Groin pain can be a difficult problem for patients as well as their clinicians. Part of the problem is that the location of the pain is often a poor indicator of the where the pathology actually lies. Additionally, when the pain becomes chronic, multiple pathologies can be generated, adding a further layer of complexity.
It is very important to make a clear diagnosis. We should seek to look beyond merely labelling the problem as a ‘groin sprain’. There many causes of pain in the groin. Approximately 50% of groin pain can be attributed to pain generated by the hip joint; a surprise, perhaps, for younger patients. As in any medical condition, the patient’s history will give us many clues. It is extremely important to rule out sinister ‘red flags’. These could be night pain, severe pain on loading the leg, weight loss or systemic symptoms, and we need to be mindful of conditions which may occur in certain age groups, such as a slipped epiphysis in teenagers.
Common causes of groin pain besides the hip, include those generated by the lumbar spine, pubic overload (osteitis pubis), iliopsoas and adductor tendon pathologies. You need to be aware of stress responses in the femoral neck in runners. Abdominal wall hernias may cause pain which is a little higher in the groin. Less commonly, younger patients can experience the rectus femoris pulling away from its attachment at the anterior inferior iliac spine. Testicular tumours and avascular necrosis can present insidiously and we need to be on the lookout for them.
A big proportion of patients who present with groin pain as a result of hip pathology, have an underling condition known as ‘femoral acetabular impingement syndrome’, or FAI. This is essentially a problem resulting from a tear in the acetabular labrum, usually caused by repetitive trauma. This may be due to a ‘bump’ or ‘CAM’ on the head neck junction of the femur, which may be acquired or genetic.
This can cause groin pain which is worse with exercise, sitting or standing. The pain can be brought on by putting the patient in the ‘impingement position’ of hip flexion + internal rotation + adduction. In the long term, we believe that the tear in labrum causes changes in the acetabular articular cartilage next to it, and over many years, this may lead to osteoarthritis in the hip.
FAI can affect people of all ages, and is often missed in 30-40 year olds. Taking a careful history, and carrying out a thorough examination can help identify the likely cause. Imaging, such as 3t MRI of the hip, can help confirm the underlying diagnosis (as X-Ray cannot rule out FAI). It should be remembered that imaging needs to be interpreted in light of the history and examination findings. FAI may require treatment with hip arthroscopy surgery, but in some cases injection therapy and robust physiotherapy or osteopathy may be enough to get a person back to full activity.
Sports Physicians and Osteopaths are ideally placed to identify the underlying cause of unexplained groin pain, and are skilled in directing the rehabilitation necessary to resolve the problems.
If you have any problems at all and would like in to see James Dodd or one of the team at Back to Back, please call 020 8605 2323.