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Digging deeper, however, we find that the problem is often more complex - the medical community recently even used the phrase that it is the "Bermuda Triangle of sports medicine."
Important factors in the clinical differentiation of groin pain are answers to questions such as:
- when did the pain complaints begin?
- in what ways do they manifest themselves?
- what factors or activities exacerbate, or reduce, the pain?
- how to relieve groin pain?
- is it typical groin pain when walking?
- does the pain radiate in any direction, such as pain in the groin radiating to the leg?
- is it pain in both groins, or only pain in the left groin or pain in the right groin?
This is very important, as the location and quality of symptoms is helpful when clinically differentiating between intra-articular and extra-articular and musculoskeletal structures (muscles, ligaments, tendons, tendon sheaths, fascia, articular casing) and complaints from outside the musculoskeletal system (pain whose cause is the genitourinary system and which presents symptoms in the groin area).
Groin pain - possible causes
- Groin pain in the adductor muscles, patients sometimes refer to it as a groin pull
This pain is one of the most commonly cited complaints in the groin. The main function of this muscle group is the movement of adduction at the hip and stabilization of the pelvis during the lower limb transfer phase of walking. In terms of sports, they are important in any sport that requires sudden changes in direction of movement and rapid movements of the lower limb, such as kicking a ball. Palpation (tactile) soreness in the muscle attachments, stabbing pain in the groin, groin pain on walking or hip pain on walking, pain on stretching and isometric tension (tension of the muscle against resistance without movement) are clinically important indicators. The adductor longus is most often inflamed, due to its most anterior location. Groin pain provoked by the hip-lumbar muscle
This muscle is the strongest hip flexor, known as the "sprinter's muscle," which plays a very important role in maintaining proper posture, walking and running. It is most often damaged during activities that require repeated hip flexion, or external rotation at the hip joint, such as running, playing soccer, and doing gymnastics. Pain in the groin on the right side, as well as pain in the groin on the left side, usually occurs during resistance hip flexion movement and stretching of the hip flexor muscles. The bursa located under the muscle attachment at the ileum minor (within the groin) may also become inflamed.Damage to the articular rim and groin pain
The hip joint's annulus is a dense, fibrous tissue that provides additional stability in the joint. The rim can rupture or degenerate. Symptoms of damage may include a popping sound during movement at the hip (snapping hip) with pain located deep in the groin.- Groin pain vs. femoroacetabular conflict
In this case, pain usually occurs during hip flexion, internal rotation and adduction movements. Pain is often felt in the groin when walking. Changes in the bone structure of the femoral head or the acetabulum of the hip joint can provoke pain due to abnormal compressive forces on the tissues. The discomfort may resemble a "squeezing" sensation in the hip that intensifies when increasing the range of flexion motion, for example, when drawing the knee to the abdomen at an oblique angle, or when performing a forward bend in a sit-up with the leg on top when the painful limb is on top. Pain can also be triggered by less complex movement, such as merely leaning forward while standing or sitting. Read how to relieve groin pain caused by femoroacetabular conflict. - Inflammation in the pubic conjunctiva vs. pain in the groin
This inflammation is manifested by pain located centrally over the pubic conjunctiva, may radiate to the lower abdomen, may be pain in the groin radiating to the leg, to the inner side of the thigh or genitals. Passive stretching of the adductor muscles and active tension against resistance provokes the symptoms - similar to the differentiation of pain provoked by inflammation of the adductor muscle attachment. The similarity of symptoms is due to the fact that anatomically the adductor longus muscle attachment (one of the entire group of muscles of the inner side of the thigh) also gives off its fibers to the ligaments within the pubic symphysis. Often accompanied by dysfunctional changes of the sacroiliac joint. X-rays show irregular edges of the pubic bone at the pubic conjunctiva, a widened joint gap. The doctor may order an X-ray while standing on one leg, which provokes shear forces on the joint and can generate the visible asymmetries that occur with ligamentous instability. Fatigue fractures
A fatigue fracture can occur in the neck of the femur. Despite the usually rare complications of early intervention, a full fracture, including one with displacement, can occur when long-term pain symptoms are ignored. Pain in the groin when walking usually increases with distance covered, and in more advanced cases also occurs at night. Local palpation (tactile examination) is unlikely to reproduce the patient's symptoms, but defensive muscle tension caused by pain can make the examination unpleasant.Inguinal hernia
This dysfunction involves lesions in the posterior abdominal wall, and is not palpable by touch because it involves tissues deep in the fascia. Pain in the left groin, like pain in the right groin, can radiate to the adductor muscles, perineum, scrotum. An important note is that the pain does not occur at rest, but is associated with movement, such as kicking, changes in direction of movement. It is difficult to diagnose, assessed during ultrasound examination with simultaneous increase in abdominal pressure by the patient by attempting to resist expiration on inspiration. The doctor evaluates tissue continuity and possible "tissue bulges" through the posterior abdominal wall into the inguinal canal.Groin pain vs. lumbar spine complaints
Intervertebral disc herniation can provoke peri-inguinal complaints. This applies mainly to herniated discs located on the higher segments of the lumbar spine (L1-L3), however, herniated discs from lower segments (L4-L5, L5-S1) can also cause such complaints in the groin as confirmed by numerous studies.- Nerve entrapment vs. groin pain
As another of the possible causes, it causes a burning sensation and abnormal sensation in the area supplied by a particular branch of the nerve (e.g., genito-femoral nerve, iliac-femoral nerve, iliac-femoral nerve, obturator nerve, lateral cutaneous nerve of the thigh, vulvar nerve, femoral nerve). Disturbed sensation can occur in the lower abdominal region below or above where the inguinal ligament runs, the inner side of the thigh, the anterior outer side of the thigh, the genitals. It is also worth noting weakness in muscle strength, as this, too, can be an indicator of compression/tethering of a nerve branch (e.g., femoral n., obturator n.). Previous surgical procedures are important clinical information, as the nerve can become entrapped even in scar tissue and provoke complaints from a week after surgery, up to months or even years. - Complaints from outside the musculoskeletal system
Pain on the side of the trunk, radiating to the groin, and the presence of hematuria may indicate kidney disease. Inflammation of the epididymis, testicles in men, or gynecological problems in women - endometriosis, cysts on the ovaries - can radiate to the groin. A number of ailments such as kidney stones, torsion of the appendages, appendicitis, testicular inflammation, abdominal aortic aneurysm also need to be ruled out when making a diagnosis. Pain during sexual intercourse is also clinically relevant information to keep in mind when discussing with your doctor how to relieve groin pain.
Groin pain - differential diagnosis
In order to make an accurate diagnosis of how to relieve groin pain, a series of clinical tests (manual examination) are performed, which are confirmed by additional tests ordered by the doctor. First and foremost, the patient is visually assessed by viewing the painful groin area and adjacent structures to evaluate the silhouette, asymmetry and muscle atrophy (reduction of muscle belly mass). The following are evaluated: the hip (ranges of motion, muscle strength testing, palpation and specific tests), sacroiliac joint, pubic conjunctiva, abdominal cavity and spinal segments - the lumbar spine. It is carried out in various positions: standing, lying down, gait and functional activities are also observed. Differences in hip plate height, limb length or hip plate rotation are also clinically relevant. Any pain in the left groin, as well as pain in the right groin experienced by the patient, is noted and evaluated. Depending on the type of symptoms, how to relieve groin pain, the doctor may order tests such as MRI (magnetic resonance imaging), ultrasound (also dynamic ultrasound), X-ray.
Pills for groin pain
Treatment of groin pain is often multi-step. In addition to physiotherapy, the orthopedist may prescribe drug treatment. It depends on the cause of the pain. If the pain is due to inflammation, the first-choice drugs are non-steroidal anti-inflammatory drugs (NSAIDs) in both oral and topical forms (ointments, gels, etc.). If the pain is associated with damage to the articular cartilage, chon.droprotective preparations are applicable. Groin pain that is associated with problems at the level of the lumbar spine can be treated with drugs that reduce muscle tension and drugs containing B vitamins. For non-orthopedic conditions (such as gynecological, urological or surgical problems), treatment may require other medications, which will be prescribed by the doctor of the relevant specialty.
Exercises for groin pain - rehabilitation (conservative treatment)
Rehabilitation should be individualized. Taking into account a number of biomechanical factors, each case, despite similar symptoms, may be characterized by a different cause, which should be analyzed in detail by the leading physiotherapist. Biomechanical causes can include muscle imbalances in the hip joint, as well as the lumbar spine, or the entire pelvic girdle. In the absence of stabilization on the part of the trunk muscles, focusing activities only on the hip joint may not have the desired effect. The reason for the introduction of stabilization training is the fact that the transfer (transfer of action) of muscle forces through the trunk to the hip, which, with inadequate distribution of force action, can lead to dysfunction. Excessive muscle tension, lack of flexibility, lack of range of motion, and lack of stabilization are the key elements to be evaluated by physiotherapy.
The physiotherapist evaluates the relationships in muscle strength of the hip joint stabilization apparatus: flexor, extensor, adductor, abductor and rotator muscles. Muscle flexibility is an important element, allowing the full range of motion in the hip joint. With intra-articular lesions occurring with joint capsule contraction, activities focused only on stretching and muscle strengthening should go hand in hand with manual mobilization. Often occurring in people with groin pain, a deficit of internal rotation in the hip joint causes recurrent inflammation in the adductor muscle attachments.
Exercises for groin pain must be explained to the patient and, if necessary, corrected, as often a lack of accuracy in performing rehabilitation exercises translates into a lack of therapeutic effect. Over time, the set of exercises changes with the patient's changing functional status. The exercises should also meet the patient's requirements for the set end goal. In athletes, the adaptation of tissues to gradually increasing loads and a smooth transition into sport-specific motor training is very important.
Presented by physiotherapist Adrianna Wojewódzka, MA, exemplary exercises for groin pain are only a suggestion, each patient should receive an individually tailored exercise program by a physiotherapist adequate to the existing movement deficits. Each patient should also be properly corrected by a physiotherapist in order to correctly perform the exercises avoiding compensation in the movements performed.
Pain in the groin - exercise 1
Starting position - lying on your side, with your back to the wall. The patient performs a hip joint abduction movement moving the heel up and down the wall, keeping the pelvis stable, in a neutral position.
Care should be taken to avoid the wrong movement pattern, positioning the pelvis in a forward tilt (the back "straightens" ) and lifting the lower limb too high.
Pain in the groin - exercise 2
The patient, standing on one leg, maintains a stable position on a sensorimotor disk or other form of unstable ground.
Pay attention to the correct execution of the exercise, so as not to make excessive movements of the body, so that the lower limb is in alignment and the knee does not run inward.
Pain in the groin - exercise 3
Lying sideways, legs bent at the knees, above the knees there is an elastic rubber with a degree of resistance selected individually. The patient performs an abduction movement at the hip joint lifting the knee and keeping the heels together against the resistance of the rubber.
Pain in the groin - exercise 4
Standing in a half squat with an elastic band hooked over the knees. Keeping the feet stable on the ground, the patient performs a hip joint abduction movement in the possible range of motion available without changing the position of the feet, and then returns to the starting position.
Pain in the groin - exercise 5
The patient begins the exercise from a 1/4 squat position sideways to a ladder with a rubber band hooked over the ankle joint. Against the resistance of the rubber band, the patient slowly puts the limb to the side - a hip joint abduction movement, and then returns to the starting position by connecting the legs. In this exercise, the emphasis is on working the adductor muscles and maintaining the correct position of the stable limb.
Groin pain - exercise 6
The patient is in a supine position with his back sideways to the ladder, knees bent. An elastic band is hooked over the knee joint. The patient slowly against the resistance of the elastic band inhibits the movement of the knee approaching the ladders, and then brings the knees closer, returning to the starting position.
The exercises included above are only a suggestion, but to be effective, their performance and appropriateness in a particular case should be consulted with a physiotherapist.
Related articles:
Learn about other possible causes of hip pain.
Bibliography:
- Hackney RG., (iv) Groin Pain in Athletes. Orthopaedics and Trauma 2012; 26 (1): 25 – 32.
- Weir A, Jansen JACG, van de Port IGL, et al., Manual or exercise therapy for long – standing adductor – related groin pain: A randomized controlled clinical trial. Manual Therapy 2011; 16: 148 – 154.
- Jones NS., Update: Soccer Injury and Prevention, Concussion and Chronic Groin Pain. Current Sports Medicine Reports 2014; 13 (5): 319 – 325.
- Rafin BS, Tang L, Nielsen MP, et al., Hip Strenght Testing of Soccer Players With Long – Standing Hip and Groin Pain: What are the Clinical Implications of Pain During Testing? Clinical Journal of Sports Medicine 2016; 26: 210 – 215.
