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Groin Pain in Athletes

Groin pain is a prevalent and often debilitating issue in athletes, significantly impacting their performance and quality of life. It can arise from various underlying causes and affect multiple structures within the groin region.

This article offers a comprehensive review of groin pain, delving into anatomy, epidemiology, causes, symptoms, relevant activities, treatment options, red flags, alleviating and aggravating factors, and the essential role of physical therapy. Detailed rehabilitation phases, return-to-sport guidelines, and home exercises are also discussed to provide a thorough understanding of managing this condition.

Anatomy of the Groin

The groin region includes several structures, such as muscles, tendons, ligaments, nerves, and bones. Key anatomical components include:

  • Adductor Muscles: Adductor longus, brevis, and magnus, pectineus, and gracilis.
  • Hip Flexors: Iliopsoas (iliacus and psoas major), rectus femoris, and sartorius.
  • Inguinal Ligament: Runs from the pubic tubercle to the anterior superior iliac spine.
  • Pubic Symphysis: A cartilaginous joint uniting the left and right pubic bones.

Epidemiology

Groin pain is prevalent in sports that involve high-intensity activities, sudden changes in direction, and repetitive movements. It accounts for up to 5-18% of all athletic injuries, with a higher incidence in sports like soccer, hockey, rugby, and track and field.

Causes

Common causes of groin pain in athletes include:

  • Adductor Strains: Often occur due to sudden movements or overuse.
  • Hip Flexor Strains: Result from excessive force or repetitive activities.
  • Sports Hernia: Chronic groin pain due to weakening of the abdominal wall.
  • Osteitis Pubis: Inflammation of the pubic symphysis.
  • Hip Labral Tears: Damage to the cartilage around the hip joint.

Symptoms

Symptoms of groin pain vary depending on the cause but commonly include:

  • Pain: Localized to the groin region, which may radiate to the inner thigh or lower abdomen.
  • Tenderness: Over the affected muscles or tendons.
  • Swelling and Bruising: In cases of acute injury.
  • Stiffness: Limited range of motion in the hip joint.
  • Weakness: Especially in movements involving the adductors or hip flexors.

Most Relevant Activities That Cause Groin Pain

Activities most commonly associated with groin pain include:

  • Soccer: Due to frequent kicking, sprinting, and sudden changes in direction.
  • Hockey: Involves intense skating and abrupt movements.
  • Rugby: High physical contact and rapid directional shifts.
  • Track and Field: Especially in sprinting and hurdling events.

Treatment Options

Treatment for groin pain involves a combination of conservative measures and, in some cases, surgical intervention.

  1. Rest and Activity Modification: Essential to prevent further injury and allow healing.
  2. Ice and Heat Therapy: Ice to reduce inflammation and heat to relax muscles.
  3. Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and inflammation.
  4. Physical Therapy: Central to recovery (detailed below).
  5. Injections: Corticosteroid or platelet-rich plasma (PRP) injections in some cases.
  6. Surgery: For severe cases like sports hernia or labral tears.

Red Flags

Red flags that require immediate medical attention include:

  • Severe pain that does not improve with rest.
  • Swelling or bruising that spreads.
  • Numbness or tingling in the groin or leg.
  • Fever or signs of infection.
  • Inability to bear weight on the affected leg.

Alleviating and Aggravating Factors

Alleviating Factors:

  • Rest and reduced physical activity.
  • Ice application to reduce swelling.
  • Gentle stretching and strengthening exercises.
  • Proper warm-up before activities.

Aggravating Factors:

  • Continued participation in high-impact sports.
  • Poor biomechanics or technique.
  • Sudden increases in activity intensity.
  • Inadequate warm-up or stretching.

The Role of Physical Therapy

Physical therapy is crucial in managing and rehabilitating groin pain. It involves a structured program to address pain, restore function, and prevent recurrence.

Assessment

A comprehensive assessment by a physical therapist includes:

  • Medical History: Review of symptoms, activity level, and previous injuries.
  • Physical Examination: Assessment of posture, gait, muscle strength, flexibility, and joint mobility.
  • Functional Testing: To identify biomechanical issues and movement patterns.

Rehabilitation Phases

  1. Acute Phase:
    • Objective: Reduce pain and inflammation.
    • Treatment: Rest, ice, compression, elevation (RICE), and gentle stretching.
    • Exercises: Gentle range-of-motion exercises and isometric contractions.
  2. Subacute Phase:
    • Objective: Restore range of motion and begin strengthening.
    • Treatment: Gradual introduction of low-impact activities, manual therapy, and continued stretching.
    • Exercises: Progressive resistance exercises, core strengthening, and proprioception training.
  3. Rehabilitation Phase:
    • Objective: Restore full function and prepare for return to sport.
    • Treatment: Sport-specific drills, advanced strengthening, and agility training.
    • Exercises: Plyometric exercises, dynamic stretching, and functional movements.
  4. Return-to-Sport Phase:
    • Objective: Ensure readiness for competitive activity.
    • Treatment: Gradual return to full training, with monitoring and adjustment as needed.
    • Exercises: High-intensity drills, endurance training, and injury prevention strategies.

Step-by-Step Home Exercises

  1. Adductor Stretch:
    • Step 1: Sit with your legs extended and spread apart.
    • Step 2: Lean forward, reaching towards your feet.
    • Step 3: Hold for 20-30 seconds and repeat 3 times.
  2. Hip Flexor Stretch:
    • Step 1: Kneel on one knee with the other foot in front.
    • Step 2: Push your hips forward gently.
    • Step 3: Hold for 20-30 seconds and repeat 3 times on each side.
  3. Bridges:
    • Step 1: Lie on your back with knees bent and feet flat.
    • Step 2: Lift your hips towards the ceiling, squeezing your glutes.
    • Step 3: Hold for 5 seconds, lower, and repeat 10-15 times.
  4. Clamshells:
    • Step 1: Lie on your side with knees bent and feet together.
    • Step 2: Open your top knee while keeping your feet together.
    • Step 3: Hold for 2-3 seconds, lower, and repeat 10-15 times on each side.
  5. Plank with Leg Lift:
    • Step 1: Start in a plank position.
    • Step 2: Lift one leg towards the ceiling, hold for 2-3 seconds.
    • Step 3: Lower and repeat 10 times on each side.

When to Return to Sport

Return to sport should be based on the following criteria:

  • Absence of pain during activities.
  • Full range of motion and strength.
  • Ability to perform sport-specific movements without discomfort.
  • Clearance by a healthcare professional.

Consequences of Not Treating Groin Pain

Neglecting treatment for groin pain can lead to chronic pain, reduced athletic performance, and long-term disability. Early intervention and proper management are crucial to prevent complications and ensure a full recovery.

Conclusion

Groin pain in athletes is a multifaceted issue that requires a comprehensive approach for effective management. Physical therapy plays a pivotal role in the rehabilitation process, offering structured assessment, treatment, and exercises to promote recovery and prevent recurrence. Athletes should seek timely medical attention to address groin pain and follow a disciplined rehabilitation program to ensure a safe return to sport.

References

  1. Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K. M., … & Schache, A. (2015). Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, 49(12), 768-774.
  2. Serner, A., Roemer, F. W., Hölmich, P., & Crossley, K. M. (2019). Imaging hip and groin pathology in athletes: clinical and research perspectives. Sports Medicine, 49(5), 669-685.
  3. Mosler, A. B., Weir, A., Serner, A., Agricola, R., Eirale, C., Farooq, A., … & Hölmich, P. (2018). Musculoskeletal screening tests and bony hip morphology cannot identify male professional soccer players at risk of groin injuries: a 2-year prospective cohort study. The American Journal of Sports Medicine, 46(6), 1294-1305.
  4. Nevin, F., & Delahunt, E. (2014). Adductor squeeze test values and hip joint range of motion in Gaelic football athletes with longstanding groin pain. Journal of Science and Medicine in Sport, 17(2), 154-158.
  5. Reiman, M. P., & Thorborg, K. (2017). Clinical examination and physical assessment of hip joint-related pain in athletes. International Journal of Sports Physical Therapy, 12(2), 233-252.