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Non-Articular Sources of Groin Pain

Dr. Carlomagno Cardenas-Nylander

Manel Ribas (Hip unit chair)


Vittorio Bellotti, Emanuelle Astarita, Esther Moya 
Hip Preservation Institut Catalá de Traumatologia I Medicina
del Esport. Barcelona - Spain
Disclosure

• Conmed – Linvatec
• Consultant

• No conflicts of interest with this presentation


Non-Articular Sources of Groin Pain

• Where is this pain coming from? Hip joint?


• Symptoms and physical examination
• Imaging

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Non-Articular Sources of Groin Pain

• Hip joint pain patterns can be complex

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Non-Articular Sources of Groin Pain

Patients self-perception

Same patient at different times


Non-Articular Sources of Groin Pain

• Injections – intra-articular primary joint pathology


• Multiple location
• Hip-spine syndrome
• Predictor for FAI surgery results?
Non-Articular Sources of Groin Pain

Arnold DR, Keene JS, Blankenbaker DG, Desmet AA. Hip pain referral
patterns in patients with labral tears: analysis based on intra-
articular anesthetic injections, hip arthroscopy, and a new pain
"circle" diagram. Phys Sportsmed. 2011 Feb;39(1):2935

• Patients with labral tears and pain improvement after hip joint
injection

• Central groin
• Lateral peritrochanteric area Most Common

• Ischial tuberosity
• Anterior thigh

Intra-articular joint pathology


model
Non-Articular Sources of Groin Pain

Condition Symptoms
? Peritrochanteric

Intra-articular
pathology Groin pain
“C” Pattern
?

? = Differential diagnosis of groin pain


Non-Articular Sources of Groin Pain

GROIN PAIN
HIP JOINT PELVIC (FEMALE)
NEUROPATHY MUSCULAR TEARS
HERNIA SYMPHYSIS
BURSA SPINE
FRACTURES GENITOURINARY
ABDOMINAL VASCULAR-LIMPH

NON ARTICULAR SOURCES OF GROIN PAIN

Athletic pubalgia

Subspine impingement
Non-Articular Sources of Groin Pain

• Athletic pubalgia (define a group symptoms) umbrella term

• Long list pubic and groin pathology - Mixed terminology


• Historically not clearly defined or treated
• Osteitis pubis Adductor related groin pain (Hölmich -1997)

• Confusion and overlapping of conditions


• “Hernia“ or “Sports Hernia“
Non-Articular Sources of Groin Pain

• Pubic – groin pain poorly defined

• Males
• Athletes (football) twisting, kicking, pivoting and sprinting

• Affects pubis area and structures attached to it


Non-Articular Sources of Groin Pain

• Pubic joint stress


• Involved in a reactive way secondary to biomechanical stress and
instability around the pubic joint
Non-Articular Sources of Groin Pain

• Physical examination - Pubis and muscles attachments /


stabilizers
P Hölmich, L R Hölmich, A M Bjerg.Clinical examination of athletes with groin pain: an
intraobserver and interobserver reliability study. Br J Sports Med 2004;38:446–451

Palpation Resistance test


Pubis Pectineus
Adductor insertion Adductor L/B
Rectus abdominis insertion Rectus abdominis
Psoas Psoas
Inguinal canal / abd. wall
Non-Articular Sources of Groin Pain

Adductor longus Pectineus

Rectus abdominis Psoas


Non-Articular Sources of Groin Pain

• Routine imaging
• Plain X-RAY – Flamingo view
Non-Articular Sources of Groin Pain

• Routine imaging
• MRI

• Bone scan
• Reumatological disease
• Suspected stress fracture

• Ultrasound
• Suspected occult hernia
• Muscular insertions
Non-Articular Sources of Groin Pain

• Treatment:

• Conservative (rest)

• Avoidance of exacerbating activities

• Physical therapy protocol


• 12 weeks specific exercises
• Improve symptoms
• Return athletic activities
Non-Articular Sources of Groin Pain

• Public cleft injection


• Diagnostic and treatment option
• Relieve pain in recreational athletes and professional
athletes

Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic
resonance imaging, and entheseal pubic cleft injections. Schilders E, Talbot JC, Robinson
P, Dimitrakopoulou A, Gibbon WW, Bismil Q. J Bone Joint Surg Am. 2009 Oct;91(10):2455-
60
Non-Articular Sources of Groin Pain

• Surgical treatment
• Last option
• According to findings
• More 26 different procedures (repair-release tendons)

• Rising reports hip surgery for this AP patients

There is a hip pathology association with AP?


Non-Articular Sources of Groin Pain

• Verrall GM, Slavotinek JP, Barnes PG, Esterman A, Oakeshott RD, Spriggins AJ. Hip
joint range of motion restriction precedes athletic chronic groin injury. J Sci Med Sport
2007. 10(6):463-6

• 29 Australian football players (Prospective study two


seasons)
• Hip stiffness and reduced ROM was associated with
development of groin pain

• Weir A, de Vos RJ, Moen M, Holmich P, Tol J.Prevalence of radiological signs of


femoroacetabular impingement in patients presenting with long standing adductor-
related groin pain. Br J Sports Med. 2011 Jan;45(1):6-9

• 34 Athletes with long-standing proximal adductor pain

• 94% had radiographic evidence for FAI.


Non-Articular Sources of Groin Pain

Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip
pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy 2011;27:768–75

• AP alone 25% of athletes returned to sports

• If only the intra-articular pathology was addressed 50% returned


to sports

• When both intra-articular and AP pathology was surgically


addressed concurrently or at separate settings, 89% of athletes
returned to sports without limitations
Non-Articular Sources of Groin Pain

• Conclusion
• Association FAI – AP (further research)

• Limited ROM and compensatory patterns


• Stress at different muscle groups
• Stress at near joints (pubis, SI, spine)

• Be careful - remember to check patient’s hips


Non-Articular Sources of Groin Pain

• Subspine impingement
• Anterior model of anterior extra-articular impingement

• Traditionally head-neck / acetabular rim


Non-Articular Sources of Groin Pain

• 30 yo patient, cam deformity (60º + 20º IR)


Non-Articular Sources of Groin Pain

• 90º + 10 IR
Non-Articular Sources of Groin Pain

• Subspine target areas


Non-Articular Sources of Groin Pain

• Causes

Developmental or post avulsion injury Iatrogenic Post PAO


Non-Articular Sources of Groin Pain

• Soft tissue impingement


Non-Articular Sources of Groin Pain

• Physical examination:
Non-Articular Sources of Groin Pain

• Anterior Inferior Iliac Spine Morphology Correlates With Hip Range of Motion: A Classification
System and Dynamic Model. Iftach Hetsroni MD, Lazaros poultsides MD, Asheesh Bedi MD,
Christopher M. Larson MD, Bryan T. Kelly MD. Clin Orthop Relat Res (2013)

• The Arthroscopic Classification of Sub Spine Morphology in the Hip


Carton, Patrick (Ireland) ISHA 2013

Normal Level of acetabular rim Downslopping


Non-Articular Sources of Groin Pain
Non-Articular Sources of Groin Pain
Non-Articular Sources of Groin Pain

• Patients pelvic tilt / rotation may over or underestimate abnormal


subspine morphology (AP pelvis)

• Researches uses CT scans to measure it

• Amar E, Druckmann I, Flusser G, Safran MR, Salai M, Rath E. The anterior inferior iliac
spine: size, position, and location. An anthropometric and sex survey. Arthroscopy. 2013
May;29(5):87481

• CT scan better way to get spine morphology and location

• Serve as data to 3d simulation in case pre op assessment of extra-


articular pathology
Non-Articular Sources of Groin Pain

• 32 yo Male Right groin pain. + FABER, + FADIR, symptoms


aggravated flexion over 90º
Non-Articular Sources of Groin Pain

• 32 yo Male Right groin pain. + FABER, + FADIR, symptoms


aggravated flexion over 90º
Non-Articular Sources of Groin Pain

• 32 yo Male Right groin pain. + FABER, + FADIR, symptoms


aggravated flexion over 90º

Sub spine line


Non-Articular Sources of Groin Pain

• 32 yo Male Right groin pain. + FABER, + FADIR, symptoms


aggravated flexion over 90º

Sub spine line

Anterior wall (red)

Posterior wall (yellow)


Non-Articular Sources of Groin Pain
Non-Articular Sources of Groin Pain

• Arthroscopic rim trimming and subspine decompression


Non-Articular Sources of Groin Pain

• Arthroscopic rim trimming and subspine decompression


Non-Articular Sources of Groin Pain

• Conclusion

• Suspect anterior extra-articular impingement


• Patients groin pain over 90º
• Abnormal X-ray (false profile, cross table)

• 3D CT scan or 3D simulation to rule out mixed intra-extra-articular


joint pathology

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