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How does hip pathology relate to groin pain? ~ by Joanne Kemp, M.Sports Physio, PhD Candidate

“I’ve had groin issues in the past and came back a couple of times too early so instead of missing two weeks you end up missing a month. It’s important to take your time and make sure you’re over 100 per cent ready. And I think for me it has something to do with my hips being tight. When your hips are tight, then the groin has a tendency to overcompensate and that’s why you see all the hip surgeries in goalies, it’s all related.” ~ NHL goalie Jean-Sebastien Giguere appreciating the link between groin pain and hip problems (December 2010, www.theglobeandmail.com).

The hip joint has been recognized as one cause of hip and groin pain in the athletic population. Hip and groin pain is the third most commonly reported injury in the Australian Football League and is often seen in many other sports, including, tennis, ice hockey, and other football codes [1].

Groin pain is frequently reported in those with hip pathology attending for arthroscopy, evidenced by 92 percent of patients with labral tears[2] and 100% of AFL footballers with femoro-acetabular impingement (FAI) complaining of groin pain [3].

Hip pain commonly co-exists with other groin related pathology, including pubic and adductor symptoms, which can make definitive diagnosis and appropriate management difficult and often multi factorial [4]. Recent studies have found that almost all athletes with adductor related groin pain have radiological signs of FAI [5, 6].

In addition, Bradshaw et al determined that over half of all patients with longstanding groin pain demonstrated hip pathology as the primary source of pain on physical and diagnostic examination [4]. The central groin region is reported as the most common site of pain referral in people with labral tears [7].

Photo by gilmorec. Used with permission. All rights reserved. Source: www.flickr.com

Photo by gilmorec. Used with permission. All rights reserved. Source: www.flickr.com

Whilst FAI itself is not considered to be hip pathology, it may increase the risk of intra-articular hip pathology, including labral tears and articular cartilage injury [8-16], and contribute to the development of groin pain [17, 18].

When the hip joint with FAI is placed into a position of impingement, usually flexion, adduction and internal rotation, in a repetitive fashion during sport, micro-trauma may occur in the hip. This may include damage to the labrum and the acetabular articular cartilage, particularly in the anterior and superior aspect of the joint, leading to tissue breakdown and ultimately hip and groin pain.

There is recent evidence suggesting that the biomechanics of the hip and pelvis are altered in people with FAI, which may partially explain the association between FAI and groin pain. Recent studies have demonstrated reduced pelvic [19] and hip [20] movement in people with FAI.

In addition, a cadaveric study reported that rotational motion at the pubic symphysis is greater in hips with cam impingement, leading to increased opening of the anterior aspect of the pubic symphysis [21].  Combined, these findings may indicate that an increased load through the anterior aspect of the pelvis may be present in those with FAI, with potential to contribute to the development of groin pain.

Groin pain can certainly exist without hip symptoms or pathology; however, the hip joint is often implicated in athletes with groin pain. A comprehensive physical and radiographic examination of the hip joint may be useful when assessing athletes presenting with groin pain. If positive findings are evident, rehabilitation of the athlete with groin pain should include appropriate measures to manage the hip joint.

For more information about hip and groin related pain turn to Chapters 28 and 29 in Clinical Sports Medicine.

Jo Kemp is an APA-titled Sports Physiotherapist and Principal Physiotherapist at Bodysystem Physio in Hobart, Tasmania, Australia. She is presently completing her PhD at the University of Queensland examining Outcomes and Impairments Following Hip Arthroscopy.

References:

1.            Orchard, J. and H. Seward. 2008 AFL Injury Report. 2009; Available from: http://www.afl.com.au/injury%20report/tabid/13706/default.aspx.

2.            Burnett, R.S.J., et al., Clinical presentation of patients with tears of the acetabular labrum. Journal of Bone and Joint Surgery – Series A, 2006. 88(7): p. 1448-1457.

3.            Singh, P.J. and J.M. O’Donnell, The Outcome of Hip Arthroscopy in Australian Football League Players: A Review of 27 Hips. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2010. 26(6): p. 743-749.

4.            Bradshaw, C.J., M. Bundy, and E. Falvey, The diagnosis of longstanding groin pain: A prospective clinical cohort study. British Journal of Sports Medicine, 2008. 42(10): p. 551-554.

5.            Weir, A.d.V., RJ. Moen M et al, Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain. Br J Sports Med, 2010. article in press: p. 1-4.

6.            Nepple, J.J., et al., Radiographic findings of femoroacetabular impingement in National Football League Combine athletes undergoing radiographs for previous hip or groin pain. Arthroscopy, 2012. 28(10): p. 1396-403.

7.            Arnold, D.R., et al., Hip pain referral patterns in patients with labral tears: analysis based on intra-articular anesthetic injections, hip arthroscopy, and a new pain “circle” diagram. Phys Sportsmed, 2011. 39(1): p. 29-35.

8.            Beck, M., et al., Hip morphology influences the pattern of damage to the acetabular cartilage. Femoroacetabular impingement as a cause of early osteoarthritis of the hip. Journal of Bone and Joint Surgery – Series B, 2005. 87(7): p. 1012-1018.

9.            Domayer, S.E., et al., Radial dGEMRIC in developmental dysplasia of the hip and in femoroacetabular impingement: preliminary results. Osteoarthritis and Cartilage, 2010.

10.          Hapa, O., et al., Axial plane coverage and torsion measurements in primary osteoarthritis of the hip with good frontal plane coverage and spherical femoral head. Archives of Orthopaedic and Trauma Surgery, 2010: p. 1-6.

11.          Ito, K., et al., Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. Journal of Bone and Joint Surgery – Series B, 2001. 83(2): p. 171-176.

12.          McCarthy, J., et al., The role of hip arthroscopy in the elite athlete. Clin Orthop Relat Res, 2003(406): p. 71-4.

13.          Philippon, M.J., et al., Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. American Journal of Sports Medicine, 2010. 38(1): p. 99-104.

14.          Tanzer, M. and N. Noiseux, Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res, 2004(429): p. 170-7.

15.          Pollard, T.C.B., et al., Localized Cartilage Assessment with Three-Dimensional dGEMRIC in Asymptomatic Hips with Normal Morphology and Cam Deformity. The Journal of Bone & Joint Surgery, 2010. 92(15): p. 2557-2569.

16.          Nicholls, A.S., et al., The Association Between Hip Morphology Parameters and Nineteen-Year Risk of End-Stage Osteoarthritis of the Hip A Nested Case-Control Study. Arthritis and Rheumatism, 2011. 63(11): p. 3392-3400.

17.          Ganz, R., et al., Femoroacetabular Impingement: A Cause for Osteoarthritis of the Hip. Clinical Orthopaedics and Related Research, 2003(417): p. 112-120.

18.          Parvizi, J., et al., Arthroscopy for labral tears in patients with developmental dysplasia of the hip: a cautionary note. J Arthroplasty, 2009. 24(6 Suppl): p. 110-3.

19.          Lamontagne, M., M.J. Kennedy, and P.E. Beaulé, The Effect of cam FAI on Hip and Pelvic motion during maximum squat. Clinical Orthopaedics and Related Research, 2009. 467(3): p. 645-650.

20.          Brisson, N., et al., The effects of cam femoroacetabular impingement corrective surgery on lower-extremity gait biomechanics. Gait & Posture, 2012. 37: p. 258-263.

21.          Birmingham, P.M., et al., The Effect of Dynamic Femoroacetabular Impingement on Pubic Symphysis Motion. The American Journal of Sports Medicine, 2012. 40(5): p. 1113-1118.

 

 

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