The difficulty in classifying and accurately diagnosing groin pain is well documented (Holmich et al, 1999, Weir et al, 2011 and Weir et al, 2015) and known to often be a multifactorial problem (Malliaras et al 2015, Tyler 2001, Mosler et al, 2015)). The need for further good quality research into all aspects of ‘groin pain’ is widely recognised (Weir et al, 2015 and Serner et al, 2015).

In the GG&C pathway we have classified groin pain using the Doha agreement statement (Weir et al, 2015). This was chosen as it is the most up to date classification and its purpose was to agree on standard terminology and provide definitions for these. The classification system has three sub-headings of groin pain in athletes:

1. Defined Clinical Entities:
   • Adductor-related groin pain 3.9
   • Iliopsoas-related groin pain 3.3
   • Inguinal-related groin pain (out of scope of this pathway)
   • Pubic-related groin pain (out of scope of this pathway)
2. Hip-related groin pain
3. Other causes of groin pain

The main focus is on ROM, palpation and strength.  Not all tests have been subjected to all aspects of reliability and validity testing.  Most studies involve small cohorts groups with participates mainly young male athletes from a variety of sports (soccer, Aussie rules and ice hockey).  Very few studies have attempted to sub classify groin pain.

Strength

Hand held dynamometry has been commonly used to record strength.  Very limited studies in the strength have been carried out.  The evidence suggests:

1. Squeeze test (Video Link)

Strong evidence (Grade B).  This test has been found to be both reliable to assess pain (Holmich 2004, Verrall 2005) and strength (Verall et al, 2005, Mens et al, 2006 and Malliaras et al, 2009) in those with groin pain. (Mosler et al, 2015).

Squeeze test is recommended as a screening tool, to detect the presence of groin pain and to monitor treatment response.

Technique: With patient supine flex hips to 45° flexion and knees to 90°. Therapist places fist in between knees and asks patient to squeeze.

2. Hip adductor/ adductor ratio

Moderate evidence (Grade B).  Tyler et al (2001) found that those with reduced adductor strength in comparison to abduction were more likely to injury their groin. They recommend that adductor strength should be > 90% that of abductors.

3. Hip flexion

Limited evidence (when using isokinetic dynamometer).  One high quality study (Mohammed et al, 2014) demonstrated greater hip flexion strength and ratio of hip flexor/ extensor strength in those with osteitis pubis.

Hip ROM

Mosler et al (2015) suggests measuring hip rotation in 90° flexion may have greater clinical use in assessment of hip/groin pain.

1. Bent knee fall out (Video Link)

Strong evidence (grade B) that restriction is present in patients with hip/ Groin pain (Mallaris et al, 2009 and Mosley et al, 2015).

2. Internal rotation

Strong evidence (Grade B) that restriction can detect those with groin pain (Mosely et al, 2015).

3. External rotation

Limited evidence (grade B)  Studies suggest that when measured in flexion it may be able to detect groin pain (Verrall et al, 2005 and Mosler et al, 2015).

Pain Provocation Tests

Limited evidence that these tests are helpful in the diagnosis of Hip/Groin pain (tests include single leg adductor test/ bilateral adductor test/ active straight leg raise/ pelvic belt test and impingement test)

Trunk function

Strong evidence (grade B) that different aspects of core stability are altered in patients with hip/ groin pain (Holmich et al, 2011 and Mosler et al, 2015).

Patient reported outcome measures

Moderate evidence (grade B) suggests that The Copenhagen Hip and Groin Outcome Score (HAGOS) is recommended for the assessment of young to middle aged adults including athletes with groin pain (Weir et al, 2015 and Thorborg et al, 2015).

Other suitable tests include Hip outcome score (HOS), International Hip Outcome Tool-12 (IHOT-12) and International Hip Outcome Tool-33 (IHOT-33) (Thorborg et al, 2015).

X-ray

• Very limited evidence that they can differentiate between persons with or without groin pain (Mosler et al, 2015).

MRI

• Moderate evidence that the presence of pubic bony oedema and secondary cleft sign are seen in subjects with groin pain (Mosler et al, 2015).

International Hip Outcome Tool-2 (IHOT12)

International Hip Outcome Tool-33 (IHOT33)

Evidence

Holmich, P., Uhrskou, P and Ulnits, L., Kanstrup, I.L., Nielsen, M.B., Bjerg, A.M. and Krogsgaard, K. 1999. Effectiveness of active physical training for long standing adductor- related groin pain in athletes: ramdomised trial. The Lancet: 353 (9151) : 439-443 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Holmich, P., Holmich, L.R. and Bjerg, A.M. 2004. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. British Journal Sports Medicine: 38: 446-51. Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Holmich, P., Nyvold, P. and Larsen, K. 2011. Continued significant effect of physical training as treatment for overuse injury: 8- to 12-yearoutcome of a randomized clinical trial.. American Journal of Sports Medicine;39(11):2447–51 Link Here

Malliaras, P., Hogan, A., Nawrocki, A., Crossley, K. and Schache, A. 2009. Hip flexibility and strength measures: reliability and association with athletic groin pain, British Journal of Sports Medicine 43: 739 -744 Link Here (link correct as of 21/01/21). NHS Scotland Athens username and password may be required.

Mens, J., Inklaar, H., Koes, B.W. and Stam, H.J. 2006. A new view on adductor – related groin pain. Clinical Journal Sports Medicine 2006: 16:15-19

Mohammed, W.S., Abdelraouf, O.R. Elhafez, S.M., Adbel-Aziem, A.A. and Nassif, N.S. 2014. Isokinetic imbalance of hip muscles in soccer players with oseitis pubis: Journal of Sports Science: 32; 934-9 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Mosler, A.B., Agricola, R., Weir, A., Holmich, P. and Crossley, K.M. 2015. Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta- analysis. British Journal of Sports Medicine 49(12): 810 Link Here(link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Serner, A., van Eijck, C.H., Beumer, B.R., Holmich, P., Weir, A. and de Vos, R.J. 2015. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes: British Journal of Sports Medicine; 49(12): 813 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Thorberg, K., Tijssen, M., Habets, B., Bartels, E.M., Roos, E.M., Kemp, J., Crossley, K.M. and Holmich, P. 2015. Patient- reported outcome (PRO) questionnaires for young to middle- aged adults with hip and groin disability: a systemic review of the clinimetric evidence: British Journal of Sports Medicine: 49(12): 812 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Verrall, G.M., Hamilton, I.A., Slavotinek, J.P., Oakeshott, R.D., Spriggins, A.J., Barnes, P.G. and Fon, G.T. 2005. Hip joint range of motion reduction in sports-related chronic groin injury diagnosed as pubic bone stress injury. Journal of Science and Medicine in Sport 8(1):77–84 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Tyler, T.F., Fukunaga, T. And Gellert, J. 2014. Rehabilitation of soft tissue injuries of the hip and pelvis. International Journal of Sports Physical Therapy, 9(6): 785-797 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A.G., Schilders, E., Serner, A., Silvers, H., Thorborg, K., Tyler, T., Verrall, G., de Vos, R.J., Vuckovic, Z. and Holmich, P. 2015. Doha agreement meeting on terminology and definitions of groin pain in althletes. British Journal of Sports Medicine 49 (12): 768-774 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.

Weir, A., Jansen, J.A., van de Port, I.G., Van de Sande, H.B., Tol, J.L. and Backx, F.J. 2011. Manual or exercise therapy for longstanding adductor-related groin pain: a randomised controlled clinical trial. Manual Therapy 16(2): 148–54 Link Here (link correct as of 22/01/21). NHS Scotland Athens username and password may be required.