Groaning about your groin?

MDC Physiotherapy

The rate of occurrence of groin injuries should not be underestimated, ranking behind only fracture and anterior cruciate ligament reconstruction in terms of time out of training and play (1). It is an injury that should not be ignored when mild symptoms first arise. The average days lost due to groin injury per club in professional soccer can exceed to 85 days per season (2). With this, 21% of players can experience a groin injury during a season. In a study (2) with 606 professional footballers from 17 clubs, there was 206 groin injuries sustained by 150 players. Of the 206 injuries, 16% were minimal (1–3 days), 25% mild (4–7 days), 41% moderate (8–28 days) and 18% severe (>28 days). Adductor-related groin pain is the most common form of groin injury (68%) followed by iliopsoas (12%) and pubic-related (9%) groin pain. The prevalence of hip and groin pain across the elite GAA cohort in 2022 was 38% (3). Meaning 1 in 3 athletes can experience groin pain. With previous hip and groin pain in the previous season the strongest predictor of future hip and groin pain.

To start it can be sometimes difficult to distinguish if you are experiencing hip related pain, adductor related, iliopsoas or pubic related groin pain, even if you are a physio! We can often hear of terminologies such as Gilmores groin and osteitis pubis to name only a few. The Doha agreement is a great tool to identify which entity of groin pain you may have. It simplifies the possible injured entity (without the endless terminologies). From the diagram we can clearly infinity the possible sources of groin pain when hip related pain has been ruled out.

Since adductor related groin pain is deemed the most prevalent form of groin pain, lets talk about it.

The role of the adductors is to pull the thigh inwards and rotate the upper leg inwards while also stabilising your hip. So, when we visualise the changing direction demands in Gaelic football or soccer, the adductors are required to be repetitively strong in rotating your leg inwards to turn. Doing this frequently with high loads and low adductor strength levels can increase the likelihood of picking up groin pain.

There are two intrinsic risk factors for picking up a groin injury. The two include previous groin injury and low adductor strength. Adductor strength being very much modifiable. With a previous injury, players are twice as likely to sustain a recurrent groin injury. The good news is that there are excellent studies that show a large risk reduction (41 %) of adductor related groin pain in football players, and even in those players with a previous groin injury. In an interesting study (4), 35 semi-professionals football teams were randomised into an intervention group (339 players) and a control group (313 players). The intervention group performed an adductor strengthening programme using one exercise, with three progression levels, three times per week during the preseason (6-8 weeks), and once per week during the competitive season (28 weeks). The control group were instructed to train as normal. The prevalence of groin problems was measured weekly in both groups during the competitive season. The risk of reporting groin problems was 41% lower in the intervention group. The simple adductor strengthening programme significantly reduced the prevalence and risk of groin problems in football players. This study highlights how incorporating a simple exercise can very easily reduce the risk of developing groin pain. It should be a component of players training program or warm up routine, and can be easily completed in a group setting on the training pitch.

With the severity of symptoms rising, you may need to reduce your exposure of cutting and changing direction, during this time it can be a great opportunity to increasing gluteal, hamstring, hip flexor and quad strength. I advise this because of an interesting study from Enda King (5) who demonstrated a significant improvement in adductor strength in the absence of any isolated adductor strengthening during rehabilitation. The authors noted that reduced gluteal and hip flexor recruitment during hip extension can be suggested to increase anterior hip joint forces. Therefore, restoring function in both anterior and posterior hip muscle tissues are essential to optimising load distribution in the region of the groin. This not only reduces other lower limb injuries on return to full play such as hamstring strains but allows strength & power markers to remain high when out of action. With graded rehabilitation addressing the risks factors and ensuring pain free strength has been achieved the player can return to training pending the groin is pain free. After one week of full training load with no aggravated symptoms the player can be deemed ready to return to play.

I hope this helps!

References

Ekstrand, J., Hägglund, M. and Waldén, M., 2011. Epidemiology of muscle injuries in professional football (soccer). The American journal of sports medicine, 39(6), pp.1226-1232.
Mosler, A.B., Weir, A., Eirale, C., Farooq, A., Thorborg, K., Whiteley, R.J., Hӧlmich, P. and Crossley, K.M., 2018. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. British journal of sports medicine, 52(5), pp.292-297.
Carolan D, Richter C, Thorborg K, Franklyn‐Miller A, O’Donovan J, McDonald C, King E. Hip and groin pain prevalence and prediction in Elite Gaelic Games: 2703 male athletes across two seasons. Scandinavian Journal of Medicine & Science in Sports. 2022 May;32(5):924-32.
Harøy J, Clarsen B, Wiger EG, Øyen MG, Serner A, Thorborg K, Hölmich P, Andersen TE, Bahr R. The adductor strengthening programme prevents groin problems among male football players: a cluster-randomised controlled trial. British journal of sports medicine. 2019 Feb 1;53(3):150-
King E, Franklyn-Miller A, Richter C, O’Reilly E, Doolan M, Moran K, Strike S, Falvey É. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. British journal of sports medicine. 2018 Aug 1;52(16):1054-62.