Written by Dr Michael K. Van Antwerp, Edited by Andrea Vasquez
Groin and Front Hip Pain
Groin and front hip pain are common areas we see in women’s health. These can have a host of causes with some more evident than others.
Some of the causes of pain in the groin and front hip can be: hip impingement, labral tear, sports hernia, hip flexor strain, hip adductor strain, inguinal ligament sprain, endometriosis, cam or pincer deformity, hernia, arthritis, osteitis pubis, round ligament pain, stress fractures, nerve entrapments, interstitial cystitis, pelvic floor dysfunction, gynecological or urological pathologies, pelvic or hip surgery complications, SI joint dysfunction, sacral or pelvic plexus injuries.
In the first article of this series, we will look at the musculoskeletal causes.
Functional Hip Impingement
Functional hip impingement is caused by malpositioning of the ball in the hip socket which causes pressure or rubbing to occur in one area. This can be caused by prolonged sitting postures where the hip is flexed with tight hip flexor muscles and tissues. Although it seems simple, it can be debilitating in more severe cases.
Femoroacetabular Impingement (FAI)
In structural hip impingement, bone growth is present at the ball-and-socket joint limiting movement usually with some type of cam or pincer deformity. This structural limited movement and pain is referred to as a femoroacetabular impingement (FAI). It is possible for FAI to lead to osteoarthritis or labral tear. It seems plausible that limited hip movement can also lead to pelvic instability including pubic and sacroiliac joint dysfunction as well as low back pain in addition to the presence of groin/front hip pain.
The labrum is a gasket-like ring of cartilage that runs around the outside of the hip socket and acts like a suction cup. It can tear due to trauma, structural abnormalities or repetitive motions. An MRI with contrast dye (MRI arthrogram) is the best way to view a labral tear since an MRI without contrast dye can give false negatives. Sometimes labral tears will need surgery; oftentimes, they can be managed with conservative therapy, sports chiropractic and rehab.
A sports hernia is often defined as any sprain/strain of ligament, muscle or tendon in the lower abdomen or groin area. However, it may be more specific to an injury of the transversalis fascia with pressure on genital branch of the genitofemoral nerve or it might be an injury to the pubic aponeurosis. It is a different injury than a traditional hernia which is why it is sometimes referred to as athletic pubalgia and more recently core muscle injury (CMI). In the past, it was referred to as Gilmore’s groin. A sports hernia will often have no anterior bulge; whereas, a traditional hernia often has bulge from the internal organs pressing or pushing through tissue. The presence of femoroacetabular impingement and pelvic instability seem to lead to increased risk of sports hernia. A sports hernia can be quite painful with difficulty in sitting up or moving and has even ended sports careers.
Hip Flexor Strain
The psoas and iliacus are front hip muscles that help flex the hip. They can be strained in activities such as running, but oftentimes can start hurting from prolonged sitting. In addition, the upper quadriceps and upper sartorius muscle can be tender and/or strained as well. This can often mimic FAI, athletic pubalgia and labral tears initially.
Hip Adductor Strain
The pectineus, part of adductor magnus, adductor longus, adductor brevis and gracilis all attach at the pubic bone. These muscles pull the thigh inward from the hip joint and control the rate of outward movement of the thigh. These muscles can often be strained in sporting activities.
Inguinal Ligament Sprain
The inguinal ligament runs from the front point of the pelvis to the pubic bone, and one is present on each side of the pelvis. It forms the angled crease we have in our groin area. On occasion it can be sprained. In other cases, it can be quite tender although a definite sprain may not have occurred. The lateral femoral cutaneous nerve, femoral nerve, femoral artery, femoral vein, inguinal lymph nodes and genitofemoral nerve all run across this inguinal area.
Round Ligament Pain
The round ligament is a round band of fibromuscular tissue that connects the upper front part of the uterus to the groin. One is present on both the left and right sides. It is part of the several supportive ligaments of the uterus. Normally the cardinal ligaments support the uterine angle, but during pregnancy the round ligaments help maintain this angle. As the round ligaments stretch, they can cause a sharp pain and/or spasm feeling on one or both sides of the lower belly or groin. Rapid movements such as sneezing, coughing or quick exercise can set off the pain. It is often considered a normal sign in pregnancy and is more common in the second trimester. A technique for helping create space for a baby to turn when in the breeched position called the Webster Technique uses relaxation of the round ligaments along with sacral positioning.
Stress fractures can occur from repetitive stress to the bone from impact activities such as running. They can also occur from non-impact activities in individuals with osteopenia or osteoporosis.
Osteoarthritis (osteoarthrosis, wear-and-tear, degenerative joint disease) can affect the hip. The joint space of the ball-and-socket area can thin along with having bone spurs. This can be caused by wear over time. However, a previous injury could also be the cause of hip degeneration over time. In a lot of cases, movement and rehab can help keep the hip moving. In severe cases, a hip replacement can be helpful.
Osteitis pubis is inflammation of the inner pubic bones at the pubic symphysis (cartilage disc between the two pubic bones) and the surrounding muscle insertions. It can be caused by pelvic surgery, pregnancy, trauma or sports injury. The sports that this occurs more often are ones that involve repetitive quick changes of movement such as soccer, rugby and racewalking.
Sacroiliac Joint Dysfunction
Sacroiliac (SI) joint dysfunction can refer pain to the front of the hip and groin even though the problem is in the back. In the absence of hip ball-and-socket pathology, it makes sense to look at the lumbar and SI joint. It has been found that SI joint dysfunction was more likely to cause groin pain than lumbar disc herniation and lumbar spinal stenosis.
An evaluation by a licensed healthcare provider that specializes in the hip and pelvis is a good place to start in figuring out the cause of groin and hip pain. Since we are discussing musculoskeletal causes today, an extremity chiropractor, physical therapist and athletic trainer can be good place to start for this type of evaluation. Imaging with x-ray or MRI may be ordered if needed. A diagnosis is developed along with a treatment plan. An orthopedist or other surgical specialist might be needed depending on the severity of the condition. A physiatrist and pain management specialist might also be needed depending on the condition.
Functional hip impingement, hip flexor strain, hip adductor strain, inguinal ligament sprain, round ligament pain and SI joint dysfunction can all be managed with conservative care if they do not have any higher-grade tissue ruptures. They do will with rest, manual therapy, extremity chiropractic, physical therapy and eventual progression of rehab exercises. There are maneuvers that really open up movement of the hip joint as well as maneuvers to help the muscle and other soft tissue. For example, I use the wishbone maneuver by Whyte-Ferguson to aid in mobility of the hip joint and reduce anterior pressure. Mobility exercises progressed to stability and strength can be quite helpful. Eventual progression to full daily and sports activity is usually the goal.
Osteitis pubis often needs rest and removal of activities that irritate it with eventual progression to a rehab program.
FAI can often be managed conservatively, but sometimes needs surgery if the cam or pincer is too progressed and is limiting any recovery.
Suspected stress fractures need rest from impact activity, but often need imaging to confirm their diagnosis; if they are confirmed, they need to be seen by an orthopedist.
Labral tears can be managed conservatively, but need MRI arthrogram to properly visualize them with an orthopedic surgeon consult if found to be present.
Hip arthritis develops over time as is expected with wear-and-tear. Maintaining movement through a mobility and strength program along with some therapy can be helpful. It is possible that a severely arthritic hip might need a hip replacement.
Round ligament pain during pregnancy can be conservatively managed by healthcare providers experienced in therapy with a pregnant patient. There are techniques in prenatal chiropractic such as Webster Technique that can help. Therapy techniques with a physical therapist experienced in pelvic floor and prenatal can be helpful. There are specialties in athletic training and yoga for pregnancy that can be quite useful.
I am always fascinated how front hip pain can occur. It can be simple but difficult to figure out. For example, I have treated intense front hip pain from a patient that hooked one foot behind the leg of their office chair. After several weeks we finally figured out that this position tractioned the front hip at an odd angle which caused the front hip pain. I had a friend that swore they needed hip replacement because their hip was hurting so badly, but it turned out after asking questions that they were sleeping with one hip in frog-legged position. This was the cause of their intense front hip pain. A skateboarder friend who had multiple falls common to the sport turned out to nut just have impact injury and old hematomas but revealed a cam deformity that was the cause of their pain. We were able to manage it conservatively. Earlier on in practice, I was working with a racewalker that was having pubic area pain; I discussed this with a colleague who had worked as an US Olympic Team chiropractor and he gave a suggestion to check for osteitis pubis; I went back and checked, and it was; I have found this with several racewalkers since. Even though athletic pubalgia is more common in males than females, I have seen several cases in gymnasts, soccer players and dancers.
Thank you for your time. We will explore nerve impingements and organic causes of groin and hip pain in future articles.
Dr. Michael K. Van Antwerp
Dr. Michael Van Antwerp is a specialty chiropractor called a Certified Sports Chiropractic Physician (CCSP). There are only ten CCSPs in Oklahoma, and he is the first one in Tulsa. He has trained with the top extremity chiropractic practitioners in the United States and has developed his own specific hip and shoulder treatment protocols. About half of his practice involves working with extremity issues. Besides athletes, he has a full practice treating a wide variety of patients from infants to seniors. He sees patients during pregnancy and treats a variety of pelvis and hip issues.
In addition to his chiropractic degree, he has the additional professions of Certified Strength and Conditioning Specialist (CSCS), Certified Pedorthist (CPed), and Fellow of the American Society of Acupuncture (FASA). He also has a host of certifications including Chiropractic BioPhysics (CBP), Kinesio Tape (CKTP), CrossFit Movement and Mobility, MovNat and Neurokinetic Therapy (NKT).
Dr. Mike became interested in chiropractic through injuries in martial arts. He later transitioned to marathon running and cycling. He is active in yoga and climbing. He works with a variety of coaches and trainers in town.