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Groin injuries are among the most common injuries in men's soccer, accounting for 14% to 19% of all injuries. Recent epidemiological data suggest that 20 -25% of all players sustain a time-loss groin injury in a season, with recurrence injury rate ranging from 14% to 30%.

Hence, groin problems represent a significant health and performance burden in soccer. In order to successfully implement preventative measures to reduce the risk of injury incidence; the identification of risk factors associated with the occurrence of groin injury and their monitoring is essential.

Due to the complex nature of groin injuries the Doha classification system was developed by Weir and colleagues to assist in diagnosis and rehabilitation of these injuries. This classification system although giving different types of groin injury, individuals may often present with mixed presentations. It is through careful history taking and testing can a diagnosis be made, with MRI imaging used where necessary.

Anatomical representation - showing clinical entities of groin pain - taken from Weir et al. 2015.

 

For the purpose of this blog we are going to focus on adductor related groin pain. The adductor complex can be seen below in the schematic anatomical diagram. It primarily consists of three main muscles, adductor longus, brevis and magnus. The role of adduction bringing the leg inwards towards the opposite leg. This movement is also accompanied by the pectineus, obturator externus, and gracilus. A key role of this muscle group is also to stabilise the lower extremity and pelvis in closed chain motion. The location of these muscles inserting into the pubic region, close to abdominal attachments also highlights the importance of the adductor complex in how we move. Tasks involving lateral movement, trunk and limb rotation, cutting and kicking explains why the incidence is high in sports such as football.

 

Among numerous non-modifiable and modifiable risk factors associated with groin injuries in sports, two modifiable factors, i.e., hip adductor strength and hip range of motion, have received particular scientific interest in men's soccer. Previous groin injury has also been significant in the incidence of groin injuries. While the role of strength seems to be well established, there is conflicting evidence on the relationship between Range of motion and injury risk. Despite this hip range of motion is often determined in the screening and management of groin problems. Mosler and colleagues established normal values for hip range of motion in professional football players and leg dominance was not a relevant factor. The routine assessment of range of motion pre-season despite being important for movement efficiency and performance, may not be as significant for groin injury as thought. We therefore need to be careful when making assumptions and links to injury as these factors are continued to be explored in research.

 

Adductor Strength

Strength measures about the hip and trunk have been associated with hip and groin pain. Of consistent interest is absolute and relative adductor strength. Common assessment methods include the squeeze testing, during which a sphygmomanometer is used to measure the maximal isometric ability of the adductors in various supine positions. Other primary strength measures include handheld and isokinetic dynamometry. These are often measured pre-season and during season to advise on player's readiness or returning to play from injury, and general monitoring during season. Low strength ratios of hip adduction to abduction, and high hip flexion to extension ratios and trunk flexion to extension ratios have all been identified as risk factors. The timing of muscle activation may be meaningful, but it has not been determined as a cause or a result of hip and groin injury.

Studies have looked at eccentric adductor strength in particular with the incidence of adductor related groin pain. This led to the Copenhagen adductor strengthening protocol which was targeted for the football population. See the diagram below taken from Haroy et al. for examples. The protocol was based on a progression of exercises simple and easy to use exercises by the athlete. It also allowed targeting of the vulnerable muscle tissue in a progressive manner working around any limitations by pain. Following this protocol showed a 41% reduction in groin injuries within a cohort of football players. We now see this protocol an integral part of any pre-season and during season athlete preparation/conditioning. Albeit a useful baseline framework with positive outcomes, this protocol alone may not always be sufficient and bespoke for the athlete to return to play from an adductor related injury.

Examples of Adductor strengthening exercises taken from Haroy et al. 2019.

 

Throughout the rehabilitation process there must be an overarching plan for return to play and competition. Serner and colleagues proposed a criterion based framework for returning an individual with groin pain. This gives insight to planning and incorporation of various exercises for the adductor itself but also any surrounding musculature. The anatomy, biomechanics and demands on the groin region / adductor highlights this process is carefully staged particularly when considering running, directional change and sports specific tasks. This process is unique and specific to the individual athlete, utilising subjective and objective markers to progress through each phase. Serner and colleagues identified a wide range of time for achieving each milestone. On average athletes returned to full team training within a month. The severity of adductor injury meant that a MRI grade 3 injury could take up to 3 months, where as a Grade 0-2 could be clinically painful in two weeks. But again this can vary greatly from one to another, with level of play, demographics etc.

Rehabilitation phases for groin injury taken from Serner et al. 2020

 

Summary

The rehabilitation of adductor related groin injuries is a challenging task. Before starting a rehabilitation plan, full diagnosis with clearing of any co-existing pathology is required. Adductor-related groin pain can be then successfully managed with understanding of the muscle/tendon limitations, building up tissue tolerance in all ranges through the strength continuum required for the sport involved. The progressions within the rehab can be effectively measured/monitored with strength testing devices as described. The rehabilitation should integrate all aspects of the athletes physical condition and sport/technical demands, ensuring specific criteria are met at each stage. Following a simple recipe / protocol versus a bespoke individualised programme, may at times be the deciding factor for an individual to fully return to sport. Understanding the context of injury, unique athletes background whilst collaborating with the multi-disciplinary team will ultimately determine a successful outcome.

Credit - Specialist Sports / Musculoskeletal Physiotherapist

 

Key References

Werner J, Hägglund M, Ekstrand J, Waldén M. Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men's professional football: the 15-year prospective UEFA Elite Club Injury Study. British Journal of Sports Medicine. 2019;53(9):539-46.

Short SM, Macdonald CW, Strack D. Hip and Groin Injury Prevention in Elite Athletes and Team Sport - Current Challenges and Opportunities. International Journal of Sports Physical Therapy. 2021.

Mosler AB, Weir A, Eirale C, Farooq A, Thorborg K, Whiteley RJ, et al. 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. 2018;52(5):292-7.

Whittaker JL, Small C, Maffey L, Emery CA. Risk factors for groin injury in sport: an updated systematic review. British Journal of Sports Medicine. 2015;49(12):803-9.

Weir A, Brukner P, Delahunt E, Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine 2015;49:768-774.

Creighton DW, Shrier I, Shultz R, Meeuwisse WH, Matheson GO.Return-to-play in sport: a decision-based model.Clin J Sport Med. 2010;20(5):379-385.

Serner A, Weir A, Tol J, Thorborg K, Lanzinger S, Otten R, Holmich P. Return to Sport after Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes. Orthopaedic Jopurnal of Sports Medicine, 2020, 8(1).

Harøy J, Clarsen B, Wiger EG, Oyen M, Serner A, Thorborg K, Holmich P, Andersen T, Bahr R. The adductor strengthening programme prevents groin problems among male fooptball players: a cluster-randomised controlled trial. British Journal of Sports Medicine. 2019;53:145-152.

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