Groin injuries are common in all forms of sporting endeavour, especially those in which a forceful inward movement of the hip occurs, known as hip adduction. Typical sports where this injury is more common are swimming, football, skating and hockey. Groin injuries may make up five percent of all injuries in football (soccer). Groin pain in younger people such as children and adolescents and in women can be due to more serious conditions than a simple groin sprain and should be investigated and referred on appropriately.
Children with hip pain and a limp should be thoroughly investigated as the possible diagnoses include septic arthritis, a slipped epiphysis of the upper femur, Perthe’s disease and avascular necrosis of the femoral head. Such conditions require the urgent attention of an orthopaedic surgical specialist. As pain can be referred from the hip to the knee region it is important for the surrounding joints to be assessed in the examination. In adolescent athletes the growth plate at the hip is a weaker area and may be involved in traumatic injuries.
The hip is the largest joint in the body and has an extensive range of motion. It is vulnerable to damage due to its weight bearing function and repetitive activities performed. Stiffness of the hip joint may be present some time before the incidence of a groin strain and a strain may occur more readily in the presence of reduced range. Acute groin injuries such as tears, strains or sprains of the muscles and tendons occur with forceful adduction of the hip, a movement towards the midline, or if the splits occurs accidentally. Chronic groin injuries present in activities which typically overuse the muscles, such as breaststroke and running.
A groin injury can be difficult to assess as the pain areas and the type of pain described vary and can be vague. There are many medical diagnoses which can be responsible for the symptom presentation of groin pain and these need to be kept in mind. Acute injuries are common and the most prevalent is the typical groin strain, a strain of one of the many muscles running from the pelvis to the femur, maintaining the femur in the centre line under movement. Likely injuring activities include sprinting, kicking, doing the splits, running and changing direction. Sharp groin pain with some thigh radiation is typical.
The junction of where the tendon and the muscle meet is the main region of injury with bleeding from the locally ruptured muscle fibres. The formation of fibrous tissue followed by scar is the method of healing, leaving the area vulnerable to repetitive injuries, with older sports people being at higher risk than younger athletes. If the injury is severe, part of the bone can come off with the tendon, causing an avulsion injury with surgical repair being required at times. Conservative treatment is the standard management with physiotherapists employing exercise, rest and ice.
The adductor longus, one of the muscles in the adductor group of the inner thigh, is the main site of injury. The area of the junction between the tendon of the muscle and the bone is the most vulnerable spot. Muscle belly injuries can be treated relatively simply by graded stretching once the pain begins to settle, strengthening and getting back to normal function. Injuries to the tendon-bone junction need slower management with rest until there is a reduction in pain, graded exercise towards stretching, graded strengthening, and return to functional sporting activities.
Other possibilities for the diagnosis of pain in the groin region include abdominal hernias, often not diagnosable by physical examination, managed conservatively to start with and then if necessary with surgical care. High energy physical events may cause fractures around the hip although older people may fracture with relatively trivial force. Severe pain and limitation of hip movements and gait should be noted and referral made if needed. Sporting activities which involve repeated impacts such as running can cause stress fractures of the pubic rami or the neck of the femur. Other conditions to consider are avulsion fractures if pain onset is quick and inflammation of a bursa.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Oxford. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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