Caring Medical - Where the world comes for ProlotherapyGroin Pain Treatments


Ross Hauser, MD, explains the key to treating groin pain is in identifying the cause of the groin pain.

• Groin pain and tenderness develops from a variety of causes including athletic and non-athletic injuries as well as internal anatomical factors.

• Overlooked in the complexity of trying to diagnose groin pain is ligament laxity. Weakened, frayed ligaments that cause instability. Therefore, physicians experienced in ligament referral patterns should be consulted in cases of groin pain.

Iliolumbar syndrome, iliopsoas injury, pubic symphysis injury, and osteitis pubis can be related to ligament laxity and are common causes of groin pain successfully treated with non-surgical injection therapies.

Identifying groin pain

The groin areas are located on each side of the body in the folds where the abdomen joins the inner, upper thighs. The pubic area lies between the two groin areas. The groin is also called the inguinal area.

The groin area is prone to acute injury when involved in rigorous activities. Muscle pulls and ligament strains are also common.

While mild groin injuries tend to heal on their own, special medical attention is required for cases that lead to severe groin pain and discomfort.

femoroacetabular impingement

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In new research from May 2016, doctors writing in the British Journal of Sports Medicine tackled the problem of groin pain diagnosis.

The doctors representing multi-national institutions including the USA confirmed that athletic groin pain requiring surgery remains a diagnostic and therapeutic challenge. In their paper they sought to identify the most common causes of groin pain in athletes requiring surgery.

Here is what they found as to the top five causes of groin pain in athletes

pubic tubercle

The pubic tubercle

The tendency in patients with groin pain due to abdominal wall abnormalities is a history of inguinal pain that worsens with strenuous activity, especially activity stressing the abdominal muscles, such as sit-ups. On physical examination there is tenderness of the pubic tubercle and a positive jump sign is elicited. Prolotherapy, in this instance, to the muscle attachments onto the pubic symphysis is often curative. All of the other muscle attachments to the groin area, including the rectus femoris, gracilis, rectus abdominis, and adductor group, can all be treated with Prolotherapy if there is tenderness and reproduction of the athlete’s pain upon palpation of the area where the muscle attaches to the bone. If a positive jump sign is elicited, the diagnosis is made and Prolotherapy is given to the weakened fibro-osseous junction.

Causes of groin pain in women

As mentioned above, groin pain is most commonly caused by ligament injury or weakness, and is especially common in athletes in various sports. For example, hyperextension of the groin during an athletic event or extreme stretching, can lead to a strain or sprain of the groin. A study of two elite female soccer teams, found a 12% incidence rate of groin injuries.2 In other research groin pain can be found as caused by urinary incontinence.3

Groin pain in women can be more chronic, and worsen over time, such as with overuse injuries when the same activity is repeated day after day. Or, it can be acute, and occur immediately after an injury such as a direct blow or a fall, or from turning the leg in an abnormal position. High impact falls and blows directed at the groin area cause severe groin pain.

In women, groin pain can also be caused by certain medical conditions like an inguinal hernia, kidney stones, ovarian cysts, bacterial infections, swollen lymph nodes, sexually transmitted diseases, urinary tract infections, infections of the large intestine, pelvic inflammatory disease, ringworm, yeast infection, cellulitis and arthritis.

For more on groin pain in women from sports and/or post childbirth see our article Pelvic Floor Dysfunction in women.

Groin Pain Caused by Iliolumbar ligament injury

Referral or radiating pain from weakened hip ligaments, called the iliolumbar ligaments, may also be a contributing factor to groin pain.

Iliolumbar syndrome, also known as iliac crest pain syndrome, involves an inflammation or tear of the iliolumbar ligament. This ligament extends from the spine to the iliac crest, which is the back of the pelvis. It can lead to referred pain in the groin, the pelvis, the hip, the back, vaginal and rectal areas. Injury to the iliolumbar ligament can occur through repeated bending and twisting, as in a sport like golf or volleyball. Trauma, such as a car accident, can also cause iliolumbar syndrome. Conversely iliolumbar ligaments may also be the unidentified cause of lower back pain.4

What are the symptoms of iliolumbar syndrome?

Pain may be experienced in the hip or groin area. The area involved may be tender as well. Other symptoms of iliolumbar syndrome include recurrent attacks of acute low back pain in the area referred to as the “multifidus triangle” – the facet joints, erector spinae muscles, lumbar fascia, quadratus lumborum and the iliolumbar ligaments. Painful attacks are often brought on by physical exercise involving bending and twisting of the lumbar spine. Some individuals complain of pain only after prolonged sitting or standing or for a brief period in the morning after getting out of bed.

Groin pain coming from an injury of the iliolumbar ligaments may at times be mistaken for hernia injury. It is important to rule out all of the possible causes of groin pain.

 Groin pain caused by iliopsoas injury

Injury to the iliopsoas tendon can also cause groin pain. In a British prospective study of groin injuries in athletes, 9 of the 11 women had iliopsoas‐related groin pain as the primary clinical entity.4 Iliopsoas tendonitis is most commonly caused by an acute injury, usually due to quick movements. It is also caused by overuse injuries of repeated hip flexion, as in certain athletic activities such as soccer.

Iliopsoas pain is generally felt deep in the groin and extends around to the front of the hip and may radiate down toward the knee. The pain may also be noted in the lower back and buttocks. Stiffness in the groin, hip and even knee may also occur. Sometimes the iliopsoas tendon is the cause of snapping hip syndrome. When this is the case, patients may experience no problems other than the annoying snapping.

gluteus and hip referral patternWe had a case of an athlete with tenderness at the iliopsoas muscle with degeneration of the lumbar spine per MRI. The joints beneath the iliopsoas muscle are the hip joint and the lumbosacral junction (where the degeneration was located). Palpation of the hip joint did not produce pain, but a positive jump sign was elicited at the iliolumbar, lumbosacral, and sacroiliac ligaments. Since an experienced Prolotherapist understands ligament pain, referral pain, as well as palpation of the various areas, he/she will be able to differentiate and localize the area of pain.

Groin pain coming from an iliolumbar ligaments injury or dysfunctions at the thoracolumbar junction (vertebrae T11,T12,L1), may at times be mistaken for hernia injury. Patients have been referred to us after hernia repair, because the hernia repair failed to stop their groin pain. The groin pain had nothing to do with a hernia! Again, all of the possible causes of groin pain need to be considered and ruled out.

Groin pain may also be caused by ligament laxity in the pubic symphysis (the pubic joint ligament)

Iliolumbar.ligament.injectionThe pubic symphysis is a fibrocartilaginous disc. Groin pain due to laxity of the pubic symphysis is experienced while performing such activities as running, doing sit-ups and squatting. Athletes who participate in sports with repetitive kicking, side to side movement, and twisting are also more at risk.

In an Australian prospective study of 116 soccer players, 52 had clinical features of groin pain with pubic symphysis tenderness.5

Pain and tenderness is localized over the pubic symphysis and radiates outward to the upper thighs and perineum. Pubic symphysis pain may be mild or severe, and can develop into a chronic condition. In more severe cases, the pain affects activities of daily living and causes the sufferer to walk with a waddling gait, as pain is experienced while walking, climbing stairs, coughing, and sneezing. It can be a burning, shooting, grinding or stabbing pain. The person also experiences exquisite tenderness to touch in the pubic symphysis area.

Groin pain caused by osteitis pubis

Osteitis pubis is a chronic condition affecting the pubic symphysis and/or parasymphyseal bone that develops after athletic activity. The pain is usually aggravated by running, cutting, hip adduction and flexion against resistance, and loading of the rectus abdominis.

Individuals with osteitis pubis commonly present with anterior and medial groin pain and, in some cases, may have pain centered directly over the pubic symphysis.

Pain may also be felt in the adductor region, lower abdominal muscles, perineal region and inguinal region.

The pain can progress such that athletes are unable to sustain athletic activity at high levels. It is postulated that osteitis pubis is an overuse injury caused by biomechanical overloading of the pubic symphysis and adjacent parasymphyseal bone with subsequent bony stress reaction.6

The Australian study notes, “A stress injury to the pubic bone is the most likely explanation as the cause of the clinical entity osteitis pubis.”However, inflammation of the pubis is a sign that the pubic symphysis area is trying to heal something.

Generally, inflammation in a joint is a sign that the joint is becoming unstable. The ligaments or capsule are no longer able to stabilize the joint so the area becomes inflamed to overgrow bone to stabilize it.

If the area is examined, the diagnosis of osteitis pubis is commonly made, which means that the pubis is inflamed. Once this diagnosis is made, ice, anti-inflammatories, rest, physical therapy, and anything else that can be thrown to the sufferer to decrease the inflammation is given. Because the body is trying to heal the pubic symphysis area by inflammation this is exactly the opposite of what is needed.

That osteitis pubis is felt to be an overuse injury associated with excessive kicking, running, or abdominal muscle contractions, for example, when a man does too many sit-ups. This is an erroneous notion.

Inflammation of the pubis is a sign that the pubic symphysis area is trying to heal something. On bone scan there is evidence of increased circulation to the area and on x-ray there is often sclerosis or an overgrowth of bone.

On “flamingo” views, the X-ray shows some instability in the area, and this is the explanation for the problem. The treatment is not to stop the inflammation, but to promote it. A better diagnosis in this case is not osteitis pubis, but pubic symphysis diathesis. This diagnosis indicates that the pubic symphysis area is loose. Unfortunately, milder degrees of this condition are not picked up even in “flamingo” X-ray views. One side of the pubic symphysis is generally higher than the other side on physical examination of people with this condition.

Sometimes men come in with the diagnosis of pubalgia or some other kind of -algia. What they do not know is that the -algia prefix just means “pain.” A diagnosis of pubalgia, therefore, just means groin pain. In other words, the doctor who gave them the diagnosis had no idea what the cause of the groin pain was except that they have pubalgia, or groin pain. In our opinion, the most common cause of pubalgia, or groin pain, is pubic symphysis diathesis or injury to the pubic symphysis itself.

Additional causes of groin pain

Hip bursitis can cause pain that radiates to the groin. Pain or injury in other body parts may radiate toward the groin, and thereby cause pain. For instance, the pain caused by a pulled back, thigh or leg muscle, and ligament injury, may radiate towards the groin and result in pain. Spine problems in the back near the lower ribs can pinch the nerves that travel through the groin area and cause groin and thigh pain. Pulled muscles, ligaments, or tendons in the leg may cause symptoms in the groin. Stressed ligaments or tendon fibers may cause female groin pain.

Groin pains are experienced during various phases of pregnancy, as the hormonal changes cause slackness in the pelvic joint. Some women experience pain in the lower back, genital area, upper thighs and hip joints.

Common treatment for groin pain

Since groin pain can have a variety of causes, treatment will depend on the results of the examination and tests performed. As mentioned previously, ligament and tendon injuries are a common cause of groin pain. When this is the case, physicians commonly recommend complete rest, applications of ice, and anti-inflammatory medications. Although this treatment approach may bring temporary relief, it does not repair weakened ligaments or tendons. Steroids may also be recommended. These treatments have all been shown to inhibit the healing process of soft tissues and accelerate degeneration.

Research on PRP and Prolotherapy for groin pain

We have discussed that groin pains are often the result of referral pain from the hip and other regions of the body. Ligament laxity of the iliolumbar ligaments of the hip, and the ligaments of the pubic symphysis joint are the most common ligaments involved in referral pain to the groin. These ligaments can be strengthened with Prolotherapy and Platelet Rich Plasma therapy.

The Prolotherapy specialist understands the referral patterns of these ligaments and will palpate the various areas that may be involved. A good history from the patient regarding the injury and description of the pain along with the palpation will help the Prolotherapist to locate the involved ligaments and tender areas and make the appropriate diagnosis.

If snapping hip and the iliopsoas tendon and/or the iliolumbar ligament are involved, Prolotherapy to the posterior hip capsule and the involved ligaments and tendons will tighten the joint and stop the anterior protrusion of the hip. In other words, Prolotherapy helps resolve snapping hip syndrome because the underlying etiology of the problem is most often hip ligament laxity, and not tight muscles or tendons.

Prolotherapy for groin pain due to osteitis pubis or pubic symphysis diathesis entails injections into the fibro-osseous junction of the superior pubic symphysis ligament and injections into the pubic symphysis itself. Prolotherapy is extremely effective in strengthening the pubic symphysis and relieving chronic groin pain in this area.

There are times when the entire pelvic floor is involved and may need to be treated. This again is due to the fact that laxity in one area of the pelvis often leads to laxity or pain or weakness in another area of the pelvis. Back pain can also cause pain in the groin, and if the back is involved, the sacroiliac joint at the back of the pelvic bone may be involved. Prolotherapy treatments may relieve the unresolved back pain, as well as abdominal or inner leg pain, because they are all part of the referral pain pattern of the ligaments involved.

When treating groin pain in women, Prolotherapy can help heal injured ligaments that may be referring pain to the groin. Prolotherapy works by initiating a mild inflammatory response in the treated area by injecting a solution that includes D-glucose. D-glucose is the normal sugar in the body, and when injected activates the immune system. The body’s normal healing inflammatory reaction boosts the blood flow to the area and stimulates the release of immune cells to the ligaments and soft tissue areas being treated. These cells are natural reparative cells, which will cause regeneration and repair of the weakened ligaments. Once the ligaments are strengthened, the referral pain will stop, and the groin pain will resolve.

Prolotherapy offers the most curative results in treating chronic groin pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction, an area rich in sensory nerves. What’s more, the tissue strengthening and pain relief stimulated by Prolotherapy is permanent!

Clinical cases have been documented in the literature of returning high level athletes with groin pain back to their sport with Platelet Rich Plasma Injections 8,9 and Prolotherapy.10

References for this article

1 de Sa D, Hölmich P, Phillips M, Heaven S, Simunovic N, Philippon MJ, Ayeni OR. Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med. 2016 May 6. pii: bjsports-2015-095137. doi: 10.1136/bjsports-2015-095137. [Epub ahead of print] Review.

2. Engström B, Johansson C, Törnkvist H. Football injuries among elite female players. Am J Sports Med. 1991; 19(4): 372-375.

3. Nambiar A, Cody JD, Jeffery ST. Single-incision sling operations for urinary incontinence in women. Cochrane Database Syst Rev. 2014 Jun 1;6:CD008709. doi: 10.1002/14651858.CD008709.pub2.

4. Kiter E, Karaboyun T, Tufan AC, Acar K. Immunohistochemical demonstration of nerve endings in iliolumbar ligament. Spine (Phila Pa 1976). 2010 Feb 15;35(4):E101-4. doi: 10.1097/BRS.0b013e3181ae561d.

5. Hölmich P. Long‐standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. BR J Sports Med. 2007; 41(4): 247-252.

6. Verrall GM, Slavotinek JP, Fon GT. Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain. Br J Sports Med. 2001; 35:28-33. doi:10.1136/bjsm.35.1.28

7. Hiti CJ, Stevens KJ, Jamati MK, Garza D, Matheson GO. Athletic osteitis pubis. Sports Med. 2011;41(5):361-76. doi: 10.2165/11586820-000000000-00000.

8. Scholten PM, Massimi S, Dahmen N, Diamond J, Wyss J. Successful treatment of athletic pubalgia in a lacrosse player with ultrasound-guided needle tenotomy and platelet-rich plasma injection: a case report. PM R. 2015 Jan;7(1):79-83. doi: 10.1016/j.pmrj.2014.08.943. Epub 2014 Aug 16.

9. St-Onge E, MacIntyre IG, Galea AM. Multidisciplinary approach to non-surgical management of inguinal disruption in a professional hockey player treated with platelet-rich plasma, manual therapy and exercise: a case report. J Can Chiropr Assoc. 2015 Dec;59(4):390-7.

10. Topol GA, Reeves KD: Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series. Am J Phys Med Rehabil 2008;87

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