Chapter 32: Groin pain

INTRODUCTION

This chapter discusses both acute and longstanding groin injuries in athletes. It covers the anatomy where the complexity and degree of interconnections is highlighted. Epidemiology and risk factors have been updated using systematic reviews. The 2015 Doha agreement meeting on terminology and definitions in groin pain in athletes is included and the chapter follows the terminology agreed upon during this expert meeting. Clinical examination and assessment is covered including a practical guideline for systematic assessment of an injured athlete. There is a new section on imaging highlighting the lack of evidence in this area. Treatment with specific sections on adductor, iliopsoas, inguinal and pubic-related groin pain as well as acute groin injuries is covered with suggestions for rehabilitation.

ANATOMY

The word groin most likely originates from the ancient English word grynde which meant abyss or void. Confusion surrounding the groin region has made clinicians refer to this region as the ‘Bermuda triangle’ of the body.¹ In this section, we explain and simplify the complex anatomy of the groin. The groin region, where the abdomen meets the lower limbs via the pelvis, contains not only musculoskeletal structures, but also important internal organs and urogenital structures. In this section we focus on the musculoskeletal anatomy of the groin. The anatomy of the hip joint is described in Chapter 31.

We will focus on the pubic symphysis, hip adductors, hip flexors, abdominals and the inguinal region. An overview of the anatomy is depicted in Figure 32.1a.

Pubic symphysis

The pubic symphysis is a secondary cartilaginous joint connecting the two pubic rami. It is supported superiorly by ligaments and inferiorly by the superior pubic ligament and the inferior or arcuate pubic ligament respectively.² The joint is lined with hyaline cartilage. A fibrocartilaginous disc separates the two pubic bones. The pubic symphysis is the site of numerous musculotendinous attachments, which act to dynamically stabilise the anterior pelvis and the transference of large forces acting across this joint, especially during specific sporting activities such as kicking and cutting.

Hip adductors

The hip adductors include pectineus, gracilis and adductor longus, brevis and magnus. The adductors are the most commonly injured groin muscle in soccer^{3, 4} and the adductor longus is the most commonly injured adductor muscle.⁵ It ...