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.
How common are groin injuries?
What are the symptoms of a groin injury?
How are groin injuries incurred?
Other causes of groin pain.
How do I know what has caused my groin pain?
What is the most common cause of groin pain?
How to prevent groin injury.

groin injuries

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
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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.

  1. Increase eccentric sport specific training to the thigh and core musculature to reduce risk of groin injury.
  2. Sport specific warm ups should be done so as to warm the body and ready it for activity without fatiguing the individual.
  3. Static stretching to lengthen the adductors should be done after training while the muscles are warm to reduce the likelihood of groin strain.
  4. Strengthening should address weaknesses in the adductors relative to the abductors, and weaknesses in the hip extensors relative to the hip flexors.
  5. 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.

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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.