Hip and groin pain in the professional athlete

Hip and groin pain is a common condition in professional athletes and may result from an acute injury or from chronic, repetitive trauma. It is responsible for significant morbidity, which leads to time away from training and competition, and may result in a career-ending injury. The anatomic and biomechanical causes for hip and groin injuries are among the most complex and controversial in the musculoskeletal system. This makes clinical differentiation and subsequent management difficult because of the considerable overlap of symptoms and signs. This review article will evaluate several pathologic conditions of the hip and groin in athletes, divided into acute (secondary to single event) and chronic (secondary to altered biomechanical load or repetitive microtrauma) injuries, with an emphasis on imaging in the diagnosis of these injuries. Appropriate use of imaging along with clinical findings can allow accurate diagnosis and subsequent appropriate management of these patients to ultimately allow return to athletic activity.     

Hip arthroscopy in athletes.

The limited data (n = 42) and diverse pathology within this study make statistical analysis difficult, although the observations are still meaningful. Diagnostic arthroscopy has defined elusive causes of disabling hip pain in an athletic population including occult labral and chondral damage and rupture of the ligamentum teres. Operative arthroscopy has been effective in reducing the symptoms associated with many of these forms of pathology. For more evident causes of hip pain, such as loose bodies or impinging osteophytes, arthroscopy offers an excellent alternative to traditional open techniques. This study has defined that many intraarticular disorders initially may go unrecognized. The benefit of earlier diagnosis seems intuitive and may minimize extraneous investigative studies, but there are a few caveats. First, various forms of extraarticular pathology (e.g., muscle strains) far outnumber intraarticular injuries and thus the temptation for an extensive intraarticular work up for every hip injury should be avoided. Second, as mentioned, does earlier diagnosis always mean early intervention? There is much that we may not fully understand regarding the natural history of many of these intraarticular disorders that we are only now learning to diagnose.     

Hip and groin injuries in athletes

Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, they can result in extensive rehabilitation time. Thus, an accurate diagnosis and well-organized treatment plan are critical. Because loads of up to eight times body weight have been demonstrated in the hip joint during jogging, presumably even greater loads can occur during vigorous athletic competition. The available imaging modalities are effective diagnostic tools when selected on the basis of a thorough history and physical examination. Considerable controversy exists as to the cause and optimal treatment of groin pain in athletes, or the so-called "sports hernia." There has also been significant recent attention focused on intraarticular lesions that may be amenable to hip arthroscopy. This article briefly reviews several common hip and groin conditions affecting athletic patients and highlights some newer topics.     

Current concepts in imaging the adult hip.

Diagnostic imaging plays a key role in the evaluation of adult hip pain. Cornerstone to the initial assessment of hip pain is the plain radiograph. The need for secondary imaging of the hip and choice of imaging modality depends on the clinical presentation, results of the plain radiograph series, and clinical question to be answered. CT is primarily used in acute trauma, particularly in cases of an acetabular fracture or hip dislocation to detect intraarticular fragments and associated articular surface fractures and to better depict fracture patterns for surgical planning. In the setting of normal plain radiographs and unexplained hip pain, MR imaging is particularly helpful in detecting marrow-based abnormalities and demonstrating intra- and extraarticular pathology. MR athrography is useful in the detection of labral injuries and potentially may demonstrate additional intraarticular pathology, including chondral damage, loose bodies, and injuries of the ligamentum teres.     

Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury

Traumatic osteitis pubis is a non-specific entity that relates to chronic groin injury and has recently been described as being akin to a pubic bone stress injury. It is uncertain whether or not reduction of hip joint range of motion occurs in traumatic osteitis pubis. The purpose of this study was to establish whether there is a reduction of hip range of motion in athletes who have chronic groin injury diagnosed as pubic bone stress injury. A case-control study was performed whereby 89 Australian Rules footballers underwent, with clinical history unknown, clinical and MRI examination of the groin region. Clinical criteria (pain with tenderness) and MR-criteria (pubic bone marrow oedema) were used for diagnosis of pubic bone stress injury. End-range internal and external rotation hip motion was measured using a goniometer. Athletes with and without symptoms were compared, as were athletes with current symptoms with athletes who had recovered from their groin pain episode. Chronic groin injury was diagnosed in 47 athletes with 37 having pubic bone stress injury. Thirteen athletes had previous groin injury. A reduction of internal and external hip range of motion was demonstrated in athletes with pubic bone stress injury (p < 0.05) and in athletes who had current symptoms compared to those who had recovered from their groin pain episode (p < 0.05). A reduction in hip range of motion was evident in athletes with chronic groin injury diagnosed as pubic bone stress injury. There may be a role for increasing hip range of motion in rehabilitation.     

Hip and groin function and strength in male ice hockey players with and without hip and groin problems in the previous season- a prospective cohort study

ObjectiveTo describe and compare hip and groin strength and function of male ice hockey players over one season in players with and without hip and groin problems in the previous season.DesignProspective cohort study.SettingSwedish male ice hockey.ParticipantsWe followed 193 players from 10 teams during the 2017/2018 season.Main outcome measuresHip adduction and abduction strength, 5 s squeeze test (5SST), and self-reported hip and groin function (Hip and Groin Outcome Score). Changes over the season and differences between players with and without problems in the previous season were analyzed by linear mixed models.ResultsAdduction strength decreased slightly from pre-to mid-season and abduction strength increased slightly over the full season. However, self-reported function or pain did not change. Players with hip and groin problems in the previous season had significantly worse self-reported function, and more groin pain during the 5SST compared to players without. Strength measurments did not differ between groups.ConclusionsHip muscle strength, groin pain, and self-reported function appear to remain stable throughout the season in male ice hockey players. Remaining impairments in players with problems in the previous season suggest that function does not recover by ice hockey participation alone.     

Characteristics of acute groin injuries in the hip flexor muscles — a detailed MRI study in athletes

Hip flexor injuries account for one‐third of acute groin injuries; however, little is known about specific injury characteristics. The aims of this study were to describe acute hip flexor injuries using magnetic resonance imaging (MRI ) in athletes with acute groin pain and to compare specific muscle injuries with reported injury situations. Male athletes with acute groin pain were prospectively and consecutively included during three sports seasons. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. All athletes with an MRI confirmed acute hip flexor muscle injury were included. A total of 156 athletes presented with acute groin pain of which 33 athletes were included, median age 26 years (range 18‐35). There were 16 rectus femoris, 12 iliacus, 7 psoas major, 4 sartorius, and 1 tensor fascia latae injury. Rectus femoris injuries primarily occurred during kicking (10) and sprinting (4), whereas iliacus injuries most frequently occurred during change of direction (5). In 10 (63%) rectus femoris injuries, tendinous injury was observed. The iliacus and psoas major injuries were mainly observed at the musculotendinous junction (MTJ ), and two included tendinous injury. We have illustrated specific injury locations within these muscles, which may be relevant for the clinical diagnosis and prognosis of these injuries. Most proximal rectus femoris injuries included tendinous injury. In contrast, distinct acute iliacus and psoas injuries predominantly occurred at the MTJ . Only the iliacus or psoas major were injured during change of direction, whereas rectus femoris injuries occurred primarily during kicking and sprinting.     

Bursae and abscess cavities communicating with the hip. Diagnosis using arthrography and CT

Bursae or abscess cavities communicating with the hip joint were demonstrated by hip arthrography or by computed tomography (CT) in 40 cases. The bursae or abscess cavities were associated with underlying abnormalities in the hip, including painful hip prostheses, infection, and inflammatory or degenerative arthritis. Structures communicating with the joint capsule included iliopsoas bursae (13 cases), bursae associated with the greater trochanter (21 cases), ischiotrochanteric bursae created by abnormal articulation between the ischium and lesser trochanter (two cases), and abscess cavities not associated with a bursa (four cases). Symptoms may be produced directly as a result of infection or indirectly as a result of inflammation or pressure on adjacent structures. In cases of suspected infection, direct puncture and aspiration of the bursa or abscess cavity, in addition to joint aspiration, may be necessary to obtain organisms for culture as joint aspiration may not yield fluid. Hip arthrography can confirm a diagnosis of bursae and abscess cavities communicating with the hip joint in patients with hip pain or soft-tissue masses around the groin. Differentiation of enlarged bursae from other abnormalities is important to avoid unnecessary or incorrect surgery.     

Field-based evaluation of hip adductor and abductor strength in professional male ice hockey players: Reference values and influencing factors

ObjectivesTo provide reference values and examine the influence of hip/groin pain on hip adductor and abductor strength in professional male ice hockey players, by using a straightforward 5-min procedure.DesignCross-sectional study.SettingOn-field assessment of hip/groin muscle strength with dynamometry, together with the concomitant level of hip/groin pain with a visual analogue scale.ParticipantsProfessional male ice hockey players competing in the Swiss National League (n = 187).Main outcome measuresHip abductor strength, hip adductor strength and hip adductor:abductor ratio.ResultsReference values by playing position (goalkeepers, defenders and forwards) are provided for asymptomatic athletes. Players with hip/groin pain during adduction displayed lower hip adductor strength (p = 0.001) and hip adductor:abductor ratio (p = 0.012) than their symptom-free peers.ConclusionsThe presence of hip/groin pain during adductor testing may contribute to selective hip adductor weakness, whose cause-effect relation with possible groin problems remains to be demonstrated.     

Prevalence and severity of hip and groin pain in sub‐elite male football: a cross‐sectional cohort study of 695 players

The purpose of this study was twofold: (a) to investigate the prevalence of hip and groin pain in sub‐elite male adult football in Denmark and (b) to explore the association between prevalence and duration of hip and groin pain in the previous season with the Copenhagen Hip and Groin Outcome Score (HAGOS) in the beginning of the new season. In total 695 respondents from 40 teams (Division 1–4) were included. Players completed in the beginning of the new season (July–Sept 2011) a self‐reported paper questionnaire on hip and/or groin pain during the previous season and HAGOS. In total 49% (95% CI: 45–52%) reported hip and/or groin pain during the previous season. Of these, 31% (95% CI: 26–36%) reported pain for >6 weeks. Players with the longest duration of pain during the previous season had the lowest HAGOS scores, when assessed at the beginning of the new season, P < 0.001. This study documents that half of sub‐elite male adult football players report pain in the hip and/or groin during a football season. The football players with the longest duration of pain in previous season displayed the lowest HAGOS scores in the beginning of the new season.     

Male basketball players who report hip and groin pain perceive its negative impact both on- and off-court: A cross-sectional study

ObjectivesTo identify if basketball players aged <20 years (U20) self-report hip and/or groin pain and if they perceive this as a problem. To determine potential differences in self-reported playing (training and match play) loads and Copenhagen Hip and Groin Outcome Score (HAGOS) between those with and without hip/groin pain.DesignCross-sectional.MethodsFifty-one pre-elite (state/national representative level) male U20 basketball players (Australian n = 38; Italian n = 13) self-reported current/historical hip/groin ‘discomfort/pain’ and ‘problems’, and playing loads. A two-factor regression model was fitted including main effects for hip/groin pain and Cohort and their interaction, with outcome variables playing loads and HAGOS subscale scores and dependent variable hip/groin pain.ResultsTwenty-one players (41%) self-reported hip/groin ‘discomfort/pain’, of which nine perceived no ‘problems’. Two of these nine players reported training/playing time loss due to pain. Those self-reporting hip/groin discomfort/pain scored lower than those without in HAGOS subscales Symptoms (mean difference in score 8.94; 95%CI ?25.24, ?5.97), Pain (5.00; ?16.42, ?2.81), Function in daily living (0.00; ?26.72 to ?5.59), Function in sport and recreation (6.25; ?21.24, ?5.33), and hip and/or groin Quality of Life (5.00; ?28.63, ?8.10), indicating worse hip/groin problems. Participation subscale scores were different only for Italian players (36.25; ?51.25, ?20.00), with players self-reporting hip/groin discomfort/pain scoring lower.ConclusionMost players who perceive both hip/groin ‘discomfort/pain’ and ‘problems’ also report training/playing time loss, suggesting players’ perceptions of problematic symptoms and time-loss are associated. Adolescent basketball players perceive hip/groin pain to negatively impact their daily lives and sporting function.     

Hip joint range of motion restriction precedes athletic chronic groin injury

Although a restricted hip range of motion has been previously associated with chronic groin injury the temporal course of this association remains unclear. Accordingly the purpose of this prospective cohort study was to report preliminary findings examining whether hip joint range of motion restriction is associated with subsequent onset of athletic chronic groin injury. End-range internal and external hip joint range of motion was determined in 29 elite Australian football players, without previous history of groin injury. The players were followed for two subsequent playing seasons for the development of chronic groin injury. Four athletes developed chronic groin injury defined as at least 6 weeks of groin pain and missing match playing time. In athletes that developed chronic groin injury a lower body weight (p = 0.02) and reduced total hip joint range of motion (p = 0.03) were found to be associated. This study suggests that hip stiffness is associated with later development of chronic groin injury and as such may be a risk factor for this condition. This work should be viewed as preliminary and caution is advised in applying the conclusion to clinical practice as the numbers in this study were small.     

An overview of hip injuries in running

Running has steadily gained in worldwide popularity and is the primary exercise modality for many individuals of all ages. Its low cost, versatility, convenience and related health benefits appeal to men and women of broad cultural, ethnic and economic backgrounds. With more children and adults participating in recreational and competitive running, the incidence of injuries has steadily increased. Most running-related injuries affecting the lower extremities are due to preventable training errors, and some may necessitate medical evaluation or a significant reduction in training.Hip injuries in runners are due to interactions of intrinsic and extrinsic factors that adversely affect the complex regional anatomy. Acute or chronic hip pain presents a diagnostic and therapeutic challenge because the vague, nonspecific symptoms and signs may originate from local, regional or distant foci. Muscle strains and tendonitis are the most common aetiologies of hip pain and typically result from sudden acceleration/deceleration manoeuvres, direction changes or eccentric contractions. Apophysitis and avulsion fractures may affect younger runners and produce localised pain at muscle attachment sites. Iliotibial band syndrome is a common cause of lateral hip and knee symptoms characterised by sharp or burning pain that is exacerbated by activity. Bursitis, due to repetitive activity or acute trauma, may affect the trochanteric, ischial or iliopectineal bursae. Hip osteoarthritis may also produce persistent pain that worsens with running. Stress fractures are potentially serious conditions that affect women more frequently than men. Snapping hip syndrome is a benign condition that results from tight connective tissues' passing repeatedly over the greater trochanter, anterior hip capsule, lesser trochanter, femoral head or iliopectineal eminence. Acetabular labral tears, sports hernias and nerve entrapment syndromes are also potential causes of persistent hip pain in runners.Treatment of hip pain in running should focus not only on addressing the symptoms but also identifying the underlying conditions that precipitated the injury. Injury prevention and comprehensive rehabilitation are essential, since prior hip injuries increase the risk of subsequent ones. Coaches, trainers and medical personal who care for runners should advocate running regimens, surfaces, shoes, technique and individualised conditioning programmes that minimise the risk of initial or recurrent hip injuries.     

Assessing Acute Hip Injury

A serious sports-related hip injury is rare, but potential consequences can be devastating. The athlete with hip pain may have a variety of clinical symptoms such as groin discomfort, knee pain, swelling, and ecchymosis. A six-step evaluation involving a brief history, visual inspection, palpation, neurovascular assessment, range of motion, and lab and radiographic data will assist in expedient diagnosis and treatment. Injuries can be graded as type 1, 2, or 3, with triage decisions based on injury type and varying from observation and rehabilitation to referral to a specialist.     

Clinical presentation of femoroacetabular impingement

The purpose of this study was to identify subjective complaints and objective findings in patients treated for femoroacetabular impingement (FAI). Three hundred and one arthroscopic hip surgeries were performed to treat FAI. The most frequent presenting complaint was pain, with 85% of patients reporting moderate or marked pain. The most common location of pain was the groin (81%). The average modified Harris Hip score was 58.5(range 14–100). The average sports hip outcome score was 44.0 (range 0–100). The anterior impingement test was positive in 99% of the patients. Range of motion was reduced in the injured hip. Patients who had degenerative changes in the hip had a greater reduction in range of motion. The most common symptom reported in patients with FAI was groin pain. Patient showed decreased ability to perform activities of daily living and sports. Significant decreases in hip motion were observed in operative hips compared to non-operative hips. Research performed at the Steadman Hawkins Research Foundation, Vail, CO.     

Groin pain: clinical assessment and the role of MR imaging

Groin pain is a common problem in the elite athlete and may lead to prolonged inactivity if inadequately treated. Groin pain, arising from injuries to the hip and pelvis, accounts for 5 to 6% of athletic injuries in adults and 10 to 24% of these injuries in children. Lower limb-dominated athletic activities such as football, rugby, ice hockey, running, and ballet are particularly at risk. Comprehensive evaluation of all the anatomical locations prone to injury including the hip joint, sacrum, ilium and proximal femora, pelvic tendon attachments, and pelvic musculature is required. Magnetic resonance (MR) imaging provides superb soft tissue contrast resolution, multiplanar capabilities, and a wide field of view to evaluate many potential causes of groin pain. Careful clinical examination allows the optimal use of MR imaging and MR arthrography to evaluate the articular, osseous, tendinous, and muscular structures, which may be the source of groin pain. Accurate diagnosis is essential for appropriate management and rehabilitation plans. This article reviews the role of clinical assessment in guiding diagnostic imaging and also describes the relevant MR imaging findings in athletes presenting with groin pain.     

The clinical assessment of hip muscle strength in professional rugby union players

Groin/hip injuries are prevalent in rugby union (RU). Assessment of hip muscle strength is important when designing bespoke injury prevention and rehabilitation programmes.ObjectiveThe primary aim of this study was to determine normative values of hip muscle strength in elite-level RU players. A secondary aim of this study was to compare the Copenhagen Hip and Groin Outcome Score (HAGOS) between players with and without a history of groin/hip injury.DesignCross-sectional cohort study.SettingProfessional RU club.Participants58 male professional RU players competing in the PRO14 league elite club level competition.Main outcome measuresHandheld dynamometry eccentric strength values of hip abduction (ABD), adduction (ADD), internal rotation (IR) and external rotation (ER), HAGOS.ResultsPlayers' dominant (DOM) and non-dominant (NDOM) hip strength values were, 2.38 and 2.34 N m/kg for ABD, 2.79 and 2.71 N m/kg for ADD, 2.69 and 2.55 N m/kg for IR, and 2.65 and 2.54 N m/kg for ER. ADD:ABD strength ratio was 1.17 ± 0.26 for the DOM limb and 1.16 ± 0.24 for the NDOM limb. There was no clinically significant difference in strength between players’ DOM and NDOM limbs. Players with a history of groin/hip injury scored lower on four of the HAGOS subscales (pain; symptoms; sport; quality of life) compared to those without a history of groin/hip injury.ConclusionsThis study may help establish normative hip strength and HAGOS values for elite-level RU players. The results presented have important implications for the assessment of hip muscle strength and could provide clinical markers for return-to-play following injury.     

A review of femoroacetabular impingement in athletes

There are a multitude of well recognized hip and groin injuries that commonly affect athletes; however, a more recently recognized and possibly often overlooked cause of hip pain is that of femoroacetabular impingement (FAI). FAI is characterized by abutment of the femoral neck against the acetabular rim, which may occur by two mechanisms known as 'CAM' or 'pincer' impingement, although most commonly by a mixture of both. CAM impingement is characterized by abutment of the femoral neck against the acetabulum due to a morphological abnormality of the femoral head-neck junction. Pincer impingement occurs where an abnormality of the acetabulum results in impingement against an often normal femoral neck. Both CAM and pincer impingement are known to result in pathological consequences of cartilage delamination and labral lesions, leading to significant pain and disruption to athletic performance and activities of daily living in athletes. There are currently several methods of assessing the degree of impingement by use of CT and magnetic resonance imaging scans, which can be used in conjunction with magnetic resonance arthrography and arthroscopy to assess the damage caused to the underlying structures of the hip. Both open and arthroscopic surgical methods are used, with recent reports in athletes showing excellent results for lifestyle improvement and frequency of returning to sport. In cases of hip and groin pain in athletes, it is important to remember to look for typical history, and examination and imaging findings that may suggest a diagnosis of hip impingement. This article goes some way to explaining the principles, consequences and management of FAI.     

Football players with long standing hip and groin pain display deficits in functional task performance

Objectivesi) Compare functional task performance between football players with and without hip/groin pain. ii) Explore the relationship, and sex-specific effects, between functional tasks and the Copenhagen Hip and Groin Outcome Score (HAGOS) in players with hip/groin pain.DesignCross-sectional.SettingLaboratory.Participants183 (38 women) football players with a self-reported history of >6months of non-time-loss hip/groin pain and a positive flexion-adduction-internal rotation test, and 61 (14 women) asymptomatic players.Main outcomeParticipants completed the hop-for-distance (HFD), one leg rise (OLR), side bridge (SB) endurance, and HAGOS. Study aims were assessed using linear models, controlling for body mass index and age, incorporating sex-specific interaction terms.ResultsPlayers with hip/groin pain could not hop as far (adjusted mean difference: -9 cm, 95% CI: -15 cm to -2cm, P=0.012) and completed fewer OLR repetitions (adjusted mean difference −7, 95% confidence interval −11 to −3 repetitions, P=0.001) compared to asymptomatic players. Symptomatic women, but not symptomatic men, with worse HAGOS scores had lower SB endurance. Independent of sex, football players with worse HAGOS scores could not hop as far and completed fewer OLR repetitions.ConclusionFootball players with hip/groin pain demonstrated deficits in HFD and OLR with the performance of these tasks associated with their HAGOS results. The study identifies potential impairments that can be targeted as a component of rehabilitation programs for football players with hip/groin pain.