{"id":10859,"date":"2023-11-10T06:00:10","date_gmt":"2023-11-10T05:00:10","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=10859"},"modified":"2023-11-09T02:08:56","modified_gmt":"2023-11-09T01:08:56","slug":"groin-pain-into-the-bermuda-triangle-part-3","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2023\/11\/10\/groin-pain-into-the-bermuda-triangle-part-3\/","title":{"rendered":"Groin Pain: Into the Bermuda Triangle Part 3"},"content":{"rendered":"

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

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

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

This is the penultimate Blog in a series dealing with Groin Pain.\u00a0 Part 1, on Adductor Related Groin Pain (ARGP) and Part 2, Iliopsoas Related Groin Pain (IRGP), can be found here: Part 1<\/a>; Part 2<\/a>.\u00a0 This part deals with Inguinal Related Groin Pain (IgRGP).<\/p>\n

Whilst the majority of groin related injuries in sport will be musculoskeletal in origin, clinicians should be cognisant of other potentially sinister pathologies such as cancer (1)<\/a>.\u00a0 A systematic review from Darren de et al., (2016) found that groin pain in athletes can be attributed to inguinal pathology in 10% of cases (2)<\/a>.\u00a0 Unfortunately, there is a dearth of high quality studies for the most efficacious management and rehabilitation for IgRGP (3)<\/a>.<\/p>\n

Inguinal Related Groin Pain (IgRGP)<\/span><\/p>\n

The diagnosis of IgRGP is pain in the inguinal canal region and tenderness of the inguinal canal (Figures 1 (12)<\/a> and 2 (13)<\/a>); no palpable inguinal hernia is present (4)<\/a>.\u00a0 Diagnosis of IgRGP is more likely if aggravated with abdominal resistance (Figure 3 (13)<\/a>) or valsava manoeuvre (5)<\/a>; cough or sneeze.\u00a0 Inter-examiner reliability for diagnosis of IgRGP from clinical examination has been found to be poor with no one clinical test identified to confirm the diagnosis (6)<\/a>.In some instances, if conservative measures have failed then surgical treatment is an option.\u00a0 The Lloyd Release (7)<\/a> being one such procedure.\u00a0 However, it would be prudent to exhaust all conservative measures before considering such invasive treatment.\u00a0 This could include, for example:<\/p>\n

Sports Surgery Clinic Sports Medicine Groin Lab – Abdominal Series YouTube<\/span><\/a> (8)<\/span><\/a><\/p>\n

The principles of <\/span>rehabilitation focused on inter-segmental control<\/span> (Sports Surgery Clinic Sports Medicine, 2018) <\/span>\u00a0<\/span>(9)<\/span><\/a> has been associated with improved Hip and Groin Outcome Scores (HAGOS) <\/span>(10)<\/span><\/a> scores and good rates of pain-free return to sport across <\/span>(11)<\/span><\/a> a variety of groin pain diagnoses <\/span>(4)<\/span><\/a>.<\/span>\u00a0<\/span><\/p>\n

The Copenhagen Hip and Groin Outcome Score (HAGOS) <\/span>(10)<\/span><\/a> is an appropriate patient reported outcome measure (PROM) to monitor rehabilitation from IgRGP; whether that is conservative rehabilitation or post-surgery rehabilitation.\u00a0 It has substantial test-retest reliability with adequate measurement qualities for use with physically active, young to middle-aged patients with long-standing hip and\/or groin pain.<\/span><\/p>\n

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Figure 1 Mean prevalence of palpation pain locations in athletes classified with IgRGP.\u00a0 *Scrotal Invagination (Vuckovic Z, Serner A, Heijboer WMP, <\/b>et al<\/i><\/b>., 2022) <\/b>(12)<\/span><\/a><\/p>\n

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Figure 2 Abdominal Palpation Tests (Serner A, Weir A, Tol JL, <\/b>et al<\/i><\/b>., 2016) <\/b>(13)<\/b><\/a><\/p>\n


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Figure 3 Abdominal Resistance Tests (Serner A, Weir A, Tol JL, <\/b>et al<\/i><\/b>., 2016) <\/b>(13)<\/b><\/a><\/p>\n

An exemplar series of HAGOS<\/span> (10)<\/b><\/a> scores for an apprentice footballer in a semi-professional environment is shown in Figure 4.\u00a0 Scores for each sub-scale range from 0 (extreme hip\/groin problems) to 100 (no hip\/groin problems) and can be easily calculated <\/span>(14)<\/span>.\u00a0 Surgical intervention via Llyod release was used in this case following diagnosis of IgRGP <\/span>(4)<\/span><\/a> which was recalcitrant to conservative physiotherapy rehabilitation.<\/span><\/p>\n

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Figure 4 Player Hip and Groin Outcome Scores (HAGOS) (Thorborg K, Holmich P, Christensen R, <\/b>et al<\/i><\/b>., 2011) <\/b>(10)<\/b><\/a><\/p>\n

As can be seen from Figure 4, there was a reduction in scores across all sub-scales (except symptoms), indicating worsening of the condition, during the period 17\/08\/2018 to 24\/08\/2018.\u00a0 This was due to increased training load prior to surgical intervention at request of the surgeon to aid in confirmation of diagnosis prior to surgical intervention.\u00a0 Following surgery in late August 2018, the HAGOS <\/span>(10)<\/b><\/a> scores showed an increasing trend across the sub-scales indicating improvement in condition.\u00a0 Approximately six weeks post-surgery, the player had improved sufficiently to return to full training being available for selection.\u00a0 Objective testing of isometric adductor strength (via hand held dynamometer) was used in conjunction with HAGOS <\/span>(10)<\/b><\/a> scores to guide return to play decisions.\u00a0 This allowed for monitoring of potentially low isometric adductor strength, or between-limb strength asymmetry, with the former potentially putting players at increased risk of groin injury <\/span>(15)<\/span><\/a>.<\/span><\/p>\n

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