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A clinicAl ApproAch to groin pAin

By dr. Mohammad Ashfaq Konchwalla and dr. Ganaraj Bhaskar, Medcare hospital, dubai, UAE

F E AT U R E

O RT H O PA E D I C S

Causes of groin pain

Table 1:

common causes 1. Adductor muscle tendinopathy 2. osteitis pubis 3. Trochanteric bursitis 4. obturator nerve entrapment 5. Referred pain from SI joint, lS spine.

less common 1. Iliopsoas strain/bursitis 2. Stress fracture-neck of femur, pubic ramus 3. Inguinal hernia-Indirect hernia, direct hernia, tear external oblique aponeurosis Gilmore hernia. 4. Infection- osteomyelitis, 5. hip Joint-femoro acabular impingement, synovitis, oA, labreal tear, Snapping hip 6. nerve entrapment- lateral cutaneous nerve of thigh,ilioinguinal nerve, genitofemorl nerve 7. Avulsion apophysitis, Anterior superior/inferior iliac spine

not to be missed 1. Slipped capital femoral epiphysis 2. Intraabdominal pathologyAppendicitis, UTIs, pelvic inflammatory diseases 3. AVn 4. perthes disease 5. Testicular cancer

opposite anterior superior iliac crest. pain in the sacroiliac area indicates a problem with the sacroiliac joints. Investigation X ray cT scan MRI bone scan

InTRodUcTIon
Groin pain is a common entity in athletes, difficult to diagnose and treat. determining the exact cause of groin pain can be difficult for several reasons. In our clinical practice it has been seen that it is frequent to occur in sports related injuries. Acute presentations usually have a straightforward diagnosis. In case of chronic groin pain it takes a diagnostic and clinical expert to provide better treatment.

TopIcS In dETAIl
Femoroacetabular Impingement Mechanism of Impingement see figure 2&3 1. cam impingement caused by nonspherical femoral head (damage to the ant-superior acetabular cartilage). 2. pincer Impingement caused - lateral acetabular cover (cartilage damage located circumferentially). FAI Diagnosis Groin pain in active young/middle age adults no hx of trauma Ant-Sup FAI (IR) Test: Symptoms produce with hip in flexion, adduction and IR post-inferior FAI: Symptoms produce with ER of an extended leg plain x- ray: Ap- Flattened head-neck junction and acetabular rim sclerosis lat Increase femoral neck off-set, pistol grip deformity MR arthrogram: Investigation of choice, good at detecting labral tears and chondral damage. Triad of MR arthrographic findings in patients with cam-Type FAI (see figure 4). FAI management non-op treatment: Symptomatic and modification of life style Surgical management: open and arthroscopic techniques - arrthroscopic assessment of the hip can include

examination of both central and peripheral compartments. The central compartments include the labrum and all the structures located medially. The peripheral compartment includes structures lateral to the labrum still inside the capsule like femoral head, femoral neck with joint capsule itself. The aim of surgery is to improve the clearance for hip movement and to alleviate the abutment of the proximal femur against the acetabular rim. Bony injuries These are avulsion fractures and apophyseal injuries due to failure of bone at tendon insertion, skeletal immature athlete. Mechanism The result of sudden, forceful concentric and eccentric contraction or passive lengthening. Stress fractures result from chronic repetitive forces. They occur when the absorption of bone exceeds metabolic repair during the bone remodeling process in response to repetitive mechanical loads. A metabolic imbalance can occur, such as increased mechanical loads, from high levels of training. Secondary to interference with the bones remodeling capacity by various insults, include drugs such as glucocorticoids, nutritional deficiencies, namely calcium and vitamin d, hormones such as a hypoestrogenic state which occurs after the menopause, and athletic amenorrhea. The athletes at the highest risk for these fractures include distance runners, jumpers, ballet and aerobic dancers, and triathletes. With Site Femur, Ischium, and Inferior pubic ramus, patients will develop discomfort in the groin while standing unsupported on the Ipsilateral leg.

Femoral stress fractures They are problematic because of the possibility of progression to displacement and osteonecrosis of the femoral head (see figure 4). Types compression: Inferior medial aspect, non weight bearing. Tension: Transverse superior margin needs Internal Fixation. Stress fractures of the superior aspect should be considered as surgical emergency and treated with urgent internal fixation and strict bed rest. Osteitis Pubis osteitis pubis is a syndrome characterized by pain and bony erosion of the symphysis pubis. historically,

clInIcAl AppRoAch
Anatomy- see figure 1 An approach should be by definition to localize the area of abnormality. Symptoms extending laterally to the pubic symphysis, medically to the anterior superior iliac spine, superiorly to the lower abdomen and inferiorly 5 to 10 cm of the anterior thigh. This may be in the adductor muscle group, where causes like tendinopathy and chronic muscle pain is common in the hip joint as a result of labral tear, synovitis of hip joint, trochanteric bursitis, or a stress fracture of the neck of femur. pubic bone abnormalities include osteitis pubis and stress fracture of pubic ramus in consideration with lower abdominal musculature, iliopsoas strain, rectus abdominis tendinopathy, inguinal hernia. Referred pain in the groin can be from lower thoracic spine, sacro iliac joint and abdominal causes. Causes of groin pain (table 1): Adult-osteoarthritis, AVn, fracture, infection, femoro-acetabular impingement
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Adolescent-SUFE Young child-septic arthritis /synovitis/ perthes disease.

ASSESSMEnT oF pATIEnT WITh GRoIn pAIn


Examination Look on standing Walking Supine position. Feel Tenderness, abductor muscle/pubic symphysis and rectus abdominalis Movement; Active and passive movement of the hip Functional movement: deep squat, SlRT, hurdle step. Special test The FABER test stands for Flexion, Abduction, and External Rotation of the

hip. This test is used to distinguish hip or sacroiliac joint pathology from spine problems. To perform Ask the patient to lie supine on the exam table. place the foot of the effected side on the opposite knee (this flexes, abducts, and externally rotates the hip). pain in the groin area indicates a problem with the hip and not the spine. press down gently but firmly on the flexed knee and the

Cam Impingement

Pincer Impingement

Abnormal contour femoral head neck junction

Abnormal superior labral tear

FIG 1: top Fig 2: middle FIG 3: bottom


Arab Health Issue 3 2010 47

F E AT U R E

O RT H O PA E D I C S

Stress fractures result from chronic repetitive forces


and swelling using the RIcE regimen. Avoid early stretching which could lead to chronic tendinopathy. Bursitis primary and Secondary (direct injury) Trochanter Bursitis Greater Trochanter and Fascia lata Ischiogluteal Bursitis Ischial Tuberosity and G maximus, Iliopsoas Bursitis, Iliopsoas muscle and pelvic ring (see figure 5). Snapping Hip Syndrome It is commonly seen in professional ballet dancers. There are two forms of snapping hips. one is localised to lateral aspect of hip and is produced by tensor fascia lata/abducting fibers of gluteus maximus sliding over the greater trochanter and producing a typical sound (reproduce with passive hip flexion from adducted position). The second type is caused by the psoas tendon as it passes over the hip joint (reproduce extension and internal rotation of the hip from flexed and externally rotated position). this condition has been considered an infectious complication of pelvic infection and instrumentation or a complication of excessive pubic symphysis mobility during pregnancy. Recently, reviews in athletes have identified a predominance of patients with a mechanical etiology and a smaller number of patients with an obstetric or inflammatory etiology. The syndrome occurs most often in soccer, rugby, tennis and ice hockey players, with males affected more often than females. Adductor Muscle Strain This is a common injury in sports that involves a sudden change of direction. The onset is acute and the area of tenderness is usually well localised, either to the belly of adductor longus, the proximal musculotendinous junction or the tendon near its origin on the inferior pubic ramus. Examination localized tenderness, pain in passive abduction and pain on restricted adduction and/or combined flexion/ adduction. Treatment- initial reduction of bleeding

example, difficulty in sitting or participating in activities that cause contraction of hip flexor and Internal rotator (ice skating). Sportsmans hernia, Occult Hernia This is also more commonly known as Footballers hernia. no palpable hernia occurs. An increasingly recognized cause of chronic groin pan in athletes has been detected. The suspected causes include weakness along the posterior aspect of the abdominal wall with occult direct or indirect hernia, injury or avulsion of the internal oblique muscle or fascia, tearing of the external oblique muscle and aponeurosis. The patient usually presents with insidious onset of activityrelated unilateral groin pain that abates with rest. physical examination will show no detectable hernia, tender dilated superficial inguinal ring and tenderness of the posterior wall of the inguinal canal. Imaging studies are usually normal and treatment is conservative/operative reinforcement of posterior inguinal wall.

Athletic Pubalgia An athlete complains of lower abdominal pain located in the inguinal canal near insertion of rectus abdominis muscle on pubis on exertion. This occurs in high levels of athletes with lower abdominal pain upon exertion. pain occurs with resisted adduction of the hip. Obturator Neuropathy The patient presents with proximal groin pain, which radiates towards the distal thigh. Associated weakness or a feeling of lack of proportion of limb during running and sometimes numbness. This controversial condition should be considered as a subset of adductor tendinopathy. on examination weakness of resisted adduction and numbness over the distal medial thigh is noted. Bone scan in this condition often shows increased uptake over the ipsilateral pubic tubercle. The diagnosis is confirmed by needle EMG. other nerve entrapmentsIlioinguinal nerve supplies skin around

the genitalia and inside of the thigh and produce pain as a result of entrapment. Genitofemoral nerve innervates skin just above the groin fold. The lateral cutaneous nerve of the thigh is called meralgia paresthetica. Treatment usually all conditions spontaneously resolve. Meralgia may sometimes need corticosteroid injection at the site where the nerve exits.

REFERREd pAIn To ThE GRoIn


Abdominal causes such as: Ureteric colic Abdominal aortic aneurysm pyelonephritis Appendicitis - only rarely

conclUSIon
Groin pain needs a thorough history, clinical examination, special tests, and investigation Ah like x-rays/ bone scan/MRI scans.

REFEREnCES
References available on request (magazine@iirme.com)

clInIcAl EXAMInATIon
The patient is placed on their side. The knee is flexed 90 degrees and the hip extended to neutral. The examiner holds the leg up by the foot. normally, the knee falls down. ITB is very tight, the leg hangs up (very impressive). Moderately tight, the knee falls halfway to the table. Acetabular Labral Tears Acetabular labrum tears are responsible for chronic anterior hip pain. Symptoms may or may not follow a traumatic event. patients with this injury generally have activity-related sharp groin and anterior thigh pain that often becomes worse with extension. Episodes of deep clicking and a feeling that the hip is giving way are common. Pyriformis syndrome This is caused by compression of the sciatic nerve by the piriformis muscle.The patient usually complains of groin pain and symptoms of sciatic nerve distribution, for
Arab Health Issue 3 2010 49

FIG 4
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FIG 5