1. Diagnosis And Medical Management Of chronic Groin pain
Dr Mark Wotherspoon
MB BS, DipSportsMed(Lond), FFSEM
Consultant in Sports and Exercise Medicine

2. Introduction Groin injury is common Large differential diagnosis
Seen in sports with kicking/sprinting/change direction
i.e football/rugby/hockey
Complex anatomy
No consensus on pathology/pathophysiology or management

3. Pubalgia Pain arising from local structures in the pubic area
2-5% of sporting injuries
5-7% football injuries
Chronic and debilitating condition
Prolonged recovery period
Difficult to assess clinically
Poorly imaged/interpreted
On-going debate/research
Reflects chronic stress in pubic region resulting in breakdown in a variety of ways
Similar to “Shin Splints”

4. Causes of Pubalgia Bone Pubic: osteitis pubis Joint
Nonpubic: pelvic stress fractures
Joint
Pubic: pubic instability/disc degeneration
Nonpubic: hip joint/SIJ/Lumbar spine
Musculotendinous
Pubic: adductor tendinopathy/rectus abdominis
inguinal canal pathology
conjoint tendinopathy
Nonpubic: iliopsoas dysfunction
rectus femoris injury
Nerve Entrapment
Ilio-inguinal Nerve/Obturator Nerve
Genito-urinary
Prostatitis/salpingitis/epididymitis
Other
Hernias/tumours(osteiod osteoma)
Infection/seronegative spondarthropathy

5. Main Causes Sportsmans surgical groin/Abdominal related groin pain
Pubic Bone stress Response
Chronic Adductor Tendinopathy/Adductor Related Groin Pain
Hip related groin pain

6. Risk Factors Previous groin pain Level of sport
Number of training sessions
Flexibility
Muscle imbalance
Poor core stability / functional movement
Reduced hip ROM especially internal rotation

7. Symptoms Pain in groin Worse with twisting,sprinting,kicking
Stiff/sore after sport
Non specific loss of power / speed
Radiates into upper thighs,perineum,testicles
Unilateral/bilateral
Coughing/sneezing
Turning over in bed/getting out of a car
Insidious onset and often play with it
Sit-ups
Exclude the hip

8. Signs Exclude the hip, SIJ’s and back Localisation of pain
Resisted single and bilateral SLR
Resisted sit up
Adductor squeeze in all ranges
Adductor signs
Sites of tenderness
Modified Thomas test/ crossover sign
Exclude psoas
Burden of evidence

9. Investigations X-ray +/- stork views Bone scan CT scan / CT spect
MRI / MR arthrogram
Herniography
Ultrasound
Diagnostic LA injection into hip
Hip arthroscopy

10. Abdominal Related Groin Pain
Abdominal symptoms
Pain with cough and sneeze
Tenderness over conjoint tendon at pubic tubercle
Tender/dilated superficial inguinal ring
Number of different surgical theories/operations
? Rx with belt

11. Abdominal Related Groin Pain
Munich Approach
David Connell’s radio-ablation
Gilmore’s technique
David Lloyd’s tenotomy

12. Munich Approach
Swelling in stretched / weak posterior inguinal canal wall
Identified digitally or via ultrasound
Transversalis fascia dilates widening Hasselbach’s triangle
With abdominal muscle contraction swelling increases
Compression of genital branch of genitofemoral nerve (dull pain radiating around pubic region)
Tension on rectus abdominis insertion at pubic tubercle (pubalgia)

13. Munich Approach No mesh Laparoscopic
Genital branch of genitofemoral nerve indentified and if necessary partially excised
Reduction in tension of rectus abdominis at pubic bone by special suture repair
Repair of weak posterior wall of inguinal canal with sutures
Local anaesthetic

14. Munich Approach Day case surgery Jogging / cycling at 2 days
Sprinting / change of direction at 3-4 days
Full training 5-6 days
Back to sport at 6-7 days
1,100 operations per year
7% of which are elite athletes
99% successful

15. Pulsed Radiofrequency
Assumption is that inguinal related groin pain is nerve entrapment/irritation around inguinal ligament
Under LA
Along inguinal ligament past genitofemoral nerve and ilioinguinal nerve
Pulsed radiofrequency stuns the nerves for 9 months. Rest 2 days after and start rehab

16. Laparoscopic Inguinal Ligament Tenotomy
Acute/chronic injury of inguinal ligament at pubic tubercle
Tatty scarred inguinal ligament at insertion into pubic tubercle with holes and ruptures
Sutures if previous surgery
Mesh to re-inforce posterior wall of inguinal canal and change pressure onto mesh rather than inguinal ligament
Divide inguinal ligament and scar tissue

17. Inguinal Ligament Tenolysis
Aggressive rehab with stretches
No sutures so safe
Train at 1 week
Full training at 2 weeks
Return to play at 4 weeks
400 operations
Few failures

18. David Lloyd’s Main Criteria
Unilateral pain
Abdominal related groin pain
Pain radiates < 5cm from superior pubic tubercle
Tender superior pubic tubercle
Pain with cough/sneeze
Pain reproduced by resisted sit ups/Valsalva manoevre

19. Prognosis Good outcome if 4 main criteria present
Low success if pain radiates > 5 cm from superior pubic tubercle especially if laterally

20. Abdominal Related Groin Pain – is it a continuum ?
Munich Approach
David Connell’s radio-ablation
Gilmore’s technique
David Lloyd’s tenotomy

21. Pubic Bone Stress Response
Repetitive minor trauma leads to painful non infectious/stress related lesion at pubic symphysis and local muscle insertions/origins
Men more than women
Maximum tenderness at or adjacent to symphysis
Stress reactions at adductor tubercle and pubic tubercles
Shearing forces across symphysis
Rare as primary problem / asymptomatic finding

22. Investigations X-ray - if early nothing
sclerosis, erosions, widening of symphysis, periosteal reactions, moth eaten
Bone scan - hot
MRI stress reactions and marrow oedema,fluid in symphysis etc

23. Treatment Modified rest/prevent shearing Rehabilitation/flexibility
NSAID’s to reduce inflammation
U/S guided cortisone injections
Usually 2-3 months
Can last 3-6 months
Graded return to sport
Bisphosphonates

24. Chronic Adductor tendinopathy
Easy diagnosis with pain resisted contraction,local tenderness adductor tubercle and pain and resisted stretch
Usually adductor longus
Insertion into pubic tubercle +symphysis ie blends in not one insertion site
U/S and MRI confirm diagnosis
Local physio Rx, ? U/S guided cortisone, ? Dry needling and autologous blood / PRP
Adductor tenotomy
Graded rehabilitation programme

25. Iliopsoas Related Groin Pain
Pain on stretch – Thomas’s test
Pain on resisted hip flexion at 90
Tender on palpation
Snapping hip(hip flexion/abduction and extend)
Psoas bursae – one deep to psoas can become symptomatic (one anterior to hip like Baker’s cyst in knee)

26. Iliopsoas Related Groin Pain
U/S or MRI
Local physio Rx / rehab
U/S guided injection

27. Summary Spectrum of same problem Conditions can co-exist
Prevention best treatment/Pre-hab
All need rehabilitation as main stay of Rx
MRI Ix of choice
4-6 wks rehab/Rx and re-asses/pick off what is left
Multidisciplinary Team/Groin clinic

28. Summary Exclude other pathology eg hip/back
History particularly coughing/sneezing/turning in bed
Examination chronic adductor + pubic symphysis tendernes
Choose patients for surgery + surgeon + when
New developments

29. Iv pamidronate/calcitonin
Groin Pain
assessment
Ix with MRI +/- US
Rehab 4-6 wks
If improving C/T
review
PBS response
Iv pamidronate/calcitonin
Chronic adductor
Autologous blood
Sportsman’s hernia
surgery
Psoas dysfunction
us guided inj
C/T rehab