Groin Pain in Sportsmen

Groin pain in Sportsmen (Osteitis pubis / sportsmans groin (hernia) / hip impingement / stress fractures)

Sportsman’s Groin

Sportsman’s Hernia (Sportsman’s groin, “Gilmore’s groin”) often presents with gradual onset of groin pain often at the end of a game or training session. Initially these symptoms can be quite mild and often does not affect level of performance. However, as the condition progresses the pain becomes gradually more problematic and activities such as sprinting or kicking soon become painful. Coughing and sneezing often exacerbates the symptoms.

The groin canal (inguinal canal) connects the inside with the outside of the abdomen and is an opening in the stomach muscles that contains the spermatic cord. The canal has 4 sides: front layer (external oblique fascia), back layer (posterior wall), inner layer (straight abdominal muscles) and outer layer (inguinal ligament).

This is often a tear in the front layer (external oblique fascia) of the groin canal combined with a weakness in the muscle that forms the posterior wall of the groin canal. There is, however, usually no visible lump or protrusion unlike a conventional hernia. This condition can occur in most sports. The diagnosis is usually made with an appropriate history & clinical examination. Ultrasound scan can provide additional diagnostic information. MRI scans can be useful for ruling out other injuries.

Non-operative treatment of the sportsman’s hernia is usually unsuccessful. Some patients report improvement of their symptoms at rest, but the pain usually reoccurs when patients return to their sporting activity.

Overall, there is a consensus that surgery is the best option to treat this condition. The surgery is performed with a minimal incision technique to repair and strengthen the torn structures. The surgery can be done as a day case or with overnight stay. A return to sports is usually achieved after 3 to 6 weeks.

The most important issue with this condition is obtaining an accurate diagnosis as there are many conditions that can mimic a sportsman’s groin. There is no single clinical test or investigation which will confirm the diagnosis which needs to be made by an experienced clinician. Surgery will be effective for a true sportsman’s groin but will not work for other groin issues. A Sports Physician can ensure that the diagnosis is correct and the proposed management plan is appropriate.

Osteitis pubis

This is a condition that affects the pubic symphysis which is the area where your pelvic bones meet at the front of the pelvis. It often occurs in sports that involve sprinting, kicking and sudden changes of direction, such as running, football and tennis.

The most common symptom is pain or tenderness around the front of the pelvis and upper, inner thigh when walking or exercising. You may feel pain when twisting, turning and kicking. Some people feel pain when walking up stairs, coughing, sneezing and lying on their side. You may also hear clicking or popping when turning over in bed, walking on uneven ground or rising from sitting. Men may feel pain in their scrotum after ejaculation.

The exact cause of osteitis pubis is often unknown. It is thought that it may be caused by excess stress across the pubic symphysis during physical activity.

You should seek treatment from a sports medicine professional, such as a sports physician or a sports physiotherapist.

Physiotherapy can be helpful. Your physiotherapist will give you rehabilitation exercises to strengthen and stretch the muscles around your pelvis to reduce the stress across the pubic symphysis. He or she will use various techniques such as stretching and massage therapy to reduce muscle tightness.

If your symptoms don’t improve or your symptoms are severe, a steroid injection can be helpful. Sometimes intravenous injections of biphosphonate drugs (eg Bonviva) can be given by experienced Sports Physicians or Rheumatologists. Rarely, you may need surgery.

Adductor Tendinopathy

The adductor muscle group (adductor longus, adductor magnus, adductor brevis, pectineus & gracilis) are situated in the inner, upper thigh and are responsible for bringing the leg in to the midline (adduction). Injuries to the adductor muscles can involve a strain or a tear. The adductor longus is most commonly involved. These injuries are very common in sports, particularly football.

A thorough assessment of adductor injuries by an experienced clinician can reduce the risk of these injuries becoming a chronic problem which unfortunately happens all too commonly.

Scans may sometimes be needed to confirm the adductor injury and exclude other causes of groin pain. Most will respond to a supervised adductor strengthening programme after the acute symptoms have settled with appropriate treatment.

Injections of steroid or platelet rich plasma can be considered for the more troublesome cases. In rare cases surgical decompression of the tendon may be needed.

FAI

Hip impingement or Femoro-acetabular impingement (FAI) is a condition which produces too much friction in the hip joint. Two types are recognized, CAM & Pincer although often they co-exist. It can present as progressive groin pain and can be associated with labral tears within the hip and the development of hip osteoarthritis.

A thorough clinical assessment of the hip, groin and low back is important to establish an accurate diagnosis.

Investigations may include x-rays and special MRI scans with injection of dye into the hip joint (arthrogram). It is very important that the clinician establishes that any impingement signs on imaging are responsible for the patients’ symptoms because hip impingement can be asymptomatic.

For problematic cases surgery is often required. Dr Davies can facilitate a surgical opinion if required.

Referred pain from Lx spine

Lumbar spine problems can refer pain to the groin which is why assessment of groin pain should include a thorough assessment of the Lumbar spine. A prolapsed lumbar disc at the 2nd / 3rd lumbar level can present with groin pain, sometimes without LBP.

Dr Davies is very experienced at assessing all types of groin pain and his assessment will always include a thorough assessment of the lumbar spine and testing the function of the nerves to the lower limb.

Stress Fracture  eg femoral neck

Stress fractures can often present in a non-specific fashion hence early diagnosis by an experienced clinician is essential Failure to diagnose this condition in a timely fashion can lead to major complications. The treating clinician must have a high index of suspicion from stress fractures particularly in endurance athletes and they are more common in females. Following a detailed history and thorough examination investigations may include plain x-rays and MRI scans. Usually this condition is managed conservatively although in rare cases surgery may be required. Appropriate follow-up is required to ensure appropriate healing and assess the risk factors to reduce the chance of a future episode.

Dr Davies, particularly with his 7 years’ experience of working within the military setting, is very experienced at diagnosing and managing a wide variety of stress fractures.