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[Physio Explained] Clinical pearls in groin pain assessment with Dr Andrea Mosler

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In this episode with Dr Andrea Mosler, we discuss some great clinical pearls when assessing and treating groin pain. We explore:

  • Assessment tools to explore impairments
  • Categorisation of groin related groin pain
  • Battery of tests for differential diagnosis
  • Top tips for the objective examination

This episode is closely tied to Andrea’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Andrea’s Practical here with our 7-day free trial:
https://physio.network/practicals-mosler

Dr. Andrea Mosler is a Specialist Sports and Exercise Physiotherapist and a Senior Research Fellow (Athlete Health) at the La Trobe Sport and Exercise Medicine Research Centre. Her current research focuses on hip and groin pain, injury prevention, and women's participation in sport. She completed her PhD on risk factors for hip and groin pain in professional male footballers while working at Aspetar in Qatar, where she held roles as Senior Physiotherapist and Head of Continuing Medical Education/Professional Development. 

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Our host is @sarah.yule from Physio Network

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UNKNOWN:

Thank you.

SPEAKER_02:

So flexion, adduction, internal rotation test is a very sensitive test, but it's not specific. So if you have pain with that movement, it does not mean they have hip-related groin pain. If you don't have pain with that movement and you have normal hip range of motion, it's very unlikely that they have hip-related pain. So it's good at ruling out hip-related pain, but not so good at ruling in.

UNKNOWN:

Music

SPEAKER_01:

In today's episode, we unpack practical tips to help you differentiate sources of groin pain, choose the right assessment tools, and make your consults more clinically sharp and patient-centered. Andrea Mosler is a specialist sports and exercise physiotherapist and senior research fellow at La Trobe Sport and Exercise Medicine Research Centre. She's currently working on hip and groin pain, injury prevention, and women in sport research projects. Today's discussion was one I'm sure you'll enjoy. I'm Sarah Yule, and this is Welcome to the podcast today, Andrea.

SPEAKER_02:

Thank you very much for inviting me. It's wonderful to have this opportunity for knowledge translation,

SPEAKER_01:

Sarah.

SPEAKER_02:

one of the areas that is really confusing and can cause some difficulty for clinicians depending on their level of experience with hip and groin pain. So one of the things that we know about groin pain and, you know, it has been called the Bavina Triangle of sports medicine for a reason, there is a lot of complexity in terms of the anatomy and there's a lot, multiple sources that can produce pain within the groin. So one of the things that I find really helpful helpful when teaching about hip and groin pain is to separate out our assessment tools, which can benefit us in terms of thinking about the category of groin pain or potentially a structure versus assessments tools that can determine impairments. And it will be variable. Some of them will interrelate, but by considering these things separately, it will help plan your management plan more appropriately. So if If we think about looking at assessment tools for diagnosis or categorization, we have the Doha Agreement, which has made it really simple for us to make a clinical diagnosis of category of groin pain. And using the Doha Agreement, we can separate out into hip flexor-related or soles-related groin pain, inguinal-related groin pain, pubic-related groin pain, or adductor-related groin pain. And then we have the two additional diagnoses or categories of hip-related groin pain, and other includes all of those medical causes of groin pain, such as gynecological things, referral in some sort of ilioingonal nerve entrapment, or some more scary things like testicular cancer, or some of the other, prostatitis, some of the other medical causes of groin pain. So if we initially target our assessment towards working out the category of groin pain, that will really guide us in terms of which impairments we want to assess. And then once we're comfortable with the kind of category of groin pain, then we need to look at impairments in terms of range of motion, strength, so using things like dynamometers to look at impairments in particularly adduction and abduction strength. And then we might look at some muscle length tests, so particularly looking at rectus femoris length. Then we'll look at some sort of functional tests, so things like side plank or abdominal strength, particularly separating our upper and lower abdominal strength. And then finally, we look at some of our functional measures, which we know can differentiate those with and without pain. So things like your star excursion balance test or a bilateral squat. So by considering your assessment tools in those two different aims can really help plan the assessment for hip and pain.

SPEAKER_01:

That's a fantastic summary. So it's sounding like we're going category first and then we're rolling into the impairments.

SPEAKER_02:

Yeah. And look, I think, you know, don't forget things like our nerve mobilization as well. So femoral nerve and obturator nerve can also influence pain in this region and examining other joints as well. So particularly lumbar spine, knee function, so quads function and looking at ankle range of motion are other areas of the body that are important to including your assessment, even potentially the SIJ test if we're wanting to eliminate SIJ as a source of pain.

SPEAKER_01:

I feel like you've just said femoral nerve and ulcerator nerve. At what point do those sort of neural tests fall out in your assessment? Are they when you're really hunting for something or do they fall part of your sort of normal battery?

SPEAKER_02:

Yeah, generally that would be more when I'm hunting for different sources of pain or or if something doesn't quite fit, or if there's any kind of presentation of neural symptoms. So something like numbness, pins and needles, burning pain, it's not uncommon. Lateral fibromyalgia, cutaneous nerve of the thigh can often be a component of the presentation. So yeah, it's probably not something I would necessarily do in a routine way in the first assessment, but more if I'm looking for hunting for pain. And it's not uncommon to have some sort of neural component to the present particularly for anterior hip pain in women where there's a lot of psoas involvement and that can often result from some sort of lumbar and femoral nerve overlay.

SPEAKER_01:

That does all make sense. Do you mind running through when you're going to differentiate between these categories, do you have a battery of tests that you're tending to roll through? That's something

SPEAKER_02:

that really becomes very efficient with experience and the great thing about the agreement is that it really is a clinical diagnosis. We don't need imaging to do this categorization of groin pain. The only time we potentially might look at imaging is if we feel that the category is hip-related groin pain and we want to differentiate between potentially femoris etabular impingement syndrome, hip dysplasia, or some sort of intra-articular problem without a bony morphological variant. So that's our three categories that were defined in the Zurich Agreement for hip-related pain. But in terms of the Doha Agreement, it's really well set out in the 2014 publication of Adam Weir, who was the lead author. And as I mentioned, it's a very clinical diagnosis based on resisted tests and palpation. So for ductal-related groin pain, if you have pain on resisted adduction and tenderness on palpation, that's and that gives you that category of adductor-related groin pain. So it's really very simple. And for things like iliosolus-related groin pain, it's a very sensitive test of palpation over the iliosolus, but more likely if you have pain with resisted hip flexion. So even though that's how it's published within the Doha Agreement, in my clinical practice, I won't rule in iliosolus-related groin pain unless I have pain with resisted hip flexion. In the agreement, it says more likely and also more likely if there's pain on stretch. And they don't necessarily have to have pain on stretch, but they often do. But in my clinical practice, yeah, I won't rule in cells-related groin pain based only on palpation. They need to have pain on resisted hip flexion as well. And then inguinal-related groin pain is, again, pain on palpation, but more likely if there's pain on some of the darsalva maneuvers. So things like pain on sit-up, pain on coughing. And again, in my clinical practice, they will have to have pain on power patient pain in the area of pain. So the patient interview gives you a lot of indications as to which category it's likely to be in terms of the area of pain. And then, yeah, pain reproduced, their pain with some sort of valsalva manoeuvre is needed for ruling inguinal-related groin pain.

SPEAKER_00:

Music We'll see you next time.

SPEAKER_01:

That's a really nice summary. In terms of, and this is one of my favourite questions, how much of your assessment with groin pain is subjectively driven versus where the objective measures come in as well? What sort of subjective signs and symptoms might clue you in as to where the symptom source might be?

SPEAKER_02:

Yeah, great question, Sarah. And look, I think in my clinical practice, just with the level of experience with clinical patterns that I had Often I've already made a decision, which I shouldn't do, but often I have already made a decision based on their patient interview. I'm being nice and honest here. And I'm really just confirming that with the objective examination. But I'm often surprised. So it is really important, particularly for clinicians with lesser experience, to stay really open and think about all the likely sources and then use the objective examination, particularly our diagnosed tools to confirm what we're already thinking from our subjective examination. So the kind of things that I will spend a lot of time talking through the history and finding out about what led the pain, what changed in training, etc. And often, groin pain is an overuse injury, so it has a gradual onset. So there is often a lot of things to tease out in terms of training load changes and potentially some changes in activity in the gym if there are a higher level athlete that may be contributing to the problem. Also finding out about family history of any kind of hip-related problems, such as dysplasia, can often be familial. Other things like hip osteoarthritis can also be familial. Asking about loading history during adolescence is essential for thinking about the propensity, particularly in male athletes, of developing cam morphology. And we know that soccer players, football players, they are far more likely to have a cam morphology in their hip than not. So up to 65% of their hips will have a cam morphology if they have played football at a higher level during adolescence. So asking about loading during those growth phases is really important. But in terms of the activities that exacerbate the pain, so sitting is a real classic. So if they have pain that is worse with sitting and particularly worse with driving, and it's a deep pain, that can really allude you to the fact that it might be hip-related groin pain. Because Often the other sources of groin pain, unless it's medical, will be better with sitting or better with rest. Things like rolling over in bed, getting out of a car can be really typical things of adductor-related groin pain and pubic-related groin pain. And then obviously inguinal-related is often sort of intensity of load and can often be worse with these kind of Valsalva manoeuvres. So worse with after gym or during gym, those types of activities. So describing where the pain is, the quality of the pain, the depth of the pain, and then the activities that aggravate the pain can really assist you in terms of understanding what the source of the groin pain might be.

SPEAKER_01:

You can certainly hear how subjectively that will direct you towards certain assessments objectively.

SPEAKER_02:

Yeah, and I just want to make a note about female athletes as well. So one of the things that we're looking at a lot more is how gynecological health and pelvic floor problems may relate to the presence of groin pain in female athletes. So that's something really important to ask female athletes, their menstrual health. Do they have a diagnosis of endometriosis? Obviously, whether they've had children, pregnancies, et cetera, because that can be a really big factor in terms of their ability to stabilize the pelvis. So there might be a mechanical or biomechanical factor, or there could be some sort of component of their problem that is a referral from the gynecological part of their body for particularly things like endometriosis. But one of the other things we need to think about is if there is really significant problems with menstrual pain that can really inhibit function of the lower abdominals, which can affect capacity to stabilize the the pelvis, which then can be a component or an impairment that can contribute to the presence of groin pain. So it doesn't necessarily need to be the actual source of pain, but it could be a contributing factor. So always important to delve into those sort of questions with female athletes.

SPEAKER_01:

And going all the way back to that adductor-related groin pattern, do you notice it's certain muscles that come up every time or do you notice any patterns that do present in your subjective or objective assessment of adductor-related groin pain?

SPEAKER_02:

Yeah, well, we know that particularly for football players, and I'm talking round ball football, that adductor-related groin pain is the most common entity for both females and males. It's around two-thirds of presentations of groin pain are adductor-related groin pain. So that is definitely something I would suggest for up-and-coming physios to get really good at assessing and managing and rehabilitating. And it's almost always adductor longus is involved. You may have some of the other adductor muscles involved, but you rarely have the other adductor muscles and not adductor longus. So almost always it's adductor longus and it could result from adductor longus really taking over the role of maybe adductor magnus as a stabiliser or also being overused in the kicking in external rotation, which we see a lot in soccer, but also change in direction. So there's a there's a really high demand on the adductor muscle group in general. And we know that having reduced adduction strength, both relative to abductions and the ratio or relative to normal is a risk factor for developing groin injuries in football players. So looking at adduction strength relative to abduction and in football players or any kind of change in direction sports, we want a ratio of about 1.2. So we want the adduction strength to be about at 20% stronger than the abduction strength. That might be different in different sports, but that's what we know in change in direction sports.

SPEAKER_01:

So AD duction, 20% stronger than AB duction. Yeah. Fabulous. Before we wrap up, I'm curious for those young physios, for anyone practicing and looking at this sort of groin pain, what would your top tips

SPEAKER_02:

be? So don't be fooled by a positive fader. That's probably my number one tip. hip that we would love for our flexion, adduction, internal rotation test, which is described as an orthopedic test for hip-related pain. We would love it to be a really sensitive and really specific test. So if it's positive, it means they have hip-related groin pain, but it is not specific. So it is very sensitive. It'll pick up a lot of pain, very commonly will pick up pain, even in completely asymptomatic athletes that have never had hip and groin pain, 2% of them will have pain with fader and up to 6%, between 2% and 6%. So selection, adduction, internal rotation test is a very sensitive test, but it's not specific. So if you have pain with that movement, it does not mean they have hip-related groin pain. If you don't have pain with that movement and you have normal hip range of motion, it's very unlikely that they have hip-related pain. So it's good at ruling out hip-related pain, but not not so good at rolling in. And same with faber. Faber is a little less sensitive, but again, not specific. So a lot of other presentations of groin pain will also have pain with faber, and it doesn't mean that they have hep-related pain.

SPEAKER_01:

Devastating news that the faber test doesn't give us everything.

SPEAKER_02:

Yeah, so that's probably one of my top tips. And then don't be too fussed if you are finding difficulty identifying the exact source of the pain. The most important thing is looking at the category of pain and rehabilitating based on impairments. And the category can be really successful without ever actually knowing the exact structure which is causing pain, ingrown pain.

SPEAKER_01:

I think that's a really fantastic piece of advice because sometimes it's very easy to get caught up in the weeds of a specific diagnosis. But if we're strengthening what's weak and mobilizing what needs mobilizing all the those things and treating the impairments, I think we're heading in the right direction.

SPEAKER_02:

Can I do one third top tip, Sarah? Of course. The third top tip is that we have two randomized controlled trials which have shown efficacy of using compression bike shorts, particularly for doctor-related groin pain. So if you have any patients presenting with a doctor-related groin pain, particularly when it's chronic, pop them in some compression bike shorts and they'll feel more comfortable. So that's a very easy management tip, which could make a really good difference to your patients.

SPEAKER_01:

Fantastic tip. You'll be able to see who's listening to the Physio Network podcast now. Everyone will just be walking around in Lycra.

SPEAKER_02:

Exactly. Doesn't have to be full Lycra, as short as the mouth.

SPEAKER_01:

In for a penny, in for a pound. Andrea, thank you so much for spreading your knowledge. I think we're all running to go and have a look at the Doha agreement now as well. But those are some fantastic tips to help us stay more clinically sharp so thank you so much for your time and knowledge.

SPEAKER_02:

Yeah my pleasure Sarah and as I said it's always a delight to enhance knowledge translation for clinicians and I'm always happy to talk about hip and groin pain. Thank you.

SPEAKER_01:

Thanks Andrea.

UNKNOWN:

Music