Groin pain the athletic population has many labels, some of which are confusing, outdated or even unhelpful. Many patients are given a diagnostic label such as ‘Osteitis Pubis’, ‘Adductor tendon strain’, ‘Gilmore’s Groin’ or even ‘Sportsman’s hernia’. It’s perhaps more helpful to think of a clinical entity which is really about mechanical overload of structures which insert into the pubic bone area at the front of the pelvis. The anterior part of the bony pelvis is essentially two pubic bones meeting in the middle, separated by fibrocartilaginous joint called the pubic symphysis. The abdominal wall musculature (rectus abdominis muscle) attaches into this area from above, and the two adductor longus muscles attach into this area from below. Both are bonded by a tough, fibrous structure called an aponeurosis. The vast majority of patients who present with groin pain do not have a hernia, lump or torn structures, and do not need surgery. Biomechanical groin pain presents with pain which may be felt in the lower abdomen and an adductor muscles in the groin, and it feels as though it’s centred at the pubic bone area. It may be painful if you cough or sneeze, or sit up in bed. It tends to be flared up with activities such as kicking or running, and calms a little on days when you are relaxing. Unfavourable patterns of biomechanical loading across the pelvis (such as gluteal and lumbar control issues), create a compressive pattern of forces across the bony pelvis, and stress the structures that attach around it. On MRI imaging we can see the bony ‘oedema’ (overload) and inflammation within the symphysis and the surrounding structures, and this can be corrected with correcting the biomechanics causing the overload in the first place, sometimes with the use of injection therapy to help this along.

Stress fractures (and bony stress ‘responses’) are a spectrum of bony injuries that can occur anywhere in around the hip and pelvis as a result of biomechanical overload. Bone needs mechanical stress to be healthy, but too much biomechanical loading (as we commonly see when patients who have weak muscles ramp their training volumes) can lead to bone weakening. This initial stage of bone injury is often described as stress response, and if it continues, it may lead to the bone actually fracturing. It’s rare that the stress fracture will actually cause mechanical failure in the limb, but this is mostly because patients avoid loading through pain. Bony stress fractures are very common, but frequently missed, because patients or clinicians misinterpret the symptoms. Key features of bony stress injuries include pain when loading the hip or pelvis (e.g. pain with hopping or transferring weight from one leg to the other), and awareness of discomfort at night time, and (surprisingly), pain which may be difficult for a therapist to reproduce on examination. X-Rays are not a reliable way to rule out a stress fracture, and MRI is the gold standard investigation. We frequently see patients with femoral neck stress fractures, stress fractures of the pubic bones, and an area in the sacral bone known as the ‘ala’. Bony stress injuries are particularly frequent amongst runners, and people who have taken up a new physical challenge.

Stress fractures (and bony stress ‘responses’) are a spectrum of bony injuries that can occur anywhere in around the hip and pelvis as a result of biomechanical overload. Bone needs mechanical stress to be healthy, but too much biomechanical loading (as we commonly see when patients who have weak muscles ramp their training volumes) can lead to bone weakening. This initial stage of bone injury is often described as stress response, and if it continues, it may lead to the bone actually fracturing. It’s rare that the stress fracture will actually cause mechanical failure in the limb, but this is mostly because patients avoid loading through pain. Bony stress fractures are very common, but frequently missed, because patients or clinicians misinterpret the symptoms. Key features of bony stress injuries include pain when loading the hip or pelvis (e.g. pain with hopping or transferring weight from one leg to the other), and awareness of discomfort at night time, and (surprisingly), pain which may be difficult for a therapist to reproduce on examination. X-Rays are not a reliable way to rule out a stress fracture, and MRI is the gold standard investigation. We frequently see patients with femoral neck stress fractures, stress fractures of the pubic bones, and an area in the sacral bone known as the ‘ala’. Bony stress injuries are particularly frequent amongst runners, and people who have taken up a new physical challenge.

Posterior hip or buttock pain can be enormously frustrating for patients. There are several common causes which can include: hamstring paratendinopathy, ischiofemoral impingement and overload of the piriformis and hip rotator muscles. Buttock pain can also be caused by sciatica (which is pinching of the sciatic nerve created by an intervertebral disc bulge in the spine), and also pain which is referred from the spine’s facet joints. Pain which is felt in the ‘sit bone’ (ischial tuberosity) area is frequently due to hamstring overload. Pain which is felt in the buttock area when lying down with the hip turned out (as in the ‘frog’ position) is often due to a pinching of the quadratus femoris muscle between the ischial tuberosity and a bony structure on the femur called the less trochanter. This painful condition is called ‘ischiofemoral impingement’. Some patients have been told that they have a problem with their piriformis muscle called ‘piriformis syndrome’. This is actually a rare condition relating to an anatomical abnormality of the sciatic nerve passing through the piriformis muscle, and tends to be over-diagnosed. Some patients will experience pain in the piriformis muscle and hip rotator area (which approximates to where the top edge of a jeans pocket would sit), but it’s usually generated by over-tensioning of these structures which creates sore areas within them (sometimes called trigger points). Careful examination and MRI imaging can get to the root cause of buttock pain.