Groin pain is a common and often complex injury experienced by athletes in over-ground sports, in particular, those with frequent changes of direction or kicking such as football (soccer), Rugby and basketball.
There are many different groin injuries, often where multiple diagnoses mean the same pathology which can become confusing when it comes to diagnosis and treatment of groin pain – especially when it is longstanding or ongoing. In order to reduce this confusion a consensus meeting known as the Doha agreement was held in 2014 by 24 international experts to discuss and resolve the confusion behind the diagnosis of groin related injuries.
Systematic reviews (highest level of evidence) and this Doha agreement have resulted in breaking groin pain into 4 clinical entities for groin pain:
Adductor Related (Blue):
What is it?
The adductors are a group of 3 main muscles (adductor longus, adductor magnus and adductor brevis) that bring the leg towards the body, these muscles sit on the inside of your thigh and run up into the pubic bone.
Signs/ Symptoms:
We can diagnose injury to this area when there is pain with resisted movement or when there is a pain when pressing down on the muscles and their tendons. This pain can also radiate down the inside of the thigh.
The early signs of adductor-related pain are the feeling of tightness or stiffness in the region during activity, a reduction in maximum sprinting speed, a reduction in the distance when long kicking, and/or discomfort when decelerating during running.
Treatment/ Management:
Supervised active rehabilitation (general exercise and specific strengthening) has been shown to have equal and in some cases better results than passive treatment options (including rest and/or shock wave therapy). It is important with adductor injuries to monitor the amount of exercise done with the Glutes, Adductor muscle group and abdominal muscles. There is an option for a surgical release of the adductor tendon, however, research has shown that this can result in weakness in the adductor muscles, and therefore should be carefully considered. Research has found that up to 75% of patients with adductor-related groin pain have returned to the previous pain-free level of activity using supervised rehabilitation and a general exercise program.
Iliopsoas Related (Green):
What is it?
The iliopsoas is a combination of two muscles (iliacus and psoas major) that work with the quads to bend the hip. These muscles start at the lumbar spine and run down the inner side of your pelvis. These injuries usually occur as a result of repetitive kicking and sprinting, and are known as an overuse injuries (when you repetitively do the same action or movement).
Signs/ Symptoms:
Iliopsoas pain is often associated with pain around the front of the hip, closer to the hip than the groin or pubic bone. The main signs of iliopsoas-related injury are a pain when pressing down on the muscles or when there is pain associated with bending your knees to your chest with resistance or stretching these muscles.
It can often feel like a deep ache that is hard to pinpoint.
Treatment/ Management:
An exercise program with specific strengthening tailored to the patient can be used to treat this condition, with a particular focus on hip, gluteal and hip flexor strength. A surgical approach can also be used to release the tendons of the iliopsoas; however, this procedure generally results in weakness in the iliopsoas muscle. At current there is no research to suggest that exercise or surgery is the better treatment option, therefore it is suggested to try a patient-specific exercise and strengthening program, and if no significant changes within 3 months, look towards a surgical treatment option.
Inguinal Related (Purple):
What is it?
This ligament runs from the top front corner of the pelvis to the middle of the inside of the pelvis and holds a variety of nerves, blood vessels and muscles/ tendons in place.
Signs/ Symptoms:
Injury to the inguinal ligament is identified by pain when using the abdominal muscles (even when coughing or sneezing), and is often very painful to touch along the ligament.
Injury to the inguinal region often presents as pain towards the end of an activity, and as the injury progresses the pain comes on earlier and earlier during activity/ exercise. The pain can be felt on both sides and is often made worse when increasing intra-abdominal pressure.
Treatment/ Management:
There are both surgical and non-surgical options for inguinal-related groin pain. The non-surgical approach includes exercises specific to the weaknesses of the patient, usually focusing on adductor, abdominal and glute strength. These exercises can be done in combination with injections based on the individual presentation. Studies have shown that the non-surgical approach resulted in 50% of participants fully recovering after 1 year using a non-surgical approach. It is ideal to trial a non-surgical approach first, and if no progress is being achieved, a surgical approach can include laparoscopic hernia surgery, however, as per all surgeries, there is a risk of complications.
Pubic Related (Yellow):
What is it?
The pubic symphysis is where the two pelvic bones meet at the front of the pelvis and are joined by hyaline cartilage and fibrocartilage which make it a very strong joint.
Signs/ Symptoms:
This joint can be very painful to touch when it is injured – which is our main way of determining if it is the cause of your groin pain.
Treatment/ Management:
This type of injury is very specific to pain on the pubic symphysis and is most commonly treated by modifying factors that put a load onto the pubic symphysis which is often unique to each patient and the sports/ activities they do. As pubic-related pain can present very similar to adductor-related pain, therefore a supervised active rehabilitation program focusing on monitoring the adductor, abdominal and gluteal loads is commonly used.
Get in touch with your local Sports & Spinal team and see how our Physio team can assist you