Hip and groin pain affecting athletes has received a lot of attention in the media the past few years. Pick your favorite professional sport and chances are there have been any number of athletes that have been affected, to the point where practice and game time, as well as performance, have been impacted.

Since this is football season, you only have to look as far as the other week to read that Corey Clement, starting running back for the University of Wisconsin Badgers, is sidelined with a groin injury. Closer to home, Zach Ertz of the Philadelphia Eagles missed time this season with a groin injury. This is no longer an injury that is only prevalent in soccer or ice hockey players.

Tricky injuries to self-diagnose

While the sports medicine community has a better understanding of these injuries, there is still a need for improved evaluation and management of an active person with pain in the hip, groin and core area of the body.

For the athlete with hip, groin or core pain that is associated or exacerbated by their sport or exercise, it is important to differentiate between symptoms that originate from within the hip joint versus those whose genesis is outside of it. This can be very difficult for the athlete to determine themselves unfortunately. And further confusing the issue, is that pain in this area may not even be related to the musculoskeletal system (muscles, tendons, ligaments, bones and joints)—it might actually be coming from the gastrointestinal or gynecologic organs and systems of the body. The pain could also be referred from the lumbar spine.

Putting aside these other causes of hip, groin and core pain, however, we will focus here on the causes of hip, groin and core pain that are related to the muscle, tendons, ligaments, bones and joints of the hip and pelvis in the active person—problems that would be treated by sports medicine professionals.

What is causing the pain?

Inside the ball and socket hip joint there can be multiple etiologies to an athlete's hip pain, and here are just a few that may be seen in athletes: damage to the articular cartilage that lines the joint (degenerative joint disease); an injury to the labrum, the lip of cartilage around the socket that helps stabilize the ball shaped head of the femur; bony changes from repetitive movement that can result in impingement within the joint (femoral acetabular impingement), developmental issues like developmental dysplasia of the hip in which the joint is not formed fully; a stress fracture of the hip, avascular necrosis in which there is dead bone within the joint, and abnormal thickening of the synovium that lines the joint.

Outside the femoral acetabular joint, there are a number of muscle and tendon structures that are necessary for running, jumping, cutting, pivoting and deceleration – all of these can be injured and cause pain in the athlete: the rectus abdominis, the adductor muscles (there are three), the hamstring muscles (also three), gluteus muscles, piriformis, iliopsoas, sartorius, and iliotibial band. It is important to note that an injury to any or several of these muscle-tendon structures may be acute or more often acute on chronic, and that there does not have to be an acute specific tear for it to be injured. More commonly we are seeing tendinopathy of these structures, which in a general sense can mean that scar tissue has formed within the tendon itself – i.e., there are tendon structural changes that cause pain and dysfunction in the athletes.

There can also be bony or mechanical causes of hip, groin and core pain: the pelvis can have stress fractures in any part (pubic rami, ischial tuberosity, sacrum); there are other joints including the symphysis pubis (osteitis pubis refers to irritation of this joint) and the sacro-iliac joints that can cause pain; snapping hip syndrome where the iliopsoas muscle may snap over the rim of the pelvis causing a painful snapping sensation with certain movements; iliotibial band (IT) syndrome where the IT tendon pops back and forth over the greater trochanter prominence; and less commonly ischio-femoral impingement, another area of possible painful impinging outside the ball and socket joint.

In younger athletes, apophyseal injuries to the growth plates can occur in the hip and groin area, specifically the anterior superior iliac spine, the anterior inferior iliac spine, the ischial tuberosity, and the lessor trochanter; these are areas of insertion of specific muscles into the hip and pelvis and thus areas under tension especially in sports and exercise related activities. These are sometimes referred to as growing pains in a young athlete, but this term can be misleading as it implies a benign nature to the condition.

When should you see a doctor?

If something hurts to the point where the athlete's performance is impaired, he or she is avoiding certain activities because of the symptoms, or is taking a pain medication, consider seeking further professional evaluation.  Certainly pain that is waking the athlete—of any age—from sleep, or that is associated with normal routine activities like using the bathroom, sitting, standing, or walking may be an indication for further medical advice.

So having mentioned a number of causes of hip, groin, and core pain in an athlete (and the list above is by no means 100 percent complete), where and how do we, as healthcare providers for athletes, begin in the evaluation?

  • A thoughtful intake of the history, a careful physical exam, and a judicious use of supporting studies are important.
  • A multidisciplinary approach to the athlete is also helpful – sports medicine physicians, general surgeons, orthopedic surgeons, physical therapists and sometimes gynecologists can all play a role.
  • Often there can be multiple issues in the same athlete. It is critical to have an assessment of all the factors, etiologies, and concerns that are impacting the athlete.
  • Sometimes imaging studies and other diagnostic studies are ordered to further support or to disprove certain diagnoses.

Only from there can a careful, thoughtful approach to the management begin—one that will hopefully, allow the athlete to return to play. It is important to prioritize what may be contributing to the athlete's symptoms, and then develop the plan of action, or plans of action, according to the priority list of contributing factors.

A further challenge for healthcare providers in treating an athlete with hip, groin and core pain is to think globally and holistically about the patient. Physicians in particular are trained to think linearly – point A leads to point B leads to point C and so on. Sometimes in caring for athletes with hip, groin, and core injuries point A leads to point B which leads to point X or Y. Fortunately, physicians are also trained to assimilate a lot of different information, from multiple directions, and then synthesize a working diagnosis, or sometimes multiple diagnoses simultaneously; we then formulate a rational, and hopefully optimal, approach to the evaluation and management of the concern and ultimately the patient.

Our ultimate goal as healthcare providers for athletes is to help the patient maximize their comfort and to restore, maximize and preserve their function, including sports and exercise for all ages and levels of performance – from ages 5 to 95 (and beyond) and for weekend warriors to professional athletes alike.  As the American College of Sports Medicine likes to say: Exercise is Medicine!

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