Approach
Treatment is directed according to likely underlying condition.
Stress fracture
Stress fractures may be treated nonoperatively if deemed stable, but may require surgical treatment if unstable.
Superior femoral neck (tension-side) stress fracture
Must be identified and treated promptly with internal fixation to prevent complications of fracture progression and displacement, including nonunion, malunion, and post-traumatic arthritis.
Inferior femoral neck (compression-side) stress fractures
Unlike their tension-side counterparts, these fractures are mechanically stable and can be treated nonoperatively, with excellent healing rates in compliant patients.
The mainstay of successful treatment is immediate cessation of high-impact activities and protected weight-bearing (cane or crutches) for 6 to 8 weeks.
Follow-up imaging to ensure proper healing is advisable.
Traumatic or athletic overuse injury and negative plain radiographs
Initial management:
Appropriate initial management includes rest, activity modification, ice or heat, judicious use of nonsteroidal anti-inflammatory drugs (NSAIDs), and protected weight-bearing (cane or crutches).
Physical therapy with a gradual return to activities should be commenced once symptoms have abated, usually within 4 to 6 weeks of initiating treatment.
Addressing the specific structure (often muscle/tendon) that is injured with specific exercises is very important, but the delicate balance that exists around the pelvis involving balance, coordination, and strength should also be restored before return to sports.
Failed initial conservative management
First, patient compliance with conservative measures is ensured.
More advanced imaging studies (usually ultrasound or MRI) are then considered.
Referral to an orthopedic surgeon should be considered.
Specific management for types of traumatic/overuse injuries:
Long-standing adductor-related groin pain
A specific exercise therapy program aimed at improving strength and coordination of the muscles acting on the pelvis is significantly better than a conventional physical therapy program.[22]
Adductor longus tenotomy may be performed in cases of chronic, debilitating groin pain due to adductor injury that has failed to respond after 6 months of nonoperative treatment.[23]
Osteitis pubis
Some of the literature reports that this is a self-limited condition where symptoms can take 1 year or more to resolve.[24]
It is probably a reflection of other entities and should in most cases be treated along the lines of adductor-related groin pain.
Inguinal-related groin pain (also known as incipient hernia, sports hernia, or athletic pubalgia)
No evidence exists for the treatment of this injury. However, a large number of surgical treatments are described in the literature, all with good but uncontrolled results.
An initial treatment along the lines of adductor-related groin pain but with specific focus on the abdominal muscles and the core stability is suggested for at least 8 to 10 weeks before surgery is considered.
Iliopsoas-related groin pain
No evidence exists for the treatment of this injury.
It is suggested that the iliopsoas is strengthened isometrically, eccentrically, and concentrically. Stretching is warranted if the muscle is tight. If doing the exercise therapy is too painful, ultrasound-guided corticosteroid injections can be helpful in order to lower the pain and enable the exercises to continue.
The specific exercises should be accompanied by a pelvic stabilization program.
Labral tears
If a labral tear is diagnosed with MRA/MRI and is symptomatic, arthroscopic surgery of the hip joint with debridement or labral refixation should be considered.
Concomitant femoroacetabular impingement pathology of the femur and/or acetabulum should be corrected at the same time.[25]
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