Muscular strains/avulsion fractures: Sports and age play a role
Although strains can affect any of the anterior muscles around the hip, in active individuals the adductors are most commonly affected. Skeletally immature patients are an exception: apophyseal fractures at the origin of the sartorius and rectus femoris muscles are more common than muscular strains in this patient population.
Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required—eg, football, hockey, and soccer35—and generally are able to tell you exactly what they were doing when the injury occurred. Physical examination can reveal focal findings, with swelling and tenderness confined to the anteromedial aspect of the hip along the adductor muscle group. MRI can help differentiate the site of true pathology.36
Treatment of adductor strains is nonoperative, with rest, ice, and activity modification until the tendon heals. In the rare case in which complete tendon avulsion is found, surgical reattachment is needed.
Apophyseal fracture in skeletally immature patients typically occurs during participation in a sport that requires rapid acceleration and deceleration with the hip in an extended position. In such patients, stretching the affected muscle should reproduce the pain. Radiographs are diagnostic and will often show minimal displacement of the apophysis. Treatment is almost always nonoperative. Surgical intervention is rarely needed, and only indicated with displacement >2 cm.37
Athletic pubalgia: A challenging Dx
Also referred to as sports hernia, athletic pubalgia is an enigmatic cause of anterior hip pain in athletes. Diagnosis can be especially challenging, and patients may have lingering symptoms for years before the cause is discovered.38 A sports hernia, unlike other hernias, does not involve a bulge of tissue protruding through one body part into another. In contrast, a sports hernia occurs when the oblique abdominal muscles strain or completely tear away from the pubis. A recent systematic review found that the underlying etiology involves posterior inguinal wall weakening, which can be a result of poorly balanced hip adductor and abdominal muscle activation.39
Patients with sports hernia will often present with anterior hip and/or groin pain, especially with hip extension, twisting, and turning. In addition, patients can have pain in the lower abdomen and, in males, in the testicles. Physical examination will usually show pubic point tenderness, which is exacerbated by resisted hip adduction.40 MRI and ultrasound are extremely helpful in diagnosing and forming a treatment plan.39
The initial treatment of choice for sports hernias is nonoperative, and the first step is always activity modification or temporary avoidance of symptom-producing activities. Additional modalities include NSAIDs, ice, and physical therapy to strengthen the surrounding muscles. Surgical intervention, if needed, may be done laparoscopically or via an open approach with direct repair.40,41
Less common causes to consider
While the conditions detailed here account for most anterior hip etiologies, there are other less common causes to consider. One such cause is osteitis pubis, an umbrella term for conditions that affect the area surrounding the symphysis pubis. Patients with osteitis pubis present with pain over the anterior aspect of the pelvis that is worse with sit-ups, rising from a chair, or any activity where contraction of the rectus muscles occurs.29 Tenderness is found directly over and just lateral to the pubic symphysis. Radiographs are frequently negative, but occasionally chronic degenerative changes at the symphysis are present in addition to symphyseal narrowing. Additional imaging is often necessary for diagnosis.
Neuropathies. When history, physical examination, and imaging studies have ruled out other causes, neuropathies (ilioinguinal, genitofemoral, and obturator) should be considered, particularly in patients with vague, radiating anterior hip and/or groin pain.42 In pediatric patients, Legg-Calve-Perthes disease and slipped capital femoral epiphysis are possibilities, as well.
Getting patients back on track
Rehabilitation after hip injury resulting in anterior hip pain will be determined by the site, type, and mechanism of injury, as well as the severity. Restrictions in weight bearing and the use of an assistive device may be needed to prevent excessive stress on bone and supporting soft-tissue structures in the early stages of healing. Physical therapy, as needed, should initially focus on early controlled ROM of the hip joint to prevent both intra- and extra-articular adhesions and excessive scar tissue formation.2
For patients who undergo surgery, much of the focus will be on strengthening the supporting musculature—the hip abductor group, anterior and posterior thigh musculature, and core stabilizing muscles. Neuromuscular training may be needed to promote normal biomechanics and minimize compensatory movement patterns. For athletes, cardiovascular training and a return-to-play program should be implemented, as well.2,43,44