The definitive treatment of groin pain in elite athletes

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Groin pain

Consider the inguinal ligament for upper groin pain and the adductor tendon for lower groin pain

 

Groin pain is a common complaint amongst sportsmen and women and members of the public alike. It affects many athletes, and particularly those participating in sports involving kicking, rapid acceleration and deceleration, and sudden changes of direction. It has been shown to be a regular occurrence amongst football, rugby and hockey players but any athlete could develop this condition, and it has been suffered by cricketers, marathon runners, equestrian eventers, baseball players and ice-hockey players to name but a few.

The true incidence of groin injury is unknown, but estimates have been as high as 30 - 40% amongst all sportsmen. Severe groin pain, defined as that which significantly disrupts performance and requires surgical intervention, has a reported career-incidence of 4 - 6 % in professional football players. Most players undergo routine hernia surgery with unpredictable results, but the Lloyd Release Procedure has been specifically developed to address the cause of groin pain which is due to tension in the ligaments which attach to the pubic tubercle.

 

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It is very important to assess whether the pain arises from above the pubic tubercle (upper groin pain) or below the pubic bone (lower groin pain). Upper groin pain is usually due to inguinal ligament strain and in this group of patients the results from a Lloyd Release Procedure are excellent. Palpation along the inguinal ligament usually elicits the painful symptoms. Many physiotherapists and doctors will place a finger in the upper scrotum and elicit pain by invaginating the skin to try and assess whether the external inguinal ring is dilated. This is a misleading clinical sign as the assessments are always subjective and causes pain in most men even if they don't have groin strain! Sometimes the pain is quite deep inside the pelvis and difficult to localise. This may be due to the fact that the attachment of the inguinal ligament and the lacunar ligament, deep in the groin is strained. This can be assessed either by pressure over the femoral canal or above the inguinal ligament just lateral to the rectus muscle. If most of the symptoms arise from the lower groin or perineal area, then an adductor tendon strain should be considered. Many athletes have pain which starts around the inguinal ligament but radiates down to the inner thigh and adductor area. This is probably caused by referred pain in the obturator nerve.

Groin pain can be of insidious onset in some athletes occuring over several months and is exacerbated by exercise. The pain often radiates into the upper groin around the insertion of the inguinal ligament or rectus muscle onto the pubic tubercle or down to the lower groin area near the perineum (adductor region). Occasionally there is a documented precipitating injury or event, but many athletes simply complain of pain during or even after rigorous exercise. In many athletes, the pain is located near the pubic bone around the insertion of the inguinal ligament onto the pubic tubercle. Most commonly, the athlete has rested the injury, undergone physiotherapy, and subsequently developed a recurrence of the pain upon recommencing activity.

Other conditions in this area of the body may include pain arising from the adductor muscles, the hip joint or obturator nerve. Osteitis pubis (inflammation of the pubic bones) is very often over-diagnosed, but there is an extensive list of different causes. Clinical examination and a sound knowledge of groin anatomy are of paramount importance in reaching an exact diagnosis. An MRI scan may exclude other significant pathology, but exact localisation of the pain can only be done by an expert with a full knowledge of the underlying anatomy. Many specialists consider that athletes with groin pain have some kind of hernia and call it a 'sportsman's hernia', despite the fact that often a hernia does not exist!

THE TERM 'SPORTSMAN'S HERNIA' SHOULD BE ABANDONED - IT SHOULD BE REFERRED TO AS A GROIN STRAIN

A hernia is defined as a lump or protrusion, yet in most athletes complaining of groin pain a lump cannot be felt. Therefore, these patients do not have a hernia and the term ‘sportsman's hernia' should be abandoned as it is factually wrong and very misleading. Athletes with groin pain have a strain injury in and around the pubic tubercle; there may be additional small tears of the tissues in the groin region, but the cause of the pain is strain of the inguinal, lacunar or pectineal ligaments, or rectus sheath attachment.

A groin strain is analogous to tennis elbow, whereby it has been proven to be due to an ‘enthesopathy' of the insertion of the extensor tendon onto the periostium of the lateral epicondyle of the humerus - that is to say the insertion (the enthesis) has become inflamed and pathological. In severe cases of tennis elbow, dividing the extensor tendon surgically improves the pain and allows full recovery. Using similar principles, dividing the ligamentous attachments around the pubic tubercle will relieve groin pain in athletes.