Groin Pain Syndrome

In February, the Journal of the American Medical Association (JAMA) published a review of groin pain syndrome.

The condition goes by multiple names: sports hernia, athletic pubalgia, core-muscle injury, athlete’s groin, prehernia complex, etc. Review authors Brian Zuckerbraun, MD, et al. argue for “groin pain syndrome” as the preferred term. The fact that even the terminology is still debated underscores the evolving nature of this conversation. Some refute the diagnosis for lacking clear pathophysiologic features.2

The JAMA review defines groin pain syndrome as chronic groin pain (not hip- or hernia-related) caused by an imbalance in force exerted on the pubic bone by surrounding muscles and tendons. It may be caused by deconditioning, pathology of the inguinal canal, pathology of the pubic bone, injury to the rectus abdominus, and/or injury to the adductor longus (including tendons).

Lesions may or may not be apparent in imaging. Furthermore, some of the “abnormal findings” apparent in imaging prove common among asymptomatic athletes, calling into question the causal nature of these findings.13 However, there is moderate evidence bone marrow oedema and secondary cleft signs are associated with hip and groin pain in athletes compared to asymptomatic controls.14

The authors describe diagnosis as challenging. In a later interview with Reuters Health, Zuckerbraun comments, “It’s a very typical story for me to hear that someone has seen four or five different specialists before they saw the person who made the right diagnosis or referral.”

Groin pain syndrome has a reported prevalence ranging between 3% and 23%, occurring most often among athletes and active individuals.3-5 Fortunately, when correctly identified, physiotherapy proves highly effective. A systematic review combining 56 papers and 3,332 patients finds that rehabilitation returns athletes to play 83% to 96% of the time.6 The JAMA review recommends physiotherapy as the firstline approach for groin pain syndrome.

Those patients who do not respond in four to six weeks should be evaluated for surgery. There is now good evidence that groin pain syndrome is related to decreased hip range of motion.7 Rehabilitation for athletic groin pain has traditionally involved targeted stretching, manual therapies, and modalities including cryotherapy.8-10

More recent years have seen increased focus on targeted strengthening as the role of failed healing responses becomes more apparent in various musculoskeletal disorders.11,12 .

References

1. Zuckerbraun BS, Cyr AR, Mauro CS. Groin Pain Syndrome Known as Sports Hernia: A Review. JAMA Surgery. 2020 Apr 1;155(4):340-8.

2. Renovales FD, Urdampilleta JC, Morin BI, Camiña JC, Arrizabalaga CM. Groin pain syndrome, imaging approach. ESSR 2018 Annual Scientific Meeting.

3. Orchard JW, Seward H, Orchard JJ. Results of two decades of injury surveillance and public release of data in the Australian Football League. Am J Sports Med. 2013; 41: 734-41.

4. Junge A, Dvorak J. Injury surveillance in the World Football Tournaments 1998-2012. Br J Sports Med. 2013; 47: 782-8.

5. Murphy J, O’Malley E, Gissane C, et al. Incidence of injury in Gaelic football: a 4-year prospective study. Am J Sports Med. 2012; 40: 2113-20.

6. King E, Ward J, Small L, et al. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med. 2015; 49 (22): 1447-1451.

7. Tak I, Engelaar L, Gouttebarge V, Barendrecht M, Van den Heuvel S, Kerkhoffs G, Langhout R, Stubbe J, Weir A. Is lower hip range of motion a risk factor for groin pain in athletes? A systematic review with clinical applications. British Journal of Sports Medicine. 2017 Nov 1;51(22):1611-21.

8. Yuill E, Pajaczkowski J, Howitt S. Conservative care of sports hernias with soccer players: a case series. J Bodyw Mov Ther. 2012; 16: 540-8.

9. Jarosz B. Individualized multi-modal management of osteitis in an Australian rules footballer. J Chirpor Med. 2011; 10: 105-10.

10. Weir A, Veger S, Van De Sande H, et al. A manual therapy technique for chronic adductor-related groin pain in athletes: a case series. Scand J Med Sci Sports. 2009; 19: 616-20.

11. Kristensen J, Franklyn-Miller A. Resistance training in musculoskeletal rehabilitation: a systematic review. Br J Sports Med. 2012; 46: 719-26.

12. McCarthy A, Vicenzino B. Treatment of osteitis pubis via the pelvic muscles. Man Ther. 2003; 8: 257-60.

13. Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, Lovell G, Meyers WC, Muschaweck U, Orchard J, Paajanen H. Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine. 2015 Jun 1;49(12):768-74.

14. Mosler AB, Weir A, Hölmich P, Crossley KM. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis. British Journal of Sports Medicine. 2015 Jun 1;49 (12):810

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