Groin pain is commonly seen in active athletes who participate in sports like soccer, rugby, fast bowling, hockey, and running (1). The pathologies responsible for groin pain may include but are not limited to adductor muscle tendinitis, osteitis pubis, FAI (Femoroacetabular impingement), and marrow edema. These may be present individually or in a combination (2, 3).

PROGNOSIS

The prognosis depends upon the setting in which we see the patients. Some patients may get screened by family physicians and go to an orthopedic surgeon, while others you may see in the field with acute groin pain.

DIAGNOSIS OF ATHLETIC GROIN PAIN

Soft tissue injuries (Acute groin pain)

A study of 110 male athletes with sports-related acute groin pain showed that the most common cause was adductor-related injuries. Other causes included iliopsoas and rectus femoris injuries. Most of the injuries showed no signs on imaging, but clinically diagnosed adductor injuries were confirmed on imaging (4).

Intra-articular injuries (chronic groin pain)

A study with 499 patients with chronic groin pain presented to two orthopedic surgeons concluded that femoroacetabular impingement was the most prevalent cause of chronic groin pain (5).

Risk factors for athletic groin pain (6-8)

•    The presence of a positive adductor squeeze test
•    Reduced ROM in hip internal and external rotation
•    Reduced ROM in bent knee fallout test
•    Previous groin injury
•    Reduced hip adductor strength
•    Lower level of sport-specific training

Process of diagnosing Athletic Groin pain

Reproduced from TrustMe-Ed lecture

DIAGNOSIS OF FEMOROACETABULAR IMPINGEMENT

Reproduced from TrustMe-Ed lecture

According to the Doha agreement meeting on terminology and definitions of groin pain in athletes, a triad of symptoms, signs, and radiological features is used to diagnose femoroacetabular impingement (9).

•    Symptoms of hip pain, clicking, catching, stiffness, or giving way
•    Clinical signs consistent with FAI syndrome (e.g., restricted ROM or positive impingement test)
•    Radiological findings of Cam or Pincer morphology on plain radiographs

This triad can be supplemented by 
•    Diagnostic hip injection to confirm hip as a source of pain
•    Additional cross-sectional imaging when indicated (e.g., CT/ MRI)

Subjective examination

A common presentation of patients with Femoroacetabular impingement syndrome.
Most of the patients with femoroacetabular syndrome present with (10):
•    Symptomatic hip pain
•    Actively or movement-related pain
•    Mechanical hip symptoms
•    Moderate/ severe groin pain
•    Combination of above

Duration of femoroacetabular impingement (FAI) syndrome symptoms

A study by Reiman et al. concluded that the mean duration of symptoms in patients with FAI was 27.7 ± 21.5 months, and the minimum duration of symptoms was 4.1 ± 2.8 months (11).

Clinical examination

The clinical signs may include (10):
•    Limited flexion and internal rotation of the hip
•    Limited internal rotation
•    Non-specific
Non-specific means vague pain around the hip or groin region with or without other signs of FAI, including clicking, catching, or giving way.

Special Tests

FADIR Test
FADIR test is flexion to 90ᵒ, adduction and internal rotation. FADIR test can impinge soft tissue structures in the hip region, causing pain. A positive test suggests a potential issue at the hip joint, while a negative test indicates that the hip joint might not be the cause of groin pain (12).

Squat Test
The test starts with the patient in a standing position and is instructed to squat as far as they can. The positive finding is the reproduction of the patient’s symptoms. The test only has a 6.1% incremental diagnostic ability, so its utility is limited in FAI diagnosis (13).

Radiological Examination

AP pelvis and Frog lateral view radiographs are more suggestive. MRI or MRA can further help in the diagnosis. Imaging studies have more diagnostic accuracy than subjective or clinical examinations (14). Intra-articular injection can be helpful in the diagnosis of FAI. A negative response to intra-articular injection tends to rule out and screen intra-articular pathology (14).

Contextual factors as predictors of hip pain and function in Femoroacetabular impingement syndrome.

Patient factors, including mental health, sex, age, and smoking predict pain levels more accurately than intra-articular findings (15).

SCREENING IN ATHLETIC GROIN PAIN

Screening may help diagnose athletic groin pain. A study suggests Cam morphology and limited hip ROM can cause early osteoarthritis in adolescent athletes (16). Research shows that males tend to have Cam impingement owing to a large femoral head, while females tend to have impingement on the acetabular side, called pincer impingement (17).

Limited hip ROM, in general, and hip internal rotation, in particular, are significant for screening athletes with femoroacetabular impingement syndrome in addition to special clinical tests (18).

A study by Frank JM et al. comprising asymptomatic athletes and the general population found that athletes had more hip Cam morphology on radiographs than the general population, while Pincer morphology and labral injury were more common in the general population than athletes (19).

False positives

The incidence of false positives based on FADIR’s test is significant. A study comprising youth ice hockey players performed FADIR’s test on asymptomatic athletes. They sent all the players with positive or negative FADIR tests for imaging to see for Cam or Pincer morphology. The results showed that the FADIR test was more falsely positive than truly positive. Most participants with a positive FADIR test had no imaging correlation with Cam or Pincer morphology (20).

SUGGESTIONS FOR HIP EXAMINATION FOR FEMOROACETABULAR IMPINGEMENT

Hip Examination Suggestions

Consider the environment

Consider your working environment. While dealing with acute groin pain, look for adductor, iliopsoas, inguinal, or pubic-related pathologies (21).

Listen to your athlete

Listening to the athlete is important. It can provide essential information regarding the injury, like how they got hurt, felt a pop or had other mechanical symptoms related to the pathology. Mechanical symptoms may suggest intra-articular pathology, like labral tear or osteoarthritis.

Consider the discrepancy between clinical and radiological examination

There can be discrepancies between the clinical and radiological examinations. Some studies suggest a correlation between the limited hip internal rotation and the Cam morphology, while others suggest the opposite. So, these discrepancies should be considered when examining athletes with groin pain.

Comprehensive assessment

Do a comprehensive assessment utilizing the Doha and Warwick agreements (9, 22). Also, consider contextual factors while assessing the patients with groin pain.

EPIC Rehabilitation

Education and Calming
Educate the patient regarding their condition and avoid pain-provoking movements.

Progressive Building
Gradually progress the movements and activities. If the patient experiences pain in low bar back squat, we might suggest high bar back squat or front squat and progress further when these become pain-free.

Individualized
Rehabilitation should be athlete-centered. Goals, biomechanics, strength, and endurance vary from athlete to athlete, so individualized rehabilitation is key to a good prognosis.

Considerations
Consider the patient’s goals and priorities. Whether the patient wants to return to sports, be pain-free, or perform recreational activities. It will significantly improve rehabilitation, prognosis, and patient confidence.

REFERENCES
1.    Cavalli M, Bombini G, Campanelli G. Pubic inguinal pain syndrome: the so-called sports hernia. Surg Technol Int. 2014;24:189-94.
2.    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(3):213-20.
3.    Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery. 2011;150(1):99-107.
4.    Serner A, Tol JL, Jomaah N, Weir A, Whiteley R, Thorborg K, et al. Diagnosis of Acute Groin Injuries: A Prospective Study of 110 Athletes. Am J Sports Med. 2015;43(8):1857-64.
5.    Larson CM, Safran MR, Brcka DA, Vaughn ZD, Giveans MR, Stone RM. Predictors of Clinically Suspected Intra-articular Hip Symptoms and Prevalence of Hip Pathomorphologies Presenting to Sports Medicine and Hip Preservation Orthopaedic Surgeons. Arthroscopy. 2018;34(3):825-31.
6.    Mosler AB, Agricola R, Weir A, Hölmich P, Crossley KM. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis. British Journal of Sports Medicine. 2015;49(12):810.
7.    Tak I, Engelaar L, Gouttebarge V, Barendrecht M, Van den Heuvel S, Kerkhoffs G, et al. Is lower hip range of motion a risk factor for groin pain in athletes? A systematic review with clinical applications. Br J Sports Med. 2017;51(22):1611-21.
8.    Whittaker J, Small C, Maffey L, Emery C. Risk factors for groin injury in sport: An updated systematic review. British Journal of Sports Medicine. 2015;49.
9.    Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49(12):768-74.
10.    Peters S, Laing A, Emerson C, Mutchler K, Joyce T, Thorborg K, et al. Surgical criteria for femoroacetabular impingement syndrome: a scoping review. Br J Sports Med. 2017;51(22):1605-10.
11.    Reiman MP, Peters S, Sylvain J, Hagymasi S, Ayeni OR. Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review. Arthroscopy. 2018;34(4):1319-28.e9.
12.    Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2015;49(12):811.
13.    Ayeni O, Chu R, Hetaimish B, Nur L, Simunovic N, Farrokhyar F, et al. A painful squat test provides limited diagnostic utility in CAM-type femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):806-11.
14.    Reiman MP, Thorborg K, Goode AP, Cook CE, Weir A, Hölmich P. Diagnostic Accuracy of Imaging Modalities and Injection Techniques for the Diagnosis of Femoroacetabular Impingement/Labral Tear: A Systematic Review With Meta-analysis. Am J Sports Med. 2017;45(11):2665-77.
15.    Westermann RW, Lynch TS, Jones MH, Spindler KP, Messner W, Strnad G, et al. Predictors of Hip Pain and Function in Femoroacetabular Impingement: A Prospective Cohort Analysis. Orthop J Sports Med. 2017;5(9):2325967117726521.
16.    Wyles CC, Norambuena GA, Howe BM, Larson DR, Levy BA, Yuan BJ, et al. Cam Deformities and Limited Hip Range of Motion Are Associated With Early Osteoarthritic Changes in Adolescent Athletes: A Prospective Matched Cohort Study. Am J Sports Med. 2017;45(13):3036-43.
17.    Levy DM, Hellman MD, Harris JD, Haughom B, Frank RM, Nho SJ. Prevalence of Cam Morphology in Females with Femoroacetabular Impingement. Front Surg. 2015;2:61.
18.    Pålsson A, Kostogiannis I, Ageberg E. Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome. Knee Surg Sports Traumatol Arthrosc. 2020;28(10):3382-92.
19.    Frank JM, Harris JD, Erickson BJ, Slikker W, 3rd, Bush-Joseph CA, Salata MJ, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy. 2015;31(6):1199-204.
20.    Casartelli NC, Brunner R, Maffiuletti NA, Bizzini M, Leunig M, Pfirrmann CW, et al. The FADIR test accuracy for screening cam and pincer morphology in youth ice hockey players. J Sci Med Sport. 2018;21(2):134-8.
21.    Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, et al. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. J Orthop Sports Phys Ther. 2018;48(4):239-49.
22.    Griffin DR, Dickenson EJ, O'Donnell J, Agricola R, Awan T, Beck M, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. 2016;50(19):1169-76.