Groin pain: sports hernia, hip impingement or hip flexor overuse?

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, it's your co-host Sebastian with the Restoring Human Movement podcast. Thanks for joining the movement movement today. We are going to talk about different reasons for groin pain. If you've been following our YouTube channel or some of our podcasts, you realize that we see tons of people with hip impingement, sports hernias, adductors and endopathies, and so on. And today I wanted to cover what a few of these common ones that I've seen are.

And I've been fortunate to see so many people with groin pain. I'm not talking about lower abdominal today. I'm talking about just mainly groin and the crease of the hip. But I'm going to tell you some stories of what I commonly see anecdotally. And we can discuss potentially what the treatment options are, the success rates, and so on. I'm hoping that you guys are going to get good information about these conditions today from my experience and what I've seen in our clinic and through our telehealth versus just only what reading and what research is saying. Because we all know, or at least in the field, we kind of know that it takes 10 years for research to really catch up with what we're seeing and doing here in practice.

It doesn't mean you can't do the things we're doing in practice, but it takes time for research to really catch up. So it appears that research is limited in some of these things, but actually I think we're seeing it today in our practice. So I'd say the number one reason why we're seeing people with unresolved groin pain is because many people actually have a condition called hip impingement, but they lack seeing the correlation associated to the mechanics or biomechanics or compensation with the condition. So we're going to cover hip impingement today. We will cover a sports hernia today, and we're going to cover hip flexor syndrome today or hip flexor conditions.

I hate using the term syndrome because syndrome is actually a collection of different symptoms and not everybody has. So we'll say hip flexor things today. It may not be a tendinopathy, but it's an overuse of the hip flexor. So in one of our recent podcasts, I did cover some of my favorite exercises for hip impingement, which I think are a great starting point for you guys to listen to if you haven't already. We also cover it in the YouTube channel, which I will link in the description as well. But the problem that we oftentimes see with people with hip impingement, especially when in their 40s and so on, is that they feel very defeated about being told they have hip impingement because hip impingement, by definition, it kind of insinuates that it's a bony structure that's not going to change.

And I would agree with that. Your bony structure will not change, nor does it need to change. But the defeating aspect about it saying, well, this is the damage that I did. This is how it is. I guess it's the way it's going to be until I have the surgery done and they project that I'm going to have it 10 years from now, which I think is completely false. You can't predict anybody's future. You can give reasonable expectations of what they may end up finding, but no one should be telling you, hey, you're going to need a hip replacement within about 10 years because that's what it's going to be.

That's terrible to tell somebody. But I think giving warning signs about like, look, if you continue to do what you're doing, yeah, within, you know, 10, 20 years, you may end up having more hip pain. You could be a candidate for hip replacement. Maybe, you know, maybe, maybe. It's not a definitive yes or no, because no one really does. But the big missing win that people have when they're dealing with hip impingement is they don't realize that the biomechanics of the pelvis really, really, really do matter. If you look at some of the back history of people with hip impingement and how it occurs, it actually occurs in adolescence.

So it occurs when people are very active teenagers or preteens. And because there's still a growth plate right there on the femur, that it makes it oblong shaped instead of an, instead of like a ball. And so it creates what we call the cam. The cam will not change. It will not change. Not everybody has, excuse me, sorry, I'm getting over cold and I do have some allergies. So I'm maybe a little raspy today. They also can have something called a pincer, which is an overgrowth of the pelvis aspect of it. But when you look at some radiology studies, you see that people with an anterior pelvic tilt, because of the way they move, not because that's their default or their structure, they have an anterior pelvic tilt as a compensation from other things.

You see some other type of back condition or poor core stability or some other type of thing. It actually makes their femur run out of room more and quicker than those who have a posterior pelvic tilt. Now, I've had this question over and over again about, do I need to get rid of a pelvic tilt? Do I need to make sure that I'm never in posterior tilt or anterior tilt? And no, you should be able to go in and out of a anterior or pelvic, posterior pelvic tilt at any point in the day based upon activity. It, you should be able to have access to both. Now, if you don't and it's hard to do so, it's probably because you have some stiffness involved.

Again, usually from an old injury. It's very common after people who have a lower back pain from a disc injury or a back procedure that they end up having more of an anterior tilt. And it's because they don't always go back into acquiring the posterior tilt. And for some people, I know their older years, yeah, it's a little bit harder to get more spinal mobility. It's like, you're not going to be as mobile as a ballerina. That's a given. But for those of you in your 30s and 40s, like, yeah, you should be able to get some of this back. You haven't had enough time to create a lot of structural changes.

You've had some time, so you may be having some findings of arthritis in the hip or in the lower back, but there's still a lot of time to make an improvement. And this is where rehab exercises, lifestyle change, and also realizing that there's not a danger in doing a posterior tilt with a lot of movements are very important parts. There's a concept called a fear virus, we call it, where people will never do something ever again. Like, I was told I should never have a posterior tilt, so I don't. And because of that, they miss out on all of the benefits of a posterior tilt, such as better hip range of motion, less hip impingement, more range of motion of the hip, which is not painful, less activity of the hip flexor.

So there's a lot of biomechanical aspects that you can exploit with most people to help them avoid things like surgery, get them out of pain very quickly. But again, it all starts with just understanding that it is a structural change. Impingement is a structural change, but it doesn't mean that is the only factor associated to it. By the way, before we get on the other ones, I hope you guys realize we do have telehealth sessions available to you. So if you ever want to pick our brains, we have to do something called a discovery session. It's very affordable. We're licensed in various states, and we'd love to help you out if we can.

If we can help you, we'll tell you that as well. But consider contacting us at 1-4-5-0-2-4-2-4-3, or our contact is in the description for the podcast. Now, when we go into sports hernias, realize too, I will cover this in very brief detail because I wrote a whole 60-page book on this, which also is available in the description for the podcast player. That's completely free. Look at it, because a lot of the problems that we see with conditions like sporternias, overactive hip flexors, or hip impingement, biomechanically, actually have very similar mechanics. It's just the diagnosis or the structure that gets irritated is basically the power leak.

And so it's the weakest structure that takes the most force, and it just tends to have the symptom involved. It's the weakest link. And this is different for everybody, which is by everybody has different symptom generators, although they have similar mechanics, similar power leaks, similar deficiencies, but we end up seeing different diagnoses. Now, a sports hernia is super common. I didn't think years ago that I would find so many people's sports hernias. In fact, a lot of clinicians, students, because we are a clinic that we have students come in from some local schools, they've never heard of a sports hernia.

And so when they get out of school, they see a lot of people with common stuff, lower back pain, hip impingement, tendinopathies and stuff, but they've never heard of sports hernia before. A sports hernia is basically, we're trying to change the term of it here to make it a core muscle injury or an anterior chain injury. And so the reason why it was called a sports hernia years ago is because somebody, whoever first observed it, I forget their name, but they said, you know, this is not a hernia. I can't see a hernia. There's no imaging findings of a hernia, but it's in the groin area. And shoot, kind of sounds like a hernia.

Let's call it a sports hernia. But no visual evidence of a hernia, which is actually intestines outpocketing from the abdominal cavity. And that's not the case. Sports hernias can manifest in different locations, but I've seen many people have manifestation in the groin area or high into the pubic bone region. The crease of the hip is a really common location. And these are, don't always have positive imaging findings. Now, I'm going to tell you that from historically of working with people with sports hernias, the ones that actually have positive MRI findings that they've done early on in the injury cycle, like the first month or so, they've, they've had an MRI done and they have a, they have bone marrow edema in their pubic bone.

Like those are the harder ones to help, but I've met plenty of people who have been diagnosed with a sports hernia who don't have hip impingement. Like you don't really like, and not active impingement. They don't have the classic test for it because there are orthopedic tests you can do for all these. We actually do a lot of them in our telehealth sessions, but they don't have any real findings of other things too. So it, a core muscle injury is more par for the course. And these people tend to not always have that bone marrow edema finding in, in the, the pelvis and, or the, uh, pubic bone. And that's okay.

I tend, again, I tend to find the ones that have the finding, the, and the ones that have the finding, it's harder to help them. You can still help them, but they're more challenging. It just takes a little bit more work for the most part, but there are ones that we weren't able to help. We had to send over to do a surgery for, and some of them fare really well after the surgery. Uh, equally, I've met people who have had a sports treatment surgery and had no resolution in their pain. So it's, it's, I've seen it go both ways, but the, I think that the, the takeaway I would like to give you guys about a sports hernia is that there's usually a hip part of it.

Now, I know I said earlier, there's no findings of hip impingement. That's no clinical findings of hip impingement. Like we're not going to find the signs, the orthopedic tests and so on. They may have limitations in hip range of motion, and they may have, if we dig deep enough, we'll find imaging findings of some type of hip impingement, but they don't actually have a symptom generating structure, which is the hip impingement. They have other ones, which is the core muscle injury, but usually there's a hip part of it. And remember earlier, I said that there's a lot of carryover in the mechanics.

This is true. So what we find is positive tests for these people, as opposed to the hip impingement ones, is things like sit-ups will bother them. When hip impingement people, it's not always the case, hip impingement cases tend to have more pain with, if you laid on your back, apart your knee up to your chest and your opposite shoulder, they would, that would hurt, especially if passively done, it wouldn't really hurt the sports hernia people. But if you resisted that movement, if you resisted hip flexion, especially in did the sit-up, then those people with sports hernias, 75% of them or so, would end up having symptoms.

I've also met a lot of people who, the only way they can really trigger the problem of sports hernia over again is going to be, they actually find like an object in the floor in the office. A classic thing is a weight, like we have bumper plates in our office. And so a 10-pound bumper plate, they take it and they push it with the inner part of their foot. And they say, that hurts. Almost like if you're going to take your shoe off with your other foot, that hurts them. And so there's a test that we do where we have them laying on their back, their feet are fully extended, and we have them push into our hands or our hands are trying to push their feet spread apart.

And that bothers a lot of them too. And that's pretty classic of your sports hernia cases. And so for these people, the only takeaway I'm going to give you, because I've done many podcasts about sports hernias, I want you to listen to all of them because it does give better context for various things, is that do not try to challenge the adductor and do not do things like sit-ups early on in the injury process. Now, I've had people ask me, so you're saying I should not do sit-ups or adductor work ever with sports hernias? That's not what I said. I said early in the injury process. Now, if you've been listening to some podcasts, you realize I had a hamstring tear recently.

I did isometric loading of the hamstring early on. I did it in the first, actually, few days. But in this scenario, when I've met people who have done adductor and sit-up work, they almost always, without fail, they feel worse. Now, I'm not going to say there's not a time and place to do this because there can be, especially early on, but it appears left up to their own devices, reps, sets, intensities. They almost always feel worse. And so I would prefer, and I wrote this all in that free PDF, is that we don't try to challenge those tissues in the beginning, give them a break. They're usually pretty strong in these people anyways.

And we challenge something called the frontal plane or the lateral plane. We can load the lateral plane of the body. We can also just avoid those activities, targeted tissues, like the hip flexors, the core, and so on, the adductors. Like, we don't need to be doing those right now, but we can certainly do a lot of other things, which may not feel like you're targeting the actual tissue, which is actually kind of what we want. We need to make those errors work less, which is kind of what the whole problem is in the first place. They are too dominant in the anterior chain, which is the abs, the adductors, and so on.

So sports hernias, again, it can be a very complicated injury. Do not try to solve it on yourself. But we do have some of our online templated programs for it that I wrote myself. We have something called the virtual surgery we put together, and we have a 12-week, sorry, eight-week online program. Now, I just said, if you heard me, okay, I just said, don't try to solve on your own. I stand by that. We still put out our content because we want people to understand that there is a theory and a methodology to deal with these things. But any condition, I would suggest if it came down to time, you had the time, you had the money, just pay for professional help.

Like, I have a good friend who he is, he's pretty straightforward with things. He says, look, most people solve their own problems at some point, but how many years do you have to waste? If it took years to solve this on your own, do you have that time to waste? Now, that may be pretty brash, and like, not everybody solves it in years, but there are a lot of times where you can solve it in literally weeks to months if you just have someone give you a cheat code to it, which is why professional help exists. There were cheat codes with it. So, sport turn is, they do get better. Don't give up. It will get better.

But if you want to make it better sooner, normally professional help is needed. Now, on the last one here is the hip flexor overuse condition. Now, I've never really seen anybody with a hip flexor tendinopathy. I'm sure they are out there, but I would venture to say that they are actually pretty strong and overused, just like the adductors are. There's a lot of tissues in the body which are overused, not because you're overusing them with your activity all the time, but because they're made to do too much work because other tissues are off. Vladimir Yanda was a professional years ago who observed this with various different movements.

He coined the term lower cross, upper cross. You can look those up on Google, which talk about how certain tissues like the hip flexors and hamstrings are always super helpful. The glutes and the abs are always generally kind of lazy. And a lot of rehab is revolving around this. It's not a bad idea to challenge the tissue, excuse me, that is painful, but it's not okay to feel worse after the fact. People with hip flexor conditions oftentimes will mirror a lot of the symptom patterns with people with hip impingement, but the thing that makes them different is passive versus active range of motion.

So hip impingement is if you bring your knee to your chest into the opposite shoulder passively, meaning your arm to the work, all the work, it'll probably hurt. Now, if you did that actively, either condition will work. It's going to hurt, whether it's hip flexor or it's going to be hip impingement. It's both of them are going to hurt. But the big difference is the passive part, because if you think about it, what we're testing in the hip impingement scenario is passive tissues. We're testing bone, joint, labrum, and so on. If you're testing hip flexor overuse, you're testing active tissue, tendon, muscle, which needs to have a contraction to be able to be challenged.

So normally it's going to require a battery of resisted test and passive test, because you need to see that the data points generally lay out that the passive tests are normal, the active tests are abnormal, and you need to make sure that other conditions are ruled out, such as sports hernia, adductor to monopathy, and so on. And this is why diagnosing is so hard, because there is no one single test that actually tells you that it's definitively one thing. And I've been irritated about this for so many years that the confidence of a lot of people out there saying, well, I am 100% that you have this.

There's no way that you have that. I'm sure of it. And there is always, always some air of uncertainty when you're diagnosing somebody. We're just using our best judgment at that time. And sometimes giving somebody a treatment protocol and realizing that they don't actually respond to it is part of examination. So if I gave you, say I was able to give medications, I'm not. If I thought you had one type of bacteria and I gave you one type of antibiotic and you didn't respond to it, it would lend me to believe that that's not the bacteria that the problem was. It was a different one. You know, and we come to this conclusion all the time with your like staph aureus or antibiotic resistant staph.

So if it's your normal staph, then you're going to respond to antibiotic. If it's your antibiotic resistant staph, it's not going to respond to that antibiotic, right? And how could you really know unless you treated the person first? So there's always some uncertainty and I think finding a healthcare provider which can give you some evidence of what it possibly is, but also give you guidelines of how we're going to make sure we rule that out or rule it in in the future is actually important too. Because if I were to tell you 100% confident you have hip impingement, you're going to need surgery in 10 years, I don't think I'm doing you a good service.

I need to make sure that I tell you this is probably what it is, it's probably provoking factors with it. Here's probably the exercises that are going to work with it. And let's see how that works over the next two, three weeks. And if it doesn't respond, let's reevaluate you because why continue to do treatment or suggestions with the wrong diagnosis forever just because you were so confident in the beginning? That's not 100% the case. So I hope this was helpful today by everybody, at least clear as mud and you understand that there's three common reasons for groin pain that are not all exactly the same.

But I think a lot at the end of the tunnel here is that the mechanics use are very similar. Although that book that I'm talking about in the show notes is for sports hernias specifically, get it and read it and find the mechanics section and you'll see that they're so close. It's so close. Everything is 90% the same between these three conditions with slight variable changes. But when you understand mechanics, you'll understand, oh, all these issues are active. Oh, this is where the deficiencies typically are. Maybe my rehab and my lifestyle should revolve around solving those problems. And so I mitigate reoccurrence because I think that's what we all want.

We want pain to go away, but also we want it to not reoccur. That's how we can confidently continue with our sports and so on. So if you guys are interested in that, please take advantage. Again, if you're looking for help, remember, we do have telehealth 714-502-4243 or contact us in the description for the podcast player. We'd love to help you guys out. We have a passion for helping people with these conditions. We'll see you next time.