“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 .
Groin pain is frequently reported in those with hip pathology attending for arthroscopy, evidenced by 92 percent of patients with labral tears and 100% of AFL footballers with femoro-acetabular impingement (FAI) complaining of groin pain .
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 . 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 . The central groin region is reported as the most common site of pain referral in people with labral tears .
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  and hip  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 . 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.
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