Age

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  Groin injury occurs more common in athletes who have been competing at an elite level for a number of seasons.

  
  
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  They were uncommonly seen in rookies in a study of NFL footballers with 95% of players with this injury having played in the NFL for 5 years or longer.

  
  
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  Average age in the majority studies for patients presenting with this injury is in the late twenties.

Sex

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  Groin injury is almost exclusively reportedly as an injury of the male athletic population, most likely because of the sports it has been studied in such as NFL football, soccer, and ice hockey.

  
  
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  The statistics and reasons for the different incidence between males and females have not been specifically studied.

Sport

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  Certain sports, namely ice hockey and soccer, report the highest amount of groin injuries, with an incidence of 0.8 to 1.3 injuries per 1000 hours of athletic activity, and strains, accounting for up to 43% of all muscle strains in elite Finnish ice hockey players and 10% of all injuries in a study of elite Swedish Ice hockey players.

  
  
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  The incidence of groin strains in a single National Hockey League (NHL) team was 3.2 strains per 1000 player-game exposures.

  
  
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  Only limited information exists on acute groin injuries. The only study looking exclusively at acute groin injuries in soccer reports a groin injury incidence of 0.8 injuries per 1000 hours play. In male soccer a prospective study of the elite teams hip/groin injuries accounted for 12% to 16% of all injuries per season. The total injury incidence was 1.1/1000 hours with 3.5/1000 match hours and 0.6/1000 training hours. Adductor-related and iliopsoas-related groin injuries were the most common injuries and 15% of the injuries were re-injuries.

  
  
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  In the National Football League (NFL) (American football) the most common muscle-tendonous injuries related to the groin were rectus femoris strain and adductor strains.

Position

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  The effect of position seems to be far less important than the type of sport. In a review of NFL data, the problem appears to predominantly affect linesmen whereas most playing positions in soccer and ice hockey (the two most common sports for this injury) position has not been highlighted as playing such an important role. Recently, however, it has been shown that hip and groin injuries account for one third of the injuries in goalkeepers in soccer.

  
  
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  The incidence of hip and groin injuries is higher in goalkeepers than in field players. This highlights that sporting actions such as kicking, stretching out in an abnormal position or rapid change of direction may be of particular importance, and responsible for the development of these injuries.

Intrinsic Factors

The tendons of the rectus abdominis and the adductor longus effectively form a continuous structure, termed by some authors as the “common adductor-rectus abdominis origin” ( Figure 25-1 ). Biomechanically this acts as a dynamic stabilizer of the pubic symphysis such that any dysfunction of either tendon unit predisposes the other to failure as a result of increased load. Secondary loss or dysfunction of the stabilizers of the symphysis can lead to increased load on this joint as well and as a result symptoms and signs in the region can be distributed over a wide area. Injury to the attachment of the posterior wall of the inguinal canal as part of the anterior rectus sheath can result in hernia-like formation and symptoms as part of the spectrum of injuries in this region.

Schematic representation of the confluent but apposing muculotendinous units of the rectus abdominis and adductor longus muscles.

(Courtesy of Prof. Adam C. Zoga, Department of Radiology, Thomas Jefferson University, Philadelphia, PA.)

Injury to the structures around the groin is intrinsically related to repeated loading of this complex of muscles and the joints they support. It can be seen that specific muscles are activated during the different phases of kicking a football and the maximal activation of the adductors as the leg is reversed from a fully extended position approaching impact with the ball. This places this musculotendinous structure of the adductors at risk of injury. Musculotendinous structures of the adductors are at greatest risk when at their maximal length, which is also the part of the kicking phase (the initial swing phase) where there is peak adductor longus activation, predisposing this region to injury. Also, the specific action of skating on the ice and the necessity for rapid and often unplanned changes of direction, again especially stressing the adductors and the abdominals places repeated maximal loads on the groin region. It is possible that the nature of the walking gait as man has become bipedal also changes the muscle dynamic of the adductor region. Rather than going through phases of rapid stretch and forceful muscle activation, this muscle is seldom stressed in this way in regular walking so activities that require sports-specific movements such as kicking and skating could be seen as atypical for this muscle group ( Figure 25-2 ).

Timing of the swing phase.

(From Charnock BL, Lewis CL, Garrett WE Jr, Queen RM. Adductor longus mechanics during the maximal effort soccer kick. Sports Biomech 8(3):223-224, 2009.)

Extrinsic Factors

The unique nature of skating on ice including the rapid acceleration/deceleration and changing direction on skates clearly demonstrates how increasing forces can play a role in this injury. Similarly, injuries to the rectus abdominis insertion have been described in tennis players because of the unique repeated loading of this muscle in this sport. The role of the introduction of artificial turf into the frequency of groin-related injuries has been discussed with American Football injuries, but no good study has been able to correlate an increasing reported incidence of this injury with changes to the playing surface as a significant dependent variable.

Traumatic Factors

Acute muscle tear or strain: Injuries that are the result of a direct blow or rapid stretching/twisting movement can potentially injure a number of structures in the groin region. Characteristically, the patients describe planting and twisting or getting twisted or rapidly bringing the leg from a neutral to an abducted position. Once this region has been injured, it is often the case that repeated minor trauma can continue to aggravate the symptoms and cause ongoing recalcitrant pain, restriction and avoidance of provocative maneuvers whenever possible.

Adductor/Abdominal Muscle-Tendinous Injury

Pain arising from adductor tendon damage can be very difficult to localize. The tendon of insertion of the rectus and origin of the adductor have been shown to be very close anatomically and their function is antagonistic in stabilizing the pelvis and the symphysis in a variety of activities. Pain in this region can therefore be classically referred into both areas as well as towards the symphysis and almost impossible to separate out. Such diagnoses fall under the classification of most tendon strains or chronic injuries and can be grouped as the treating physician prefers and finds useful. This can include clinical grading such as that described by Blazina ( Box 25-1 ) in association with the degree of damage defined by imaging studies. Less severe injuries may just have an awareness of pain aggravated by intense loading of the muscles concerned, more symptomatic examples may have pain or discomfort at rest that is initially eased by activity only to return and with increased intensity once the activity has ceased.

Muscular or tendinous injury in this region is far more common in males than females and so making the diagnosis in the female should always make the examiner check for other “pelvic”-related problems as a potential source. Relationship of the pain to the frequency or intensity of activity should allow the examiner to lean towards a tendon or muscle strain or tendinopathy. Aggravation of symptoms by palpation and resisted isometric testing of the affected muscle, either during adductor contraction or abdominal “crunch” type activity, brought on by repeated use or testing can help attribute the symptoms to either one or the other but often testing of both muscles can bring on the symptoms. Use of local anesthetic injection may help localize the pathology but in more severe examples, which have been going on for some time and chronicity, where the pain can be over a wide area and reference zone, makes localizing of the cause of the pain more difficult.

Iliopsoas Muscle-Tendinous Injury

The iliopsoas muscle can also be acutely strained or injured through repetitive overuse. This usually happens as a consequence of specific of repetitive forceful hip flexion during running, skating, jumping, or kicking. It can also be injured during an eccentric contraction, as when the thigh is suddenly forced into extension and the iliopsoas will try to decelerate the movement by an instantaneous eccentric muscle action. The overused iliopsoas tendon will sometimes appear with a spindle shape, near the insertion point on the trochanter minor, which can be visualized by ultrasound examination. Again the use of use of local anesthetic injection may also help localize the pathology from other structures, as iliopsoas symptoms can often coexist with other pathologies, such as adductor related injuries and intraarticular hip problems.

History

These patients will often give a history of one precipitating event or action but may on more detailed questioning admit to having had some aching discomfort in the groin region before this. These minor symptoms are so common in the sports such as soccer and ice hockey that players almost accept it as the “norm.” It is only with sudden worsening of intensity to the point where performance begins to be affected do they bring it to the treating clinicians attention. Characteristically these patients have a central aching discomfort in the groin region on one side or the other, aggravated by activity and localizing tenderness to clinical examination made worse by bracing maneuvers or single leg stance loading. The pain will often linger long after exercise has finished and may create sleep disturbance and early morning symptoms. This pain is characteristically brought on by resisted adduction of the leg, typically worsened when performed in an abducted position.

Muscular or tendinous injury in this region is far more common in males than females and so making the diagnosis in the female should always make the examiner check for other “pelvic”-related problems as a potential source. Relationship of the pain to the frequency or intensity of activity should allow the examiner to lean towards a tendon or muscle strain or tendinopathy. Relationship of the pain to bracing or “crunching” activities but not so obvious with resisted adduction should make the clinician consider a hernia or “sports hernia” as part of the differential diagnosis.

A number of risk factors ( Table 25-1 ) have been identified and should be looked for in the history and examination of these patients to alert the examiner to possible cause(s) of the pain. Previous injury, increasing age, weak adductors, and low levels of off-season sports-specific activities have been shown to be significant risk factors for sustaining a groin injury. In Australian Rules Football (AFL) young players reporting a previous hip or groin injury at the draft medical assessment demonstrated a rate of hip/groin injury in the AFL more than six times higher than players without a pre-AFL hip or groin injury history.

Table 25-2 highlights the range of clinical entities that can contribute alone or in combination when taking a history and examining these types of patients.

Physical Examination

Examination of these patients must be comprehensive and cover a large number of potential entities that can contribute to the problem and as can be seen from the previous table, more than one entity can appear to be contributing to the symptoms.

Assessment of gait and leg length is mandatory, as well as signs of bruising for evidence of acute muscle/tendon injury which is usually an obvious sign (see Figure 25-3 ). In less obvious cases, local tenderness at the origin of the adductor tendons is helpful but localizing tenderness for other of the differential diagnoses is difficult to elicit and the pain can often be in a broad region making localizing the source difficult. Any swellings or signs of true hernias should be checked for and recurrence of symptoms more proximally in the region, with abdominal “crunching” testing may be more indicative of a “sports hernia” as a potential source of the pain. This, however, is usually a diagnosis of exclusion, often after surgical treatment of other conditions has failed ( Figure 25-3 ).

Bruising associated with acute adductor longus rupture injury.

Hip range of motion is often reduced and has led to the theory, unsupported by scientific evidence so far, that hip impingement may be a contributing factor.

Pain on palpation and aggravation of symptoms by resisted isometric testing of the affected muscle, either during adductor contraction or abdominal “crunch” type activity, brought on by repeated use or resistance testing can help attribute the symptoms to either one or the other but often testing of both the adductors and the abdominal rectus can bring on the symptoms. Use of local anesthetic injection may help localize the pathology but in more severe examples, which have been going on for some time and chronicity, the pain can be over a wide area and reference zone, making localizing of the cause of the pain more difficult.

Quantifying adductor strength will often make obvious more subtle differences in adductor related problems and highlight the need for a strengthening program as an essential part of overall treatment. Use of a hand-held dynamometer to do this has been shown to be accurate and reproducible and is most sensitive when performed at the ankle with the leg in 0° of hip flexion ( Figure 25-4 ).

Use of a hand-held dynamometer to measure adductor strength.

(From Thorborg et al. Clinical assessment of hip muscle strength is reliable. SJMSS 20:493-501, 2010, with permission.)

One of the challenges with these patients is that the examination findings may be almost entirely normal or very difficult to isolate a single cause for the patient’s symptoms. Use of imaging to support the clinical suspicions and exclude such pathologies as stress fractures can be diagnostic. At times “abnormal findings” on imaging will not correlate with your clinical findings and imaging studies should not replace clinical assessment and examination findings.

Imaging

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  X-rays of the hip and pelvis are mandatory and a loaded view of the pubic symphysis (the flamingo view) may show evidence of subtle symphyseal instability. Views to look for FAI are considered mandatory for some clinicians and certainly indicated where hip range of motion is markedly reduced.

  
  
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  CT scanning can further investigate associated hip abnormalities, early osteoarthritis of the hip or changes in the symphysis pubis. Stress fractures of the femoral neck or pubic ramus may also be better seen on CT.

  
  
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  Ultrasound is useful in acute injuries in particular and if any swellings are visible at examination.

  
  
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  MRI scanning is usually an inevitable investigation in these patients and many will bring such imaging with them that has been interpreted in a variety of ways by a variety of physicians they have seen previously. Positive findings on MRI scan that correlate with clinical findings are definitely supportive information for the clinician and patient, however, abnormal reported findings that do not have a close clinical correlate should be treated with caution. Features such as edema in the parasymphyseal region of the pubic symphysis may warrant reexamination of the patient, taking these findings into consideration. The diffuse nature of the pain on presentation can make localization of the pathology and diagnosis difficult, so having a structured examination system and correlating findings with MRI changes is likely to produce the highest clinical accuracy.

  
  
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  A bone scan can be useful in isolating problems to the symphysis or revealing a stress fracture around the groin such as pubic rami or femoral neck. A CT scan to show the detail of the bony injury is then indicated ( Table 25-3 and Box 25-2 ).

  
  
  
  

  Table 25-3

  
  

  Checklist for MRI Evaluation of Adductor Injury

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Muscle and Tendon	Sign/Symptom
  Adductor longus	– tendinous (superficial) and muscular (deep) origin on anterior pubic bone (bone without perisoteum) – avulsion usually associated with bone fragment
  Adductor brevis	– muscular origin posterior to adductus longus
  Adductor tendon injury	– myotendinous injury—proximal (or distal)
  Pectineus	– origin lateral public symphysis and superior pubic crest
  Obturator externus	– origin postero-lateral pubic systems
  Gracilis	– origin anteroinferior pubic symphysis and superior pubic arch
  Grading of Injury
  Adductor muscle strain
  Acute	– increased T2 signal
  Chronic	– Hypertrophic – Atrophic

   
  
  
  
  

  Box 25-2

  
  

  MRI and Radiology of Groin Injury Associated Pathologies

  
  

  
  

  Rectus Abdominis

  
  

  
  

  
  
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    Attachment to superior pubic ramus

    
    
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    Medial and lateral heads

  
  

  
  

  Rectus Abdominis/Adductor Aponeurosis

  
  

  
  

  
  
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    Attachment to antero-inferior pubic bone

  
  

  
  

  Rectus Abdominis/Adductor Aponeurosis Injury

  
  

  
  

  
  
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    Ipsilateral rectus abdominis distal detachment + adductor aponeurosis partial or complete detachment

    
    
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    Unilateral rectus abdominis atrophy

    
    
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    Unilateral or bilateral adductor aponeurosis injury

  
  

  
  

  Rectus Abdominis/Adductor Aponeurosis Plate Disruption

  
  

  
  

  
  
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    Secondary Cleft Sign

    
    
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    Antero-inferior pubic bone curvilinear increased T2 signal

  
  

  
  

  Symphysis Pubis

  
  

  Bone marrow edema

  
  

  Location:

  
  

  
  
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    Superior = rectus abdominis

    
    
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    Antero-inferior = RA/AA

    
    
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    Lateral = pectineus

    
    
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    Postero-lateral = obturator externus

  
  

  
  

  Unilateral or bilateral

  
  

  Degenerative change

  
  

  
  
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    Subchondral cystic change

    
    
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    Subchondral sclerosis

    
    
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    Erosions

  
  

  
  

  Acquired Inguinal Wall Deficiency

  
  

  Frequent coexistent adductor tendon injury

  
  

  Anterior inguinal ring insufficiency

  
  

  Tear medial aspect external oblique, resulting in patulous external inguinal ring

  
  

  Proposed that pain is caused by entrapment of cutaneous branches of the ilioinguinal nerve and genital branch of genitofemoral nerve

  
  

  Clinical diagnosis

  
  

  Rare to have findings on MR or US

  
  

  MR—may see hyperintensity of external inguinal ring

  
  

  Posterior Inguinal Wall Insufficiency

  
  

  Conjoint tendon or transversalis fascia attachment tear or weakness

  
  

  Use of imaging debated for diagnosis

  
  

  US Posterior inguinal wall bulging—not sensitive or specific sign, as can be present in asymptomatic population

  
  

  MR dynamic imaging

  
  

  Asymmetrical focal protrusion of the posterior inguinal wall without a hernia

  
  

Nonoperative Management

Groin injuries can be difficult to treat and are often ignored by athletes and trainers, thus developing into a chronic stage before being recognized as affecting a player’s or patient’s performance and function. The primary treatment of choice for both acute and longstanding conditions in musculoskeletal groin injuries is an active treatment approach consisting of mobilization and exercise. Treatment is based on a systematic examination and an exact identification of the painful structure(s). This examination is based upon thorough history-taking and identification of the specific injury by palpation and isometric contractions where specific structures are isolated and specific pain responses are elicited. Diagnostic imaging can be relevant to exclude differential diagnoses, and in determining severe structural injury, such as complete and partial ruptures, but it is not advisable to be to obsessed with discrete imaging findings in isolation, as the exact understanding of such findings is not established. Therefore, treatments should primarily be based on clinical findings and their related dysfunctions, instead.

Surgical Indications

The surgical management of groin injury depends primarily on accurately identifying the source of the pain. It cannot be emphasized too frequently that detailed clinical examination is the mainstay of making the correct diagnosis and supported by imaging studies. A subgroup of these patients have potentially multiple contributing pathologies and whether taking care of what seems the primary pathology will allow the others to recover or dealing with all apparent recalcitrant causes of pain and restriction is much argued about and seldom agreed on. For those patients with conditions identified that can be helped with nonoperative strategies outlined above, particularly adductor, rectus and psoas related problems, all patients should have undergone a supervised, rigorous, and appropriate rehabilitation schedule, as outlined in detail in following chapters, before surgery should be considered. Similarly the importance of a well-supervised, graduated, detailed progression of strengthening and proprioceptive retraining cannot be under emphasized as the key to a successful outcome. All treatment strategies, be they surgical or nonsurgical have the alleviation of pain to allow the restoration of strength as the primary goal.

Outcome Evaluation

Reliable, valid, and responsive outcome measures are important in the evaluation of patients with groin injury. The Copenhagen Hip And Groin Outcome Score (HAGOS) is developed specifically for younger patients with hip and groin pain. HAGOS is a patient-reported outcome measure employing five-item Likert scales. HAGOS consists of six subscales: pain, other Symptoms, physical function in daily living (ADL), Function in sport and recreation (Sport/Rec), participation in physical activities (PA), and hip-related quality of life (QOL). HAGOS can be used to assess groups and to monitor individuals, it is patient-administered and the format is user-friendly, and takes about 10 minutes to fill out. HAGOS is self-explanatory and can be administered in the waiting room or used as a mailed survey. HAGOS was found reliable, valid, and responsive in younger patients with hip and groin pain.

Isometric and eccentric strength is also important to evaluate in patients with groin injury. Reliable measures with hand-held dynamometry exist for hip adductors and hip flexors and can be used in the evaluation of when muscle strength is normalized in this region in the clinical setting. Pain during palpation and isometric maximal contraction are also good indicators of improvement in function. Different sports-specific activities, and range of motion measures, are other relevant measures that can be obtained and used for prospective evaluation of the recovery process of these injuries.

Phase I : Muscle Activation (weeks 0 to 2)

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  Static adduction against soccer ball placed between feet when lying supine; each adduction 30 seconds, 10 repetitions

  
  
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  Static adduction against soccer ball placed between knees when lying supine ( Figure 25-5 ); each adduction 30 seconds, 10 repetitions

  
  

  
  

  
  

  

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