Resolving Groin Injuries
Groin injuries are a common athletic injury in both contact and non-contact sports. Injuries to the groin can occur from direct trauma in sports such ice hockey, basketball, football, rugby, and in non-contact sports such as gymnastics. In hockey, 10% of the injuries that occur each year are groin injuries. These injuries should be taken seriously because, once an athlete injures their groin, they are twice as likely as other players to incur the same injury again.
Anatomically your groin is the area where your upper thigh meets your pelvis (lower abdomen), essentially the crease or fold between these two areas. In reality, groin injuries involve a much larger area than just this. A groin injury can encompass an area that extends from your lower abdomen, to your pelvis, to your hip and inner thigh, and right down to your knee.
Since a groin injury can cover such a large anatomical region it can involve muscles, tendons, ligaments, joints, connective tissue (fascia), neurological, circulatory structures and even internal organs in the lower abdomen. In this blog we will limit our focus to musculoskeletal causes, except for a quick review on some conditions that must be ruled out.
A differential diagnosis refers to the process of determining the probability of one condition over another. It is the process of making sure we are actually dealing with a musculoskeletal condition and not something more serious (pathological).
Fortunately most groin injuries are musculoskeletal injuries (mechanical problems) that will respond well to manual therapy and exercise. However, it is still important to evaluate other causes of groin pain (pathological causes) rather than assuming the problem is just a simple muscle strain. Some of the other problems that must be considered are:
A hernia is a condition that must be ruled out whenever a groin injury presents itself. Minor hernias do respond to rest, ice, and range of motion exercises. More severe hernias require surgery (mesh reinforcement).
The hip contains approximately eighteen superficial and deep bursae. Bursae are small pouches with slippery surfaces that reduce friction between two moving surfaces (increase gliding). The bursae are usually located in areas where muscles and tendons glide over bones. When the bursa becomes inflamed it loses the ability to decrease the friction between the moving surfaces. As inflammation increases, instead of providing ease of movement, they become a source of friction and pain. Chronic bursitis can be due to an underlying inflammatory condition. Examples of common sites of hip pain due to a bursa are the:
- Superficial bursa.
- Directly over the greater trochanter.
- Deep bursa.
- Between gluteus maximus tendon and the greater trochanter (posterolateral prominence).
Fractures (Frank or Stress fractures)
If the initial groin injury has been caused by trauma (in a contact sport) then possible fractures must be considered. The two most common sites for stress fractures are in the upper leg (femoral neck) and in the pelvis (pubic rami). A simple X-ray is often all that is needed.
An avulsion often refers to a bone injury where the tendon (which attaches muscle to bone) is torn away from its insertion point. Some of the possible sites of avulsions in a groin injury are:
- ASIS (anterior superior iliac spine) – The site of the sartorius muscle attachment.
- AIIS (anterior inferior iliac spine) – This is the site where the middle quadriceps (rectus femoris) attaches.
- Ischial tuberosity – This is the site of attachment for your hamstrings.
This condition is also known as gracilis syndrome. It is a repetitive stress injury that affects the pubic symphysis. This is an injury that can occur in runners, or sports that involve jumping or kicking. Osteitis Pubis can be increased after childbirth due to ligamentous laxity.
Nerve compression can be a common problem associated with a groin injury. An example would be compression of a nerve called the femoral cutaneous nerve. When this nerve is compressed it creates a condition called Meralgia Paresthetica. This condition creates alter sensations on the outside of the hip.
When discussing a groin injury, the hip is a logical place to start. Your hip joint is the largest weight bearing joint in your body. It is designed to absorb shock, generate force, while maintaining an impressive range of motion when functioning correctly. Unfortunately this has also made the hip joint very susceptible to injury due to the amount of repetitive motion and force this joint is subject to.
The successful resolution of a groin injury often involves a complex understanding of kinetic chain relationships, and a functional understanding of how motion of the hip is related to specific anatomical structures. When you observe a deviation from normal hip motion after a groin injury, it is often a direct indication of which anatomical structures are involved in creating and perpetuating a groin injury.
A mechanical groin injury that involves the hip will be a combination of four functional muscle groups:
- Agonists (Prime mover) – Muscles that contract to produce a specific movement. Example: The quadriceps are prime knee extensors.
- Antagonists – Muscles on the opposite side of the joint of the agonist. Example: Hamstrings are antagonists to the quadriceps.
- Synergist – Muscles that limit motion as the prime movers contract and also assist motion. Example: The Iliopsoas, and tensor fascia latae (TFL) are synergists to the quadriceps.
- Stabilizers – Muscles that fix or stabilize the bones of the origin of the prime movers.
An understanding of these structures, combined with a whole body examination of kinetic chain relationships, provides a practitioner insight into all the structures that may be involved.
Notice that only certain sections of muscles are involved in some specific actions and that the same muscles help to perform multiple actions depending on hip joint position. Once a practitioner has an understanding of these structures, they can often obtain a considerable amount of information just by observing patient motion. If the patient is having a problem performing a specific action, and it’s just a mechanical problem, it is most likely due to a combination of the following structures:
Muscles involved in hip flexion:
- Psoas and Iliacus
- Medial Quadricep (Rectus Femoris)
- Adductor longus, brevis and magnus (The superior portion of the adductor magnus is involved in hip flexion)
- TFL (Tensor fasciae latae)
- Gluteus medius (Anterior portion of the muscle)
Muscles involved in hip extension:
- Gluteus Maximus – This is a prime hip extensor. If it is weak, an increased load will be passed onto the hamstrings. In addition, if the psoas muscle is tight, the gluteus maximus muscles will be turned off.
- Gluteus medius (Posterior portion of the muscle)
- Hamstrings (Semimembranosus, semitendinosus, biceps femoris – long head)
- Adductor magnus (Inferior portion of the muscle)
Muscles involved in hip adduction:
- Adductor Magus, Longus and Brevis – Adductor longus is the most common muscle injured in a groin strain
- Obturator externus
- Gluteus Maximus (The lower section of the muscle)
Muscles involved in hip abduction:
- Gluteus medius and minimus
- Gluteus maximus (upper section of the muscle)
- TFL (Tensor Fascia latae)
- Piriformis muscle, gemellus superior, gemellus inferior, obturator internus (These muscles are involved in abduction when the hip is flexed)
Muscles involved in medial rotation of the hip (Internal rotation):
- Gluteus Medius (Anterior section of the muscle)
- Gluteus minimus
- TFL (Tensor Fascia latae)
- Medial hamstrings (Semimembranosus and Semitendinosus)
- Adductor Magnus and longus
Muscles involved in lateral rotation of the hip (external rotation):
- Gluteus Maximus and medius (posterior section of the medius)
- The deep six (Obturator externus, quadratus femoris, gemellus superior, gemellus inferior, obturator internus, piriformis) – In cases of sciatica it is often assumed that the entrapment involves the pirformis muscle, when, in reality, entrapment of the sciatic nerve can involve any of these muscles.
- Lateral hamstring (biceps femoris – long head)
- Popliteus (This muscle is behind the knee – and is primarily involved in lateral rotation of the hip when the leg is in a fixed position
The 72-hour phase after an injury is characterized by swelling and pain. During this phase, use ice to reduce inflammation (ice massage), and if required, take an over-the-counter anti-inflammatory medication. Avoid using these medications after the first 72 hours since they can have a negative effect on tissue regeneration. Even during this initial stage, it is important to get some motion into the affected area in order to speed the healing process.
During this stage, I recommend that you get as much rest as possible. I also recommend you use a compression strap which will help to prevent further injury. Elevating the injured leg while doing the ice massage every 2 to 3 hours is also essential (ice only 7 to 9 minutes each time).
Manual therapy should be implemented as soon as possible. The longer that the injured person waits for therapy to begin, the longer the resolution time may be. The period of time that you will be unable to perform your usual activities will depend on the cause of injury and the degree of injury.
This will give them an initial hypothesis as to which structures are involved. Refer to the previous section of this blog to see which muscles are involved.
The first thing practitioners must do in treating a groin injury is perform a biomechanical analysis. In this process they evaluate the patients gait for alteration in movement patterns.Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction present. The practitioner will feel an alteration in normal tissue consistency, it will feel ropy, rigid, and there will be a lack of tissue glide between adjacent structures. Once the area needing treatment has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions; they include: Active Release, Graston Technique, Massage Therapy, and Fascial Manipulation.
The success rate in resolving a groin injury is very high in the hands of an experienced soft tissue practitioner. As the practitioner work through the soft tissue restrictions they will be looking for changes in tissue consistency, movement and function. Some of these changes are often noted even during the first treatment.
When you are being treated for a soft tissue injury, it is very important to communicate to the practitioner how the treatments are going, and how the condition is improving, if at all. In most cases, improvements in symptoms (decrease in pain) and functionality (ability to perform tasks better) will be noted if the right structures are being treated.
Exercise is essential in the treatment of a groin injury for a complete recovery and to prevent any recurrences. In many of my blogs I stress the importance of stretching, strengthening, and balance training for a complete recovery. Without these three essential elements, your injured tissues will not remodel correctly and you will only be setting yourself up for a series of groin injuries.
During the first 48 hours to six weeks after an injury, collagen is formed and laid down to repair the injured area. If the injured person is performing the correct stretching exercises, the majority of the collagen will be laid down in the same direction as the tissue being repaired, making the repaired tissue stronger and more capable of performing its function. If the individual is not stretching, the tissue will be laid down in more random patterns, leading to the development of weaker tissue that is easily re-injured.
- Groin Stretch (Core Performance)
- Lateral Lunge Moving – Dynamic Stretch (Core Performance)
Tissue remodeling can last up to 12 months after an injury. During this phase, the collagen fibers increase in size, diameter, and strength. The collagen remodels to withstand the stresses that are placed up on it. In other words, tissue remodeling is dependent on the forces that are applied the tissue. If the injured person is performing appropriate strengthening exercises, the collagen will remodel to withstand the stresses placed upon it. With exercise, this remodeling will lead to a complete recovery of the injured tissue, along with a decreased chance of re- injury. Without appropriate strength training, the possibility of re-injury is very high, no matter what therapy the patient has received.
- Lateral Squat – Low (I first learned this exercise in martial arts to increase my range of motion)
Balance Exercises – Proprioceptive Training
Whenever a groin injury occurs, the injury is usually not restricted to just the ligaments, tendons, muscle fibers, and fascial fibers. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) perform an essential role in positional control. Any damage to these structures can have the effect of decreasing stability, which can lead to problems.
Fortunately this damage can be repaired with exercise protocols that involve balance and proprioception. Some of the proprioceptive exercises we use with our patients at the clinic are:
- One-legged StandThis is a good initial exercise to try, with a slow progression into partial single leg squats. Do all of this exercises within a pain-free range-of-motion.
- Wobble board trainingSlowly increase the difficulty of wobble board exercises from the two-legged balance exercises, into a single-leg exercise that combines full-body motions. Once you are ready, you can even try the single-legged version with your eyes closed. Note: The eyes-closed version should only be attempted after you are fully recovered and you are ready to work on increasing athletic performance.
Returning to Activities
In order to return your normal sports and activities (hockey, soccer etc.), you should be able to perform all movements required by that sport or activity without significant pain.
The time needed to return to a sport will vary depending on the movements required. Distance runners are only required to move in relatively straight lines compared to hockey player who requires constant force changes in direction during normal play. Returning too soon to a particular activity could set an athlete up for a series of injuries.