Acute and chronic groin pain are a frequent occurrence in sports and are one of the three most common injuries seen in the various codes of football. They are frequent in sports that involve running, kicking, sprinting, acceleration and a change of direction.
Mechanisms Involved in Hip Flexor and Groin Injuries
Research using MRI on elite and sub-elite athletes within a week of an acute groin and hip flexor injury, have established that kicking and change of direction are the most common situations leading to injury.
Adductor injuries are the most common, with the adductor longus being the most frequently injured muscle in the group. The most common mechanism of injury is a sudden change in direction or kicking from hip extension to hip flexion, and hip abduction to adduction with the hip externally rotated.
In the hip flexor group, the proximal rectus femoris is most frequently injured followed by the iliacus and the psoas muscle.
The rectus femoris injuries occurred predominantly during kicking and sprinting, were as Iliacus injuries occurred during a change of direction.
Acute or Gradual Groin Pain
The onset of groin pain may be acute or gradual.
In gradual onset groin pain or stiffness in the early stages of physical activity, with the symptoms reducing as they warm up. Longstanding groin pain may lead to more complex presentations, involving other muscles and structures that may need rehabilitation.
Aims of Treatment:
Decrease recurrence rates
A multimodal approach has been found to be the most effective this may include manual therapies, exercise, dry needling and functional training.
In the initial stages, Pain management is important.
Analgesics, manual therapies, Dry Needling, taping and compression garments may be useful.
Adequate range of motion, and mechanotherapy to load the injured structure is important for tissue capacity.
The Copenhagen adductor exercise has been found to be a good indicator of adductor muscle strength in rehabilitation.
Train for sport specific risk factors that may influence injury, such as kicking sprinting and eccentric loading.
There may be other factors, such as Lumbo-pelvic stiffness, strength or stability.
The maintenance of cardiovascular fitness is of optimal importance during recovery.
Risk Factors for Groin Injuries in Athletes
Prior groin injury.
Higher level of play.
Lower adductor strength relative to abductors.
Reduced relative, and absolute adductor strength.
Having lower levels of sport specific training.
Differential Diagnosis (Musculoskeletal):
Lumbar spine referral.
Sacroiliac joint referral.
Referral patterns from other muscles.
In young adolescents presenting with groin pain, the clinician must be suspicious of possible differential diagnosis of Perthes disease or Slipped Upper Femoral ephiphysis.
In middle aged female distance runners with groin pain, its important to consider possible stress fractures of Pubic Ramus, or Neck of the Femur.
Clinical Examination-based Classification System
Assessment has been challenging and confusing for many years to due to the nomenclature in use by clinicians, often the same anatomical entity uses a different diagnostic term or pain terminology.
To resolve this problem, The First World Conference on Groin Pain in Athletes was held in Doha, Qatar in November 2014, with over twenty-four experts invited from around the world to review the various factors and issues in involved in regard to groin pain and agree on a standard classification.
The new clinical examination-based classification system on groin pain in athletes can be defined as:
Adductor related groin pain
Iliopsoas/ hip flexor related groin pain.
Inguinal related groin pain.
Hip related groin pain.
Treatment is based on accurate history and functional assessment of the respective areas.
Screening may involve active, passive range of movement, strength and sports specific movements that may involve the whole kinetic chain.
Optimal strength ratio for adductor/abductors is 1.2:1.0.
JA Davis, MD Stringer, SJ Woodley. 2012.New insights into the proximal tendons of adductor longus, adductor brevis and gracilis. BJSM; 46: 871-876.
EC Falvey, E king, S Kinsella et al. 2016. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients- clinical findings, MRI findings and patient-reported outcome measures at baseline. BJSM. 50: 423-430.
J Harøy, B Clarsen, EG Wiger, et al. 2018. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. BJSM Published on line first: 10 June 2018.
9th Interdisciplinary World Congress on Low Back and Pelvic Girdle Pain. Progress in Evidence Based Diagnosis and Treatment. Singapore 2016.
E King, A Franklin-Miller, C Richter et al. 2018. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort 205 patients. BJSM; 52:1054-1062.
A Serner. 2017. Diagnosis of acute groin injuries in athletes. BJSM. 51 (23): 1709-1710.
A Serner, AB Mosler, JL Tol, et al. 2018 Mechanisms of acute abductor longus injuries in male football players: a systematic video analysis. BJSM. Published on line first 13 July 2018.
K Thorborg, S Branci, MP Nelson, et al. 2017. Copenhagen five-second squeeze: a valid indicator of sports-related hip and groin function. BJSM; 51: 594-599.
A Weir, P Brukner, E Delahunt, et al. 2015 Doha agreement meeting on terminology and definitions in groin pain in athletes. BJSM. 49 (12): 768-774.
A Weir, SA Verger, HB Van de Sande, EW Bakker, et al. 2008. A manual therapy technique for chronic adductor-related groin pain in athletes: a case series. Scand J Med Sci Sports; 19 (5): 616-620.