Athletic Groin Pain Assessment: The Bermuda Triangle of Sports Medicine!

During the football World Cup (2014) players including Steven Gerrard, Vincent Kompany, Robin Van Persie and Nigel De Jong all suffered groin injuries with Robin Van Persie reporting that he has been suffering with groin pain for the last 6 years! Groin pain has previously been described as the bermuda triangle of sports medicine! Due to its complexity and the amount of pathologies that could be causing the athletes pain (Bizzini 2011). Groin pain in athletes is quite common in sports that require a large amount of kicking especially including football, aussie rules with groin injuries also occurring in ice hockey, running, tennis, rugby, American football and basketball. These conditions are notoriously difficult to diagnose and groin pain represents a significant clinical challenge due to the difficulty experienced in identifying the injured structure(s), which is due in part to the complex anatomy of the region. This blog will go through assessment methods to aid clinical reasoning for myself and possibly others in ruling in and out potential diagnosis’ for groin pain.

Anatomy

A review by Robertson et al (2009) identified three key disparities in descriptions of the musculoskeletal anatomy of the pubic region that have implications for the pathogenesis and clinical management of athletes with chronic groin pain. The proximal attachment of  the adductor longus (AL) may be predominantly muscular, rather than entirely tendinous as previously described. It showed that the adductor longus muscle was composed of a thin tendon anteriorly, and muscular fibres on the deep surface of its pubic attachment. The relative contribution of tendon fibres was found to be only 38% and this proportion decreased with further distance from the origin. This implies that 62% of the pubic attachment of AL is composed of muscle fibres, which is in striking contrast with textbook and common descriptions of an entirely tendinous origin. The adductor longus was also found to be attached to the pubic symphysis capsular tissues.  The lower fibres of Internal Oblique and transverse abdominus (TrA) appear to exist more commonly as separate entities attaching into the rectus sheath than as a ‘conjoint tendon’ into the pubic bone. The adductor longus and rectus abdominus are reported to attach in continuity via the capsular tissues of the pubic symphysis. These tissues were also reported to merge with the interpubic disc and adjacent articular cartilage. Finally, the rectus sheath is reported to be continuous with adductor longus; via the pubic symphysis capsular tissues. This confluence of soft tissue structures anterior to the pubic symphysis may provide the anatomical medium for a composite stabilizing or force transmission mechanism.

Muscle attachments in the groin region: (a) rectus abdominis; (b) decussating fibres of rectus abdominis; (c) inguinal ligament; (d) attachments of rectus abdominis and adductor longus in continuity and (e) adductor longus (Robertson et al, 2009)

Muscle attachments in the groin region: (a) rectus abdominis;
(b) decussating fibres of rectus abdominis; (c) inguinal ligament;
(d) attachments of rectus abdominis and adductor longus in continuity and (e) adductor longus (Robertson et al, 2009)

 Subjective

The clinician should rule out hip and pelvis fractures and other red flags, especially of the urologic and gynecologic systems. Focus should be on duration and multitude of symptoms with athletes often playing and training on with these symptoms and also previous studies by Holmich showing most athletes to have more than one symptom and pain when presenting for treatment. Also provocative actions, mechanisms of injury if any and symptoms during coughing, sneezing, lifting and so on should be identified in the subjective interview. Athletes who take part in kicking sports often report early on that they aren’t able to kick as far or as hard that they could do. Athletes suffering chronic adductor pain often report symptoms that have a  gradual onset which starts as dull ache after sport / training that progresses to dull ache or pain during sport / training before symptoms eventually lead to the athlete unable to partake in sport or training at all.

The Copenhagen Hip and Groin Score (HAGOS)
The HAGOS consists of six separate subscales assessing Pain, Symptoms, Physical function in daily living, Physical function in Sport and Recreation, Participation in Physical Activities and hip and/or groin-related Quality of Life (QOL). Test–retest reliability was substantial, with ICC’s ranging from 0.82 to 0.91 for the six subscales. Construct validity and responsiveness were confirmed with statistically significant correlation coefficients (0.37–0.73, p < 0.01) for convergent construct validity and for responsiveness from 0.56 to 0.69, p < 0.01 in young and middle aged adults (Thorborg et al, 2011).

Objective

A study by Holmich et al (2004) assessed 18 athletes by 2 physiotherapists and 2 doctors with subjects  n=9 had groin pain and n=9 were symptomatic. Intraobserver agreement was above 0.60 in 11 of 14 tests, and those for the interobserver agreement of the pain tests were above 0.60 in eight of 10 tests. The only test without acceptable interobserver reliability was the strength test for iliopsoas muscle. This assessment is outlined below and has then been utilised to classify patients into three main groin pain entities in a more recent study by Holmich (2007).

  • Adduction of the legs against resistance; pain and strength evaluated.
  • Palpation of the insertion of the adductor longus muscle at the pubic bone; pain evaluated (VAS).
  • Passive stretching of the adductor muscles; pain evaluated.
  • Palpation of the symphysis joint; pain evaluated.
  • Palpation of the rectus abdominis muscle at the pubic bone; pain evaluated
  • Functional testing against resistance of the abdominal muscles; pain and strength evaluated.
  • Palpation of the psoas muscle above the inguinal ligament; pain evaluated.
  • Passive stretching of the iliopsoas muscle (the modified Thomas’ test) with overpressure pain, and tightness evaluated.

Step by step instructions and pictures of the examination technique are found here from Holmich et al (2004). The assessment outlined above  has then been utilised to classify patients into three main groin pain entities in a more recent study by Holmich (2007) which uses the below diagnostic criteria to separate groin pain into different entities. Where when assessing 207 athletes with groin pain adductor related (58%) and illipsoas related (35%) were the most prevalent. Having more than one entitie was also common underlying the importance of a thorough clinical examination.

(Holmich 2007)

(Holmich 2007)

Adductor related pain was shown to be the most prominent feature of athletes with groin pain therefore testing of the adductors for strength and pain is vital for this population group.

For hip adduction and flexion strength testing substantial intra-tester reliability for both isometric and eccentric testing with Intraclass Correlation Coefficients >0.90, with no systematic error between tests and individual measurement variation of less than 10%. Inter-tester reliability is not as good as intra-tester reliability, but adequate values can be obtained with skilled testers has been found. Adductor isometric and eccentric and hip flexor isometric strength testing positions below (Thorborg, 2014). Strength can be assessed using the Oxford muscle grading scale but if the equipment is available muscle strength assessment by hand held dynamometer is a more accurate muscle strength assessment.

groin4

A reliability study by Malliaras et al (2009) on hip flexibility and strength measures. Showed the bilateral adductor squeeze test using a sphygmomanometer at 0 and 30 degrees were participants are instructed to squeeze their legs together at hard as possible, was able to distinguish from athletes with groin pain and those without. It also showed acceptable test rest and inter-rater reliability (ICC >0.80). No although hip flexibility or strength measures, although reliable were not able to distinguish from athletes with groin pain and controls without.

Adductor squeeze test (Malliaras et al, 2009)

Adductor squeeze test (Malliaras et al, 2009)

 

Strength of the abductor muscle groups should also be carried out to assess the strength ratio adductors : abductors looking for a 1:1 ratio as closely as possible.

Functional assessment that looks at kicking, running, changing direction, single leg squat and jumping / landing technique to potential modify any actions that lead to the condition in the first place.

Pathoanatomical Approach to Groin Pain Assessment

Falvey et al (2009) proposed an assessment method including the groin, gluteal and greater trochanter triangle areas that are based on pathoanatomical principles for a systematic examination of the chronically painful groin, which enables the clinician to discriminate more easily between pathological conditions and target their investigation and subsequent management to specific diagnoses.

Groin Triangle

The anatomical apex points of the triangle are as follows: the anterior superior iliac spine (ASIS); the pubic tubercle and the 3G point. The 3G point is the point in the anterior coronal plane was the mid-distance point between the ASIS and the superior pole of the patella, and in the posterior coronal plane double the distance from the spinous process of the L5 lumbar vertebrae to the ischial tuberosity in the line of the femur. The Pubic Clock is also shows attachments and their location on the pubic tubercle.

groin6                                                              Pubic Clock

These anatomical land points could assist with differential diagnosis of pain in and around the pubic / groin region with a table below showing possible diagnosis’s below with tehir associated signs and symptoms.

(Falvey et al, 2009)

(Falvey et al, 2009)

Differential Diagnosis

Due to the multitude of possible painful structures and conditions referring pain to the groin region ruling out pathologies and pain from these joints and structures is important to miss out on other serious pathologies and also to treat the correct dysfunctional area(s). When examining the other related areas, looking for reproduction of the patients symptoms and pain.

Lumbar spine

Repeated lumbar motion, the patient repeats forward, backward, and side bending. If repeated motions don’t reproduce the pain, the lumbar spine is ruled out (Sensitivity (SN) 92; Likelihood Ratio (LR) 0.12) (Donelson et al., 1997).

SIJ

Two of four positive SIJ tests (distraction, compression, thigh thrust or sacral thrust) SN 0.88, Specificity 0.78. When all six SIJ provocation tests are negative, painful SIJ pathology can be ruled out (Laslett et al, 2005).

Hip OA

Lack of limitation in any hip motion. With OA of the hip, there is generally a loss of ROM in 2 or more planes. If ROM is limited in 1 or less planes,
OA is unlikely SN 100 (Birrell et al., 2001). Also age >50 and feelings of hip stiffness aid the diagnosis of OA.

Hip impingement/intra articular pathology

Flexion-adduction-internal rotation (FADDIR) test, Clinician passively moves the patient’s leg to 90° of hip and knee flexion. The leg is then passively adducted and internally rotated with overpressure to end range, looking for clicking, locking, catching and patients pain, SN 99%, SP 7% (Reimann et al, 2013).

Flexion-internal rotation test, Clinician passively performs the combined movements of flexion to 90° and internal rotation. A positive test is reproduction of concordant pain, locking, clicking or catching SN 96%, SP 17% (Reimann et al, 2013).

Femoral fracture /stress fracture

Patellar-pubic percussion test, Clinician places a stethoscope over the pubic tubercle of the patient. Clinician taps the patella of patient’s leg
being assessed by their finger or a tuning fork and qualitatively reports the sound. A positive test is diminished percussion compared with contralateral side, SN 95%, SP 86% (Reimann et al, 2013).

Fulcrum test, Clinician places one forearm under patient’s thigh to be tested. Clinician arm is used as a fulcrum under the thigh and is moved from the distal to the proximal thigh as gentle pressure is applied to the top of the knee with the opposite arm. A positive test is reproduction of patient’s concordant discomfort/sharp pain, usually accompanied by apprehension, SN 93%, SP 75% (Reimann et al, 2013).

Gluteal Tendinopathy

Resisted external derotation test: Patient supine, hip flexed 90°, and in external rotation. Patient then actively returns the leg to neutral position
(placing leg along the axis of the bed) against resistance. If test result is negative, the test is repeated with patient lying prone, hip extended and knee flexed to 90°, SN 88%, SP 97.3% (Reimann et al, 2013).

Neurological

Myotomes, dermatomes, reflexes, lower limb neural tension tests. Due to nerve pathologies and entrapment’s possible in this area for the obturator, illioguinal and genitofemoral nerve.

Conclusion

Due to the complexity of the anatomy and the vast amount of possible diagnosis’ for pain in this region I have found it difficult to diagnose painful pathologies and structures here. I’ve used this blog to aid my assessment and clinical reasoning skills for this area and would love to know any comments in how others assess this tricky area and any feedback would be greatly appreciated!

References

Binkley JM, Stratford PW, Lott SA, Riddle DL. 1999. The Lower Extremity Functional Scale (LEFS): Scale Development, Measurement Properties, and Clinical Application. Physical Therapy,  vol. 79 no. 4 371-383.

Bizzini M. 2011. The groin area: the Bermuda triangle of sports medicine? Br J Sports Med, Vol 45 No 1.

Holmich P, Holmich LR, Bjerg AM. 2004. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med, 38:446–451.

Holmich P. 2007. Long-standing groin pain in sportspeople falls into three primary patterns, a ‘‘clinical entity’’ approach: a prospective study of 207 patients. Br J Sports Med, 41:247–252.

Laslett M, Aprill CN, McDonald B, Young SB. 2005. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests, Manual Therapy, Volume 10, Issue 3, 207–218.

Malliaras P, Hogan A, Nawrocki A, Crossley K, Schache A. Hip flexibility and strength measures: reliability and association with athletic groin pain. Br J Sports Med.  43(10):739-44.

Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. 2013. Diagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysis. Br J Sports Med. 47(14):893-902.

Robertson BA, Barker PJ, Fahrer M, Schache AG. 2009. The anatomy of the pubic region revisited: implications for the pathogenesis and clinical management of chronic groin pain in athletes. Sports Med.  39(3):225-34.

Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. 2011. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med. 45(6):478-91.

Thorborg K. 2014. Strength measurements in athletes with groin pain. aspetar sports medicine journal. Volume 3 Issue TT4 – GROIN PAIN.

4 Comments

  1. I have some experience treating athletes with groin issues – 15 years with elite amateur football (National Team) and MLS players, and 7 years as clinical therapist with the Calgary Flames of NHL. My experience has led me to the (simplified here for brevity) conclusion that in the absence of traumatic joint involvement, the vast majority of groin/sports hernia problems are related to overuse of the groin musculature in compensation for poor core/pelvic/lumbar stability and functional weakness within the adductor musculature itself (most commonly as a result of strength-inhibiting trigger points in the distal adductor musculature). Treating adductor longus and magnus (particularly the TP’s in distal 1/3 of these muscles), combined with multiplanar core stabilization has for me produced very positive results in relatively (in relation to common chronic states of these problems- Van Persie’s 6 years!) short time frames.

  2. So, I appreciate the typical assessment approaches though this Bermuda Triangle concept is more true than you know. I take the Aston Kinetics approach to see how forces move through this area. Force vectors and kinetic chain aspects of this particular issue is more of a concern than strenght alone.

  3. I utilize internal palpation within the inguinal canal and if positive for peripheral neuropathy, it will provoke familiar severe pain. I scour the circumference and palpate spermatic cord as the ilioinguinal innervates that structure. The testicular complex is more “complex” with innervation from both ilioinguinal (iliohypogastric?) and genital portion of genitofemoral. The ilioinguinal and iliohypogastric are functionally the same due to a high degree of anastomosis. The unhappy triad of inguinal peripheral neuropathy are superficial at approximately 2cm inferior and medial to the inferior shelf of the ASIS. For severe chronic debilitating pain a triple neurectomy can be performed. Additional info can be found on my web site and on you tube. I hope this is additive to the good work referenced above. Jerry Hesch, Hesch Institute

  4. Great blog post Paul. Very informative. Looking forward to reading more.

    Cheers
    Mark

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