What Separates Athletes With Hip and Groin Pain From Those Without

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Find the direct links in your podcast player. Now on to the show. 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. And now, your host, Dr. Sebastian Gonzales. Hey everyone, it's your host, Sebastian, with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time on the show. Welcome. You've missed a lot of episodes. This is, I think, at 279 now. We spent a lot of time recently talking about sports hernias, which is one type of groin and lower abdominal pain.

A lot of people do experience sometimes tenderness of the pubic bone, the adductor area, the lower abdominal. And it is a topic that, if you guys have questions on it, you should certainly listen to the last few podcasts, because there is very limited information on it on the internet for some reason. And so, we cover it in detail. And as always, I do my best, and the other hosts do their best to relay the most relevant information to you guys. So, today I want to cover one of the research articles that I pulled up. And so, we can get a better idea of how to manage people, how to give good information, so you guys can make informed decisions about how to manage your condition.

And for this one, we're going to cover the article, which is called, Which Factors Differentiate Athletes with Hip and Groin Pain from Those Without a Systematic Review with Meta-Analysis? And this will cover things in relationship to hip impingement and your hip arthritis and labral tears and tendinopathies and so on. Remember, this is talking about hip and groin pain. It's not specific to all those conditions. So, take it how you will. But there's many different reasons why you could have hip and groin pain when we see all these at Perforans Place. And so, the first thing to realize before we get into this podcast is know that you guys can get better.

Most people do get better. Most people do not require surgery. Most people get better with just good old-fashioned programming and hard work. All right? Random exercises and stretches from YouTube and Instagram and all the social medias can help. Some do help temporarily. But if your problem keeps coming back over and over again, there's a potential that you're missing something really easy. And we're going to cover some of those things today. And if ever you have questions about how to manage them, you just reach out to us. So, first off, this article is from 2015. And it actually encompasses many different research articles.

And the systematic review and meta-analysis usually is not just one research article. It's usually a bunch of them together. And so, if you ever go on to some of the literature sites, when you find things like that, it's like, oh, this is one of the higher-up ones. It helps me screen out ones that are biased and unbiased and so on. So, they took into consideration 2,251 articles, actually. 17 were picked. And then at that point, it was boiled down to actually 10, which were considered high quality. In this paper, they cover three basic categories, which they consider evidence for. So, strong evidence for, moderate evidence for, and limited evidence for.

Because there's a lot of things you guys have probably heard about that it's like, oh, well, this is something that everyone keeps talking about. Like, surely it has to do with hip and groin pain, how to resolve it. It must be true. Well, no, not all these things are necessarily proven to be true. It's important to note that some things that actually may help you are not always proven yet. But, as we kind of say, it's important to do things that are evidence-based or evidence-informed. But, it's probably a good idea not to go against the evidence. Like, if you find out that, you know, eating broccoli is something that grandma said is good for groin and hip pain, and evidence strongly suggests that it's not, perhaps it's a good idea to not go against it.

But, if there's never been an article proving that broccoli is good for it, and, you know, everybody who eats broccoli doesn't have any groin pain, maybe it's a good idea to eat broccoli. You know, so you can kind of spin this two ways. But, generally, we try not to go against the evidence. Just use it to inform us of making good decisions. So, the article found good, strong evidence for, and some of these are going to be like no-brainers. But, some of them I'm going to dig a little bit more into, is patient-reported outcome scores. And, this is, one of them is called the Copenhagen Hip and Groins Outcome Score.

The other one is called the Hip Disability and Arthritis Outcome Score. Basically, in these questionnaires, people are asked a bunch of different questions about their problem, and if they have a problem, they say yes. So, obviously, a strong evidence for people who report pain have pain, right? It's kind of a no-brainer. So, one of them is patient-recorded outcome scores. I won't talk about it much going forward. The other ones on the list, which I will boil down a little bit more, is pain on adductor squeeze tests, lack of hip internal rotation, bent knee fallout, knee, sorry, adductor squeeze strength, and altered trunk muscle function.

Now, again, this next one with the pain on adductor squeeze test, the reason why it's highlighted in here is because there's a stronger relationship with this test than other tests that we'll cover a little bit more later. But other tests that sometimes are done for identification if someone's actually suffering from a groin condition versus something else which is causing their pain is a single adductor, a single adductor test, bilateral adductor test, active straight leg raise, pelvic belt, impingement test. And those can help us identify maybe what's going on, but the one that really has the strongest indicator to someone who has groin pain is going to be pain on the adductor squeeze test.

Later in this podcast, we'll talk about how they tested that actually to see maybe potentially what's happening in that too. But I would think of this kind of the other way. If you had pain in the adductor squeeze test and you walk into an office and you're like, well, I have groin pain oftentimes and I'm not quite sure what's going on or, you know, if it's still prevalent or if I can go back safely into sports and so on. But it doesn't bother me right now because a lot of times people's groin and hip issue only comes on as they start to increase activity or go back into sport. So in theory, you can do something like an adductor squeeze test, which is basically you kind of put something between your knees and squeeze it.

And a lot of people use their fists. Sometimes people use like yoga blocks and stuff like that. But if it's painful to do so, then potentially it would be reasonable to think that when you get back into sport or full activity, it may return. And it's not a predictor 100%. It's strongly related, it says. So maybe this is something that we should address before you start to go full bore into activity again. And that's kind of the point of rehabilitation and giving people good advice about what to expect and how to manage flare-ups and how to decrease potential flare-ups. So the third one is the lack of hip internal rotation.

This is usually tested at 90 degrees. So kind of in a hip flex position and you test internal rotation, which is actually when your foot moves out. So it's hip internal, but the ankle goes external or outward. And so they say that reduced hip range of motion associated with athletic groin pain has been proposed to result from pain, muscle spasm, or capsular scarring. So they're saying maybe this is happening because of it hurts to do so. Muscle spasm, which is maybe guarding it, or capsular scarring, which is like it's just firm, right? There's other things that I think that could be creating that too.

One of them is what we call threat, which is very nondescript. But we had a client the other day that his hip internal rotation was limited on his left side. And we had him do a remedy or a treatment for his lower back disc injury. It was just a couple minutes. We came back and his range of motion actually had improved. So in that case, it can't be really capsular scarring because that wouldn't really change with the intervention that we did. So there's other things that can create that too, at least in my experience. So, but over and over again, a lack of hip internal rotation is consistently throughout research that I've seen on things like sports hernias and labral tears and hip FAI or cam deformities and so on, which we're going to talk about a little bit later too.

Bent knee fallout is a test where you basically just kind of let the knee fall out. This is something that's pretty related to people having groin pain, like if they have a positive finding with that. Or it's limited in range, just limited range. It doesn't always have to be painful. Like the lack of hip internal rotation is limited, but not painful. And it's different side to side. So these are things that we can look at, even if you're not really having the problem. And just to see, these are things that, these are opportunities where we can improve things. I always like to say that, you know, you have a symptom generator.

And then you also have contributing factors. There's a reason why it's probably happening on the right side only. You keep having your lower abdominal strain or your pubic bone pain or your groin pain or your hip issue on the right side. And we see that that one's always lacking range. Also, related to other factors like knees and muscle strains into the thigh, even lower back pain, they're going to take the hit if the range of motion is really not available, whether the range of motion deficit hurts or not. So bent knee fallout and lack of internal hip rotation are things that we can reasonably measure and just look at on a physical exam once we want to see.

Another thing is the adductor squeeze strength. So this one was, it was a small, there was a small scale soccer study that they did where basically the lower adductor squeeze test, if it was low, or sorry, low, low, a lower adductor squeeze result, like a lower value on one side. They said that it preceded the onset of groin pain in some of those individuals. So that wouldn't be interesting to see, because if you don't have any problem, but you have, you test side to side strength wise, and a provider can help you do that, the side that is at higher risk of returning or flare up is going to be the one with lower strength, right?

And so, so far, range of motion and strength of the hip, or at least in this case, the adductor, which is going to end up partly being core and glute involved too, in my experience. Those are things that are opportunities that you can work on. They have nothing to do with surgery, whether you have a surgery or not, it doesn't change these. It would change the hip rotation possibly if it was a bony obstruction or a labrum, but in the other classifications, it really doesn't change it. That's something that has to be conditioned. The last thing that has strong value is altered trunk muscle function.

And there was three studies they did on this. There was the electromyogram activity of the transverse abdominus, the internal oblique and the external oblique, and the rectus femoris. So rectus femoris is one on the thigh. And so they tested, they hooked electrodes all up to these and measured activity. And they found in this study that the transverse abdominus activity relative to the rectus femoris activity was delayed. So the rectus abdominis, one of the deep core muscles, was delayed in its activity in relationship to the thigh one. And so the transverse abdominus is also a muscle that over time has been a highlight reel on a lot of the research with various different conditions.

Low back pain, pelvic floor dysfunction, hip conditions. I mean, you name it. Like, it's all over the board. Which is why hollowing, abdominal hollowing, where people suck their belly in to activate the transverse abdominus. That's why that came around years and years ago. Over the years, they found out that actually you can increase the transverse abdominus activity better with improving intra-abdominal pressure, which is not sucking in. It's actually expanding in 360 degrees, which is hard for some people to do, which makes sense, because if they're having problems with that musculature, it's hard to get that activity.

But it can be done. But the transverse abdominus is an important part of the core. And if it's not working well, then it tends to, the core function is sacrificed. Now, in the cases of sports hernias, by the way, if you listened to the previous episodes, we were talking about the conjoined tendon that comes from the internal oblique and the transverse abdominus, which becomes the abdominal apoderosis, which inserts into different parts of the rectus abdominus in the pubic bone. And so the conjoined tendon is one that's, it's, it's a factor, right? And so in this scenario, since they tested the internal oblique, they really found more deficiency in the transverse abdominus.

So I would imagine even with sports hernias, conditioning, the deep core is more important than that. It's, it's an important factor. I don't want to say it's more important than a, than a surgery if it's needed, but it would certainly be a really easy starting point for a lot of people. Study two, they, they tested, this was an ultrasound study where they put a probe on someone. They watched the musculature as it, as it activated, as they did a certain test. In this case, they did the active straight leg test, which is laying on your back and bringing your leg up to the sky. And the adductor squeeze, which is the one where you're squeezing some between your knees.

They found that the hip and groin pain participants had significantly thinner transverse abdominus. Again, there's that muscle again, compared to the controls. What controls are people who don't really have any problems when they were at rest, when they weren't really doing the exercise yet. Although there wasn't really a big difference found in the internal bleak thickness. So there is a thinner muscle. Now we can say that relates to strength or conditioning or, or something like that. But, you know, it's just, call it, we see it right now. It's just visually thinner. I would say it probably has an association to its functionality.

Probably the thinner it is, the less it functions well. But in this case, again, the internal bleak really wasn't a big deal. So we talked about that conjoined tendon between those two muscles. Study three, they did an isokinetic test, which was to assess the abdominal and back extensor muscle strength. So we looked at, study one was going to be, was based upon activity time, like a delayed or not. Number two was visually. How does it look? Number three is strength. All different classifications. And they found out that they're significantly lower concentric or shortening contraction back strength and eccentric or lengthening contraction strength of the abdominal muscles.

So, nice findings, right? These are things that are all good opportunities. You can improve hip rotation. You can improve hip mobility with the bent knee fallout. You can improve addict or squeeze strength if you work on the transverse abdominus and deep core probably. And make sure that you structure your progressions over time really well. And we can certainly work on deep core function as in the altered trunk muscle strength. Or, sorry, altered trunk muscle function because only one of those states is based upon strength. Would you like to work with us here at Performance Place? Perhaps pick our brain about your situation?

You can. For a limited time, we're offering a $29 special. That's 30 minutes to discuss with us any questions or concerns you may have about your current situation. We call this the Discovery Session. You get to learn if you want to work with us. And we get to learn if we should work with you with your specific case. Contact us at info at p2sportscare.com to learn more. So, those are all the things that really have strong evidence. Again, patient reported outcome scores, pain with adductor squeeze tests, lack of internal rotation of the hip, bent knee fallout, adductor squeeze strength, and then altered muscle, trunk muscle function.

Now, we're on to the ones with moderate evidence. These are the ones that are kind of like, yeah, it looks promising, but it's kind of wishy-washy at the same time. So, it's going to be funny. These ones are actually imaging-based. And I don't know how many people I've seen over the years. I'm sure Dawne Costantino has seen a lot of these people, too, where they're really, really concerned about their imaging finding, which is merited. Again, moderate evidence. But also, too, it's not the whole story. Notice everything above, which is basically not imaging-based. All the stuff, the questions we ask in the patient-reported outcome scores, the testing, the rotation, the function, those are things that are seen with movement or can be tested with a physical exam.

Although they tested it with things like EMGs and ultrasounds and so on, a good examiner can figure these things out by watching you move and testing things. Like tactile touch and watching movement is an important part of the exam and more important in my experience than imaging. Although imaging does play a part, as I'm going to talk about right here. So these ones are going to be pubic bone edema. Edema is like a fluid accumulation within the bone itself. Usually it coincides with some type of longer-standing, low-level injury. It's not trauma-based. It's not necessarily a fracture, but imagine like a bone bruise.

Like you're hitting it, and then it just starts to create some cracks on the inside and creates a little bit of fluid in there. Usually on an MRI, if you're looking at one certain slide, it'll turn out more white. When white shouldn't be there, it'll look white. And then the other thing is a secondary cleft sign, and that's a little bit more x-ray-based. So the first thing on pubic bone edema. And so the first thing they talked about was they did a little study with 19 junior soccer players and found that 13 of them who didn't have symptoms actually had findings of bone marrow edema, right? So that's more than half actually had findings of it but had no pain whatsoever.

But then in another study, they found that no bone marrow edema was found in 100 controls. So 100 people who didn't have pain also didn't have bone marrow edema. There's a contradiction here, right? So that's why it's in the moderate evidence section. The other thing with the cleft sign. So cleft sign is kind of a marker on a, sorry, it's not an x-ray, you'll find it on an MRI. But it's a marker of a short adductor attachment injury. So where the adductor attaches into the pubic bone. So it's the gracilis, the adductor brevis, and the pectineus muscles are the hot spot injuries of possibly having issues there.

So if you go onto Google and you look up secondary cleft sign or it says it on your images, these are signs that it's probably going to be possibly related to your pain. But again, the things that we mentioned above are going to be a stronger thing that you can actually have control over. Like these things are more signs. These are signs that you have something going on and that it can be addressed. It doesn't need to be surgically changed. In fact, bone marrow edema typically goes away after, I think it's a handful of months, it's just changing or decreasing activity. So secondary cleft sign is something that you should just be familiar with, but maybe not hang your hat completely on.

Now we're on to the limited evidence things. Again, it's limited evidence either because it's not really proven or it hasn't really been studied too much yet. So I think there's a big difference between saying evidence says this doesn't work versus evidence didn't even look at it yet. Okay. So pain provoking test other than squeeze test, which we talked about some of the other adductor tests, the active straight leg raise, some impingement tests I mentioned earlier. Also hip external rotation and 90 degrees flexion. So we said internal rotation is related to things, but external rotation really hasn't been shown to be as strong in relationship.

X-ray abnormalities of the pubic bone. Now early we talked about MRIs mostly. Radiology features of FAI. So femoral acetabular impingement and then biomarkers of cartilage degradation. And so hip rotation, again, external rotation is not really that related. X-rays of the pubic bone, really not too related. And then the FAI one is probably something that's going to be a hot topic for a lot of people. I've covered this at length in a lot of other podcasts as well. But I'll just read verbatim on this. There's many studies suggesting that radiology features of FAI are highly prevalent in athletic populations and in athletes with groin pain.

So we find that people who are active as younger adults, probably prepubescent kids, will have FAI or cam deformity, maybe even pincer. But that's also found in people with hip or groin pain. So I wouldn't hang your hat on it. I know a lot of people with FAI or radiology signs of FAI not having any hip or groin pain, and they're perfectly fine. I don't think it's a need to run off and reshape the bone or anything. Now, the last one is those biomarkers for cartilaginous to grade. To be fair, this is not something I really spend a lot of time in. I don't have people going out for blood work all the time, and rarely ever, unless I'm looking for something else or the person's not responding, which is pretty rare with hip and groin stuff.

Usually they're pretty simple. They just have to do a little bit of work. But I'm going to do my best to relay the information to you guys so you know what's going on because it's in here. So the biomarkers for cartilage to grade can be found circulating within the blood, but also they're related to an inflammatory effect. So COMP is one of them, C-O-M-P, and the other one's C-R-P. COMP means, and I'm going to get this wrong, cartilage oligometric matrix protein. And I know there's no T in the oligometric, but that's the only way. Like, I miss say names all the time, and I can't get this one right for the life of me.

The other one is C-reactive protein, which is CRP. And COMP is more associated with joint inflammation and osteoarthritis. CRP is more related to, it's a biomarker associated with inflammation. And that could be things like tissue healing, injury, infection. Like, there's a lot of different reasons why this could be up. But they found that athletes with symptomatic hip impingement, or FAI, had a 24% increase in circulating levels of COMP and a 276% increase in circulating levels of CRP. So, they said there's limited evidence that the biomarkers for cartilage degradation and inflammation are elevated in athletic males with hip and groin pain compared to controls.

You notice he said males, right? And this is why it's like research is helpful, but not like, in this case, we can't say this about females, right? So, but we can extrapolate to say it's probable, but we don't really know because it hasn't been proven or disproven or so on, right? So, just to recap on some things here before we actually end the podcast, and I want to let you guys know that there's a lot of opportunity in what we just discussed here. Without even understanding all the parts of the research, understand this. A physical exam, a good thorough physical exam, can tell you if you are deficient in the things that have strong evidence in relationship to hip and groin pain.

You need to test things. You need to have someone watch you. You need to see if you're doing things right for your corrective exercises or your habits or your activities because there's a chance that you're doing things just poorly. And doing things poorly for a long time means no results, right? If you're sucking your belly button in and trying to hollow and try to activate your transverse abdominus, like the activity level of that musculature is actually going to be better and quicker for results if you do it a different way, such as 360 diaphragmatic breathing. So just know there's plenty of evidence to help us guide you in the right direction for care.

It is hard to have the problem, the hip and groin stuff of various different diagnoses, but don't get muddied up with all the information out there. Usually a good assessment, a good assessment of somebody who can actually correlate even some of your images together if you have them already and give you a rundown of exactly what you should be doing. Most people really don't need to do more than 15 minutes a day, a few days a week to feel improvement. And the adaptation that we're trying to create is the one that's going to help you out in regards to making your flare-up potential or frequency or severity go down, right?

If we get better movement of the hip and internal rotation, we get better activation of the deep core muscles, that should, in theory, decrease your probability of flare-up, no matter how active you are, because there's strong evidence that those are related factors, right? And so doing those over the course of a handful of weeks can really change the function, that those exercises have a purpose. They're not just random exercises or stretches. They have a purpose. They're trying to address a deficiency. Another takeaway is that imaging can provide good information, but it's not everything you need to hang your hat on.

It is helpful. It's helpful to see if there's any actual signs of changes happening within the pelvis area. Usually the MRI is going to be the better option, but x-rays and ultrasounds can certainly see things if we're looking to screen out different types of diagnoses. Again, this was a general thing for hip and groin pain. Also, if you work with a good provider, they're going to be able to tell you if you need an image or not. Not everybody needs to start with an image to be able to start with care. And in fact, most people don't. I'd say a strong 9 out of 10 people do not require any imaging of any type.

Your provider's job is to figure out if you need the image and to spend your resources and time looking at the image. And typically they perform the image not necessarily to see things like the cleft sign and the bone marrow edema, although it can be part of what we're looking to confirm. We're also looking to see things that we shouldn't be treating. You know, tumors, infections, osteoarthritis, which you can treat. But say if the hip is really arthritic, that's probably a good reason why the hip rotation is limited. And in that case, maybe something like a hip replacement may be more appropriate to get that range back to decrease the flare-ups, the possible flare-ups in the future.

So these are all opportunities. And if you guys are looking for help about how to structure a program that is right for you, that's safe for you, that feels hard, that makes the changes that you need to change. And, like, if you only have a limitation of hip rotation and your core is perfectly fine, why bother working on core stuff or vice versa? So spend your time wisely. I don't know about you guys, but I only have a certain amount of time in the day to focus on my own body. I have other things going on. I'm sure you guys do, too. So if you're looking for help, reach out to us. You can call us at 714-502-4243 or email us, info at p2sportscare.com, and we can coach you through the right things to do.

So, all right, we'd love to be on your side, help you decrease the potential of any flare-ups, and we'd love to give you reassurances about what's safe, what's not, and what your activities may look like going forward if you're going to be using the hip and the groin and your body as aggressively as you want to. Like, what are expectations you should really have? So we'll see you guys next time. Subscribe to the show and take care.