CTOBER15,2001 / VOLUME64,Nwww.aafp.org/afpAMILYHYSICIAN - PDF document

CTOBER15,2001 / VOLUME64,Nwww.aafp.org/afpAMILYHYSICIAN unclear in approximately 30 percent ofcases.ctors that complicate the diagnosis include T Groin injuries comprise 2 to 5 percent of all sports injuries. Early diagnosis and proper oin Injuries in AthletesVINCENT MORELLI,M.D.,Louisiana State University School ofMedicine,New Orleans,LouisianaVICTORIA SMITH,M.D.,Louisiana State University Health Sciences Center,Kenner,Louisiana Differential Diagnosis of Nonathletic Causes of Groin PainIntra-abdominal disorders (e.g., aneurysm, appendicitis, diverticulosis, prostatitis, scrotal and testicular abnormalities, gynecologic abnormalities,nephrolithiasis)Referred lumbosacral pain (e.g., lumbar disc disease)Hip joint disorders (e.g., Legg-CalvŽ-Perthes disease, synovitis, slipped femoralhead, avascular necrosis of the femoral head, osteoarthritis, acetabular labral tears) don tears.Ultrasound is useful for diagnos-ing muscle and tendon tears,but not musclestrains.The most common site ofstrain isthe musculotendinous junction oftheadductor longus or gracilis.Complete avul-sions ofthese tendons also occur,but muchless frequently.Once the diagnosis ofadductor strain hasbeen established,three questions must be con-sidered.First,are there biomechanical abnor-malities that may predispose to injury? Footand lower leg malalignment,muscular imbal-ances,leg length discrepancy,gait or sport-specific motion abnormalities can all theoret-ically place abnormal loads on the adductors.Although controlled clinical studies demon-strating a causal relationship between biome-hanical abnormalities and adductor strainshave not been conducted,many physiciansspecializing in sports medicine believe thatthese are important contributing factors.present,these abnormalities should be evalu-ated and corrected ifpossible.Second,what is the location ofthe tear?This has important therapeutic and prognos-tic implications.Ifan acute tear occurs at theusculotendinous junction,a relatively ag-essive approach to rehabilitative treatmentcan be undertaken.When an acute partialear occurs at the tendinous insertion oftheadductors into the pubic bone,a period ofest must be completed before pain-free phys-ical therapy is possible.Third,what is the chronicity ofthe symp-ms? Athletes often do not recall an acuteinciting incident and complain instead ofpain ofan insidious onset.These athletes aredifficult to treat because they remain able toplay their sports (at least for a while) after agood warm-up and are not motivated to taketime offand undergo proper rehabilitation.Although few controlled studies oftheeatment ofadductor strains exist in the lit-erature,most clinical experience dictates thatacute treatment include physical therapymodalities (i.e.,rest,ice,compression,eleva-tion) that help prevent further injury andinflammation.Following this,the goal oftherapy should be restoration ofrange ofmotion and prevention ofatrophy.Finally,the patient should regain strength,flexibilityand endurance.en the athlete hasgained at least 70 percent ofhis or herstrength and pain-free full range ofmotion,areturn to sport may be allowed.This returnmay take four to eight weeks following anacute musculotendinous strainand up to sixmonths for chronic strains.One randomized trial of68 athletes withnic adductor strainmpared physicaltherapy (i.e.,friction massage,stretching,anscutaneous electrical nerve stimulation,laser treatment) with active training exercise.A significantly greater number ofparticipants(23 versus four in the physical therapy group)were able to return to their sport after anAMILYHYSICIANwww.aafp.org/afpOLUME64,N8 / OCTOBER15,2001 Adductor brevis muscle . . . . eight- to 12-week active training program.ther studies may corroborate this initialinvestigation,and active training methodsmay be the future in treating acute andnic adductor strains.Nonsteroidal anti-inflammatory drugs (NSAIDs) and steroidinjections have been mentioned in the treat-ment ofthese conditions,but their efficacy isdebatable and lacks support in the literature.tients with chronic adductor longusstrains that have failed to respond to severalmonths ofconservative treatment have beenshown to do well after surgical tenotomy andshould be referred to a sports medicine sur-geon for this consideration.mpletears ofthe tendinous insertion from thebone,though rare,generally do better withsurgical repair.Osteitis pubis is characterized by pubicsymphysis pain and joint disruption.occurs commonly in distance runners andsoccer players,and has been found in somesports medicine clinics to be the most com-mon cause ofchronic groin pain.Osteitispubis may be difficult to distinguish fromadductor strains,and the two conditions mayoccur concomitantly in the same patient.Also,one must remember that osteomyelitisofthe pubic symphysis,although usually seenfollowing a surgical procedure around thepelvis,has been reported to occur sponta-neously in athletes.The most likely mechanism is repetitivestress from increased shearing forces on thepubic symphysis or from increased stressplaced on the joint from the traction ofthepelvic musculature.Other factors,such aslimitation ofinternal rotation ofthe hips orfixation ofthe sacroiliac joint,also placeessive stresses on the joint.No pub-lished clinical studies have addressed the rolethat biomechanical abnormalities ofthelower limb (e.g.,leg length discrepancies,essive pronation,varus or valgus deformi-ties) might play in the genesis ofosteitispubis.However,it is plausible that suchabnormalities could place the pelvis in thepath ofexcessive force.The clinical symptoms ofosteitis pubisinclude exercise-induced pain in the lowerabdomen and medial thighs.Symptoms areadual in onset,slowly increasing in severity ifactivities are not curtailed.One review articlenoted the following incidence ofsymptoms inpatients with documented osteitis pubis:adductor pain in 80 percent,pain around thepubic symphysis in 40 percent,lower abdomi-nal pain in 30 percent and hip pain in 12 per-nt.Referred scrotal pain,which is said to bepical,was found in only 8 percent.On physical examination,tenderness overthe pubic symphysis is usually present,andlack ofsuch tenderness usually excludes thediagnosis.ain can often be provoked byactive adduction ifthe distal symphysis isinvolved,or by sit-ups ifthe proximal portionis involved.Plain radiographs may show widening ofthe pubic symphysis,irregular contour ofarticular surfaces or periarticular sclerosis.in early or mild disease,radiographicfindings may be normal.Plain films are alsonfusing in young patients because almostidentical radiographic ÒabnormalitiesÓmay beseen during normal ossification.In one studyofprofessional soccer players,diographichanges around the symphysis were found in76 percent ofasymptomatic players.isotope bone scan may demonstrate in-creased uptake in the area ofthe pubic sym-physis,but some patients who have symptomsfail to show any abnormality.Thus,cliniciansare helped only by a positive scan.In a recentreview ofosteitis pubis,it was noted that theelation between symptoms and eitherdiograph or isotope bone scan is difficult.Groin InjuriesCTOBER15,2001 / VOLUME64,Nwww.aafp.org/afpAMILYHYSICIAN Osteitis pubis occurs commonly in soccer players anddistance runners and is a frequent cause of groin pain. MRI shows marrow edema in the pubicbones early in the course ofthe condition,fol-lowed by low signal on T-weightedimages as the disease progresses.ity is becoming increasingly useful in thediagnosis ofosteitis pubis.eatment begins with reassurance to theathlete that the condition is self-limited.it can take more than one year tompletely heal.One studyfound the aver-age time to healing in osteitis pubis to be general,treatment is based on physicalhabilitation.Pain-producing activity shouldbe avoided and pain-free exercise should bemaintained in the interest ofgeneral fitness.Physical therapy should progress in the usualstepwise fashion,with particular attention tohip range ofmotion and adductor stretchingand strengthening.In addition,any biome-hanical abnormalities that would placeundue shear stresses on the pelvis (leg lengthdiscrepancy,excessive pronation,etc.) shouldbe corrected.ntroversy surrounds the use ofcortico-steroid injections in this condition;however,they can be helpful in selected patients (e.g.,athletes with acute osteitis pubis ofless thantwo weeksÕduration.)Sports Herniasosterior abdominal wall abnormalitiescausing groin pain include Òsports herniasÓand groin disruption (Figures 2 and 3)sports hernia is caused by weakening oftheposterior inguinal wall,resulting in an occultdirect or indirect hernia.Because only theposterior abdominal wall is violated,no clin-ically detectable inguinal hernia is found onphysical examination.Some researchersbelieve that sports hernias may be the mostmmon cause ofchronic groin pain in ath-letes.Other investigators have found thembe only a rare cause ofchronic groin pain.Clinically,the sports hernia is characterizedinsidious-onset,gradually worsening,dif-fuse,deep groin pain.It may radiate along theinguinal ligament,perineum and rectus mus-cles.Maneuvers that cause increases in intra-abdominal pressure will usually increase pain.Radiation ofpain to the testicles is present inabout 30 percent ofsymptomatic patients.Clinically,it is difficult to distinguish betweensports hernia,distal rectus strain/avulsionand groin disruption.(See next section.)the pain ofsports hernia is usuallylocated more laterally and proximally than inoin disruption.Radiographs,isotope bone scan and MRImay help exclude other causes ofgroin painbut are not useful in the diagnosis ofsportshernia.Nonoperative treatment is rarelyAMILYHYSICIANwww.aafp.org/afpOLUME64,N8 / OCTOBER15,2001 A Òsports herniaÓ results from weakening of the posterioringuinal wall. No clinically detectable inguinal hernia is found Internal oblique muscleExternal . . . . . successful,but because a definitive diagnosisis often difficult to make,a trial ofseveraleks ofconservative treatment may be war-anted.Ifsymptoms persist,the patientshould undergo surgical exploration andpair.A 90 percent success rate is reported.Groin Disruptionoin disruption was first described in 1980when three professional soccer players withnic,apparently career-ending groin painunderwent surgical exploration and repairand were then able to return to competitivesport.The phrase Ògroin disruptionÓtoday is often used interchangeably with sports her-nia,and the literature is not clear on properminology.The posterior abdominal wall abnormali-ties found in groin disruption are more variedthan those associated with sports hernias.They may include tears ofthe external obliqueaponeurosis,tears ofthe conjoined tendon ordehiscence ofthe conjoined and inguinal liga-Ñagain without any evidence ofaegularÓhernia.In a study of157 athleteswho underwent surgery for chronic groin57 percent were found to have Òloose-feeling inguinal floors.ÓForty-eight percenthad external oblique aponeurosis defects and23 percent had a thin insertion or tear oftherectus abdominus.Clinically,these patients present with groinpain on exertion,but pain with ValsalvaÕsmaneuver,coughing or sneezing is uncom-mon (10 percent ofpatients).Many patients(about 65 percent) also have pain withesisted adduction ofthe hip.ain and ten-derness may be provoked with pressure orwhen the patient does halfsit-ups.Radiographs,computed tomographic (CT)scans,isotope bone scans and MRI are help-ful in excluding other injuries,but less helpfulin establishing the diagnosis ofgroin disrup-tion.Diagnosis is usually made only at thetime ofsurgery.r a trial ofconservative treatment,defin-itive surgical repair is usually required.In morethan 95 percent ofcases,the athlete returns tohis or her pre-injury level ofcompetition.The anatomy ofthe region ofthe iliopsoasis shown in igure 4largest bursa in the body and communicatesith the hip joint in 15 percent ofpatients.rsitis is caused by overuse and friction asthe tendon rides over the iliopectineal emi-nence ofthe pubis.The condition is associ-ated with sports requiring extensive use ofthehip flexors (e.g.,soccer,ballet,uphill running,ling,jumping).Iliopsoas bursitis is char-acterized by deep groin pain,sometimes radi-ating to the anterior hip or thigh,often ac-mpanied by a snapping sensation.(Seesection on snapping hip syndrome.) Ifsevereenough,it may be accompanied by a limp.The pain is difficult for patients to localizeand difficult for clinicians to reproduce.In fact,the average time from the onset ofsymptomsdiagnosis is 31 to 42 months.PhysicalGroin InjuriesCTOBER15,2001 / VOLUME64,Nwww.aafp.org/afpAMILYHYSICIAN Area of herniaArea of groin Area of . . xamination will,however,reveal pain on deeppalpation over the femoral triangle (adjacentthe femoral artery),where the musculo-ndinous junction ofthe iliopsoas can be pal-pated.igure 5shows the anatomy ofthison.) Pain may also be produced when theaffected hip is extended or when the supinepatient raises his or her heels offthe table atabout 15 degrees.In the latter position,theonly active hip flexor is the iliopsoas.Iliopsoas bursitis is best visualized on MRI,which reveals a collection offluid coursingadjacent to the muscle.eatment is conser-vative and consists ofrest followed by stretch-ing ofthe hip flexors and rotators,thenstrengthening and gradual return to sport.Asin any overuse injury,biomechanical abnor-malities must be sought and corrected.Corti-steroid injections,usually performed withimaging localization,may be helpful inselected patients.Rarely,surgical manage-ment ofrecalcitrant cases is warranted.Stress FracturesThe two commonly encountered stressfractures centered in the groin region arefemoral neck stress fractures and pubic ramusfractures.These are caused by repetitiveeruse and overload as seen in distance run-ners or military recruits.Contributing riskfactors include relative osteoporosis in youngfemale athletes with nutritional or hormonalimbalances,muscle fatigue (which may re-AMILYHYSICIANwww.aafp.org/afpOLUME64,N8 / OCTOBER15,2001 cle and iliopsoas bursa. FIGURE 5. Palpable area (outlined in blue) of VINCENT MORELLI, M.D., is an assistant professor in the Department of Family Medi-cine at Louisiana State University School of Medicine, New Orleans. He received hismedical degree from the University of Southern California, School of Medicine, LosAngeles. Dr. Morelli completed a family practice residency at Whittier/USC and a sportsmedicine and arthroscopic fellowship at Jonkoping Hospital, Sweden. Currently, he isVICTORIA SMITH, M.D., is a resident in the Louisiana State University Medical Centerfamily practice residency program in Kenner, La. She received her medical degree fromHarvard Medical School, Boston.Address correspondence to Vincent Morelli, M.D., LSU Health Sciences Center, FamilyPractice Residency Program, 200 W. Esplanade Ave., Ste. 510, Kenner, LA 70065. Re-Area for palpating . . . . . . duce shock-absorbing abilities),changes infoot gear or training surface,or suddenincreases in the training regimen.Femoral neck stress fractures present withoin or anterior thigh pain that is exacerbatedactivity and relieved by rest.Again,the painis difficult to localize on physical examination,but the diagnosis may be suggested by painfullimitation ofinternal rotation ofthe hip.the diagnosis is suspected by history,radi-ographs may be obtained,keeping in mindthat changes (when present) normally lagbehind the onset ofsymptoms by two to foureks.Isotope bone scan or MRI should beperformed to make an early,definitive diagno-mpared with isotope bone scan,MRIhas a similar sensitivity but an improved speci-ficity,and is becoming the diagnostic proce-dure ofchoice in some medical centers.unners with stress fractures ofthe inferiorfemoral neck (compression side) seen on MRIor CT can be treated conservatively,with goodprognosis for uneventful healing.Many clini-cians recommend follow-up imaging toensure healing before progression ofactivity.turn to running usually occurs in two tothree months.Superior femoal neck stress fractures(traction/tension) are more worrisome andust be treated with open reduction andinternal fixation because the risk ofprogres-sion to complete fracture,displacement andascular necrosis is high.ferior pubic ramus stress fracture is lessworrusually occurs in female dis-tance runners and military recruits,and isfairly easily diagnosed.On physical examina-tion,pain may be elicited on palpation directlyer the pubic ramus.Pain is also elicited byone-legged standing or jumping.The diagno-sis can be confirmed by a bone scan.Treat-ment is conservative and straightforward:foursix weeks ofrelative rest followed by grad-ual return to sport.Most athletes show com-plete healing within three to five months.femoral neck and pubic ramus stress frac-tures,treatment would be incomplete withoutalso addressing and modifying risk factors.aintenance ofhormonal and nutritional bal-ance,modification offoot gear and trainingsurface,and conscientious review ofthe ath-leteÕs training program should be undertaken.vulsion Fracturesulsions are seen mainly in adolescentathletes and occur in three main locations(Figure 6)First,avulsions from the anteriorGroin InjuriesCTOBER15,2001 / VOLUME64,Nwww.aafp.org/afpAMILYHYSICIAN The two most commonly encountered stress fractures in thegroin region are those involving the femoral neck and the iliac spine Ischial tuberosity . . superior iliac spine (ASIS) are caused byapid sartorius contraction and are experi-enced during jumping sports.Second,avul-sions from the anterior inferior iliac spine(AIIS) are caused by strong rectus femorisntractions and are seen mainly in kickingsports such as soccer.Third,avulsions fromthe ischial tuberosity occur when the ham-strings are subject to violent contractions insprinting and hurdling sports.Nonoperative eatment is generally recom-mended for avulsions from the ASIS and AIIS,and good results can be expected.Treatmentofavulsions ofthe hamstrings from the ischialtuberosity is controversial.Orthopedic evalu-ation is warranted in these patients.Largefragments displaced greater than 1 to 2 cmmay require surgical fixation.Nerve Compression e compression in the groin is uncom-mon but can include injury to the ilioinguinalnerve,lateral femoral cutaneous nerve or theobturator nerve.ILIOINGUINALNERVEIlioinguinal nerve compression is a well-established cause ofchronic groin pain inpatients who have undergone appendectomyor herniorrhaphy.It is also a cause ofchronicoin pain in athletes,in whom the nerve canbe injured by direct trauma or by overzealousaining ofthe abdominal musculature.The nerve transmits sensation from thebase ofthe penis and scrotum (or in women,the labia majora and mons pubis) and fromthe upper medial thigh.It traverses theinguinal canal/superficial inguinal ring andcrosses through the abdominal musculaturewhere compression can occur (Figure 7)Diagnosis ofilioinguinal nerve compres-sion can often be determined by elicitingnelÕs sign and can be confirmed when aninjection oflocal anesthesia over the site ofentrapment or injury relieves pain.ment consists oflocal corticosteroid injectionsor,ifpain is refractory,surgical neurolysis.OBTURATORNERVEObturator nerve entrapment is becomingmore widely recognized as a cause ofchronicoin pain in athletes.The obturator nervesupplies the adductor muscles and has a vari-able cutaneous distribution to the medialthigh (Figure 8)nt studies from Aus-ewed 182 cases ofobturator-induced chronic groin pain.These athletes(Australian-rules football players and soccerplayers) experienced deep aching centered onthe adductor origin at the pubic bone.Withercise,the pain became more severe anddiated down the medial thigh toward theknee.Some ofthe athletes also experiencedercise-related weakness in the affected leg,especially when attempting to jump.Pares-thesias were rarely present.Diagnosis can be made by electromyogram(ifsymptoms are present longer than threemonths) where a denervation pattern oftheadductor longus and brevis is seen.eatment is surgical neurolysis,with athletesturning to sport within several weeks.LATERALFEMORALCUTANEOUSNERVEThe lateral femoral cutaneous nerve passesunder or through the inguinal ligament,where compression and meralgia parestheticaAMILYHYSICIANwww.aafp.org/afpOLUME64,N8 / OCTOBER15,2001 Area of nerve compression . (paresthesias in the proximal lateral portionofthe hip) can occur (Figure 9)Lateralfemoral cutaneous nerve entrapment hasbeen noted in women who sit with theinvolved leg underneath the body.It has alsobeen seen in rifle team members who werequired to sit in this same position for pro-longed periods.Treatment is composed offraining from the offending activity;rarely,surgery is warranted.Snapping Hip Syndromenapping hip syndrome refers to a snap-ping sensation felt about the hip with move-ment.Less than one third ofthese patientsperience pain with snapping.mality may be classified as external/lateral oras interior/medial/anterior.The more com-mon external/lateral syndrome occurs whenthe iliotibial band,tensor muscle offascia lataor gluteus medius tendon rides back andforth across the greater trochanter,wherebursitis may also develop.nal causes ofsnapping hip include theiliopsoas tendon passing over the iliopectinealeminence,acetabular labral tears,subluxationofthe hip and loose bodies.The physician should attempt to identifythe source ofthe clicking on physical exami-nation and treatment should be undertaken ifpain is present.Correcting any contributingbiomechanical abnormalities and stretchingtightened muscles (e.g.,iliopsoas muscle,ili-otibial band) are important.CorticosteroidGroin InjuriesCTOBER15,2001 / VOLUME64,Nwww.aafp.org/afpAMILYHYSICIAN FIGURE 8. Obturator nerve. FIGURE 9. Lateral femoral cutaneous nerve.Lateral femoral . Groin Injuries injections can be useful ifbursitis is present.urgical treatment is rarely indicated unlessloose bodies are the cause ofthe syndrome.The family physician should be aware ofthemplex anatomy in the groin region,keep inmind the many diagnostic possibilities andapproach the physical examination in a system-atic manner.Correct diagnosis is paramount toensure that proper treatment is started so thatathletes may be optimally rehabilitated andturned to sport in a timely fashion. 1.Karlsson J, Sward L, Kalebo P, Thomee R. Chronicgroin injuries in athletes. Recommendations for treat-ment and rehabilitation. Sports Med 1994;17:141-8. 2.Renstrom P, Peterson L. Groin injuries in athletes. Brestlin N. Groin pain in athletes from Southern Swe-den. Sports Med Arthroscopy Rev 1997;5:280-4.4.Roos HP. Hip pain in sport. Sports Med Arthroscopy5.Ekberg O, Persson NH, Abrahamsson PA, Westlin NE,Lilja B. Longstanding groin pain in athletes. A multi-disciplinary approach. Sports Med 1988;6:56-61.6.Hoelmich P. Adductor-related groin pain in ath-letes. Sports Med Arthroscopy Rev 1997;5:285-91. 7.Karlsson J, Jerre R. The use of radiography, mag-netic resonance, and ultrasound in the diagnosis ofhip, pelvis, and groin injuries. Sports Med Arthro-8.Fricker PA. Management of groin pain in athletes.9.Lynch SA, Renstrom PA. Groin injuries in sport:treatment strategies. Sports Med 1999;28:137-44.10.Dahan R. Rehabilitation of muscle-tendon injuriesto the hip, pelvis, and groin areas. Sports MedArthroscopy Rev 1997;3:326-33.11.Holmich P, Uhrskou P, Ulnits L, Kanstrup IL, NielsenMB, Bjerg AM, et al. Effectiveness of active physi-cal training as treatment for long-standing adduc-tor-related groin pain in athletes: randomised trial.12.Akermark C, Johansson C. Tenotomy of the adduc-tor longus tendon in the treatment of chronic groin13.Martens MA, Hansen L, Mulier JC. Adductor ten-dinitis and musculus rectus abdominis tendopathy.14.Renstroem AF. Groin injuries: a true challenge inorthopaedic sports medicine. Sports Med Arthro-15.Combs JA. Bacterial osteitis pubis in a weight lifterwithout invasive trauma. Med Sci Sports Exerc16.Hedstrom SA, Lidgren L. Acute hematogenous17.Fricker PA. Osteitis pubis. Sports Med Arthroscopy18.Williams JG. Limitation of hip joint movement as a19.Miller JA, Schultz AB, Andersson GB. Load-dis-placement behavior of sacroiliac joints. J Orthop20.Fricker PA, Taunton JE, Ammann W. Osteitis pubis21.Harris NH, Murray RO. Lesions of the symphysis in22.Holt MA, Keene JS, Graf BK, Helwig DC. Treatmentsteroid injections. Am J Sports Med 1995;23:601-6.23.Hackney RG. The sports hernia: a cause of chronicgroin pain. Br J Sports Med 1993;27:58-62.24.Meyers WC, Foley DP, Garrett WE, Lohnes JH,Mandlebaum BR. Management of severe lowerathletes. PAIN (Performing Athletes with Abdomi-nal or Inguinal Neuromuscular Pain Study Group).25.Gilmore J. Groin pain in the soccer athlete: fact, fic-tion, and treatment. Clin Sports Med 1998;17:26.Johnston CA, Wiley JP, Lindsay DM, Wiseman DA.27.Rolf C. Pelvis and groin stress fractures: a cause ofgroin pain in athletes. Sports Med Arthroscopy Rev28.OÕKane JW. Anterior hip pain. Am Fam Physician29.Bradshaw C, McCrory P, Bell S, Brukner P. Obtura-tor nerve entrapment. A cause of groin pain in ath-30.Brukner P, Bradshaw C, McCrory P. Obturator neu-opathy: a cause of exercise-related groin pain.31.Boyd KT, Peirce NS, Batt ME. Common hip injuriesAMILYHYSICIANwww.aafp.org/afpOLUME64,N8 / OCTOBER15,2001 Snapping hip syndrome refers to a snapping sensation feltaround the hip with movement. Less than one third of