Aetiology

The differential diagnosis for groin pain is very broad and complex. Pain referred to the groin can be caused by traumatic injury to various intra-articular structures (cartilage, labral, osseous) or extra-articular tissues (muscle, tendon, bursa). The pain may be caused by common degenerative conditions, such as osteoarthritis, or anatomical and mechanical distortions seen in conditions such as femoroacetabular impingement or hip dysplasia. Additionally, pain may be referred from non-musculoskeletal areas, including the abdomen, genitourinary tract, and lumbar spine.

Pathophysiology

The cause of overuse lesions is not fully understood. Micro-lesions leading to degenerative changes or to chronic inflammation have been suggested. The lesion can be located in the muscle, the tendon, or the enthesis. The changes seen in the pubic bone and around the pubic symphysis probably reflect the amount of stress inflicted by the sport or activity involved, although these changes are not a definite sign of pathology but rather a sign of a repair reaction.[9]

In the hip joint, femoroacetabular impingement (FAI) can be caused by a variety of dysplasia especially related to the acetabulum, and by the so-called cam lesion, which is perhaps inflicted in puberty by excessive loads from sport. FAI and other types of trauma or overuse can lead to intra-articular lesions of the labrum, cartilage, or the ligamentum teres.

Classification

The ESSKA-EHPA-ESMA consensus and the Doha consensus

The 2015 Doha consensus remains the most widely accepted framework for defining and categorising groin pain.[1]​ It describes four key clinical entities: adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain. It also acknowledges hip-related groin pain and other potential causes, including non-musculoskeletal conditions.[2]

The 2024 consensus by the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), the ESSKA European Hip Preservation Associates (EHPA), and the ESSKA European Sports Medicine Associates (ESMA) builds upon the Doha framework and other previous classification systems for hip and groin pain in athletes.[1]​ It reaffirms the four clinical entities for groin pain described in the Doha consensus, and establishes three distinct diagnostic terms for hip-related groin pain.

The classification of groin pain, hip-related groin pain, and other causes of groin pain, as defined by the ESSKA-EHPA-ESMA consensus, is outlined below.[1]

Groin pain

  1. Adductor-related groin pain

  2. Iliopsoas-related groin pain

  3. Inguinal-related groin pain

  4. Pubic-related groin pain

Hip-related groin pain

  1. Femoroacetabular impingement syndrome

  2. Acetabular dysplasia and/or hip instability

  3. Other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions)

Other musculoskeletal causes

  • Inguinal or femoral hernia

  • Post-hernioplasty pain

  • Nerve entrapment

  • Referred pain

  • Apophysitis or avulsion fracture

Other non-musculoskeletal causes (including orthopaedic, neurological, rheumatological, urological, gastrointestinal, dermatological, oncological, and surgical)

  • Stress fracture (e.g., neck of femur, pubic ramus)

  • Osteoarthritis, avascular necrosis/transient osteoporosis of the head of the femur, arthritis of the hip joint (reactive or infectious)

  • Inguinal lymphadenopathy

  • Intra-abdominal abnormality (e.g., prostatitis, urinary tract infections, kidney stones, appendicitis, diverticulitis)

  • Gynaecological conditions

  • Spondyloarthropathies (e.g., ankylosing spondylitis)

  • Tumours (e.g., testicular tumours, bone tumours, prostate cancer, urinary tract cancer, digestive tract cancers, soft-tissue tumours)

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