Groin Injuries

Injury to the groin is a very common sporting injury and may occur in about 25-50% of elite athletes. Long-standing groin pain without a detectable hernia is termed occult hernia, sports hernia or athletic pubalgia, and often doesn’t respond to conservative treatment with physiotherapy and rehabilitation.

 A wide range of sports which require repetitive twisting, turning and kicking movements can cause these injuries. These injuries are not frequently seen in women, but occasional cases have been encountered. The typical patient will often have had ongoing groin pain for often between 2 – 3 years before getting something done about it. There may be co-existing injuries of tendons and nerves.

Diagnosis

The onset of pain is usually gradual, but in some sports such as touch football, a sudden injury from slipping on a moist grass surface or during a specific tackle or ruck can cause a sudden disruption. The pain is typically well localised to the area around the pubic bone and pain is often also described in the region of the Adductor tendon insertion with radiation to the testicle or to the other side and also around the bottom area (perineum).

Examination

Physical examination usually demonstrates pain in the pubic area and lower abdomen on resisted sit-up, and often squeezing the knees against the examiner’s fist (squeeze test) may also be a positive clinical sign. Seldom is there a positive cough impulse to indicate a hernia is present.

Radiology

Plain X-rays of the pelvis, ultrasound, dynamic CT scanning and Magnetic Resonance Imaging (MRI) scan are the most reliable forms of diagnostic radiology. Herniography is not favoured because of the incidence of false negative cases and because of the risk of accidentally sticking a needle into the intestines. Sometimes bone scan is necessary to confirm the diagnosis of osteitis pubis.

Treatment

Surgical treatment is usually only considered after a three to six month trial period of non-operative treatment in the hands of an experienced Sports Physician and/or a Physiotherapist. About 20% of patients will show some improvement in a six month period.

Surgical Techniques

The surgery is a variant of the standard open hernia repair (not “key hole”), which involves gathering of deep fascia with a blanket stitch, and a darn repair of the muscles of the posterior wall of the inguinal canal. Other injuries such as a conjoint tendon tear may need to be fixed by sutures placed along the pubic crest and release of a torn or damaged Adductor tendon may also be combined with the hernia operation. Occasionally release of the entrapped Obturator or lateral femoral cutaneous nerve will be also necessary. Physioroom.com demonstrates a satisfactory web-based post-operative rehabilitation programme that has proven to be satisfactory.

Success Rates of Surgery

The rates of success in surgery are reported to vary between 63 and 93%, but there are no randomised control trials yet published.

Post-operative rehabilitation

Enthusiastic participation in rehabilitation enables return to sport between 6 to 8 weeks after surgery. In the first few weeks, power walking, stationary cycling and swimming are all that is recommended. Thereafter, the Sports Physician or Physiotherapist takes over with a specific treatment protocol. Preventative physiotherapy for players who are at risk of groin injury is encouraged and certain strategies have been devised which consist of the use of the Swiss ball for increasing flexibility and strength of muscles arising from or acting across the hip joint, concentrating on symmetrical conditioning and stabilising pelvic muscles are encouraged.