Written by Gayle Hulme, PT
I think most of us will grimace when we watch re-runs of the Simpson’s where the old man gets hit in the groin with a football. Okay, haha – it’s also a little bit funny. These comical collisions might be avoided by our beloved cartoon’s character’s lightning-speed reflexes, but in reality painful impact injuries to the groin do occur.
The good news is that physiotherapists treat these injuries, along with a multitude of other groin injuries and pain syndromes. As treatment options broaden, some physiotherapists are also advancing their training to include the field of Men’s Pelvic Health Physiotherapy.
First, a Lesson in the Male Pelvic Anatomy
The “groin” is often considered the triangular part of the upper thigh which is bordered by the pubic bone, abdomen and the femur (long thigh bone).
The soft tissue and other important bits that are around this area include the testicles, femoral artery/vein, thigh muscles such as the adductors, the abdominal muscles, nerves, and of course, the pelvic floor muscles. There’s a lot going on in that little triangle – no wonder it hurts so much if a stray football makes contact!
Despite the proximity of the hip to the painful groin, the hip is just one of the many areas of the body that can cause groin pain and dysfunction. Having a qualified physiotherapist examine your whole body is crucial to determine the source of your groin pain.
Injury vs No Injury
A football or other blunt trauma to the groin area seems pretty straight forward in terms of the source of injury. The impact of the trauma can bruise the surrounding tissue, leading it to become inflamed and tender to the touch. Bearing weight on that leg might be difficult for a short period and it might be sore to move the leg for a couple of days. In this case, applying ice, resting, and wearing compression shorts may be the treatment indicated for the following few days. (If you want to know about using ice read our recent blog article here.)
But what if the pain doesn’t go away in a few days? Or, what if you have groin pain that didn’t come from a direct injury?
Important: When to Seek Medical Attention
Groin pain in men can be from serious testicular or other medical problems that a physiotherapist cannot treat. The Mayo Clinic advises you to seek immediate medical attention if you are experiencing the following:
- Groin pain associated with back, abdomen or chest pain
- Sudden, severe testicle or groin pain
- Testicle pain and swelling accompanied by nausea, vomiting, fever, chills or blood in the urine
- A lump or swelling in or around a testicle
Other Sources of Groin Pain
A strained “groin muscle” is a common culprit of groin pain.
This can happen from a slip on ice, an over-zealous push-off to start a race, or repetitive use of the inner thigh muscles. Abdominal muscles are also suspected in this area as these muscles can also be strained from repetitive movements or overtraining. Even with a specific muscle in mind that is leading to the pain, other muscles also need to be looked at to determine if there are any imbalances that contribute to the groin pain. We now start looking more globally to complete the clinical picture and get things on the mend.
The pelvic floor muscles really need a mention here. They play a key role in supporting the pelvis, abdomen, and hip. The 5 S’s of function of the male pelvic floor muscles are:
- Sphincteric: pelvic floor muscles contract to prevent urine leakage and relaxes to allow voiding
- Support: muscular base of the abdomen, supports organs against gravity and increases in abdominal pressure
- Stability: key stabilizer muscle of the pubic bone and sacroiliac joints
- Sexual: plays a role in achieving/sustaining erection, and propelling ejaculate down the urethra
- Sump-Pump: pumps blood and lymphatic fluid up towards the heart
There is a likelihood that some groin pain conditions have a dysfunctional pelvic floor muscle component. If there is an imbalance between the hip adductor muscles and abdominal muscles, the pelvic floor muscles will respond to try and correct the forces on them. This can cause tight and less responsive pelvic floor muscle contractions leading to a number of disorders:
- Pubic symphysis disorder: often mistaken for groin strain, abdominal strain or bladder pain. The pain can be referred into the hip, groin, scrotum, or perineum.
- Sacro-iliac joint (SIJ) pain: the pelvic floor muscles can tug on the sacrum which may contribute to its malposition and pelvic asymmetry
- Coccydynia (tailbone pain): the pelvic floor muscles and gluteal muscles need to be balanced with each other to prevent the tailbone’s position to be altered.
- Hip: pain and dysfunction at the hip can lead to gait changes which impacts the muscle use around the hip and pelvic floor
- Bladder: too tight pelvic floor muscles may result in bladder pain or frequency. Weak pelvic floor muscles may result in urine leakage.
The pudendal nerve comes from the sacral spinal nerve supply.
This nerve provides motor control to the pelvic floor muscles. It also provides sensation to the perineal area and genitals. It can be injured with falls onto the buttocks, cycling or pelvic surgeries. If the pelvic floor or hip muscles are too tight and overactive this can lead to compression of the pudendal nerve. Symptoms of pudendal neuralgia are varied but can include pain at the lower buttocks and inner thigh (groin).
Other nerves such as those running along the front of the lumbar spine and across the groin can have a regional pain effect. Any dysfunction from the upper lumbar area (L1, L2) could potentially cause groin, thigh, or genital type pain.
Groin pain can also mean a hernia.
Specifically, an inguinal hernia in men is where the intestines push through a weak spot or a tear in the lower abdominal wall, often in the inguinal canal. The inguinal canal is where the spermatic cord passes from the abdomen to the scrotum in this groin “triangle”. If your physiotherapists suspect an inguinal hernia, they will refer you to see your doctor and gets tests done to confirm.
This type of groin pain may require surgery or medications. Where physiotherapists play a role is to show you how to use your body’s biomechanics to its fullest potential, without placing excessive pressure on your abdomen or groin. Often this means learning proper lifting techniques, improving breathing patterns, and reducing constipation.
Once the source of the groin pain is determined, the physiotherapist will make a treatment plan to address eliminating the pain, restoring balance to the muscular system, and guiding you back to activity and sport while giving you strategies to prevent issues from recurring.
When the pelvic floor is involved, see a pelvic health physiotherapist who is specially trained to access these muscles. For men, this means a rectal exam and treatment of these muscles internally. Often, trigger point release of these tight muscles is very beneficial to relieving the pain. When pelvic floor treatment is indicated, patients soon realize the value and importance of treating their pelvic floor, and other areas in order to eliminate their groin pain.