28. All you need to know about Groin Pain.

In a previous blog, we discussed FAI (Femoroacetabular Impingement) as an underrated and fascinating cause of hip pain. Interestingly because the diagnosis of FAI is quite precarious, most of the Imaging findings don’t correlate with the symptoms as well as we’d hope, and complaints aren’t consistent among the population with vs without pain or even among people with pain and disability.

And the fact that FAI also overlaps/presents as ‘Groin Pain’ (Pain at or around ‘between the thighs, crotch’) further animates this comic situation.

The Groin in musculoskeletal health is considered an obscure location, even dubbed the ‘Bermuda Triangle’ by Mario Bizzini- “The groin area: the Bermuda triangle of sports medicine?”

The notoriety isn’t just because of the difficulties in diagnosis and differentiation. It’s a common theme among MSK medicine & rehab that Hip and Groin are somewhat grinding to manage.

Add to it the countless words/labels/diagnoses used to explain or identify Groin pathology. No wonder, many clinicians feel overwhelmed while dealing with such presentations. The 2014 Doha Agreement (Doha agreement meeting on terminology and definitions of groin pain in athletes) attempts to simplify a few key details that clinicians and patients should keep in mind regarding groin pain Incidence, diagnosis, and management.

Here’s what you need to know about Groin pain:

1. What is Groin Pain?

There’s a whole host of non-descriptive terms like athletic pubalgia, athletic groin pain, sports groin pain, athletes’ groin, etc. that exist to define what it’s supposed to be. But, in the larger scheme of all things ‘groin’ it’s pretty blurry, especially because what ‘I’ mean by groin might not be what ‘you’ mean by groin, it is not as direct and well defined as knee. Between a clinician and a patient:

But it is commonly accepted that the wide variety of possible pain & function impairment presentations, injuries, and Identifiable anatomical abnormalities of this roughly demarcated location in symptomatic populations are considered ‘Groin Pain’. (Fig. 2)

The Doha Agreement has further identified and determined the classification of Groin Pain into separate (still not entirely well-defined/understood) entities.

*It is important to note that this classification system is solely based on a thorough history and physical examination, as the role of imaging in Groin pain isn’t quite clear yet. (Palpation unlike other instances can be a useful tool here as there are various distinct structures to be ruled out in close proximity.)

Majorly Divided into Acute Goin Pain (sudden onset of pain) and Longstanding Groin Pain(>3-12wk. Regardless of the mode of onset– Jaap Jansen)

A. Sub-Class: Defined causes (Ref. Fig. 2: Defined Causes for Groin pain)

• Adductor-related groin pain Adductor tenderness + pain on resisted adduction testing (adductor squeeze test).
  

• Iliopsoas-related groin pain Iliopsoas tenderness + pain on resisted hip flexion AND/OR pain on stretching the hip flexors.
  

• Inguinal-related groin pain Tenderness of the inguinal canal. No palpable inguinal hernia present (Superficial inguinal ring invagination + Ring occlusion test) + if the pain is aggravated with resistance testing of the abdominal muscles (resisted crunches) or on Valsalva/cough/sneeze.
  

• Pubic-related groin pain Tenderness of the pubic symphysis and the immediately adjacent bone. +Hop test for femoral and pubic stresses

B. Sub-Class: Hip-related Groin pain. (Check for Details on FAI) Hip-related groin pain can be hard to distinguish from other causes and it may coexist with other types of groin pain. + C-sign *FADIR (tests) in all Groin pain presentations.

C. Sub-Class: Other conditions for Groin pain Many orthopedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological, and surgical, conditions can cause Groin pain. Must be ruled out via the concerned specialist (See Fig.1 & Fig.3 Table)

(Fig.3: Table Ref: Doha Agreement)

2. How common is it?

Groin pain is a fairly common occurrence among athletes and physically active populations.

• Football: 4-19% of all injuries in males and 2-14% in females. (With the rate of injury and absolute prevalence higher in males)
  

• Non-Football: Males are 2.45-2.92 times more likely to have Groin pain, especially in ice hockey and football codes where field kicking is common (Australian football, Gaelic football).
  

• Overall: Groin injuries account for up to 6% of all athletic injuries and 10% of all visits to sports medicine centers.

Some cohorts suggest an even higher prevalence when specific sports and the sporting population are considered-

• Risk Factors: Several sports-specific factors such as: - A previous groin injury, - A higher level of play, - Reduced hip adduction (absolute and relative to abduction) strength and - Lower levels of sport-specific training may be associated with a higher risk of injury and development of Groin pain in athletes.
  

3. Role of Imaging: X-rays, MRIs

Although X-rays and MRIs can be helpful in the identification of pathology (especially fractures of the neck or femur) that relates to groin pain.

Thus, soft tissue and degenerative findings like- degenerative changes of the symphyseal joint, adductor muscle insertion pathology, pubic bone marrow oedema and secondary cleft signs commonly assigned to groin pain can’t be relied upon for treatment or prognosis due to the high prevalence of these ‘changes’ in asymptomatic(pain-free) athletes and difficult interpretation of observable pathology because of confusing terminology and undefined diagnostic labels often used.

Therefore diagnosis and classification of Groin pain are usually clinical, and imaging is used only to rule out other confounders, mimickers or sinister pathology.

4. Treatment considerations:

Due to the complexities of diagnosis/classification and the possible involvement of various structures like muscles, tendons, blood vessels, bursae, the pubic symphysis and hip joint, as well as the intestinal and reproductive organs that can give rise to Groin pain. Generalizing treatment considerations is a bit tricky,

Although a fair amount of treatment pointers available can be generalised to defined causes of Groin pain (especially Adductor-related GP): (Ref. Doha Agreement)

1. Supervised active physical training results in a higher success and percentage of athletes returning to play than passive physical therapy modalities.

2. Multimodal treatment including manual adductor manipulation can result in a faster return to play, but not a higher treatment success, than a partially supervised active physical training program.

3. Partial release of the adductor longus tendon is effective for return to sport over time.

4. Additionally, there is moderate evidence that, for athletes with inguinal-related groin pain, laparoscopic hernia repair results in lower pain and a higher percentage of returning to play than conservative treatment.

5. Differentiating from other common pathology is key in treatment planning.

Ref. Comprehensive Approach to the Evaluation of Groin Pain (Fig. 4,5,6 Algorithms)

Conclusion:

This collection of brief pointers is to establish what Groin pain is, what are the various flavors of groin pain that we know of, what are the odds that one gets it, the risk factors, and some treatment and diagnostic pointers for clinicians and patients.

• It is important for clinicians to realise that the idea of ‘groin’ is vastly different for patients, mostly discounting other structures that we deem clinically important or a part of ‘groin’ so communicate and be on/ bring them on the same page.

• It is important for patients to participate and seek education about various causes of groin pain, the pain may come from a structure or a cause that’s unexpected. There’s often no need to worry or push for scans.

• We’ll discuss management and other specifics for Hip and Groin pain in a separate post soon.

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Disclaimer: This blog is for educational purposes only.

Cover Photo by Kafeel Ahmed from Pexels