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[ clinical commentary ]

KRISTIAN THORBORG, MSportsPhysio, PhD1   •  MICHAEL P. REIMAN, PT, DPT2 • ADAM WEIR, MBBS, PhD3,4
JOANNE L. KEMP, PT, PhD5 • ANDREAS SERNER, PhD4  •  ANDREA B. MOSLER, PT, MAppSc (Sports Physio)4 • PER HÖLMICH, MD, DMSci1

Clinical Examination, Diagnostic


Imaging, and Testing of Athletes
With Groin Pain: An Evidence-Based
Approach to Effective Management
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G
roin pain is common in athletes participating in has led to poor communication
multidirectional sports. It is especially prevalent in and research interpretation be-
the various football codes and in ice hockey, which tween clinicians. However, dur-
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ing the past decade, the field has


involve repetitive and forceful hip movements, such as
evolved and an evidence-based
those that occur during high-intensity kicking, skating, and understanding is now emerg-
direction change.22,62,104 Traditionally, groin pain has been considered ing.33,94 Numerous groups around the
difficult to understand, diagnose, and in understanding hip joint pathologies world are working together to create clear
manage.33 A lack of detailed scientific un- causing groin pain in athletes have made terminology, provide information on the
derstanding concerning the underlying pa- the clinical examination and classification diagnostic accuracy of relevant clinical
thology of pain originating from the pubic of groin pain more complex and compre- examination and imaging techniques, and
symphysis, adjacent bone, and many sur- hensive, sometimes resulting in an ambig- improve the assessment of impairment,
Journal of Orthopaedic & Sports Physical Therapy®

rounding musculotendinous attachments uous diagnostic work-up process.94 function, and performance to optimize
has caused controversies and disagree- Until recently, a lack of agreement re- management of athletes with groin pain.
ments concerning diagnoses and terminol- garding terminology, definitions, or clas- The aim of this paper was to synthe-
ogy.94 Furthermore, current improvements sification of groin pain in athletes85,94,105 size recent advances in the clinical exami-
nation, diagnostic imaging, and testing of
athletes with groin pain. Furthermore, we
UUSYNOPSIS: Groin pain is common in athletes has evolved rapidly, and an evidence-based under-
describe how information from reliable
who participate in multidirectional sports and has standing is now emerging. This clinical commen-
traditionally been considered a difficult problem
and valid clinical examination, diagnos-
tary discusses the clinical examination (subjective
to understand, diagnose, and manage. This may history, screening, physical examination); imaging;
tic imaging, and testing of impairment,
be due to sparse historical focus on this complex testing of impairments, function, and performance; function, and performance can guide
region in sports medicine. Until recently, there and management of athletes with groin pain in current evidence-based management of
has been little agreement regarding terminol- an evidence-based framework. J Orthop Sports athletes with groin pain.
ogy, definitions, and classification of groin pain The clinical framework suggested
Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018.
in athletes. This has made clear communication
doi:10.2519/jospt.2018.7850 in this commentary (FIGURE 1) is based
between clinicians difficult, and the results of
UUKEY WORDS: abdominals, adductors, athletes,
on consensus between experts31,105 and
research difficult to interpret and implement into
practice. However, during the past decade, the field groin, hip, pubic symphysis reliable and valid investigations where
available.9,36,58,83,86,92,98

1
Sports Orthopaedic Research Center-Copenhagen, Copenhagen University Hospital, Amager-Hvidovre, Denmark. 2Department of Orthopaedic Surgery, Duke University Medical
Center, Durham, NC. 3Department of Orthopaedics, Erasmus University Hospital Academic Centre for Groin Injuries, Rotterdam, the Netherlands. 4Sports Groin Pain Center,
Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar. 5La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, College of Science, Health and
Engineering, La Trobe University, Bundoora, Australia. Drs Thorborg, Weir, Serner, and Hölmich were part of the Doha agreement meeting and consensus process. Drs Thorborg,
Reiman, Weir, and Hölmich were part of the Warwick Agreement meeting and consensus process. The authors certify that they have no affiliations with or financial involvement
in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Kristian Thorborg,
Sports Orthopaedic Research Center-Copenhagen, Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark. E-mail: kristianthorborg@
hotmail.com t Copyright ©2018 Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 239


[ clinical commentary ]
CLINICAL EXAMINATION practice. Acute strains often occur at the rection.84 In comparison, acute rectus
musculotendinous junction, specifically femoris injuries primarily occur during
History of the adductor longus, rectus femoris, kicking and sprinting, whereas acute

G
roin pain is generally more and iliopsoas muscles.87,88 Acute adduc- iliacus and psoas major injuries mainly
common in male athletes,62,104 but tor longus and rectus femoris injuries occur with movement requiring change
some specific injuries, such as stress may also involve tendinous rupture/ of direction.88 Runners and dancers can
fractures in and around the pelvic ring, avulsion, primarily at the proximal inser- also present with groin pain, often due
are more common in female athletes.23 In tions (FIGURE 2).87,88 In contrast to strains, to overuse. Hip flexor injuries, hip joint
young, skeletally immature athletes, the groin overuse injuries more often involve pain, and stress fractures are the most
pelvic apophyses are vulnerable to injury.74 bone and tendons and their insertions, common injuries seen in these individ-
High-load activities, such as kicking and and rarely involve the rectus femoris.34 uals,8,43,47,66 and, like most other overuse
sprinting, may result in avulsion fractures, Acute adductor muscle injuries usually injuries, these are more often related to
with the anterior inferior and superior occur during kicking and change of di- repetitive and accumulated overload.
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iliac spines being the 2 most frequently


injured locations.72,81 Additionally, as the
pubic symphysis is the last part of the hu- Athlete history and
symptoms
man skeleton to mature, pubic apophysi-
tis should be considered in the differential
Refer Refer
diagnosis of hip and groin pain in athletes
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Groin pain
as they age into their early twenties.74 Ad-
Other Red flags
olescent athletes are also at increased risk
of hip-related problems if they have a pre-
vious history of slipped capital femoral Screen for lumbar Clinical differentiation
epiphysis,18 Legg-Calvé-Perthes disease,55 spine/sacroiliac joint
or acetabular dysplasia. Hip-related groin
pain is more likely to occur in mature ath-
letes starting in their early twenties,16,45 Adductor Pubic Inguinal Iliopsoas Hip
related related related related related
and hip joint osteoarthritis (OA) as a
Journal of Orthopaedic & Sports Physical Therapy®

cause of groin pain should also be consid-

Potential imaging
ered in older athletes.16 Ultrasonography/magnetic Ultrasonography Radiograph/
resonance imaging magnetic
resonance
Types of Sports and Injuries imaging
Due to the high number of athletes com-
peting in multidirectional sports, such
as football, many athletes with either Management
acute strains or overuse injuries related
FIGURE 1. Framework for the clinical examination of athletes with groin pain.
to the groin region are seen in clinical

Adductor Longus Rectus Femoris Iliopsoas


Proximal insertion Proximal injury near
of the direct tendon the insertion of the
Proximal insertion posterior-medial part
Proximal of the indirect tendon of the iliacus
insertion
MTJ of the anterior superficial
tendon aponeurosis of the Distal MTJ of the
MTJ of the posterior-medial
proximal tendon proximal direct tendon
part of the iliacus
MTJ of the intramuscular MTJ of the posterior superficial
MTJ of the part of the indirect tendon. tendon aponeurosis of the
distal tendon Potential tendinous distal tendon
disruption.
Distal MTJ
of the psoas
major
FIGURE 2. Typical anatomical locations of acute groin injuries in athletes. Images reproduced with permission from Serner et al.87,88 Abbreviation: MTJ, myotendinous junction.

240 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy


Screening for Serious Pathology cular necrosis, and epiphysiolysis of the meeting.84,86 These studies demonstrate
Causing Groin Pain femoral neck.6,30 that clinical examination is accurate in
Evidence supporting diagnostically accu- locating acute injuries to the adductors,
rate red flag signs and symptoms in the Physical Examination generally with an accuracy greater than
groin region is limited21 and inconsistent Once serious pathology has been ruled 90% for the various adductor tests.86 For
across current practice guidelines.48 Still, out, the clinician should screen for poten- acute hip flexor injuries, it can sometimes
clinicians must be aware of abdominal tial lumbar spine– and sacroiliac joint– be hard to distinguish between iliopsoas
and pelvic organ disorders mimicking related pathology using subjective history or proximal rectus femoris involvement
musculoskeletal-related groin pain.15 A and clinical examination tests that are based on clinical findings. The accuracy
history of cancer, such as prostate can- highly sensitive. A lack of peripheraliza- of the different hip flexor tests is not
cer in men, breast cancer in women, or tion or centralization (sensitivity, 92%; much better than flipping a coin.86 Im-
cancer in any reproductive organs, is a negative likelihood ratio = 0.12) of the portantly, absence of palpation pain in
potential red flag, as it is associated with athlete’s symptoms with repeated lumbar the adductors and hip flexors has the
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metastases in the hip and groin region.32 spine ROM testing and negative straight highest predictive value for ruling out
Other red flags of concern are history of leg raise (sensitivity, 97%; negative like- acute injury in these structures, with an
trauma, fever, unexplained weight loss, lihood ratio = 0.05) and slump testing accuracy greater than 90%.86
painful urination, night pain, and pro- (sensitivity, 83%; negative likelihood ratio Hip-related intra-articular pathology
longed corticosteroid use.29,51,100 = 0.32) assist with ruling out the poten- is a possible cause of groin pain in ath-
Serious pathology causing groin pain tial existence of discogenic/radiculopathy letes.31 Clinical tests work best as screen-
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

includes avascular necrosis, femoral neck pathology.19,101 Facet joint pathology is ing tests, with negative tests assisting in
fracture, or femoral shaft stress fracture. best ruled out with a negative extension- ruling out intra-articular hip pathology.
Information on screening for avascular rotation test (sensitivity, 100%; negative A positive test can only indicate the need
necrosis is limited, but it has been suggest- likelihood ratio = 0.00).50,82 Despite the for further investigation of the hip.67,68 To
ed that having normal hip range of motion controversial nature of sacroiliac joint pa- further elucidate actual intra-articular
(ROM) is helpful in ruling out this condi- thology testing, the thigh thrust test has injury, diagnostic imaging is necessary to
tion.42 The patella-pubic percussion test good clinical utility to rule out (sensitivity, corroborate the athlete’s symptoms and
(sensitivity, 95%; negative likelihood ratio 88%; negative likelihood ratio = 0.18) po- the clinical findings.69 This approach was
= 0.07) and fulcrum test (sensitivity, 88%; tential sacroiliac joint pathology.49 established by a panel of specialists and
Journal of Orthopaedic & Sports Physical Therapy®

negative likelihood ratio = 0.92) provide The Doha agreement regarding the formulated in the 2016 Warwick Agree-
good to limited clinical utility to help rule examination of athletes with groin pain ment on femoroacetabular impingement
out femoral neck fractures and femoral suggests classifying athletes according (FAI) syndrome. Femoroacetabular im-
shaft stress fractures, respectively.68 to certain clinical entities based on pain- pingement syndrome was defined as a
If there is suspicion of serious under- provocation tests.34,36,105 Tenderness with motion-related clinical hip disorder with
lying pathology, specific imaging should palpation is present in the defined clinical a triad of symptoms, clinical signs, and
always be performed. Plain radiographs entities of adductor-, pubic-, inguinal-, imaging findings.31 The primary symp-
are a good primary examination to detect and iliopsoas-related groin pain (TABLE). toms of FAI syndrome are motion- or
neoplasms in the skeleton. Even in seem- Tenderness with palpation denotes the position-related pain in the hip or groin
ingly healthy athletes, this should be con- presence of recognizable pain related to region,31 with potential clicking, catching,
sidered for unexplained or long-standing anatomical structures encompassed by locking, stiffness, restricted hip ROM, or
groin pain not improving with treatment. the specific entity (FIGURE 3).105 The same giving way (TABLE).
If a stress fracture is considered, radio- applies to resistance testing of the adduc- Therefore, current best evidence sup-
graphs are frequently negative, especially tors, where the pain must be felt in the ports a comprehensive examination (eg,
in the early stages, and therefore cannot adductor region to be classified as being subjective history, screening, physical
be used to rule out these injuries.17,47 Al- adductor-related groin pain.105 Good in- examination) of the entire groin region
ternatively, magnetic resonance imag- traobserver and interobserver agreement for athletes presenting with groin pain
ing (MRI), which visualizes bone stress for this approach (κ ≥0.70)36 has been (FIGURE 1).
reactions at an earlier stage, especially documented. New studies examining the
in high-risk sites, is therefore recom- accuracy of the clinical examination of IMAGING
mended.17,47 In the skeletally immature pain-provocation tests using palpation,

D
adolescent athlete, plain radiographs are stretch, and resistance testing in ath- oes imaging add to clinical deci-
used to detect osseous avulsions in mus- letes with acute groin injuries have been sion making beyond its potentially
culotendinous distraction injuries, avas- published since the Doha agreement important role in the detection/

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[ clinical commentary ]
ruling out of serious pathology? When Imaging for Pubic- and Adductor-Related bic bone marrow edema severity grading
serious pathology is not suspected, the Groin Pain is associated with a longer rehabilitation
guidelines from the Doha agreement clas- Abnormal imaging findings around the time has never been reported, but can-
sification system are useful.105 For athletes pubic symphysis are commonly reported not be discarded. Based on current evi-
with symptoms and clinical findings who in athletes with adductor- and pubic-re- dence of imaging findings in relation to
can readily be classified into 1 or more of lated groin pain.11 Many of these findings, the symphysis joint and the adjacent pu-
the 4 defined clinical entities (TABLE, FIGURE such as low-grade pubic bone marrow bic bone, clinicians need to consider age,
3), there is currently no available evidence edema, are also found in asymptomatic type of sport, loading, and the athlete’s
to suggest an improvement of diagnostic athletes.10 In football players with and presenting symptoms when interpreting
or prognostic indicators with imaging.11 without groin pain, only higher grades of these imaging findings. In adolescents,
Additionally, inappropriate and excessive pubic bone marrow edema and a protru- pubic- or adductor-related groin pain
use of imaging can be problematic, be- sion of the symphyseal joint disc were as- could be due to apophysitis.74 This is an
cause morphology alone does not equate sociated with pain.10 Pubic bone marrow important differential diagnostic consid-
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to pathology.10,26 The consequence of un- edema can be described as a bone stress eration, as the mainstay of treatment is
necessary imaging is that athletes may fo- reaction, as histologic analyses of bone bi- supervised load management. The best
cus on these normal morphological tissue opsies show no signs of inflammation.102 imaging modality to show the apophyses
changes, which may make them fearful of Therefore, the diagnostic term “osteitis is computed tomography, a modality not
movement and exercise and impede effec- pubis” is not recommended based on recommended for young athletes due to
tive treatment. current evidence. Whether a higher pu- the high dose of ionizing radiation. In-
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.


TABLE Classification System of Groin Pain in Athletes*

Nomenclature Symptoms Definition More Likely if Patient Presents With


Adductor-related groin pain† Pain around the insertion of the adductor longus Adductor tenderness and pain on resisted adduc- Pain on adductor stretching
tendon at the pubic bone. Pain may radiate tion testing
distally along the medial thigh
Journal of Orthopaedic & Sports Physical Therapy®

Iliopsoas-related groin pain† Pain in the anterior part of the proximal thigh, Iliopsoas tenderness (either suprainguinal or Pain reproduced with resisted hip flexion and/or
more laterally located than adductor-related infrainguinal) pain with hip flexor stretching
groin pain
Inguinal-related groin pain† Pain in the inguinal region that worsens with Pain in the inguinal canal and inguinal canal Pain reproduced with resisted abdominal muscle
activity. If pain is severe, often inguinal pain tenderness, or pain with Valsalva maneuver, testing
occurs when coughing or sneezing or sitting coughing, and/or sneezing. No palpable ingui-
up in bed nal hernia found, including on invagination of
the scrotum to palpate the inguinal canal
Pubic-related groin pain† Pain in the region of the symphysis joint and the Local tenderness of the pubic symphysis and the No particular resistance test, but more likely if
immediately adjacent bone immediately adjacent bone pain is reproduced by resisted abdominal and
hip adductor testing
Hip-related groin pain† Clinical suspicion that the hip joint is the source Mechanical symptoms present, such as catching,
of groin pain, either through history or clinical locking, clicking, or giving way
examination
FAI syndrome‡ Motion- or position-related pain in the hip or Motion-related clinical disorder of the hip with a Limited range of hip motion, typically restricted
groin. Pain may also be felt in the back, triad of symptoms, clinical signs, and imaging internal rotation, and evidence of labral and/or
buttock, or thigh. Patients may also describe findings. Cam and/or pincer morphology must chondral damage on imaging
clicking, catching, locking, stiffness, restricted be present on imaging
range of motion, or giving way
Other† Clinical suspicion if symptoms cannot be easily Any other orthopaedic, neurological, rheuma-
classified into any of the commonly defined tological, urological, gastrointestinal, derma-
clinical entities tological, oncological, or surgical condition
causing pain in the groin region
Abbreviation: FAI, femoroacetabular impingement.
*Adapted from Griffin et al31 and Weir et al.105

Doha agreement.

Warwick Agreement.

242 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy


stead, age, location of the pain at the ad- sonography. However, bulging alone has and/or pincer morphology is required for
ductor insertion on the pubic bone, and not been associated with groin pain, and the diagnosis of FAI syndrome.31 Initial
uncharacteristic worsening of pain with there is a high risk of false-positive find- diagnostic imaging should therefore in-
adductor exercises should make one con- ings due to the high prevalence of bulg- clude an anteroposterior radiograph of
sider this diagnosis. ing in asymptomatic athletes.63 Currently, the pelvis and a lateral femoral-neck view
Imaging may be considered to deter- there is no evidence on the validity or re- to examine bony hip morphology and
mine the initial severity of acute adductor producibility of these ultrasonography determine the presence of other possible
muscle strains. Avulsion injuries account imaging findings,11,63 and therefore ul- sources of hip-related groin pain.31
for a high proportion of injuries at the trasonography findings in athletes with In prospective studies, the presence
proximal adductor longus insertion,87 inguinal-related groin pain should be of acetabular dysplasia and the presence
and these injuries generally have a lon- interpreted with caution. of cam morphology are associated with
ger rehabilitation time than lower-grade an up to 5-fold2 and 10-fold1,61 increased
injuries.79,107 Therefore, if an avulsion is Imaging for Iliopsoas-Related Groin Pain risk of OA development, respectively, in
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suspected, ultrasonography or MRI can In athletes with groin pain, diagnosing middle-aged cohorts presenting with hip
be used for confirmation.84,86 In athletes iliopsoas-related groin pain can some- pain. Large cam morphology, defined as
with long-standing adductor-related times be difficult,84 as widespread pain an alpha angle greater than 78°, has been
groin pain, ultrasonography is often the can result in multiple positive clinical identified as the threshold best distin-
imaging modality of choice.35 examination tests.86 Magnetic resonance guishing hips that proceed to develop OA.3
imaging or ultrasonography may there- In contrast, it appears that the presence of
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Imaging for Inguinal-Related Groin Pain fore be helpful to improve accuracy in a pincer deformity may have a protective
In inguinal-related groin pain, ultraso- the initial diagnosis,7,59 although evidence effect against the development of OA.3,73
nography is also most often the imaging regarding the therapeutic or prognostic Whether these findings can be extrapolat-
of choice, used as part of the diagnostic relevance of such findings is currently ed to athletes younger than 40 years of age
process. One proposed etiology of in- lacking. is currently unknown. In older athletes,
guinal-related pain is that posterior ab- hip OA should always be considered and
dominal wall weakness leads to bulging Imaging for Hip-Related Groin Pain is clinically indicated by hip flexion of 115°
of abdominal structures that compresses In hip-related groin pain, there are several or less and hip internal rotation less than
the genital branch of the genitofemoral cases where imaging may assist in the di- 15°, and radiographically verified as joint
Journal of Orthopaedic & Sports Physical Therapy®

nerve.14 This weakness can sometimes agnosis.67,68,71 As previously mentioned, as- space narrowing or presence of femoral or
be visualized through dynamic ultra­ sessment of radiological measures of cam acetabular osteophytes.5
If further assessment of morphology,
cartilage, or labral injury is warranted,
then cross-sectional imaging is appro-
priate, preferably using 3.0-T MRI.3,31
In accordance with the Warwick Agree-
ment31 and other work,70 we also suggest
that imaging findings of intra-articular
pathology be matched with clinical ex-
amination findings and the athlete’s
symptoms before a specific diagnosis is
provided under the umbrella of hip-relat-
ed groin pain.
Based on the many false-positive find-
ings and the lack of understanding be-
tween the specific underlying pathology
and its specific manifestation on imaging,
utilizing imaging as the main guide for
treatment is not recommended. How-
ever, as previously mentioned, imaging
FIGURE 3. Palpation areas and defined clinical entities for groin pain in athletes according to the Doha agreement. has a role in detecting serious pathology,
Images reproduced with permission from Weir et al105 and from Brukner and Khan13 (Brukner & Khan’s Clinical and may in some cases also serve to give
Sports Medicine, 5th ed. ©2016 McGraw-Hill Education).
more credence to the diagnostic work-up

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 243


[ clinical commentary ]
process if it matches clinical signs and ments in athletes reported no significant pain46 and is important to target through
symptoms. differences in ROM between athletes with rehabilitation. Athletes with adductor-
FAI syndrome and healthy controls.28 The and pubic-related groin pain have also
IMPAIRMENT AND clinical value of including hip ROM still shown reduced hip abduction and ab-
FUNCTION TESTING remains uncertain. If clearly measurable dominal muscle strength.46,57
side-to-side differences or changes be- Objective measurements of hip

M
ost athletes with groin pain tween test and retest exist (greater than strength in all planes of motion are
are able to continue training for 5°),90 then this could potentially inform therefore important. When using hand-
several months prior to pain forc- individually targeted management strat- held dynamometry, results can either be
ing them to discontinue their sport.93 egies.31 However, it is important to un- interpreted based on published norma-
Continuing to train and play with groin derstand whether ROM restrictions are tive values for specific populations (types
pain can result in movement compen- caused by bony morphology or are the of athletes)58 or in comparison with the
sation strategies, resulting in decreased consequence of underlying chondral sta- unaffected limb in individuals with uni-
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function and performance.24,27,41,56,57,93 tus and/or protective muscle guarding. lateral presentations.58 When compar-
Therefore, in addition to the use of ing to the unaffected side, a lower-limb
pain-provocation tests,69,92 joint ROM, Hip Muscle Strength symmetry index can then be calculated
muscle strength, function, and perfor- Decreased hip muscle strength seems to by dividing the strength of the affected
mance must be systematically assessed be a consistent finding in athletes with limb by the unaffected limb. In addition,
(FIGURE 4)69 and the appropriate patient- groin pain.46,57 Hip muscle strength defi- ratios between agonist and antagonist
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

reported outcome measures must be cits have been demonstrated in athletes hip muscle groups have been reported
completed (FIGURE 5).69 with adductor- and pubic-related groin for athletes with and without groin pain,
pain,53,93 and in individuals with hip-re- providing additional reference criteria
Hip ROM lated groin pain, FAI syndrome, or after for measuring progress.58,93,97,99 Clinically,
There is conflicting evidence on whether having hip arthroscopy, often for several changes/differences in muscle strength
athletes with groin pain have impairments hip movement planes.20 In particular, greater than 15% to 20% can be reliably
in ROM compared to controls.46,57,90 A re- reduced hip adduction strength is com- measured across all movement directions
cent systematic review examining impair- monly reported in athletes with groin of the hip when using the same tester.96
Journal of Orthopaedic & Sports Physical Therapy®

100
90
80
HAGOS Profile

70
60
50
40
30
20
10
0
in

PA

L
om

AD

Qo
tio
Pa

ea
pt

cr
m

re
Sy

t/
or
Sp

Healthy
Hip related (FAI, 1 y postsurgery)
Adductor related
Hip related (FAI)
Hip related (dysplasia)

FIGURE 5. Patient-reported outcome measures used


in the evaluation of athletes and physically active
individuals with different hip and groin problems,
here exemplified by the HAGOS profile (mean values)
FIGURE 4. Physical testing of impairments, function, and performance. (A) Bent-knee fall-out for testing hip range from 3 scientific studies.40,60,75 Abbreviations: ADL,
of motion. (B) Adductor squeeze strength test for pain (0-to-10 numeric pain rating and traffic-light analogy) and activities of daily living; FAI, femoroacetabular
force using a handheld dynamometer. (C) Star Excursion Balance Test for testing balance and mobility. (D) Timed impingement; HAGOS, Copenhagen Hip and Groin
10-meter test for cutting performance (5-m sprint with 75° cut and 5-m sprint finish).20,52,54,57,92 This figure includes Outcome Score; PA, participation in physical activity;
images reproduced with permission from Thorborg et al.92 QoL, quality of life.

244 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy


Interestingly, deficits greater than 20% are reliable, valid, and responsive mea- treatments, such as manual adductor ma-
for adductors and abdominals have been sures for patients with hip and/or groin nipulation or shockwave therapy, in addi-
frequently documented in athletes with pain.98 Both of these measures have re- tion to exercises seems to result in a faster
adductor- and pubic-related pain.53,60,77,93 cently been translated and validated in return to play,80,106 but not higher overall
Adductor squeeze strength testing is a different languages and by different re- treatment success, than a supervised ac-
very precise clinical measure.52,53 In ath- search groups, and reference values have tive physical training program alone.39
letes with adductor- and pubic-related been provided in different subgroups.98 Around 50% to 75% of athletes with
pain, a numeric pain rating (0-10) can be The HAGOS has been translated into 14 adductor-related groin pain will return
obtained simultaneously,108 and the test is languages and is easily accessible and free to their previous pain-free level of activ-
a quick, valid indicator of hip- and groin- of charge (www.koos.nu). Standard and ity using a general exercise approach.39,106
specific sports function.92 repeated completion of the HAGOS and/ Monitoring of impairment, function, and
or the international Hip Outcome Tool performance can help individualize the
Function and Physical Performance can help evaluate progress and guide the plan of care. For athletes with adductor-
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The use of the single-leg stance, single- treatment plan. Clinically, changes of 10 and pubic-related groin pain, hip adduc-
leg squat, and the Star Excursion Bal- to 30 points can be measured at the indi- tor and abductor muscle strength, as well
ance Test for athletes with hip pathology vidual level, depending on specific patient as abdominal muscle strength, is impor-
is supported by a recent systematic re- population and the subscale used.91,95 tant to monitor for optimal loading in
view.20 However, functional and physical Such changes also exceed the minimal the rehabilitation program. In refractory
performance deficits have not been con- important change,91,95 and most athletes cases, level 2 evidence suggests that par-
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sistently reported in athletes unless clear with groin pain will seek treatment when tial surgical release of the adductor lon-
hip pathology or a history of hip surgery their HAGOS scores for sports-related gus tendon may be effective for returning
is present.109 In athletes without clear function and participation/performance athletes to preinjury level.78 Weakness of
hip pathology or a history of hip sur- are less than 50 points on a 100-point the adductors is a possible consequence
gery, decreased functional performance scale, where 100 points indicates perfect of adductor tenotomy,4 and tenotomy
has only been documented in labora- function.76,93 should therefore be avoided if possible.
tory settings, using 3-D motion analy- Athletes with adductor-related groin
sis, showing changes and differences in EVIDENCE-BASED pain and cam morphology on imaging
kinematics during movements requiring MANAGEMENT have a good long-term prognosis using an
Journal of Orthopaedic & Sports Physical Therapy®

changes of direction.24,27 Although these exercise-based rehabilitation program.38

A
results are intriguing, it is not yet clear t present, there is limited evi- Therefore, imaging findings of cam
how clinically applicable these kinematic dence based on clinical trials com- morphology appear less important in
measures are and how they relate to man- paring nonsurgical to surgical athletes with adductor-related groin pain
agement. Performance measures that in- interventions for groin pain in athletes, than in athletes with hip-related groin
clude actual cutting time, however, seem but a recent systematic review has indi- pain. The clinical difference between
promising, as cutting functionally relates cated that nonsurgical and surgical in- adductor-related and pubic-related pain
to pelvic lateral tilt range and lateral tho- terventions have similar return-to-play in the current literature seems mini-
rax rotation.54 In addition, cutting-time times.44 We therefore generally recom- mal.10,11,25,39,80,89,103,106 Therefore, pubic-re-
testing is reliable and possible in most mend nonsurgical management as the lated pain should be treated in a manner
clinical settings.54 More research is, how- first line of treatment for athletes with similar to adductor-related groin pain.
ever, needed prior to suggesting the wide- hip and groin pain. This less invasive op-
spread, standard clinical implementation tion will in many cases result in satisfac- Athletes With Inguinal-Related
of performance-related tests for athletes tory results. Groin Pain
with groin pain that is not hip related. For athletes with inguinal-related groin
Athletes With Adductor- and pain, laparoscopic hernia surgery has
Patient-Reported Outcome Measures Pubic-Related Groin Pain been shown to result in lower pain and a
Athletes with groin pain demonstrate For athletes with adductor-related groin higher percentage returning to play than
substantial reductions in self-reported pain, there is level 1 evidence that a su- nonsurgical treatment in a randomized
questionnaire scores on pain, physical pervised active approach to rehabilita- controlled trial.64 However, as nonsurgi-
function, participation/performance, and tion, including physical training, results cal treatment with exercises and injec-
quality of life.76,93 Both the Copenhagen in a higher success of return to play when tions showed some promise, with 50% of
Hip and Groin Outcome Score (HAGOS) compared to the use of passive physical participants fully recovered after 1 year
and the international Hip Outcome Tool therapy modalities.39 The use of adjunct in this randomized controlled trial,64 we

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 245


[ clinical commentary ]
advise a nonoperative approach first, testing using the evidence-based instru- org/10.1055/s-2008-1067934
given the risk of possible surgical com- ments provided in this clinical commen- 8. Bradshaw CJ, Bundy M, Falvey E. The diagnosis
plications. Again, monitoring hip adduc- tary are also recommended for these of longstanding groin pain: a prospective clinical
cohort study. Br J Sports Med. 2008;42:851-854.
tor, hip abductor, and abdominal muscle athletes.
https://doi.org/10.1136/bjsm.2007.039685
strength is relevant in relation to individ- 9. Branci S, Thorborg K, Bech BH, et al. The Co-
ual weaknesses in these patients.46 CONCLUSION penhagen Standardised MRI protocol to assess
the pubic symphysis and adductor regions of

T
athletes: outline and intratester and intertester
Athletes With Iliopsoas-Related his clinical commentary high-
reliability. Br J Sports Med. 2015;49:692-699.
Groin Pain lights an evidence-based examina- https://doi.org/10.1136/bjsports-2014-094239
There is no high-level evidence to support tion and management approach to 10. Branci S, Thorborg K, Bech BH, Boesen M,
or refute the use of exercise or other non- athletes with groin pain based on science Nielsen MB, Hölmich P. MRI findings in soccer
players with long-standing adductor-related groin
surgical treatments to address iliopsoas- and consensus among clinical experts
pain and asymptomatic controls. Br J Sports
related groin pain. We therefore propose around the world. Further improve-
Downloaded from www.jospt.org at on November 10, 2018. For personal use only. No other uses without permission.

Med. 2015;49:681-691. https://doi.org/10.1136/


to base treatment on impairments and ments are needed in relation to nonsur- bjsports-2014-093710
functional deficits. Because arthroscopic gical and surgical management—and the 11. Branci S, Thorborg K, Nielsen MB, Hölmich P. Ra-
diological findings in symphyseal and adductor-
iliopsoas release or tenotomy results in il- timing of these management approaches.
related groin pain in athletes: a critical review of
iopsoas atrophy with substantial volume Such progress is now easier due to better the literature. Br J Sports Med. 2013;47:611-619.
loss and reduced hip flexion strength,12 clinical differentiation and management https://doi.org/10.1136/bjsports-2012-091905
surgery is not recommended as first-line strategies being reported. t 12. Brandenburg JB, Kapron AL, Wylie JD, et
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

al. The functional and structural outcomes


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