Groin, Hip, and Thigh Injuries

Question 1

Based on the “Doha agreement on terminology of groin pain” paper, what is an acceptable definition of groin pain?

Answer 1

Groin pain is an umbrella term that encompasses pain related to:
Adductors
Iliopsoas
Inguinal
Pubic
Hip
Characterized by local tenderness and pain on resistance.

Question 2

What sports and populations is groin pain most common?

Answer 2

Sports that require rapid acceleration and forceful hip movements, like soccer or hockey. More common in men than in women.

Question 3

RED FLAGS pathologies for groin pain? Why should you refer in these cases?

Answer 3

MJ THREADS
Cancer
Infections (UTIs) 
Neurology 
Fractures (undiagnosed!) 
Inflammatory conditions

They will not improve with treatment

Question 4

What are 3 sources of referred pain in the groin?

Answer 4

1) Discogenic nerve pain (lumbar)
2) Facet joint pain (lumbar)
3) SI joint pain

Question 5

What are 3 screening tests for differentiating groin pain from intra-articular hip joint pathology?

Answer 5

1) FABER
2) FADIR
3) Flexion-intolerant rotation test

Question 6

Define apophysitis and avulsion fractures.
Mechanism? (3)
How do these relate to groin pain patients?
RIsk factors (2)
Special tests
Management

Answer 6

1)
Apophysitis - Traction stress injury to the growth plate of the pubis.
Avulsion fracture - Traumatic traction resulting in bone being pulled away from the origin or insertion of a muscle.
2) Both conditions share mechanisms of:
- Pull of muscle strain at origin
- Repetitive overuse injury
- Can be a discrete powerful event

3) Both conditions present as a dull groin pain, similar to muscle strain.

4) Risk factors:
Repetitive overuse
Poor flexibility

5) Special Tests
Pain on passive and resisted stretch
Palpation of apophysis

6) 
POLICE
Relative rest
Gentle progressive stretching 
Possible surgery

Question 7

What is the clinical presentation of adductor related groin pain? (3)

Answer 7

1. Location of pain
   • Pain near the insertion of the adductor longus on pubic bone.
   • Pain at proximal muscle/tendon junction
   • Pain at distal muscle/tendon junction
2. Pain on palpation
3. Pain on resisted adduction

Question 8

What is the clinical presentation of iliopsoas related groin pain (4)

Answer 8

1. Location:
   Pain in central area of groin, possibly over inguinal ligament
   Pain directly lateral to rectus abdominus when running (esp. uphill)
2. Pain on palpation of iliopsoas (controversial)
3. Pain on passive + resisted hip flexion
4. Iliopsoas bursitis

Question 9

What are two conditions causing inguinal-specific groin pain?

Answer 9

1) Inguinal hernia - Weak abdominal muscle allows the intestine to “bulge” outward - usually as a result of high intra-abdominal pressure.
2. Sportsmans hernia - Overuse abdominal injury (ext obliques and TA) leading to tear in abdominal wall.

Question 10

What is the clinical presentation of inguinal-specific groin pain? (2)

Answer 10

1. Pain location:
   Pain is located over inguinal region.
2. Pain on resisted sit-up and increased intra-abdominal pressure
3. Pain can radiate into scrotum, perineum, and lumbar spine
   Same impairments of groin and iliopsoas groin pain

Question 11

What are clinical presentations of pubic-related groin pain? (2)

Answer 11

1. Weakness in abdominal, gluteal, and hip flexor muscles

2. Palpation of pubis (chaperoned)

Question 12

What are 2 key impairments that accompany groin pain patients

Answer 12

1. Reduced capacity in muscle group (ex. hip flexors, adductors,etc)
2. Loss of function for forceful hip movements - ie kicking, changing direction, acceleration

Question 13

What are 4 outcome measures for groin pain?

Answer 13

1. Hand-held dynamometer
2. Copenhagen hip and groin outcome score (HAGOS)
3. Numerical rating for pain /10
4. Patient-specific functional scale (PSFS)

Question 14

General management of adductor pain? (5)

Answer 14

POLICE
Work synergists
Consider trunk/abdominal control
Active approach > passive approach
Copenhagen adductor protocol 
Return to function/sport

Question 15

Management of inguinal groin pain?

Answer 15

1) Laporoscopic surgery
2) Injection
3) Isometric strengthening hip abd/add, and abdominals

Question 16

What is the difference between stress and insufficiency fractures?
Populations(4)
Locations (2)

Answer 16

Insufficiency:
A fracture without a traumatic event = gradual onset from daily life.

2) Stress fractures - Overload in sportspeople

Populations
Women 
Elderly 
Osteoporosis 
Young and overloaded 

Location
Sacrum, pubic rami.

Question 17

What are contributing factors to stress/inconsistency fractures?

Answer 17

Poor diet
Poor bone health
Female athlete triangle
Training errors/loads 
Weak muscles

Question 18

What are 3 symptoms of stress/inconsistency fractures, what are 3 treatments?

Answer 18

SSx:
Progressive pain on loading that doesn’t settle with rest.
Localized tenderness
Night pain, pain @ rest

Tx:
Adequate rest and strength training program
Orthopaedic referral
Bone protective medication

Question 19

Osteoarthritis in the hip: 
Populations (2) 
Onset: 
Pain characteristics (2) 
Clinical presentation (4) 
Treatment (6)

Answer 19

Populations:
Older 45+
Perthes/obesity

Onset;
Insidious

Pain:
Groin/anterior thigh and knee/buttock.
Worse on weightbearing tasks and early morning/late day.

1. Loss of ROM in all directions. Fixed flexion (loss of extension)
2. • FABER, FADIR, FAIR
3. Muscle atrophy. Trendelenburg or antalgic gait.
4. Creptitus and instability.

Treatment

1. Education
2. Pain control
3. Maintain ROM
4. Strength
5. Injections
6. Surgery

Question 20

OA treatment goals (6)

Answer 20

1. Education
2. Pain control
3. Maintain ROM
4. Strength training
5. Injections
6. Surgery

Question 21

What are 2 common patterns contribute to intracapsular hip pain. What can this lead to?

Answer 21

1. Hip impingement pattern
2. Instability pattern

Both can lead to labrum pathology

Question 22

For labral tears, define: 
Symptoms (4) 
Mechanism (4) 
Populations (2) 
Objective tests (2) 
Treatment (7) 
Imaging

Answer 22

Symptoms: 
Unilateral hip or groin pain
Constant dull pain that worsens with activity 
Mechanical clunking/clicking/giving way
Osteochondral lesions

Mechanism
Acute - Twisting injury 
Repeated hip rotation/flexion
Running w/internal rotation of hip
Can be degenerative and asymptomatic

Population:
Sporting population
Car accident victims

Objective tests:
Painful FADIR
Pain on quadrant testing

Treatment: 
Cryotherapy 
Analgesia
Manual therapy 
Graded return to rotation
Glute strengthening 
Balance training
Surgical Repair

Imaging: MR arthrogram

Question 23

What are the imaging findings for femoro-acetabular impingement syndrome? (FAIS) (3)

Answer 23

CAM = Bony overgrowth of the femoral neck.
PINCER = Bony overgrowth over acetabular rim. 
MIXED = Both CAM and PINCER present.

Question 24

FAIS?
Subjective ssx
Clinical presentation
Special tests to perform
Aim of physio
Management
Prognosis

Answer 24

Subjective ssx:
Pain in groin +/- posterior hip
Pain w/hip flexion +/- adduction based activities
Soccer, hockey, tradespeople
People with FAIS may demonstrate
• Posterior pelvic tilt/flattened lumbar spine
• Muscle weakness for all hip muscle groups
• Reduced proprioceptive awareness and poor single leg stance.
• Compensatory movement patterns due to pain.
Objective findings:
Reproduction of patient pain and symptoms on:
• Quadrant testing
• Hip impingement testing
• FADIR

Aim of physio:
• Pain reduction + Symptom control
• Increase capacity – squatting/lunging
• Improving single leg static and dynamic balance
• Global hip muscle strengthening
• Improve functional patterns
• Train controlled sports skills

Set pain limits – avoid pain inhibition.
Management
• Shared decision making process discussing treatment options
• No high level evidence to support a definitive conservative protocol
• Education, activity modification, NSAIDs, steroid injection, watchful waiting
Prognosis
• Without treatment, the symptoms likely worsen.
• With treatment, can fully return to activity.

Question 25

``` Hip Instability Definition Populations Subjective symptoms Objective findings Aim of physio Management ```

Answer 25

Definition: Extra physiological hip motion that causes pain w/wo symptoms of hip joint unsteadiness. This results in increased movement of the femoral head relative to the acetabulum and eventual damage to the labrum, cartilage, and capsular structures Populations • Developmental hip dysplasia • Connective tissue disorders • Females <40 ``` Subjective Symptoms • Unilateral anterior hip or groin pain • Constant dull pain that worsens with activity • Audible hip clicking/popping • Mechanical clicking/clunking/giving way. • Pain with extension-based movements Objective Findings: • Quadrant testing • Hip impingement testing • FADDIR • Anterior pelvic tilt/hyperlordosis • Traction to the limb producing distraction apprehension • Laxity on the Dial test ``` ``` Aim of physio: EXACT same as impingement: • Pain reduction + Symptom control • Increase capacity – squatting/lunging • Improving single leg static and dynamic balance • Global hip muscle strengthening • Improve functional patterns • Train controlled sports skills ``` Set pain limits – avoid pain inhibition. Management • No high level evidence to support a definitive conservative protocol • Activity modification • Saggital and frontal plane hip ROM exercises • General hip ROM strengthening • Lumbo-pelvic dissociation / core control exercises • Analgesics and NSAIDs

Question 26

``` Perthe's Disease Definition Mechanism Population Subjective symptoms Objective findings Tests Prognosis Management goals ```

Answer 26

Perthe’s Disease • Idiopathic avascular necrosis of the femoral head in skeletally immature patients Mechanism • Repeated or single episode of ischaemia • Repetitive microtrauma • Linked to maternal smoking while pregnant, childhood obesity Population: • Children 4-18 years • Boys > girls 4:1 Subjective symptoms • Low grade ache/pain in the thigh, groin, or knee • Usually unilateral (10-15% bilaterally) • Typically worse during physical activity • Worse later in day Objective findings • Limp or trendelenberg gait • Differences in leg length • Adduction contracture • Glute and quads atrophy Tests • Limited abduction or internal rotation of the affected hip • + FABER Prognosis • Recovery can take years • Good outcome • 50% need a hip replacement in their 50s ``` Management goals: • Gait retraining • Balance retraining • Pain free global hip strengthening • Strength training progression • Reduction of mechanical stress • Preservation of joint congruence ```

Question 27

List 4 intracapsular hip pathologies

Answer 27

``` Femoral acetabular impingement Hip instability Acetabular labrum tear Perthe's Disease etc. ```

Question 28

List 5 extracapsular hip pathologies

Answer 28

1. Nerve entrapment 2. Arterial compromise 3. Deep gluteal syndrome 4. Myositis Ossificans 5. Greater Trochanteric Pain syndrome

Question 29

What is the mechanism of nerve entrapment?

Answer 29

Mechanism: Repeated low level injury or high force trauma to soft tissue surrounding nerves can create scar tissue that reduces smooth excursion of the nerve.

Question 30

``` For arterial compromise, describe: Mechanism (1) Population (2) Symptoms (3) Objective findings (2) Imaging (3) Prognosis (1) Treatment (2) ```

Answer 30

``` II) Arterial Compromise Mechanism: Functional kinking of the external iliac artery from repeated movements causing microtrauma, scarring, and stenosis – reducing blood flow to tissues Population: • Males under 40 • Hip/lumbar flexion based athletes ``` SSx: • Unilateral exercise induced weakness/burning/cramping/pain in quadriceps, hamstinrgs, glutes, adductors, or gastroc muscles • Abdominal pain/cramps during activity • Pain on activity that settles with rest, unless stenosis is severe. Objective Findings: • Reduction in distal pulse (tibial, femoral, dorsalis pedis) • Temperature differences in distal limb Imaging CTA MRA Arteriogram Prognosis • Likely surgical intervention through stenting Treatment • Minimize repeated/sustained hip flexion • Change sporting technique to avoid pulling up in pedals

Question 31

``` Deep Gluteal syndrome: What is it? Mechanism (3) Population (2) Subjective Ssx (6) Objective tests (4) Treatment (4) If conservative treatment fails: (2) Imaging: (3) ```

Answer 31

Deep Gluteal Syndrome Buttock pain and sciatic type symptoms caused by irritation of the sciatic nerve in the sub-gluteal space. Multiple structures may be involved. Mechanism • Gradual onset and progression with repeated episodes of hip flexion • Long periods sedentary • Acute trauma Population • Plyometric sports • Manual jobs involving heavy lifting Subjective Symptoms • Unilateral mid-buttock pain, deep diffuse • Worse on sitting, intolerance of sitting for 30+ minutes • Mimics a hamstring pull • Aching, burning sensation or cramping in the buttock or posterior thigh • Unilateral sciatica • Can have night pain Objective Tests; • Neurointegrity / neuroprovocative tests • Active side lying piriformis test • Passively seated piriformis test • FAIR test (passive hip flexion, adduction, int rot) Treatment • Education about aggravating factors and sitting breaks • Pain management • Stretching hip lateral rotators (piriformis) • Sciatic nerve glide ``` If conservative Rx fails: • Anaesthetic injection • Surgery in chronic severe cases Imaging/investigations • MRI/ultrasound • Nerve conduction tests ```

Question 32

Myositis Ossificans What is it? Mechanism? Symptoms (3)

Answer 32

IV) Myositis Ossificans Calcification/osteogenesis occurring in soft tissues, usually after haematoma/injury Mechanism • Provoked by aggressive treatment/repetitive injury in high frequency Symptoms • Localized pain, tenderness, and stiffness with a palpable mass • Adductors / rectus femoris • Suspect if worsening outcome with treatment

Question 33

``` Greater trochanteric pain syndrome. What is it? Mechanism (4) Population (2) Symptoms (3) Objective tests ( 5) Treatment (6) ```

Answer 33

V) Greater trochanteric pain syndrome An umbrella term for a collection of common, non-arthritic hip pathologies affecting the lateral hip. This includes gluteal tendinopathy, local bursas. Mechanism • Most common – tendinopathy of the gluteus medius/minimus tendon • Compression of deep tendon against greater trochanter • Trochanteric bursa • Associated with weakness in glutes ``` Population • Common in 40+, females > males • Common in distance runners SSX: • Pain over GT/lateral hip • Exacerbated by sleeping on side • Pain w/adduction and single leg stance ``` ``` Objective Testing • Pain on lateral hip GT palpation • + FABER w/ lateral hip pain • Non-specific hip pain • Pain on SLS after 30s • FADER-R, ADD-R Treatment • Progressive loading program in hip abduction exercises • Treatment with corticosteroid – good short term, poor long term • NSAIDs/ice • Addressing kinetic chain muscle faults • Relative rest – avoids aggs • EDUCATION ```

Question 34

MUSCLE INJURY Mechanisms (3) Symptoms ( 3) Objective testing (7)

Answer 34

``` Mechanism • Acute, overuse, external trauma SSX: • Pop, pull/strain during activity • Loss of function (instant or progressive) • Worse w/activity, better with rest Objective testing: • Pain on resisted contraction • Pain on passive stretch • Weakness to varying degrees • Localized pain on palpation • Loss of continuity of muscle • Local swelling / oedema • Two joint muscles more vulnerable ```

Question 35

Muscle Injury Classification Ryan 1969 | Grades (4)

Answer 35

``` Muscle Injury Classification Ryan 1969 – Grade 1 – 4 tears Grade 1 – Overexertion Grade 2 – Neuromuscular Grade 3 - Partial tear Grade 4 - Full tear / avulsion ```

Question 36

What is a quadriceps contusion? What is it caused by? | What should be avoided in treatment?

Answer 36

II) QUADRICEPS CONTUSION Intramuscular swelling or haematoma Direct impact to the area Treatment: DO NOT use heat.

Question 37

The British Injury Classification 2014 What imaging does this classification rely on? Grades (5) Locations (3)

Answer 37

``` Grades 0-4 according to MRI features 0 = DOMS 1 = small injury / tearing 2 = moderate injury /tearing 3 = extensive muscle injury / tearing 4 = Complete tear Location 1) Myofascial 2) Muscle-tendon junction 3) Intratendinous ```

Question 38

Hip flexion injury: Mechanism Objective Tests (3)

Answer 38

Mechanism - Injury with kicking/sprinting/changing direction Objective: Mostly rectus femoris or iliopsoas IIIb) Rectus Femoris injury • High incidence due to multitude of attachment points Test: • Palpation • Resisted muscle test • Stretch (modified Thomas test)

Question 39

Hamstring Injury Susceptibility (2) Mechanism (2) Objective signs (2)

Answer 39

IV) Hamstring Injuries Susceptibility • Muscle imbalance, tightness, neural restrictions, previous injury • Weakness in eccentric strength for hamstrings Mechanism a) Slow speed stretch injury • Targets semimembranosus tendon b) Fast speed stretch injury • Targets biceps femoris tendon (long head) Objective Signs • Pain on resisted knee flexion • Pain on passive knee extension with hip flexion

Question 40

``` Proximal Hamsting Tendinopathy What is it? Mechanism? (2) Population (1) Symptoms (1) Objective findings (4) Treatment (2) ``` DDX? (3)

Answer 40

Proximal Hamstring Tendinopathy Compression of tendon against ischial tuberosity Mechanism • Onset after sudden or intense change in training (eg hills) • May include ischiogluteal bursa irritation Population • Common in sprinters Symptoms • Dull, achy pain intensifying with activity Objective Findings • Activate hamstring under compression(taking hip to 90 degrees flexion, then bending knee) • Pain on stretch and resisted contraction • Pain on palpation local to ischial tuberosity • Confirmation by MRI or US. Treatment Same as any other tendon: • Eccentric exercises away from hip flexion DDX • Sciatic nerve compression • Referred hip pathology / lumbar spine pathology • Piriformis or biceps femoris compression

Question 41

PRINCIPLES OF REHABILITATION Early (2) Intermediate (3) Late (2)

Answer 41

PRINCIPLES OF REHABILIATION Early rehab • Managing the inflammatory process (POLICE) • Maintenance of neuro-physiological integrity Intermediate rehab • Promotion of re-modelling process • Increase strength / flexibility (start isometric, then isotonic) • Restoration of muscle balance Late rehab • Function-related progression • Return to function