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ATHLETIC GROIN PAIN – TIME TO MOVE FROM AN ANATOMICAL TO A BIOMECHANICAL APPROACH? FEATURE / ENDA KING PHD & DR. ANDY FRANKLYN MILLER Athletic groin pain (AGP) is often a frustrating challenge facing medical teams in elite football due to diagnostic confusion, a lack of clarity around the most effective management strategies, and the lack of outcome consistency. At the Sports Surgery Clinic in Dublin, over 400 patients with AGP are seen per year. The clinic is combining biomechanical analysis and academic research, with the aim to improve understanding of these challenges and further enhance AGP management. AGP is an umbrella term used to describe the chronic presentation of pain and dysfunction in athletes around the anterior hip, pelvis and abdominal muscles.5 The prevalence of groin pain symptoms is high in elite football,1 with many continuing to play with ongoing symptoms4. Players that do have to stop playing often miss considerable amounts of playing time.3 A reduction in player availability, alongside a high training load and a busy fixture list, reduce time for recovery and the ability to cope with the external demands to
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play and perform, make it a challenging environment to manage AGP athletes. Much of the initial challenge is around the clarity of a diagnosis. In acute groin injury this is often easily identified through clinical examination and imaging.3, 17 On the other hand, chronic presentations are far more challenging diagnostically. The most prevalent diagnoses reported vary from sportsman’s hernia and its various versions13 (although its existence has been questioned)18 , adductor related groin pain,9 and pubic aponeurosis.5 This is further complicated by most athletes reporting multiple sites of symptoms9, with a high co-prevalence of radiological femoroacetabular impingement.20 Given that the majority of management strategies are dictated according to the derived anatomical diagnosis, the variation in the research can lead to a plethora of management strategies for what are, ultimately, the same group of athletes. This difference in diagnosis may be due in part to misinterpretation of pain
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provocation tests, poor correlation between radiology and clinical findings, and to training and clinician bias. There is poor specificity of the pain provocation tests.5 While a squeeze test or resisted sit up may re-produce an athlete’s symptoms,10 it loads the entire medial groin and anterior pelvic ring and often reproduces low abdominal, pubic or adductor symptoms in isolation or combination. This is further compounded by athletes reporting multiple sites of symptoms, especially in more chronic presentations. Clinical palpation of the region can often be challenging given the number of overlapping structures, such as the pubic tubercle and pubic symphysis. This can make identification of discrete structures challenging. Reliance on MRI reports can lead to a number of radiological “false positives”, due to the high level of “abnormal” findings on scanning at the pubis2 and hip6 in asymptomatic athletes. Falvey et al. reported on the largest cohort of AGP athletes in the literature. They attempted to reduce the variance of AGP by localising the athlete’s
