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Approach to hip and groin pain in the athlete and active adult

Approach to hip and groin pain in the athlete and active adult
Literature review current through: Jan 2024.
This topic last updated: Dec 05, 2022.

INTRODUCTION — Hip and groin injuries occur less frequently than injuries of the knee and ankle in the athletic population but contribute significantly to morbidity among the physically active. The broad differential diagnosis and nonlocalizing pain typical of many hip and groin conditions can make a diagnosis difficult to establish. Injuries of the hip and groin are most easily classified as extra-articular and intra-articular injuries. Unlike most joints of the musculoskeletal system, the hip joint is deep, protected by pelvic musculature, and not readily palpable. In fact, according to some studies, patients with intra-articular hip pathology see an average of 3.3 clinicians before a clear diagnosis is established [1,2]. Thus, an informed, systematic approach to assessment and diagnosis is important.

The evaluation of hip and groin pain in athletic and active adults is reviewed here, including a general scheme for differentiating among the common causes of such pain based upon the history and key clinical findings. Detailed discussions of some of the specific conditions and injuries that cause hip and groin pain are found separately. (See "Greater trochanteric pain syndrome (formerly trochanteric bursitis)" and "Overview of stress fractures" and "Sports-related groin pain or 'sports hernia'" and "Osteitis pubis" and "Hamstring muscle and tendon injuries" and "Adductor muscle and tendon injury" and "Quadriceps muscle and tendon injuries" and "Clinical manifestations and diagnosis of osteoarthritis".)

Hip and groin injuries in children and adolescents, particularly those related to the immature skeleton, are reviewed separately. (See "Approach to hip pain in childhood" and "Evaluation of limp in children" and "Evaluation and management of slipped capital femoral epiphysis (SCFE)" and "Developmental dysplasia of the hip: Clinical features and diagnosis".)

EPIDEMIOLOGY — Approximately 10 percent of those seeking care for injuries in offices of sports medicine clinicians present with hip and/or groin pain, usually of a chronic nature [3]. Excluding hip osteoarthritis (OA), as many as 14 percent of adults over 60 years complain of significant hip pain on a weekly basis [4].

Hip and groin pain encompass a wide variety of conditions and injuries. In a review of 894 young adult athletes (ages 26 to 30) with chronic groin pain who participated in soccer, rugby, and Gaelic sports, 24 different combinations of clinical injury were identified [5]. Isolated injury to the hip joint was common and occurred in 55.98 percent. Common causes of pain included femoroacetabular impingement (FAI), which was more common in males and accounted for 40 percent of the hip joint problems, labral injury, which was more common in females, accounted for 33 percent, and hip OA accounted for 24 percent [5]. (See "Femoroacetabular impingement syndrome" and "Clinical manifestations and diagnosis of osteoarthritis".)

Similar results were noted in a cohort of 218 consecutive patients seen in a sports practice with a wider age range (11 to 77 years) [6]. The sports associated with groin pain in men were typically soccer and rugby, but running was most common among women. Hip pathology accounted for 50.4 percent of the injuries, with pubic injury most common (21 percent). While pubic injuries most often resulted from kicking sports (eg, soccer), running was a common source of hip-related injury. Among dancers and gymnasts, chondro-labral injuries of the hip appear to be most common [7].

Injury patterns for both intra-articular and extra-articular hip injuries vary by sex. In a narrative review, researchers found that female athletes had higher rates of labral and ligamentum teres injuries, stress fractures, ischiofemoral impingement, nerve entrapment, and musculotendinous injuries of the iliopsoas, gluteal, and hamstring muscles than their male counterparts [8].

ANATOMY AND BIOMECHANICS — The anatomy and biomechanics of the hip and groin are reviewed separately. (See "Musculoskeletal examination of the hip and groin", section on 'Anatomy and biomechanics'.)

EXAMINATION — The physical examination of any joint is classically divided into inspection, palpation, range of motion testing, strength and neurovascular testing, and special maneuvers to assess for specific diagnoses. Special tests are selected based upon the most likely diagnostic category, which is based in turn upon the history, including the mechanism of any injury and the chronicity of pain. Guidance about which examination techniques are most useful for diagnosing specific conditions is provided in the text below; performance of examination maneuvers to diagnose musculoskeletal conditions of the hip and groin is reviewed separately. (See "Musculoskeletal examination of the hip and groin".)

DIAGNOSTIC APPROACH — The broad differential diagnosis and nonlocalizing pain typical of many hip and groin conditions in the athlete or active adult can make a diagnosis difficult to establish. Patients with symptoms or signs suggestive of a systemic illness as the cause of hip or groin pain should undergo a comprehensive medical evaluation. We have provided tables summarizing the key findings associated with the common causes of hip and groin pain in athletes (table 1) and listing the potential causes of groin pain in adults generally (table 2). (See 'Medical concerns' below.)

For athletes or active adults without symptoms or signs of systemic illness, whose pain is most likely due to a musculoskeletal condition related to their activities, we suggest taking a stepwise approach beginning with an attempt to establish the timing of the condition (acute, subacute, or chronic). Note that there is some potential overlap among these three categories. Next, a careful history and examination are used to identify the pattern of presentation, which often suggests a particular injury or subset of possible injuries related to a particular structure. Finally, more specific diagnostic maneuvers, typically including imaging studies of some type, are used to establish a diagnosis.

Step 1 – Differentiate conditions likely to cause acute, subacute, or chronic pain using the history primarily and analysis of the mechanism of injury:

Acute injury: Acute hip and groin injuries in the athlete and active adult include the following:

-Tendon strain

-Bone stress injury, including stress fracture

-Trochanteric pain syndrome (formerly known as Trochanteric bursitis)

-Labral tear

Conditions in this category generally involve a discrete history of recent-onset pain or acute injury with a clear mechanism. For injuries involving tendons, there is usually a particular muscle action that is stressful and elicits focal pain. For bone stress injuries, there is often a history of intense training during which the athlete develops progressive acute localized pain. For trochanteric pain syndrome, there is a history of activity stressing tendons or muscles that cross an area predisposed to such conditions, most often the greater trochanter or ischial tuberosity. These areas may be tender.

The activities involved may include running, where the gluteus medius and tensor fascia lata are activated in the stance phase, but more often sports requiring cutting and turning, which involve the external rotators of the hip (eg, piriformis, gluteus maximus). The onset of pain is less acute but usually within 24 hours. For labral injury, particular hip movements (most often flexion) produce sharp groin pain, which may increase with any activity that involves loading the hip. By convention, acute injuries are ones in which pain has been present six weeks or less.

Subacute or acute on chronic injury: Among active adults and athletes, subacute and acute-on-chronic causes of hip and groin pain include the following:

-Osteitis pubis

-Piriformis syndrome

-Trochanteric pain syndrome (formerly known as Trochanteric bursitis)

-Femoroacetabular impingement (FAI)

-Labral tear (generally degenerative or milder acute tears)

-Tendinopathy

-Athletic pubalgia (also referred to as sports hernia or core muscle injury)

While the history provided by patients with subacute or acute-on-chronic hip or groin injuries may include a sudden exacerbation of pain, when asked, patients are usually aware of a pre-existing pattern of ongoing pain in the hip or groin region. Often these conditions arise from overuse, repetitive activity, and delayed treatment. Each of these conditions causes a specific pain pattern that may limit the athlete's movement or prevent sports participation. Some athletes experience a substantial increase in pain and become unable to participate in sport after training too vigorously. Subacute conditions are generally those present more than six weeks but less than three months.

Chronic injury: Conditions causing chronic hip or groin pain in the athlete and active adult include the following:

-Osteoarthritis (OA)

-Osteitis pubis

-Severe FAI

These conditions cause pain that is present daily or several days per week and has persisted longer than three months. In adults, the most common cause is OA of the hip, which causes morning stiffness and night pain as well as pain brought on by activity. More severe bone damage (eg, from avascular necrosis) may cause constant pain. Osteitis pubis causes pain localized over the symphysis pubis that frequently radiates into the groin and is elicited by activity, or sometimes by routine actions such as coughing. Pain may persist for many months. Severe FAI may cause pain with any activity involving hip flexion, such as rising from a chair. While these three conditions cause a significant portion of chronic hip and groin pain, any of the conditions described above as acute or subacute can become chronic if misdiagnosed or inadequately managed.

Step 2 – Within each category (acute, subacute, and chronic), use the history and physical examination findings, including specific diagnostic maneuvers, to identify common patterns of presentation and the most likely cause of hip or groin pain. Special examination maneuvers to confirm the preliminary diagnosis are discussed in the sections below devoted to individual conditions. A table summarizing the key findings associated with the most common diagnoses is provided (table 1).

The following inquiries are important for all patients with hip or groin conditions:

Is pain elicited by specific common activities? As examples, pain walking up steps suggests hip flexor injury or an intra-articular problem. Pain from standing suggests OA or bone stress injury of the hip.

Is the pain brought out by specific resistance testing of a given muscle or muscle group? This suggests tendon strain (acute) or tendinopathy (subacute or chronic). (See 'Extra-articular muscle and tendon injuries' below.)

Is there focal pain with deep palpation over an area where bursae are usually present—particularly bony prominences of the greater trochanter, ischial tuberosity, or iliopectineal eminence? These findings suggest trochanteric pain syndrome (formerly known as trochanteric bursitis). (See 'Trochanteric pain syndrome (bursitis)' below.)

Is there dysesthesia, burning, aching, or a radicular pattern of pain to areas of the pelvis or lower extremity? Such a history combined with pain with provocative testing, such as direct pressure, suggests nerve entrapment but is also commonly found with athletic pubalgia, which often involves the ilioinguinal nerve. (See 'Neuropathies' below and 'Athletic pubalgia (sports hernia, core muscle injury)' below.)

The following inquiries are important for patients with subacute and chronic pain:

Is the pain of insidious onset, focused over the groin, proximal thigh, or buttocks, and associated with extensive endurance training? Is it made worse by weight-bearing activity, such as running or hopping, or by axial loading of the hip joint during examination? These findings suggest bone stress injury (eg, stress fracture). Immediate pain relief with non-weight-bearing also suggests bony injury. (See 'Bone stress injuries' below.)

Does the patient have unilateral or bilateral groin pain with significant tenderness directly over the symphysis pubis? Is there pain with kicking, especially kicking across the body? Is there pain or painful clicking at the pubis symphysis rolling over in bed? Has pain around the symphysis pubis developed in the post partum period of an athletic mother returning to exercise? This suggests osteitis pubis and additional testing is needed. (See 'Osteitis pubis' below.)

Does the patient have insidious, poorly localized groin pain that may involve the os pubis, conjoint tendon, or adductor origin? This pattern may accompany athletic pubalgia. Findings such as pain with resisted hip adduction or abdominal crunches may or may not be present. (See 'Athletic pubalgia (sports hernia, core muscle injury)' below.)

The following inquiries are important for patients with chronic pain:

Does the patient have insidious groin pain possibly present for years that has worsened recently and is associated with loss of internal rotation and pain reproduced by FADIR testing (picture 1)? This history plus a positive FADIR test strongly suggest labral pathology. (See 'Acetabular labrum injury' below.)

Does the patient have pain brought on by sports activity that can be sharp, brought on by sitting, painful with going from sitting to standing or walking down stairs? This pain pattern occurs with labral injury but also with FAI. Many patients have both problems simultaneously. (See 'Acetabular labrum injury' below and 'Femoroacetabular impingement' below.)

Does the patient have chronic aching pain in the groin worsened by activity but also present at rest and during the night that is associated with limited hip internal rotation or general limitations in hip motion? Night pain plus diminished hip internal rotation strongly suggests OA of the hip. (See 'Osteoarthritis' below.)

Step 3 – Use appropriate diagnostic imaging studies as necessary to confirm the likely diagnosis [9,10]. Based upon the initial history and examination, the clinician makes a preliminary assessment as to the most likely diagnosis. Before obtaining imaging studies, consultation with a radiologist can be helpful to help ensure that appropriate views for plain radiographs and the most useful studies are obtained.

Ultrasound Ultrasound is useful for diagnosing tendon and soft tissue injury around the hip and groin. The attachment of the hamstrings, abductors and adductors can be visualized in most individuals. Hypoechoic changes and bursal-type swelling around tendon insertions commonly occur with tendinopathy. Soft tissue contusions, tears within muscle, tendon tears, and bony avulsions all have distinct patterns on ultrasound. (See "Musculoskeletal ultrasound of the hip".)

Standard plain radiographs – Plain radiographs are generally obtained for any patient with chronic groin pain and limited internal rotation of the hip, and often help to confirm a diagnosis of OA. Fracture too can be diagnosed and signs of FAI are often apparent on standard hip radiographs. However, plain radiographs are less helpful for other conditions.

MRI, MRA, and CT – Bone stress injuries (eg, stress fracture) of the femoral neck often show little if any change on initial plain radiographs and magnetic resonance imaging (MRI) is needed to make the diagnosis. Labral injuries are difficult to diagnose even with standard MRI studies and may require a magnetic resonance arthrogram (MRA) for diagnosis. When ultrasound is not diagnostic, MRI confirms the diagnosis of tendinopathy. Complete tendon ruptures and extensive muscle injury is best defined with MRI.

Computed tomography (CT) entails significant radiation exposure and is used infrequently in the initial workup of athletes and healthy, active adults. However, when a subtle bone stress injury or nonhealing fracture is suspected, CT can provide valuable information.

Diagnostic injection ‒ As both the intra-articular and extra-articular differential diagnosis for groin pain are extensive, an ultrasound-guided or fluoroscopically-guided intra-articular injection of glucocorticoid and/or local anesthetic may be useful to help differentiate among sources of pain [11]. Evidence about the use of this technique for diagnosis is scant and approaches vary among clinicians. Resolution of symptoms following an intra-articular injection of analgesic increases the likelihood of the hip joint as the source of symptoms. Failure of the patient to gain relief of symptoms does not exclude intra-articular pathology as the source of pain but does make an extra-articular source more likely.

ADDITIONAL ULTRASOUND RESOURCES — Instructional videos demonstrating proper performance of the ultrasound examination of the hip, groin, and related pathology can be found at the website of the American Medical Society for Sports Medicine: sports US hip pathology, US guided interventional procedures of the hip. Registration must be completed to access these videos, but no fee is required.

COMMON CONDITIONS CAUSING HIP OR GROIN PAIN

Extra-articular muscle and tendon injuries — Extra-articular injury of muscles and tendons are the largest source of hip and groin pain in active adults. Among runners and athletes involved in running-based sports, acute muscle strains and tendinopathies are the most common cause [3].

Common muscle and tendon injuries — The proximal portion of one of the hip adductor muscles (figure 1) may be injured during intense, repetitive, weight-bearing activity involving side-to-side movements (eg, skating) or external hip rotation. Adductor injuries may be sustained acutely (classic muscle "groin strain") or from repetitive athletic activity. Such a history combined with suggestive examination findings, including focal pain in the muscle or at its tendon origin, particularly with resisted hip adduction (picture 2), are generally sufficient to make the diagnosis. Ultrasound can help to confirm the presence of injury, but magnetic resonance imaging (MRI) is typically unnecessary as acute avulsions or complete tendon tears are rare. Adductor injuries are reviewed in detail separately. (See "Adductor muscle and tendon injury".)

Muscle and tendon strains of the proximal anterior thigh, adjacent to the hip and groin, most often involve the rectus femoris muscle, the most anterior of the quadriceps muscles (figure 2 and figure 3 and figure 4). The rectus femoris is responsible for hip flexion and knee extension. Injuries typically occur during sprinting or jumping [12]. Injuries near the muscle origin at the anterior inferior iliac spine are more common than distal strains. Activities involving hip flexion and knee extension, such as climbing or descending steps, are painful. Resisted hip flexion and knee extension reproduces pain and helps to confirm the diagnosis. Rectus femoris strains and other quadriceps injuries are reviewed in detail separately. (See "Quadriceps muscle and tendon injuries".)

Proximal hamstring strain, specifically of the biceps femoris (figure 5 and picture 3 and figure 6), is the most common muscle injury causing hip pain [13,14]. The proximal musculotendinous junction is the most common site and injury typically occurs acutely during sprinting or uphill and downhill running. The hamstring may be injured more proximally at its origin on the ischial tuberosity. Focal pain at the tuberosity suggests avulsion injury, which should be confirmed with diagnostic imaging (image 1). The diagnosis of acute hamstring strain is usually straightforward based on the history and examination findings, including focal tenderness and pain with resisted knee flexion and hip extension. With the patient prone, resistance testing with the knee in external rotation at 30 degrees of flexion helps to isolate the biceps femoris muscle. Local swelling and ecchymosis are often present, and may extend to the knee. Hamstring injuries are reviewed in detail separately. (See "Hamstring muscle and tendon injuries".)

Iliotibial band syndrome (ITBS) is another muscle-tendon injury associated with running sports that may have a pelvic component, although it is most often associated with lateral knee pain. The ITB is a tendon-like structure that represents a continuation of the gluteus maximus and the tensor fascia lata, extending to the insertion on Gerdy's tubercle on the anterolateral tibia just below the lateral knee joint line, fibular head, and lateral patellar retinaculum (figure 7) [15]. ITBS can present with the insidious onset of lateral hip and thigh pain, which may extend along the lateral thigh and to the area of the lateral femoral condyle. Symptoms are usually more bothersome when climbing hills or steps. Pain may be present during or after a run or athletic practice. Given such a history, the diagnosis is strongly suggested by pain that is reproduced by palpating over the lateral femoral condyle while passively flexing the knee up to approximately 30 degrees. Significant strength deficits of the gluteus medius and maximus commonly accompany this injury. Diagnostic imaging is generally unhelpful, although ultrasound often reveals hypoechoic areas at and just superior to the femoral condyle. (See "Iliotibial band syndrome".)

Snapping hip — The term "snapping hip" is used to describe any of several musculotendinous conditions associated with hip discomfort. Athletes with "snapping hip" notice an audible or palpable "snap" with certain movements. Pain may or may not accompany the sensation. The more common extra-articular causes of snapping hip involve movement of the gluteus maximus tendon, tensor fascia lata, or iliotibial band over the greater trochanter (figure 8 and figure 9). As symptoms are noted at the greater trochanter, this is sometimes referred to as external snapping hip. The "snapping" is produced by a combination of hip flexion, abduction, and external rotation. A less common extra-articular form of snapping hip occurs as the hip moves from flexion to extension, causing the iliopsoas tendon to snap over the iliopectineal eminence, femoral head, or lesser trochanter [16]. As symptoms are noted along the medial hip, this is sometimes referred to as internal snapping hip. In most cases of snapping hip, symptoms are minimal and there is little impact on athletic activity. In many cases, symptoms resolve with physical therapy focused on improving the function of the gluteus maximus, gluteus medius, and iliopsoas. The intra-articular cause of "snapping hip" is usually an acetabular labral tear, which is discussed below. (See 'Acetabular labrum injury' below.)

Trochanteric pain syndrome (bursitis) — The hip and groin region contains numerous bursae, but only three are clinically relevant: the trochanteric, iliopectineal, and ischial (figure 9 and figure 8) [17]. The region around the trochanteric bursa overlying the lateral aspect of the greater trochanter is most commonly symptomatic. The trochanteric bursa protects the greater trochanter as the gluteal tendons and iliotibial band glide over the greater trochanter during hip movement. Pain in the area of the greater trochanteric bursa is referred to as trochanteric syndrome or tendinopathy. Such pain is caused most often not by inflammation of the bursa, as was thought, but rather by insertional tendinopathy involving the gluteus medius or minimus. True bursitis with bursal inflammation is a less common finding. Patients with trochanteric syndrome complain of pain that localizes directly over the greater trochanter. Pain often worsens after running or other sports activity, and possibly with prolonged standing. Examination reveals tenderness over the greater trochanter. In addition, resisted hip abduction (picture 4) and to a lesser extent, hip rotation, often elicit pain. Bursal swelling and tendon abnormalities typically can be visualized with ultrasound. Greater trochanteric pain syndrome is reviewed in detail separately. (See "Greater trochanteric pain syndrome (formerly trochanteric bursitis)".)

The iliopectineal bursa cushions the iliopsoas muscle as it courses over the iliopectineal eminence and femoral head [3]. As with trochanteric pain syndrome, pain in this region may be due to tendinopathy, but it is classically referred to as iliopectineal bursitis and should be included in the differential diagnosis of anterior groin pain, particularly in athletes and active adults. Besides anterior groin pain, iliopectineal bursitis may cause an accompanying snap in the hip that occurs with significant hip flexion or a change of position involving hip movement, such as arising from sitting. Pain may be reproduced by direct palpation, unlike pain due to most other deep structures in the groin.

Pain from ischial bursitis may also be due to tendinopathy and is less common than the other clinically relevant pelvic bursal problems, but it occurs with some frequency in distance runners, who often complain of proximal hamstring pain. Direct trauma from a fall on the ischial tuberosity is a likely cause. Chronic insertional hamstring tendinosis mimics ischial bursitis or may occur coincidentally. Ultrasound imaging frequently demonstrates some bursal type swelling at insertion in high hamstring syndrome.

Diagnostic injection of a local anesthetic under ultrasound guidance performed by a knowledgeable clinician may help to determine if these syndromes account for a patient's symptoms.

Neuropathies

Overview and general findings — Entrapment and other forms of peripheral neuropathy of the hip and groin can cause pain or other symptoms that mimic both extra-articular and intra-articular hip problems (figure 10 and figure 11). Although the relative occurrence of these problems in adult athletes is difficult to quantify, estimates in runners attribute 10 to 15 percent of episodes of lower extremity pain involving either the thigh or lower leg to entrapment neuropathies [18]. The four most common causes of nerve symptoms arising from the pelvis or upper thigh, with symptoms extending into the lower extremity, are lumbo-sacral radiculopathy, sciatica, and femoral and lateral femoral cutaneous nerve entrapments. Peripheral nerve syndromes and lumbosacral radiculopathy are discussed in detail separately. (See "Overview of lower extremity peripheral nerve syndromes" and "Acute lumbosacral radiculopathy: Etiology, clinical features, and diagnosis".)

The character of the pain associated with nerve entrapment varies widely, ranging from dysesthesias to burning to aching in the distribution of the affected nerve [19]. If a motor component of the nerve is affected, weakness may accompany the pain. The symptoms of nerve entrapment may occur at rest or only during physical activity. Examination may reveal numbness or weakness but in many cases there are no abnormal physical findings. The Tinel sign may reproduce symptoms and is worth attempting. The Tinel sign can be elicited by striking over the femoral nerve in the inguinal triangle or over the sciatic nerve at the piriformis region. Electromyography (EMG) and nerve conduction studies of the suspected nerve may assist with diagnosis. Subtle findings may be noted with magnetic resonance imaging (MRI) or ultrasound. Both may show flattening or enlargement of the affected nerve at the site of entrapment with increased signal intensity on MRI and hypoechoic signal with ultrasound [19].

Nerve entrapments — The obturator nerve (figure 12) can be compressed in the obturator canal at the ischium. Symptoms of obturator nerve entrapment (eg, sensory loss) occur along the medial thigh radiating toward the groin and thigh. If a motor component is affected, there may be hip adductor weakness [20]. While uncommon, obturator nerve entrapments have been reported in Australian Rules football, soccer, and triathletes [21]. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Obturator nerve'.)

Among cyclists, pudendal nerve entrapment is relatively common (figure 10) [20]. Symptoms often include perineal pain and penile or labial numbness. Occasionally, impotence may occur. A modified style of bike saddle (eg, wider seat or split saddle) may help to relieve symptoms [22].

Ilioinguinal nerve entrapment is another cause of groin pain radiating to the genitalia [20]. Although the underlying cause is not well understood, the condition is seen in bodybuilders, hockey players, and some other athletes, and may occur postoperatively after laparotomy or herniorrhaphy, and during pregnancy. Entrapment may occur as the nerve crosses the iliac crest, exits the transverse abdominis, or crosses the internal oblique aponeurosis. In addition to groin pain, there may be reproducible tenderness about 2 to 3 cm below the anterior superior iliac spine (ASIS). Recovery is usually spontaneous but may require 6 to 12 months. Ilioinguinal nerve entrapment is associated with sports-related groin hernia. (See "Sports-related groin pain or 'sports hernia'".)

The femoral nerve accompanies the femoral artery and vein through the groin (figure 13). Forceful hip flexion, gymnastics, and jumping activities all can lead to injury that can compress the femoral nerve. Entrapment can cause paresthesias or sensory loss over the anterior and anteromedial thigh. Ultrasound can assist in diagnosis. If the saphenous nerve is affected, sensory loss may extend to the medial shin and the arch of the foot. Motor nerve involvement may cause quadriceps weakness [20]. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Femoral nerve'.)

The lateral femoral cutaneous nerve is exclusively sensory. Compression of the nerve (known as meralgia paresthetica) near the ASIS or inguinal ligament can occur from a tight belt or other compressive phenomena. Repetitive trauma, as might occur with a gymnast repeatedly performing a routine on the uneven parallel bars, can also damage the nerve. Burning pain, paresthesia (numbness and tingling), and hypesthesia (diminished sensation) over the upper outer thigh is the classic presentation of meralgia paresthetica. The onset of pain is typically subacute. Sensory loss is quite discrete, and it is often possible to demarcate the area of numbness precisely. The patient often rubs the outer thigh when describing the symptoms. Modifying the factors causing nerve trauma results in symptom resolution in the large majority of cases, although recurrence is common. Ultrasound may identify changes to the nerve consistent with entrapment. (See "Meralgia paresthetica (lateral femoral cutaneous nerve entrapment)".)

Piriformis syndrome — Piriformis syndrome is a controversial entrapment neuropathy (figure 14 and figure 15 and figure 11) [23,24]. Controversy is due to the limited research about the condition and the difficulty of making the diagnosis, particularly as symptoms mimic many other more common diagnoses. Piriformis syndrome may account for 0.3 to 6 percent of sciatic-like syndromes [25]. The sciatic nerve normally passes inferior to the piriformis muscle. Entrapment of the sciatic nerve may develop following trauma to the buttocks or piriformis muscle strain causing scarring and fibrosis around the nerve, or due to the structure of the piriformis, such as when branches of the nerve pass through a bifid piriformis muscle [26]. During downhill running or sprinting, the piriformis muscle undergoes eccentric contraction and some runners may develop the syndrome via this mechanism. The most common presenting symptom is buttock pain of gradual onset that increases with sitting [27]. The "wallet sign" associated with the syndrome is when a male patient finds he can no longer sit on his wallet without causing symptoms. Paresthesias may develop, but the classic radicular symptoms of sciatica are not common.

Clinically, the diagnosis of piriformis syndrome is considered when the classic signs of a lumbar radiculopathy elicited by provocative testing are absent, neurologic examination is normal, and other causes of gluteal and sacroiliac pain are ruled out. A provocative test (Freiburg test) suggesting piriformis syndrome is performed by placing the hip in extension and internal rotation, and then resisting external rotation. Pain or sciatic symptoms denotes a positive test [28]. Another test (Pace sign) involves having the seated patient resist abduction and external rotation. Pain and reproduction of symptoms marks a positive test. When necessary, plain radiographs and MRI of the hip and pelvis are obtained to rule out other causes of symptoms. EMG and nerve conduction studies are rarely positive in piriformis syndrome but can be useful for eliminating other diagnostic possibilities. According to a small, preliminary study, ultrasound assessment of piriformis thickness and cross-sectional area may assist diagnosis [29].

Treatment begins with physical therapy involving strengthening of the pelvic and hip region and stretching of the piriformis. Appropriate analgesics for neuropathic pain are taken as needed. Physical therapy is effective in the majority of cases [27]. Ultrasound-guided glucocorticoid injections have been beneficial in some cases, and botulinum toxin injections have also been used. Surgery (typically a piriformis tenotomy) may be considered if symptoms are debilitating and persist despite appropriate nonoperative therapy.

Bone stress injuries — "Bone stress injury" refers to all clinically symptomatic stress reactions in bone, including stress fractures. Bone stress injuries can develop from almost any athletic activity, weight-bearing or otherwise, and comprise a significant percentage of sports-related injuries, including those affecting the pelvis and groin. Groin or buttock pain can result from bone stress injuries of the sacrum, pubic ramus, femoral neck, or proximal femoral shaft.

Athletes with bone stress injuries, particularly stress fractures, typically describe an insidious onset and progression of pain. As the injury worsens, pain becomes more severe and its onset more predictable, and localizes to the groin, anterior thigh, or buttocks, depending on the affected bone. Weight-bearing activity exacerbates symptoms. Bone stress injuries of the femoral neck are of particular importance in distance runners and other athletes. Important aspects of the presentation of bone stress injuries that cause hip or groin pain are discussed below; stress fractures are reviewed in detail separately. (See "Overview of stress fractures".)

Femoral neck injury – Femoral neck stress fractures are considered high-risk and referral to a knowledgeable orthopedic surgeon is recommended in nearly all cases. The consequences of misdiagnosing these stress fractures can be substantial. Most athletes involved in running or jumping sports experience compression-side (ie, inferior aspect) femoral neck stress injuries. Dancers also sustain such injuries. Less common and more serious are tension-side (ie, superior aspect) femoral neck stress fractures, which more often affect active older adults and athletes. Women are more commonly affected than men with a ratio of about 2 to 1 [30]. Tension-side femoral neck stress fractures are at risk for nonunion and conversion to a complete fracture. Typical symptoms for either fracture consist initially of vague groin pain that over time is provoked more predictably by running, and ultimately by any weight-bearing activity. If symptoms have been chronic, radiographs may reveal subtle changes in bone lucency or periosteal activity. MRI is the preferred imaging study for diagnosis and to distinguish between compression-side and tension-side fractures (image 2). If a femoral neck stress fracture is suspected, the patient should be made non-weight-bearing on the affected extremity. (See "Femoral stress fractures in adults".)

Femoral shaft injury – Stress fractures of the proximal femoral shaft often present insidiously. The initial symptom is often a vague ache in the anterior thigh that has minimal effect on training. As symptoms progress, weight-bearing becomes uncomfortable prompting evaluation. In most athletes and active adults, the proximal femoral shaft cannot be palpated due to the bulk of the quadriceps. Hopping on the symptomatic leg usually reproduces symptoms and the fulcrum test is usually positive (picture 5) [31]. If plain radiographs of the femur are negative but clinical suspicion persists, MRI should be obtained. Although these fractures are considered low risk for developing complications, crutches may be necessary initially if weight-bearing is painful, with the patient progressing to weight-bearing as symptoms permit.

Sacral injury – Sacral bone stress injuries are much more common in women athletes and result from a combination of shear forces transmitted through the pelvis and vertical forces transmitted from the spine to the sacrum. Pain localizes to the sacroiliac joint and directly over the sacrum, although some pain extends across gluteal area. A wide variety of running and jumping activities have been implicated. The clinical evaluation must distinguish among gluteal muscle injury, sacroiliac dysfunction, and stress injury. Pain at night and pain that persists even when the patient is inactive raise suspicion for stress fracture. With a stress fracture, resisted strength testing of the gluteal muscles typically causes no discomfort, whereas palpation of the bony prominences of the sacrum, especially over the fracture site, produces tenderness diffusely and not over the sacroiliac joint alone. Plain radiographs are unlikely to demonstrate changes consistent with a stress fracture and MRI is the study of choice for diagnosis. As with all stress fractures at low-risk sites, treatment consists of rest from offending activities until symptoms resolve, followed by a gradual return to sport.

Pubic ramus injury – Pubic ramus stress fractures are likely a result of repetitive activity involving the hip adductor and hamstring muscles, creating stress at their origins on the pelvis. Women sustain these fractures more often than men. Examination reveals focal tenderness at the pubic ramus, and pain may increase if the clinician rocks or compresses the pelvis. Patients limp if they try to run. Plain radiographs showing periosteal elevation or early callus formation confirm the diagnosis, but MRI is the definitive test when necessary. Pubic ramus stress fractures are at low risk for complications and treatment consists primarily of rest from inciting activity, with weight-bearing as tolerated. Recovery can be variable, but anecdotally most stress fractures involving the pubic ramus require approximately six weeks of protected function before beginning a graduated return to training.

Osteitis pubis — Osteitis pubis is a stress injury of the symphysis pubis. It occurs more often in men and is associated with sports involving rapid acceleration and deceleration, kicking, and pivoting (eg, soccer, ice hockey) [32]. Abnormal shear stresses exerted through the pelvis in the frontal and transverse planes by the rectus abdominis, hip adductors, and gracilis are thought to be involved [33]. Other reports suggest loss or limitation of internal rotation of the hip creates abnormal pelvic stresses contributing to osteitis pubis [34]. Athletes with osteitis pubis experience a gradual onset of groin pain that may be unilateral or bilateral, and may be referred to the inferior abdomen or toward the hip or thigh. Males may complain of testicular pain with activity. Patients may report symptoms when moving from sitting to standing or participating in sport. The diagnosis and management of osteitis pubis are reviewed in detail separately. (See "Osteitis pubis".)

Examination findings consistent with osteitis pubis include reproducible tenderness when palpating the symphysis pubis. Tenderness may also occur along the superior pubic ramus on either or both sides of the symphysis pubis. Passive stretch of the hip adductors frequently reproduces symptoms, as does provocative testing by resisting hip adduction. Ideally, resisted hip adduction is performed with patient in several positions. This is because osteitis pubis entails a range of pathologic changes and early in the process some patients develop pain only in particular positions that stress the adductor muscles. Provoking pain during resisted hip adduction with the hips and knees neutral (picture 2), hips flexed to 45 degrees, knees flexed to 90 degrees, or hips and knees maximally flexed (picture 6) suggests the diagnosis. Direct tenderness over the pubic symphysis, pain with nonspecific activity like hopping, or with unrelated actions like coughing or sneezing, or a "clicking" sensation at the symphysis when rolling from side to side, all suggest a diagnosis of osteitis pubis rather than uncomplicated adductor strain. In addition, adductor strain is most often associated with an acute injury recalled by the patient. (See "Adductor muscle and tendon injury".)

Standing radiographs of the pelvis in patients with long-standing symptoms (several weeks to months) may show cystic changes or sclerosis along one or both sides of the symphysis pubis with irregular osteolysis at the symphysis apparent in some (image 3 and image 4). MRI is the definitive study, when necessary (image 5). Osteitis pubis is a self-limited problem with an excellent prognosis, but recovery is slow and requires cessation of offending activities. Finding pain-free alternate activities can be difficult for some athletes and complete rest may be required.

Athletic pubalgia (sports hernia, core muscle injury) — "Athletic pubalgia" is a nonspecific term used by many sports medicine clinicians to refer to sports hernia (another common term is "core muscle injury"). Although several groups are attempting to establish more consistent criteria for the condition, the terminology remains nonspecific. For the purposes of this topic, the term athletic pubalgia refers to sports hernia, which is any condition causing persistent unilateral pain in the groin, typically in an athlete, without demonstrable hernia. Sports hernia is discussed in detail separately. (See "Sports-related groin pain or 'sports hernia'".)

Athletic pubalgia is more common in men, although the diagnosis is being made more frequently in women. It typically develops in athletes who participate in intense sports that involve running, skating, kicking, and/or sudden changes in direction (eg, soccer, ice hockey, rugby, American football). Pain localizes to the groin in the vicinity of the common attachment of the rectus abdominis and inguinal ligament and the origin of the adductor longus on the superior pubic ramus. The condition can be associated with ilioinguinal nerve injury, which may result in burning pain. One common explanation for the condition holds that repetitive trunk extension and excessive hip abduction and core rotation create shear forces resulting in injury at the insertion of the rectus abdominis and adductor longus, often leading to subsequent injury of the posterior abdominal wall.

Athletes with pubalgia generally describe the pain as insidious in onset, but sometimes onset is acute with persistent symptoms thereafter. Symptoms are present during athletic activity but not at rest. Diagnosis is clinical and such conditions as adductor muscle-tendon strain and inguinal hernia must be ruled out. (See "Adductor muscle and tendon injury" and "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

Given the limited evidence about athletic pubalgia, the diagnosis can be approached in a number of ways. According to the British Hernia Society, any three of the following five clinical findings may confirm the diagnosis [35]:

Localized tenderness at the pubic tubercle at the insertion of the conjoint tendon

Tenderness over the deep inguinal ring

Dilatation and/or pain at the external inguinal ring without obvious hernia

Tenderness at the origin of the adductor longus tendon

Diffuse pain in the groin, perineum, or inner thigh

In many clinics, patients with three or more of the findings above are referred to a surgeon with experience treating sports hernia. Clinicians with expertise in diagnostic ultrasound may first perform an ultrasound examination looking for signs consistent with sports hernia. However, many patients have vague presentations without three or more of the above signs. If such a patient fails to improve with appropriate nonoperative care, including rehabilitation of the abdominal and adductor muscles, the clinician should pursue diagnostic imaging or surgical consultation.

Many of the injuries discussed in this topic can mimic the symptoms of sports hernia. Imaging studies are most useful for ruling out other causes of groin pain [35]. However, MRI can reveal changes in the conjoint tendon, inguinal ligament, rectus abdominis, and adductor longus associated with athletic pubalgia. According to one small observational study, MRI demonstrates 68 percent sensitivity and 100 percent specificity for rectus abdominis tendon injury [36]. Potentially confusing MRI findings include marrow edema of the symphysis pubis (osteitis pubis) and fluid in the symphysis pubis, as these findings occur in a number of patients who do not appear to have pain related to the symphysis. Skilled sports ultrasonographers are often able to identify tendinopathy of the adductor longus, irregularity and spurring of the pubic body, and tearing of the aponeurotic plate of the rectus abdominis and adductor longus [37].

Treatment for athletic pubalgia is discussed separately. (See "Sports-related groin pain or 'sports hernia'", section on 'Treatment'.)

Femoroacetabular impingement — Femoroacetabular impingement (FAI) is abnormal contact between the anterior femoral head and the acetabular rim, which impairs movement and may increase the risk for osteoarthritis (OA) of the hip. FAI is reviewed in greater detail separately. (See "Femoroacetabular impingement syndrome".)

Two hip morphologies are associated with FAI:

Cam morphology refers to a nonspherical femoral head with an abnormal femoral head-neck offset (image 6). In other words, the taper from the femoral head to the neck is less distinct due to the thickened neck. The nonspherical femoral head creates abnormal compressive and shear forces during hip flexion and internal rotation.

Pincer morphology refers to "over-coverage" of the femoral head by the acetabulum (image 7). In other words, the superior rim of the acetabulum extends further over the femoral head than with a normal hip.

A combination of both cam and pincer impingement is more common than either deformity in isolation (image 8). In the setting of either deformity, trauma from repetitive hip flexion and internal rotation can damage the articular cartilage of the acetabulum. A pincer deformity also places the acetabular labrum at risk of injury.

FAI is more common among athletes. The clinical presentation of FAI is insidious and often deceptive. Mild symptoms of groin pain may occur variably for a long time (years) before abruptly worsening, finally affecting sport participation. Less commonly, pain is noticed in the buttocks. Early in the course, symptoms are minimal but are usually most noticeable after sitting with hips flexed to 90 degrees for a relatively long period (eg, working at a desk, taking a long automobile or plane ride) and then rising to the standing position. As symptoms progress, sporting activity is increasingly affected. Since the differential diagnosis for FAI is broad, a thorough examination of the hip should be performed, guided by the history. Range of motion testing with the hip in 90 degrees of flexion often reveals diminished internal rotation (<30 degrees) and near normal external rotation. A flexion-adduction-internal rotation test (FADIR, anterior impingement) at 90 degrees usually reproduces the groin pain the athlete has experienced. Maximal active hip flexion with knee flexed may also reproduce pain, as may a FABER (flexion abduction external rotation) maneuver. Pain with hip extension, abduction, and external rotation often occurs in those with symptomatic pincer deformities. While these tests are suggestive, imaging with plain radiographs is necessary to establish the presence of these hip deformities. (See "Musculoskeletal examination of the hip and groin", section on 'Tests for acetabular pathology'.)

Radiographs are valuable for demonstrating both cam and pincer morphologies, although the presence of such deformity on an imaging study does not prove the diagnosis, as such abnormalities are common in asymptomatic populations. The approach to imaging when FAI is suspected and measurements for the determination of FAI deformity on plain radiographs are discussed separately. (See "Femoroacetabular impingement syndrome", section on 'Measurement of FAI morphology'.)

Iliopsoas impingement — Iliopsoas or psoas impingement occurs when the psoas muscle is compressed or stretched over the hip joint and acetabular labrum, causing the psoas tendon to snap across the joint during hip flexion [38,39]. This form of impingement occurs in ballet dancers, high-kick dancers, figure skaters, and hockey players. Mechanical symptoms occasionally occur in the groin. Physical therapy with brief activity modification often solves the problem. Failing that, arthroscopic surgery can debride or repair the labrum. Lengthening of the iliopsoas can be performed to relieve compression and pain. However, loss of strength in the hip flexors is a possible sequela of this procedure.

Acetabular labrum injury — The labrum is critical for a healthy hip. An intact labrum seals the central portion of the hip joint from the periphery, thereby keeping synovial fluid in the central compartment and creating negative pressure within the joint, which enhances stability and resistance to femoral head subluxation. Synovial fluid nourishes the articular cartilage, which maintains a smooth interface with the femoral head within the acetabulum. Thus, any disruption of the labrum adversely affects the health of the articular cartilage and joint stability, and hastens the development of OA.

Tears of the acetabular labrum generally occur from two possible mechanisms: a single, acute episode of significant trauma, most often involving forceful resistance of hip flexion while an athlete is kicking or running (as might occur with a tackle in American football or rugby), or repetitive microtrauma in a hip with chronic, degenerative bony changes [40]. According to a small, retrospective study, 87 percent of labral tears that occur in the absence of acute trauma demonstrate evidence of femoroacetabular impingement (FAI), hip dysplasia, or OA [41].

The large majority of patients with labral tears presents with groin pain exacerbated by athletic activity. In some athletes, this is triggered by jumping or sprinting that requires more aggressive hip flexion. In distance runners the pain may occur during longer runs as fatigue sets in or runs involving a lot of hills. Other patients note groin pain with sitting or when assuming a standing position after being seated, or groin pain when descending stairs [40]. In addition, patients often report difficulty putting on shoes and stockings while seated. Pain with hip flexion and anterior impingement tests are highly suggestive of labral pathology. The tests that elicit pain most often are repeated hip flexion, hip flexion against resistance, and FADIR testing, but none is specific for labral injury. The signs and symptoms of labral tears overlap with those of FAI and advanced imaging may be required to establish a diagnosis, if this is required.

Plain radiographs of the pelvis are the initial studies obtained when a labral tear is suspected. Standard views include a standing anteroposterior (AP), cross-table lateral or Dunn lateral, and false profile. The most accurate imaging study for diagnosing labral tears is a magnetic resonance arthrogram (MRA) (image 9) [42,43]. 3.0-Tesla MRI has been compared with MRA for diagnosing acetabular labral tears and shown similar accuracy [44]. If a noninvasive test is preferred, 3.0T MRI may be a suitable alternative. Appropriate imaging should be determined in consultation with a musculoskeletal radiologist. For symptomatic tears, an ultrasound-guided injection of anesthetic or combined glucocorticoid and anesthetic can be used to help confirm the diagnosis, if pain resolves following injection. Anesthetic may also be combined with the contrast material injected during an MRA.

Initial management of labral tears consists of activity modification (ie, rest from inciting activities) and physical therapy. Strengthening of the pelvic and lower extremity muscles helps to stabilize the joint and correct abnormal pelvic tilt, relieving some of the abnormal stress placed on the labrum. As animal studies have demonstrated the healing capabilities of the labrum, a trial of nonoperative treatment is warranted [45]. If physical therapy fails, arthroscopic surgery is indicated. Given the importance of the labrum for hip joint health, surgery should be directed toward restoration of the labrum rather than debridement or excision whenever possible.

Osteoarthritis — Chronic degeneration of articular cartilage can ultimately lead to osteoarthritis (OA) of the hip. Although body mass index (BMI) is the major risk factor cited in most studies, some aspects of sports participation may increase risk. As an example, dancers, ice skaters, and others who require extensive hip motion for their sport may have increased rates of hip OA [46]. Conversely, the risk for hip OA and total hip arthroplasty is decreased in walkers and runners, probably due to their lower BMI [47]. Hip OA develops most often in patients over 40 years and manifests as progressive hip pain that increases with activity and is relieved by rest. Episodic flares in pain severity are characteristic, and joint stiffness is common. Plain radiographs reveal sclerosis, loss of joint space, spurring, and other changes typical of OA (image 10). The presentation and treatment of OA is reviewed in detail separately. (See "Clinical manifestations and diagnosis of osteoarthritis" and "Overview of the management of osteoarthritis".)

MEDICAL CONCERNS — Groin or hip pain in an individual with urologic or gynecologic symptoms or signs (eg, dysuria, hematuria, vaginal or penile discharge), fevers, sweats, weight loss, palpable mass, or other signs of systemic illness mandates a comprehensive medical evaluation. Osteitis pubis in particular has been associated with infections and post-partum complications. The assessment of hip or groin pain presumed to be orthopedic should always include general questions about systemic symptoms and signs, urologic and gynecologic symptoms and signs, and overall health. A table listing potential diagnoses in adults presenting with groin pain is provided (table 2).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General issues in muscle and tendon injury diagnosis and management" and "Society guideline links: Muscle and tendon injuries of the lower extremity (excluding Achilles)" and "Society guideline links: Hip and groin pain".)

SUMMARY AND RECOMMENDATIONS

History – The history is critical to understanding the cause of an athlete or active adult's hip or groin pain. Important elements include distinguishing between acute (symptoms for six weeks or less), subacute (symptoms between six weeks and three months), and chronic hip pain (symptoms over three months), identifying any preceding trauma and the mechanism of injury if trauma was involved, and understanding what activities the patient participates in that may contribute to their symptoms. (See 'Diagnostic approach' above.)

Physical examination – The physical examination consists of inspection, palpation, range of motion testing, strength and neurovascular testing, and special maneuvers to assess for specific diagnoses. Special tests are selected based upon the most likely diagnostic category, which is based in turn upon the history. The performance of examination maneuvers to diagnose musculoskeletal conditions of the hip and groin is reviewed separately. (See "Musculoskeletal examination of the hip and groin".)

Diagnostic approach – A diagnostic approach to the active adult and athlete with hip or groin pain is provided in the text, and a table summarizing the key findings associated with the most common diagnoses is provided (table 1). The major steps include the following (see 'Diagnostic approach' above):

Step 1 ‒ Differentiate conditions likely to cause acute, subacute, or chronic pain using the history primarily and analysis of the mechanism of injury:

Acute hip and groin injuries include:

-Tendon strain (see 'Extra-articular muscle and tendon injuries' above)

-Stress fracture (see 'Bone stress injuries' above)

-Trochanteric pain syndrome (bursitis) (see 'Trochanteric pain syndrome (bursitis)' above)

-Labral tear (see 'Acetabular labrum injury' above)

Subacute or acute-on-chronic injuries include:

-Osteitis pubis (see 'Osteitis pubis' above)

-Piriformis syndrome (see 'Piriformis syndrome' above)

-Trochanteric pain syndrome (bursitis)

-Femoroacetabular impingement (FAI) (see 'Femoroacetabular impingement' above)

-Labral tear

-Tendinopathy (see 'Extra-articular muscle and tendon injuries' above)

-Athletic pubalgia (see 'Athletic pubalgia (sports hernia, core muscle injury)' above)

Chronic injuries may include:

-Osteoarthritis (OA) (see 'Osteoarthritis' above)

-Osteitis pubis

-Severe FAI

Step 2 – Within each category (acute, subacute, and chronic), use the history and physical examination findings, including specific diagnostic maneuvers, to identify common patterns of presentation and the most likely cause of hip or groin pain. Special examination maneuvers to confirm the preliminary diagnosis are discussed in detail in the sections devoted to individual conditions.

Step 3 – Use appropriate diagnostic imaging studies as necessary to confirm the likely diagnosis.

Pain associated with signs of systemic illness – Groin or hip pain in an individual with urologic or gynecologic symptoms or signs (eg, dysuria, hematuria, vaginal or penile discharge), fevers, sweats, weight loss, palpable mass, or other signs of systemic illness mandates a comprehensive medical evaluation (table 2). Osteitis pubis in particular has been associated with infections and post-partum complications. The assessment of hip or groin pain presumed to be musculoskeletal should always include general questions about systemic symptoms and signs, urologic and gynecologic symptoms and signs, and overall health.

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Topic 100491 Version 20.0

References

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