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Diagnosis A nd Medical Management Of chronic Groin pain PowerPoint PPT Presentation

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Diagnosis A nd Medical Management Of chronic Groin pain . 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

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Diagnosis A nd Medical Management Of chronic Groin pain

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Diagnosis And Medical Management Of chronic Groin pain

Dr Mark Wotherspoon

MB BS, DipSportsMed(Lond), FFSEM

Consultant in Sports and Exercise Medicine


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


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


Pubic: osteitis pubis

Nonpubic: pelvic stress fractures


Pubic: pubic instability/disc degeneration

Nonpubic: hip joint/SIJ/Lumbar spine


Pubic: adductor tendinopathy/rectus abdominis

inguinal canal pathology

conjoint tendinopathy

Nonpubic: iliopsoas dysfunction

rectus femoris injury

Nerve Entrapment

Ilio-inguinal Nerve/Obturator Nerve




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


  • 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


  • 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


  • 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


  • 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


  • 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


  • 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


  • 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


  • 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


Ix with MRI +/- US

Rehab 4-6 wks

If improving C/T


PBS response

Iv pamidronate/calcitonin

Chronic adductor

Autologous blood

Sportsman’s hernia


Psoas dysfunction

us guided inj

C/T rehab

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