Muscle strain, sprain, tearing, overstretching, and overuse can all contribute to a groin injury. Groin injuries and pain are sometimes grouped together under the term sports hernia, but there can be numerous causes for groin injuries. If an athlete receives a sports hernia diagnosis, they are encouraged to ask their Physiotherapist to elaborate on which structures are involved.
Groin injuries
A groin injury is common, comprising 2 to 5 percent of all sports injuries. Typical groin injuries can vary according to the athlete’s age, gender, and sport, with some injuries more commonly occurring in certain sports. By far the most common type of groin injury is a pulled groin muscle, or groin strain. Symptoms of a groin strain are difficult to differentiate from other groin injury symptoms, such as fracture, so obtaining an accurate diagnosis from a physiotherapist trained in sports medicine is recommended.
Groin anatomy and injury
The groin area is made up of a complex and interconnected construction of bones, muscles, ligaments, tendons, and other soft tissue located in the lower abdomen, upper thighs, and urogenital area. The groin’s complex anatomy presents multiple opportunities for athletic injury, which can range from stress fractures in bones to pulled muscles to problems with the digestive and reproductive organs.
Common causes of groin injury
Groin injuries commonly occur in sports due to one or a combination of the following:
- Sudden stops and starts of the lower body, which are common in sports such as rugby, soccer and netball
- Overuse due to repetitive stress, such as the impact of distance running and triathlon training
- Sudden trauma, such as getting tackled hard on a playing field in rugby
Groin pain most often results from some type of injury to the muscle, tendon, or ligament(s) in the groin, upper leg, or hip area. These injuries frequently occur in athletes who play high-impact sports.
Groin injuries can be difficult to diagnose because many types of injuries in the groin area have similar symptoms. Injuries in nearby parts of the body, such as the hips, pelvis, lower back, abdomen, and upper leg can also cause referred pain in the groin. It is therefore advisable for any athlete experiencing an acute or chronic groin injury to seek medical attention for a diagnosis and treatment plan.
Signs and Symptoms of a Groin Injury
There are several indicators that a groin injury has occurred, most notably pain in the upper thigh or lower abdominal area. However, groin pain is not the only symptom, and sometimes pain in the groin area is actually referred from an injury in another nearby part of the body.
The most common symptoms of groin injury include:
Groin pain
Pain in the groin may appear suddenly, such as when a muscle, ligament, tendon or labrum is torn during sports. It may also develop over time due to overuse of either soft tissues or bones in the groin and hip area. Depending on the type of groin injury and its severity, the pain may be a nuisance, severe and debilitating, or somewhere between these two extremes.
Abdominal pain
Pain in the lower abdomen may be indicative of a groin injury. Some groin injuries that may cause either direct or referred abdominal pain include osteitis pubis and inguinal hernia. Coughing, sneezing, or straining during a bowel movement may worsen abdominal pain.
Pain that subsides with rest
Some types of groin injuries, such as athletic pubalgia (more commonly known as a sports hernia) have pain symptoms that go away during rest periods but come back when you return to playing sports. Pain may worsen during any twisting movements, such as turning the body to receive a catch or while doing a “cutting stride” in soccer.
Pain or tenderness at the touch or with deep muscle compression
Some types of groin injuries only cause pain and/or tenderness when the skin over the affected tissues is touched or pressed. Other times pain only appears when you do certain types of exercises that place strain on the deep pelvic-floor muscles, such as half sit-ups (abdominal crunches).
Swelling, discoloration, or stiffness
Swelling may develop in the groin, upper leg, or hip, depending on which tissue(s) is affected. Skin over the injury site may become red, bluish, black-and-blue, or black due to tearing of musculoskeletal tissue and surrounding blood vessels. You may have difficulty moving the hip or leg.
Joint disruption
Hip joint dislocations or subluxations are a rare but severe traumatic injury that occurs when the hip ball (head of the femur) comes out of the hip socket. The hips or upper legs may be visibly misaligned or shorter, and/or walking may be impossible. This injury requires immediate medical attention and transferring the athlete to the nearest emergency room.
Fever, nausea, or vomiting
Some groin injuries cause secondary symptoms such as joint or bone infections (osteomyelitis), strangulated intestines or other digestive disruptions, or otherwise compressed tissue that can result in either localized or systemic infections. Some of these secondary infections can be life-threatening, so anyone experiencing groin pain along with fever, nausea, or vomiting is strongly advised to seek immediate medical attention.
Pain in the genitals
Some types of musculoskeletal groin injuries can also affect one or more components of the reproductive system, especially in males. Pain in the scrotum is especially associated with inguinal hernia.
Athletes who experience one or more of the above symptoms are advised to consult with a qualified medical professional for evaluation and treatment.
Common Types of Groin Injury
There are many types of groin injury, some of which can occur together. In fact, as many as 90 percent of athletes experiencing groin pain have multiple types of groin injuries simultaneously.
Adductor strain (groin strain or pull)
By far the most common type of groin injury, a groin strain occurs when the adductor muscles, which are the major muscles on the inside of the thigh where it meets the pelvis, are stretched or torn beyond their normal range of motion. These muscles are especially prone to stretching or tearing when athletes make sudden stops or turns. Groin strains are common in runners and soccer players.
Groin strains typically cause pain and tenderness in the groin area and the inside of the thigh. Pain may intensify when patients bring their legs together or raise their knees, such as when taking high steps or doing plyometric (jumping) exercises. Athletes may feel a popping or snapping sensation in the adductor muscle at the time of injury when the fibers are stretched or torn.
Stress fractures of the femoral neck and/or pubic ramus bone
Stress fractures are tiny cracks that form in the bone over time and cause pain. The neck of the femur, or the narrow portion between the ball-shaped head and shaft where it joins the pelvis, can be subject to stress fractures in athletes in which repetitive impacts on the lower body are common, such as distance running, soccer, and dancers.
The pubic ramus bone is located at the bottom of the pelvis behind the genital area and is also associated with repetitive-impact fractures. Groin pain from a stress fracture in the pubic ramus bone may also spread to the buttock.
Avulsion fracture
An avulsion fracture occurs when the tendons that connect muscles to bone are torn at the connection site, resulting in pain and muscle weakness. Avulsion fractures in the groin are most common in adolescent athletes because the pelvic growth plates have not yet solidified.
Avulsion fractures in the pelvis are most likely to occur along the iliac crest (top of the hip bone). Avulsion fractures can also occur at the ischial tuberosity, which is the lowest point of the pelvic bone where it meets the hamstring.
Inguinal hernia
Inguinal hernia occurs when the lower abdominal muscles stretch or tear, often resulting in a bulge in the groin area as the abdominal organs press against or push through the weakened muscles. In addition to causing pain, an inguinal hernia can cause a pulling or dragging sensation in the groin, especially when lifting, stretching, bending over, or coughing. Inguinal hernias are more common in men, and are often associated with weightlifting.
Osteitis pubis
This condition’s symptoms are similar to adductor strain, but the injury is different. Instead of a muscle strain, it is characterized by chronic inflammation in the pubic symphysis joint and its surrounding soft tissue due to repetitive stress on the pelvis. Distance runners, soccer players, and dancers are most at risk.
Snapping hip syndrome
This term is applied to a number of different conditions that can cause a snapping sensation in the hip during movement. It often occurs when a muscle or tendon in the hip area is misaligned. While snapping hip syndrome can be more of an annoyance than a cause of severe groin pain, it can be a precursor to hip bursitis.
Sports hernia
Sports hernia is a term that is commonly applied to many types of groin injury. Tears that occurr in the muscles, ligaments, and tendons of the lower abdomen where they meet the adductors, rather than just a simple strain of the adductor(s) themselves. Unlike inguinal hernias, a sports hernia does not cause a visible bulge in the groin but rather pain in the lower abdominal area and hip adductor insertion.
Hip labral tears
Hip joint pain from a tear in the cartilage or labrum is another common cause of groin pain in athletes. These injuries can either occur suddenly or gradually over time. Hip labral tears are commonly associated with subtle bone deformities known as femoroacetabular impingement (FAI). It is becoming a more commonly recognized source of groin pain that may require surgical intervention if unresponsive to conservative treatment.
Physeal injuries
Also called growth plate injuries, physeal injuries can occur in younger athletes. They occur when a fracture affects the growth plate, a section of cartilage at the ends of longer bones in the body that gradually hardens, or ossifies, as part of the body’s growth process during childhood and adolescence. They can occur due to overuse or as acute injuries. The injury mechanism is similar to other soft-tissue sports injuries, but the weak point is the growth plate, rather than the bone, tendon or ligament. Physeal injuries in the groin generally occur in the top femoral growth plate where it meets the hip.
While uncommon, some types of groin injury have potentially life-threatening complications, such as bone infections or intestinal strangulation. While rare, the possibility of a serious injury, as well as the fact many athletes sustain multiple groin injuries at the same time, means even moderate levels of groin pain merit a consult at our physiotherapist.
Groin Injury Causes & Risk Factors
Dancers, soccer, and rugby players have the highest risk for adductor strain (also called a groin strain or pulled groin muscle), which is the most common type of groin injury. Rapid starts and stops while running and jumping are the chief causes of this injury.
Common causes of groin injury include:
Repetitive stress. There are several bony structures in the hip, pelvis, groin, and upper leg that can be subject to overuse stress fractures. These bones include the femoral head, the femoral neck, and the pubic ramus bone, among others. Other common groin injuries such as osteitis pubis and snapping hip syndrome are typically associated with repetitive stress that occurs over a long period of time.
Short, intense training periods. Some types of injuries that are typically associated with long-term overuse, such as pelvic stress fractures and osteitis pubis, may also develop quickly as a result of an intense training over a brief period, such as preparing for an upcoming sports event or dance recital.
Not resting following an acute groin injury, such as an adductor strain (groin pull). If an athlete “plays through the pain” rather than taking an appropriate break from the sport that contributed to the groin problem, an acute groin injury can become chronic.
Other groin injury risk factors
There are a number of factors that can increase an athlete’s risk of groin injury. These factors can increase athletes’ risk for sustaining a groin injury, but people without any of these can still develop a groin injury.
- Adolescent girls are at a higher risk of stress fractures in the groin area and elsewhere, though they can occur in both sexes and at many ages.
- Adolescent athletes of both sexes are at higher risk for avulsion fractures in the pelvis than adults.
- Military recruits undergoing basic training and athletes increasing the number and intensity of their training sessions frequently experience stress fractures.
- Sudden changes in athletic foot gear or playing surface can increase the risk of stress fractures.
- Overuse-related groin injuries’ gradual onset and relative low level of pain means that many athletes ignore symptoms until the injury becomes severe, which can complicate otherwise easy-to-treat injuries.
- Men are at greater risk of hernia, especially inguinal hernia.
Groin Injury Diagnosis
The complexity of groin anatomy and groin injuries in general can make them a challenge to diagnose. Athletes consulting their physiotherapist about their groin injury are advised to plan for a comprehensive examination process that may require more than one visit.
As a general rule, it is advisable to consult a physiotherapist with a specialization in sports medicine for diagnosing groin pain. Physiotherapist typically use a multi-tiered approach to diagnosing the root cause of groin pain.
Detailed patient history
The first and most important part of the diagnostic process is a complete patient history so a treatment plan can be customized to meet the unique needs of the patient. This usually consists of a thorough patient interview to determine exactly how, when, and where the symptoms began. For example, who is the patient and what are his or her athletic demands? When and where did the groin injury occur? How did the injury happen? What is the character of the pain and what makes the pain better or worse?
Physical examination
The physio will tailor the physical exam around the findings from the patient history. Patients may be asked to sit, stand, lie prone, and walk during the exam, so the physio can evaluate their gait, balance, hip flexion and range of motion, strength, and other factors such as pelvic alignment. Physiotherapist may palpate (touch) the injury site to determine which tissue(s) is affected or place the joint in specific positions to attempt to reproduce the pain.
Diagnostic imaging
X-ray or ultrasound are typically used initially, based on the physio’s probable suspected diagnosis. Magnetic resonance imaging (MRI) is frequently necessary to diagnose soft tissue groin injuries and some stress fractures.
Blood tests
Because some types of groin injury involve secondary infections and/or other systemic symptoms. A Physiotherapist may refer you to Physician to do a complete blood count and other common types of blood tests when diagnosing groin injuries.
Once the cause of the groin injury is determined, the correct treatment protocol can be applied.
