What Kind of Groin Pain Do You Have?

Welcome back to Squat University! Last week we opened our series on hip pain with an article on how to rehab a hamstring strain. This week we’re going to discuss groin pain.

Groin injuries commonly occur in sports with kicking, quick change of direction, twisting, and turning.⁴ While the amount of athletes sustaining this injury is higher in sports such as soccer and hockey, they can still occur in any sport including weightlifting, powerlifting and CrossFit.

Injuries to the groin can be difficult to diagnose and treat. Primarily because there are many different reasons someone can develop pain in this region. ¹ The anatomy in the groin region is very complex and to make things worse, multiple injuries can occur at the same time and present with very similar symptoms.

To simplify things, we are going to focus on four possibilities of groin pain today:

• Adductor
• Hip Flexor
• Hip Impingement
• Sports Hernia

There are other possible causes of groin pain, but these four represent a large majority of the problems I see with athletes.

Screening

Each type of groin pain will present a little different than the others. If you can figure out which kind of injury you have, it will give you a better understanding for what to do next.

Adductor

A strain of the adductor muscles is thought to be one of the most common forms of groin related pain. While it’s hard to say exactly how often this injury occurs (as it’s common for many athletes to play through minor groin pain), research has reported adductor strains account for anywhere between 8% and 43% of all muscular strains depending on the athlete’s sport.^7,8 Injury to this muscle is often seen in those who participate in ice hockey and soccer (sports where tremendous force is placed on the adductor muscles as they lengthen).³

Anatomically, there are 6 muscles in that are considered “adductors:” the adductor longus, magnus, and brevis, the gracilis, obturator externus and pectineus.³ Research has shown that the adductor longus (one of the largest muscles of the inner thigh) is the most commonly injured of this group.²

A strained adductor longus will often cause tenderness on the upper and inner thigh, close to where this muscle connects to your pubic bone.² It is also common to have pain during a resisted adduction test.

To try this test, start by lying on your side. Straighten your bottom leg and lift it off the floor about ~12 inches. Hold your leg and try to keep it from moving as a friend attempts to push your leg down (with their hand applying force around your ankle).^6,7 This test is positive if it reproduces pain in your inner groin.

Hip Flexor

Finding the exact cause of why an athlete has pain in the front of the hip can be a challenge. There may be pain due to the iliopsoas muscle, a labral tear of the hip, or arthritis. If we’re only talking about the iliopsoas muscle, it can be strained, compress the underlying bursa sac (fluid filled bag that prevents friction) or the iliopsoas muscle can snap back and forth over a bony prominence with leg movement. We’re going to focus on these three possibilities within this category, and label it simply Iliopsoas syndrome.

Iliopsoas syndrome occurs often due to overuse (as opposed to a specific one time tear seen more often with adductor strains).¹² This particular injury therefore can be more prevalent in those who participate in weightlifting, powerlifting or CrossFit.²

The Iliopsoas is actually comprised of two different muscles: the iliacus and psoas major It is also the only muscle that directly connects the spine with the lower body.¹² It is activated during many movements you perform throughout your day and when training. The main role of the Iliopsoas is to stabilize the core/pelvis and maintain posture. It can also be called upon to be a main mover in pulling your torso upwards during a sit up. The Iliopsoas is comprised mainly of slow twitch muscle fibers.

Iliopsoas injuries:^1,12

• Will often have pain with resisted hip flexion
• Pain/stiffness when stretching the hip flexors
• Pain when pushing deep with your index fingers 1-2 inches from the inside of your AIS

To try the strength test, assume a seated position in a chair. Raise your knee of the injured leg off the chair a few inches. Attempt to hold this position as a friend tries to push your leg back to the chair. This test is positive if holding your leg against this downward force creates pain in your groin.

The modified Thomas test is often used to determine the flexibility of the hip flexors and quads.  Start by standing next to a bed or a bench. Your hips should be in contact with the edge. Grab one of your knees and pull it towards your chest as you gently fall backwards. The knee you grab should be pulled as close to your chest as possible. As you lie on your back while holding onto your leg, allow your other leg to relax completely. If performing this test reproduces pain in the groin region of your extended free leg or your free leg hangs off the bed or bench a few inches, it may signify the reason for your pain is due to the hip flexors.

Hip-Related

The hip joint should always be considered as a possible cause of groin pain.¹ While not nearly as prevalent as those previously described, some research has shown the hip joint can still account for around 5% of groin injuries.

A hip impingement or FAI (femoral acetabular impingement) is one of the most common causes of hip joint related groin pain. If the femur comes in contact with the front of the hip socket (acetabulum) as you descent into a squat, it will cause a pinch-like pain. If this contact happens enough, new bone will actually form around the area as compensation (called a cam or pincer depending on if the bone forms on the femur or hip socket). These bone formations can eventually lead to a tearing of the labrum that surrounds the hip joint, which often requires surgery to repair.

Hip impingements will often present:

• With a pinching pain in the anterior hip at bottom of a squat
• Pain that follows a C shape around the hip (called a ‘C Sign’)
• Pain with the log roll test
• Pain with the FADIR test

People with a hip impingement will often complain of pain that wraps around the hip, from the side to front (called a C-Sign). Make a ‘C’ with your thumb and fingers and place it on your side. If your pain follows this pattern and appears when internally rotating your hip, squatting or with prolonged sitting, there’s a chance you have a hip impingement.

Next, try the log roll test. Grab a friend and lie on your back. With your leg straight, have your friend turn your entire leg inwards by turning at the foot and ankle (called hip internal rotation. The goal of this test is to see if it recreates pain in the hip.

Last, try the FADIR test (which stands for flexion-adduction-internal rotation). Start by lying on your back. Have a friend push your thigh towards your chest while at the same time pushing you’re your knee across to your opposite shoulder and pulling your foot away from the midline of your body. This test is positive if it reproduces pain in the hip.

If you only had one positive test out of these three tests, the chances of having a hip impingement is fairly low. ^13,14  If you tested positive for all three tests (C-Sign, log roll and FADIR test), you can make an educated guess that you are dealing with true hip impingement or FAI.

Depending on the severity of the impingement, corrective exercises can be very helpful at decreasing this pain. If it is allowed to linger (while you continue to push through your daily life and workouts) it could potentially lead to a torn hip joint labrum, which often requires surgery to repair.

Sports Hernia

A “sports hernia” is a basically a catch-all term for several different injuries that can occur around the inguinal canal (the area just above the rope like ligament that creates the “V” in your lower abs). Despite the prevalence of this injury, the research is actually quite vague and contradictory in terms of how to diagnose and treat a sports hernia. In fact a “sports hernia” doesn’t even refer to an actual hernia, as there is no actual tear or deformity in the abdominal wall.¹⁰ Technically, the term encompasses two groin injuries: inguinal disruption and athletic pubalgia (both of which will have very similar symptoms).

Regardless of how accurate the name “sports hernia” is, its use is still very commonplace. The current consensus amongst experts in the field is that a sports hernia describes a chronic pain (lasting many weeks to years) around the inner hip-crease (inguinal area) or pubic region that is felt when exercising.⁹

The exact reason for sustaining a sports hernia is also unclear. Some of the causes are:⁹

• Excessive high velocity cutting and twisting
• Imbalances in strength of the lower body compared to the rectus abdominus and core muscles
• A congenital abnormality (basically you’re born with anatomy that sets you up to have this issue).

Diagnosing for this injury is quite difficult as there is no definitive “gold standard” test available to date. To make matters worse, a large number of those with this injury will have pain that mimics other forms of groin pain. For example, it’s somewhat common to have pain with resisted hip adduction if you have a sports hernia (the same test for a strained adductor longus muscle).¹⁰ To distinguish it from an adductor strain, you’ll sometimes notice pain when doing abs (sit ups for example) or when performing the Valsalva maneuver (holding your breath and engaging core/diaphragm to create intra-abdominal pressure), coughing or sneezing.¹ 

Researchers have however recently outlined five signs that may give us a better idea if a sports hernia is present:¹¹

1. Complaints of deep groin/lower abdominal pain
2. Pain that is made worse with physical activity such as sprinting, cutting and sit-ups. Rest usually decreases pain.
3. Tenderness if you poke around the pubic ramus (the front part of your pelvis near your inner groin)
4. Pain with resisted hip adduction (the test discussed for an adductor longus strain)
5. Pain with resisted abdominal sit-up.

This injury should also be suspected if the athlete has been complaining of groin pain for months on end that does not get better with rest or any traditional corrective exercises. If this is the case for you or someone you know, we highly recommend you see an orthopedic specialist for a thorough examination. 

Final Thoughts

Evaluating and treating groin pain can be very difficult as multiple injuries can occur at the same time and cause similar symptoms. If you have any catching, locking, click in the hip, radiating shooting pain down your thigh or sensation of your leg giving out, you should absolutely seek out a medical professional. These symptoms may be indicative of a neurological issue or a serious hip issue (labral tear).

For the next few weeks, we will go into detail with each type of groin pain.

Until next time,

With

References

1. Weir A, Brunker P, Delahunt E, Ekstrand J, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49:768-774
2. Renstrom P & Peterson L. Groin injuries in athletes. Br J Sports Med. 1980;14:30-36
3. Tyler TF, Silvers HJ, Gerhardt MB, et al. Groin injuries in sports medicine. Sports Health. 2010;2(3):231-236
4. Serner A, Tol JL, Jomaah N, et al. Diagnosis of acute groin injuries: a prospective study of 110 athletes. The American Journal of Sports Medicine. 2015;43(8):1857-1864
5. Werner J, Hagglund M, Walden M, et al. UEFA injury study: a prospective study of hip and goin injuries in professional football over seven consecutive seasons. Br J Sports Med. 2009;43(13):1036-1040
6. Tyler TF, Nicholas Sj, Campbell RJ, et al. The effectiveness of a preseason exercise program to prevent adductor muscle strains in professional ice hockey players. Am J Sports Med. 2002;30(5):680-683
7. Tyler TF, Nicholas SJ, Campbell RJ, et al. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128
8. Seward H, Orchard J, Hazard H, et al. Football injuries in Australia at the elite level. Med J Aust. 1993;159:298-301
9. Unverzagt CA, Schuemann T & Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. JOSPT. 2008;38(2):63-70
10. Ellsworth AA, Zoland MP & Tyler TF. Athletic pubalgia and associated rehabitation. Invited clinical commentary. IJSPT. 2014 Nov;9(6):774-784
11. Kachingwe AF, Grech S. Proposed algorithm for the management of athletes with athletic pubalgia (sports hernia): a case series. J Ortho Sports PHys Ther. 2008;38(12):768-781
12. Tyler TF, Fukunaga T & Gellert J. Rehabilitation of soft tissue injuries of the hip and pelvis: invited clinical commentary. IJSPT. 2014 Nov; 9(6):785-797
13. Laborie LB, Lehmann TG, Engesaeter IO, et al. Is a positive femoroacetabular impingement test a common finding in healthy young adults? Clin Orthop Relat Res. 2013 Jul; 471(7):2267-2277
14. Tijssen M, van Cingel R, Willemsen L, et al. Diagnostics of femoroacetabular impingement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy. 2012 Jun;28(6):860-71