Groin Injury
Suffering a groin injury in sports such as hockey, skiing, fencing, horseback riding, soccer, and football is common. Any sport that requires a large hip range of motion, quick stops and starts, and changes in direction. Groin injuries can be difficult and time consuming to treat so prevention is always best, and if an injury occurs - rapid diagnosis and treatment are critical. Groin pain can be due to a large number of causes, not all of which will be discussed here, but should be kept in mind when seeking a diagnosis.
Contents
How common are groin injuries?
What are the symptoms of a groin injury?
How are groin injuries incurred?
How do I know what has caused my groin pain?
What is the most common cause of groin pain?
How common is a groin injury?
About 10 to 13 percent of soccer injuries are related to the groin.(1)
After a groin injury occurs there is likelihood of long term play
loss(2). There is also a high rate of recurrence with groin
injuries.(3) Previously injured athletes have a risk of injury that is
twice as high as those that had never been injured.
What are the symptoms of a groin injury?
After an acute groin injury one may experience a few or all of the
following symptoms:
- Pain at rest
- Pain during exercise
- Morning stiffness
- Stiffness after exercise
- Tenderness
- Weakness in the adductor and/or hip flexor groups
How are groin injuries incurred?
Acute, sudden onset sports related groin injuries are likely due to
overstretching, straining, and ruptures. Gradual onset sports related
injuries are more likely due to biomechanical overload.
An adductor or groin strain may occur during sudden eccentric activity in the
muscle - when the muscle is forced into extreme abduction, or with
loaded adduction such as two soccer players kicking the ball at the
same time, or a rapid acceleration.
After an injury like this there may be local swelling, bruising that
shows up days later, pain at the site of muscle disruption.
Occasionally the muscle may rupture without significant complaints of
pain.
A hip flexor strain will also cause pain in the groin and can be the
result of forceful or repetitive hip flexion, especially in those
sports that require a lot of hip extension.
Groin injuries can also be due to impact injuries, falls, or hits
causing traumatic bursitis.
There are 13 or more bursae around the hip, over boney prominences, and
between tendons. Direct trauma to these can cause inflammation and on
occasion bleeding into the bursa. Subsequent scarring and adhesions can
lead to chronic pain and inflammation if not treated. The iliopectineal
bursa is the largest bursa found in the body. Inflammation in this
bursa can cause pain and tenderness in the groin.
Other causes of groin pain.
• Torn acetabular labrum
• Femoral head avascular necrosis
• Bursitis (traumatic, inflammatory, or septic)
• Lumbar disc herniation
• Legg-Calve-Perthes
• Myositis ossificans
• Osteitis Pubis
• Symphysis pubis separation
• Sacroiliac joint disorders
• Slipped capital femoral epiphysis
• Stress fractures
• Abdominal aortic aneurysms
• Diverticulitis
• Hydrocele or Varicocele
• Inflammatory bowel disorders
• Lymphadenopathy
• Ovarian cysts
• Prostatitis
• Testicular cancers
• Testicular torsion
• Urinary tract infections
• Adductor tendinitis
• Avulsion injury
• Conjoined tendon dehiscence
• Hernia
• Spinal pathology
• Nerve root entrapment
• Arthritis
• Pubic symphysis instability
• Spondyloarthropathies
• Snapping hip syndrome
• Pudendal neuropathy
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How do I know what has caused my groin pain?
The broad symptomatology, and likelihood of multiple problems pose diagnostic challenges for physical therapists and physicians. It is important that your health care professional get a complete history, duration of pain, history of sports played, and a thorough examination of the area as the first step in obtaining a diagnosis. Once you have a diagnosis conservative therapy can be started to address the causes of the pain.
What are risk factors for recurring adductor pain?
- Poor lumbopelvic stability
- Weak transversus abdominis
- Hip adductor weakness
- Increased age
- Prior injuries
- inadequate rehabilitation
- high level of play
- Decreased hip abduction range of motion
- Muscle imbalances
Athletes that have previously been injured have a risk of re-injury
that is two times higher than athletes that had never been injured and
players that have weak adductors have been found to be four times as
likely to have a recurring adductor injury.(4) Reduced hip abduction
range of motion (ie adductor flexibility) has also been shown to be a
significant risk factor for adductor strains.(5)
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What is the most common cause of groin pain?
Chronic groin pain in athletes is most commonly caused by adductor longus strain(4). This can account for 62% of groin injuries. It is thought that this muscle is particularly vulnerable because of its small origin of attachment, superficial location of the muscle, and poor blood supply. Injury is most common near its origin on the pubic bone, is accompanied by tenderness and weakness and pain on resisted hip adduction.
Grade 1 strain: minimal restriction and loss of strength
Grade 2 strain: decreased strength in the muscle due to the damage to the muscle but not a loss of complete function
Grade 3 strain: complete disruption of the musculotendinous unit and loss of muscle function.
How to prevent groin injury.
Groin strains in athletes have got to be one of the most frustrating
and difficult injuries to rehabilitate. With its high rate of
recurrence, prevention is the best way to keep people active. Factors
listed above that are not modifiable such as age, previous injury, and
inadequate rehabilitation of previous injuries, we have no control
over. Those we do have control over such as correcting muscle
imbalances, improving lumbar control and stability, strengthening
transversus abdominis, and lengthening the adductors, we can start
right away.
Off season sport specific training has been shown to be important in
preventing adductor strains.(7) Hockey players who have less than 18
bouts of sport specific training in the off season were found
to sustain groin injuries three times as often during training camp.
- Increase eccentric sport specific training to the thigh and core musculature to reduce risk of groin injury.
- Sport specific warm ups should be done so as to warm the body and ready it for activity without fatiguing the individual.
- Static stretching to lengthen the adductors should be done after training while the muscles are warm to reduce the likelihood of groin strain.
- Strengthening should address weaknesses in the adductors relative to the abductors, and weaknesses in the hip extensors relative to the hip flexors.
- Risk of groin injury has been shown to be increased significantly in individuals with weakness in transversus abdominis and/or inability to recruit the transversus abdominis, so training this area is a must.
References
1. RD Hawkins, MA Hulse, C Wilkinson, A Hodson, M Gibson. The
association football
medical research programme: an audit of injuries in professional
football. Br J Sports Med. 2001; 5: 43–47.
2. P Renström, L Peterson. Groin injuries in athletes. Br J
Sports Med. 1980; 14:30-6.
3. L Maffey, C Emery. What are the risk factors for groin
strain injury in sport? A
systematic review of the literature. Sports Med 2007; 37: 881-94.
4. AH Engebretsen MD, G Myklebust PT, PhD, I Holme PhD,
L Engebretsen MD, PhD, and R Bahr MD, PhD Intrinsic Risk
Factors for Groin Injuries
Among Male Soccer Players Am J Sports Med October 2010 38 2051-2057
5. A Arnason, SB Sigurdsson, A Gudmundsson, et al. Risk
factors for
injuries in football. Am J Sports Med. 2004;32:5S-16S
6. PA Renstrom. Tendon and muscle injuries in the groin area. Clin
Sports Med. 1992;11:815-831.
7. CA Emery, WH Meeuwisse: Risk factors for groin injuries
in hockey. Med Sci Sports
Exerc 2001; 33(9):1423.