Hip and Core Muscle Injuries in Soccer

ILIOPSOAS-RELATED GROIN PAIN

Iliopsoas strains account for 25% of acute groin strains and typically result from an impact that causes eccentric overload while kicking the ball.^7,12 Iliopsoas-related groin pain is defined by the Doha Agreement as groin pain that is reproducible with resisted hip flexion or hip flexor stretch.⁶ Iliopsoas strains respond well to conservative treatment such as rest, anti-inflammatory medication, and physical therapy. Rarely do these athletes become surgical candidates in the acute setting. Chronic cases of iliopsoas pathology occasionally require an arthroscopic intervention.

INGUINAL-RELATED GROIN PAIN

Inguinal-related groin pain is one of the most misleading diagnoses in sports because of its poorly defined and under-researched nature. The varying nomenclature of this entity illustrates the heterogeneity and includes sports hernia,^9,13-15 athletic pubalgia,¹⁶ core muscle injury,¹⁷ athletic hernia,¹⁸ Gilmore’s groin,¹⁵ osteitis pubis,¹⁹ sportsman’s hernia,^20,21 sportsmen’s groin,²² symphysis syndrome,²³ and inguinal disruption.²⁴ It is important to realize that in inguinal-related groin pain, regardless of the nomenclature, there is no true hernia present. The Doha Agreement has defined inguinal-related groin pain as “pain in the location of the inguinal region with associated tenderness of the inguinal canal,” which “is more likely if the pain is aggravated with resistance testing of the abdominal muscles or on Valsalva/cough/sneeze.”⁶ The condition is a painful soft tissue injury in the groin or inguinal area, involving a constellation of various anatomic areas including the abdominal musculature, sacroiliac joint, neural structures, pubic symphysis, adductors, and hip joint. This may account for up to 50% of chronic groin pain.^25,26

One important theory in the development of inguinal-related groin pain is its relationship with femoroacetabular impingement (FAI). Cadaver studies demonstrate that cam deformities cause a 35% increase in motion at the pubic symphysis altering the biomechanics of the adductors and abdominal musculature and, with repetitive stress, may lead to tearing or attenuation of the transversalis fascia, rectus abdominis, internal obliques, and/or external obliques.^12,27,28 Another prevailing theory of this is that the increased pubic stress causes weakness in the posterior portion of the inguinal canal, which then stretches and entraps the genitofemoral, ilioinguinal, lateral femoral cutaneous, or obturator nerves, ultimately causing pain.^28,29

Physical examination findings include pain over the conjoined tendon, pubic tubercle/symphysis (present in 22% of patients), adductor origin (36%), and inguinal ring.^25,30 Pain with resisted sit-ups is present in 46% of patients and pain with coughing/Valsalva is present in 10%.^25,30,31 Selective injections can be a critical part of the evaluation to differentiate inguinal-related groin pain from FAI, osteitis pubis, and adductor strains while helping to determine the appropriate treatment.^25,32 The role of advanced imaging is unclear as the clinical entity is still uncertain and the standard imaging findings have not been definitively established.³³ However, several studies have reported MRI findings suggestive of inguinal-related groin pain. One of the more common MRI findings is the “secondary cleft sign,” which requires injecting a dye into the pubic symphysis.³⁴ Several studies have shown that the radiographic dye extravasates preferentially into the side where the groin symptoms exist and are thought to be secondary to micro-tearing at the common attachment of the musculotendinous structures to the anterior pubis.^34,35 However, it should be noted that the lack of imaging findings does not exclude the possibility of inguinal-related groin pathology.

Initial treatment consists of rest, anti-inflammatory medication, injections, and physical therapy with core strengthening.²⁵ A study by Paajanen and colleagues³⁶ suggested that early surgical intervention may be preferred over conservative management in a randomized trial comparing physical therapy, injections, anti-inflammatory medication, and rest vs an extraperitoneal laparoscopic mesh repair behind the pubic symphysis. In the conservative group, 20% of athletes returned to sport at 1 month, 27% at 3 months, and 50% at 12 months.³⁶ In comparison, the surgical group had 67% return to sport at 1 month, 90% at 3 months, and 97% at 12 months.³⁶ If surgical management is chosen, there are a variety of surgical options including laparoscopy, open or mini-open repairs of the abdominal musculature/fascia or pelvic floor with and without mesh, neurolysis, and adductor release. Muschawek and Berger³⁷described a series of 129 patients that had an open-suture repair of the posterior wall of the inguinal canal with 67% of professional athletes returning to sport within 2 weeks and 83.7% of athletes returning to sport overall. The rates of return to play are consistently 80% to 100% without demonstrated superiority of one technique over another up to this point.³⁰

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