Athletic Groin Pain (Sports Hernia/Athletic Pubalgia)

Adductor-related groin pain (most common entity — ~63% of hip/groin injuries in elite football, Werner 2018, PMID 29691289)

Clinical features:

• Pain with adduction resistance (squeeze test positive)
• Pain on palpation of adductor tendons (especially longus)
• Pain with stretching adductors
• Pain with kicking or change of direction

Physical examination:

• Adductor squeeze test at 0, 45, 90 degrees hip flexion
• Palpation of adductor longus enthesis (tender)
• Strength testing (often weak compared to contralateral)
• Assess adductor:abductor strength ratio

Imaging:

• MRI: Adductor longus tendinopathy, partial tear, bone marrow oedema at enthesis
• Ultrasound: Dynamic assessment of adductor tendon

Inguinal-related groin pain (sports hernia)

Clinical features:

• Deep groin ache, worse with exertion
• No palpable hernia bulge
• Inguinal canal tenderness on examination
• May have "dilated superficial inguinal ring"

Physical examination:

• Palpation of inguinal canal (tender)
• Cough impulse assessment
• Resisted sit-up test (pain with rectus contraction)
• Check for true inguinal hernia (usually absent)

Imaging:

• MRI: Posterior inguinal wall deficiency, conjoint tendon injury
• Ultrasound dynamic: May show bulging during Valsalva

Pathology: The "sports hernia" is a weakness or disruption of the posterior inguinal wall (transversalis fascia, conjoint tendon) without a frank hernia sac. Creates imbalance between strong hip flexors/adductors and weak abdominal core.

Pubic-related groin pain (osteitis pubis)

Clinical features:

• Localized pubic symphysis pain
• Pain with running, kicking
• Point tenderness over pubic symphysis
• Bilateral in 50% of cases

Physical examination:

• Palpation of pubic symphysis (tender)
• Pain with single-leg stance
• Pain with resisted hip adduction
• May have waddling gait

Imaging:

• MRI (gold standard): Bone marrow oedema in pubic bodies, secondary cleft sign (parasymphyseal cyst), adductor insertional changes
• X-ray: Sclerosis, irregular pubic margins (late finding)
• Bone scan: Increased uptake (non-specific)

Secondary cleft sign: Fluid-filled cyst adjacent to pubic symphysis on MRI. Highly specific for chronic pubic stress. Represents extension of symphyseal pathology into adjacent bone.

Hip-related groin pain (FAI/labral)

Clinical features:

• Deep anterior groin pain
• C-sign (patient cups anterior hip with hand)
• Pain with hip flexion and internal rotation
• Catching or clicking sensation

Physical examination:

• FADIR test (flexion-adduction-internal rotation) - impingement
• FABER test (flexion-abduction-external rotation) - labral
• Hip internal rotation limited (compare to contralateral)
• Anterior hip tenderness

Imaging:

• Hip MRI with intra-articular contrast (MR arthrogram): Labral tear, chondral damage
• AP pelvis X-ray: Alpha angle (cam lesion), lateral center-edge angle (pincer), crossover sign
• Frog-leg lateral: Best view for alpha angle measurement

Alpha angle measurement:

• Normal: Less than 55 degrees
• Cam morphology: Greater than 55 degrees
• Measured on frog-leg lateral X-ray or radial MRI cuts

Adductor-Related Groin Pain Treatment

Goal: Restore adductor strength and endurance, normalize adductor:abductor ratio

Copenhagen Adductor Protocol (detailed):

Progressive exercises performed 3 times per week:

1. Isometric adductor squeeze (various angles)
2. Copenhagen adductor plank (side plank with leg support)
3. Eccentric adductor slide (standing slide-board)
4. Single-leg adductor stability
5. Sport-specific movements (kicking progressions)

Surgery if conservative fails:

If conservative management fails after 12 weeks, adductor tenotomy (release of adductor longus) can be considered. Reserved for chronic recalcitrant cases. Results are variable with 60-85% return to sport rates.

Inguinal-Related (Sports Hernia) Treatment

Goal: Strengthen core, repair posterior wall if deficient

Pubic-Related (Osteitis Pubis) Treatment

Goal: Reduce pubic stress, allow bone healing

Conservative management (almost always):

Surgery rarely indicated:

• Pubic symphysis curettage and fusion (historical)
• Poor outcomes, high morbidity
• Reserve for extreme chronic cases only

Hip-Related (FAI/Labral) Treatment

Goal: Address intra-articular pathology

Conservative trial:

• Hip-specific physiotherapy
• Avoid impinging positions
• Core and hip strengthening
• Activity modification

Surgery if conservative fails:

• Hip arthroscopy for FAI and labral repair
• Cam resection (osteochondroplasty)
• Pincer rim trimming
• Labral repair or debridement
• Capsular management

Return to sport after hip arthroscopy:

• 4-6 months typical
• Success rate 85-90% in athletes
• Addressing FAI often resolves "groin pain"

Minimal Repair Technique (Muschaweck)

Indications:

• Failed 12+ week conservative management
• Inguinal-related groin pain
• Posterior wall deficiency on imaging
• No true hernia present

Outcomes:

Return to sport typically 8-12 weeks. Success rate 85-95% with proper patient selection. Complications include infection, hematoma, and chronic pain (less than 5%).

Adductor Longus Tenotomy/Release

Indications:

• Chronic adductor-related pain
• Failed 12+ week Copenhagen protocol
• MRI shows chronic adductor pathology
• Last resort - controversial procedure

Postoperative:

• Protected weight-bearing 2 weeks
• Progressive rehabilitation 6-12 weeks
• Return to sport 3-4 months
• Success rate variable: 60-85%

Hip Arthroscopy for FAI/Labral Tear

Indications:

• Hip-related groin pain
• Failed conservative management
• FAI morphology (cam, pincer, or mixed)
• Labral tear on MRI
• No significant arthritis (Tonnis grade 0-1)

Key steps:

• Traction on fracture table or in lateral position
• Central compartment: labral repair, chondroplasty
• Peripheral compartment: cam resection (femoroplasty)
• Pincer rim trimming if indicated
• Capsular management (repair vs leave open)

Outcomes in athletes:

• Return to sport: 4-6 months
• Success rate: 85-90% in athletes
• Predictors of good outcome: Young age, minimal arthritis, isolated cam lesion

Postoperative Protocol After Sports Hernia Repair

Return to sport criteria:

Pain-free with all movements, core strength normalized, passed functional testing, and medical clearance obtained before full return to competition.

Postoperative Protocol After Adductor Tenotomy

Potential concerns:

Adductor weakness may persist in some athletes. Altered biomechanics and compensatory patterns are common. Requires ongoing strengthening and monitoring for recurrence.

Postoperative Protocol After Hip Arthroscopy

Key principles:

Capsular healing takes 6-8 weeks (avoid excessive motion during this period). Labral repair requires protection from impingement positions. Progressive loading is essential for cartilage healing and long-term success.