Approach to hip and groin pain in the athlete and active adult
- Rob Johnson, MD
Rob Johnson, MD
- Professor of Family Medicine and Community Health
- University of Minnesota
- Team Physician
- University of Minnesota Athletics
- Section Editors
- Peter Fricker, MBBS, FACSP
Peter Fricker, MBBS, FACSP
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Exercise, Sports Nutrition, and Miscellaneous; Sports-Related Injuries
- Adjunct Professor
- Griffith University
- Institute of Sport, Exercise, and Active Living
- Victoria University
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Hip and groin injuries occur less frequently than injuries of the knee and ankle in the athletic population but contribute significantly to morbidity among the physically active. The broad differential diagnosis and nonlocalizing pain typical of many hip and groin conditions can make a diagnosis difficult to establish. Injuries of the hip and groin are most easily classified as extra-articular and intra-articular injuries. Unlike most joints of the musculoskeletal system, the hip joint is deep, protected by pelvic musculature, and not readily palpable. In fact, according to some studies, patients with intra-articular hip pathology see an average of 3.3 clinicians before a clear diagnosis is established [1,2]. Thus, an informed, systematic approach to assessment and diagnosis is important.
The evaluation of hip and groin pain in athletic and active adults is reviewed here, including a general scheme for differentiating among the common causes of such pain based upon the history and key clinical findings. Detailed discussions of some of the specific conditions and injuries that cause hip and groin pain are found separately. (See "Greater trochanteric pain syndrome (formerly trochanteric bursitis)" and "Overview of stress fractures" and "Sports-related groin pain or 'sports hernia'" and "Osteitis pubis" and "Hamstring muscle and tendon injuries" and "Adductor muscle and tendon injury" and "Quadriceps muscle and tendon injuries" and "Clinical manifestations and diagnosis of osteoarthritis".)
Hip and groin injuries in children and adolescents, particularly those related to the immature skeleton, are reviewed separately. (See "Approach to hip pain in childhood" and "Approach to the child with a limp" and "Evaluation and management of slipped capital femoral epiphysis (SCFE)" and "Developmental dysplasia of the hip: Clinical features and diagnosis".)
Approximately 10 percent of those seeking care for injuries in offices of sports medicine clinicians present with hip and/or groin pain, usually of a chronic nature . Excluding hip osteoarthritis (OA), as many as 14 percent of adults over 60 years complain of significant hip pain on a weekly basis .
Hip and groin pain encompass a wide variety of conditions and injuries. In a review of 894 young adult athletes (ages 26 to 30) with chronic groin pain who participated in soccer, rugby, and Gaelic sports, 24 different combinations of clinical injury were identified . Isolated injury to the hip joint was common and occurred in 55.98 percent. Common causes of pain included femoroacetabular impingement (FAI), which was more common in males and accounted for 40 percent of the hip joint problems, labral injury, which was more common in females, accounted for 33 percent, and hip OA accounted for 24 percent .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am 2006; 88:1448.
- Nunley RM, Prather H, Hunt D, et al. Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients. J Bone Joint Surg Am 2011; 93 Suppl 2:17.
- Paluska SA. An overview of hip injuries in running. Sports Med 2005; 35:991.
- Christmas C, Crespo CJ, Franckowiak SC, et al. How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey. J Fam Pract 2002; 51:345.
- Rankin AT, Bleakley CM, Cullen M. Hip Joint Pathology as a Leading Cause of Groin Pain in the Sporting Population: A 6-Year Review of 894 Cases. Am J Sports Med 2015; 43:1698.
- Bradshaw CJ, Bundy M, Falvey E. The diagnosis of longstanding groin pain: a prospective clinical cohort study. Br J Sports Med 2008; 42:851.
- Agten CA, Sutter R, Buck FM, Pfirrmann CW. Hip Imaging in Athletes: Sports Imaging Series. Radiology 2016; 280:351.
- Blankenbaker DG, De Smet AA. Hip injuries in athletes. Radiol Clin North Am 2010; 48:1155.
- Hoeber S, Aly AR, Ashworth N, Rajasekaran S. Ultrasound-guided hip joint injections are more accurate than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med 2016; 50:392.
- Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001; 29:521.
- Bencardino JT, Palmer WE. Imaging of hip disorders in athletes. Radiol Clin North Am 2002; 40:267.
- Brubaker CE, James SL. Injuries to runners. J Sports Med 1974; 2:189.
- Messier SP, Edwards DG, Martin DF, et al. Etiology of iliotibial band friction syndrome in distance runners. Med Sci Sports Exerc 1995; 27:951.
- Janzen DL, Partridge E, Logan PM, et al. The snapping hip: clinical and imaging findings in transient subluxation of the iliopsoas tendon. Can Assoc Radiol J 1996; 47:202.
- Renström PA. Tendon and muscle injuries in the groin area. Clin Sports Med 1992; 11:815.
- Peck E, Finnoff JT, Smith J. Neuropathies in runners. Clin Sports Med 2010; 29:437.
- Meadows JR, Finnoff JT. Lower extremity nerve entrapments in athletes. Curr Sports Med Rep 2014; 13:299.
- DeLee J, Drez D, Miller M. DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice, 3rd ed, Saunders, Philadelphia 2010.
- Bradshaw C, McCrory P. Obturator nerve entrapment. Clin J Sport Med 1997; 7:217.
- Schwarzer U, Sommer F, Klotz T, et al. Cycling and penile oxygen pressure: the type of saddle matters. Eur Urol 2002; 41:139.
- Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J 2010; 19:2095.
- Miller TA, White KP, Ross DC. The diagnosis and management of Piriformis Syndrome: myths and facts. Can J Neurol Sci 2012; 39:577.
- Byrd JW. Piriformis syndrome. Oper Tech in Sports Med 2005; 13:71.
- Natsis K, Totlis T, Konstantinidis GA, et al. Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome. Surg Radiol Anat 2014; 36:273.
- Cass SP. Piriformis syndrome: a cause of nondiscogenic sciatica. Curr Sports Med Rep 2015; 14:41.
- Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: etiology, diagnosis, and management. Eur Spine J 2010; 60:1003.
- Fields KB. Running injuries - changing trends and demographics. Curr Sports Med Rep 2011; 10:299.
- Masters S, Fricker P, Purdam C. Stress fractures of the femoral shaft--four case studies. Br J Sports Med 1986; 20:14.
- Miller C, Major N, Toth A. Pelvic stress injuries in the athlete: management and prevention. Sports Med 2003; 33:1003.
- Johnson R. Osteitis pubis. Curr Sports Med Rep 2003; 2:98.
- Williams JG. Limitation of hip joint movement as a factor in traumatic osteitis pubis. Br J Sports Med 1978; 12:129.
- Sheen AJ, Stephenson BM, Lloyd DM, 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; 48:1079.
- Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med 2008; 42:954.
- Balconi G. US in pubalgia. J Ultrasound 2011; 14:157.
- Smith-Petersen MN. Treatment of malum coxa senilis, old slipped upper femoral epiphysis, intrapelvic protrusion of the acetabulum, and coax plana by means of acetabuloplasty. J Bone Joint Surg Am 1936; 18:869.
- Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003; :112.
- Tranovich MJ, Salzler MJ, Enseki KR, Wright VJ. A review of femoroacetabular impingement and hip arthroscopy in the athlete. Phys Sportsmed 2014; 42:75.
- Sankar WN, Matheney TH, Zaltz I. Femoroacetabular impingement: current concepts and controversies. Orthop Clin North Am 2013; 44:575.
- Ejnisman L, Philippon MJ, Lertwanich P. Femoroacetabular impingement: the femoral side. Clin Sports Med 2011; 30:369.
- Cross MB, Fabricant PD, Maak TG, Kelly BT. Impingement (acetabular side). Clin Sports Med 2011; 30:379.
- Philippon MJ, Maxwell RB, Johnston TL, et al. Clinical presentation of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2007; 15:1041.
- Khanna V, Caragianis A, Diprimio G, et al. Incidence of hip pain in a prospective cohort of asymptomatic volunteers: is the cam deformity a risk factor for hip pain? Am J Sports Med 2014; 42:793.
- Frank JM, Harris JD, Erickson BJ, et al. Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A Systematic Review. Arthroscopy 2015; 31:1199.
- Keogh MJ, Batt ME. A review of femoroacetabular impingement in athletes. Sports Med 2008; 38:863.
- Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. J Bone Joint Surg Am 2006; 88:1735.
- Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy 2008; 24:540.
- Ng VY, Arora N, Best TM, et al. Efficacy of surgery for femoroacetabular impingement: a systematic review. Am J Sports Med 2010; 38:2337.
- Hellman MD, Riff AJ, Frank RM, et al. Operative treatment of femoroacetabular impingement. Phys Sportsmed 2014; 42:112.
- Lynch TS, Terry MA, Bedi A, Kelly BT. Hip arthroscopic surgery: patient evaluation, current indications, and outcomes. Am J Sports Med 2013; 41:1174.
- Domb BG, Shindle MK, McArthur B, et al. Iliopsoas impingement: a newly identified cause of labral pathology in the hip. HSS J 2011; 7:145.
- Freehill MT, Safran MR. The labrum of the hip: diagnosis and rationale for surgical correction. Clin Sports Med 2011; 30:293.
- Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res 2004; :145.
- Chan YS, Lien LC, Hsu HL, et al. Evaluating hip labral tears using magnetic resonance arthrography: a prospective study comparing hip arthroscopy and magnetic resonance arthrography diagnosis. Arthroscopy 2005; 21:1250.
- Naraghi A, White LM. MRI of Labral and Chondral Lesions of the Hip. AJR Am J Roentgenol 2015; 205:479.
- Miozzari HH, Clark JM, Jacob HA, et al. Effects of removal of the acetabular labrum in a sheep hip model. Osteoarthritis Cartilage 2004; 12:419.
- Kolo FC, Charbonnier C, Pfirrmann CW, et al. Extreme hip motion in professional ballet dancers: dynamic and morphological evaluation based on magnetic resonance imaging. Skeletal Radiol 2013; 42:689.
- Williams PT. Effects of running and walking on osteoarthritis and hip replacement risk. Med Sci Sports Exerc 2013; 45:1292.
- ANATOMY AND BIOMECHANICS
- DIAGNOSTIC APPROACH
- ADDITIONAL ULTRASOUND RESOURCES
- COMMON CONDITIONS CAUSING HIP OR GROIN PAIN
- Extra-articular muscle and tendon injuries
- - Common muscle and tendon injuries
- - Snapping hip
- Trochanteric pain syndrome (bursitis)
- - Overview and general findings
- - Nerve entrapments
- - Piriformis syndrome
- Stress fractures
- Osteitis pubis
- Athletic pubalgia (sports hernia)
- Femoroacetabular impingement
- Acetabular labrum injury
- MEDICAL CONCERNS
- SUMMARY AND RECOMMENDATIONS