{"id":10818,"date":"2023-10-13T06:00:22","date_gmt":"2023-10-13T05:00:22","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=10818"},"modified":"2023-10-14T09:11:57","modified_gmt":"2023-10-14T08:11:57","slug":"groin-pain-into-the-bermuda-triangle-part-2","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2023\/10\/13\/groin-pain-into-the-bermuda-triangle-part-2\/","title":{"rendered":"Groin Pain: Into the Bermuda Triangle Part 2"},"content":{"rendered":"

Diagnosing, managing & rehabilitating injuries in the Bermuda Triangle<\/i><\/b><\/p>\n

Keywords<\/b>: <\/span>Groin Pain; Iliopsoas; Rehabilitation<\/b><\/p>\n

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Introduction<\/b><\/p>\n

Iliopsoas<\/span> related groin pain (IRGP), , is the second most common injury in the groin area, after adductor related groin pain (ARGP)<\/span>(1)<\/span><\/a>, <\/span>(2)<\/span><\/a> &<\/span> (3)<\/span><\/a>.\u00a0 This blog is the second in a series discussing some of the complexities of diagnosing, managing and rehabilitating groin injuries; this part focusing on IRGP.<\/span><\/p>\n

Iliopsoas Related Groin Pain (IRGP)<\/b><\/p>\n

IRGP is defined as <\/span>iliopsoas<\/span> tenderness and is most likely if there is pain on resisted hip flexion testing and\/or<\/span> pain on stretching the hip flexors <\/span>(4)<\/span><\/a>.\u00a0 Within the literature there is insufficient evidence to recommend a specific exercise protocol or modality <\/span>(5).\u00a0 The protocol studied by Thorborg <\/span>et al. <\/span><\/i>(2016) <\/span>(6) involving progressive resisted hip flexion concludes that simple hip flexor<\/span> strength training using elastic bands as external loading, for 6 weeks, substantially improves hip flexor<\/span> muscle strength.\u00a0 Exercises involved<\/span> using isometric, concentric and eccentric contractions.\u00a0 Fixation of the elastic band from below emphasises strengthening of <\/span>iliopsoas<\/span><\/i> (Figure 1) (Sportsinjuryclinic.net (2012) <\/span>(7)<\/span><\/a>).<\/span><\/p>\n

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Figure 1<\/strong>: Hip Flexion Using an Elastic Band Emphasising Strengthening of Iliopsoas (Sportsinjuryclinic.net 2012)<\/b><\/a> (7)<\/b><\/a><\/p>\n

It is possible that in combination with exercise therapy other interventions such as heat, manual therapy and stretching could prove beneficial for rehabilitation for IRGP, as such a multi-modal approach was found to result in a quicker return to sport compared to exercise therapy and return to running for ARGP <\/span>(8)<\/span><\/a>.A study by King <\/span>et al<\/span><\/i>. (2018) <\/span>(9)<\/span><\/a> found that athletes presenting with multiple painful anatomical sites of groin pain, including IRGP and ARGP, have improved Copenhagen Hip and Groin Outcome Scores (HAGOS) <\/span>(10)<\/span><\/a>.<\/span>They also found athletes had high rates of pain-free return to sporting participation and improved cutting performance due to biomechanical changes, when rehabilitation focused on inter-segmental control<\/span>.\u00a0 Assessment and improvement of neuromuscular control for hip flexion is well described by King <\/span>et<\/span><\/i> al.<\/span><\/i> (2018) <\/span>(11)<\/span><\/a>: see link: <\/span>Sports Surgery Clinic Sports Medicine Groin Lab- Hip Flexor Series<\/b><\/a> (11)<\/span><\/a>.\u00a0 With the focus being activation of deep hip flexor and prime mover <\/span>iliopsoas<\/span><\/i>, as opposed to use of more superficial synergist hip flexors such as <\/span>sartorius, adductor longus<\/span><\/i> or <\/span>tensor fascia latae<\/span><\/i>.<\/span><\/p>\n

Sports Surgery Clinic Sports Medicine Groin Lab- Hip Flexor Series<\/b><\/a> YouTube <\/span>(11)<\/span><\/a>\u00a0<\/span><\/p>\n

Due to the complex interplay between causes for groin pain <\/span>(4)<\/span><\/a> it is not surprising that rehabilitation involving therapeutic exercise on long-standing ARGP in athletes is beneficial for IRGP too<\/span>, particularly for lumbo-pelvic control (Figure 2) (12)<\/a>.\u00a0 The original rehabilitation of ARGP from <\/span>Holmich <\/span>et al<\/span><\/i>. (1999) <\/span>(13)<\/span><\/a> has been modified by the work of Yousefzadeh <\/span>et al.<\/span><\/i> (2018) <\/span>(12)<\/span><\/a>; the latter being reported as safer and more effective for return to play due to a greater emphasis on abdominal and pelvic stabilisation exercises.<\/span><\/p>\n

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Figure 2: <\/b>(a) \u2013 (j) Exercises for Early Inter-segmental Control (Yousefzadeh A, Shadmehr A, Olyaeu GR, et al.<\/i> 2018) (12)<\/a><\/p>\n

KEY<\/b> ABD: Abduction; BOS- Base of Support; CAD: Copenhagen Adduction.<\/span><\/p>\n

For clinicians working in sport with adolescents an important differential diagnosis is anterior inferior iliac spine (AIIS) avulsion fracture (Figure 3) <\/span>(14)<\/span><\/a>.\u00a0 AIIS avulsion fracture incidence is between 14.8 and 22.1%; more than 90% of these are mostly in males aged 14 to 17 years <\/span>(15)<\/span><\/a>.\u00a0 Common mechanisms of injury include concentric contraction (commencing sprinting); eccentric contraction (sliding-type injuries, pre-kicking actions <\/span>(16)<\/span><\/a> &<\/span> (17)<\/span><\/a>.\u00a0 Injury at the weaker apophysis compared to musculotendinous junction of <\/span>rectus femoris<\/span><\/i> occurs with AIIS avulsion fracture, often with a loud sound of rupture, followed by severe pain and disability of the injured limb <\/span>(14)<\/span><\/a> & <\/span>(18)<\/span><\/a>.<\/span><\/p>\n

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Figure 3:\u00a0<\/b>Plain Radiograph Pelvis Anteroposterior View Showing Right Anterior Inferior Iliac Spine Avulsion Fracture \u00a0<\/span>(Serbest S, Tosun HB, Tifikci U, et al<\/i>. 2015) (14)<\/a><\/p>\n

Conclusions<\/b><\/b><\/p>\n