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Groin Pain

SEVEN

Groin Pain

The Complexity

of Groin Pain

www.sportdoclondon.co.uk

Groin pain can be a difficult problem

for patients and their clinicians. Part of

the problem is that the location of the

pain is often a poor indicator of where

the pathology lies. Additionally, when

the pain becomes chronic, multiple

pathologies can be generated; adding

a further layer of complexity. It is very

important to make a clear diagnosis,

and we should seek to look beyond

merely labelling the problem as a ‘groin

sprain’.There are many causes of pain

in the groin, but approximately 50% of

groin pain may be attributed to pain

generated by the hip joint; a surprise,

perhaps, for younger patients. As in any

medical condition, the history will give

us many clues. It is extremely important

to rule out sinister ‘red flags’, such as

night pain, severe pain on loading the

leg, weight loss or systemic symptoms;

and we need to be on the lookout for

conditions which may occur in certain

age groups, such as slipped epiphysis

in teenagers.

Common causes of groin pain besides

the hip include those generated by the

lumbar spine, pubic overload (osteitis

pubis), iliopsoas and adductor tendon

pathologies and stress responses in the

femoral neck in runners. Abdominal

wall hernias/conjoint tendon and rectus

abdominis sheath problems may cause

pain which is a little higher in the groin,

and less commonly, younger patients

can avulse the rectus femoris from its

proximal attachment at the anterior

inferior iliac spine. Many of the cases

we see of ‘pubic overload’ (osteitis

pubis), and bony stress responses, occur

because of inadequate lumbar pelvic

control and poor gluteal conditioning.

Sportsmen and sportswomen love

to train for their sport, but may

neglect to carry out the conditioning

work necessary to prevent injury. A

trained eye can spot the problem, and

correcting these faults helps to prevent

a recurrent pattern of breakdown.

Finally, testicular tumours and avascular

necrosis can present insidiously and we

need to be mindful of these conditions.

A large proportion of patients who suffer

with groin pain as a result of hip pathology

have an underlying condition known

as ‘Femoral Acetabular Impingement

Syndrome’ (FAI).This is essentially

a problem resulting from a tear in the

acetabular labrum, usually caused by

repetitive trauma due to a ‘bump’ or

‘CAM’ on the head neck junction of the

femur; which may be familial in terms of

its inheritance.This can cause groin pain

which is worse with exercise, sitting or

standing, and the pain can be brought on

by putting the patient in the ‘impingement

position’ of hip flexion + internal rotation

+ adduction. In the long term, we believe

that the tear in labrum causes changes

in the acetabular articular cartilage next

to it, and over many years, this may lead

to osteoarthritis in the hip. FAI can affect

people of all ages, and is often missed in

30-40-year-olds.Taking a careful history,

and carrying out a thorough examination

can help identify the likely cause. Imaging,

such as MRI arthrography of the hip, can

help confirm the underlying diagnosis (as

X-ray cannot rule out FAI), but it should

be remembered that imaging needs to

be interpreted in light of the history and

examination of findings. FAI may require

treatment with hip arthroscopy surgery,

but in some cases injection therapy and

robust physiotherapy or osteopathy

may be enough to get a person back to

full activity. Sports physicians are ideally

placed to identify the underlying cause

of unexplained groin pain, and are skilled

in directing the rehabilitation necessary

to resolve the problems.

Dr Spencer-Smith qualified in

1995 from St Bartholomew’s

Hospital, and trained in Sports

Medicine at Bath University. She

has worked with an extensive

range of different sports,

treating patients ranging from

Olympians and Paralympians

to the occasional exerciser. She

was a Sports Physician at the

2002 Commonwealth Games,

and has worked with GB rowing,

track and field sports, marathon,

endurance and outdoor

adventure sports. She developed

an MSc Programme at Bangor

University, and is a keen lecturer.

Dr Spencer-Smith specialises in

the diagnosis and treatment of

all musculoskeletal conditions,

whether acquired through sport

or otherwise. She has expertise

in groin, hip, knee and ankle

conditions, overuse injuries, and

injuries affecting the shoulder

and spine. She has a particular

interest in helping people

recover after surgery, or those

who have failed to recover

despite previous treatment.

Dr Spencer-Smith is ideally placed

to assess and direct treatment.

Many injuries can be successfully

managed through physical

rehabilitation and ultrasound

guided injections, but can also

swiftly coordinate surgical referral

and post-operative care.

Dr Catherine

Spencer-Smith

Physician in Sports

& Exercise Medicine

MBBS DRCOG MRCGP MSc Sport

& Exercise Medicine MFSEM(UK)

Private only

Secretaries: Christine Milton

and SueWinters

T: 020 7483 5372

F: 020 7900 2032

[email protected] www.sportdoclondon.co.uk