The definitive treatment of groin pain in elite athletes

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Groin Anatomy

Knowledge of groin anatomy is of paramount importance in the understanding of the causes of groin pain. The groin region consists of ligaments, tendons, muscles and fascia all of which attach to the pubic bone. The majority of groin pain arises from the attachment of the inguinal ligament and lacunar ligament, the rectus muscle insertion, the pectineal fascia and ligament (also known as Cooper's ligament) as well as problems arising from the adductor tendon insertion. Due to the complicated nature of this anatomical region only an intricate knowledge of this region will help in the accurate diagnosis of groin pain.

Central to the groin area is the inguinal ligament, which marks the lower most fibres of the abdominal wall musculature. Inguinal hernias arise above this ligament and it plays a pivotal role in the causation of groin pain. The inguinal ligament attaches to the pubic bone, curls downwards as the lacunar ligament and joins the pectineal ligament (Cooper's ligament). The pectineus muscle attaches the femur to the superior pubic ramus. This muscle is covered by a thick fascia (pectineal fascia), which joins the pectineal ligament. Tension in any of these ligaments or fasciae will cause pain in athletes. It is important to try to assess whether groin pain arises above the pubic tubercle (i.e. upper groin pain) or from below e.g. from the adductor tendon origin (lower groin pain).

The adductor tendon inserts into the front of the pubic bone and also connects underneath. The fascia arising from the adductor tendon and the inguinal ligament - together with the fibres coming from the rectus muscle insertion - form a continuous sheet of fibres. This may explain why it is quite difficult for some athletes to separate symptoms arising from the inguinal ligament/rectus attachment and the attachment of the adductor tendon fibres.