Sports-related groin pain is a common condition in athletes.
It results from chronic, repetitive trauma or stress to the muscle and tendon
portions of the groin or from overuse of the lower abdominal musculature and
muscles of the upper thigh. The groin pain usually develops gradually. It can
be associated with virtually any sport but most often is encountered in hockey,
soccer, rugby and football – sports that require frequent bending or leaning
The most common culprit of sports-related groin pain is the
tearing of the external oblique muscle, with injury to the ilioinguinal nerve
that courses through that area. Other causes include inflammation of the pubic
tubercle and strain to the adductor muscles.
The physician would examine the groin to make sure there is
no inguinal hernia present. The pain from groin strain can usually be
reproduced by performing simple maneuvers, such as sit-ups or crunches. Ultrasound
is often used to evaluate the groin area for any tendon abnormalities.
Sometimes, if the inflammation of the pubic tubercle is suspected, an imaging
test called a bone scan is ordered to determine if there is inflammation
present in that part of the body. X-rays are usually not very helpful in
The most important part of the initial treatment is rest and abstinence from the physical activities that caused the
groin strain. Patients who insist on continuing to play the sport despite groin
pain will take considerably longer to heal. It is also beneficial to apply ice
packs to the sore area three to four times per day for approximately ten
minutes. Over-the-counter pain medications, such as ibuprofen, are useful for
pain relief. Gentle physical therapy exercises may be helpful in some cases.
Unfortunately, the groin pain often tends to return once the sport activity is
Surgical exploration may also be used in cases of severe and
persistent groin pain or when a prompt return to the sport activity is
required. This is often performed laparoscopically using a camera inserted
through a small groin incision, but sometimes open surgery is required to
correct the abnormality. Surgery is not recommended in the cases of adductor muscle
strain, which is best treated with physical therapy.
According to studies, long-term improvement is usually seen
in 90 percent of surgically treated patients.
A hamstring strain, often called a pulled hamstring, is a common injury to one or more of the hamstring muscles, during which muscle or tendon fibers are stretched, or partially or completely torn. These injuries are graded according to severity, with Grade 1 being mild, Grade 2 being moderate, and Grade 3 being severe, with a complete rupture.
The hamstring muscle group consists of three muscles: the semitendinosus, semimembranosus, and the biceps femoris. These muscles originate from the lower edge of the pelvis at a part called the ischial tuberosity. They travel down the back of the thigh, across the knee and attach to the tibia and fibula, the bones of the lower leg. At each end of the muscles are tendons, strong cords of connective tissue. Tendon fibers begin within the muscle fibers and extend to the bones where they have their attachments. A hamstring injury can happen at any point along the muscle: at the origin; where the tendon and muscle fibers join; in the belly of the muscle; or where the muscle inserts into bone.
The function of the hamstrings is to allow you to extend your leg straight back, and also to help you bend your knee.
Hamstring strains are almost always caused as a result of overloading. This means stretching the muscle while at the same time loading it with weight and force necessary for motion. An example of loading the hamstrings is an athlete sprinting: the rear leg is straight and the toes push against the ground. In this situation the hamstrings are stretched (to allow the straight leg) and loaded with body weight and the force needed to propel the body forward.
Overloading the muscle, or subjecting it to too much force, can cause a hamstring strain. For this reason, athletes are particularly prone to this injury. Adolescent athletes are also at risk, due to the fact that muscles and bones do not develop at the same rate. If the bone has grown faster, the hamstring will be tight and therefore vulnerable.
Poorly conditioned, tired, or tight hamstring muscles are more likely to be injured. Often, a person’s quadriceps muscles, in the front of the thigh, are stronger than their hamstrings, so the hamstrings will tire faster, increasing the risk of injury.
Symptoms of a hamstring strain will depend somewhat on the severity of the injury, but may include the following:
- Sudden, severe pain in the back of the thigh, causing you to stop immediately. You may hop or fall down, unwilling to put weight on the injured leg.
- Possible popping or snapping sensation at moment of injury.
- Swelling, the extent of which will depend on your injury.
- Bruising on the back of the leg, below the knee.
- Tenderness over the injured area.
- Weak hamstring muscles.
Your doctor will ask you about your medical history, including any previous injuries to your leg. He or she will also ask you about the circumstances of your current injury and the type and severity of your symptoms. You will have a physical examination, during which the doctor will palpate (touch) your leg to assess areas of tenderness. Depending on your particular injury, you may be asked to lie on your front and bend your knee against resistance. This may cause pain.
An X-ray may be taken to see if the hamstring injury has torn away a small piece of bone. This can sometimes happen with a severe strain, and is known as a tendon avulsion. These normally occur at the upper (proximal) end of the muscle rather than the lower (distal).
Magnetic resonance imaging (MRI) scans may be taken as these are better than X-rays at showing soft tissues such as muscles and tendons. MRIs are therefore often used to evaluate the extent of the injury and aid decisions regarding treatment.
Early treatment for a hamstring strain has been shown to provide the quickest and best recovery. It is extremely important to follow medical advice and allow yourself time to heal otherwise you will be at risk of recurrent hamstring injuries.
Most hamstring strains heal with conservative (non-surgical) treatment, resulting in a full recovery and a return to normal, pre-injury levels of activity. A mild Grade 1 strain will heal swiftly, whereas a Grade 3 injury, which may require surgical repair, might take 3 to 6 months to heal properly.
During the acute stage of the injury, that is, the first one to five days, the strain can be treated with the following methods:
Physical therapy: When advised by your doctor, a graduated program of exercises can be initiated, beginning with gentle stretching and gradually including strengthening exercises. Always follow medical advice as to when it is safe to begin exercising, and when you can return to sporting activities. Physical therapy might include massage to align muscle and tendon fibers so that they heal in the correct position. This also minimizes the formation of scar tissue.
A Grade 3 strain may require surgical repair. If the injury is a tendon avulsion, where the tendon has pulled away a piece of bone as it ruptured, surgery will always be required. Your surgeon would reposition any bone fragment or tendon or muscle fibers, and hold them in place with surgical stitches or staples. After surgery you would need to avoid putting weight on the leg. You may have to wear a brace and use crutches to help you get around until the injury has fully healed.
- Rest: Avoid any activity that either caused the injury or makes your symptoms worse. You may wish to use crutches temporarily, to keep weight off your injured leg. Your doctor may recommend that you wear a knee splint for a while. This would prevent your leg fully straightening, thereby avoiding any further strain on the hamstrings.
- Ice: Ice, crushed in a bag and wrapped in a towel, can be applied to the back of the thigh for as long as is comfortable, several times a day. This will help to reduce swelling and pain.
- Compression: Wearing a compression bandage on your leg will prevent excessive swelling and minimize bruising.
- Elevation: Raising your leg above the level of your heart will help reduce swelling. This will be most easily achieved at night, when you can rest your leg on a pile of pillows while you sleep.
- NSAIDs: Over-the-counter non-steroidal anti-inflammatory medications will help relieve pain and swelling.
Hip Flexor Strain
Hip flexors are a group of muscles in frontal part of the
hip; they include the rectus femoris and iliopsoas, which originate at the hip
and run down to the femur bone. They are used primarily during walking and
running. When the hip flexors contract, tension is placed through the
hip flexor muscle fibers. Too much tension may cause muscle fibers to tear,
resulting in hip flexor strain.
Shop Hip Flexor Strain Supports
Hip flexor strains are commonly seen in
running and kicking sports such as football and soccer. The muscle
fibers become injured either due to overuse from excessive training or when
used to compensate for another injury, such as Achilles tendonitis or plantar
The symptoms of hip flexor strain may develop suddenly due
to a pulled muscle or gradually due to wear and tear over time.
A sudden sharp pain or pulling
sensation in the front of the hip or groin at the time of injury
Pain is worse when raising the lower extremity
against resistance or during stretching
Tenderness when pressure is applied to the front
of the hip (not always present)
Pain and stiffness upon waking in the morning
(not always present)
Swelling or bruising in the case of severe
To diagnose flexor hip strain, pull the knee toward the
chest and have someone apply pressure to push it downwards against your
resistance. Pain with this maneuver indicates hip flexor strain.
Hip flexor strain is classified in Grades I-III according to
the number of muscle fibers torn. Grade I results in minor pain only. Grade II
is associated with moderate pain and some loss of leg function. Grade III is a
complete tear, with severe pain and major loss of function.
Rest or use of crutches
Ice application to reduce inflammation
Medication for pain relief
Physical therapy with stretching exercises
initially, later with the addition of strengthening exercises when the pain
Compression therapy (such as specially designed
Bio Skin compression shorts) to treat and prevent further injury during the
Minor hip flexor strain usually gets
better in one to three weeks. With larger tears, recovery may take four to
eight weeks – or even longer, depending on the severity of the injury.
hip is one of the most anatomically stable joints, but it is susceptible to
injury when it is in the flexed position. Thus, hip sprains are uncommon sports
injuries, accounting for less than 4% of all sprains. These injuries usually
occur as a result of severe twisting or traumatic impact to the hip, such as
what may occur during a fall or with direct and forceful contact. Hip sprains
can also result from overuse and overstretching of the hip, especially among
individuals who do not warm up sufficiently before activity.
hip joint has a capsule that is comprised of multiple circular and longitudinal
ligaments, including the transverse ligament, the iliofemoral ligament, the
pubocapsular ligament, and the ischiocapsular ligament. A ligament is a band of
tissue that connects bones together. Because the bones of the hip anchor
muscles that travel down the leg, across the abdomen, and into the buttocks, a
sprain in the hip area may radiate pain to any of these sites.
Pain that is felt directly over
the injured ligament and that increases with activity
Swelling and bruising (in severe
Stiffness and muscle spasm
The partial or full loss of joint
Discomfort or pain with walking
physician will examine the affected area and apply pressure to the areas of
suspected injury to identify points of maximum tenderness. Patients may be
asked to perform certain movements to determine the range of motion, the
stability of the joint, and muscle strength. Radiographs should be taken to
rule out fracture, dislocation, and subluxation. Magnetic resonance imaging is
used to look for labral tears, which can be confused with joint sprain.
the injured area
relative rest and use crutches with no or partial weight bearing until walking
is no longer painful.
to rehabilitation of the muscles, range-of-motion exercises, and proprioception
activities around the joint. Progressive chiropractic adjustments may address
concomitant joint dysfunction.
prognosis for this condition depends on the severity of the strain. With
conservative treatment, mild to moderate sprains will usually heal on their own
within a few weeks to a couple of months. Severe injuries may require surgery
followed by a physical therapy rehabilitation program. It is important to allow
the injury to heal completely before resuming physical activity to avoid the
risk of reinjury. Special medical athletic wear (e.g., Bio Skin compression shorts) helps to increase proprioception and
control muscle movements to improve recovery time after injury.
Lymphedema is an abnormal accumulation of protein-rich fluid
in the interstitial space. This not only can cause swelling, but can also
result in changes to the skin, infection, and decreased wound healing where
wounds are present.
What is the cause of Lymphedema?
There are two main classes of Lymphedema - Primary and
Secondary. Primary lymphedema in some instances is congenital or often arises
later in life. Secondary lymphedema arises as the result of damage to
components of the lymphatic system, (i.e. radiation, surgery, trauma, or
The primary clinical presentation of lymphedema is swelling,
caused by the accumulation of fluid and protein in the interstitial space. As
lymphedema progresses, the skin can become fibrotic and darkened. This is due
to the accumulation of proteins and other elements that would normally be
removed by the lymphatic system.
With lymphedema, there is an increased risk of infection
because protein rich fluid accumulation creates an environment favorable to
quad contusion is the result of a direct blow to the anterior thigh. This is a
common athletic injury among players of football, basketball, soccer, or any
contact sport. It may present with immediate sharp pain and loss of function;
however, often the pain does not fully develop until several hours later, when
the muscle are no longer warmed up.
quadriceps muscle group is made up of four large muscles of the anterior thigh:
the rectus femoris, the vastus medialis, the vastus lateralis, and the vastus
intermedius. The rectus femoris is a long muscle that originates at the hip
joint, and the remaining muscles originate at the femur bone. The quadriceps
muscles act to extend (straighten) the knee. They are primarily active when a
person is kicking, jumping, or running.
physician will feel your anterior thigh along the length of the injured muscles
to locate the area of maximum tenderness, to feel for any defects, and to test
the strength of the quadriceps muscles by extension against resistance.
is usually not necessary, but sometimes radiography is used to rule out a
concomitant bone fracture. Ultrasound can be used to look for bleeding or
hematoma or to evaluate torn tendons and muscles. Magnetic resonance imaging
provides a detailed look at the thigh musculature when a precise
characterization of the injury is necessary.
A history of a blow to the front
of the thigh
Weakness and pain in the anterior
Tightness and swelling
The inability to bend the knee
Bruising (this may not develop
until 24 hours after injury)
A hematoma (i.e., a collection of
blood) that can be felt inside the muscle
active knee flexion of >90°, normal gait, and mild pain
active knee flexion of 45° to 90°, mild limp, and moderate pain
active knee flexion of <45°, severe limp, and extreme pain
Initial Treatment (immediately after the injury):
Apply an ice pack while lightly
stretching the muscle for 20 minutes; repeat this process every 2 hours for 48
to 72 hours.
Use an elastic compression wrap or
a brace to maintain the leg in a flexed position.
Use crutches if walking is painful
or if a limp is present.
Maintain complete rest for 3 days.
Avoid heat, massage, or aggressive
Follow-up Treatment (for 3 to 7 days after the
Perform quadriceps stretches 2 to
3 times per day.
Slowly reintroduce light activity
(e.g., swimming, walking) as long as it does not cause pain.
Ice the quadriceps area after
Return to Sports:
athlete must be free of pain and attain 120° of knee flexion with the hip
extended. Protective thigh padding is recommended when the athlete resumes his
or her participation in sports to prevent recurrence.
average time of disability is 13 days for mild contusion, 19 days for moderate
contusion, and 21 days for severe contusion. A complication associated with
severe contusion is called myositis ossificans,
which is a calcification of the injured muscle. This condition should be
suspected if symptoms worsen after 2 to 3 weeks and if there is persistent
swelling. Myositis ossificans is diagnosed with the use of radiography. Prompt
treatment and complete rest immediately after the injury are crucial to prevent
A thigh bruise, medically known as a quadriceps contusion and commonly called a dead leg, is an injury to the quadriceps muscles that causes damage to the muscle fibers and bleeding within the thigh.
The quadriceps muscle group consists of four large and powerful muscles that run down the front and sides of the thigh: the vastus medialis, vastus intermedius, vastus lateralis, and the rectus femoris. At each end of the muscles are tendons, strong cords of connective tissue. Tendon fibers begin within the muscle fibers and extend to the bones where they have their attachments. The quadriceps originate at the ilium (located at the upper edge of the pelvis) and the femur (thighbone). At their lower ends their respective tendons join together into one quadriceps tendon that surrounds the patella (kneecap). The tendon then becomes known as the patellar tendon, which inserts into the tibia (shinbone). The quadriceps are responsible for flexing (bending) the hip, straightening the leg at the knee, and are used in nearly every movement of the legs.
Damage to the quadriceps can cause bleeding, the severity of which depends on the force of the injury. Bleeding can be either intramuscular, which means that the bleeding is contained within the muscle compartment, or intermuscular, where the blood escapes from the fascia (sheath of tissue) that surrounds the muscle and flows downward within the leg, between the muscle compartments. Intermuscular bleeding is less severe. Intramuscular bleeding can be serious as the blood, trapped within the fascia, increases pressure within the muscle compartment. This can lead to the development of compartment syndrome, which causes muscle and nerve damage and impaired blood flow that can result in the death of leg tissue in the injured area.
An external blow to the front of the leg is the normal cause of a thigh bruise. The impact crushes the muscle against the femur. These injuries often occur during sporting activity, such as playing football, basketball, soccer or rugby, when a player receives a kick to the thigh, or is hit with a piece of sporting equipment, such as a bat.
The severity of the symptoms will depend on the force behind the blow, but will likely include the following:
- Sudden pain, which may be severe, at the moment of injury
- Bruising, which may travel down the leg
- Inability to fully bend or straighten the knee
- Inability to place full weight on the leg
- Stiffness, made worse if the athlete continues to play after injury
The doctor will ask about the circumstances of the injury, and physically examine the thigh. If it is an older injury and ossification is suspected, X-rays might be taken.
It is extremely important to treat a thigh bruise properly as, without such treatment, blood can form pools in the damaged muscle that calcifies, or hardens, with time, resulting in stiffness and lumps within the muscle. This condition, known as osteomyositis ossificans, sometimes needs remedial surgery.
Regardless of whether bleeding from a quadriceps contusion is intra- or intermuscular, initial treatment should be the same. An ice pack should be placed on the thigh immediately. If no ice pack is available, one can be made by placing ice in a bag and crushing it. The bag should be wrapped in a towel before placing it against the skin.
The knee should be fully flexed (bent) when the leg is iced. If the knee is straight when the leg is first iced, stiffness in the leg the following day will be markedly worse. If the knee is flexed, the quadriceps will remain much more flexible. Icing can be repeated for as long as is comfortable, every two hours for the first two days following injury. Between each icing the leg should be kept wrapped in a compression bandage.
Crutches can be used to aid mobility. To minimize swelling, the patient should keep the leg elevated above the level of the heart, as often as possible. This is best achieved by lying on the back with the leg resting on a pile of pillows.
NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen (Advil), naproxen (Aleve), or aspirin can be taken, according to direction, to reduce pain and alleviate inflammation.
Physical therapy might include instruction on proper rehabilitation techniques, ultrasound, and electrical stimulation to promote healing.
After the acute stage of the injury, which is the first two or three days, gentle rehabilitation of the quadriceps can begin. It is important not to cause any pain when exercising. If pain is felt, the patient is doing too much and recovery time will be lengthened. Damaged muscle fibers need to be allowed to heal properly.
Sitting on the floor with the injured leg straight out in front and the unaffected leg bent with the foot on the floor, contract the thigh muscles of the injured leg (the quadriceps) by pressing the knee towards the floor. Hold the position for 5-10 seconds then relax. Repeat 10 times, 3 times a day.
Lying on your back, bend the injured knee and keep the foot on the floor. Slide the heel towards the buttocks as far as you can without pain. Repeat 10-20 times.
Straight leg raise:
Lying with the back on the floor, bend the unaffected knee and rest the foot on the floor. Keeping the knee of the injured leg straight, contract the thigh muscles and lift the leg up until the heel is about 6 inches off the ground. Hold for 5-10 seconds then relax. Repeat 10 times, 3 times a day.
Quad stretch 1:
Lie on the floor on the stomach, with the injured leg on a pillow. Slowly bend the knee until a gentle stretch is felt. Hold the stretch 30-60 seconds. Repeat 10 times, 3 times a day.
Quad stretch 2:
Using a wall for support, hold the right foot with the right hand and gently pull the foot up and behind, towards the buttocks, stopping when you feel a gentle stretch. Keep the knees together and the pelvis neutral (neither tilted forwards nor backwards). Hold the stretch for 10 seconds then relax. Switch legs and repeat exercise.
As a thigh bruise is an accidental injury, there is little to be done to prevent it occurring. However, if the patient is returning to contact sports, padding can be worn over the thigh to protect the quadriceps muscles.
A bursa is a small fluid-filled sac that sits near a bone. It cushions and protects nearby tissues when they rub against or slide over bones. Bursitis happens when a bursa gets irritated and swollen. In the case of trochanteric bursitis, bursitis occurs due to an exaggerated movement of the gluteus medius tendon over the outer femur.
Inflammation of trochanteric bursa is one of the most common causes of hip pain. The normally paper-thin bursal wall thickens and loses its lubrication, resulting in outer thigh pain. Most of the cases of trochanteric bursitis are caused by an abnormal gait due to various conditions, such as knee arthritis, ankle sprains, leg length discrepancy, back pain and others.
- Outer thigh pain
- Local tenderness
- Difficulty walking
- Difficulty sleeping on the affected side
- Morning stiffness
Each patient is examined for local tenderness at the greater trochanter area and during hip rotation, as well as for low back flexibility and gait abnormality.
Plain X-rays of the hip should be performed to exclude other causes of hip pain. Occasionally, calcifications may be seen in the region of the bursa or adjacent soft tissue. If symptoms persist for six to eight weeks despite treatment, then CT or MRI tests of the low back should be ordered. Ultrasound may be used in diagnosing a suspected gluteus medius tendon tear.
Regional Anesthetic Block:
Regional injection of a local anesthetic, such as lidocaine, can be very helpful in order to distinguish trochanteric bursitis from pain referred from the back. Relief of pain with the injection is consistent with a diagnosis of bursitis.
- Heat treatments applied to the outer thigh for 15–20 minutes to prepare the area for stretching
- Passive stretching: cross-leg pulls to reduce the pressure over the bursa
- Knee-chest pulls to increase the flexibility of the lower lumbosacral spine.
- Therapeutic ultrasound
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Aleve, Motrin, etc. can be prescribed at full dose for the first four weeks
- Correction of underlying gait disturbances (shoe lift for leg discrepancy, knee brace, high-top shoes for ankle support or custom-made food orthotics)
- Reduce weight-bearing activities (less standing or temporary crutches)
- Weight loss for overweight patients
- Using a cushioned seat to decrease pressure on the joint
- Injection of glucocorticoids (steroids) in the trochanteric bursa is very effective in reducing the acute inflammation
Surgery for trochanteric bursitis is rarely performed. It may be considered in patients who have had refractory symptoms for more than one year despite steroid injections. A surgical approach usually includes release and lengthening of the iliotibial band over the greater trochanter and excision of the subgluteal bursa.
Venous disease, affecting the venous system, is one of the most common maladies to affect the legs of people and to negatively impact their quality of life. Mild forms present cosmetic concerns with the more severe forms resulting in serious symptoms significantly reducing the quality of life, mobility and productivity. The recently published Bonn study reported just over 90% of the population has some level of venous disease with 17% experiencing the more severe levels.
Venous disease presents in two main categories – chronic venous insufficiency or venous thromboembolisms (blood clots).
Chronic venous insufficiency (CVI) is marked by a failure of valves in the vein to function properly, resulting in stasis of blood and ambulatory venous hypertension over an extended period of time. However, there are transient occurrences of venous insufficiency such as during pregnancy, which often reverse following the pregnancy. The most common presentation of venous disease is telangiectasias (spider veins) found in 60% of the population and varicose veins, which affect over 14% of the population. The more severe presentations are swelling (edema), skin discoloration and ulceration.
Reflux occurs when valve malfunction allows backflow in veins. The pump function is ineffective. Veins stay full, valves don't close, and pressure in the veins remains abnormally high (venous hypertension).
Valve malfunction can be congenital (when a person is born with it), which is rare; or acquired. Valve malfunction can be acquired different ways:
Weak vein walls or valves can give way under "normal" stresses.
High pressures or prolonged pressure (e.g. people who stand in one place without moving for prolonged periods) can stretch vein wails so valves don't work.
Valves can become damaged from obstructions in the veins (blood clots)
Venousthromboembolism (VTE) is the formation of blood clots in the venous system and is comprised by Deep Vein Thrombosis (DVT), which are clots in the deep veins of the legs and torso affecting over 600,000 in the USA each year and Pulmonary Embolism (PE) clots found in the lungs. PE is a life threatening condition resulting in over 100,000 deaths per year in the USA alone.
These clots will typically resolve themselves over time, however many develop into a chronic condition developing into permanent obstructions in the veins, which result in valve damage and hypertension. This condition is known as Post Thrombotic Syndrome (PTS).
Common Hip, Leg & Groin Pain & Injuries
The hips, groin and legs are obviously all vital parts of your healthy, moving body. An injury, no matter how small, to any part of the lower extremities can affect your gait and your ability to move around normally. It’s easy to get slowed down by thigh or calf pain due to overwork or some type of trauma. Luckily, hip, groin, calf, quadriceps and hamstring injury or strain is relatively easy to prevent with proper movement and conditioning.
In the professionally written articles above, MMAR Medical provides information on everything from the causes of hip flexor pain to dealing with a minor case of calf pain or strain. You and your sports medicine professional can identify and begin treating your lower extremity ailment, either with physical therapy or with an appropriate hip brace or leg brace. Start your recovery today!