Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients--clinical findings, MRI findings and patient-reported outcome measures at baseline

É C Falvey, E King, S Kinsella, A Franklyn-Miller, É C Falvey, E King, S Kinsella, A Franklyn-Miller

Abstract

Background: Athletic groin pain remains a common field-based team sports time-loss injury. There are few reports of non-surgically managed cohorts with athletic groin pain.

Aim: To describe clinical presentation/examination, MRI findings and patient-reported outcome (PRO) scores for an athletic groin pain cohort.

Methods: All patients had a history including demographics, injury duration, sport played and standardised clinical examination. All patients underwent MRI and PRO score to assess recovery. A clinical diagnosis of the injured anatomical structure was made based on these findings. Statistical assessment of the reliability of accepted standard investigations undertaken in making an anatomical diagnosis was performed.

Result: 382 consecutive athletic groin pain patients, all male, enrolled. Median time in pain at presentation was (IQR) 36 (16-75) weeks. Most (91%) played field-based ball-sports. Injury to the pubic aponeurosis (PA) 240 (62.8%) was the most common diagnosis. This was followed by injuries to the hip in 81 (21.2%) and adductors in 56 (14.7%) cases. The adductor squeeze test (90° hip flexion) was sensitive (85.4%) but not specific for the pubic aponeurosis and adductor pathology (negative likelihood ratio 1.95). Analysed in series, positive MRI findings and tenderness of the pubic aponeurosis had a 92.8% post-test probability.

Conclusions: In this largest cohort of patients with athletic groin pain combining clinical and MRI diagnostics there was a 63% prevalence of PA injury. The adductor squeeze test was sensitive for athletic groin pain, but not specific individual pathologies. MRI improved diagnostic post-test probability. No hernia or incipient hernia was diagnosed.

Clinical trial registration number: NCT02437942.

Keywords: Epidemiology; Football; Groin; MRI; Overuse.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
The groin triangle—ASIS, anterior superior iliac spine, 3G point—point midway between the ASIS and upper pole of patell. TFL, tensor fascia lata; Pec, pectinius; ilioPs, iliopsoas; AL, adductor longus; Gr, gracilis; Sar, sartorius; RF, rectus femoris; VL, vastus lateralis; VM, vastus intermedius.
Figure 2
Figure 2
Schematic representation of the groin and pubic aponeurosis.
Figure 3
Figure 3
Fat suppressed sagittal view of the groin. SCF, subcutaneous fat; RA, rectus abdominis; P, pubic bone; ALT, adductor longus tendon; PAD, pubic aponeurosis defect.
Figure 4
Figure 4
Fagan nomogram showing pretest and post-test probability and likelihood ratios of tests for pubic aponeurosis injury. BMO, pubic bone marrow oedema; MRI; PA, pubic aponeurosis; SQ0°, adductor squeeze test at 0°.

References

    1. Moore KL. The lower limb. In: Satterfield TS, ed. Clinically oriented anatomy. Williams & Wilkins, 1992:373–497.
    1. Walden M, Hagglund M, Ekstrand J. Football injuries during European Championships 2004–2005. Knee Surg Sports Traumatol Arthrosc. 2007 Sep;15(9):1155–62. Epub 2007 Mar 21.
    1. Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med 2001;35:28–33. 10.1136/bjsm.35.1.28
    1. Murphy JC, O'Malley E, Gissane C, et al. . Incidence of injury in Gaelic football: a 4-year prospective study. Am J Sports Med 2012;40:2113–20. 10.1177/0363546512455315
    1. Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med 1999;9:151–6. 10.1097/00042752-199907000-00006
    1. Brooks JH, Fuller CW, Kemp SP, et al. . Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med 2005;39:757–66. 10.1136/bjsm.2005.018135
    1. Brooks J, Fuller C, Kemp S, et al. . Epidemiology of injuries in English professional rugby union: part 2 training Injuries. Br J Sports Med 2005;39:767–75. 10.1136/bjsm.2005.018408
    1. Waldén M, Hägglund M, Ekstrand J. The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med 2015;49:792–7. 10.1136/bjsports-2015-094705
    1. Serner A, van Eijck CH, Beumer BR, et al. . Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med 2015;49:813 10.1136/bjsports-2014-094256
    1. Verrall GM, Hamilton IA, Slavotinek JP, et al. . Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury. J Sci Med Sport 2005;8:77–84. 10.1016/S1440-2440(05)80027-1
    1. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med 1998;17:787–93, vii 10.1016/S0278-5919(05)70119-8
    1. Ziprin P, Prabhudesai SG, Abrahams S, et al. . Transabdominal preperitoneal laparoscopic approach for the treatment of sportsman's hernia. J Laparoendosc Adv Surg Tech A 2008;18:669–72. 10.1089/lap.2007.0130
    1. Moeller JL. Sportsman's hernia. Curr Sports Med Rep 2007;6:111–14.
    1. Brown RA, Mascia A, Kinnear DG, et al. . An 18-year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results. Clin J Sport Med 2008;18:221–6. 10.1097/JSM.0b013e318172831a
    1. Sheen AJ, Stephenson BM, Lloyd DM, et al. . ‘Treatment of the sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 2014;48:1079–87. 10.1136/bjsports-2013-092872
    1. Muschaweck U, Berger LM. Sportsmen's groin-diagnostic approach and treatment with the minimal repair technique: a Single-Center Uncontrolled Clinical Review. Sports Health 2010;2:216–21. 10.1177/1941738110367623
    1. Brannigan AE, Kerin MJ, McEntee GP. Gilmore's groin repair in athletes. J Orthop Sports Phys Ther 2000;30:329–32. 10.2519/jospt.2000.30.6.329
    1. Lloyd DM, Sutton CD, Altafa A, et al. . Laparoscopic inguinal ligament tenotomy and mesh reinforcement of the anterior abdominal wall: a new approach for the management of chronic groin pain. Surg Laparosc Endosc Percutan Tech 2008;18:363–8. 10.1097/SLE.0b013e3181761fcc
    1. Maffulli N, Loppini M, Longo UG, et al. . Bilateral mini-invasive adductor tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes. Am J Sports Med 2012;40:1880–6. 10.1177/0363546512448364
    1. Mann CD, Sutton CD, Garcea G, et al. . The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women. Br J Sports Med 2009;43:579–83. 10.1136/bjsm.2008.053132
    1. Meyers WC, McKechnie A, Philippon MJ, et al. . Experience with “sports hernia” spanning two decades. Ann Surg 2008;248:656–65. 10.1097/SLA.0b013e318187a770
    1. Bozic KJ, Chan V, Valone FH III, et al. . Trends in hip arthroscopy utilization in the United States. J Arthroplasty 2013;28(8 Suppl):140–3. 10.1016/j.arth.2013.02.039
    1. Montgomery SR, Ngo SS, Hobson T, et al. . Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661–5. 10.1016/j.arthro.2012.11.005
    1. Reiman MP, Thorborg K. Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence? Br J Sports Med 2015;49:782–4. 10.1136/bjsports-2014-093821
    1. Jardi J, Rodas G, Pedret C, et al. . Osteitis pubis: can early return to elite competition be contemplated? Transl Med UniSa 2014;10:52–8.
    1. King E, Ward J, Small L, Falvey E, et al. . Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes Br J Sports Med 2015;49:1447–51.
    1. Weir A. From disruption to consensus: the thousand mile journey. Br J Sports Med 2014;48:1075–7. 10.1136/bjsports-2013-092958
    1. Renström P, Peterson L. Groin injuries in athletes. Br J Sports Med 1980;14:30–6. 10.1136/bjsm.14.1.30
    1. Hölmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med 2007;41:247–52; discussion 52 10.1136/bjsm.2006.033373
    1. Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med 2008;42:851–4. 10.1136/bjsm.2007.039685
    1. Hölmich P, Uhrskou P, Ulnits L, et al. . Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 1999;353:439–43. 10.1016/S0140-6736(98)03340-6
    1. Weir A, Jansen JA, van de Port IG, et al. . Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial. Man Ther 2011;16:148–54. 10.1016/j.math.2010.09.001
    1. Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med 2009;43:213–20. 10.1136/bjsm.2007.042259
    1. Zoga AC, Mullens FE, Meyers WC. The spectrum of MR imaging in athletic pubalgia. Radiol Clin North Am 2010;48:1179–97. 10.1016/j.rcl.2010.07.009
    1. Robinson P, Bhat V, English B. Imaging in the assessment and management of athletic pubalgia. Semin Musculoskelet Radiol 2011;15:14–26. 10.1055/s-0031-1271956
    1. Thorborg K, Branci S, Stensbirk F, et al. . Copenhagen hip and groin outcome score (HAGOS) in male soccer: reference values for hip and groin injury-free players. Br J Sports Med 2014;48:557–9. 10.1136/bjsports-2013-092607
    1. Thorborg K, Hölmich P, Christensen R, et al. . The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med 2011;45:478–91. 10.1136/bjsm.2010.080937
    1. SSC. Examination of the painful athletic groin. Secondary Examination of the painful athletic groin [Online resource] 2013.
    1. Malanga GA, Nadler SF. Physical examination of the hip. In: Malanga GA, ed. Musculoskeletal physical examination–an evidence-based approach. Philadelphia, PA: Elsevier Mosby, 2006:251–78.
    1. Hölmich P, Hölmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med 2004;38:446–51. 10.1136/bjsm.2003.004754
    1. Brukner PB, Kahn K. Groin pain. Clinical sports medicine. 4th edn Syndey: McGraw-Hill, 2012.
    1. Gaenslen FJ. Sacro-iliac arthrodesis. JAMA 1927;89:2031–5. 10.1001/jama.1927.02690240023008
    1. Cyriax J. Perineuritis. Br Med J 1942;1:578–80. 10.1136/bmj.1.4244.578
    1. Estridge MN, Rouhe SA, Johnson NG. The femoral stretching test. A valuable sign in diagnosing upper lumbar disc herniations . J Neurosurg 1982;57:813–17. 10.3171/jns.1982.57.6.0813
    1. Robinson P, Barron DA, Parsons W, et al. . Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings. Skeletal Radiol 2004;33:451–7. 10.1007/s00256-004-0753-2
    1. Riley GM, McWalter EJ, Stevens KJ, et al. . MRI of the hip for the evaluation of femoroacetabular impingement; past, present, and future. J Magn Reson Imaging 2015;41:558–72. 10.1002/jmri.24725
    1. Bui KL, Ilaslan H, Recht M, et al. . Iliopsoas injury: an MRI study of patterns and prevalence correlated with clinical findings. Skeletal Radiol 2008;37:245–9. 10.1007/s00256-007-0414-3
    1. Comin J, Obaid H, Lammers G, et al. . Radiofrequency denervation of the inguinal ligament for the treatment of ‘Sportsman's Hernia’: a pilot study. Br J Sports Med 2013;47:380–6. 10.1136/bjsports-2012-091129
    1. Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005;365:1500–5. 10.1016/S0140-6736(05)66422-7
    1. Sansone M, Ahldén M, Jonasson P, et al. . Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes. Knee Surg Sports Traumatol Arthrosc 2014;22:786–92. 10.1007/s00167-013-2738-y
    1. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport 1995;27:76–9.
    1. Holmich P, Dienst M. [Differential diagnosis of hip and groin pain. Symptoms and technique for physical examination]. Orthopade 2006;35:8, 10–5 10.1007/s00132-005-0888-4
    1. Branci S, Thorborg K, Bech BH, et al. . MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls. Br J Sports Med 2015;49:681–91. 10.1136/bjsports-2014-093710
    1. Robinson P, Grainger AJ, Hensor EM, et al. . Do MRI and ultrasound of the anterior pelvis correlate with, or predict, young football players’ clinical findings? A 4-year prospective study of elite academy soccer players. Br J Sports Med 2015;49:176–82. 10.1136/bjsports-2013-092932
    1. Ansede G, English B, Healy JC. Groin pain: clinical assessment and the role of MR imaging. Semin Musculoskelet Radiol 2011;15:3–13. 10.1055/s-0031-1271955
    1. Palisch A, Zoga AC, Meyers WC. Imaging of athletic pubalgia and core muscle injuries: clinical and therapeutic correlations. Clin Sports Med 2013;32:427–47. 10.1016/j.csm.2013.03.002
    1. Delahunt E, McEntee BL, Kennelly C, et al. . Intrarater reliability of the adductor squeeze test in Gaelic games athletes. J Athl Train 2011;46:241–5.
    1. Thorborg K, Serner A, Petersen J, et al. . Hip adduction and abduction strength profiles in elite soccer players: implications for clinical evaluation of hip adductor muscle recovery after injury. Am J Sports Med 2011;39:121–6. 10.1177/0363546510378081
    1. Weir A, de Vos RJ, Moen M, et al. . Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain. Br J Sports Med 2011;45:6–9. 10.1136/bjsm.2009.060434
    1. Frank JM, Harris JD, Erickson BJ, et al. . Prevalence of femoroacetabular impingement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy 2015;31:1199–204. 10.1016/j.arthro.2014.11.042
    1. van den Berg JC, de Valois JC, Go PM, et al. . Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol 1999;34:739–43. 10.1097/00004424-199912000-00002

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