Adductor-related Longstanding Groin Pain
Unfortunately, most patients with this condition continue with their usual sporting or recreational activities until pain prevents them doing so. When the condition has reached this stage, a lengthy period of rest and rehabilitation is required.
Treatment
Basic principles underpin a treatment regimen :-
1. Soft tissue treatment techniques
2. Ensure that exercise is performed without pain.
3. Improve lumbo-pelvic stability
4. Strengthen local musculature
5. Progress patients level of activity through regular clinical assessment.
Surgery
If the patient does not respond to the above conservative treatment and rehabilitation protocol, then a partial adductor tendon release may be helpful.
Iliopsoas-related Longstanding Groin Pain
This muscle frequently becomes tightened with neural restriction. It usually presents as a poorly localised ache that patients describe as being a deep ache in one side of the groin. Pain on palpation of this muscle together with tightness on stretch and pain on resisted hip flexion from the stretched position indicate its involvement in the presenting symptoms.
It is important also to examine the lumbar spine as there is frequently an association between iliopsoas tightness and hypomobility of the upper lumbar spine from which the muscle originates.
Treatment
The emphasis is on soft tissue treatment of the muscle, stretching with the addition of a neural component and mobilisation of the lumbar intervertebral joints.
Abdominal-wall related Longstanding Groin Pain
The subject of “hernias” is a common cause of groin pain in the athletic population.
Sportsman’s Hernia
Patients present with a long history of gradually worsening, poorly localised pain aggravated by activity, especially kicking. This diagnosis is popular amongst footballers. It is important to note that this presentation is uncommon in women.
Pathology
Included are, a tear in the transversalis or external oblique fascia, a tear in the external oblique aponeurosis, a tear in the conjoined tendon, a separation of the inguinal ligament from the conjoined tendon or tearing of the conjoined tendon from the pubic tubercle. Some or all of these pathologies may lead to dilation of the external inguinal ring.
The condition is commonly bilateral and the onset of pain is usually insidious. The pain initially tends to occur after or near the end of activity. As the condition progresses, the pain worsens and occurs earlier in activity. The pain is usually located in the posterior inguinal floor inside the external ring. It may also radiate to the testicles, adductors or laterally in the upper thigh. The pain is usually aggravated by sneezing, coughing and sexual activity. Symptoms have a tendency to settle after prolonged absence from sporting or aggravating activity, only to recur when high-intensity exercise is resumed.
Examination
Maximal tenderness s usually over the pubic tubercle. The most helpful diagnostic sign is dilation and/or discomfort to palpation of the external inguinal ring after invagination of the scrotum. There is some evidence that ultrasound examination and MRI scanning may be able to detect these hernias.
Treatment
Surgery is the most popular treatment for this condition. The procedure can be performed as an open operation or laparoscopically.
Theoretically, a rehabilitation programme consisting of strengthening of the abdominal obliques, transversus abdominis, adductors and hip flexors should help in this condition, and a trial of such a programme may be worthwhile before resorting to surgery.
‘Gilmore’s’ Groin
A similar condition described by the surgeon Gerry Gilmore, involves a torn external oblique aponeurosis, causing dilatation of the superficial inguinal ring and a torn conjoint tendon. Gilmore advocates surgical repair of the defect with a reported 96% of his patients returning to sport within 15 weeks.
Inguinal Hernia
Inguinal hernias occur within the general population. Small hernias may become painful as a result of exertion. Symptoms may include a characteristic dragging sensation to one side of the lower abdomen, and is aggravated by increased intra-abdominal pressure, such as coughing. On examination, there is occasionally an obvious swelling and there may be a palpable cough impulse. Treatment consists of surgical correction of the defect.
Pubic Bone Stress-related Longstanding Groin Pain
Groin pain can arise from bony stress around the pubic symphysis, known as ‘osteitis pubis’. This diagnosis is typically confirmed by MRI and CT scanning.
Treatment
The use or corticosteroids both as a local injection into the symphysis pubis and in oral form has been shown to be helpful in settling the pain, thus enabling the patient to commence the rehabilitation programme earlier.
Dextrose prolotherapy injections have also been shown to be helpful on a monthly basis into the adductor origins, suprapubic abdominal insertion and symphysis pubis. On average, up to 3 injections may be required.
Additionally, 3 to 6 monthly courses of intravenous injection of the biphosphonate pamidronate have also been found to be helpful with this condition.
Surgery has been advocated by some clinicians, whereby surgical exploration and debridement of the symphysis can be carried out when appropriate.
Obturator Neuropathy
This condition is a fascial entrapment of the obturator nerve as it enters the adductor muscle compartment and accounts for approximately 4% of patients with longstanding groin pain.
It presents as exercise-related groin pain, which can radiate distally towards to inner thigh. There may be associated weakness or a feeling of a lack of propulsion of the limb during running. Examination will also reveal weakness of resisted thigh adduction and numbness over the distal medial thigh.
Treatment
The definitive treatment of this condition is surgical. This involves releasing the entrapped nerve from the underlying fascia over the adductor brevis muscle. Post-surgery, a graduated return to full activities encompassing stretching and strengthening exercises of the adductor musculature over a period of 4-6 weeks is required.
Hip Osteoarthritis
Because people in their sixth decade and beyond often remain active, it is increasingly common to see patients at the clinic with groin pain related to osteoarthritis of the hip joint. This condition is a degenerative joint process.
Treatment
Included is rest from aggravating activities, but when pain is unremitting, joint replacement surgery should be considered. Interim measures, may be helpful in reducing pain, include anti-inflammatory medication and intra-articular corticosteroid injection, which may delay the need for joint replacement surgery.
‘Snapping’ Hip
This is a condition commonly seen in ballet dancers, referring to a snapping noise in the hip region. There are two forms of snapping hip. Lateral snapping hip is localised at the lateral aspect of the hip and is produced by the tensor fascia lata sliding over the greater trochanter and producing a characteristic sound. It is usually not painful. Although the condition may resolve with rest, attention to pelvic stability and stretching exercises of the involved tissues may hasten recovery.
A second form of snapping hip (internal snapping hip) is caused by the iliopsoas tendon as it flips over the iliopectineal eminence. The patient complains of pain with hip flexion. Treatment consists of iliopsoas stretches and soft tissue therapy to the iliopsoas muscle. Rarely, surgical release may be required.
