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Adolescent Hip Pain

Groin Pain in Athletes

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Overview:
Groin pain is a common compliant in athletes It is typically a multifactorial injury that can involve many different structures and is usually categorized by the region/tissue suspected to be involved. Multiple diagnoses are often common with groin injuries due to the overlapping structures and symptoms. The most common sub-grouping categories are:
  • Adductor muscle related
  • Abdominal wall related
  • Pubic bone related
  • Psoas muscle related
  • Hip joint related

Causes:
Are typically multifactorial and involve: adductor dysfunctions, osteitis pubis, abdominal wall weakness, and muscle strains (typically adductors)

Risk Factors:
  • Participation in sports such as soccer, ice hockey, and rugby that require sudden acceleration or changes in direction, and overstretching of the hip in abduction and external rotation
  • Previous groin injury
  • Low levels of sport-specific preseason training, including: decreased preseason hip abduction range of motion, hip adductor weakness, and imbalance between hip abductor and adductor strength ratio
  • Core muscle weakness or delayed muscle activation of transverse abdominus
  • Age - less common in pediatric populations

Pathogenesis:
  • Tissue damage and/or entrapment of anatomical structures resulting from strain placed on musculoskeletal structures through repeated loading
  • Direct anatomical connections and close proximity of bony fixations on the anterior pelvis(6) cause overlapping pathology
  • Increased adductor muscle tone may be present as a protective mechanism to provide stabilization to the area
  • Osteitis pubis occurs from inflammation of the pubis symphysis and is characterized by bony changes of the pubis symphysis and hardening of the ligament
  • Bone stress injury may occur as a consequence of repetitive loading - most common cause in runners due to primarily sagittal motions
  • Decreased neuromuscular control of transverse abdominus muscle during activity

Clinical Presentation:
  • Acute: a groin injury that does not resolve or may develop gradually with no identified injury
  • Chronic: pain is variable and often associated with vague or diffuse symptoms, inconsistent findings, and varied response to interventions
  • Athletes can present with complaints that may have been recurrent or longstanding
  • There is typically a gradual onset of exercise-induced pain in the lower abdomen and/or medial thigh that affects function or athletic performance
  • Pathologies are often already well established at presentation due to chronic nature and/or insidious onset

Examination:
--History -
  • Mechanism of injury, including typical sporting activities
  • Previous injury/therapy
  • Aggravating factors (typically activity) Easing factors (typically rest)
--Diagnostic Tests/Imaging/Tests and Measures -
  • Hip active/passive range of motion (typically limited in hip abduction or extension)
  • Hip muscle testing (usually weak and/or painful on adduction or flexion)
  • Hip joint integrity: FABER, Gillet test for SI Dysfunction
  • Palpation and skin assessment
  • Neurological testing: sensation and reflexes should be intact and equal bilaterally
  • X-ray radiography to rule out fractures; MRI to assess for soft tissue injury/tears

Differential Diagnosis:
  • Palpable inguinal hernias should be referred to a surgeon
  • Genitourinary abnormalities such as: urinary tract infection, prostatitis, testicular abnormalities, or gynecological abnormalities)
  • Intra-abdominal disorders: appendicitis or inflammatory bowel disease
  • Acetabular labral tear
  • Inguinal neuralgia
  • Pubic stress fracture
  • Hip/pelvic fracture (femoral, acetabular, pubic, or ischial)
  • Lumbar radiculopathy

Clinical Bottom Line:
Refer if a fracture or other non-musculoskeletal cause is suspected. Acute treatment should include symptom reduction, rest, light passive stretching, and pain-free AROM and strengthening. Chronic treatment should include: reduction of tissue dysfunction; strengthening/stretching as appropriate; sport specific training when full pain-free ROM and strength are achieved.

See Groin Pain in Athletes References
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