Groin pain in athletes: understanding the problem and the role of ultrasound
https://doi.org/10.24835/1607-0771-361
Abstract
Groin pain in athletes remains one of the most challenging and controversial issues in modern sports medicine. Behind the apparent simplicity of clinical manifestations lies a wide spectrum of pathological conditions requiring thorough differential diagnostic analysis. Diagnostic errors often lead to the chronicity of the condition, reduced athletic performance, and prolonged rehabilitation periods. This review is dedicated to the systematization and critical assessment of current perspectives on the terminology, classification, anatomy, and clinical presentation of groin pain in athletes. Particular attention is paid to the issues of medical imaging and the capabilities of ultrasound as a primary and dynamic method for assessing the state of the groin region in athletes.
About the Authors
E. D. Khudorozhkova
Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation
Russian Federation
Russian Federation
Ekaterina D. Khudorozhkova – MD, Assistant Professor, Diagnostic Ultrasound Division, Russian Medical Academy of Continuous Professional Education, Moscow
https://orcid.org/0000-0002-3348-8343
V. G. Saltykova
Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation
Russian Federation
Russian Federation
Victoria G. Saltykova – MD, PhD, Doct. of Sci. (Med.), Professor, Diagnostic Ultrasound Division, Russian Medical Academy of Continuous Professional Education, Moscow
https://orcid.org/0000-0003-3879-6457
M. D. Mitkova
Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation
Russian Federation
Russian Federation
Mina D. Mitkova – MD, PhD, Associate Professor, Diagnostic Ultrasound Division, Russian Medical Academy of Continuous Professional Education, Moscow
https://orcid.org/0000-0002-3870-6522
Scopus Author ID: 57192940046
V. V. Mitkov
Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation
Russian Federation
Russian Federation
Vladimir V. Mitkov – MD, PhD, Doct. of Sci. (Med.), Director, Diagnostic Ultrasound Division, Russian Medical Academy of Continuous Professional Education, Moscow
https://orcid.org/0000-0003-1959-9618
Scopus Author ID: 57192938926
References
1. Bezuglov E.N., Kanner D.Yu. Groin pain syndrome in athletes: etiology, diagnosis, and treatment. Sports Medicine: Research and Practice. 2015; 4: 83–88. (In Russian)
2. Mitrousias V., Chytas D., Banios K. et al. Anatomy and terminology of groin pain: current concepts. J. Isakos. 2023; 8 (5): 381–386. https://doi.org/10.1016/j.jisako.2023.05.006
3. Thorborg K., Reiman M.P., Weir A. et al. Clinical examination, diagnostic imaging, and testing of athletes with groin pain: an evidence-based approach to effective management. J. Orthop. Sports Phys. Ther. 2018; 48 (4): 239–249. https://doi.org/10.2519/jospt.2018.7850
4. de Sa D., Hölmich P., Phillips M. et al. Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br. J. Sports Med. 2016; 50 (19): 1181–1186. https://doi.org/10.1136/bjsports-2015-095137
5. Chopra A., Robinson P. Imaging athletic groin pain. Radiol. Clin. N. Am. 2016; 54 (5): 865–873. https://doi.org/10.1016/j.rcl.2016.04.007
6. Dempsey P.J., Power J.W., MacMahon P.J. et al. Nomenclature for groin pain in athletes. Br. J. Radiol. 2021; 94 (1126): 20201333. https://doi.org/10.1259/bjr.20201333
7. Serner A., van Eijck C.H., Beumer B.R. et al. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br. J. Sports Med. 2015; 49: 813. https://doi.org/10.1136/ bjsports- 2014-094256
8. Whittaker J.L., Small C., Maffey L., Emery C.A. Risk factors for groin injury in sport: an updated systematic review. Br. J. Sports Med. 2015; 49 (12): 803–809. https://doi.org/10.1136/bjsports-2014-094287
9. Weir A., Brukner P., Delahunt E. et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br. J. Sports Med. 2015; 49 (12): 768–774. https://doi.org/10.1136/bjsports-2015-094869
10. Sheen A.J., Stephenson B.M., Lloyd D.M. et al. Treatment of the sportsman's groin: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br. J. Sports Med. 2014; 48 (14): 1079–1087. https://doi.org/10.1136/bjsports-2013-092872
11. Bisciotti G.N., Volpi P., Zini R. et al. Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete. BMJ Open Sport Exerc. Med. 2016; 2 (1): e000142. https://doi.org/10.1136/bmjsem-2016-000142
12. Bisciotti G.N., Zini R., Aluigi M. et al. Groin pain syndrome Italian Consensus Conference update 2023. J. Sports Med. Phys. Fitness. 2024; 64 (4): 402–414. https://doi.org/10.23736/S0022-4707.23.15517-4
13. Zuckerbraun B.S., Cyr A.R., Mauro C.S. Groin pain syndrome known as sports hernia: a review. JAMA Surg. 2020; 155 (4): 340–348. https://doi.org/10.1001/jamasurg.2019.5863
14. Lee S.C., Endo Y., Potter H.G. Imaging of groin pain: magnetic resonance and ultrasound imaging features. Sports Health. 2017; 9 (5): 428–435. https://doi.org/10.1177/1941738117694841
15. Eckard T.G., Padua D.A., Dompier T.P. et al. Epidemiology of hip flexor and hip adductor strains in National Collegiate Athletic Association Athletes, 2009/2010–2014/2015. Am. J. Sports Med. 2017; 45 (12): 2713–2722. https://doi.org/10.1177/0363546517716179
16. Werner J., Hägglund M., Ekstrand J., Waldén M. Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men’s professional football: the 15-year prospective UEFA Elite Club Injury Study. Br. J. Sports Med. 2019; 53 (9): 539–546. https://doi.org/10.1136/bjsports-2017-097796
17. Pilkington J.J., Obeidallah R., Baltatzis M. et al. Totally extraperitoneal repair for the ‘sportsman’s groin’ via ‘the Manchester Groin Repair’: a comparison of elite versus amateur athletes. Surg. Endosc. 2021; 35 (8): 4371–4379. https://doi.org/10.1007/s00464-020-07930-9
18. Sheen A.J., Pilkington J.J., Dudai M., Conze J.K. The Vienna Statement; an update on the surgical treatment of sportsman’s groin in 2017. Front. Surg. 2018; 5: 45. https://doi.org/10.3389/fsurg.2018.00045
19. Kler A., Sekhon N., Antoniou G.A., Satyadas T. Totally extra-peritoneal repair versus trans-abdominal pre-peritoneal repair for the laparoscopic surgical management of sportsman’s hernia: a systematic review and meta-analysis. Surg. Endosc. 2021; 35 (10): 5399–5413. https://doi.org/10.1007/s00464-021-08554-3
20. Sheen A.J., Montgomery A., Simon T. et al. Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman’s hernia. Br. J. Surg. 2019; 106: 837–844. https://doi.org/10.1002/bjs.11226
21. Scillia A.J., Pierce T.P., Simone E. et al. Mini-open incision sports hernia repair: a surgical technique for core muscle injury. Arthrosc. Tech. 2017; 6: e1281–1284. https://doi.org/10.1016/j.eats.2017.05.006
22. Rennie W.J., Lloyd D.M. Sportsmans Groin: the inguinal ligament and the Lloyd technique. J. Belgian Soc. Radiol. 2017; 101: 16. https://doi.org/10.5334/jbrbtr.1404
23. Gill T.J., Wall A.J., Gwathmey F.W. et al. Affiliations Expand Surgical release of the adductor longus with or without sports hernia repair is a useful treatment for recalcitrant groin strains in the elite athlete. Orthop. J. Sport Med. 2020; 8:2325967119896104. https://doi.org/10.1177/2325967119896104
24. Pesquer L., Reboul G., Silvestre A. et al. Imaging of adductor-related groin pain. Diagn. Interv. Imaging. 2015; 96 (9): 861–869. https://doi.org/10.1016/j.diii.2014.12.008
25. Strauss E.J., Campbell K., Bosco J.A. Analysis of the cross-sectional area of the adductor longus tendon: a descriptive anatomic study. Am. J. Sports Med. 2007; 35: 996–999. https://doi.org/10.1177/0363546506298583
26. Robinson P., Salehi F., Grainger A. et al. Cadaveric and MRI study of the musculo-tendinous contributions to the capsule of the symphysis pubis. Am. J. Roentgenol. 2007; 188: 440–445. https://doi.org/10.2214/AJR.06.1238
27. Weir A., Robinson P., Hogan B., Franklyn-Miller A. MRI investigation for groin pain in athletes: is radiological terminology clarifying or confusing? Br. J. Sports Med. 2017; 51 (16): 1185–1186. https://doi.org/10.1136/bjsports-2016-096973
28. Dimitrakopoulou A., Schilders E. Current concepts of inguinal-related and adductor-related groin pain. Hip. Int. 2016; 26 Suppl 1: 2–7. https://doi.org/10.5301/hipint.5000403
29. Thorborg K. Current clinical concepts: exercise and load management of adductor strains, adductor ruptures, and long-standing adductor-related groin pain. J. Athl. Train. 2023; 58 (7–8): 589–601. https://doi.org/10.4085/1062-6050-0496.21
30. Schilders E., Bharam S., Golan E. et al. The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept. Knee Surg. Sports Traumatol. Arthrosc. 2017; 25 (12): 3969–3977. https://doi.org/10.1007/s00167-017-4688-2
31. Tharnmanularp S., Muro S., Nimura A. et al. Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain. Anat. Sci. Int. 2024; 99 (02): 190–120. https://doi.org/10.1007/s12565-023-00750-6
32. Mathieu T., Van Glabbeek F., Denteneer L. et al. New anatomical concepts regarding pubic-related groin pain: a dissection study. Ann. Anat. 2024; 254: 152238. https://doi.org/ 10.1016/j.aanat.2024.152238
33. Branci S., Thorborg K., Nielsen M.B., Hölmich P. Radiological findings in symphyseal and adductor-related groin pain in athletes: a critical review of the literature. Br. J. Sports Med. 2013; 47 (10): 611–619. https://doi.org/10.1136/bjsports-2012-091905
34. Bisciotti G.N., Di Pietto F., Rusconi G. et al. The role of MRI in groin pain syndrome in athletes. Diagnostics (Basel). 2024; 14 (8): 814. https://doi.org/10.3390/diagnostics14080814
35. Falvey E.C., King E., Kinsella S., Franklyn-Miller A. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients – clinical findings, MRI findings and patient-reported outcome measures at baseline. Br. J. Sports Med. 2016; 50 (7): 423–430. https://doi.org/10.1136/bjsports-2015-094912
36. Schilders E., Talbot J.C., Robinson P. et al. Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J. Bone Joint Surg. Am. 2009; 91: 2455–2460. https://doi.org/10.2106/JBJS.H.01675
37. Branci S., Thorborg K., Bech B.H. et al. The Copenhagen standardised MRI protocol to assess the pubic symphysis and adductor regions of athletes: outline and intratester and intertester reliability. Br. J. Sports Med. 2015; 49: 692–699. https://doi.org/10.1136/bjsports-2014-094239
38. Omar I.M., Zoga A.C., Kavanagh E.C. et al. Athletic pubalgia and “sports hernia”: оptimal MR imaging technique and findings. Radiographics. 2008; 28: 1415–1438. https://doi.org/10.1148/rg.285075217
39. Khan W., Zoga A.C., Meyers W.C. Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice. Magn. Reson. Imaging Clin. N. Am. 2013; 21 (1): 97–110. https://doi.org/10.1016/j.mric.2012.09.008
40. Becker I., Woodley S.J., Stringer M.D. The adult human pubic symphysis: a systematic review. J. Anat. 2010; 217: 475–487. https://doi.org/10.1111/j.1469-7580.2010.01300.x
41. Pesquer L., Rennie W.J., Lintingre P.F. et al. Ultrasound of groin pain in the athlete. Semin. Musculoskelet. Radiol. 2024; 28 (6): 672–682. https://doi.org/10.1055/s-0044-1790525
42. Genovese E.A., Tack S., Boi C. et al. Imaging assessment of groin pain. Musculoskelet. Surg. 2013; 97 Suppl 2: 109–116. https://doi.org/10.1007/s12306-013-0278-8
43. Campbell R. Ultrasound of the athletic groin. Semin. Musculoskelet. Radiol. 2013; 17 (1): 34–42. https://doi.org/10.1055/s-0033-1333912
44. Ostrom E., Joseph A. The use of musculoskeletal ultrasound for the diagnosis of groin and hip pain in athletes. Curr. Sports Med. Rep. 2016; 15 (2): 86–90. https://doi.org/10.1249/JSR.0000000000000248
45. Jacobson J.A., Khoury V., Brandon C.J. Ultrasound of the groin: techniques, pathology and pitfalls. AJR Am. J. Roentgenol. 2015; 205(03): 513–523. https://doi.org/10.2214/AJR.15.14523.
46. Lungu E., Michaud J., Bureau N.J. US assessment of sports-related hip injuries. Radiographics. 2018; 38(03): 867–889. https://doi.org/ 10.1148/rg.2018170104
47. Santilli O.L., Nardelli N., Santilli H.A., Tripoloni D.E. Sports hernias: experience in a sports medicine center. Hernia. 2016; 20(01): 77–84. https://doi.org/10.1007/s10029-015-1367-4
48. Dallaudiere B., Sylvain B., Poussange N. et al. Ultrasound feature variants of the adductor longus tendon in asymptomatic sportive subjects: management implications. Eur. J. Radiol. 2021; 144: 109928. https://doi.org/10.1016/j.ejrad.2021.109928
49. Sailly M., Whiteley R., Read J.W. et al. Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Br. J. Sports Med. 2015; 49 (12): 828–834. https://doi.org/10.1136/bjsports-2014-094436
50. Murphy G., Foran P., Murphy D. et al. “Superior cleft sign” as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman's hernia. Skeletal Radiol. 2013; 42 (6): 819–825. https://doi.org/10.1007/s00256-013-1573-z
51. Jin W., Kim K.I., Rhyu K.H. et al. Sonographic evaluation of anterosuperior hip labral tears with magnetic resonance arthrographic and surgical correlation. J. Ultrasound Med. 2012; 31 (03): 439–447. https://doi.org/10.7863/jum.2012.31.3.439
52. Mosler A.B., Weir A., Eirale C. et al. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. Br. J. Sports Med. 2018; 52: 292–297. https://doi.org/10.1136/bjsports-2016-097277
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For citations:
Khudorozhkova E.D., Saltykova V.G., Mitkova M.D., Mitkov V.V. Groin pain in athletes: understanding the problem and the role of ultrasound. Ultrasound & Functional Diagnostics. 2025;31(4):81-92. (In Russ.) https://doi.org/10.24835/1607-0771-361
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