Groin Pain in Athletes
June 1, 2000 4 minutes read
Groin Pain in Athletes
abstract & commentary
Synopsis: Because numerous etiologies exist for groin pain in athletes, a systematic diagnostic approach is necessary.
Source: Lacroix VJ. A complete approach to groin pain. Physician and Sportsmedicine 2000;28:66-86.
The article, "a complete approach to groin Pain," by Vincent J. Lacroix, MD, provides a comprehensive overview of the many pathologic entities that can present as "groin pain" in the athlete. These include stress fractures of the pubic symphysis and femoral neck, avulsion fractures about the pelvis, hip joint problems such as acetabular labral tears and slipped capital femoral epiphysis, as well as inguinal hernias, ilioinguinal neuralgia, strained muscles about the hip and lower pelvis (e.g., strains to the rectus abdominis and adductors), and osteitis pubis. To help remind us of these many diagnoses, Lacroix uses the mnemonic HTAGP, which is short for How to Approach Groin Pain (hips/pelvis, thigh, abdomen, genitalia, pain "referred").
A table listing 40 diseases that can present as groin pain is provided in Lacroix’s article, as well as a discussion of the salient points of a thorough history and physical examination on athletes with complaints of pain in this anatomic region. For each suspected diagnosis, Lacroix lists appropriate radiographic studies to help confirm initial suspicions. For example, in an acetabular labral tear Lacroix suggests obtaining an arthrogram or magnetic resonance image (MRI) or doing arthroscopy to confirm the diagnosis.
Two often elusive diagnoses that may present as groin pain are ilioinguinal neuralgia and sports hernia or its variant, "hockey player’s syndrome." The ilioinguinal nerve, which originates from the L1 and L2 nerve roots and innervates a portion of the transversus abdominis and internal oblique muscles as well as the skin overlying the inguinal region, can become entrapped as it passes through the abdominal muscles, resulting in burning or shooting pain in the distribution of the nerve. Local anesthetic infiltrated about the area of irritability may be diagnostic and therapeutic.
Sports hernia, defined by Lacroix as a disruption of the area of the inguinal canal, may involve tears of the transversus abdominis muscle or tendon of the internal oblique and transversus abdominis (conjoined tendon). The presentation of this entity is frequently insidious, involving unilateral groin pain that is exaggerated by sudden movements. A variant or subset of the sports hernia is the tearing of the external oblique aponeurosis, which can be seen in hockey players (hockey player’s syndrome or "slap-shot gut"). It occurs on the player’s side that is opposite his forehand shot. Surgical repair of the injured structure(s) is frequently required for pain relief of a sports hernia, with rehabilitation following the procedure for 6-8 weeks before the athlete is able to return to his or her sport.
Comment by Letha Y. Griffin, MD, PhD
There has been a recent increase in the interest and understanding of incapacitating groin pain in athletes. This is exemplified not only by two papers on sports hernias selected for presentation at the March 2000 meeting of the AAOS in Orlando, Florida, but also by this subject being the focus of several recent journal articles. For example, the January/February issue of the American Journal of Sports Medicine has an article on the management of severe lower abdominal and inguinal pain in high-performance athletes by Meyers et al.1 That article details the experience of Meyers et al with groin pain localized in the inguinal canal near the attachment of the rectus abdominal muscles, which, they believe, is caused by a tear of the attachment of the rectus abdominis tendon to the pubis (athletic pubalgia). They propose that the mechanism of injury is abdominal hyperextension and thigh hyperabduction. Furthermore, Meyers et al propose that injury to the rectus abdominis tendon results in anterior tilt of the pelvis, which increases the pressure on the adductor compartment, resulting in groin pain.
In Meyers et al’s series, 149 of the 157 patients who underwent surgery for this diagnosis had preoperative MRIs, and only 14 patients (9%) were noted to have a true tear of the rectus abdominis muscle near its insertion on the pubic symphysis. Forty-six patients had nonspecific findings (i.e., small avulsion fractures or swelling or edema in the area). The recommended treatment, repair of the pelvic floor, is in agreement with the suggestion of Lacroix in his article.
Both Lacroix and Meyers et al suggest that this is a difficult diagnosis to make and a careful history and physical examination are needed to methodically exclude other entities that can present as nonspecific groin pain.
Reference
1. Meyers WC, et al. Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med 2000;28:2-8.
Groin pain in the athlete may be caused by:
a. stress fractures of the femoral neck.
b. osteitis pubis.
c. inguinal hernia.
d. entrapment of the ilioinguinal nerve.
e. All of the above
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