach and management of groin injuries

1. Dr Davinder Singh
Director Professor
Sports injury center
VMMC & Safdarjung Hospital
New Delhi
Groin injuries in Athletes

2. Groin pain
• Common in multidirectional sports
• Traditionally a difficult problem to
understand, diagnose, and manage.
• Due to sparse historical focus on this
complex anatomical region.
• Little agreement regarding terminology,
definitions, and classification of groin pain.
• Athletic publagia, , Gilmore’s groin, groin
disruption, hockie- goalie syndrome, hockey
groin, osteitis pubis, sports groin,
sportsman hernia

3. The Doha agreement
examination of athletes with groin pain
 Classified according to certain clinical entities based on
1. pain provocation tests.
2. Tenderness present in the defined clinical entities of adductor-, pubic-, inguinal-,
and iliopsoas-related groin pain
Since the Doha agreement meeting.
 Clinical examination is accurate in locating acute injuries to the adductors, with an
accuracy greater than 90% .
 For acute hip flexor injuries, at times hard to distinguish between iliopsoas or proximal
rectus femoris involvement based solely on clinical findings.

4. Groin pain
• More common in male athletes,
• Stress fractures of the pelvic , are more common in female athletes.
• In skeletally immature athletes, the pelvic apophyses are prone to injury.
• High-load activities, such as kicking and sprinting, may result in avulsion fractures of the
anterior inferior and superior iliac spines
• Adolescent athletes at increased risk of hip-related problems if they have a previous H/O
• slipped capital femoral epiphysis,
• Legg-Calvé-Perthes disease,
• Acetabular dysplasia.
• HIP OA as a cause of groin pain in older athletes.

5. Types of sports and injuries
Multidirectional sports e.g. football acute strains at the MTJ of AL, RF & IP
Overuse injuries Bone, tendons and their insertions, rarely involve RF
Acute adductor muscle injury kicking and change of direction
Acute rectus femoris injury kicking and sprinting
Acute iliopsoas injury movement requiring change of direction
Runners and dancers Overuse injuries

6. Risk factors
• Previous groin injury
• Higher level of play
• Reduced hip adduction
• Lower level of sports specific training
• Strong evidence that athletes with hip and
groin pain have
Lower patient – reported outcome
scores ( PROM)
Altered trunk muscle function

7. Clinical overview
• Initially, Pain located in medial upper thigh around prox. adductors and pubic rami
• Unilateral to start with but becomes bilateral
• Aggravated by exercise, running, twisting/turning and kicking
• To start with, pain present late during or after physical activity, pain & stiffness next
morning
• Later on, pain immediately on exercise
• NSAID and rest temporary reduces the intensity
• Pain becoming worse on exercise : stress fracture or apophysitis

8. Type site movements
Adductor pain attachment of AL to pubis on side to side
movements, kicking ,
twisting and running
Iliopsoas pain central in groin and prox. thigh on straight running,
jogging
Inguinal pain Along inguinal ligament on sit-ups, coughing
Pubic pain Symphysis pubis & bone
immediately adjacent to it
On resisted abdominal
& adductor testing
Type and Site of Pain

9. Clinical Examination
Once serious pathology has been ruled out,
 Screen for potential lumbar spine– and
sacroiliac joint– related pathology
 Lumbar spine
ROM testing and
Negative straight leg raise
 Facet joint pathology is best ruled out with
a negative extension rotation test
 sacroiliac joint the thigh thrust test has
good clinical utility to rule out potential
sacroiliac joint pathology.

10. CLINICAL AND FUNCTIONAL TESTING
 Continuing to train and play with groin pain can result in
movement compensation strategies, resulting in decreased function and
performance.
 Therefore, in addition to the use of pain-provocation tests
Joint ROM,
Muscle strength,
Function, and
Performance must be systematically assessed and
 Appropriate patient reported outcome measures must be completed.

11. Hip ROM
 Conflicting evidence on whether athletes with groin pain have impairments in ROM
compared to controls.
 A recent systematic review reported no significant differences in ROM between athletes
with FAI syndrome and healthy controls.
 If clearly measurable side-to-side differences or changes between test and retest exist
(greater than 5°)
FIND OUT
whether ROM restrictions caused by
 Bony morphology or
 Chondral changes
 Protective muscle guarding

12. Hip Muscle Strength
 Decreased hip muscle strength a consistent finding ,esp hip adduction in
Adductor- and pubic-related groin pain,
Hip-related groin pain,
FAI syndrome, and after hip arthroscopy,
 Adductor and pubic-related groin pain have reduced hip abduction and abdominal muscle
strength
 Differences > 15- 20% reliably measured across all movement of the hip
 Better assessment of impairment as quantified objectively,
 Helps in monitoring of clinical progress/deterioration
 Assessed using hand held dynamometer/ or as squeeze test
 Hip adductor/ abductors ratio < 0.8 risk of future adductor injuries

13. Function and Physical Performance
 Single-leg stance,
 Single leg squat, and
 Star Excursion Balance Test for athletes with hip
pathology
Performance measures that include
 Actual cutting time are promising, as cutting
functionally relates to pelvic lateral tilt range
and lateral thorax rotation
 Cutting-time testing is reliable and possible in
most clinical settings.

14. Patient-Reported Outcome Measures
 Copenhagen Hip and Groin Outcome Score (HAGOS)
• is reliable, valid, and responsive measures for hip and/or groin pain.
• Standard and repeated completion helps to evaluate progress and guide the treatment
plan.
• Clinically, changes of 10 to 30 points can be measured at the individual level, depending
on specific patient population.
• most athletes with groin pain will seek treatment when their HAGOS scores are less
than 50 points on a 100-point scale

15. TYPE MODALITY FINDINGS REMARKS
Pubic- and Adductor MRI (P)
US(A)
CT(A)
pubic bone marrow oedema
protrusion of the symphyseal joint disc
Apophyses avulsions
found in asymptomatic athletes
high dose of radiation
Inguinal- US (P)
MRI(A)
Posterior abdominal wall weakness High false-positive findings
no evidence on the validity or
reproducibility
Iliopsoas US(A)
MRI (P)
snapping iliopsoas tendon syndrome
iliopsoas tears and impingement
Iliopsoas bursitis
Evidence relevance of such findings is
currently lacking
HIP MRI(P) Occult stress fracture, FAI 3.0-T MRI
Imaging In Groin Pain
MR imaging is the principal imaging modality
MR imaging may be positive in asymptomatic persons
• Radiologists should describe their findings—and do not attempt to make the clinical diagnosis

16. EVIDENCE-BASED MANAGEMENT
Athletes With Adductor- and Pubic-Related Groin Pain
adductor-related groin pain,( level 1 evidence )
• supervised active approach to rehabilitation, including physical training, results in higher
return to play as compared to passive physical therapy.
• adjunct treatments, such as
• manual adductor manipulation or
• shockwave therapy,
• result in a faster return to play , but not higher overall treatment success, than a
supervised active physical training program alone.
• Around 50% to 75% of athletes with adductor-related groin pain will return to their
previous pain-free level of activity using a general exercise approach

17. adductor and pubic-related groin pain
 In refractory cases, level 2 evidence that partial release of the AL tendon effective for
returning to preinjury level.
• Adductor tenotomy should be avoided as Weakness of the adductors
• Athletes with adductor-related groin pain and cam morphology on imaging have a good
long-term prognosis using an exercise-based rehabilitation program.
• The clinical difference between adductor-related and pubic-related pain in the current
literature seems minimal.
• Therefore, pubic-related pain should be treated in a manner similar to adductor-related
groin pain.

18. Athletes With Inguinal-Related Groin Pain
• laparoscopic hernia surgery result in
• lower pain and
• higher percentage returning to play in randomized controlled trials.
• Nonsurgical treatment with exercises and injections results, with 50% of participants fully
recovered after 1 year in a randomized controlled trial,
• Nonoperative approach first, given the risk of possible surgical complications.
• Monitoring hip adductor, hip abductor, and abdominal muscle strength is relevant in
relation to individual weaknesses in these patients.

19. Athletes With Iliopsoas-Related Groin Pain
• No high-level evidence to support or refute the use of exercise or other nonsurgical
treatments.
• Treatment protocol depends on impairments and functional deficits.
• Arthroscopic iliopsoas release or tenotomy results in
• Iliopsoas atrophy
• Reduced hip flexion strength
• Surgery is not recommended as first-line treatment.

20. Prevention
• No proven effective intervention
• Active exercise strategy for strengthening and improving muscle functions, load transfer
and tolerance in pelvic region may help.
• Athletes in off season should concentrate on treatment and recovery rather than simply
resting
• Any deficit found should be target for improvement in off season, carefully combined
with sport specific training
• Careful consideration of training load
• Monitoring for hip muscle strength to predict the onset of groin pain

21. THANK YOU