Groin Pain

The spectrum of groin pain ranges from simple  muscle strains with subtle performance compromise to recurrent, debilitating groin pain preventing sports participation. The most frequently discussed causes of resistant groin pain are

1. Osteitis Pubis

2. Sports hernia (Gilmores Groin)

3. Adductor Enthesopahties

I’ve put together a detailed list of differential diagnostic factors to consider under both mechanical and non-mechanical categories.

Clinical features and treatment

Musculoskeletal Causes	Key features	Treatment options
Abdominal muscle tear	Localised tenderness to palpation; pain with activation of rectus abdominus	Relative rest, analgesics
Adductor tendinitis	Tenderness over involvd tendon, pain with resisted adduction of lower extremity	NSAIDS, rest, physiotherapy (PT)
Avascular necrosis of the femoral head	Inguinal pain with internal rotation of hip; decreased hip ROM	Mild: conservative measures severe: THR
Avulsion fracture	Pain on plpation of injury site; pain with stretch of involved muscle	Relative rest; ice; NSAIDS; possibly crutches
Bursitis	Pain over site of bursa	Injection of cortisone, anesthtic, or both
Conjoined tendon dehiscence	Pain with Valsalva’s manouver	Surgical referral
Herniated nucleus pulposis	Positive dural or sciatic tensions signs	PT or appropriate referral
Muscle strain	Acute pain over proximal muscles of medial thigh region; swelling; occasionally bruising	Rest; avoidance of aggravating activities; initial ice, with heat after 48hrs; hip spica wrap; NSAIDS for 7 to10 days
Myositis Ossificans	Pain and decreased ROM in involved muscle; palpable mass within substance of muscle	Moderately aggressive active or passive ROM exercises; wrap thigh with knee in max flexion for first 24 hrs; NSAIDS used sparingly for 2 days after trauma
Nerve entrapment	Burning or shooting pain in distribution of nerve; altered light touch sensation in medial groin; pain exacerbated by hyperextension at hip jt, possibly radiating; tenderness near superior iliac spine	Infiltration of site with local anesthetic; topical cream ( eg capsaicin )
Osteitis pubis	Pain around abdomen, groin, hip or thigh increased by resisted adduction of thigh	Relative rest; initial ice and NSAIDS; possibly crutches; later stretching exercises
Osteoarthritis	Inguinal pain with hip moton, especially internal rotation	Nonnarcotic analgesics or NSAIDS; hip replacement for intractable pain
Pubic instability	Excess motion at pubic symphysis; pain in pubis, groin or lower abdomen	PT, NSAIDS, compressive shorts
Referred pain from knee or spine	Hip ROM and palpation response normal	Identify true source
Seronegative spondyloarthropathy	Signs of systemic illness, other joint involvement	Refer to rheumatologist
Slipped capital femoral epiphysis	Inguinal pain with hip movement; insidious development in ages 8 to 15; walking with limp, holding leg in external rotation	Discontinue athletic activity; refer to orthopaedic surgeon
Stress fracture
Pubic ramus	Chronic ache or pain in the groin, buttock and thighs	Relative rest; avoid aggravating activities
Femoral neck	Chronic ache or pain in the groin, buttock and thighs or pain with decreased hip ROM ( internal rotation in flexion)	Refer to orthopod if radiographs show lesion; for nonoperative fractures strict non-weight bearing until pain free with gradual return to activity
Non-musculoskeletal Causes	Key features	Treatment options
Genital swelling/inflam
Epididymitis	Tenderness over superior aspect of testes	Antibiotics if appropriate, or refer to urologist
Hydrocele	Pain in lower spermatic cord region	Refer to urologist
Variocele	Rubbery, elongated mass around spermatic cord	Refer to urologist
Hernia	Recurrent episodes of pain; palpable mass made more prominent with coughing or straining; discomfort elicited by abdominal wall tension	Refer for surgical treatment
Lymphadenopathy	Palpable lymph nodes just below inguinal ligaments; fever, chills, discharge	Antibiotics
Ovarian cyst	Groin or perineal pain	Refer to gynecologist
Pelvic inflammatory disease	Fever, chills, purulent discharge	Refer to gynecologist
Postpartum symphysis separation	Recent vaginal delivery with no prior history of groin pain	Physiotherapy, relative rest, analgesics
Prostatitis	Dysuria, purulent discharge	Antibioics, NSAIDS
Renal lithiasis	Intense pain that radiates to scrotum	Pain control, ­fluids until stone passes; Hospital adm sometimes necessary
Testicular neoplasm	Hard mass palpated on the testicle; may not be tender	Refer to urologist
Testicular torsion or rupture	Severe pain in the scrotum; nausea, vomiting; testes hard on palpation or not palpable	Refer immediately to urologist
Urinary tract infection	Burning with urination; itching, frequent urination	Short course of antibiotics

The key differential criteria are to exclude surgical cases – which constitute a small proportion of the total population and then decide on a specific course of targeted rehabilitation to address the groin pain. More on the specific’s for another post.

Enjoy the clinical challenge.

David

Sacroiliac Joint Dysfunction

The sacroiliac joint has now been well established to actually move yet clinicians of my generation and older would certainly be aware of the argument that the sacroiliac joint did not normally move except in pregnancy.  Suffice to say that we have now moved beyond this argument for the normal population and the clinical challenge is diagnosing not only the existence of sacroiliac dysfunction but the mechanism behind the dysfunction.

Radiological imaging does not particularly add to the diagnostic work-up so we are left to rely on clinical assessment.  In the last decade Vleeming and Schneider’s have advanced the concept of both “form and force closure” as the primary mechanisms maintaining sacroiliac stability.

Form & Force Closure

In brief, form closure refers to the configuration of the joint surfaces, the alignment of these surfaces relative to gravity and bodyweight, and the tension in the restraining ligaments associated with normal alignment of the segments.

Force closure refers to the interaction of multiple muscle groups, which act across the joint to enhance compression on the joint surface to assist in joint stability.  This is the so-called oblique sling system, which has been conceptualised to involve the ipsilateral Glueteus Maximus and Tensor Fascia Lata in conjunction with the contra lateral latissimus dorsii.  This is enhanced anteriorly by the oblique abdominal system and the contra-lateral hip adductors.

These two oblique systems effectively form an X  (cross shape) on the anterior and posterior aspects of the pelvis and constitute the dynamic mechanism by which joint integrity is maintained.  These concepts appear to hold some clinical validity and have provided an enhanced framework for us to approach our treatment of the sacroiliac joint.

Lee has integrated this approach with some of the traditional osteopathic models to provide a clinical algorithm for determining sacroiliac dysfunctions. This involves evaluation of:

1)      Lumbar spine

2)      Pelvic landmarks,

3)      Sacral landmarks.

This provides a practical framework where we as clinicians can try to differentiate primary or secondary pelvic dysfunction and therefore target our treatment in the most appropriate way.  Because of the functional interaction of body segments a lumbar scoliosis, for example, can have secondary effects on the sacroiliac joint alignment and conversely sacroiliac mal-alignment may produce secondary scoliosis in the lumbar spine.  This is the classic “chicken and egg” scenario.

So using the above categorisations we can quantify spinal alignment using:

Visual observation

Palpating bony landmarks

Correlating with movement pattern in the lumbar spine.

Looking specifically at the pelvis we can define the position of the bony landmarks on the pelvis using:

ASIS,

PSIS

Ischial tuberosities

as reasonably reliable landmarks to assess the positional orientation of these bones.

The spectrum of pelvic dysfunctions which have been described include:

Anterior innominate rotation

Posterior innominate rotation

Innominate inflare

Innominate outflare

Innominate upslip

Innominate downslip.

Much debate exists regarding the reliability and mechanism of these syndromes so it is largely a clinical diagnosis.

The principle assumption of quantifying bony pelvic orientation is that the pelvic position will determine the position of the sacrum and therefore mal-alignments of the pelvis should be prioritised over sacral mal-alignments when they are observed to co-exist.

Corrective Measures

In general the principles of correction are either to use manipulative thrust procedures, joint mobilisation or muscle energy / myofascial techniques to help to realign the pelvic structures using the leverage of the torso or lower limbs.  This then leaves us in a situation of assessing the sacral position within the corrected pelvic rim and then ascertaining the sacral orientation. A number of sacral dysfunctions have been categorised.

These include:

1)      Nutated sacrum

2)      Counter- nutated sacrum

3)      Oblique axis twist indicating a spinning mechanism where one side of the sacrum lies deep and the other lies more superficial.

Assessing sacral position within the pelvis is challenging clinically, produces more inter-tester variability and is harder to be confident with.  However it is well worthwhile using this clinical algorithm to define  joint mal-alignments clinically and plan treatment strategies.

Crossing the first hurdle of defining the dysfunction the challenge is then to determine why mal-alignments have occurred and whether we can assess breakdowns in functional control (force closure mechanisms) which may be associated with overload- but that’s another day’s work and a discussion for another time

.

Enjoy the clinical challenge.

David

Pubic Symphysis Dysfunction

Following on from our introduction to groin dysfunction we’ll now take a closer look at Pubic Symphysis dysfunction.

Osteitis Pubis is the most widely recognized pathology in this region with the spectrum of pathology ranging from….

joint strains.

Pubic Symphysis mal-alignment

Osteitis Pubis.

Mechanism of Pubic Symphysis Dysfunction

Shear stresses acting across the symphysis as a result of repetitive contractions of the adductors in sporting activities has been indicated as a likely factor in the development of osteitis pubis. This can be associated with  pubic bone marrow oedema evident on MRI – also  suggestive of a stress injury to the pubic bone.

Given the evidence in the literature showing a relationship between the movements of the lumbar spine and hip and the association of  low back pain with both SIJ  symptoms and hip joint dysfunction , it may be acceptable to consider the hip musculature from the perspective of deep local stabilizing muscles and more superficial global stabilising muscles as previously discussed for the spinal musculature

Review of Hip Muscle Anatomy

A biomechanical model of gluteus medius consisting of three segments each with a separate innervations has been proposed.  It is suggested that the main function of the posterior gluteus medius and all of gluteus minimus is to stabilize the head of the femur in the acetabulum during the gait cycle.   In a dissection study of gluteus minimus in twenty cadaver hips reported a deep muscular attachment to the capsule in all specimens and suggested a similar role for gluteus minimus as that of the rotator cuff of the shoulder due to its capsular attachment.  These findings are suggestive of a stability role gluteus minimus and the posterior part of gluteus medius in the hip.

The deep external rotators of the hip namely…

Obturator internus

Gemelli

Quadratus femoris

have been described as a functional unit.  In an anatomical and histological study of these muscles in cats the muscle fibers were found to be short with small fiber length:muscle length ratios and low angles of pinnation which the authors suggest is the optimal design for hip stability In the same study the deep hip muscles were found to contain a high percentage of type 1 slow fibers again suggestive of a stability role.

Psoas

Psoas has been proposed as a contributor to lumbar stability due to it attachments to the lumbar vertebrae and intervertebral discs particularly in upright stance.

All of the above evidence regarding the potential stability role of the deep external rotators, gluteus minimus, posterior part of gluteus medius and psoas major is anatomical and biomechanical in nature and lacks clinical studies to support or refute the hypotheses of deep local muscle motor control at the hip.  However taken on its merits and in combination with the concept of motor control, it may be valid clinically as part of a clinical reasoning approach to consider specific deep muscle activation in the hip region as part of an early motor control program for the hip, SIJ and lumbar region.

1.      Evaluate hip function in the context of pelvic stability during applied load.

2.       Evaluate specific hip muscle control in multiple planes

3.      Identify specific “plane of motion” dysfunction

4.      Determine mechanical restrictive components

5.      Determine muscle control deficits

6.      Identify movement pattern breakdown

7.      Prioritise treatment targets

8.      Define progression markers

9.      Identify potential bottlenecks

10.  Quantify relevant outcome measures.

Enjoy the clinical challenge

David

Groin Rehabilitation-10 Tips

Differential diagnosis in persistent groin dysfunction is notoriously difficult. This is likely due to the overlap in pathology and the lack of specificity with provocation tests. The treating clinician needs to be aware of the pathological spectrum primarily with a view to identifying potential surgical cases. As the treatment outcome is often variable with the duration of rehabilitation extending over months it is important for the therapist to have markers of progress and sequential progressions to evaluate treatment response. When dealing with groin dysfunction which is mechanical in origin it is useful to have a checklist to dictate interventions.

Groin Rehabilitation – 10 Tips for differential Diagnosis

Oesteitis Pubis

Sports hernia

Adductor tendinopathy

Peripheral entrapment neuropathy

Hip  Pathology

Rectus abdominis insertion strain

Pubic symphysis dysfunction

SI Dysfunction

Lumbar Spine

Hamstrings

Of all of these diagnostic possibilities only sports hernia and Adductor tendonopathy have possible surgical management options. Therefore the first clinical priority is to segregate out these possibilities and then focus the clinical exploration on the mechanism of breakdown and prioritising legitimate targets to address. We will return to these challenges in future posts.

Here is a link to a paper addressing the role of core stability in groin dysfunction…….

groin2

Enjoy the clinical challenge
David

Groin Pain – making a difference?

Are you happy with the differential diagnosis around the groin?

Clinically the extent of overlap between pathologies reduces diagnostic certainty.

Frequently, by a process of elimination, surgical pathologies are excluded and the rest are left to time, steroid infiltration and a miriad of pallative measures.

What do you think are the most effective rehabilitation tools to employ with chronic groin dysfunction?