II. Risk Factors: Groin Injury in Athletes

  1. Groin Injury accounts for 2-5% of sports injury
  2. Related to chronic, repetitive stress injury
  3. Higher risk sports for Groin Injury
    1. Soccer (Incidence 5-7%, up to 58% report a history of Groin Pain)
    2. Ice hockey
    3. American Football
    4. Australian Football
    5. Fencing
    6. Handball
    7. Cross Country Skiing
    8. Hurdling
    9. High Jumping
  4. Other risk factors
    1. Increased competition level
    2. Decreased relative hip adduction strength (compared with abductors)
      1. Adductor Squeeze Test with decreased strength
      2. Hip internal rotation reduced
    3. Inadequare off-season training or sport specific conditioning
    4. Older age
    5. Low Vitamin D Levels
    6. Prior Groin Injury

III. Precautions: Risk Factors for serious pathology

  1. Age over 65 years
  2. Pain on Hip Range of Motion
    1. Intrinsic hip pathology
    2. Septic Arthritis of the hip
  3. Inability to bear weight
    1. Hip Stress Fracture
    2. Hip Septic Arthritis
    3. Avascular Necrosis of the Hip
    4. Femoral lesion (e.g. malignancy)
    5. Unstable Slipped Capital Femoral Epiphysis (8-15 years old)
  4. Abdominal Pain
    1. Abominal aortic aneurysm (may present with back pain if retroperitoneal bleeding)
    2. Appendicitis
    3. Renal Calculi
    4. Pelvic tumors
    5. Ectopic Pregnancy
    6. Pelvic Inflammatory Disease
    7. Abdominal Hernia or Inguinal Hernia
  5. History of malignancy (or Night Sweats, weight loss)
  6. Hip Trauma
  7. Alcohol Abuse
  8. Night pain, Constant pain, Weight loss
    1. Malignancy
  9. Fever
    1. Septic Arthritis of the hip
    2. Malignancy
    3. Perirectal Abscess
    4. Appendicitis
  10. Chronic Corticosteroids, Chronic inflammatory conditions or Coagulopathy
    1. Avascular necrosis of the hip
  11. Cardiovascular Risk Factors (e.g. Diabetes Mellitus, Tobacco Abuse, Coronary Artery Disease, Carotid Stenosis)
    1. Aortoilliac Occlusive Disease

IV. History

  1. Sporting activity
    1. Frequency, duration and intensity
    2. Injury mechanism
      1. Stopping, cutting or kicking
  2. Pain characteristics
    1. Location, timing, region, radiation, palliative and provocative
  3. Associated symptoms
    1. Swelling
    2. Ecchymosis
    3. Locking or catching (Labral Tear or other intraarticular cause)
    4. Popping or clicking (Labral Tear or other intraarticular cause)
    5. Instability
    6. Altered sensation, Paresthesias or weakness (nerve entrapment)
  4. Referred pain sources
    1. Spine (radiculopathy)
    2. Abdomen and Pelvis
    3. Genitourinary tract
    4. Skin (e.g. Shingles)

V. Exam

  1. See Hip Exam
  2. Observe for groin Ecchymosis (avulsion, muscle tear, abdominal wall hematoma)
  3. Observe for bulge in the abdominal and inguinal region (Hernia)
    1. Also palpate the Superficial Inguinal Ring with valsalva or cough
  4. Examine in frog-leg position
    1. Palpate the lower Abdomen and pupic symphysis
    2. Palpate adductor insertions (pubic tubercle, medial inferior pubic ramus)
    3. Palpate abdominal muscles
    4. Palpate anterior superior iliac spine (ASIS, sartorius and tensor fasciae latae insertion)
    5. Palpate anterior inferior iliac spine (AIIS, rectus femoris insertion)
    6. Palpate anterior hip
  5. Perform active range of motion and passive range of motion
    1. See Hip Range of Motion
  6. Specific Tests
    1. Hip Adduction Test
      1. Also includes Single Hip Adductor Test, Bilateral Hip Adductor Test
    2. FABER Test
      1. Flexion ABduction External Rotation
      2. Also known as Patrick's Test or Figure of Four Test
    3. FADIR Test
      1. Flexion ADduction Internal Rotation
    4. Hip Scour Test (Hip Quadrant Test)
      1. Hip Flexed to 90 degrees and examiner applies axial load
      2. Internally rotate and externally rotate hip
  7. Other examination
    1. Perform an abdominal exam and back exam on all Hip Pain patients
    2. Evaluate sensation and motor function
    3. Evaluate femoral and pedal pulses
  8. Findings most suggestive of hip intra-articular cause
    1. Pain on external and internal hip rotation
    2. Pain on hip axial loading (force applied at foot or knee towards hip)

VI. Differential Diagnosis

VII. Imaging

  1. Hip XRay
    1. Obtain Anteroposterior View (AP View) and Frog-Leg Lateral View
    2. Indications
      1. First-line study in hip Pain Evaluation
      2. Evaluate for bony lesions (e.g. malignancy)
      3. Femoral Neck Stress Fracture
      4. Hip Avulsion Fracture
      5. Slipped Capital Femoral Epiphysis
      6. Avascular Necrosis of the Femoral Head
      7. Osteoarthritis
      8. Hip Joint lesions (e.g. pincer lesion, cam lesion)
      9. Osteitis Pubis
    3. Low yield for Osteoarthritis (36% Test Sensitivity)
      1. Kim (2015) BMJ 351:h5983 +PMID:26631296 [PubMed]
    4. Hip XRay may miss non-displaced Femoral Fractures
      1. Consider MRI or CT for negative XRay with higher index of suspicion
      2. Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
      3. Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]
  2. Hip MRI (or Hip CT if MRI unavailable) Indications
    1. Hip Pain with non-diagnostic XRay
    2. Muscle tears and Tendon Strains
    3. Avulsion Fractures
    4. Hip Avascular Necrosis
    5. Hip Labral Tear
    6. Hip cartilage defects
  3. Hip MRI with arthrography
    1. Indicated for suspected Hip Labral Tear (Test Sensitivity 90% contrasted with 36% for standard MRI)
  4. Hip Ultrasound
    1. Long axis view detects hip effusion and can direct hip needle aspiration if septic hip is suspected
    2. Also indicated in Functional Evaluation of hip
    3. Test Sensitivity approaches 80-85% for identifying hip effusion in children
      1. Vieira (2010) Ann Emerg Med 55(3): 284-9 +PMID:19695738 [PubMed]
  5. Bone Scan (Scintigraphy) Indications
    1. Stress Fracture
    2. Osteomyelitis
    3. Sacroiliitis
    4. Osteitis Pubis

VIII. Diagnostics

  1. Electromyography (EMG) or Nerve Conduction Study
    1. Consider for undifferentiated pain with suspected neuropathic origin
  2. Diagnostic Herniography
    1. Contrast injected within the peritoneum
    2. Patient performs Valsalva Maneuver
    3. Imaging demonstrates abnormal contour of contrast

IX. References

  1. Fields (1997) Lecture: AAFP Sports Medicine, Dallas
  2. Ruane (1998) Physician SportsMed 26(4):78-103
  3. Schleihauf (2019) Crit Dec Emerg Med 33(5): 19-28
  4. Shahideh (2013) Crit Dec Emerg Med 27(9):10-18
  5. Braly (2006) Clin Sports Med 199-210 [PubMed]
  6. Brunner (2003) Am Fam Physician 67(3):537-42 [PubMed]
  7. Fricker (1997) Br J Sports Med 31:97-101 [PubMed]
  8. Lynch (1999) Sports Med 28:137-44 [PubMed]
  9. Morelli (2001) Am Fam Physician 64(8):1405-14 [PubMed]
  10. Wilson (2014) Am Fam Physician 90(1): 27-34 [PubMed]

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Related Studies

Ontology: Hip pain (C0019559)

Concepts Sign or Symptom (T184)
ICD10 M25.559 , M25.55
SnomedCT 49218002, 268065004, 156598006, 202473003, 156592007, 202486007
LNC MTHU020861
English Coxalgia, Arthralgia (hip), Hip arthralgia, hip joint pain, hip joint pain (symptom), hip pain, Pain in hip, Painful hips, Pain in unspecified hip, painful hip, hip arthralgia, hip pains, Pain;musculoskeletal;hip, Pain;hip, hip joints pain, hips pain, pain in hip, hip joint pains, arthralgia - hip, arthralgia - pelvis / hip / femur, arthralgia of hip (diagnosis), arthralgia of hip, Pain in joint - coxalgia, Hip painful, Hip pain, Arthralgia of hip, Hip joint pain, Hip pain (finding), coxalgia, hip; joint pain, hip; pain, joint, Hip Pain, musculoskeletal hip pain
Dutch pijnlijke heupen, pijn in heup, coxalgia, heup; gewrichtspijn, heup; pijn, gewricht
French Coxalgie, Hanches douloureuses, Douleur dans la hanche
German schmerzhafte Hueften, Schmerz in der Huefte, Koxalgie
Italian Coxalgia, Anche doloranti, Dolore all'anca
Portuguese Dor na anca, Ancas dolorosas, Coxalgia
Spanish Coxalgia, Caderas dolorosas, Dolor en cadera, coxalgia (hallazgo), coxalgia, dolor de cadera
Japanese 股関節痛, コカンセツツウ
Czech Bolest v kyčli, Bolestivé kyčle, Koxalgie
Hungarian Fájdalmas csípők, Fájdalom a csípőízületben, Coxalgia

Ontology: Inguinal pain (C0239783)

Concepts Sign or Symptom (T184)
SnomedCT 207217001, 102570003, 271856002
English PAIN GROIN, [D]Groin pain, Groin Pain, [D]Groin pain (context-dependent category), Inguinodynia, groin pain (symptom), groin pain, inguinal pain, Pain groin, groin pains, Pain;groin, inguinodynia, [D]Groin pain (situation), Groin pain (finding), Inguinal region painful, Groin pain, Inguinal pain, Inguinal pain (finding), groin; pain, pain; groin
Italian Dolore inguinale
Dutch pijn in de lies, lies; pijn, pijn; lies, liespijn
French Douleur à l'aine, DOULEUR INGUINALE, Douleur inguinale
German Schmerz in der Leiste, Leistenschmerzen
Spanish Dolor de ingle, [D]dolor en la ingle (categoría dependiente del contexto), [D]dolor en la ingle, [D]dolor inguinal, [D]dolor en la ingle (situación), dolor en la ingle, dolor inguinal (hallazgo), dolor inguinal, inguinodinia (hallazgo), inguinodinia, Dolor inguinal
Japanese 鼡径部痛, ソケイブツウ
Portuguese DOR NA VIRILHA, Dor inguinal
Czech Bolest třísla
Hungarian Lágyék fájdalom, Lágyéktáji fájdalom

Ontology: Injury of groin (C0272438)

Concepts Injury or Poisoning (T037)
ICD10 S30-S39
SnomedCT 11805005
English injuries to the groin, groin injuries, groin injury, injury of lower extremity groin, Injury of groin (diagnosis), Injury of groin, Groin injury, Injury of groin (disorder), groin; injury, injury; groin, injury; iliac region
Dutch letsel; lies, letsel; regio iliaca, lies; letsel
Spanish injuria de la ingle, injuria inguinal, lesión traumática de la ingle (trastorno), lesión traumática de la ingle