What is the initial management of a groin injury in a patient with generalized joint hypermobility?

Initial Management of Groin Injury in Hypermobile Patients

Begin with a comprehensive biopsychosocial assessment that includes joint hypermobility screening using the Beighton score (≥5/9 in adults <50 years), evaluation of physical status including lower limb joint alignment and proprioception, and assessment of pain patterns, activities of daily living, and motivation to self-manage. 1, 2

Immediate Clinical Assessment

Joint Hypermobility Evaluation

• Perform the Beighton score assessment to quantify generalized joint hypermobility: passive dorsiflexion of fifth fingers >90°, thumb apposition to forearm, elbow hyperextension >10°, knee hyperextension >10°, and palms flat on floor with knees extended (1 point each side, maximum 9 points). 2, 3
• A score ≥5/9 in adults under 50 years confirms generalized joint hypermobility and warrants specific management considerations. 2, 4

Groin-Specific Physical Examination

• Assess hip joint status including range of motion, strength, joint alignment, proprioception, and posture as part of the lower limb evaluation. 1
• Evaluate for soft-tissue injury patterns including bursitis, tendonitis, or muscular tension pain due to muscular imbalance, which are common in hypermobile patients. 3, 5
• Document any skin hyperextensibility, easy bruising, or tissue fragility that may indicate underlying Ehlers-Danlos syndrome. 2, 4

Rule Out Systemic Connective Tissue Disorder

• Screen for systemic manifestations including cardiovascular (aortic root dilation occurs in 25-33% of hypermobile EDS), gastrointestinal (affects up to 98% of hEDS patients), and autonomic dysfunction (POTS). 2, 6
• If systemic features are present, refer to medical genetics for formal evaluation and potential EDS diagnosis. 2, 6

Initial Conservative Management

Physical Therapy as Cornerstone Treatment

Physical therapy with low-resistance exercise to increase muscle tone and improve joint stability is the cornerstone of treatment for hypermobile patients with groin injury. 6

• Implement neuromuscular re-training focused on developing protective reflex reactions and strengthening surrounding musculature. 3, 7
• Include myofascial release techniques to address muscular tension and imbalance. 6
• Start with levels of exercise within the patient's capability, building up the "dose" sensibly over several months using "small amounts often" (pacing). 1
• Focus on strengthening exercises for both legs, including quadriceps and proximal hip girdle muscles, using sustained isometric exercises. 1

Activity Modification and Education

• Provide individualized education regarding the nature of joint hypermobility, its causes, consequences, and prognosis specific to the patient's groin injury. 1
• Address maintenance and pacing of activity to prevent repetitive use injury, which is common in asymptomatic hypermobility that becomes symptomatic. 3, 5
• Link exercise regimens to daily activities so they become part of lifestyle rather than additional events. 1

Pharmacological Options (If Needed)

• When not contraindicated, oral NSAIDs should be used for symptomatic pain associated with the groin injury. 1
• Oral acetaminophen may be considered as an alternative when NSAIDs are contraindicated. 1
• Avoid opioids for chronic pain management, especially if gastrointestinal manifestations are present. 2, 6

Critical Pitfalls to Avoid

• Do not dismiss groin pain as simple muscle strain without assessing for generalized joint hypermobility, as this may lead to repetitive injury and altered biomechanics at other body sites. 3, 5
• Avoid invasive procedures or surgery until conservative management has been thoroughly attempted, as surgery must be advocated with care in hypermobile patients and is reserved for secondary complications. 7
• Do not overlook systemic manifestations that may indicate underlying Ehlers-Danlos syndrome, particularly vascular EDS which carries significant mortality risk. 2, 6
• Recognize that "asymptomatic" hypermobility may become symptomatic later in life or cause biomechanical alterations, so preventive strengthening is essential even if current symptoms are mild. 3, 5

Follow-Up and Monitoring

• Establish an individualized management plan with both long-term and short-term goals, intervention plans, and regular evaluation with possibilities for program adjustment. 1
• If symptoms persist despite 6-8 weeks of appropriate physical therapy and activity modification, consider referral to sports medicine or orthopedics for further evaluation. 1
• Monitor for development of systemic symptoms that may warrant genetics referral or multidisciplinary team involvement. 2, 6