Groin Pain In Sports

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INTRODUCTION

Groin Pain among sports players is very common. There are a number of anatomical structures (systemic, gynaecological, urogenital, gastrointestinal, neurological, musculoskeletal) in the groin area that can cause pain and a wide variety of possible injuries to these structures which increases the complexity (Jansen et al., 2008; Weir et al., 2015).

Acute and long-standing groin pain are problems in sports involving rapid change of directions (COD) and kicking. Muscle strains in football account for 31% of total injuries (Ekstrand et al., 2009). Groin injuries stand second in football only after hamstring strains, accounting for 4-19% and 2-14% of all injuries in male and female football respectively. Males are prone to groin injury when compared to females. Groin injury rates in males were 0.2–2.1/1000 hours and 0.1–0.6/1000 hours in women (Weir et al., 2015). Second to football, ice hockey was a sport which showed high numbers of groin injuries (Weir et al., 2015). Some of the risk factors for this injury are previous groin injury, age, decreased hip ROM, decreased hip muscle strength, overuse and higher BMI (Ryan et al., 2014).

CLASSIFICATION

Classification for groin pain/injuries are (Weir et al., 2015):

  1. Defined clinical entities for groin pain-
    1. Adductor muscle-related groin pain- Will have adductor muscle tenderness and pain on resisted adduction testing. Commonly affected adductor muscles are adductor longus, and rectus femoris muscle at musculotendinous junction.
    2. Iliopsoas-related groin pain- Will have Iliopsoas tenderness and more likely if there’s pain on resisted hip flexion and/or pain when stretching the hip flexors
    3. Inguinal-related groin pain- will have pain/tenderness at inguinal canal with no palpable inguinal hernia and more likely if the pain is aggravated with resistance testing of the abdominal muscles OR on Valsalva/cough/sneeze
    4. Pubic-related groin pain- will have tenderness at pubic symphysis and adjacent bones but no specific resistance tests that provoked this pain
  2. Hip-related groin pain
    1. Hip pathologies like Femoroacetabular impingement and labral tears can have symptoms of groin pain. Proper history, pain nature, passive and active ROM and strength testing along with special tests like Flexion-abduction-external rotation (FABER) and Flexion-adduction-internal rotation (FADIR) test) can be used to rule out hip-related groin.
  3. Other conditions causing groin pain
    1. Conditions like hernias, nerve entrapments, referred pain from joints/structures adjacent to groin, urological, gastrointestinal, dermatological, oncological and surgical can cause groin pain

EXAMINATION

Clinical examination would start with subjective assessment taking proper history, pain nature and site. Also, brief history about the sports they play and playing load (volume/intensity/duration of play) they are under. Objective assessments will include inspecting the area of pain for any swelling, range of motion both active and passive, strength testing, muscle length, palpation for tenderness and temperature changes on the site. Adductor related pain will have pain on palpation and muscle stretch, may or may not have pain in adductor squeeze test but lesser strength will be seen on affected side and reduced hip ROM (Weir et al., 2015).

Most important thing about clinical examination is to rule out any adjacent joint affection like lumbar and sacroiliac joint. A lack of peripheralization or centralization (sensitivity, 92%; negative likelihood ratio = 0.12) of the athlete’s symptoms with repeated lumbar spine ROM testing and negative straight leg raise (sensitivity, 97%; negative likelihood ratio = 0.05) and slump testing (sensitivity, 83%; negative likelihood ratio = 0.32) assist with ruling out the potential existence of discogenic/radiculopathy pathology (Devillé et al., 2000). Facet joint pathology is best ruled out with a negative extension-rotation test (sensitivity, 100%; negative likelihood ratio = 0.00) (Leerar et al., 2007). Despite the controversial nature of sacroiliac joint pathology testing, the thigh thrust test has good clinical utility to rule out (sensitivity, 88%; negative likelihood ratio = 0.18) potential sacroiliac joint pathology (Laslett et al., 2005).

PREVENTION

Adding Copenhagen exercises to FIFA 11+ program seemed to beneficial as it reduces the risk of injury by increasing eccentric hip adduction strength (Harøy et al., 2017). Proper warmup sessions with good strengthening, mobility exercises, stretching, load monitoring, hydration, nutrition, proper rest along with cool-down sessions have all been seen to be beneficial to reduce the risk of adductor injury.

TREATMENT (LeBlanc and LeBlanc, 2003; Larson and Lohnes, 2002)

Treatment for an in-season athlete are prescribed RICE protocol for the first two weeks followed by progressive resistance hip adductor strengthening like Copenhagen exercises, stretching exercises, treating imbalances at hip and abdominal muscles, endurance training, core exercises, coordination/balance exercises progressing to sports-specific functional tasks and gradual return to full sporting activities.

REFERENCES

Devillé WL, van der Windt DA, Dzaferagi A, Bezemer PD, Bouter LM.; The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs. Spine (Phila Pa 1976). 2000; 25: 1140– 114

Ekstrand, J., Hagglund, M. and Walden, M. (2009). Injury incidence and injury patterns in professional football: the UEFA injury study. British Journal of Sports Medicine, [online] 45(7), pp.553–558. doi:10.1136/bjsm.2009.060582.

Harøy, J., Thorborg, K., Serner, A., Bjørkheim, A., Rolstad, L.E., Hölmich, P., Bahr, R. and Andersen, T.E. (2017). Including the Copenhagen Adduction Exercise in the FIFA 11+ Provides Missing Eccentric Hip Adduction Strength Effect in Male Soccer Players: A Randomized Controlled Trial. The American Journal of Sports Medicine, 45(13), pp.3052–3059. doi:10.1177/0363546517720194.

Jansen, J. a. C.G., Mens, J.M.A., Backx, F.J.G., Kolfschoten, N. and Stam, H.J. (2008). Treatment of longstanding groin pain in athletes: a systematic review. Scandinavian Journal of Medicine & Science in Sports, [online] 18(3), pp.263–274. doi:10.1111/j.1600-0838.2008.00790.x.

Larson, C.M. and Lohnes, J.H. (2002). Surgical management of athleticpubalgia. Operative Techniques in Sports Medicine, 10(4), pp.228–232. doi:10.1053/otsm.2002.35874.

Laslett, M., Aprill, C.N., McDonald, B. and Young, S.B. (2005). Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy, 10(3), pp.207–218. doi:10.1016/j.math.2005.01.003.

LeBlanc, K.E. and LeBlanc, K.A. (2003). Groin pain in athletes. Hernia, 7(2), pp.68–71. doi:10.1007/s10029-002-0105-x.

Leerar, P.J., Boissonnault, W., Domholdt, E. and Roddey, T. (2007). Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain. Journal of Manual & Manipulative Therapy, 15(1), pp.42–49. doi:10.1179/106698107791090105.

Ryan, J., DeBurca, N. and Mc Creesh, K. (2014). Risk factors for groin/hip injuries in field-based sports: a systematic review. British Journal of Sports Medicine, 48(14), pp.1089–1096. doi:10.1136/bjsports-2013-092263.

Serner, A., van Eijck, C.H., Beumer, B.R., Hölmich, P., Weir, A. and de Vos, R.-J. (2015). Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. British Journal of Sports Medicine, 49(12), pp.813–813. doi:10.1136/bjsports-2014-094256.

Thorborg, K., Reiman, M., Weir, A., Kemp, J., Serner, A., Mosler, A. and Holmich, P. (2018). Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. [online] Journal of Orthopaedic & Sports Physical Therapy. Available at: https://www.jospt.org/doi/10.2519/jospt.2018.7850.

Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J., Paajanen, H., Philippon, M., Reboul, G., Robinson, P., Schache, A.G., Schilders, E., Serner, A., Silvers, H., Thorborg, K. and Tyler, T. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, [online] 49(12), pp.768–774. doi:10.1136/bjsports-2015-094869.