7.15 Sports injuries in the pelvic region

Injuries around the pelvis usually cause pain, which tends to be in one of three regions:

There may be a degree of overlap of the site of the pain and sometimes, especially with primary hip joint pathology, the pain may be felt deeper within the pelvis. The diagnosis can usually be made following a detailed history and examination, which may include special tests. This can be confirmed by imaging, in particular magnetic resonance imaging (MRI) and ultrasound scanning.

Groin pain may be caused by local pathology but several systems can cause referred pain into the groin. There is, therefore, a large differential diagnosis (Table 7.15.1).

Acute symptoms are usually due to strains and minor tears which can be managed expectantly with a good outcome. However, chronic groin pain is often complicated by the fact that multiple pathologies may coexist. Furthermore the aetiology of the so-called ‘sports hernia’, a diagnosis commonly made in athletes, is poorly understood. Therefore the assessment and treatment of chronic groin pain can be difficult.

These two injuries often coexist and although the description of osteitis pubis is well established, the diagnosis of sports hernia is poorly understood. This injury has been described by many terms, such as sportsman’s hernia, athletic pubalgia, and Gilmores groin. It is predominantly an injury of the male athlete. Both the aetiology and pathophysiology are controversial. The most common view is that it is due to a weakness or deficiency of the posterior inguinal wall. Findings at surgery include tears to the transversalis fascia or conjoint tendon and dilatation of the superficial inguinal ring.

The cause is thought to be the strong pull of overconditioned adductors against the relatively underconditioned lower abdominal muscles creating a shearing force across the front of the pelvis. This may also lead to instability of the symphysis, hence the association with osteitis pubis.

The main symptom is a chronic, activity-related uni- (or bi-) lateral groin pain, which occurs in cutting and kicking sports, such as football, rugby and hockey. The onset is usually insidious initially with discomfort after a game. Gradually the pain comes on during a game, especially with cutting movements rather than running in a straight line. This then affects the ability of the athlete to train and perform. Examination findings are variable but can include tenderness over the pubic tubercle and around the superficial inguinal ring, which may be enlarged. There may be pain on testing the muscles groups attached around the symphysis, including the adductors and lower abdominals (tests include the adductor squeeze, double leg raise, and sit-up). Conventional hernia tests are negative.

Imaging may show changes around the symphysis with changes on x-ray and bone oedema on MRI, both suggestive of osteitis pubis. MRI may also show tears and tendinosis of the rectus insertion and adductors. In experienced hands, changes can sometimes be identified on ultrasound.

Treatment should initially be conservative. This should include a period of relative rest from the provoking activities. Non-steroidal anti-inflammatory drugs (NSAIDs) may help to control the pain while the symptoms of osteitis pubis may respond to an intravenous bisphosphonate. Physiotherapy should include conditioning exercises involving the muscle groups around the front of the pelvis with core stability/strength training involving the lower abdominals. A progressive training ladder gradually working back to full sporting activity should then be followed. This process to full recovery can take about 4 months.

In those who don’t respond to this regimen or in those who want a quicker resolution of the injury (e.g. the professional athlete), surgery should be considered. The options are either an open or laparoscopic approach with exploration and repair of the abdominal wall, using a mesh or performing a modified Bassini repair. The success rate following surgery is extremely high with most studies reporting greater than 90% of the athletes back to full sporting activity within 4–8 weeks. Unfortunately there are no randomized, controlled trails comparing surgical with conservative interventions.

These injuries are typically seen in footballers and ice hockey players. They usually occur acutely and can be graded from mild where minimal playing time is lost (grade I) to severe where there is almost complete loss of muscle function (grade III). The athlete complains of groin pain with tenderness over the adductor and/or at its insertion around the symphysis. There is pain on passive abduction and on active adduction. It is thought that without adequate rehabilitation there is a danger that an acute adductor strain may go on to a more chronic tendinopathy.

These occur at the attachment to the superior pubic ramus as a result of excessive lifting or intensive ‘sit-up’ type exercises. There is usually tenderness around the site of attachment and pain on active contraction of the lower abdominals. The injury responds to relative rest and physical therapy.

These occasionally cause groin pain in the athlete. There may be an obvious swelling with a positive cough impulse. They respond to surgical treatment.

The diagnosis of obturator neuropathy is controversial. It is due to fascial entrapment leading to exercise-induced pain together with weakness of the adductors and numbness in the distal medial thigh immediately post-exercise. Electromyography (EMG) may show denervation in the adductor muscle. It often responds to conservative therapy but may require surgical release.

The iliopsoas arises from the lumbar vertebrae and anterior surface of the ilium and inserts into the lesser trochanter of the hip. It is a powerful hip flexor and recurrent kicking actions can lead to an overuse injury. This is seen typically in dance but may also occur in football. The athlete complains of groin pain while examination findings include pain on iliopsoas stretch and on resisted hip flexion. Treatment consists of rest from kicking movements and reconditioning of the iliopsoas.

A bursa lies adjacent to the tendon insertion into the lesser trochanter. This can sometimes get inflamed and swollen. Symptoms and signs are similar to iliopsoas tendinopathy. Treatment includes image-guided aspiration and injection of the bursa.

The snapping hip syndrome is a condition commonly seen in ballet dancers. It can be associated with pain and is most commonly due to the iliopsoas tendon as it passes over the anterior aspect of the hip (anterior snap). A less common cause in dancers is from the iliotibial band (ITB) as it passes over the lateral aspect of the hip (lateral snap). The anterior snapping hip can be confirmed on ultrasound assessment and usually responds to stretching exercises.

See Chapter 7.16.

Sero-negative arthropathy typically occurs in the young adult population and may present as an isolated monoarthritis of the hip. Alternatively, hip involvement may be part of a more generalized arthropathy involving several large joints including the sacroiliac joints. The athlete will present with unilateral groin pain with limitation of movement of the hip. X-rays are usually normal but MRI may show evidence of both synovitis and bone marrow oedema. Treatment involves NSAIDs and possibly second-line agents. An image-guided steroid injection can be very effective especially in an isolated monoarthritis.

This occurs in distance runners, more commonly in females. The athlete will complain of groin pain and have localized tenderness. Early diagnosis can be made either by bone scan or MRI as changes occur within 48h whereas the plain x-ray may remain normal. Treatment involves rest from weight-bearing sport and correction of relevant biomechanical factors. The injury usually heals within 6–8 weeks.

This injury is relatively uncommon, occurring in weight-bearing sports usually following a period of increased training. The diagnosis is often missed in the early stages as there is usually an insidious onset of exertional groin pain, a symptom that has a wide differential diagnosis. Furthermore, examination findings are often non-specific (with pain at end-of-range on hip examination) while plain x-ray is normal for several weeks. Diagnostic delay is therefore quite common and unfortunately this can lead to extension of the fracture with associated complications. Early diagnosis requires a high index of clinical suspicion supported by further imaging (either MRI or bone scan).

There are two types of fracture:

This injury occurs during adolescence, typically associated with sprinting and kicking. It occurs at the site of attachment of the rectus femoris to the anterior inferior iliac spine. It usually responds to conservative treatment but surgical re-attachment is occasionally necessary.

Lateral hip pain typically occurs in long distance runners. It is commonly attributed to trochanteric bursitis. However, with improved availability of MRI and ultrasound scanning it is relatively uncommon to find a bursal swelling as the cause of lateral hip pain in an athlete. The trochanteric pain syndrome is a more useful description of this problem.

The athlete complains of pain, which tends to radiate down the lateral aspect of the thigh. The aetiology is probably due to a tight ITB as it passes around the greater trochanter. Occasionally this can cause a snapping hip. With time this leads to an irritation of the ITB, the adjacent soft tissues, or the bursa, which is then responsible for the pain. Treatment consists of ITB stretches, gluteal conditioning exercises, and sometimes a local cortisone injection. In recalcitrant cases, surgery involving lengthening of the ITB can help.

This is an increasingly recognized cause of lateral hip pain and tenderness around the greater trochanter. There may also be pain on stretching the gluteus medius. Diagnosis can be confirmed on either ultrasound or MRI. Treatment involves reconditioning exercises for the gluteus medius and, occasionally, image-guided injections.

Referred pain from the lower back or sacroiliac joint is the most common cause of buttock pain.

Sacroiliac joint pain can occur as a result of instability or due to inflammation. It causes unilateral buttock and possibly low back pain, which can radiate into the groin and the region of the symphysis pubis. It can also radiate into the thigh. Injury to the joint can occur as a result of intensive weight-bearing exercise especially in an athlete with a leg-length difference.

Treatment should consist of analgesia, correction of any biomechanical issues, and physical therapy techniques, including stability exercises. Therapeutic steroid injections may have a role to play. Surgical stabilization is rarely indicated.

This uncommon injury does occur in distance runners and has been reported in other sports including tennis and hockey. Risk factors include biomechanical abnormalities, such as leg-length difference. The athlete complains of low back and buttock pain sometimes radiating down the thigh. Diagnosis can be made on MRI. The injury usually resolves with rest within 8–12 weeks.

Piriformis muscle overuse or trauma can give rise to symptoms as a result of its close anatomical relationship with the sciatic nerve. The sciatic nerve may be compressed or otherwise irritated by the piriformis muscle causing pain, tingling, and numbness in the buttocks and along the path of the sciatic nerve. Treatment involves physical therapy, analgesia, and avoidance of contributory activities. Injections or surgical decompression are needed if symptoms do not resolve with conservative therapy.

Occasionally there may be a strain of the piriformis, which can cause buttock pain. Diagnosis can be made with clinical testing. The condition responds to conditioning exercises.

This injury typically occurs in sprinters as either a tendinopathy or as an enthesial injury at the attachment to the ischial tuberosity. It causes deep buttock and posterior thigh pain. Although it can come on acutely, it more commonly has an insidious onset. It can usually be diagnosed on physical examination and then confirmed on imaging. Most cases respond to physical therapy including mobilizations, stretching and strengthening exercises. Occasionally steroid injections or surgical release is required.

These occur in the adolescent athlete and present with proximal posterior thigh pain and tenderness with pain on testing the hamstring. Therefore they can often be mistaken for a proximal hamstring injury and treated inappropriately.

Apophysitis of the ischial tuberosity usually occurs as an overuse injury in early adolescence. Diagnosis can sometimes be made on x-ray but more obvious findings occur on MRI where bone oedema may be seen. Treatment consists of relative rest and gradual reconditioning of tight hamstrings.

Usually occurs as an acute injury in late adolescence. The fragment of bone should be visible on x-ray. Usually this injury will respond to conservative treatment over a 6 – 12-week period. However, if there is a wide separation of a large fragment then surgical reattachment may be required.