Kal Parmar, ISEH Consultant in Sport & Exercise Medicine spoke at
the recent ISEH Masterclass on athletic hip and groin pain to a group of
sports team doctors, general practitioners and physiotherapists.
"Athletic hip and groin pain can be complex to diagnose and rehabilitate. Frequently, no one pathology exists, but several. The anatomy is complex; in elite athletes who can run, side step, twist and turn at high speed, large forces traverse the hip and groin region and can lead to complex multifactorial injury.
The history is usually one of a sprint and side step or twist. Sometimes immediate pain is felt, either in a specific place or in the general groin area; it may also be associated with clicking.
Examination findings frequently can suggest a variety of pathologies. These focus on likely pathologies such as: hip joint pathology; sportsman’s hernia; adductor shear injury and pubic symphyseal problems.
Imaging is key to diagnose the problem. I have my own protocol when imaging complex groin pain. An MRI scan of the pelvis is requested - it is key to ask for symphyseal views – these take oblique sections through the symphysis and any symphyseal fluid, irregularity and cystic change can be seen together with the adductor origins and pubic rami.
Secondly, instability view x-rays of the pubic symphysis – this is a coned view of the symphysis to minimise radiation dose. The patient is ask to stand on one leg and then the other. This is a very good way to assess instability within the symphyseal joint where a step in easily seen.
Lastly, a dynamic ultrasound of the inguinal region - this is to look for posterior inguinal wall insufficiency or indirect inguinal hernia – both are termed “sportsman’s hernia” and can lead to pain slightly higher than the groin crease.
The above imaging can lead to an accurate diagnosis in most cases. This will invariably involve several pathologies co-existing at once. Management depends on the imaging findings and progression clinically with occasionally injections and surgery (sportsman’s hernia, adductor release) needed.
Other cases of groin and hip pain centre around differential diagnoses such as sacral and hip joint pathology.
Bony stress around the sacroiliac joint and ischio-femoral impingement can be a differential for deep gluteal pain. Hip joint pathology includes: femoro-acetabular impingement with associated labral pathology and osteoarthritis of the hip joint. An interesting and new diagnostic problem is ligamentum teres injury - either synovitis or tear. This can lead to signs of hip joint pathology and also an instability feeling.
At ISEH, we see many elite athletes but also recreational athletes at varying level. Hip and groin pain is a common presentation for patients and the principles of management remain the same. The above relates to some of the more common athletic hip and groin pathologies that can exist and ways to image to establish a firm diagnosis. Rehabilitation strategies can then be tailored once a diagnosis is established."