Groin Strains - Diagnosis to Resolution

Hockey and soccer players often experience the painful repercussions of groin strains, however, these injuries are not exclusive to these sports, they also occur in others like cross country skiing, fencing, handball, and track & field. This is due to the frequent and forceful eccentric contraction of the adductor muscles found on the inner thigh, which these sports necessitate. (1)

In the National Hockey League (NHL), groin strains comprise about 10% of all recorded injuries. Intriguingly, the majority of these strains are not caused by direct contact or impact. Instead, they tend to occur more frequently during the pre-season compared to the regular season. (2) This observation has prompted researchers to establish a relationship between the strength of the adductor muscles, located on the inner thigh, and the incidence of groin injuries, specifically adductor strains. (3)

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What is a Groin Strain

A groin strain is an injury to the muscles of the inner hip and thigh (adductor muscles). These muscles fan out from the pelvis all the way to the inner part of the upper leg. The adductor longus is the most commonly injured muscle in the adductor group. (4)

The primary action of the adductor muscles is to pull the leg inwards (adduction) and also to help bend and rotate the leg at the hip joint. A strain occurs when one or more of the groin muscles is either stretched too far, or is forcefully contracted while it is being stretched, resulting in torn muscle fibres.

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Symptoms Associated With A Groin Strain

Groin strains present a range of symptoms that primarily manifest as discomfort and limited mobility in the affected area. These symptoms are generally intensified during activities that involve moving the legs, such as walking, or during actions that require bending at the hip, such as sitting down or standing up.

This discomfort often takes the form of an aching sensation, but in some cases, it may also be characterized by a burning feeling. Moreover, in certain instances where nerve irritation accompanies the injury, the pain can even resemble an electric shock.

The severity and impact of a groin strain tend to vary according to the extent of damage sustained by the muscle fibres. Consequently, these strains are often categorized into three grades, each reflecting a different level of injury and subsequent impairment of physical activities.

• A Grade I Strain: The mildest form, is characterized by a slight tear in a limited number of muscle fibres. The accompanying pain is typically mild and barely impedes one's regular activities.

• A Grade II Strain: Represents a moderate injury, where a more substantial number of muscle fibres have been torn. This results in moderate pain and a noticeable limitation in performing certain activities. Symptoms might also include moderate bruising and swelling around the groin area.

• A Grade III Strain: This is the most severe form of groin strain, involving an extensive or, in some rare instances, a complete tear of the muscle fibres. The pain experienced in this case is severe and significantly hinders the sufferer's ability to engage in physical activities. Moreover, significant bruising and swelling are commonly observed with a Grade III strain.

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Skating Biomechanics

To comprehend why hockey players are prone to groin injuries, it's crucial to delve into the fundamental skating stride and the muscles at play in executing this intricate motion. A basic skating stride comprises two primary stages:

Support Phase

• The first stage is known as the Support Phase, which involves a skater propelling themselves forward by pushing off with one leg while gliding. During this phase, the groin muscles are instrumental in balancing the forces necessary to drive the skater forward. These forces originate from the hip, knee, and ankle. As a skater thrusts off sideways during the Support Phase, the hip extends backwards and moves outward (abduction), the knee straightens (extension), and the ankle bends downwards (plantar flexion), collectively contributing to forward movement.

Swing Phase

• The second stage is referred to as the Swing Phase, where the leg is drawn back to the central position, preparing for the next push-off. In reaction to these movements, the groin muscles stretch under tension, performing what is known as an eccentric contraction. This action aids in maintaining balance, absorbing impact, and capturing the kinetic energy used to bend the hip and draw the leg inward (adduction) during the Swing Phase. This crucial process ensures that the leg used for the push-off is efficiently returned to the center, setting up the next push-off with the opposite leg. This mechanism facilitates seamless transition between movements and promotes consistent fluidity of motion.

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Why Hockey Players Are Prone To Groin Strains

In the context of ice skating, particularly hockey, there are several factors that make the players vulnerable to groin injuries. A major contributing element is the inherent muscle imbalance between the hip abductors, which are the gluteal muscles, and the adductors, or the groin muscles. This imbalance is further exacerbated by muscle fatigue and overuse, thereby setting the stage for groin injuries.

In the biomechanics of hockey players, the gluteal muscles are typically more robust than the groin muscles.

This strength disparity often leads to the gluteal muscles overpowering the groin muscles, creating an imbalance. This particular imbalance is a significant risk factor for injury during the dynamic movements required in skating.

When a hockey player skates, there's a need for strong eccentric contractions by the adductor muscles to balance the outward leg motion during the Support Phase of skating. Eccentric contractions occur when a muscle lengthens under tension, as the groin muscles do when countering the outward leg motion.

However, if the groin muscles are weaker in comparison to the gluteal muscles, they are subject to excessive strain during these movements. The overpowering force from the stronger gluteal muscles can overload the groin muscles. This overload may cause the groin muscles to stretch too far, leading to pulling and tearing of the muscle fibres, resulting in a groin strain.

Therefore, the combination of muscular imbalance, fatigue, and the rigorous demands of ice hockey can contribute significantly to the susceptibility of hockey players to groin strains. Regular conditioning and strengthening of the groin muscles can help mitigate these risks and improve performance on the ice.

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Treating Groin Injuries

Groin injuries can cause significant discomfort, particularly in the acute stage. At Kinetic Health, our treatment approach is customized to align with the different stages of a groin injury. It's crucial to collaborate with your healthcare provider throughout all stages to achieve a complete recovery. Our treatment strategy is segmented into three pivotal phases:

1. Acute Phase

2. Sub-acute Phase

3. Sports Specific Training

Treatment During the Acute Phase of a Groin Injury

Even in the Acute Phase, it's crucial to attend to the groin injury promptly to expedite the individual's return to their activities. The main elements of our treatment protocol and suggested exercises during the Acute Stage of a groin injury include:

• Implementing the RICE protocol: rest, ice, compression, and elevation. For further information on when to use ice or heat, refer to Dr. Abelson’s blog post, “Ice or Heat – Which Should I Use”.

• Administering gentle manual therapy, as tolerated.

• Conducting passive hip range-of-motion exercises, but only within a pain-free range.

• Engaging in bent knee isometric strengthening, with sub-maximal effort, avoiding straight legs to prevent re-injuring the adductor muscles.

• Introducing progressive resistance exercises, which are non-weight-bearing and within a pain-free range.

• Incorporating flexibility exercises targeting muscles not involved in the injury.

• Encouraging strengthening of the muscles in the lower extremity on the side opposite to the injury (contra-lateral side).

Sub-acute Phase

Treatment During the Sub-acute Phase of a Groin Injury Transition to the Sub-acute Phase of treatment can occur only after the patient can contract the adductor muscles against gravity without pain. The primary components of our treatment protocol and recommended exercises during the Sub-acute Stages of a groin injury include:

• Continuing with manual therapy while expanding the focus to a larger kinetic chain of involved structures.

• Permitting cycling and swimming; cycling serves as an excellent warmup.

• Implementing a flexibility program that extends beyond the adductors. "Sam's Daily Five Stretches" would be an ideal routine.

• Introducing balance exercises on one leg.

• Carrying out progressive resistance exercises, including concentric adduction, within a pain-free range of motion. We suggest standing adduction exercises using a Theraband. Research has demonstrated that eccentric training can be effective in rehabilitating groin injuries.

• Incorporating forward lunges coupled with reciprocal arm movements.

• Performing pelvic tilt exercises.

• Including goblet squats in the exercise routine.

• Introducing wobble board squats within a pain-free range of motion.

Sports Specific Training for Groin Injuries

This final stage is aimed at transitioning the patient back to their specific sport or activity. The following are some of the key components of our treatment protocol and exercises we recommend during this stage:

• Sport-specific training exercises.

• Advanced balance and proprioception exercises.

• Continuing strengthening and flexibility exercises.

• Gradual reintroduction to sports activities, starting with non-contact drills and progressing to full contact as tolerated.

Throughout all phases, it's important to communicate with your healthcare provider about your symptoms and progress. This ensures that your treatment plan is adjusted as needed to support your recovery and prevent re-injury.

During this phase of the rehabilitation process, the primary goal is to enhance the adduction strength on the injured side to reach at least 90 to 100 percent of the abduction strength on the uninjured side. To achieve this, consider the following guidelines:

1. Always take the time to thoroughly warm up before embarking on any exercise. This can significantly reduce the risk of recurring groin injuries, which are typically quite common.

2. Engage in standing resistance training that closely replicates the specific activity. For instance, if the injury occurred during skating, mimic the skating stride or kneel on a surface similar to ice and perform adductor pull-together exercises.

3. Incorporate multi-planar lunges into your exercise routine. These exercises work multiple muscle groups, enhancing overall strength and stability.

4. Utilize slider boards in multi-planar vectors for improving your balance, agility, and strength. They are excellent tools for rehabilitating groin injuries as they simulate the lateral movements common in many sports.

5. Perform exercises such as bent-knee to straight-leg ball squeezes. These exercises specifically target the adductor muscles, thereby aiding in the recovery process and preventing future injuries.

Remember, the aim of sports-specific training is not just to recover from the injury, but to return to your sport stronger and more resilient. Always ensure that you listen to your body and adjust your training regime accordingly to prevent overexertion and potential re-injury.

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Conclusion

Groin injuries, particularly strains, are common and can significantly impede an individual's activity level, especially for athletes involved in sports like hockey. Understanding the biomechanics of movements such as the skating stride and recognizing the susceptibility of hockey players to such injuries is crucial.

At Kinetic Health, we offer a comprehensive, phase-oriented approach to treating groin injuries. This includes tailored strategies for the Acute Phase, the Sub-acute Phase, and the Sports Specific Training Phase. Our approach focuses on reducing pain, restoring mobility, strengthening the involved muscles, and ultimately, returning the individual to their sport or activity.

Our treatment regimen incorporates the use of the RICE protocol, gentle manual therapy, range-of-motion exercises, progressive resistance exercises, and sports-specific training exercises. We focus on addressing muscle imbalances, enhancing flexibility, and improving overall strength.

Remember, a groin strain is a serious injury that requires prompt attention and proper management. Therefore, it's crucial to communicate with your healthcare provider about your symptoms and progress throughout your treatment. This allows your treatment plan to be adjusted as needed, supports your recovery, and helps prevent re-injury.

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DR. BRIAN ABELSON, DC. - The Author

With over 30 years of clinical experience and a track record of treating more than 25,000 patients, Dr. Abelson developed the Motion Specific Release (MSR) Treatment Systems to provide powerful and effective solutions for musculoskeletal issues.

As an internationally best-selling author, he is passionate about sharing knowledge and techniques that can benefit the broader healthcare community. A perpetual student, Dr. Abelson continually integrates cutting-edge methods into the MSR programs, with a strong emphasis on multidisciplinary and patient-centered care.

Beyond his professional life, Dr. Abelson is a dedicated husband and father of two. He and his wife share a deep love for international travel, immersing themselves in different cultures, music, and the joy of connecting with people around the world. An Ironman triathlete and marathon runner for over 30 years, he is also a committed environmentalist with a passion for human rights. His practice, Kinetic Health, is based in Calgary, Alberta, Canada.

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Citations

1. Nicholas, S.J., & Tyler, T.F. (2002). Adductor muscle strains in sport medicine. Sports Medicine, 32(5), 339-44.

2. Kluin, J., den Hoed, P.T., van Linschoten, R., Ijzerman, J.C., & van Steensel, C.J. (2004). Endoscopic evaluation and treatment of groin pain in the athlete. Am J. Sports Medicine, 32(4), 944-949.

3. Tyler, T.F., Nicholas, S.J., Campbell, R.J., & McHugh, M.P. (2001). The association of hip strength and flexibility on the incidence of groin strains in professional ice hockey players. Am J. Sports Medicine, 29(2), 124-128.

4. Kiel, J., & Kaiser, K. (2018). Adductor Strain. StatPearls Publishing, Treasure Island.

5. Harvard Medical School. (n.d.). Muscle Strain. Retrieved from https://www.health.harvard.edu/a_to_z/muscle-strain-a-to-z.

6. Upjohn, T., Turcotte, R., Pearsall, D.J., & Loh, J. (2008). Three-dimensional kinematics of the lower limbs during forward ice hockey skating. Sports Biomech, 7, 206–221.

7. Pearsall, D., Turcotte, R., Lefebvre, R., & Bateni, H. (2001). Kinematics of the foot and ankle in forward hockey skating. Paper presented at the International Society of Biomechanics in Sports, San Francisco, USA.

8. Lafontaine, D. (2007). Three-dimensional kinematics of the knee and ankle joints for three consecutive push-offs during ice hockey skating starts. Sports Biomech, 6, 391–406.

9. Emery, C.A., & Meeuwisse, W.H. (2001). Risk factors for groin injuries in hockey. Med Sci Sports Exerc, 33(9), 1423-1433.

10. Hagglund, M., Waldén, M., & Ekstrand, J. (2006). Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J. Sports Medicine, 40(9), 767-772.

11. Tyler, T.F., Campbell, R., Nicholas, S.J., Donellan, S., & McHugh, M.P. (2002). The effectiveness of a preseason exercise program on the prevention of groin strains in professional ice hockey players. Am J. Sports Medicine, 30(5), 680-683.

12. Esteve, E., Rathleff, M.S., Bagur-Calafat, C., Urrútia, G., & Thorborg, K. (2015). Prevention of groin injuries in sports: A systematic review with meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 49(12), 785-791.

13. Serner, A., Tol, J.L., Jomaah, N., Weir, A., Whiteley, R., Thorborg, K., Robinson, M., & Hölmich, P. (2015). Diagnosis of acute groin injuries: a prospective study of 110 athletes. American Journal of Sports Medicine, 43(8), 1857-1864.

14. Mosler, A.B., Weir, A., Eirale, C., Farooq, A., Thorborg, K., Whiteley, R.J., & Hölmich, P. (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), 292-297.

15. Drew, M.K., Raysmith, B.P., & Charlton, P.C. (2017). Injuries impair the chance of successful performance by sportspeople: a systematic review. British Journal of Sports Medicine, 51(16), 1209-1214.

16. Delahunt, E., Thorborg, K., Khan, K.M., Robinson, P., Hölmich, P., & Weir, A. (2017). Minimum reporting standards for clinical research on groin pain in athletes. British Journal of Sports Medicine, 51(15), 1116-1120.

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