Pain around the hip and pelvis may also be related to soft tissues (Figure 2.1). Soft tissues are non-bony structures that connect, support, or surround other structures and include:

• the muscles, which allow you to move
• the tendons, which connect your muscles to the bone
• the bursae – small, flat pockets of fluid that help all these things slide and glide against one another, reducing friction. There are bursae are all around the body in places where different structures may rub against one another, for example where a tendon runs around a bone.
• the fascia – stretchy, thin, white fibrous tissue. All our muscles are enveloped in fascia, like stretchy stockings that help transfer energy from muscle and movement. Fascia also forms sheaths or tunnels for safe passage of blood vessels and nerves and wraps and supports all our bodily organs.

There are many muscles located in this region that support and move the hip and pelvis. The adductor muscles of the groin sit on the inner side of the thigh, between the pelvis and the knee (Figure 2.2).

This group of muscles includes:

• the adductor magnus (large adductor)
• the adductor longus (long adductor)
• the adductor brevis (short adductor), that sits underneath the adductor longus muscle
• the gracilis (a long strappy muscle)
• pectineus (a smaller muscle)

The abdominal muscles extend from the ribcage down to the pelvis, supporting the spine and allow the trunk to curl up forwards or to the side. They also help control the position of the pelvis. The rectus abdominis (the ‘6 pack’ muscle) joins onto the pubic bone and connects into the adductor muscles and the pubic aponeurosis (Figure 2.3). There are also another 3 layers of abdominal muscles (external oblique, superficially, internal oblique beneath and transversus abdominis deepest) that wrap around your body like a corset. At the front, they join into a big ligament that runs across the groin – the inguinal ligament (Figure 2.3).

Adductor Related Groin Pain

Tears or strains may occur within the adductor muscles; where the muscles & tendons join (musculotendinous junctions); or within the tendons. Traumatic injury resulting in a rapid onset of pain, is usually associated with sporting actions such as:

• changing direction at speed
• sliding sideways
• kicking

A single cause for more longstanding groin pain can however be much more difficult to establish. One of the main reasons for this is the large amount of interconnection between the soft tissues around the pubic region. Magnetic Resonance Imaging (MRI) scans of someone who has had groin pain for more than 3 months will often reveal a variety or combination of findings, and you may receive a diagnosis of:

• adductor tendinopathy, tendinitis or tear – tendon pain, inflammation or a tear of one or more of the inner thigh muscles
• pubic aponeurosis tear – a tear in the blended fibrous tissue at the front of the pubic bone
• rectus abdominis tendinopathy/enthesopathy, tendinitis or tear – tendon pain, inflammation or a tear of the rectus abdominis (six pack) muscle

Inguinal Related Groin Pain

In the region where the abdominal muscles join onto the pelvis and the inguinal ligament (Figure 2.4), tears or weakening of some of the connections can occur, leading to pain and/or a hernia. A hernia is where the pressure of the bowel against the weakened area can cause the appearance of a bump, as the bowel pushes into the area. More severe hernias are easily visible, but most of the time inguinal hernias are small and only picked up on ultrasound scans.

Your Hip Pain Professional can:

• provide a thorough assessment of all the soft tissues in the groin region
• refer you for appropriate scans, if necessary
• provide or refer you for rehabilitation of this area,
• provide advice and/conditioning for successful return to sport
• refer you to a surgeon or provide surgery (if your HPP is a surgeon) – this is rarely required but may be necessary with more severe hernias or abdominal tendon tears.

Although relatively more rare than soft tissue or joint problems, bony problems such as a fracture, stress fracture or very rarely, infection or tumour within the bone may cause pain in the groin and the inside of the thigh.

Bone Related Pain in the Groin Region

The most likely bone-related issues associated with pain in the groin region, are fractures or stress fractures of the femur or front of the pelvis (pubic ramus) (Figure 3).

A fracture:

• is the medical term for a broken bone
• usually occurs from a traumatic event like a fall, car accident or more severe sporting injury
• is more likely to occur in a weakened bone e.g. osteoporosis or genetic diseases like osteogenesis imperfecta

The most common fractures around the hip and pelvis include a fracture of the neck of the femur (common in older women with osteoporosis), or fractures through the pelvis related to large traumas or where stress fractures have not been attended to early enough.

A stress fracture:

• is the medical term used for a fracture that occurs due to a build-up of repetitive stress
• is usually related to overuse -an accumulation of repeated small traumas e.g. long-distance running
• is more likely to occur with rapid increases in athletic training volume and/or inadequate recovery time
• starts as localised swelling in the area of bone exposed to highest stress (you won’t see this at skin level as it is just within the bone)–this may be called a stress reaction or bony stress response
• may progress to full fracture if you don’t rest

Stress fractures may occur in a number of sites around the hip and pelvis. Sites that are most likely to be associated with groin pain are the top of the thighbone (neck of the femur) and the bones at the front of the pelvis (the pubic ramus) (Figure 3).

Other growth-related bony issues:

• Perthes disease or Legg-Calvé-Perthes Disease – is misshaping of the femoral head related to issues with blood flow to the bone. Most common during ages 4-10 years.
• Slipped Capital Femoral Epiphysis or Slipped Upper Femoral Epiphysis-usually a small shift in the growth plate in the neck of the femur that can change the shape of the head and neck of the femur. Most common during ages 8-15 years.

Pain related to the bones could be felt anywhere around the hip or pelvis region depending on the bone affected and the cause of the bone pain.  Click on our Pain Locator Map to review the areas you feel pain and learn more about the bones that may be related to pain in each area.

Your Hip Pain Professional can:

• perform a thorough assessment and let you know if a bone issue may be suspected. In these cases, you may be advised to undertake further imaging or referral to a medical specialist for further advice
• provide or refer you for rehabilitation at an appropriate time following bony injury
• provide important information about managing sporting activity and recovery in those with bony stress injuries

Pain experienced around the hip and pelvis sometimes has nothing to do with problems in this area.

Problems in the lower back can result in back pain and/or pain through the hips and down into the legs. There are two main ways this might occur:

Referred pain

Referred pain is pain felt in a part of the body other than its actual source. For example, if there is a problem in the lower back (lumbar or sacral spine) discs or joints (L3-S1), small nerve endings serving these structures generate ‘danger’ messages that are transmitted along small nerve fibres into the spinal cord.

However, this area of the spinal cord also receives information from structures in the hip and pelvis.The brain is unable to distinguish where the information came from, (the back, the hip or the pelvis) so you might feel pain in any one or a combination of these areas (Figure 4.1).

Referred pain:

• is usually a dull, aching or gnawing pain
• can expand into a wide area that is difficult to localize
• is not related to a problem of the nerve roots in the spine
• is not associated with other nerve-related symptoms such as tingling or numbness

Radicular Pain

Radicular pain is pain associated with irritation of the nerve roots as they exit the spine. Most commonly this is associated with inflammation or compression from the nearby disc. The nerve roots that exit at each level of the spine give rise to sensation indifferent areas of the skin, called dermatomes (Figure 4.2).

The nerve roots that exit at each level of the spine give rise to sensation in different areas of the skin, called dermatomes (Figure 4.2). When a nerve root is irritated at the spine, pain may be felt in the area of skin that the nerve root supplies. For example, compression of the nerve roots that exit between the upper lumbar vertebrae (L1 & 2) could, for some people, result in painful sensations across the groin region (Figure 4.2).

Radicular pain:

• is related to a problem of the nerve roots in the spine
• is usually accompanied by stabbing or shooting pains
• is usually easier to localise than referred pain
• may also be associated with an additional or background, deep, dull ache
• may be accompanied by other nerve related symptoms such as tingling, itching, burning or numbness

If the pain in your hip is due to a problem in the back, you can spend valuable time and money getting unnecessary treatment on the wrong area and this might delay an important diagnosis and your recovery.

Your Hip Pain Professional can:

• provide a skilled assessment
• help figure out the actual source of the symptoms and if you have more than one area contributing to those symptoms
• develop a comprehensive plan–If your pain is lumbar-referred or radicular, you may need treatment on your back and not your hip or if you have two areas contributing to your symptoms, both will need to be addressed within a comprehensive management plan
• recommend further tests or refer you to another specialist if the condition does not appear to be related to the musculoskeletal system.

The nervous system (Figure 5.1) is a complex network of nerves and cells that carry messages between the brain and spinal cord and your body. It is through this system that we feel, move and control our bodily functions.

Nerve roots leave the spinal cord via the intervertebral foramina (holes or spaces between the vertebrae) and join together from various levels of the spine to travel as cord-like structures, called nerves, to their destinations.

It is these nerves that travel outside the spinal cord that are referred to as “peripheral nerves”.

Some peripheral nerves travel only a short distance and others all the way from the lower back to the foot. Along their journey they run between and through muscles and fibrous tunnels.

While radicular pain arises from a problem as the nerve root exits the spine, nerve-related pain may develop due to a problem along the pathway of a peripheral nerve, outside the spine. Pain related to a nerve is called “Neuralgia”.

Neuralgia felt around the hip and pelvis may develop in many ways including excessive compression or stretch of the nerve. This may be caused by a sudden, acute mechanism, for example a fall or blow to the area resulting in compression, or the leg being caught and wrenched, resulting in stretch.

Alternatively, the onset may be subtle, with a gradual onset associated with sustained postures or repetitive movements that cause cumulative nerve irritation.

Nerves will also be influenced by the health of the tissues they run through or alongside. For example, high muscle tension or tendinopathy may over time result in irritation of neighbouring nerves.  Nerve related symptoms are usually experienced differently from pain associated with muscle and joint problems.

Peripheral nerve irritability may result in:

• symptoms in the area served by that peripheral nerve (which is different from dermatomal patterns associated with nerve root irritation -radicular pain)
• burning pain
• odd zings or zaps of pain
• tingly sensations or numbness
• weakness – only for those nerves that supply muscles, like the femoral nerve

Be aware that some nerves may cross through and supply more than one region around the hip and pelvis. Additionally, some areas of skin may have several nerves that serve the area. This sometimes makes accurate diagnosis tricky. Your hip pain professional will help to identify the cause of your pain.

Nerves of the Groin Region:

Nerves that supply the front to inside of the hip, groin and thigh (Figure 5.2) include:

• the iliohypogastric nerve
• the ilioinguinal nerve
• the obturator nerve
• the anterior femoral cutaneous nerve (a branch of the femoral nerve)

Nerve Related Pain/Neuralgia in the Groin Region

Irritation or damage to the ilioinguinal, iliohypogastric and genitofemoral nerves may occur as they travel through the muscles of the back and abdomen. Most commonly, symptoms may arise following some sort of abdominal or groin surgery, such as hernia repair.

The nerves may be damaged at the time of surgery or become entrapped in the scar tissue or mesh used for hernia repair. Endometriosis may also sometimes affect these nerves.

The symptoms are usually pain, with or without tingling or numbness in the area of nerve supply (Figure 5.3). The iliohypogastric and ilioinguinal nerves also provide some motor supply (the ability to make the muscles contract and work) to the abdominal muscles, so there may be some weakness of the abdominals experienced in conjunction with the nerve irritation.

The obturator nerve runs through the pelvic cavity and may be affected by pregnancy or pelvic surgery, as it exits the pelvis through a tunnel called the obturator canal, or as it runs between some of the deep muscles (the obturator externus & pectineus).

People with obturator neuralgia may experience pain, tingling or numbness in its area of skin supply (Figure 5.3) and may experience some weakness of the adductor (inner thigh) muscles it supplies.

The symptoms are often only felt during/after activity when the nerve has been compressed between contracting muscles.

Neuralgia of the femoral nerve is not very common, but may develop following pelvic surgery (gynaecological, prostate, bladder surgery), hip surgery or sometimes associated with problems of the adjacent soft tissue structures (psoas bursa or iliopsoasmuscle and tendon).

Femoral nerve related symptoms may be felt in the front of the thigh (in the region of the anterior femoral nerve branches that serve the skin) (Figure 5.3).

Sometimes symptoms may also be felt over the inner surface of the calf and shin (served by another branch of the femoral nerve called the saphenous nerve).

If the femoral nerve is more severely affected, muscle weakness may occur in the hip flexors (muscles at the front of the hip that lift the thigh) and the quadriceps (muscles at the front of the thigh that straighten the knee).

For Pain Related to the Nerves/Neuralgia of the Groin Region

Your Hip Pain Professional can:

• Perform specific tests in the clinic to see if nerve involvement is likely
• Provide treatments and give you exercises that may improve the health or movement of the nerve
• Help improve health of the muscles and tendons beside the nerve (this may be the source of nerve irritation)
• Review the position you spend time in and activities you perform daily and provide strategies when performing these tasks that might help protect the nerve, thus reducing your symptoms.  This may include changing your sitting or lying posture, or changing stretches or strength exercises that you may have been performing that may be contributing to the irritation of the nerve.
• Provide nerve gliding or mobility exercises that can be useful in some situations.
• Refer you for further tests or to a neurologist, orthopaedic specialist or other pain specialist required.
• In some case, your hip pain professional may refer you to a pelvic floor physio for further assessment should they consider the pelvic floor muscles are involved.

*Please note: Nerve supply can overlap and be quite variable between individuals.  The diagram provided in this section provides an approximate guide only of the nerve supply in this region.

There are other processes that may produce pain around the hip and pelvis, including the groin region.

These include:

• Systemic/Rheumatological conditions: eg Rheumatoid Arthritis, Polymyalgia, Polyarthralgia
• Infective processes: Septic arthritis, Osteomyelitis, Viral Arthritis
• Neoplastic processes (cancer)
• Vascular issues: Avascular Necrosis, External Iliac Artery Entrapment, varicotic gluteal vessels compressing the sciatic nerve

These conditions are relatively rare compared to musculoskeletal pain, but when present you will need to see a medical practitioner and usually a specialist for that system or problem, for example, a Rheumatologist, Orthopaedic Specialist, Oncologist or Vascular Specialist.

Groin pain can also be associated with organ problems (ovaries, uterus, bowel, bladder, prostate).

One of the most common causes of organ-related pain in females is endometriosis. This occurs when tissue that is similar to the lining of the uterus (womb) grows out side the uterus attaching to other structures such as the pelvic ligaments or the bladder and bowel.This can lead to debilitating pain that may be cyclic, relating to the menstrual cycle. Diagnosis and management of organ related problems will usually require the assistance of a specialist, for example a gynaecologist (female reproductive organs), urologist (bladder and prostate) or gastroenterologist (gut/bowel).

A skilled assessment by a Hip Pain Professional will help clarify if the problem requires further medical attention and whether it is likely to be related to a musculoskeletal problem or not.

Your Hip Pain Professional can:

• provide a detailed assessment
• assist in determining if the problem is musculoskeletal or not
• develop a plan to help if the problem is musculoskeletal
• recommend further tests or send you to another specialist if the problem does not appear to be in the musculoskeletal system.