Athletic groin pain remains a common field-based team sports time-loss injury. The existing cross-sectional studies in this area of research vary considerably in presenting diagnosis. None of the studies had a complete series of prospectively-gathered standardized clinical examination, MRI and patient-reported outcome measures (PROM).
The authors of present study aimed to describe clinical presentation, physical examination, MRI findings and PROM for a consecutive group of athletes presenting to a secondary and tertiary referral clinic with athletic groin pain. This is the largest prospective cohort of patients with athletic groin pain in the literature to date, and the first to directly combine clinical and MRI findings in making a diagnosis. The paper outlines an integrated physical examination and radiological review for accurate diagnosis of athletic groin pain.
A total of 382 consecutive male patients with athletic groin pain for a median time of 36 (range 16–75) weeks presented for investigation and rehabilitation (age, 24.6±5.1 years; height, 181.1±5.4 cm; mass, 81.9±9.1 kg). The majority listed gaelic football (57.9%) as their primary sport, followed by soccer (13.6%), hurling (10.5%) and rugby (8.6%).
All patients had a history including demographics, injury duration, sport played and standardized clinical examination. Clinical examination of patients included the assessment of hip joint range of motion (flexion, internal and external rotation). The following tests were performed: hip provocation tests, flexion adduction internal rotation (FADIR), flexion abduction external rotation (FABER), adductor squeeze tests (bilateral resisted adduction) at 90°, 45° and 0° hip flexion, the crossover test and squeeze test (to measure pain provocation and load tolerance through the pelvic ring), prone internal and external rotation of the hip, Gaenslen’s test and hip extension, slump test, femoral slump test, Thomas and Modified Thomas tests. Palpation of the adductor insertion to tubercle, pubic symphysis and superficial and deep inguinal ring scrotal invagination were performed. All patients completed the Copenhagen hip and groin outcome score (HAGOS), a validated PROM, at presentation.
A clinical diagnosis was the product of directed history, clinical examination and MRI findings. Statistical assessment of the reliability of accepted standard investigations undertaken in making an anatomical diagnosis was performed.
A primary clinical diagnosis of pubic aponeurosis (PA) injury was made in 240 (62.8%) cases, hip injury was diagnosed in 81 (21.2%) cases these overlapped in 8 (2.1%) cases. Adductor injury was diagnosed in 56 (14.7%) cases, iliopsoas injury in 10 (2.6%) and inguinal injury in 3 (0.8%) cases.
The adductor squeeze test (90° hip flexion) was sensitive (85.4%) for athletic groin pain, but not specific for adductor, PA or iliopsoas pathology (negative likelihood ratio 1.95). The specificity and post-test probability of diagnosis were improved by combination of clinical (palpation) and radiological findings in series.
Analyzed in series, positive MRI findings and tenderness of the pubic aponeurosis had a 92.8% posttest probability. The improved post-test diagnostic probabilities seen following the incorporation of MRI in the diagnostic process highlights the benefits of immediate correlation between clinical examination and MRI by the sports physician. Surgery for presumed inguinal pathology dominates the literature yet the authors failed to identify a hernia, clinically or radiologically, despite MRI findings of a variety of concomitant abnormalities in any subject.
Nearly two-thirds of patients (63.6%) demonstrated pain and abnormality in multiple anatomical structures. This implies that at any point in time a number of structures may be ‘pathological’ resulting in pain. The authors argue that focusing on injury mechanism may be more productive than attempting to isolate individual pathological structures. Diagnostic and rehabilitation strategies aimed at and designed toward treating single pathological anatomical entities are likely to be limited.
The authors point that the diagnosis of PA, as the most common one, should be considered more often by clinicians working in this area—failure to do so underestimates the role of lower abdominal musculature in the genesis of athletic groin pain.
The authors conclude that reliance on clinical tests alone to make the diagnosis has the potential for inaccuracy and MRI support may improve diagnostic likelihood ratios. The conclusions highlight the presentation of multiple concurrent pathologies (a combined clinical radiological diagnosis) and lack of sensitivity of individual physical diagnostic tests.
Future work should be directed at understanding the underpinning biomechanical loads in change of direction and the development of femoroacetabular impingement and pubic bone oedema.
Direct link to our open access paper below:
Falvey EC et al. (2015) Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients – clinical findings, MRI findings and patient-reported outcome measures at baseline. Br J Sports Med.