Groin Pain – Referrals and Soft Tissue Therapy
The lumbo-pelvic-hip complex is an extremely dynamic area of the body when it comes to sports performance. Groin pain is something that plagues many athletes, especially those in sports that require a high amount of cutting, change of direction, and rapid acceleration and deceleration.
The topic of hip issues and groin pain has been a popular one as of late with my friend and colleague Dr. Jeff Cubos posting a great blog article last week on Femoroacetabular Impingement and offered some of his ideas for treatment. Kevin Neeld, a strength coach who works with hockey athletes in New Jersey, wrote a blog about the same topic, Training Around Femoroacetabular Impingement, offering some of his training recommendations for his athletes suffering from this issue. Additionally, Kevin also did a webinar for strengthandconditioningwebinars.com and talked more about the anatomy of this region and ways that he assesses the hip for his athletes to ensure that appropriate training recommendations are made. Finally, two years ago, I wrote an article on groin pulls and talked a bit about training recommendations – Groin Pulls: Ouch!
Today, I’d like to touch on some of the things I look at when performing soft tissue therapy for athletes who have referral pain into the groin. The groin and hip region can be very complex and many injuries can overlap each other with regard to how the symptoms present. For this reason, it is essential that the athlete gets checked out by an appropriate medical professional to ensure that the proper course of action is taken. Some of these referral patters can actually go into the testicles and making sure that the athlete is not dealing with something more dangerous (IE, testicular cancer) is a must in this situation.
Nerves that can refer to this region
There are a few nerves that can refer to the groin and testicular region. Additionally, these nerves can be influenced/affected by various structures (soft tissue, boney, ligamentous, fascia, etc) along the way and after looking at the nerves themselves we will get into some of the structures that can influence and might be a target of our soft tissue treatment.
- Ilioinguinal (L1) – Supplies cutaneous distribution to the scrotum (labia for females).
- Iliohypogastric (T12-L1) - Supplies cutaneous innervation to the lower abdominal and groin region.
- Genitofemoral (L1-L2) - Supplies cutaneous distribution to the scrotum (labia for females).
- Pudendal (S2-S4) - Provides innervation to the external genital region in both males and females.
- Obturator nerve (L2-L4) - The obturator nerve is often cited as a reported source of groin pain (Morelli et al, 2005) and innervates the adductor muscle group as well as the obturator externus.
- Femoral nerve (L2-L4) - Aside from innervating the quadriceps muscle group, sartorious, pectineus, and iliopsoas, the femoral nerves anterior cutaneous branch supplies sensory innervation to the medial thigh and can have referral pain into the groin region.
Structures to check which can influence these nerves
All of these nerves, aside from the pudendal nerve which is arising from the sacral plexus, are coming from the lumbar plexus, so evaluating this region for any sort of abnormalities would be a wise decision: checking joint play, looking at muscles that can influence these vertebral segments, evaluating the skin over the paraspinals for any abnormal changes between the two sides, looking at muscle length and strength, looking at fascial connections, etc. There are many ways to do all of these things and having your own system of evaluation to create a sort of “check list” would be a wise thing to do.
The obturator nerve has been occasionally found to be entrapped in the obturator foramen by thickened fascia which surrounds the adductor muscles. This region may be palpated for thickness, density, tenderness, as well as seeing if palpation creates referral symptoms that mimic the client’s complaint.
The psoas and iliacus should be evaluated for increased tone/tension as well, as they have influence over the femoral nerve. The genitofemoral nerve also runs between the psoas and can receive a greater amount of pressure there. Hip extension, tenderness just medial to the ASIS, and/or a positive tinnel’s sign over the inguinal ligament may reproduce the client’s symptoms and help guide your soft tissue strategy.
The psoas major has a lot of influence over structures in this region and Chaitow and DeLany discuss this in Clinical Application of Neuromuscular Techniques Vol 2: The Lower Body. They explain that the psoas communicates with the testicular/ovarian vessels, the genitofemoral nerve, the lumbar plexus, and the femoral nerve. Thoroughly evaluating this muscle and muscles which connect with it and influence such as iliacus, diaphragm, and quadratus lumborum, is extremely important.
The pudendal nerve passes through the pudendal canal, which is partially formed by the obturator internus and increased tone in this tissue may influence the nerve. Additionally, the nerve runs along the sacrotuberous ligament where it can receive a greater amount of pressure than normal and may warrant treatment.
Trigger Points (or peripheral nerve irritation or abnormal impulse generating sites or whatever people what to call it these days…)
- The oblique musculature has a referral pattern into the groin area and can also refer pain into the testicles.
- The quadratus lumborum has a referral pattern to the anterior side of the body into the lower abdominal and groin region (as well as a referral to the lateral hip). As mentioned earlier, the quadratus lumborum has a fascial connection with the psoas and the diaphragm. Not only should this muscle be checked for trigger points that mimic the referral pain, but this would also be a good time to stress the importance of breathing (breathing 101, breathing assessment, breathing corrections). Stabilizing the thoracic-lumbar junction in this case, as Charlie Weingroff has talked about (Supine Sagital Stability and the T-L Junction), fits in well with this discussion.
- The iliolumbar ligament has a referral pattern into the groin as well as the outer hip.
- The adductor musculature can produce referral pain into the groin. Evaluating the tissue healthy of the adductors, the muscle bellies and the attachment points, can be helpful.
As you can tell, groin issues can get pretty extensive with regard to all the things you have to take into consideration. I try and see the big picture as best I can and look at all the possible influences and gather a sense of all the anatomical connections, as Willem Kramer has talked about with his anatomy links concept. Of course, this is only a small piece of the pie as I am only talking about the things that can refer into the groin. We can certainly expand upon these connections and look even more globally at the structures that are influencing the structures referring to the groin. This is where having a holistic approach and thought process will help you out the most.
Morelli V, Weaver V. Groin Injuries and Groin Pain in Athletes: Part 1. Prim Care Clin Office Pract 2005; 35: 163-183.
Morelli V, Espinoza L. Groin injuries and groin pain in athletes: Part 2. Prim Care Clin Office Pract 2005; 32: 185-200.
Chaitow L, DeLany J. Clinical Application of Neuromuscular Techniques Vol 2: The Lower Body. Churchill Livingstone. 2002.
Gilroy AM, MacPherson BR, Ross LM. Atlast of Anatomy.Thieme. New York, NY. 2008.
Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual – The Lower Extremities. Lippincott, Williams, & Wilkins.