Hip and Groin Related Pain
Chronic hip and groin pain can be extremely common in the clinical setting especially during the commencement of certain competitive sporting seasons.
In the world of sports the prevalence of groin and hip injuries usually present in disciplines that require frequent and quick change of direction, sprinting, fast cutting movements, and kicking. Unfortunately males tend to suffer from Groin and Hip injuries more than females.
Here’s what we do know about Chronic Hip and Groin Related Pain:
10% of The general population suffer from various forms of hip pain.
10–20% of hip and groin pain come from Sporting Injuries.
30% of those with an existing groin and hip pain may go on diagnosed.
50% of Pro-footballers have an episode of groin related pain in a season.
There are 22 different muscles that have influence on the hip joint
We do know that groin pain can be brought on by various conditions and can be very multifaceted in nature. Meaning that these pains can come from the muscular and non-muscular system of the body; and can sometimes be located deep in the joints or even superficial to the joints.
To make things more challenging for physiotherapists — Unlike the many other superficial joints in the body the hip joint can be very deep and difficult to palpate accurately.
The close relationship between the lumbar spine and pelvic region can make further serve to make things complicated. I do know of many patients that also suffer from more than one thing going awry in their body — to bring up the statistics; it is worth considering that 63.6% of patients with hip pain suffer from various pathologies meaning that their pain sources could originate from multiple pathologies at a single point in time.
When it comes to Performing a Differential Diagnosis for Chronic Groin Pain It Is Always of Utmost Importance to ask Is the pain coming from:
- Hip joint (Intra-Articular)
- Outside the hip Joint — Extra Articular)
- or Pain referral (From other parts of the body)
Common Clinical Tests You could be using for the Groin Region:
Note that these orthopaedic tests can often times be highly sensitive and non-specific as they often times stress more than one structure. Always pay close attention to the “Type, Region and Quality” of Pain and Symptoms described by the patient.
- Squeeze Test (45 Deg Hip Flexion)
- Squeeze Test (No Hip Flexion)
- Squeeze Test (In Outer Range Abduction)
- Palpation Skills
- Bent Knee Fallout (Muscle Length Test and Objective Measurement)
*The squeeze Test is commonly utilized stress test for Rectus Abdominis & Obliques; Adductor Muscle Group; Pubis Symphysis and Pubic Bone*
Adductor Related Groin Pain
Muscles to be Familiar with are: Pectineus, AddBrevis, AddLongus, AddMagnus, Gracilis (Arranged from Proximal to Distal)
As we delve into adductor related pain it is important to understand that these muscles play a very crucial role in our open and closed kinetic chain system.
Role of Hip Adductors?
- They are not seem as prime movers of the lower limb however they react in reflex responses to gait changes.
- Work with Abductors in synergy to stabilize pelvis (side to side stabilization)
- Activate in Bilateral Stance
- As a group the adductors are larger than hamstrings and comprise of 1/5th of Lower Limb Muscle Mass
- As a group they have the capability of exerting Combined Peak Forces of larger than Gluteus Maximus!
Adductor Magnus is probably owns the most unique characteristics amongst all of them adductor muscles. In the strength and conditioning circles Adductor Magnus is commonly known as 4th Hamstring. It functions to aid us in actions such as Hip Extension and Posterior Pelvic Tilt . Weakness of hamstrings will lead to an increase in load in this muscle during running and sprinting.
(Origin and Insertion of Adductor Magnus Muscle Ischial Tuberosity, Linea Aspera, Adductor Tubercle)
Adductor Longus is known to be a culprit and shady muscle. It is probably involved in 62% of all acute groin injuries
Gracilis is the exception when it comes to adductor roles. As it functions as a medial knee stabilizer as it crosses 2 joints)
Risk Factors For Adductor Related Groin Pain
- Weakness in Adductor Muscle Strength (>10% Difference in Left & Right Sides)
- Poor Hip External Rotation
- Poor Hamstring Strength (Leads to load primarily in Adductor Magnus)
- Poor Adductors to abductor strength ratio
- Know that in any groin injury, weakness in adductors may precede symptoms by up to 2 weeks. I find it helpful for my athletic clients to never neglect adductor muscle training.
Common Signs and Symptoms of Adductor Related Groin Pain
- Pain on Squeeze Test
- Pain during Passive Stretch
- Pain upon Palpation (Please always check and palpate common adductor origin)
- Weakness (Usually Chronic)
Neurological Signs in Hip Pain?
Occasionally you may stumble upon neurological signs and symptoms that appear alongside groin pain patients. These patients will commonly be complaining of specifically exercise induced thigh pain followed by episodes of pins and needles with pain present. Upon closer examination these pain and neurological signs and symptoms can be present during the performance of hip extension and neural provocation testing.
If this is the case you will want to:
- Always screen the lumbar spine for lumbar involvement.
- Be on the lookout for the possibilities of Nerve Entrapment (Most Likely in Groin related pain it’ll be Obturator Nerve, Femoral Nerve)
- Check for Specific Weakness in Quadriceps Muscle Group (The presence of weakness Unilaterally or Bilaterally can bring you closer to a clearer clinical picture of the diagnosis)
Osteitis Pubis
This is a common bony type injury that can come along with chronic groin and adductor related pain. Often times Osteitis Pubis can be present together with adductor tendinopathies and overuse injuries due to the nature these conditions have with regard to the overuse or overload on present on the Publis Symphysis. Think Bone Stress Response*
The pubis symphysis houses attachments from Rectus Abdominis, Levaetor Ani, Adductor Brevis, Adductor Longus, Gracilis. This makes it a prime spot for bony stress injuries occurring from shear forces being exerted on it during activities such as repetitive Kicking, Sprinting, Changing of Direction.
Common Signs and Symptoms of Osteitis Pubis
- Complaints of early morning stiffness
- Tenderness on the Symphysis Pubis
- Pain On Squeeze Test
- Pain on Abdominal Exercises and stress testing such as Sit-ups/Crunches
- In severe cases pain will be present with a cough or sneeze
- MRI will commonly reveal some Bone Marrow Changes
*A lack of range of motion in the hip joints can also cause load transference to the symphysis pubis*
Sports Hernia (Very Rare unless Working in High Level Sports Setting)
Sports Hernia can also be termed Athletic Pubalgia in sports medicine circles. This is more of an Abdominal Wall Related Groin Pain than a traditional hernia. It can be extremely common in Golfers and footballers.
Think of a Sports Hernia as either an Injury to:
- External Oblique
- Conjoined Tendon
- Posterior Abdominal Wall
I find that Athletic Pubalgia most commonly presents in clinic and these clients usually complain of a deep or groin related lower abdominal pain that can even go to as low as the testicles.
Signs and Symptoms of Sports Hernia
- Pubic Pain and Groin Pain Radiating to Pubis
- Burning Pain or Fullness in the Pubis
- Tenderness at insertion of Rectus Abdominis or Conjoined Tendon
- Pain is Worse on Exertion (Sprints, Sit-ups)
- Pain Relieved upon rest (Therefore generally should not appear during night or at moments of rest)
- Deep Groin or Lower Abdominal Pain
- Pain with Resisted Hip Adduction
- MRI can appear Normal — But Ultrasound is better.
Rehabilitation for Sports Hernia
Please see my Medium Article For Rehabilitation Tips on Sports Hernia
Femoral Acetabular Impingement (FAI)
Here’s what a typical story of a client with hip impingement may sound like;
“Doctor — I find that my hip started hurting about a few months ago after introducing golfing and gym sessions to my fitness program. It hurts most at the bottom of my squat especially when I’m tired and squat with my knees falling inwards. My personal trainer told me that squatting with my knees buckling inwards is bad — and his tips did help initially but is still unable to help with me during the deep squat. The other day I had this immense pain when chasing my dog, and I had to limp for quite some time. My hip was clicking and snapping at me whenever I moved at certain angles. Last weekend it was so painful for me to sit in my car when travelling to my grandmother’s place out of town, even the thought of putting on my shoes and socks can scare me. My lower back is fine, and it scares me that my hip clicks when I try sitting cross legged or bend my hips inwards.”
Signs and Symptoms of Hip Impingement
- Hip Related Pain that commonly exceeds 3 months
- Groin Pain can be present
- Poor Internal Rotation (<20 degrees tested in 90 deg Hip Flexed positions)
- Clicking, catching and snapping Sensations
- Radiological Findings
- Limping when walking
- Difficulties Sitting for prolonged periods
- Pain with Transitioning into deep hip flexion positions (Loaded > Unloaded)
- Dynamic Valgus Drop is common in fatigued stages of loaded squat testing
*Please know that the prevalence of Femoral Acetabular Impingement FAI is very common in radiological imaging and can sometimes be of no relation to the groin pain an individual is experiencing*
It is paramount to keep close tabs on what clients are reporting versus what you are finding in clinic and with clinical imaging. The education towards the conveying of message to cater to the different client types can also be a source of despair or empowerment to them. People with Cam impingements can occasionally have a quicker progression into hip arthritis, which to me means that early action and intervention is better than none.
Hip Impingement Treatment Plans:
Initial Goal:
- This is where clients are encouraged to steer clear of any painful activities
- Treatment is focused on getting back pain-free range of motion in the hip (I find that a combination of Hands on therapy and Mobility Drills works best)
- Adductor Strength must be maintained
- Aerobic Fitness must be maintained pain-free
Mid Term Goal:
- Hands on Treatment can be continued here.
- Adductor Strength must be progressed to a reasonable level for their sports/activity requirements
- Lower Limb Strength must also be progressed
- It is important to teach Lower Limb and Hip Motor Control in specific ranges
- Address dysfunction or sub-optimal situations in other body parts such as the knees, foot, and lower back
Long Term Goal:
- The occasional hands on techniques and manual treatment can be ongoing depending on the needs of the client.
- Focus on Eccentric Hip Adductor Control and strength — it is best of clients to understand that this is vital to their long term prognosis.
- Glute Med Control and Strength is also just as important
- The ability to hinge appropriately from the hips with neutral spine is also important.
- Return to sport must be gradual with part-practice in the beginning to make the transition.
The tipping point in helping individuals with Hip Impingement came for me when I understood the role and importance of hip adductors. I found that doubling down on hip adductors can sometimes provide a quicker return to function and sports as compared to purely working on the gluteus medius which will also commonly be found weak or under active in these clientele.
To Conclude
I hope you enjoyed my take on Hip and Groin Related Pain. The reason for me posting this article is to be used as future study reference in physiotherapy practice.
PM If you want to talk Hip and Groin Related Pain or have your own spin on it.
My Physical Therapy Practice Website:
My Further Recommended Readings on the Topic
Brukner and Khan Clinical Sports Medicine
Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am 2006; 88:1448.
Reiman, Michael P, and Kristian Thorborg. “Clinical examination and physical assessment of hip joint-related pain in athletes.” International journal of sports physical therapy vol. 9,6 (2014): 737–55.
Rankin AT, Bleakley CM, Cullen M. Hip Joint Pathology as a Leading Cause of Groin Pain in the Sporting Population: A 6-Year Review of 894 Cases. Am J Sports Med 2015; 43:1698.
Johnson R. Osteitis pubis. Curr Sports Med Rep 2003; 2:98.
Khanna V, Caragianis A, Diprimio G, et al. Incidence of hip pain in a prospective cohort of asymptomatic volunteers: is the cam deformity a risk factor for hip pain? Am J Sports Med 2014; 42:793.
