Groin Pain and Return To Play

Groin pain is common in athletes, particularly those who play sports that require multi-directional, rapid acceleration/deceleration, high loading activities using the lower abdominal muscles and proximal musculature of the thigh (hockey, football, soccer, martial arts).

Unilateral lower abdominal, deep groin, and proximal adductor pain are the hallmark presentations of groin pain. Pain levels tend to be activity-related and rest usually leads to resolution of symptoms. These injuries can be challenging because there is a high level of reaggravation when the athlete attempts to return to sport.

Many athletes with groin pain present with acute strains or overuse injuries. Acute strains typically occur at the musculotendinous junction, specifically of the adductor longus, rectus femoris, and iliopsoas muscle. In contrast to strains, groin overuse injuries, involve the bone and tendon insertions and rarely involve the rectus femoris.

adductor-brevis.jpg

Clinical examination has become increasingly challenging due to the lack of understanding of underlying pathologies originating from the pubic symphysis and surrounding musculoskeletal structures.

The Doha agreement (Weir et al. 2015) introduced the classifications of adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain.

Tenderness with palpation and resistance testing indicates which of the anatomical structures are involved. The pain must be felt in the adductor region to be classified as adductor-related groin pain.

Management of groin pain is an active approach. We will specifically discuss how to rehab adductor-related and lower abdominal pain. It is important to find the right balance of training and rest to prevent reaggravation from happening. For some athletes, it may be appropriate to stop training for a period of targeted rehabilitation.

Rectus Abdominis Tendinopathy or Pubic Related Groin Pain

The rectus abdominis tendon directly inserts on the pubic symphysis where tendinopathy may result from over demand of the abdominal muscles. An acute 2-day history of pain may suggest a reactive tendon, in which treatment should mainly consist of load management (avoid increasing abdominal recruitment such as a sit-up) followed by a gradual reloading after one week.

If symptoms have been ongoing for more than 6 weeks, there may be underlying biomechanical causes rather than acute overload. This condition should be treated in a similar way to adductor-related tendinopathies.

The initial aim should be to restore hip range of motion, especially hip extension. Tak et al. (2016) suggests that decreased hip range of motion is associated with increased hip and groin related symptoms.

A restriction in hip extension may increase compensation in spinal extension, which in turn increases the tension of the abdominals and increases the tension load on the rectus abdominis tendon.

Here are some common exercises that can improve your hip extension range of motion

  1. Couch Stretch – 2-3 sets x 2 mins holds per side

    • In order to increase the stretch without tensioning the abdominals, engage a posterior pelvic tilt instead of sliding the whole body forward.

  2. Prone Hip Extension Holds10 reps x 30-second holds per side

    • When increasing an athlete’s hip extension, it is important to also strengthen and control at the same time.

  3. Quadruped Hip Extension Holds 10 reps x 30 second holds per side

  4. Standing Eccentric Hip Flexion – 3 sets of 10 repetitions per side

    • Start at 30 degrees of hip flexion

Couch Stretch

Couch Stretch

Prone Hip Extension Holds

Prone Hip Extension Holds

Quadruped Hip Extension Holds

Quadruped Hip Extension Holds

Standing Eccentric Hip Flexion

Standing Eccentric Hip Flexion

While working on hip mobility, it is also important to start loading the rectus abdominis. Sit ups should be performed in supine with legs straight to isolate more abdominal recruitment and reduce hip flexor activation.

  1. Supine Tempo Sit Ups – 2 sets of 5 reps

    1. Move slow and utilize this tempo: 6 seconds peel off, 6 seconds lowering.

Supine Tempo Sit-up - Start Position

Supine Tempo Sit-up – Start Position

Supine Tempo Sit-up - Finish Position

Supine Tempo Sit-up – Finish Position

Adductor-related Groin Pain

Isometrics are useful in the early stages of rehabilitation as they load the adductor region with low irritability. When performing isometrics, athletes do not need to be pain-free during the exercise but must rate their pain as less than 3/10 in order to decrease the likelihood of a flare-up.

  1. Seated Adductor Arm Squeeze – 10 reps of 30-second holds per side

    • In order to progress, the athlete should be able to perform this with no increase in pain levels afterward. The athlete should be able to perform 10 repetitions of each Copenhagen progression on each leg before running.

  2. Copenhagen Planks Straight Leg with Lower Leg Assist – 10 reps of 30-second holds per side

  3. Copenhagen Planks Straight Leg – 10 reps of 30-second holds per side

  4. Copenhagen Planks Straight Leg with Contralateral Hip Flexion – 10 reps of 30-second holds per side

Seated Adductor Arm Squeeze

Seated Adductor Arm Squeeze

Copenhagen Planks, Straight Leg with Lower Leg Assist

Copenhagen Planks, Straight Leg with Lower Leg Assist

Copenhagen Plank, Straight Leg

Copenhagen Plank, Straight Leg

Copenhagen Planks, Straight Leg with Contralateral Hip Flexion

Copenhagen Planks, Straight Leg with Contralateral Hip Flexion

Running should be gradually introduced after 3-4 weeks and progressed from jogging to interval training to high-speed training. Running should be progressed when the athlete has minimal pain when running and minimal reaction afterward. Here is a progression of running exercises.

  1. Straight Line Running – 5-meter build-up, 30-meter run, 5-meter cool down

    1. Prerequisite to zig-zag running – 10 repetitions of straight-line running at 60% intensity.

  2. Zig Zag Running 

    1. Prerequisite to T-test running – perform 10 x 30-meter sprints and 2 x 3 zig-zags at 80% intensity.

  3. T-test Running

    1. Prerequisite to return to sport – perform straight-line sprints, zig-zag, T-test at 100% intensity.

Rehabilitation should target the demand of the athlete. If the athlete wants to return to hill running, then exercises to address this should be included in rehabilitation. It is important to note that building load tolerance may take up to 6 – 8 weeks.

Cutting is a motor skill that will need to be retrained again following groin injuries. To improve cutting, start with sidestepping tasks then agility work that focuses on the trail leg pushing off and triple extension movement patterns.

Prior to returning to sport the athlete must be able to perform all aspects of rehabilitation with confidence, with little to no pain or reaction afterward.

We hope this sheds some more light on groin-related injuries and how we rehab them.  If you have been struggling with groin related issues, please seek out the appropriate medical provider.  If you would like to work with us, fill out the form below and we will get back to you shortly. 

References: 

Thorborg, Kristian, et al. “Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management.” Journal of Orthopaedic & Sports Physical Therapy, vol. 48, no. 4, 2018, pp. 239–249., doi:10.2519/jospt.2018.7850.

Weir, Adam, et al. “Doha Agreement Meeting on Terminology and Definitions in Groin Pain in Athletes.” British Journal of Sports Medicine, vol. 49, no. 12, 2015, pp. 768–774., doi:10.1136/bjsports-2015-094869

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