Assessment of Athletes with Groin Pain

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Introduction

Groin pain including Groin strains are common among athletes who participate in sports with repetitive and forceful hip movement [ref] Ice hockey and various football codes have been identified as sports with high prevalence of groin injuries due to the high intensity nature [ref]. Groin injuries accounts for 14 - 19% of all injuries in male football clubs and 2 - 14% in women. [ref]

Groin pain is typically thought of as difficult to diagnose and manage[ref]. In a systematic review on the treatment of groin pain, 33 different diagnostic terms were used to describe groin pain.[ref] The poor understanding of underlying pathology and structural attachment has created confusion regarding diagnosis and terminologies [ref]. The current understanding of hip joint pathologies which causes groin pain adds up to the complexities surrounding the diagnosis of groin pain.[ref]

However, in November 2014, an agreement meeting was held in Doha, Qatar involving experts in sports medicine. The Doha agreement meeting on terminology and definitions of Groin pain in athletes was held to address the problem. [ref]

Assessment

The Doha agreement agreed on three (3) subheadings for classifying groin pain of athletes. [ref]

1. Defined clinical entities for groin pain:
   1. Adductor-related
   2. Iliopsoas-related
   3. Inguinal-related
   4. Pubic-related groin pain
2. Hip-related groin pain
3. Other causes of groin pain in athletes

Thorborg et al. (2018) provided a clinical framework for examination of athletes with Groin pain. The framework provides a comprehensive examination of the entire groin and hip joint region of an athlete with Groin pain. When serious pathology has been ruled out, the diagnosis can be made with focal findings on examination using the guidelines from the Doha agreement to classify the injury into 1 of the 4 clinical entities[ref]

File:Clinical framework for assessing groin pain.png

Subjective Assessment

• Location of pain: The location of pain is essential in identifying the structures involved and should be enquired from the patient. Groin pain felt more anteriorly is the thigh region indicative of the iliopsoas related groin pain. Pain located more to the proximal inner thigh is indicative of adductor related groin pain.
• Injury mechanism: change of direction, kicking, reaching and jumping are the common actions associated with groin injuries. [ref]
• Acute or gradual onset: Groin pain can either be of an acute onset or gradual onset and knowing how the pain developed is important in both examination and management.
• Systemic symptoms: unexplained weight loss, fatigue, fever, painful urination and night pain should be treated with urgency and referred for further investigations.[ref]

Objective Assessment

A groin examination classification system adapted using both the Warwick Agreement[ref] and the Doha meeting [ref] taken from Thorborg et al.(2018)

File:Groin pain examination classification.png

Adductor related groin pain

Palpation of the adductor muscle group:

Adductor groin squeeze testing :

iliopsoas related groin pain

Palpation of the iliopsoas muscle:

Resisted hip flexion test:

Inguinal related groin pain

Palpation of the inguinal ligament:

Abdominal resisted testing:

Pubic related groin pain

No resisted testing is described for pubis related pain and maybe be reproduced on adductor abdominal testing, how ever there may be local tenderness on the pubis symphysis and surrounding bones.