Groin Strain
Original Editors - Laure Lievens
Top Contributors - Vidya Acharya, Astrid Lahousse, Geubels Kaat, Nele Kiekens, Mats Vandervelde, Prince Wilson, Kim Jackson, Admin, Laure Lievens, Wanda van Niekerk, Lucinda hampton, Joao Costa, Kai A. Sigel, Uchechukwu Chukwuemeka, 127.0.0.1, Leana Louw, George Prudden, Claire Knott, Rachael Lowe, Els Van Haver and Naomi O'Reilly
Search Strategy[edit | edit source]
Keywords:
Groin tendinitis, adductor strain, adductor tendinitis, iliopsoas strain, iliopsoas tendinitis, abdominal strain, abdominal tendinitis, muscle strains, groin pain
Databases searched:
Pedro, google scholar, Pubmed, Web of Knowledge and Library of the VUB
Definition/Description[edit | edit source]
A groin strain is an injury to the muscle tendon unit that produces pain on palpation of the adductor tendons or its insertion on the pubic bone with or without pain during resisted adduction.[1]
Groin muscle strains are encountered more frequently in ice hockey and soccer than other sports.
These sports require a strong eccentric contraction of the adductor musculature during competition and practice.[2]
The underlying injury is most often a muscle or tendon strain at the insertion of the tendon of the adductor muscle to the bone.[3]
The difference between groin tendinopathy and strain are:
- First of all strains are acute and tendinosis are chronic. A tendinosis is a repetitive strain.
- The second difference is that acute injuries are more often localized in the myotendon junctions and chronic injuries are localized at the tendinous insertions on the pubic bone.
Fig. 2 [3]
Clinically Relevant Anatomy
[edit | edit source]
In human anatomy, the groin is the junctional area between the abdomen and the thigh on either side of the pubic bone. This is also known as the medial compartment of the thigh.
The groin muscles consist of three large groups of muscles that can be injured:
The abdominal-, iliopsoas- and adductors-group.
1. The adductors group:
The adductors of the hip joint include 6 muscles: the adductor longus, magnus, and brevis and the gracilis, obturator externus, and pectineus. All these are innervated by the obturator nerve, with the exception of the pectineus, which receives innervation from the femoral nerve. The primary function of this muscle group is adduction of the thigh in open chain motions and stabilization of the lower extremity and pelvis in closed chain motion. The adductor longus is most commonly injured during sporting activity.[4]
The proximal attachment of the adductor longus contributes to an anatomical pathway across the anterior pubic symphysis that is likely required to withstand the transmission of large forces during multidirectional athletic activities. Its lack of mechanical advantage may make it more susceptible to strain.[5]
As shown in fig 1., the adductors all originate on the pubic ramus as almost all insert on the linea aspera of the posterior femur. The posterior head of the adductor magnus has a proximal attachement on the ischial tuberosity antero-inferoirly and attaches distally on the medial distal femur at the adductor tubercle. The gracilis insertion is on the medial border of the tuberosity of the tibia.[3]
Hip Anatomy
2. The abdominal group:
The abdominal musculature comprise the rectus abdominis, the obliques internus and externus abdominis.
Abdominal Muscle Anatomy
3. The iliopsoas group:
The iliopsoas, comprised of iliacus and psoas major muscles, is the only muscle directly connecting the spine and the lower limb.[2]
Hip Anatomy
Epidemiology /Etiology[edit | edit source]
Groin strains are common amongst athletes who compete in sports that involve repetitive twisting, turning, sprinting and kicking.[5]
Strain injuries to the groin are among the most common groin injuries in adult male soccer players. Groin strain accounts for 11% to 16% of all soccer injuries.[6]
Groin strains are also known from other sports such as ice hockey, running, tennis, rugby, American football, basketball and others.[7]
The exact incidence of groin muscle strains in most sports is unknown because athletes often play through minor groin pain and the injury goes unreported. In addition, overlapping diagnoses can skew the incidence.[4]
Musculotendinous injuries to the groin are mainly a consequence of cumulative microtraumas (overuse trauma, repeated minor injuries) leading to chronic groin pain. Cumulative or single injury seem to be important etiological factors. Although in some cases groin pain is due to an acute injury, typically a direct injury to the soft tissues resulting in muscle haematoma, the underlying injury is most often a muscle or tendon strain at the tendinous insertion of the adductor muscles to the bone. A chronic tendinitis of the adductor muscles/tendons, especially that of the adductor longus, is the most frequently diagnosed.[8]
Injury mechanism can be divided in 3 groups:
1. Direct blunt trauma
2. Forceful contraction
3. Microtrauma by repetitive injury
And subsequently result in muscle contusions, avulsions, tears and strains.
Most common groin injury in athletes are muscle and tendon strain of the adductor muscle group. A common mechanism of this injury is when the adductors attempt to decelerate an extending, abducting leg by using an eccentric contraction to adduct and flex the hip. With the forceful eccentric contraction, the adductors may not be strong enough to withstand the force, and injury can occur. The injury may also occur during a forceful concentric contraction of the muscle.[9]
Lower-extremity athletes such as ice hockey and soccer players are naturally more prone to this pathology due to the importance of the hip adductors in lower-extremity performance[10],
who are sports that involve repetitive twisting, turning, sprinting and kicking.[11]
Characteristics/Clinical Presentation[edit | edit source]
The main sign of the adductor muscle injury is intense pain in the groin area.
Adductor Tendinitis
The muscles that cross multiple joints or have a complex structure are more sensitive to strain injury. Strain injuries often arise from excessive stretching or stretching when the muscle is being activated. When there is a strain in the muscle, the damage is often localized near the muscle tendon junction. The muscle is getting weaker and the risk for further injury rises.[12]
Muscle Strain
Clinically for an adductor strain, the patient presents with pain in the inner thigh and tenderness along the muscle belly, tendon or insertion. The pain is exacerbated by adduction. There is no loss of strength or range of movement.[13]
Tears frequently occur at the myotendinous junction, which is the weakest part of the muscle tendon unit, but is also commonly seen in the muscle belly. The same mechanism of injury that results in a muscle tear in an adult may cause an apophyseal avulsion in an adolescent.
There is a well-established clinical grading system for muscle tears, which has 3 components:
- Grade 1: no loss of function or strength
- Grade 2: severe, with some weakness
- Grade 3: complete muscle tear and complete functional loss[9]
Grade 1 muscle tears can show normal appearances or a small area of focal disruption (<5% of the muscle volume), with hematoma and perifascial fluid relatively common on imaging with US and MRI.
Grade 2 injury corresponds to a partial tear, with muscle fiber disruption seen (>5% of the muscle volume) but not affecting the whole muscle belly.
Grade 3 injuries are complete muscle tears with frayed margins and bunching and/or retraction of the torn muscle fibers.[9]
- In acute grade I or II strains of the adductor muscle, there is a very intense pain in the groin area, like a sudden stab with a knife, if the athlete attempts to continue the activity. Locally a hemorrhage and swelling can be seen a few days after the injury. A typical trauma history, localized tenderness and difficulties to contract the hip abductors.
- Complete muscle tears or grade III strains are most often found in the distal musculotendinous junction located toward the insertion on the femur.
- In chronic cases, the symptoms of groin injury are often complex and uncharacteristic. With time, as the injury becomes more chronic, there is a tendency for the pain to radiate out distally along the medial aspect of the thigh or proximally toward the rectus abdominis. In chronic and subchronic cases, the symptoms are often vague and diffuse in location. The most common symptoms are pain during exercise, stiffness after exercise and in the morning, as well as pain at rest.
Stress fractures of femoral neck or the inferior ramus of the pubic bone can be revealed by bone scintigraphy or repeated radiographic examinations.[8]
Differential Diagnosis[edit | edit source]
The literature provides no consensus on diagnostic criteria for the various causes of groin pain among athletes.[7] There is also no consensus on definitions for groin injuries and the diagnosis is often difficult because of the wide variety of different diseases that can cause pain to the groin area.[6] The insertions of the rectus abdominis and adductor longus muscles are also very close to each other, which may result in difficulties in the differential diagnosis between tendinitis or partial rupture of these muscles.[8] Evidence Based Practice: 5
Diagnostic Procedures[edit | edit source]
First of all, there needs to be a patient history and an identification of the pain character by the examination of the physiotherapist. On examination, there is tenderness to palpation with focal swelling along the adductors and decreased adductor strength and pain with resisted adduction. The diagnosis can be made with focal findings on examination. When this is followed by a clinical examination and sonographic and radiographic investigations, the differential diagnosis can be made up. The radiological examination exist of US (ultrasonography) and MRI (magnetic resonance imaging).[14]
However, MRI with gadolinium may be useful to confirm the diagnosis or differentiate between adductor strain, osteitis pubis, and sports hernia.[15]
Outcome Measures[edit | edit source]
The Copenhagen Hip and groin outcome score (HAGOS)[16] Evidence Based Practice: 2C
Examination[edit | edit source]
A complete clinical examination should be performed for every patient with groin pain.
The injured athlete should first be examined by inspection in a standing position to evaluate the alignment of extremities. The patient should then be asked to lie in a supine position in order to be able to check the motion of the hip joint and the flexibility of the groin and hip muscles. Resistive contraction tests of the knee extensors, knee flexors, abdominal muscles, and hip rotators, extensors and flexors, as well as hip adductors and abductors should be performed.[8]
Evicence Based Practice: 5
1) bilateral evaluation of adductor muscle related pain and strength: palpation at the adductor insertion at the pubic bone, adduction against resistance (squeeze tests in 0° and 45°), and passive stretching of the adductor muscles.[14] Evidence Based Practice: 2A
video squeeze test:
If adductor longus muscle is injured pain will be elucidated to the injured area by resisting leg adduction and in passive stretching at full abduction of the hip. Tenderness on palpation is localized to the injury site at the origin of the adductor longus tendon or at the musculotendinous junction.[8] Evicence Based Practice: 5
2) Evaluation of iliopsoas muscle related pain, strength and flexibility: palpation above the inguinal ligament, isometric strength test in hip flexion and a modified Thomas test.[14] Evidence Based Practice: 2A
Thomas Test
3) Abdominal muscle related pain and strength: palpation of the abdominal muscle insertion at the pubic bone and a functional sit-up test and symphysis joint tenderness at palpation.[14] Evidence Based Practice: 2A
The location of the injury was based on a minimum of 1 positive finding on palpation, stretching, or muscle resistance testing.[17] Evidence Based Practice: 1B
Prevention [edit | edit source]
Subsequent groin strains may occur, resulting in a recurrent problem. Hence primary and secondary prevention are equally important. To identify the athlete at risk and possibly correct the predisposing factor(s), the intrinsic and extrinsic risk factors for the injury type must be known.[6] Evidence Based Practice: 2B
A history of previous acute groin injury and weak adductor muscles are significant risk factors. Previously injured players have more than twice as high a risk of sustaining a new groin injury, while players with weak adductor muscles have a 4 times higher injury risk. Therefore it is important to have an adequate rehabilitation before full return to play.
Preventing the first injury should be a high priority to keep players from entering the vicious cycle of recurrent injuries to the same body part. To accomplish this, the best method may be strength exercises of the adductors. Hölmich et al demonstrated that an 8 to 12 week active strengthening program, consisting of progressive resistive adduction and abduction exercises, balance training, abdominal strengthening and skating movements on a slide board, was effective in treating chronic groin strains.[6]
Also coordination exercises (focused on the muscles related to the pelvis), core stability and eccentric exercises are a part of the prevention program.[18]
Heat retainers and stretching of the adductors are also suggested to prevent injuries.[14]
Whereas a passive physical therapy program of massage, stretching, and modalities was ineffective in treating chronic groin strains.[19]
Therapy: adductor strain injury prevention program[19] + Evidence Based Practise: 1A
Exercises: [10] + Evidence Based Practice: 4
Medical Management
[edit | edit source]
Management is non-operative with rest, ice, compression, and gentle physical therapy or ROM. Injection at the adductor longus enthesis is helpful for patients refractory to conservative management. There is a clear efficacy of nonsteroidal anti-inflammatory agents.[12]
Patients may return to sports or other activities after regaining full strength and ROM with resolution of the pain.[15]
Non-operative therapy should be tried for several months and is successful in most instances. However, if symptoms persist for more than 6 months after an appropriately administered physical therapy regimen and a period of protected weight bearing with crutches until the patient is pain-free, then surgical intervention should be considered. Adductor tenotomy has been suggested as a technique to improve symptoms. However, this is an end stage option to be tried only after all conservative methods have failed.[1]
Physical Therapy Management
[edit | edit source]
The treatment of musculotendinous groin injuries is generally conservative. Surgical treatment in acute groin injuries is rarely indicated.[8]
Conservative treatment
In the treatment of muscle-tendon injuries, immobilization should be limited to as short a period as possible to avoid the harmful effects of immobilization including muscle atrophy and loss of function. Immediate rest after the injury should be used until a diagnosis is secured.
- The primary goal of the treatment program is to minimize the effects of immobilization, regain full range of motion, and restore full muscle strength, endurance and coordination. Therefore, crutches, local cold application, and anti-inflammatory medication are recommended in the initial phase. Muscle exercises can usually be started early, but training should be performed within the limits of pain with careful isometric contractions against resistance.
- After the initial phase, heat is usually valuable, especially when muscle training is started. In general, exercises are performed in a pain-free range of motion and increased pain should not occur after activity.
- As rehabilitation progresses, mild pain can be allowed during exercise, but it should subside immediately after the cessation of training.
- When full range of motion is accomplished, the injured muscle and tendon tolerates higher loads and the goal of rehabilitation should shift towards specific strength training exercises aiming for muscular recovery, increased endurance and full range of motion.
- The final step is the gradual return to sports activity, which may in some cases take as long as 3 to 6 months.[9]
Adductor muscle strain injury program
progressing the patient through the phases of healing, has been developed by Tyler et al. and anecdotally seems to be effective (table 1). This type of treatment and rehabilitation programme, which combines modalities and passive treatment immediately, followed by an active training programme emphasising eccentric resistive exercise, has been supported throughout the literature.[1]
Key Research[edit | edit source]
Tyler, Timothy F., et al. "Groin injuries in sports medicine." Sports Health: A Multidisciplinary Approach 2.3 (2010): 231-236. Evidence Based Practise: 1A
Jarvinen Markku, et al. Groin Pain (Adductor Syndrome). Operative Techniques in Sports Medicine 1997; 5(3): 133-37. Evidence Based Practice: 5
Tyler, T. F., Silvers, H. J., Gerhardt, M. B., & Nicholas, S. J. (2010). Groin injuries in sports medicine. Sports Health: A Multidisciplinary Approach, 2(3), 231-236. Evidence Based Practice: 1A
Resources
[edit | edit source]
Video assessment techniques for Groin Injuries: https://www.youtube.com/watch?v=VfAKc6_FbLQ
Video squeeze test: https://www.youtube.com/watch?v=--W5G9lP7pM
Clinical Bottom Line
[edit | edit source]
Conclusion: there is support for an association of precious injury and greater abductor to adductor strength ratios as well as sport specificity of training and pre-season sport-specific training, as individual risk factors for groin strain injury in athletes. Core muscle weakness or delayed onset of transversus abdominal muscle recruitment may increase the risk of groin strain injury. Debate does exist in the literature reviewed regarding the role of adductor strength and length as well as age and/or sport experience as risk factors for groin injury.[21]
Recent Related Research (from Pubmed)[edit | edit source]
Serner, A., Tol, J. L., Jomaah, N., Weir, A., Whiteley, R., Thorborg, K., & Hölmich, P. (2015). Diagnosis of Acute Groin Injuries A Prospective Study of 110 Athletes. The American journal of sports medicine, 43(8), 1857-1864. Evidence Based Practice: 1B
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Nicholas, S. J., &amp;amp;amp;amp;amp;amp;amp;amp; Tyler, T. F. (2002). Adductor muscle strains in sport. Sports Medicine, 32(5), 339-344. Evidence Based Practice: 2A
- ↑ 2.0 2.1 Tyler, T. F., Fukunaga, T., &amp;amp;amp;amp;amp;amp;amp; Gellert, J. (2014). REHABILITATION OF SOFT TISSUE INJURIES OF THE HIP AND PELVIS. International journal of sports physical therapy, 9(6), 785.fckLR Evidence Based Practice: 5
- ↑ 3.0 3.1 3.2 Gino M.M.J. Kerkhoffs. Acute Muscle injuries. Evidence Based Practise: 5
- ↑ 4.0 4.1 Tyler, Timothy F., et al. "Groin injuries in sports medicine." Sports Health: A Multidisciplinary Approach 2.3 (2010): 231-236. Evidence Based Practise: 1A
- ↑ 5.0 5.1 Norton‐old, Kimberley J., et al. "Anatomical and mechanical relationship between the proximal attachment of adductor longus and the distal rectus sheath." Clinical Anatomy 26.4 (2013): 522-530. Evidence Based Practice: 2A
- ↑ 6.0 6.1 6.2 6.3 Engebretsen AH., et al. Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. American Journal of Sports Medicine 2010; 38(10): 2051–7. Evidence Based Practice: 2B
- ↑ 7.0 7.1 Hölmich, Per. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. British journal of sports medicine 2007; 41.4: 247-252. Evicence Based Practice: 1B
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Jarvinen Markku, et al. Groin Pain (Adductor Syndrome). Operative Techniques in Sports Medicine 1997; 5(3): 133-37. Evidence Based Practice: 5
- ↑ 9.0 9.1 9.2 9.3 Mc Sweeney Sean E., et al. Hip and Groin Pain in the Professional Athlete. Canadian Association of Radiologists Journal 2012; 63(2): 87-99. Evidence Based Practice: 2A
- ↑ 10.0 10.1 Delmore, R. J., Laudner, K. G., &amp; Torry, M. R. (2014). Adductor longus activation during common hip exercises. Journal of sport rehabilitation, 23(2), 79-87. Evidence Based Practice: 4
- ↑ Morrissey, Dylan, et al. "Coronal plane hip muscle activation in football code athletes with chronic adductor groin strain injury during standing hip flexion." Manual therapy 2012; 17.2: 145-9. Evicence Based Practice: 3B
- ↑ 12.0 12.1 Garrett WE. Muscle strain injuries. Am J Sports Med. 1996; 24:S2-88. Evidence Based Practice: 5
- ↑ Hureibi, K. A., and G. R. McLatchie. "Groin pain in athletes." Scottish medical journal 55.2 (2010): 8-11. Evidence Based Practise: 5
- ↑ 14.0 14.1 14.2 14.3 14.4 Hölmich. (2014) Groin Injuries in Athletes - Development of Clinical Entities,fckLRTreatment, and Prevention, Danisch medical journal. Evidence Based Practice: 2A
- ↑ 15.0 15.1 Tibor, Lisa M., and Jon K. Sekiya. "Differential diagnosis of pain around the hip joint." Arthroscopy: The Journal of Arthroscopic & Related Surgery 24.12 (2008): 1407-1421. Evidence Based Practise: 1A
- ↑ Thorborg, Kristian, et al. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. British journal of sports medicine 2011;45.6: 478-91. Evidence Based Practice: 2C
- ↑ Diagnosis of Acute Groin Injuries (A Prospective Study of 110 Athletes) Andreas Serner,*yz PT, MSc, Investigation performed at Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar. Evidence Based Practice: 1B
- ↑ Hölmich, P., Larsen, K., Krogsgaard, K. (2010). Exercise program for prevention of groin pain in football players: a cluster-randomized trial. Evidence Based Practice: 2B
- ↑ 19.0 19.1 Tyler, T. F., Silvers, H. J., Gerhardt, M. B., &amp;amp;amp;amp; Nicholas, S. J. (2010). Groin injuries in sports medicine. Sports Health: A Multidisciplinary Approach, 2(3), 231-236. Evidence Based Practice: 1A
- ↑ Jensen, J., Hölmich, P., Bandholm, T., Zebis, M. K., Andersen, L. L., &amp; Thorborg, K. (2012). Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. British journal of sports medicine, bjsports-2012. Evidence Based Practice: 2B
- ↑ Maffey L, Emery C. What are the risk factors for groin strain injury infckLRsport? A systematic review of the literature. fckLRSports Med. 2007;37(10):881-894. Evidence Based Practise: 2A
_starting_2)ending.png){kind=link}
