Member Case Study: Groin and Hip Pain

author : AMSSM

comments : 0

A lot of groin pain has led me to many radiological exams. Doing NO running or biking for a month helped, but as soon as I ease back into training, symptoms return.

Member Question

A lot of groin pain has led me to many radiological exams (+ bone scan showing hot lesser trochanter) (+arthrogram showing labral tear and frayed ligamentum teres, both repaired with hip arthroscopy in Oct). Doing NO running or biking for a month helped, but as soon as I ease back into training, symptoms return. I have had steroid injection around the tendon and bursa (which interacts with the joint space, common in 15 percent of people), lidocain challenge + (decreased pain). Have done PT, ultrasound, iontophoresis (sp), TENS, massage, stretching etc...and other advice?

Answer by Kevin D. Walter, MD, FAAP & Brian Butler, DPT, ATC/L

Member AMSSM

You describe a very difficult situation with your hip and groin pain. Without knowing the exact timing of your surgery and radiology studies but assuming that they were all done prior to your surgery, we are going to cover many issues that may be helpful to you. Most importantly, you will need to find a Sports Medicine physician in your area for an evaluation. This should be a Sports Medicine fellowship trained physician, either primary care or orthopedic. Disorders in the hip and groin can be very confusing and difficult for even experienced physicians, so regular follow-up and discussing a long term plan to find a diagnosis with a single physician is very important.

First, we are still concerned about potential surgical causes, such as a breakdown in the labral repair that was done in October 2008. We would also be sure that your physician has ruled out femoral-acetabular impingement, which is a disorder that causes pain from abnormal friction caused by the rubbing of the femur on the pelvis in your hip joint. These disorders can usually be seen on imaging studies (like x-rays and a MRI-arthrogram for the labrum).

We would also be very concerned about a femoral neck or pelvic stress fracture. This is an injury that can cause pain with activity, but symptoms may be relieved by rest. It can progress into a very severe injury that needs surgery if not properly treated. This injury is usually treated with crutches and activity restriction for 2-3 months. MRI is an excellent imaging study to assess for stress fracture, and will often give more information than a bone scan.

Once the above issues have been ruled out, we would then consider more unusual causes of chronic hip/groin pain. These include nerve entrapment syndromes, which are disorders where a nerve is pinched or irritated causing pain. Many, but not all, of these disorders are associated with numbness and tingling of the skin that the nerve supplies sensation. These injuries may need specific tests called nerve conduction studies to diagnose. Your injections may have masked symptoms due to neuropathy. Athletic pubalgia or “sports hernia” (or other more common hernias) should be considered. This is due to a weakening of the lower abdominal muscles and will often cause groin and lower abdominal pain. These injuries require an experienced surgeon for diagnosis and repair. External iliac artery endofibrosis is a serious condition that can affect elite cyclists. This blood vessel damage is similar to coronary artery disease, but it is in the pelvis. It is usually associated with numbness and pain with activity. Diagnosis can be made with specialized imaging studies and pre and post exercise blood pressure checks.

Finally, this pain may truly be muscular, or a tendonopathy. It might be related to overtraining and require more significant time off from lower body exercise followed by a slow return to lower extremity activity. Improper bike fit can be a source of chronic pain. It may also be worth investigating gait mechanics and the possible need for custom foot orthotics (shoe inserts). We would have expected physical therapy to have addressed your core and pelvic strength and biomechanics, but if it was not, then another round of therapy may be helpful. You had also mentioned several injections, which were not completely helpful. Many times these injections need to be followed by adequate rest and/or physical therapy. There is also a new therapy called PRP (platelet rich plasma) injection. This is a newer therapy that is still being studied, and not all sports medicine physicians are trained to use PRP. It could be considered if many of the previously mentioned disorders have been ruled out.

Good luck, and remember the most important thing is to get into an experienced doctor that will help you find the proper diagnosis, and then create a treatment plan allowing you to return to your sport and remain healthy and pain-free!

Kevin D. Walter, MD, FAAP
Medical College of Wisconsin
Assistant Professor, Department of Orthopedics
Program Directory, Primary Care Sports Medicine at
Children’s Hospital of Wisconsin

Brian Butler, DPT, ATC/L
Physical Therapist/Athletic Trainer
Children’s Hospital of Wisconsin-Greenway Sports Medicine Clinic
 

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date: April 22, 2009