Diagnosis a nd medical management of chronic groin pain
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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 l.jpg

Diagnosis And Medical Management Of chronic Groin pain

Dr Mark Wotherspoon

MB BS, DipSportsMed(Lond), FFSEM

Consultant in Sports and Exercise Medicine

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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

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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”

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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

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Main Causes

  • Sportsmans surgical groin/Abdominal related groin pain

  • Pubic Bone stress Response

  • Chronic Adductor Tendinopathy/Adductor Related Groin Pain

  • Hip related groin pain

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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

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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

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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

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  • X-ray +/- stork views

  • Bone scan

  • CT scan / CT spect

  • MRI / MR arthrogram

  • Herniography

  • Ultrasound

  • Diagnostic LA injection into hip

  • Hip arthroscopy

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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

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Abdominal Related Groin Pain

  • Munich Approach

  • David Connell’s radio-ablation

  • Gilmore’s technique

  • David Lloyd’s tenotomy

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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)

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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

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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

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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

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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

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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

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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

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  • Good outcome if 4 main criteria present

  • Low success if pain radiates > 5 cm from superior pubic tubercle especially if laterally

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Abdominal Related Groin Pain – is it a continuum ?

  • Munich Approach

  • David Connell’s radio-ablation

  • Gilmore’s technique

  • David Lloyd’s tenotomy

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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

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  • 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

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  • 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

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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

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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)

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Iliopsoas Related Groin Pain

  • U/S or MRI

  • Local physio Rx / rehab

  • U/S guided injection

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  • 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

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  • 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

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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