The American Journal of Sports
Medicine
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Hip Joint Pathology as a Leading Cause of Groin Pain in the Sporting Population: A 6-Year Review of
894 Cases
Alan T. Rankin, Chris M. Bleakley and Michael Cullen
Am J Sports Med 2015 43: 1698 originally published online May 11, 2015
DOI: 10.1177/0363546515582031
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Hip Joint Pathology as a Leading Cause
of Groin Pain in the Sporting Population
A 6-Year Review of 894 Cases
Alan T. Rankin,*y MBBchBao, FFSEM(UK), MRCS, PGDip Sports Med,
Chris M. Bleakley,z BSc(Hons), PhD,
and Michael Cullen,y FRCP, FFSEM(UK and Ire), FISEM, MRCGP, Dip Sports Med, DCH
Investigation performed at the Department of Sports Medicine,
Musgrave Park Hospital, Belfast, Northern Ireland, UK
Background: Chronic hip and groin pain offers a diagnostic challenge for the sports medicine practitioner. Recent consensus
suggests diagnostic categorization based on 5 clinical entities: hip joint–, adductor-, pubic bone stress injury–, iliopsoas-, or
abdominal wall–related pathology. However, their prevalence patterns and coexistence in an active population are unclear.
Purpose: This study presents a descriptive epidemiology based on a large sample of active individuals with long-standing pain in
the hip and groin region. The objectives were to examine the prevalence of key clinical entities, document coexisting pathologies,
and present prevalence patterns based on key demographics.
Study Design: Cross-sectional study; Level of evidence, 3.
Methods: A retrospective review was conducted of clinical records of all hip and groin injuries seen between January 2006 and
December 2011 under the care of a single experienced sports medicine consultant. In all cases, imaging was undertaken by
a team of specialist musculoskeletal radiologists. Diagnoses were categorized according to 5 clinical entities using contemporary
diagnostic nomenclature. The chi-square test was used to compare observed and expected frequencies across each subgroup’s
prevalence figures based on sex, age, and sports participation.
Results: Full medical records were retrieved from 894 patients with chronic hip and groin pain. The majority of patients were male
(73%), aged between 26 and 30 years, and participating in footballing codes (soccer, rugby, and Gaelic sports) or running. A total
of 24 combinations of clinical entities were found. There were significant differences (P \ .001) in prevalence patterns based on
age, sex, and sports activity. Adductor-related pain or pubic bone stress injury rarely presented in isolation. Hip joint pathology
was the most common clinical entity (55.98%) and was significantly more likely to present in isolation. The majority of hip joint
pathologies related to femoroacetabular impingement (40%), labral tears (33%), and osteoarthritis (24%). These figures were significantly different across male and female patients (P \ .001), with a higher percentage of cases of femoroacetabular impingement and labral tears in male and female patients, respectively.
Conclusion: Chronic hip and groin pain is often associated with multiple clinical entities. Hip joint pathology is the most common
clinical entity and is most likely to relate to femoroacetabular impingement, labral tears, and osteoarthritis. These pathologies
seem to be associated with secondary breakdown of surrounding structures; however, underpinning mechanisms are unclear.
Keywords: groin; hip; athlete; sport; pain; entity
Hip and groin pain is becoming a more commonly recognized problem in athletes at all competitive levels.19,21
This pain is often long-standing and continues to offer a significant diagnostic challenge10 for the sports medicine
practitioner. Although it is acknowledged that there are
various causes of chronic groin pain, until recently, there
has been little consensus on the diagnostic criteria and
nomenclature.
Holmich10 originally proposed diagnostic categorization
based on 3 clinical entities: adductor-related pain/osteitis
pubis, hernia and lower abdominal pain, and iliopsoas-related
pain. This was recently updated11 to include 2 additional
*Address correspondence to Alan T. Rankin, MBBchBao, FFSEM
(UK), MRCS, PGDip Sports Med, Department of Sports Medicine, Musgrave Park Hospital, Stockman’s Lane, Belfast, Northern Ireland BT9
7JB, UK (email: alanrankin@doctors.org.uk).
y
Department of Sports Medicine, Musgrave Park Hospital, Belfast,
Northern Ireland, UK.
z
Faculty of Life and Health Sciences, University of Ulster, Northern
Ireland, UK.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 43, No. 7
DOI: 10.1177/0363546515582031
Ó 2015 The Author(s)
1698
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Vol. 43, No. 7, 2015
Sporting Groin Pain—Review of 894 Cases
1699
TABLE 1
Criteria Used for Clinical Entitiesa
Clinical Entity
Clinical Criteria
Radiologic Criteria
Adductor related
Pain on palpation of adductor origin, pain on passive stretch.
(Diagnosis based on presence of all clinical criteria independent
of imaging.)
Pain on hip extension stretch (modified Thomas test), pain on
palpation and resisted hip flexion. ‘‘Clicking iliopsoas’’ also
included. (Diagnosis based on presence of all clinical criteria
independent of imaging.)
Tender rectus abdominis on palpation and resisted sit-up.
Positive ‘‘sportsman’s hernia’’—tender conjoint tendon, dilated
superficial ring, pain and cough impulse on invagination of
scrotum. Presence of inguinal or femoral hernia. (Diagnosis
based on clinical criteria alone.)
Tender over central pubic symphysis. Central pain on adductor
squeeze. (Diagnosis based on presence of all clinical criteria
independent of imaging.)
Reproduction of pain and restriction during hip range of motion.
(Diagnosis based on positive clinical criteria with positive
imaging findings on radiographs or MRI.)
Positive adductor pathology on MRI.
Iliopsoas related
Abdominal wall
related
Pubic bone stress
injury related
Hip joint related
(intra-articular)
MRI- or USS-positive iliopsoas bursa or
pathology.
Positive groin USS. (Imaging was used to
support clinical diagnosis when clinical
findings were not definitive.)
Increased signal on MRI scan at
symphysis.
Positive radiograph or MRI. Relief of pain
during intra-articular injection.
(Injection is occasionally required to
confirm clinical findings in the absence
of imaging abnormalities.)
a
From Bradshaw et al,4 Holmich,10 and Holmich and Bradshaw.11 MRI, magnetic resonance imaging; USS, ultrasound scan.
clinical entities: hip joint pathology and pubic bone stress
injury (PBSI), a term that has superseded osteitis pubis to
more accurately reflect the bony overload phenomenon noted
in male athletes who undertake high training loads.
Early studies suggested that incipient hernia13 and
iliopsoas pathology10 were the most prevalent entities
associated with long-standing groin pain. The advent of
increasingly accurate magnetic resonance imaging (MRI)
and advances in hip arthroscopic surgery suggest that earlier studies may have overlooked the hip joint as a primary
source of primary pain in the athlete.14 There is also an
acknowledgment that multiple pathologies can coexist in
patients with chronic groin pain,10 with hip joint pathology
thought to be a major contributor to secondary breakdown
of adjacent structures.5
No epidemiologic study has investigated the prevalence
of hip joint pathology and determined the coexistence of
other clinical entities based on contemporary diagnostic
taxonomy. Our aim was to present a descriptive epidemiology based on a large sample of active individuals with longstanding pain in the hip and groin region. Our primary
objective was to examine the prevalence of key clinical
entities and document coexisting pathologies. We also
examined prevalence patterns based on age, sex, and
sports participation.
METHODS
All the cases reviewed for this study were based on
patients who were seen at a single secondary-care sports
medicine center under the care of a single sports medicine
consultant over a 6-year period. Patients were either selfreferred or referred by physiotherapists, general
practitioners, or orthopaedic surgeons. This is a general,
public-access, sports injury service that sees a broad spectrum of athletes, varying from recreational to semiprofessional, across all age groups. The sports participants seen
broadly reflect the types of sports practiced within the geographical region. As a secondary-care service, the majority
of athletes would have sought treatment elsewhere, from
physiotherapists or their own general practitioner, prior
to referral to this service. The clinical records and radiologic reports were obtained for all patients whose cases
were coded on the clinic’s electronic record system as
‘‘hip’’ injuries presenting as a new patient episode from
January 1, 2006, to December 31, 2011.
The following demographic data were obtained for each
episode: age of patient at initial presentation, sex, and
sports participation. All cases were deemed to be chronic
or long-standing (.6 weeks)10 owing to the 10-week average waiting time from general practitioner referral to initial consultation at our clinic. Notes and radiologic
findings were reviewed in combination to establish an
injury diagnosis. Injuries were then subgrouped into 1 of
5 clinical entities using both clinical and radiologic
criteria.4,10,11
All patients were under the care of a single sports medicine consultant with .20 years of experience in full-time
sports medicine practice and an interest in athletic hip
and groin pathology. All patients underwent appropriate
imaging, and all studies were subsequently reported by
a team of specialist musculoskeletal radiologists. A standardized systematic clinical and diagnostic approach,
which can be viewed schematically in Appendix 1 (available online at http://ajsm.sagepub.com/supplemental),
was used in the assessment of all cases. A single sports
medicine doctor with experience in hip and groin injury
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1700 Rankin et al
The American Journal of Sports Medicine
TABLE 2
Clinical Entity by Sexa
100
90
80
Entity alone
Entity with others
Male
Percentage
70
60
Adductor related
Iliopsoas related
Abdominal wall related
Pubic bone stress injury related
Hip joint related
50
40
30
20
232
61
78
198
465
(22)
(6)
(8)
(19)
(45)
Female
4
24
0
5
109
(3)
(17)
(0)
(4)
(77)
10
0
Hip Joint–Related
PBSI
Abdominal Iliopsoas-Related Adductor-Related
Wall–Related
Clinical Entity
Figure 1. Interrelationships of common clinical entities.
PBSI, pubic bone stress injury. This graph displays the percentage of each of the 5 clinical entities occurring either
alone or in combination with other entities and will total
100% in each case.
initially reviewed all clinical notes and investigations.
Where any diagnostic uncertainty occurred, these cases
were discussed and reviewed in conjunction with the senior
author until agreement could be reached. If no diagnosis
could be achieved, the case was labeled as ‘‘diagnosis
unknown’’ (2 cases only).
Statistical Analyses
For analytic purposes, all diagnoses were initially categorized according to the 5 clinical entities summarized in
Table 1. We calculated prevalence figures according to
patient sex, age, and sports participation. Age was categorized into 5 subgroups (\18, 19-30, 31-40, 41-50, .51
years), and sports were categorized into 5 subgroups based
on the 4 most popular sporting activities (rugby, soccer,
Gaelic football, running) and ‘‘other’’ sports. The chisquare test was used to compare observed and expected
frequencies across each subgroup. Significance was set at
P \ .01.
RESULTS
Demographics
In the study period from January 1, 2006, to December 31,
2011, full medical records were retrieved from 894 patients
with hip and groin pain: 655 men (73.27%) and 239 women
(26.73%). The modal age range was 26 to 30 years for men
(154 cases) and 36 to 40 years for women (36 cases). The
most common activities were soccer (37.5%), Gaelic sports
(12.9%), and running (16.2%). Sporting activity was unknown
in 7.9% of cases, with no regular sporting activity in 11.3%.
Clinical Entity
The 5 clinical entities proposed featured prominently in
this cohort of patients; 84% of patients had at least 1 of
these conditions. The breakdown was as follows: hip joint,
a
Data are presented as n (%); df = 4, x2 = 99.09, P \ .001. Percentages provided are expressed as a proportion of the 5 main clinical entities for both male and female and will total 100% for each
sex.
398 cases (56%); adductor related, 236 cases (33%); PBSI,
202 cases (28%); iliopsoas related, 85 cases (12%); and
abdominal wall related, 79 cases (11%). The range of diagnoses, not related to the 5 clinical entities, are presented in
Appendix 2 (available online). A total of 24 combinations of
clinical entities were found (Appendix 3, available online).
Figure 1 shows the proportion of clinical entities presenting alone or concomitantly with others. There was a significantly higher-than-expected number of isolated cases
involving the hip joint (233 of 398; df = 4, x2 = 233.2, P \
.001). There were few cases involving adductor-related
pain or PBSI in isolation. A common pattern (observed in
22% of patients) was the coexistence of hip joint pathology,
PBSI, and adductor-related pain.
Prevalence Patterns Based on
Sex, Age, and Sporting Activity
Prevalence patterns by sex are shown in Table 2. Hip joint
pathology was the most common diagnosis in male (45%)
and female patients (77%). There was, however, a significant
difference in prevalence patterns across sexes (df = 4, x2 =
99.09, P \ .001). Adductor pathology (22%), PBSI (19%), and
abdominal wall pathology (8%) occurred much more commonly
in men. There was a lower-than-expected prevalence of female
patients with PBSI (4%) and adductor pathology (3%), and
there were no cases involving the abdominal wall (Table 2).
Table 3 shows that prevalence patterns also differed significantly across age brackets (df = 16, x2 = 58.4, P \ .001).
Around 60% of cases of PBSI, adductor, iliopsoas, and
abdominal wall pathologies involved patients in the 19- to
30-year range. The distribution of hip joint pathology was
slightly more uniform; however, the most common age
bracket to present (46%) remained 19 to 30 years. Just
\40% of cases of hip joint pathology were in patients aged
between 31 and 50 years. Adductor pathology, PBSI, iliopsoas, and abdominal wall pathology were rare in patients
aged .51 years. We found a higher-than-expected number
of younger patients with iliopsoas-related pain (14.5%).
Table 4 shows prevalence patterns by sport. The majority of patients were involved in 1 of the common footballing
codes (soccer, rugby, Gaelic sports) or running. There was
a higher-than-expected prevalence of PBSI and adductorrelated pathology in soccer, rugby, and Gaelic sports. The
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Vol. 43, No. 7, 2015
Sporting Groin Pain—Review of 894 Cases
1701
TABLE 3
Clinical Entity by Agea
\18 y
Adductor related
Iliopsoas related
Abdominal wall related
Pubic bone stress injury related
Hip joint related
Other diagnoses
22
12
1
17
36
36
19-30 y
(9.6)
(14.5)
(1.3)
(8.6)
(8)
(33)
131
49
45
127
263
30
31-40 y
(57)
(59)
(59.2)
(64.5)
(45.8)
(27.5)
56
12
22
41
141
20
41-50 y
(24.3)
(14.5)
(28.9)
(20.8)
(24.6)
(18.3)
21
10
8
12
86
12
.51 y
(9.1)
(12)
(10.5)
(6.1)
(15)
(11)
6
2
2
5
48
11
(0.3)
(2.4)
(2.4)
(2.5)
(8.4)
(10.1)
a
Data are presented as n (%); df = 16, x2 = 58.4, P \ .001.
TABLE 4
Clinical Entity by Sporta
Soccer
Adductor related
Iliopsoas related
Abdominal wall related
Pubic bone stress injury related
Hip joint related
144
26
17
124
153
Gaelic Sports
(58.5)
(32.1)
(56.6)
(59)
(39.9)
48
19
3
41
52
(19.5)
(23.4)
(10)
(19.5)
(13.5)
Running
Rugby
19
11
3
15
59
11
2
2
12
20
(7.7)
(13.5)
(10)
(7.1)
(15.4)
Otherb
(4.4)
(2.4)
(6.6)
(5.7)
(5.2)
24
23
5
18
99
(9.7)
(28.3)
(16)
(8.5)
(25.8)
a
Data are presented as n (%); df = 16, x2 = 79.4, P \ .001.
Other sports: dance, triathlon, martial arts, hockey, swimming, tennis, athletics, cycling, cricket, general fitness training, walking, golf,
badminton, trampoline, American football, squash, horse riding, skiing, motor cycling, basketball, ice hockey, ice skating, skateboarding, and
rock climbing.
b
n=15
TABLE 5
Hip Joint Pathology: Specific Diagnosis by Sexa
Diagnosis
Osteoarthritis and
arthritic change
Femoroacetabular
impingement
Labral pathology
Other
Female
Male
Total
31 (28.0)
109 (23.0)
140 (24.0)
23 (20.7)
213 (45.0)
236 (40.4)
53 (47.7)
4 (3.6)
140 (29.5)
11 (2.3)
193 (33.0)
15 (2.6)
OA and arthritic
change
n=140
Labral pathology
a
Data are presented as n (%); df = 3, x2 = 23.6, P \ .001. More
than 1 diagnosis was possible per athlete for this analysis, resulting in n = 584 (compared to n = 574 athletes presenting with hip
pathology of any cause).
prevalence of hip joint pathology was higher than expected
in all sports apart from rugby.
Hip Joint Pathology: Specific Diagnoses
Figure 2 provides a breakdown of the most common hip
joint pathology diagnoses. Femoroacetabular impingement
(FAI) of the hip joint (40%) was the most common diagnosis, followed by labral pathology (33%) and osteoarthritis
(OA)/arthritic change (24%). Patterns of diagnosis were
significantly different when they were compared across
male and female patients (Table 5) (df = 3, x2 = 23.6, P \
.0001). Although the prevalence of hip joint OA and
arthritic change was consistent across sexes, men were
more likely to have FAI (45%), whereas women were
more likely to have labral tears (47.7%).
FAI
n=193
n=236
Other
Figure 2. Hip joint pathology: Specific diagnoses. Diagnoses
under ‘‘other’’ included acetabular dysplasia (n = 7), Perthes
disease (n = 3), avascular necrosis of the femoral head (n =
1), cystic fibrodysplasia of femoral neck (n = 1), synovial
chondromatosis (n = 1), slipped upper femoral epiphysis
(n = 1), and synovial cyst (n = 1). More than 1 diagnosis
was possible per athlete for this analysis, resulting in n =
584 (compared to n = 574 athletes presenting with hip
pathology of any cause). FAI, femoroacetabular impingement; OA, osteoarthritis.
DISCUSSION
Chronic hip and groin pain is a growing concern for medical practitioners. This study addresses the complex nature
of pain presenting around the hip and groin region in
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1702 Rankin et al
The American Journal of Sports Medicine
a large sample of athletes. Although previous studies
addressed single clinical entities,6,7,17 to our knowledge
this is the largest study providing a complete description
of the pathologies involved in long-standing hip and groin
pain. It is also one of the first to present a descriptive epidemiology using contemporary diagnostic taxonomy.
Clinical Entities
Holmich10,11 proposed diagnostic categorization of chronic
hip pain based on 5 clinical entities: hip joint pathology,
abdominal wall–related dysfunction, PBSI, adductor dysfunction, and iliopsoas pathology. We found this to be a useful diagnostic approach with .80% of our sample having at
least 1 of these clinical entities. In contrast to earlier studies
that cited incipient hernia13 or iliopsoas injury10 as the primary source of groin pain, we found that hip joint pathology
was the most common clinical entity. This may relate to
advances in MRI and hip arthroscopic surgery. Indeed,
our findings align well with other smaller contemporary
studies that identified hip joint pathology in approximately
50% of patients with chronic groin hip pain.4,7
Hip pathology was relatively more common in female
patients compared with males. It was also shown to increase
in both sexes with age, primarily because of OA. A nationwide survey18 in France found that 62% of athletes aged
\50 years with hip pain showed degenerative radiologic
signs, with 25% showing evolved hip OA. There are higher
rates of hip OA in athletes participating in contact sports
than in age-matched controls.16 Other cross-sectional studies
showed that the risk of hip arthritis in former athletes is
higher than that of age-matched controls (50-93 years).20,22
We found further evidence of close interrelationships
among clinical entities. There was coexistence of 2 clinical entities in around half of our sample. Disentangling
the interrelationships among various combinations of
pathologies is challenging because of the large number of
potential combinations. We identified .20 combinations
of pathology in the current study. In conjunction with previous reports,5,7,11 we found a strong relationship between
hip joint injury and secondary pathology involving adjacent anatomic structures. Of further interest was that
few patients were diagnosed with isolated injury to the
adductor, abdominal, or pubic region; this could suggest
that hip joint pathology is implicated in the secondary
breakdown of these surrounding structures. The causal
mechanism is likely to vary according to the specific type
of hip joint pathology, age, sex, and sporting code.
Men composed .80% of the patients with longstanding groin pain. Others5,10 reported a similar sex disparity in the incidence of hip injuries. Of further interest
was that PBSI, adductor pathology, and abdominal wall
injury were extremely rare in our female population.
This may relate to intrinsic factors, including sex-related
differences in anatomy and biomechanics. Female athletes
generally have greater laxity in their pubic symphyseal
joints and may be more likely to dissipate force away
from this region, minimizing the chance of overload.6,11
There are also commonly reported differences in lower
limb biomechanics between male and female athletes.9,12,25
A key difference is the tendency for women to adopt
greater hip adduction and knee abduction during sportrelated movements. These strategies may help to dissipate
contact forces away from the hip, but a related caveat is the
associated risk of serious knee injury.
Iliopsoas pathology occurred predominantly in female
patients, with the exception of adolescents. The iliopsoas
hip flexor muscle seems to overwork and exhibit disproportionate myofascial tightness in those undertaking high
physical loads in the presence of ligamentous laxity, which
in the majority of cases are seen in female patients. In such
cases, it may be associated with a clicking sensation1 when
the hip extends from a flexed position, where the tendon
crosses the iliopectineal line.
Cross-sectional studies also reported a high prevalence of
FAI in the athletic hip.7,18 We also highlighted a large number of FAI cases, with a higher-than-expected prevalence
within our male cohort. Decreased hip range of motion
has been shown to occur in Australian footballers with
chronic groin pain.23 Despite some contradictory studies,24
it is becoming more accepted that hip pathologies such as
FAI, while not necessarily the primary cause of groin pain
itself, lead to a reduced range of hip motion.2 The prevalence
of FAI in the athletic population is increased as compared
with nonathletic controls.7 Laboratory-based studies have
demonstrated how a reduced hip range of motion can lead
to overload on central structures such as the pubic symphysis.3 A large percentage of our male cohort was involved in
footballing codes that impose very wide amplitude movement on the hip. It is pragmatic to suggest that even a slight
morphologic deformity could be enough to induce secondary
pathology in this population.
Abdominal Wall Injury
We found abdominal dysfunction in just 11% of our sample,
of which 70% had additional pathologies. Early studies13
suggested that incipient hernia is the most common cause
of chronic groin pain. We acknowledge that differences in
diagnostic approach and nomenclature can limit comparison across studies in this area. We used abdominal wall
dysfunction to describe rectus abdominis dysfunction and
pathology of the inguinal canal, be that conventional hernias or the so-called sportsman’s hernia.10,11 The sportsman’s hernia has been described by many names in the
literature, such as athletic pubalgia,15 Gilmore groin,8 posterior inguinal wall dysfunction and tears of the inguinal
ligament, external oblique aponeurosis, and conjoint tendon.11,17 Furthermore, imaging studies to diagnose these
conditions are limited and may include subtle features on
MRI scan, such a secondary cleft sign (present in adductor
dysfunction and PBSI) and evidence of posterior inguinal
wall dysfunction on dynamic ultrasound.4
Limitations and Future Study
This review is based on descriptive epidemiologic data. Its
retrospective nature is an obvious limitation; however, we
must acknowledge that our data were collected prospectively, which limits recall bias. Our clinical observations
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Vol. 43, No. 7, 2015
Sporting Groin Pain—Review of 894 Cases
are pertinent and provide useful information for those aiming to discern the complex nature of hip joint pathology.
We found further evidence that the differential diagnosis
of hip pain is broad and can involve multiple pathologies.
This was primarily an epidemiological study, based on
clinical examination. We were able to group the athletes
into 5 main clinical entities that have been previously
described.4,10,11 Further study is needed to assess this clinical approach in the hands of other clinicians and in other
populations before it can be adopted as a valid diagnostic
approach.
Disentangling the interrelationships among various
combinations of pathologies is a challenge for future
research. This should focus primarily on the high prevalence of intra-articular injuries and their effect on surrounding structures. In particular, prospective research
should ascertain the extent that hip joint pathology leads
to secondary breakdown of surrounding structures and
delineate the underpinning causes.
CONCLUSION
This study provides a descriptive epidemiology based on
a large sample of active individuals with chronic hip and
groin pain. It reinforces the concept of categorizing chronic
hip pain into 5 clinical entities. There is further evidence
that hip joint pathology is the most common clinical entity
associated with chronic hip and groin pain, with the majority relating to labral injury, FAI, and OA. These pathologies are linked to secondary breakdown of surrounding
structures; however, the underpinning mechanism is
unclear. Clinicians should be mindful that hip joint pathology is more common than previously recognized. It is also
common for multiple pathologies to coexist.
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