Navigating Sports Medicine’s ‘Bermuda Triangle’ – Part I

Assessment

Subjective assessment

Practitioners need to identify red flags during the subjective evaluation. Red flags include a history of fever, trauma, unexplained weight loss, night pain, painful urination, or prolonged corticosteroid use^(1,2). Red flags coupled with a history of prostate or reproductive organ cancer and abdominal and pelvic organ disorders are the reason for referral to relevant specialists for further investigation.

Furthermore, information regarding the athlete’s age, sport, and level of participation are relevant. For example, adolescent athletes participating in sports that require high load activities such as kicking and sprinting are at risk of avulsion fractures more than adults due to the open epiphyseal growth plates⁽²⁾.

Physical evaluation

The physical evaluation of the groin requires a thorough clinical examination which includes palpation, pain provocation, joint ROM assessment, muscular strength, and sport-specific function^(2,7). The Doha agreement meeting provides practitioners with a framework to assess and diagnoses groin pain according to the location of pain on palpation or provocation (see figure 1)^(8,9).

_________________________________________________________________

Functional testing

It is common for athletes with groin pain to continue training and playing with mild groin pain. Most athletes typically seek medical assistance when the pain impacts their sports participation or performance. Training and playing with groin pain can result in movement-compensation strategies, which practitioners can identify during the physical evaluation.

The objective assessment of impairments and function can include bent-knee fall-out for testing hip range, single-leg stance, single-leg squat, Star Excursion Balance Test for testing balance and mobility, the timed 10-m cutting sprint (5-m sprint with 75° cut and 5-m sprint finish) or T-agility test (see figure 3)⁽²⁾. However, further evidence is needed to create standard clinical performance-related tests for athletes with groin pain. Therefore, practitioners should select various tests that best simulate the sports demands of the injured athlete.

Figure 3: Timed 10-m cutting test

The athlete sprints 5 meters with a 75° cut and then sprints 5 meters to finish. Compare the time to complete a sprint between the affected and unaffected cutting leg.

Lumbar spine and SIJ screening tests

Practitioners can rule out discogenic or radiculopathy pathology of the lumbar spine without peripheral or central symptoms, normal lumbar ROM, and a negative slump and straight leg raise test. In addition, practitioners can use the thigh thrust test to rule out SIJ pathology⁽²⁾.

Differential diagnosis

Whether acute or chronic, groin pain can be, and is usually, multifactorial. For example, strains of muscles attaching to the pelvic girdle, bony injury to the pelvic girdle, the inguinal canal or hip, and lumbar spine pathology can be associated with groin pain (see table 1)^(2,4,14).

Table 1: Differential diagnosis in athletes with groin pain^(1,2,3,15)

*ASIS= Anterior superior iliac spine; SIS = Superior Iliac Spine; COD = Change of Direction

Imaging

There is currently limited evidence to suggest that imaging improves the diagnosis or prognosis of groin pain^(2,7). If practitioners consider the multifactorial nature of longstanding groin pain, imaging findings can rarely determine the cause of pain⁽⁷⁾. While imaging often shows morphological load-related changes, the challenge is to understand which of these are related to the specific pathology^(1,7). Excessive imaging may result in athletes unnecessarily focusing on normal morphological changes, making them fearful of movement and impeding effective treatment^(2,7). Currently, imaging of players with longstanding groin pain is most helpful to rule out severe potential pathology.

For acute groin pain, imaging might be more helpful. MRI is slightly more sensitive than ultrasound for acute groin injuries and indicated for adductor-, pubic- and hip-related groin pain^(1,2,7). Ultrasonography is appropriate for investigating inguinal- and iliopsoas-related groin pain. Although the best modality to show the apophyses is computed tomography, clinicians should be cautious with youth athletes due to high doses of radiation⁽²⁾. X-rays are helpful for the diagnosis of FAI syndrome, fractures, and the identification of degenerative changes in the hip^(1,2).

Conclusion

The Doha classification of groin pain provides a valuable guideline to practitioners regarding possible causes of groin pain. Unfortunately, high-quality conclusive research regarding assessment and specific treatment modalities is still scarce. However, there is consensus on the terminology and definitions of groin-related pain. The agreement provides Sports and Exercise Medicine professionals with a common language that should improve the multi-disciplinary treatment of athletes with groin pain.

Reference list

1. Br J Sports Med. 2016;50(19):1181-1186.
2. J Orthop Sports Phys Ther. 2018;48(4):239-249.
3. Acta Clin Croat. 2014;53(4):471-478.
4. Orthop J Sports Med. 2018;6(5):232596711877167.
5. J Sci Med Sport. 2018;21(10):999-1003.
6. Br J Sports Med. 2015;49(22):1447-1451.
7. Aspetar Sports Med J. 2021;10.
8. Br J Sports Med. 2015;49(12):768-774.
9. J Sci Med Sport. 2022;25(1):3-8.
10. Br J Sports Med 2015;49:803–9.
11. Br J Sports Med 2015;49:810
12. Sports Med. 2017;47(10):2011-2026.
13. Phys Ther Sport. 2021;52:272-279.
14. Co-Kinet J. 2018;(78):7-7.
15. Muscle Ligaments Tendons J. 2019;05(03):214.