Dr Mark Wotherspoon
MB BS, DipSportsMed(Lond), FFSEM
Consultant in Sports and Exercise Medicine
Introduction
Groin injury is common
Large differential diagnosis
Seen in sports with kicking/sprinting/change
direction
i.e football/rugby/hockey
Complex anatomy
No consensus on pathology/pathophysiology or
management
Pubalgia
Pain arising from local structures in the pubic
area
2-5% of sporting injuries
5-7% football injuries
Chronic and debilitating condition
Prolonged recovery period
Difficult to assess clinically
Poorly imaged/interpreted
On-going debate/research
Reflects chronic stress in pubic region
resulting in breakdown in a variety of ways
Similar to “Shin Splints”
Causes of Pubalgia
Bone
Musculotendinous
Pubic: osteitis pubis
Nonpubic: pelvic stress fractures
Joint
Pubic: pubic instability/disc
degeneration
Nonpubic: hip joint/SIJ/Lumbar
spine
Pubic: adductor tendinopathy/rectus abdom
inguinal canal pathology
conjoint tendinopathy
Nonpubic: iliopsoas dysfunction
rectus femoris injury
Nerve Entrapment
Ilio-inguinal Nerve/Obturator Nerve
Genito-urinary
Prostatitis/salpingitis/epididymitis
Other
Hernias/tumours(osteiod osteoma)
Infection/seronegative spondarthropathy
Main Causes
 Sportsmans surgical groin/Abdominal related groin
pain
 Pubic Bone stress Response
 Chronic Adductor Tendinopathy/Adductor Related
Groin Pain
 Hip related groin pain
Risk Factors
 Previous groin pain
 Level of sport
 Number of training sessions
 Flexibility
 Muscle imbalance
 Poor core stability / functional movement
 Reduced hip ROM especially internal rotation
Symptoms
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Pain in groin
Worse with twisting,sprinting,kicking
Stiff/sore after sport
Non specific loss of power / speed
Radiates into upper thighs,perineum,testicles
Unilateral/bilateral
Coughing/sneezing
Turning over in bed/getting out of a car
Insidious onset and often play with it
Sit-ups
Exclude the hip
Signs
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Exclude the hip, SIJ’s and back
Localisation of pain
Resisted single and bilateral SLR
Resisted sit up
Adductor squeeze in all ranges
Adductor signs
Sites of tenderness
Modified Thomas test/ crossover sign
Exclude psoas
Burden of evidence
Investigations
 X-ray +/- stork views
 Bone scan
 CT scan / CT spect
 MRI / MR arthrogram
 Herniography
 Ultrasound
 Diagnostic LA injection into hip
 Hip arthroscopy
Abdominal Related Groin Pain
 Abdominal symptoms
 Pain with cough and sneeze
 Tenderness over conjoint tendon at pubic tubercle
 Tender/dilated superficial inguinal ring
 Number of different surgical theories/operations
 ? Rx with belt
Abdominal Related Groin Pain
 Munich Approach
 David Connell’s radio-ablation
 Gilmore’s technique
 David Lloyd’s tenotomy
Munich Approach
 Swelling in stretched / weak posterior inguinal
canal wall
 Identified digitally or via ultrasound
 Transversalis fascia dilates widening Hasselbach’s
triangle
 With abdominal muscle contraction swelling
increases
 Compression of genital branch of genitofemoral
nerve (dull pain radiating around pubic region)
 Tension on rectus abdominis insertion at pubic
tubercle (pubalgia)
Munich Approach
 No mesh
 Laparoscopic
 Genital branch of genitofemoral nerve indentified
and if necessary partially excised
 Reduction in tension of rectus abdominis at pubic
bone by special suture repair
 Repair of weak posterior wall of inguinal canal
with sutures
 Local anaesthetic
Munich Approach
 Day case surgery
 Jogging / cycling at 2 days
 Sprinting / change of direction at 3-4 days
 Full training 5-6 days
 Back to sport at 6-7 days
 1,100 operations per year
 7% of which are elite athletes
 99% successful
Pulsed Radiofrequency
 Assumption is that inguinal related groin pain is nerve
entrapment/irritation around inguinal ligament
 Under LA
 Along inguinal ligament past genitofemoral nerve and
ilioinguinal nerve
 Pulsed radiofrequency stuns the nerves for 9 months.
Rest 2 days after and start rehab
Laparoscopic Inguinal Ligament
Tenotomy
 Laparoscopic
 Acute/chronic injury of inguinal ligament at pubic
tubercle
 Tatty scarred inguinal ligament at insertion into
pubic tubercle with holes and ruptures
 Sutures if previous surgery
 Mesh to re-inforce posterior wall of inguinal canal
and change pressure onto mesh rather than
inguinal ligament
 Divide inguinal ligament and scar tissue
Inguinal Ligament Tenolysis
 Aggressive rehab with stretches
 No sutures so safe
 Train at 1 week
 Full training at 2 weeks
 Return to play at 4 weeks
 400 operations
 Few failures
David Lloyd’s Main Criteria
 Unilateral pain
 Abdominal related groin pain
 Pain radiates < 5cm from superior pubic tubercle
 Tender superior pubic tubercle
 Pain with cough/sneeze
 Pain reproduced by resisted sit ups/Valsalva manoevre
Prognosis
 Good outcome if 4 main criteria present
 Low success if pain radiates > 5 cm from superior
pubic tubercle especially if laterally
Abdominal Related Groin Pain – is
it a continuum ?
 Munich Approach
 David Connell’s radio-ablation
 Gilmore’s technique
 David Lloyd’s tenotomy
Pubic Bone Stress Response
 Repetitive minor trauma leads to painful non
infectious/stress related lesion at pubic symphysis
and local muscle insertions/origins
 Men more than women
 Maximum tenderness at or adjacent to symphysis
 Stress reactions at adductor tubercle and pubic
tubercles
 Shearing forces across symphysis
 Rare as primary problem / asymptomatic finding
Investigations
 X-ray - if early nothing
sclerosis, erosions, widening of symphysis,
periosteal reactions, moth eaten
Bone scan - hot
MRI stress reactions and marrow oedema,fluid in
symphysis etc
Treatment
 Modified rest/prevent shearing
 Rehabilitation/flexibility
 NSAID’s to reduce inflammation
 U/S guided cortisone injections
 Usually 2-3 months
 Can last 3-6 months
 Graded return to sport
 Bisphosphonates
Chronic Adductor tendinopathy
 Easy diagnosis with pain resisted contraction,local
tenderness adductor tubercle and pain and
resisted stretch
 Usually adductor longus
 Insertion into pubic tubercle +symphysis ie blends
in not one insertion site
 U/S and MRI confirm diagnosis
 Local physio Rx, ? U/S guided cortisone, ? Dry
needling and autologous blood / PRP
 Adductor tenotomy
 Graded rehabilitation programme
Iliopsoas Related Groin Pain
 Pain on stretch – Thomas’s test
 Pain on resisted hip flexion at 90
 Tender on palpation
 Snapping hip(hip flexion/abduction and extend)
 Psoas bursae – one deep to psoas can become
symptomatic (one anterior to hip like Baker’s cyst in
knee)
Iliopsoas Related Groin Pain
 U/S or MRI
 Local physio Rx / rehab
 U/S guided injection
Summary
 Spectrum of same problem
 Conditions can co-exist
 Prevention best treatment/Pre-hab
 All need rehabilitation as main stay of Rx
 MRI Ix of choice
 4-6 wks rehab/Rx and re-asses/pick off what is left
 Multidisciplinary Team/Groin clinic
Summary
 Exclude other pathology eg hip/back
 History particularly coughing/sneezing/turning in bed
 Examination chronic adductor + pubic symphysis
tendernes
 Choose patients for surgery + surgeon + when
 New developments
Groin Pain
assessment
Ix with MRI +/- US
Rehab 4-6 wks
review
PBS response
Iv pamidronate/calcitonin
Chronic adductor
Autologous blood
If improving C/T
Sportsman’s hernia
surgery
C/T rehab
Psoas dysfunction
us guided inj