Abstract
Groin pain represents a frequent cause of disability among footballers. Groin pain in footballers is most commonly due to overuse injury as opposed to traumatic injury. Athletic groin pain presents a diagnostic and therapeutic challenge for the sports medicine physician. The complex anatomy of the hip and groin region gives rise to an extensive list of possible pathologies that all may present very similarly. Adductor pathology represents the most common cause of groin pain in footballers, but other pathologies such as abdominal, intra-articular, inguinal, and iliopsoas-related pathologies may also cause groin pain in footballers. Although the majority of groin pain pathologies can be treated with an initial trial of conservative management, the evidence for non-operative management currently available is limited. Athletes who fail conservative treatment options may ultimately require operative management. This chapter discusses return to play in footballers following non-operative management of hip and groin pain.
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Hölmich P (2007) Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med 41:247–252. discussion 252
de Sa D, Hölmich P, Phillips M, Heaven S, Simunovic N, Philippon MJ, Ayeni OR (2016) Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med 5
Werner J, Hägglund M, Waldén M, Ekstrand J (2009) UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 43:1036–1040
King E, Ward J, Small L, Falvey E, Franklyn-Miller A (2015) Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med 49:1447–1451
Falvey ÉC, King E, Kinsella S, Franklyn-Miller A (2016) 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 50:423–430
References
Hölmich P (2007) Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med 41(4):247–252
de Sa D, Hölmich P, Phillips M, Heaven S, Simunovic N, Philippon MJ, Ayeni OR (2016) Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med 50(19):1181–1186
Werner J, Hägglund M, Waldén M, Ekstrand J (2009) UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. Br J Sports Med 43(13):1036–1040
King E, Ward J, Small L, Falvey E, Franklyn-Miller A (2015) Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med 49(22):1447–1451
Falvey ÉC, King E, Kinsella S, Franklyn-Miller A (2016) 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 50(7):423–430
Murar J, Birmingham PM (2015) Osteitis pubis. In: Nho S, Leunig M, Larson CM, Bedi A, Kelly BT (eds) Hip arthroscopy and hip joint preservation surgery. Springer, New York, NY, pp 737–749
Elattar O, Choi H-R, Dills VD, Busconi B (2016) Groin Injuries (Athletic Pubalgia) and Return to Play. Sports Health 8(4):313–323
Ekstrand J, Gillquist J (1983) Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc 15(3):267–270
Engström B, Johansson C, Törnkvist H (1991) Soccer injuries among elite female players. Am J Sports Med 19(4):372–375
Lynch SA, Renström PA (1999) Groin injuries in sport: treatment strategies. Sports Med 28(2):137–144
Morelli V, Weaver V (2005) Groin injuries and groin pain in athletes: part 1. Prim Care 32(1):163–183
Adams RJ, Chandler FA (1953) Osteitis pubis of traumatic etiology. J Bone Joint Surg Am 35-A(3):685–696
Hölmich P (1997) Adductor-related groin pain in athletes. Sports Med Arthrosc 5(4):285–2891
Schlegel TF, Bushnell BD, Godfrey J, Boublik M (2009) Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med 37(7):1394–1399
Thorborg K, Branci S, Nielsen MP, Tang L, Nielsen MB, Hölmich P (2014) Eccentric and isometric hip adduction strength in male soccer players with and without adductor-related groin pain. Orthop J Sports Med 2(2):232596711452177
Ekstrand J, Gillquist J (1983) The avoidability of soccer injuries. Int J Sports Med 4(2):124–128
Gouttebarge V, Hughes Schwab BA, Vivian A, Kerkhoffs GMMJ (2016) Injuries, matches missed and the influence of minimum medical standards in the a-league professional football: a 5-year prospective study. Asian J Sports Med 7(1):e31385
Weaver JS, Jacobson JA, Jamadar DA, Hayes CW (2003) Sonographic findings of adductor insertion avulsion syndrome with magnetic resonance imaging correlation. J Ultrasound Med 22(4):403–407
Kalebo P, Karlsson J, Sward L, Peterson L (1992) Ultrasonography of chronic tendon injuries in the groin. Am J Sports Med 20(6):634–639
Ansede G, English B, Healy JC (2011) Groin pain: clinical assessment and the role of MR imaging. Semin Musculoskelet Radiol 15(1):3–13
Robinson P, Barron DA, Parsons W, Grainger AJ, Schilders EMG, O’Connor PJ (2004) Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings. Skeletal Radiol 33(8):451–457
Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Bachmann Nielsen M, Bjerg AM, Krogsgaarda K (1999) Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet 353(9151):439–443
Tyler TF, Nicholas SJ (2007) Rehabilitation of extra-articular sources of hip pain in athletes. N Am J Sports Phys Ther 2(4):207–216
Ueblacker P, English B, Mueller-Wohlfahrt H-W (2016) Nonoperative treatment and return to play after complete proximal adductor avulsion in high-performance athletes. Knee Surg Sports Traumatol Arthrosc 24(12):3927–3933
Bradshaw C, Holmich P (2009) Longstanding groin pain. In: Brukner P, Khan K (eds) Clinical sports medicine. McGraw-Hill, New York, NY, pp 405–426
Andersson E, Oddsson L, Grundstrom H, Thorstensson A (1995) The role of the psoas and iliacus muscles for stability and movement of the lumbar spine, pelvis and hip. Scand J Med Sci Sports 5(1):10–16
Abate M, Scuccimarra T, Vanni D, Pantalone A, Salini V (2014) Femoroacetabular impingement: is hyaluronic acid effective? Knee Surg Sports Traumatol Arthrosc 22(4):889–892
Anderson CN (2016) Iliopsoas: pathology, diagnosis, and treatment. Clin Sports Med 35(3):419–433
Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ (2008) The snapping iliopsoas tendon: new mechanisms using dynamic sonography. AJR Am J Roentgenol 190(3):576–581
Lewis CL (2010) Extra-articular snapping hip: a literature review. Sports Health 2(3):186–190
Schaberg JE, Harper MC, Allen WC (1984) The snapping hip syndrome. Am J Sports Med 12(5):361–365
Blankenbaker DG, De Smet AA, Keene JS (2006) Sonography of the iliopsoas tendon and injection of the iliopsoas Bursa for diagnosis and management of the painful snapping hip. Skeletal Radiol 35(8):565–571
Johnston CAM, Wiley JP, Lindsay DM, Wiseman DA (1998) Iliopsoas bursitis and tendinitis. A review. Sports Med 25(4):271–283
Wahl CJ, Warren RF, Adler RS, Hannafin JA, Hansen B (2009) Internal coxa saltans (snapping hip) as a result of overtraining: a report of 3 cases in professional athletes with a review of causes and the role of ultrasound in early diagnosis and management. Am J Sports Med 32(5):1302–1309
Mozes M, Papa MZ, Zweig A, Horoszowski H, Adar R (1985) Iliopsoas injury in soccer players. Br J Sports Med 19(3):168–170
Janzen DL, Partridge E, Logan PM, Connell DG, Duncan CP (1996) The snapping hip: clinical and imaging findings in transient subluxation of the iliopsoas tendon. Can Assoc Radiol J 47(3):202–208
Byrd JWT (2005) Snapping hip. Oper Tech Sport Med 13(1):46–54
Ganz R, Leunig M, Leunig-Ganz K, Harris WH (2008) The Etiology of Osteoarthritis of the Hip: an integrated mechanical concept. Clin Orthop Relat Res 466(2):264–272
Sammarco GJ (1984) Diagnosis and treatment in dancers. Clin Orthop Relat Res (187):176–187
Byrd JWT (2006) Evaluation and management of the snapping iliopsoas tendon. Instr Course Lect 55:347–355
Fredberg U, Hansen LB (1995) Ultrasound in the diagnosis and treatment of iliopsoas tendinitis: a case report. Scand J Med Sci Sports 5(6):369–370
Idjadi J, Meislin R (2004) Symptomatic snapping hip: targeted treatment for maximum pain relief. Phys Sportsmed 32(1):25–31
Vaccaro JP, Sauser DD, Beals RK (1995) Iliopsoas bursa imaging: efficacy in depicting abnormal iliopsoas tendon motion in patients with internal snapping hip syndrome. Radiology 197(3):853–856
Paksoy M, Sekmen Ü (2016) Sportsman hernia; the review of current diagnosis and treatment modalities. Ulus Cerrahi Derg 32(2):122–129
Gilmore OJ (1992) Gilmore’s groin. Sports Med Soft Tissue Trauma 3(3):12–14
Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A, Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, Kurzer M (2014) ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med 48(14):1079–1087
Falvey EC, Franklyn-Miller A, McCrory PR (2009) The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med 43(3):213–220
Meyers WC, Yoo E, Devon ON, Jain N, Horner M, Lauencin C, Zoga A (2007) Understanding “sports hernia” (athletic pubalgia): the anatomic and pathophysiologic basis for abdominal and groin pain in athletes. Oper Tech Sports Med 15(4):165–177
Larson CM (2014) Sports Hernia/Athletic Pubalgia: evaluation and management. Sports Health 6(2):139–144
Hawkins RD, Hulse MA, Wilkinson C, Hodson A, Gibson M (2001) The association football medical research programme: an audit of injuries in professional football. Br J Sports Med 35(1):43–47
Zoga AC, Kavanagh EC, Omar IM, Morrison WB, Koulouris G, Lopez H, Chaabra A, Domesek J, Meyers WC (2008) Athletic Pubalgia and the “Sports Hernia”: MR imaging findings. Radiology 247(3):797–807
Armfield DR, Kim DH-M, Towers JD, Bradley JP, Robertson DD (2006) Sports-related muscle injury in the lower extremity. Clin Sports Med 25(4):803–842
Kavanagh EC, Koulouris G, Ford S, McMahon P, Johnson C, Eustace SJ (2006) MR imaging of groin pain in the athlete. Semin Musculoskelet Radiol 10(3):197–207
Orchard J, Read J, Neophyton J, Garlick D (1998) Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med 32(2):134–139
Sheen AJ, Iqbal Z (2014) Contemporary management of “Inguinal disruption” in the sportsman’s groin. BMC Sports Sci Med Rehabil 6:39
Campbell KJ, Boykin RE, Wijdicks CA, Erik Giphart J, LaPrade RF, Philippon MJ (2013) Treatment of a hip capsular injury in a professional soccer player with platelet-rich plasma and bone marrow aspirate concentrate therapy. Knee Surg Sports Traumatol Arthrosc 21(7):1684–1688
Caudill P, Nyland J, Smith C, Yerasimides J, Lach J (2008) Sports hernias: a systematic literature review. Br J Sports Med 42(12):954–964
Farber AJ, Wilckens JH (2007) Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg 15(8):507–514
Swan KG, Wolcott M (2007) The athletic hernia: a systematic review. Clin Orthop Relat Res 455:78–87
Woodward JS, Parker A, Macdonald RM (2012) Non-surgical treatment of a professional hockey player with the signs and symptoms of sports hernia: a case report. Int J Sports Phys Ther 7(1):85–100
Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M (2009) European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13(4):343–403
Kluin J, den Hoed PT, van Linschoten R, IJ JC, van Steensel CJ (2004) Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 32(4):944–949
Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH (2006) Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol 187(5):1168–1178
Ostrom E, Joseph A (2016) The use of musculoskeletal ultrasound for the diagnosis of groin and hip pain in athletes. Curr Sports Med Rep 15(2):86–90
Oner A, Koksal A, Sofu H, Aykut US, Yıldırım T, Kaygusuz MA (2016) The prevalence of femoroacetabular impingement as an aetiologic factor for end-stage degenerative osteoarthritis of the hip joint: analysis of 1,000 cases. Hip Int 26(2):164–168
Byrd JWT (2010) Femoroacetabular impingement in athletes, Part 1: Cause and assessment. Sport Health 2(4):321–333
Agricola R, Bessems JHJM, Ginai AZ, Heijboer MP, van der Heijden RA, Verhaar JAN, Weinans H, Waarsing JH (2012) The development of Cam-type deformity in adolescent and young male soccer players. Am J Sports Med 40(5):1099–1106
Hunt D, Prather H, Harris Hayes M, Clohisy JC (2012) Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R 4(7):479–487
Diesel CV, Ribeiro TA, Scheidt RB, Macedo CA de S, Galia CR (2015) The prevalence of femoroacetabular impingement in radiographs of asymptomatic subjects: a cross-sectional study. Hip Int 25(3):258–263
Feeley BT, Powell JW, Muller MS, Barnes RP, Warren RF, Kelly BT (2008) Hip injuries and labral tears in the national football league. Am J Sports Med 36(11):2187–2195
Wall PD, Fernandez M, Griffin DR, Foster NE (2013) Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. PM R 5(5):418–426
Emara K, Samir W, Motasem EH, El GKA (2011) Conservative treatment for mild femoroacetabular impingement. J Orthop Surg (Hong Kong) 19(1):41–45
Jäger M, Wild A, Westhoff B, Krauspe R (2004) Femoroacetabular impingement caused by a femoral osseous head-neck bump deformity: clinical, radiological, and experimental results. J Orthop Sci 9(3):256–263
Bedi A, Kelly BT (2013) Femoroacetabular impingement. J Bone Joint Surg Am 95(1):82–92
Krych AJ, Griffith TB, Hudgens JL, Kuzma SA, Sierra RJ, Levy BA (2014) Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear. Knee Surg Sports Traumatol Arthrosc 22(4):750–755
Ayeni OR, Farrokhyar F, Crouch S, Chan K, Sprague S, Bhandari M (2014) Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 22(4):801–805
Chakraverty JK, Snelling NJ (2012) Anterior hip pain – have you considered femoroacetabular impingement? Int J Osteopath Med 15(1):22–27
Cetin C (2004) Chronic groin pain in an amateur soccer player. Br J Sports Med 38(2):223–224
Mani-Babu S, Wolman R, Keen R (2014) Quadriceps traumatic myositis ossificans in a football player: management with intravenous pamidronate. Clin J Sport Med 24(5):e56–e58
Antao NA (1988) Myositis of the hip in a professional soccer player. A case report. Am J Sports Med 16(1):82–83
Marques JP, Pinheiro JP, Santos Costa J, Moura D (2015) Myositis ossificans of the quadriceps femoris in a soccer player. BMJ Case Rep. https://doi.org/10.1136/bcr-2015-210545
Bradshaw C, McCrory P (1997) Obturator nerve entrapment. Clin J Sport Med 7(3):217–219
Brukner P, Bradshaw C, McCrory P (1999) Obturator neuropathy: a cause of exercise-related groin pain. Phys Sportsmed 27(5):62–73
Siwiński D (2005) Neuropathy of the obturator nerve as a source of pain in soccer players. Chir Narzadow Ruchu Ortop Pol 70(3):201–204
García VV, Duhrkop DC, Seijas R, Ares O, Cugat R (2012) Surgical treatment of proximal ruptures of the rectus femoris in professional soccer players. Arch Orthop Trauma Surg 132(3):329–333
Zakaria A, Housner A (2011) Managing quadriceps strains for early return to play. J Musculoskelet Med 28(7):257–262
Esser S, Jantz D, Hurdle MF, Taylor W (2015) Proximal rectus femoris avulsion: ultrasonic diagnosis and nonoperative management. J Athl Train 50(7):778–780
Straw R, Colclough K, Geutjens G (2003) Surgical repair of a chronic rupture of the rectus femoris muscle at the proximal musculotendinous junction in a soccer player. Br J Sports Med 37(2):182–184
Croisier J-L (2004) Factors associated with recurrent hamstring injuries. Sports Med 34(10):681–695
Dauty M, Collon S (2011) Incidence of injuries in French professional soccer players. Int J Sports Med 32(12):965–969
Hayat Z, Konan S, Pollock R (2014) Ischiofemoral impingement resulting from a chronic avulsion injury of the hamstrings. BMJ Case Rep. https://doi.org/10.1136/bcr-2014-204017
Kurosawa H, Nakasita K, Nakasita H, Sasaki S, Takeda S (1996) Complete avulsion of the hamstring tendons from the ischial tuberosity. A report of two cases sustained in judo. Br J Sports Med 30(1):72–74
Marx RG, Fives G, Chu SK, Daluiski A, Wolfe SW (2009) Allograft reconstruction for symptomatic chronic complete proximal hamstring tendon avulsion. Knee Surg Sports Traumatol Arthrosc 17(1):19–23
Sallay PI, Friedman RL, Coogan PG, Garrett WE (1996) Hamstring muscle injuries among water skiers. Functional outcome and prevention. Am J Sports Med 24(2):130–136
Sonnery-Cottet B, Archbold P, Thaunat M, Fayard J-M, Canuto SMG, Cucurulo T (2012) Proximal hamstring avulsion in a professional soccer player. Orthop Traumatol Surg Res 98(8):928–931
Bettin D, Pankalla T, Böhm H, Fuchs S (2003) Hip pain related to femoral neck stress fracture in a 12-year-old boy performing intensive soccer playing activities--a case report. Int J Sports Med 24(8):593–596
Giza E, Mithöfer K, Matthews H, Vrahas M (2004) Hip fracture-dislocation in football: a report of two cases and review of the literature. Br J Sports Med 38(4):E17
Nahas RM, Netto E, Chikude T, Ikemoto R (2007) Traumatic hip fracture-dislocation in soccer: a case report. Rev Bras Med Esporte 13(4):280–282
Drawer S, Fuller CW (2001) Propensity for osteoarthritis and lower limb joint pain in retired professional soccer players. Br J Sports Med 35(6):402–408
Amoako AO, Pujalte GGA (2014) Osteoarthritis in young, active, and athletic individuals. Clin Med Insights Arthritis Musculoskelet Disord 7:27–32
Bare A, Guanche C (2007) Intra-articular lesions. In: Johnson DH, Pedowitz RA (eds) Practical orthopaedic sports medicine and arthroscopy. Lippincott Williams & Wilkins, Philadelphia, PA, pp 473–489
Keene GS, Villar RN (1994) Arthroscopic anatomy of the hip: an in vivo study. Arthroscopy 10(4):392–399
Ellsworth AA, Zoland MP, Tyler TF (2014) Athletic pubalgia and associated rehabilitation. Int J Sports Phys Ther 9(6):774–784
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Horner, N.S., Ekhtiari, S., Chan, A.A., Choudur, H.N., Ayeni, O.R. (2018). Joint Specific Return to Play Recommendations: “Return to Play in Non-operative Hip/Groin Pain”. In: Musahl, V., Karlsson, J., Krutsch, W., Mandelbaum, B., Espregueira-Mendes, J., d'Hooghe, P. (eds) Return to Play in Football. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-55713-6_27
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