SPORTS INJURIES
Hip and Groin Pain
The Hip is Made for Movement
Unlike the pubic symphysis and the sacroiliac joint, the hip
is made for movement. The hip ligaments are subjected to
tremendous forces during sports and even during activities
of daily living. When the forces are too great for the
ligaments themselves, they are principally transmitted
to the hip abductor, the gluteus medius, and the gluteus
minimus muscles. Studies show that normal walking creates
a force of 1.5 to 2 times body weight, where standing on
one leg creates a force of 2.5 times body weight, climbing
produces a force of 2 to 3 times body weight, and running
forces, of 4.5 to 5 times body weight.
Because the groin or lower back pain of an athlete is diagnosed as muscle strain,
it will be important to know the various muscles around the hip and then explain
why they are seldom the cause of chronic pain problems for the athlete.
The hip joint has tremendous mobility which, on average, consists of 45 degrees
of external rotation and internal rotation, 45 degrees of abduction, 20 degrees
of adduction, 135 degrees of flexion, and 30 degrees of extension. The primary
hip extensors consist of the gluteus maximus and the ischial portion of the adductor
magnus; the secondary hip extensors are the hamstrings. The primary hip flexor
is the iliopsoas, which inserts into the lesser tuberosity, with the secondary
hip flexors being the rectus femoris, pectineus, tensor fascia lata, and sartorius.
Hip abduction is performed principally by the gluteus medius and minimus, which
insert into the greater tuberosity and secondarily by the tensor fascia lata.
Adduction is performed primarily by the adductor longus, with secondary adduction
power supplied by the adductor brevis and magnus, as well as the pectineus. The
hip is externally rotated by the short rotators (pyriformis, obturator internus
and externus, superior and inferior gemelli, and the quadratus femoris) that
insert into the posterolateral portion of the greater trochanter. Internal rotation
is relatively weak and supplied by portions of the semitendinosus, semimembranosus,
adductor magnus, gracilis and gluteus medius and minimus.
Hip and Groin Pain Is Seldom Just Related to the Hip
Seldom is the cause of an athlete's hip and/or groin pain just in the hip joint.
The sacroiliac and pubic symphysis areas are often overlooked because some physicians
arr not familiar with the ligament referral patterns from the lower back
and pubic symphysis.
Recall that the referral patterns of the ligaments from the lower back and hip
are as follows: iliolumbar refers to the groin, testicles, vagina, and inner
thigh. Posterior sacroiliac (upper two-thirds) refers to the buttock, anterior
thigh, leg (outer surface); posterior sacroiliac (lower outer fibers) refers
to the posterior thigh, and the leg (outer calf), foot (lateral toes),
accompanied by sciatica; hip (pelvic attachment) refers to the posteromedial
thigh; hip (femoral attachment) refers to the posterior thigh; lateral lower
leg refers to the big toe and second toe; and sacrospinus and sacrotuberus refers
to the posterior thigh, posterior lower leg, and then to the heel.
Again, the most common and accurate method of determining what structure is causing
an athlete's pain is his/her description of the injury, pain referral pattern,
and the
palpatory examination. Sometimes the description of the injury and the pain referral
pattern are vague so one must rely on the palpatory examination for proper diagnosis.
Prolotherapists are used to examining all of the above ligaments to find the
areas of tenderness. Generally, the pain-producing structure can be found and
a positive jump sign elicited. Because athletes have such significant muscles
that surround the lower back and hip in these areas, a positive jump sign cannot
always be elicited. The thumb may not generate enough force on the hip ligaments,
for instance, because of all the muscles. When this occurs, a diagnosis is made
relying on the history and the rest of the physical examination to determine
the most likely injured structure that is causing the pain.
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