Dr Andy Franklyn-Miller

Athletic Groin Pain

Athletic groin pain (AGP) is a term I will use to start this discussion, but includes osteitis pubis, gilmores groin, pubic bone stress, inguinal disruption etc and there are over 30 terms used broadly to mean the same thing. AGP commonly presently slowly – you may have pain after training but it won’t always stop you, a period of rest seems to settle it but it comes back. It can move from lower abdominals to thigh to groin to feeling very much in pubic bone or hip or gluteal muscles.

Cutting, turning, rotation under load all aggravate it, and kicking sometimes. As it worsens you can get pain when you wake up – sitting up in bed, putting on socks, standing on one leg, and coughing and sneezing. You will probably have had massage, strengthening, physiotherapy, and maybe injections to keep playing. Steroid injections to the adductor muscles, pubic bone and symphysis are commonly used, but do not ‘cure’ or fix, neither does rest – it is not treatment.

I am going to argue that this is a ‘Biomechanical overload’ – and that the anatomy that is sore is just the end result of overload, in the same way as your arms would be sore if I asked you to do 200 pull ups, the next day. In our research, we have seen that this condition most commonly affects the lower abdominal muscles as they attach to the pubic bone. In turn, the hip flexors or adductors can be painful, and that can extend further dependent how chronic the condition is.  Careful clinical examination helps suggest what might be the weak link, rather than what is injured, except in the rare cases when a hernia is found.

MRI including a sagittal view can rule out other causes and to get an idea of severity – this can help suggest whether this has been longstanding or acute, but some excellent work from Denmark suggests that the scan helps less than you might think , and other studies have shown that 60% of athletes have some change in the hip – without any pain – and as such those offering hip surgery as the answer to groin pain are way off the mark in most cases.

See the animation we have designed to show what happens when you change direction at speed. As you will see unless your posterior chain (Gluteals, Lumbar extensors and Hamstrings) all work in synchronous stability – your torso can tip forward, or your lumbar spine can become lordotic – i.e.  stick your butt out like a duck. This decreases hip range of motion and results in an increased load on the hip flexor and upper quad muscles. In fact some people move this way all the time – and certainly give themselves less room for error. This in turn is likely to mean an increase in bone load across the pubic bone and lower abdominal muscle. You can see the lower abs and adductors form a sling and if this is overloaded it hurts.

Our published research in the British Journal of Sports Medicine, uses 3D biomechanics to “measure not guess” the role of hip, knee, ankle and torso in leading to the overload. Consider rehabilitation as a book,  starting a book at chapter one and needing to read 60 chapters, our personalised approach allows us to prescribe based on the 3D assessment of running, jumping, strength power and cutting in our laboratories and as a result we have the fastest return to play times published in the literature at 9 weeks . You spend less, as our approach does not require regular physio therapy input, rather you work in the gym under direction  from our coaches via our app, of course you can continue to work with your own rehabilitation team on the prescription given by our specialists is you want to.

Groin Surgery is much less common than some would have you believe, and again our published work confirms it is not a quick fix at all, but those offering it can divide procedures designed to tension structures around the groin, or to de-tension these same structures. De-tensioning interventions include Adductor tenotomy, Rectus aponeurosis tenotomy and Inguinal ligament release. Tensioning interventions are targeted at potential ‘weakness’ or ‘bulging’ of the posterior inguinal wall and Gilmore, Mushaweck and  describe interventions in detail to mesh, suture or indeed cut a combination of both. You wouldn’t let someone cut your ACL to ‘fix it’ so why your groin? And given the hip bony FAI and labral changes in normal hips – we have found only a very small number of our patients benefit from hip surgery and certainly not those under 23.