Pelvic, abdominal and groin pain - by David Galea (MSc, MCSP, Senior Physiotherapist)

INTRODUCTION

The term 'groin pain' is often used to describe a multitude of pelvic and groin injuries and covers a wide variety of injury scenarios (see Table 1). The complex anatomy, the possibility of co-existing injuries, and the various sources of origin, present the clinician with an immense challenge.

THE THORACIC SPINE, THE LUMBAR SPINE, THE SACROILIAC JOINT (PELVIS), THE HIP JOINT AND THE ABDOMINAL VISCERA SHOULD BE CONSIDERED AS A POSSIBLE SOURCE OF GROIN PAIN.

Groin pain is prevalent in athletes participating in ice hockey, fencing, handball, cross country skiing, hurdling, high jumping, and soccer. It is also noted in non-athletes and encompasses both active and sedentary people. In children and adolescents presenting with groin pain should prompt medical examination to rule out septic arthritis, avascular necrosis of the hip, Legg-Calve-Perthes disease, slipped capital femoral epiphysis, and apophyseal avulsion fractures.

EXAMINATION

When a person presents with groin pain, physiotherapists undergo a thorough examination. Apart from obtaining a careful history including the onset, inciting event, and aggravating factors, the emotional state (stress levels) of the person may also be considered.

IT IS KNOWN THAT STRESS MAY CAUSE MUSCLES IN THE LUMBOPELVIC-HIP REGION TO CLAMP RESULTING IN ALTERED MOTOR CONTROL AND EVENTUALLY INJUR..

Clinical examination should include adequate exposure of the groin and hip, inspection of the symmetry and anatomic irregularity, palpation of the affected areas for tenderness, assessment of the joint range of motion, measurement for leg length discrepancy, and evaluation of gait. Occasionally, the optimum time to perform an objective examination is after performing exercise that exacerbates the individual's pain.

As physiotherapists we believe that the amount of stability within the lumbopelvic-hip region has an important role to play in the cause of groin pain. Stability may be defined as the ability of the neuromuscular system to control and protect the lumbopelvic-hip region. This means that if muscular tone in the area is altered (hyper- or hypo- tonic), such that they are unable to sustain and transfer loads required for optimal function, there will be inadequate compression or stability being provided to the joints; hence the area will be vulnerable to injury. Therefore, part of our examination in patients with groin pain, when indicated, includes assessing the muscle capacity and muscle co-ordination (timing, sequencing of activation), and determining its effect on the pelvic girdle.

WE NOT ONLY LOOK AT THE INJURED STRUCTURE (SYMPTOMS). WE ALSO LOOK AT WHAT IS CAUSING THE STRUCTURE TO GET INJURED. WE ASK OURSELVES WHY THIS STRUCTURE IS PAINFUL?

TABLE 1 Different etiologies that may cause groin pain

TREATMENT

Treatment for groin pain must be prescriptive since every individual has a unique clinical presentation. Rarely will only one dysfunction be present; more commonly, multiple problems coexist. The first step for an appropriate management is to analyze the findings from the assessment thoroughly so as to make a correct diagnosis.

In most cases of groin pain that we have come across throughout our clinical experience, we have noted that the most effective treatment consisted of a unique combination of manual techniques and exercises specific for each patient, with non-steroidal anti-inflammatory drugs (NSAID's) playing an important role when indicated.

When the diagnosis is not clear enough or when surgical intervention is deemed to be a better option than conservative treatment, then referral to an orthopaedic consultant is our line of action. At the clinic we have the benefit of an in-house orthopaedic consultant, with whom we liaise on the person's condition and together determine the ideal management for that particular individual - further investigations, or discuss benefits of surgical / conservative management, or referral to another consultant (e.g. urologist; gynaecologist; neurologist).

TABLE 2 Physiotherapy intervention

INVESTIGATIONS

Investigations have a significant role to play in the management of groin pain and include:

Plain radiographs - may show established osteitis pubis, later stages of stress fracture (neck of femur or pubic ramus) and osteomyelitis, slipped femoral epiphysis, or hip joint abnormality (e.g. osteoarthritis).

Bone scan - may help demonstrate osteitis pubis, stress fracture, osteomyelitis, synovitis, avascular necrosis, sacroilitis, tenoperiosteal lesion, or muscle tear.

CT scans and MRI - may show disc pathology, radicular lesions, osteitis pubis; and any other bone and soft tissue including fatty infiltration of muscle, cysts.

Sonograms - may be useful to show a muscle tear, haematoma, inguinal hernia, or bursitis.

Nerve conduction studies - may demonstrate ilioinguinal neuropathy or obturator neuropathy.

ACCURATE DIAGNOSIS IS PARAMOUNT IN ORDER TO ACHIEVE EFFECTIVE AND EFFICIENT MANAGEMENT OF GROIN PAIN.

Figure 1 The pelvic girdle - composed of L5-S1, SI joints, hip joints and symphysis pubis.

Figure 2 Important muscles for stability in the groin area - transversus abdominis (left); multifidus (right)

Figure 3 The lumbopelvic-hip region and some of its muscle attachments - Including pelvic floor (left); external hip rotators (right)