Mystery Groin Pain-- Sports Dr. Stumped

[WannaRun]

My case is currently being reviewed at a sports medicine conference. The sports medicine doctor I was seeing is out of ideas. Any suggestions you might have for recovery would be great.

My background:
I am a runnning/cross country coach, 34, who has not been able to run since April of 2009 due to ever increasing groin pain. I used to run 20-30 miles a week and ran a half marathon in late March. It made for a mentally challenging cross country season this year, but I am determined to find an answer.

My symptoms:
The pain in my groin was first diagnosed as a strained adducter caused by overuse. (Although in looking at my running log, it might have been from deep lunges during a workout.) No sports hernia. The pain has gotten increasingly more painful the less I have pushed it. I used to "test" the injury once a week. Initially I could run 3 miles once a week before the pain. The last time I tested it I could run only a few minutes. I have not run for 6 weeks to "test" it any longer. I have pain walking long distances, mowing the lawn, etc. I have pain in the morning. It feels like a pitch when I twist over to get out of bed in my groin. I can't kick a soccer ball or do any quick movements (A challenge when I am also the asst. soccer coach for my 5 year old son). Swimming and biking are okay.

What I have tried:
I have done PT stretches for 10 weeks, ultrasound therapy (twice a week), deep tissue massage, hot baths, daily heat pad 10 minutes in AM and PM. I do low impact cross training. I even tried one of those small hand held ultrasound machines (sent it back). Did an xray (no arthritis, no fracture). Did an MRI of groin. Groin actually looks good.

Possible theories:
L1 or L2 vertabrae issues? Doing an MRI of lower back (Will have results in a week). Seems like a long shot since there is no tingling or numbness. Pain only present when in use along the left inner thigh/glute. It looks and feels like an adducter strain yet the MRI suggests otherwise. This is what has the sports doctor stumped. When I squeese a basketball between knees I definitely feel it. If I hop and cross over, the pain is there. If I stand up from a kneeling position on my left leg, it's painful. When I do hip flexor leg stretches on my side and turn over, the pain is also there. Did a gait analysis with PT and things look good except for slight pronation on the left side. I wear Asics 2140s to correct this problem. Have for a long time. Running looks pretty good on a treadmill.

Possible therapies?
Have not tried the graston technique or acupunture. Not sure what to do next. Have tried lots of stretches (Still stretch and apply heat two times a day). I follow PT to the letter. (theraband, foam roller, etc.) The therapist said she was out of ideas and suggested I just don't "test" my running once a week. It's been 6 weeks since I have. No improvement. If anything, the pain in the morning seems increased. Would love suggestions on the next step.

Thanks in advance.

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[Dr Damien]

Dear WannaRun

Reading what you have written so far my thoughts are you have issues in your left hip.

My thoughts are as follows an imbalance involving the internal and external rotators. Some degree of rotation seem to aggravate your groin pain...

It is possible that you have either an internal/ externally rotated hip which is anteriorly displaced so that everytime you do a twisting motion you have an anterior compression in the hip...

This rotation could happen when squeezing a ball in between your thighs...

Although a lumbar spine issue could be also the cause...

do you get the pain on hip flexion, extension?

I do not know the details of your assessment with your physio or sports doctor but what i would suggest is testing the strength and comparison length of your hip external and internal rotators...


the fact that its painful in the mornings now suggests some form of arthritis, which would support the theory of a hip muscle imbalance...

It would be helpful to know the details of how this groin problem started...

In the interim joint mobilization of the hip, prone kneeling and rocking forward and back within painless limits can be trialled

what did the MRI scan report say?

[WannaRun]

Greetings Dr. Damien,

Thanks for your response.

I have had 2 MRIs at this point now. The first MRI of the adducter muscle looked fine. The second MRI of the lower spine also looked good. No referred pain.

My case was taken to a sports medicine conference. It was suggested I had bone edema where the pubic bone attaches to the origin of the adducter. Perhaps a variant of pubis osteitis.

Looking at my training log this began from an acute incident where I did deep lunges strength training last March or a chronic injury from overuse. Running lots of road races and doing a half marathon in April.

I currently still feel very stiff in the morning in the left groin area. I have not "tested" it running. I have not attempted running for 2 months. I am focusing on core strength and swimming (front crawl and flutter kick only). I was biking for many months, but it was suggested I stop even though there is not pain when biking/spinning. It is sore if I squeeze my legs together, walk a long distance, etc.

Most recently I was injected with platelets (PRP therapy). It's been 10 days since the injection. Symptoms remain. I heard PRP may take 3-6 injections for any effect. I will return for another injection in 3 weeks if there is no progress.

In a week I will get another evaluation with another PT. This is the first diagnosis that sort of makes sense.

To answer your question, no pain in the hip flexon, extension. (If I do leg lifts lying on my side to build up hip flexors I feel it more on my groin as I twist over onto my other side to repeat exercise.) I feel it as I squeeze a ball together between my knees. I also feel some pain as I cross over in an IT band stretch.

You mentioned the morning pain could be an indication of arthritis, but MRIs and X-ray show no such evidence. Still curious about the morning pain. Not sure if we are on to the right track w/diagnosis, therapy. Any suggestions would help.

Thanks again for your input. I am trying my best to stay optimistic about returning to being an active father and running coach next fall.

[physiobob]

Sound like a pelvic issue such as one half rotated on the other half. Get someone to work with you with MET (Muscle energy techniques) to see if they help. You could always go see an osteopath who is into that approach if you're not getting anywhere with the local PT. One has to believe the MRI as these are more overly positive than negative. Get in there and get your pelvis assessed.

[karlcorrea]

Urgent:

I have been in pain for the past year and a half now. It is exactly what you have described. Can you please help me?
I have gone for all tests. They have ruled out hernia to stds to everything else. Also an mri revealed I have bone marrow edema of the pelvic bone. Some say oeteitis pubis and some same other stuff. Thousands of dollars later I am at your mercy. Please tell me if you have been healed or diagnosed . Please I beg of you. I am a professional footballer(soccer) and can't kick a ball anymore. Cause after a game of football/soccer I am in terrible pain. When I shift in bed from my back to my side or I get out of bed or squeeze a ball between my legs or lift my left when I lie on my side.

Pleaseeeeeeeeeeee help me pleaseeeeeeeeee!!!

[Yarok]

hi

I had few patients having pain in groin, apart of hernias or tendos problems, usually that was reffered issue from the iliolumbar ligament or sacroiliac ligament, check as well thoracolumbar junction ( joints, discs, etc)

all the best
Yarok