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APPROACH TO THE DIAGNOSIS OF
GROIN PAINAlexandra Myers, D.O., M.S.H.S.
February 22, 2018OPSC Annual Convention
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OVERVIEW� Review the entities that may contribute to
groin pain� Discuss the approach to making an accurate
diagnosis when a patient has groin pain� Discuss modalities that are useful in diagnosis
of groin pain� Discuss treatments for groin pain
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OBJECTIVES� By the end of the lecture, the learner will be
able to do the following for a patient with groin pain:� Perform a thorough physical exam� Develop a differential diagnosis�Order imaging modalities helpful in diagnosis� Direct a treatment plan
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GROIN INJURY� Paucity of literature regarding incidence of
groin injury� Non-specific or multi-factorial diagnosis� Limited data available for review
•
10-18 groin injuries per 100 soccer players/year•
Anywhere from 9-57% of hockey players will suffer a groin strain during their career
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GROIN – WHAT DOES THAT MEAN?� The groin is a very general term that is often
misused� It encompasses the following:� The hip joint�Musculature including: adductors, hip/lumbar
flexors, knee extensors, abdominal wall�GU and GI organs� Bony pelvis� Nerves originating from the lumbar spine
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HOW TO APPROACH DIAGNOSIS� Take a thorough history�MOI
•
Was there an incident? Or gradual onset?
� Aggravating factors•
Cutting? Kicking?
� Associated symptoms� Exercise history
•
Sport(s)•
Hours/week
� Previous back/LE injuries
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HOW TO APPROACH DIAGNOSIS� Do a thorough exam�Gait analysis� Palpate the L spine, bony pelvis, lower abdomen,
musculature – be very specific� PROM/AROM L spine and ipsilateral hip, SI jt� Test for muscle strength in multiple planes
•
Try to isolate the muscle(s) that you think are contributing to the pain
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APPROACH TO DIAGNOSIS� Special Testing� FABERE’s� Thomas� Trendelenburg� Stork�Ober’s
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HOW TO APPROACH DIAGNOSIS� Keep an open mind� Know that your “working diagnosis” may be
superficial � There may be multiple diagnoses and several
modalities of treatment may need to be employed
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IMAGING� X-ray� Acute injuries�Obvious deformity
� Ultrasound� Prolonged pain� Useful in delineating exact location of pain
� CT� Trauma
� MRI� Prolonged pain�Hip joint evaluation
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DIAGNOSESSoft Tissue Bony
Pelvis/FemurIntra-articular Neuropathic
Muscle strain Avulsion fracture
Labral tear Iliohypogastric
Tendonitis/osis Apophysitis FAI Ilioinguinal
Bursitis Stress fracture OA Genitofemoral
Inguinal disruption (prev called sports hernia)
Fracture Hip dysplasia Inguinodynia
Osteitis pubis AVN CRPS
“Groin pain in athlete”
LCP Post-surgical
SCFE
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DIAGNOSISInfectious Gastrointestinal Genitourinary
Synovitis Femoral or inguinal (direct/indirect) hernia
Testicular pathology
Septic Arthritis Diverticulitis/osos Ovarian pathology
Discitis Appendicitis Varicocele
Osteomyelitis IBS/IBD UTI
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SOFT TISSUE� Muscle strain� acute
� Tendonitis/osis� chronic
� Bursitis� Chronic, positional
� Inguinal disruption (prev sports hernia)� Diagnosis of exclusion
� Osteitis pubis� Snapping hip
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SOFT TISSUE� Treatment� Relative rest� NSAIDs� Physical Therapy� Acupuncture�OMT� US guided injections
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BONY PELVIS AND FEMUR� Avulsion fracture� Pediatric, acute
� Apophysitis� Pediatric, acute vs chronic
� Hip pointer� Acute trauma
� Stress fracture� overuse� Eating disorders
� Fracture � Trauma, acute severe pain
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AVULSION FRACTURE AND APOPHYSITIS� Sartorius from the ASIS� Adductor magnus from ischial tuberosity� Gracilis and adductor brevis from pubic
ramus� Rectus femoris from AIIS� Transversus abdominus, QL from the iliac
crest� Iliopsoas from the LT
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AVULSION FRACTURE AND APOPHYSITIS� Treatment� Rest� Non-weight bearing for fractures (short term)� Progressive PT
� Indications for surgery (fractures)� Non-specific guidelines� Consider if there is significant displacement of
the avulsed fragment
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HIP POINTER� Treatment� Relative rest� NSAIDs� Ice� PT
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STRESS FRACTURE� Treatment� Evaluate underlying cause
•
Overuse•
Change in training habits
� Look for eating disorders and/or vitamin deficiencies
� Consider the biomechanical factors leading to the stress fracture
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FRACTURE� Treatment� Referral to orthopedics� Remember to identify “distracting” injuries
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INTRA-ARTICULAR� Labral tear� Chronic, certain sports
� FAI�Gradual onset
� OA� 40 + and those with CHD
� Hip dysplasia� AVN� Suspect in those who have no trauma or overuse
� LCP and SCFE� Pediatric, overweight, usually not athletic
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LABRAL TEAR� Treatment� PT� Intra-articular injection� Relative rest� If fails consider surgery
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FAI� Treatment� PT� Intra-articular injection? � Relative rest� If fails consider surgery
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OA� Treatment� PT� Activity modification� NSAIDs vs Tylenol� Intra-articular injection� If fails consider surgery
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HIP DYSPLASIA� Treatment� Activity modification� PT� Intra-articular injection?� Refer to orthopedics to discuss possible surgical
interventions
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AVN� Treatment� No actual treatment for the disorder�Mediate the symptoms
•
PT•
NSAIDs•
Activity modification•
Likely will need THA
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LCP AND SCFE� Treatment� Refer to orthopedics� Remember to check the contralateral hip� Examine/screen the rest of the family
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NEUROPATHIC� Iliohypogastric� Ilioinguinal� Genitofemoral� All 3 originate from the L spine and traverse the
groin
� Inguinodynia� CRPS� Usually with long history of pelvic/groin pain,
diagnosis of exclusion
� Post-surgical�Hip, abdominal, groin
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NEUROPATHIC PAIN� Treatment� Steroids� US guided injection� Consider general surgery referral
� CRPS� Rule out contributing factors
� Post-surgical� Steroids� Injection�General surgery referral
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INFECTIOUS� Synovitis� Pediatric, associated viral syndrome
� Septic Arthritis� Any age� Post-procedural
� Discitis� Rare, difficult to diagnose
� Osteomyelitis� Very similar to septic arthritis
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INFECTIOUS� Diagnosis and Treatment� Labs (CBC, ESR, CRP, synovial fluid analysis)� Imaging� Re-examine frequently� Consider hospitalization
� Due to the potential morbidity associated with these entities be quick to order labs and hospitalize for IV antibiotics
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GASTROINTESTINAL� Femoral or inguinal (direct/indirect) hernia� Common in those who do heavy lifting (laborers,
Olympic weight lifters)
� Diverticulitis/osis� Fever, diarrhea, hematochezia
� Appendicitis� Fever, N/V/D
� IBS/IBD� Chronic, intermittent
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HERNIA� Diagnosis� Advanced imaging – MRI vs CT vs US
� Treatment� Referral to general surgery
� Exercise restrictions� Athlete specific
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GENITOURINARY� Testicular pathology� Thorough history and exam
� Ovarian pathology� Same
� Varicocele� Common
� UTI� Common
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GROIN PAIN IN ATHLETE� “Athletic pubalgia” or “Inguinal Disruption”
or “Sports Hernia” (terms discouraged)� No actual hernia� Abnormal tension in the groin, around the
inguinal ligament attachment� May have disruption of the external oblique,
edema of surrounding tissues� Posterior inguinal wall weakness (tranversalis
fascia and parietal peritoneum)
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GROIN PAIN IN ATHLETE� Rectus abdominus, conjoint tendon, and
external oblique merge to form the pubic aponeurosis
� Pubic aponeurosis is confluent with adductor and gracilis origin
� Conjoint tendon = fusion of internal oblique + transversus abdominus
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GROIN PAIN IN ATHLETE� Diagnosis of exclusion� Likely has failed PT, relative rest, activity
modification� Imaging may show edema of the pubis,
partial or full thickness tears of the rectus abdominus, tendonitis/osis of the inserting structure
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GROIN PAIN IN ATHLETE� DOHA agreement: separation of groin pain
into categories� Adductor-related groin pain� Iliopsoas-related groin pain� Inguinal-related groin pain� Pubic-related groin pain�Hip-related groin pain� “Other causes of groin pain in athletes”
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GROIN PAIN IN ATHLETE� Adductor-related groin pain� Adductor tenderness AND� Pain on resisted adductor testing
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GROIN PAIN IN ATHLETE� Iliopsoas-related groin pain� Pain on resisted hip flexion AND/OR� Pain on stretching the hip flexors
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GROIN PAIN IN ATHLETE� Inguinal-related groin pain� Pain location in the inguinal canal AND� Tenderness of the inguinal canal� Absence of inguinal hernia
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GROIN PAIN IN ATHLETE� Pubic-related groin pain� Local tenderness of the pubic symphysis and the
adjacent bone� No special testing
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GROIN PAIN IN ATHLETE� Hip-related groin pain� FAI vs labral tear, etc.� Encompasses all hip causes of groin pain
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GROIN PAIN IN ATHLETE� Other causes of groin pain� All of the medical causes of pain in the groin not
previously described
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GROIN PAIN IN ATHLETE
� Treatment� PT�OMT� Acupuncture� Localized US guided injection (diagnostic vs
therapeutic)� Referral to general surgery� Surgical repair varies widely: laparoscopic vs
open, mesh vs no mesh. �Most studies claim a high return to sport rate
after surgery