A groin pain is described in the literature as a multi-factor complaint which may be accompanied by a series of symptoms, thus hindering diagnostics. The most frequent cause of pain deriving from musculoskeletal system is adductor muscles pain (internal side of the thigh) or flexors of the hip joint pain (front side of the thigh). If we scrutinize the issue, it turns out that the problem is more complex – recently some medical professional used a term “Bermuda Triangle of the sport medicine”.
|Significant factors in clinical differentiation are the answers to the following questions:
It is very important because location and quality of symptoms is helpful in the process of clinical differentiation between intra-articular structures and outra-articular structures and musculoskeletal structures (muscles, ligaments, tendons, tendon sheaths, fascia, articular labrum) and complaints out of the musculoskeletal system (pain caused by urogenital system and showing symptoms in the groin area).
Groin pain – possible causes
1. Groin pain in the area of adductor muscles
This pain is one of the most frequent complaints in the area of the groin. The major function of this muscle group is adduction in the hip and pelvis stabilization when moving the lower limb while walking. With reference to sport, they are important in any discipline requiring rapid changes of movement direction and sudden movements of the lower limb, such as kicking a ball. Tenderness to palpation in the area of muscle attachments, painful stretching and isometric stress (muscle stress against the resistance without moving) are clinically essential indicators. Most frequently it is a long adductor that is subject to inflammation due to its frontal location.
2. Groin pain caused by iliopsoas muscle
This muscle is the strongest hip flexor, also referred to as “sprinter’s muscle”, which plays a crucial role in keeping a suitable body posture, walking and running. It is most frequently damaged when taking actions requiring recurring hip bending, or external rotation in the hip joint, such as running, playing football, doing gymnastics. The pain occurs often when bending the hip joint and stretching hip flexor muscles. Bursa located under the muscle attachment near the lesser trochanter (in groin area) may also get inflamed.
3. Articular labrum damage
The hip articular labrum is a thick fibrous tissue which assures additional joint stability. The labrum may crack or degenerate. The damaged labrum manifests itself with a click sound when moving a hip accompanied by the pain deep in the groin.
4. Femoroacetabular impingement
This pain occurs during hip bending, internal rotation and adduction. Changes to the bone structure of thighbone head or hip joint acetabulum may cause pain as a result of unsuitable influence of compression forces on tissues. The pain may resemble a feeling of “squeezing” in the hip which intensifies when increasing the range of bending, e.g. when adducting a knee towards the belly crosswise, or when bending forward while you sit on the leg, when painful limb is lifted. The pain may also arise from less complex movements, such as bending forward when you stand, or sit.
5. Pubic symphysis inflammation
This inflammation entails pain located in the center above the pubic symphysis and may radiate to lower parts of the belly, to the internal side of the thigh or sexual organs. Passive adductor muscle stretching and active tension against the resistance leads to emergence of symptoms – similar to differentiation of the pain cased by the adductor muscle attachment inflammation. This similarity is because the long adductor attachment (one of the entire group of muscles of the internal thigh side) provides its fibers to ligaments in the pubic symphysis area. This is often accompanied by the dysfunctional changes to the sacroiliac joint. X-ray examination shows irregular edges of the pubic bone at the pubic symphysis, broader joint gap. A doctor may refer for X-ray examination with regard to one-leg standing, which causes shear forces to impact the joint and may generate asymmetries applicable to the lack of ligament stability.
6. Stress fractures
A thighbone neck may be subject to stress fracture. In spite of rare complications provided the intervention is early enough, if we ignore long-standing pain, a full fracture may occur, including dislocation. The pain usually intensifies as we walk, in more advanced cases occurs by night as well. Local palpation (empirical examination) is unlikely to reproduce patient’s symptoms, yet defensive muscle tension caused by pain may make the examination unpleasant.
7. Inguinal hernia
This dysfunction applies to changes to the rear wall of the abdominal cavity and cannot be identified through touching because it applies to tissues located deep in the fascia. The pain may radiate to adductor muscles, crotch, scrotum. It is important to note that the pain does not occur when you rest but is related to movements, such as kicking, changes of movement direction. Its diagnostics is difficult, and the complaint is evaluated on the basis of ultrasound scanning with simultaneous increase of pressure in the abdominal cavity through resistance exhalation. The doctor assesses continuity of tissues and potential “tissue bumps” through the rear wall of the abdominal cavity to the inguinal canal.
8. Complaints from the lumbar spine
Intervertebral disc hernia may cause groin pain. It mainly applies to hernias located in upper sections of the lumbar spine (L1-L3) but the studies show a possibility of projection of pain from lower sections of the spine (L4-L5, L5-S1).
9. Nerve entrapment
As another potential cause, it causes a sense of burning and sensation disorders in the area of a specific nerve branch (e.g. genitofemoral nerve, iliohypogastric nerve, ilioinguinal nerve, obturator nerve, lateral cutaneous nerve of the thigh, pudental nerve, femoral nerve). Abnormal sensation may occur in the abdominal area below or above the inguinal ligament, internal side of the thigh, frontal external side of the thigh, sexual organs. It is also essential that we pay attention to reduced muscle strength because it may also suggest nerve entrapment (e.g. femoral nerve, obturator nerve). It is crucial to provide information on previous surgeries because the nerve may get entrapped even in the scar tissue and cause pain lasting a week, months, or even years after the surgery.
10. Pain out of musculoskeletal system
The pain from the side of the torso, radiating to the groin, and hematuria may indicate kidney diseases. Epididymitis, orchitis among men, or gynecological issues among women – endometriosis, ovary cysts – may radiate to the groin. A set of complaints, such as kidney stones, ovarian torsion, appendicitis, orchitis, abdominal aortic aneurysm also must be excluded when diagnosing. The pain during sexual intercourse is also fundamental and the patient must tell the doctor about it.
Groin pain – differential diagnostics
In order to make an accurate diagnosis, a series of clinical tests (manual examinations) are carried out. They are confirmed by additional examinations referred by the doctor. The patient is primarily examined visually, i.e. his/her painful area and adjacent structures are checked in order to assess the figure, asymmetry and muscular atrophy (reduction of belly weight). The following are subject to examination: hip (range of movements, muscle strength examination, palpation, specific tests), sacroiliac joint, pubic symphysis, lumbar spine, abdominal cavity. It is conducted in various positions: when standing, lying; also walk and functional activities are monitored. There also other clinically important issues: differences in iliac ala height, limb length and iliac ala rotation. Every pain is recorded and evaluated. Depending on the type of symptoms, the doctor may refer such examination as MRI (magnetic resonance), ultrasound scanning (including dynamic ultrasound scanning), X-ray examination.
Groin pain – conservative treatment
The rehabilitation should be prepared on a case-by-case basis. Taking into account a set of biomechanical factors, despite similar symptoms, the source of the problem may vary, which must be analyzed comprehensively by the physiotherapist. The examples of biomechanical causes are muscle imbalance in the hip joint or lumbar spine, or the entire pelvic girdle. If there is lack of stabilization from the torso muscle, actions focusing on the hip joint only may turn out to be ineffective. The cause of the stabilization training is the transfer of muscle strength through the torso into the hip, which may lead to dysfunctions if the strength is wrongly distributed. Extensive muscle tension, lack of flexibility, lack of range of movements, lack of stabilization are key elements assessed by the physiotherapist.
The physiotherapist concentrates on relations in the muscle strength of the hip joint stabilizer: flexor muscles, extensors, adductors, abductors and rotators. A vital element is muscle flexibility which is responsible for full range of movements in the hip joint. With changes inside the joint with contracted joint capsule, actions focused solely on stretching and reinforcing muscles must be supplemented with manual mobilization. A internal rotation deficit in the hip joint which frequently accompanies groin pain causes recurring inflammations in the area of adductor muscles attachments.
Every exercise must be explained to the patient and possibly corrected because lack of precision in rehabilitation exercises leads to poor results of the therapy. With time exercises are modified, so are patient’s actions. The exercises should satisfy patient’s requirements, that is his/her final goal. Speaking of sportspersons, adaptation of tissues to gradually increasing loads and smooth adoption of discipline-specific motor training are substantial.
The aforesaid examples of exercises are suggested only as every patient should be provided by the physiotherapist with a workout program prepared on a case-by-case basis and corresponding to the motor deficits. Every patient should also be informed by the physiotherapist to make sure the exercises are done properly and compensation in movements is avoided.
Groin pain – exercise 1 done properly
Starting position – lying on the side, with one’s back to the wall. Patient makes abducting movements in the hip joint by sliding the heel on the wall up and down, and keeping the stable pelvis in a neutral position.
Groin pain – exercise 1 done improperly
Patient makes a wrong movement by forward bending the pelvis (back “hyperextend”) and lifts the lower limb too high, which causes the lumbar spine (lower section of the back) to be overloaded.
Groin pain – exercise 2 done properly
The patient keeps a stable position on the sensorimotor disk or other form of unstable surface.
Groin pain – exercise 2 done improperly
The patient makes extensive movements with his/her body and fails to keep stable position. The lower limb is not positioned in the axis, the knee “gives away” to the inside. This form of exercise may even lead to injury progress.
Groin pain – exercise 2 done improperly
When compared to proper position (side view), spine position is wrong. The body is bent, no torso stabilization.
Groin pain – exercise 3 – starting position
Lying on the side, legs bent at the knees, an elastic band selected on a case-by-case basis is above the knees. The patient makes abducting movements in the hip joint by lifting the knee and keeping heels together against the band.
Groin pain – exercise 4 – starting position
Standing in a half-squat position with an elastic band attached above the knees. The Patient keeps feet stable on the ground and makes any kind of abducting movements in hip joints he/she can. The position of feet must not be changed. Next he/she returns to the starting position.
Groin pain – exercise 5 – starting position
To start the exercise, the patient must squat ¼ and position himself/herself sideways to the wall bars with a band attached above the ankle joint. The patient slowly moves the limb to the side against the band – the abducting movement in the hip joint and then returns to the starting position by joining the legs. This exercise focuses on adductor muscles and keeping proper position of the stable limb.
Groin pain – exercise 5 end position
(see above, final position of the exercise)
Groin pain – exercise 6 starting position
The patient lies on his/her back positioned sideways to the wall bars, knees bent. An elastic band is attached above the knee joint. The patient slowly hinders the approaching movement of the knee to the wall bars against the band, and then approaches knees to return to the starting position.
Groin pain – exercise 6 end position
The above-stated exercises are for reference only. To guarantee positive results, it is necessary to consult a physiotherapist in the first place.
Author: mgr Kamila Drygas, Rehasport Clinic physiotherapist
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