If you play one of the football codes (Soccer, AFL, Rugby League or Union), chances are you have already or may in the future experience some groin pain. One study of almost 700 sub-elite male football players reported 50% of players had experienced groin pain in the previous season (Thorborg et al. 2017). Groin pain is highly prevalent, accounting for up to 14% of all injuries sustained in football (Haroy et al. 2017). It is common for groin pain to start in preseason training, when there is a spike in load following the off-season. The athlete is coming off a low training base into a high intensity training environment in a bid to regain fitness. The groin structures may struggle to adapt adequately to the rapidly increasing physical demands.
The typical pattern will be a gradual onset of discomfort in the groin which initially doesn’t affect your ability to train or play. You may feel stiff and sore post training and often into the next morning. As the weeks progress, you may notice that this worsens, and pivoting and kicking becomes increasingly difficult. A common scenario is that the athlete stops or modifies training to preserve him/herself for the weekend game. However, this can eventually progress to a point of being sidelined altogether.
How is groin pain diagnosed?
Groin pain diagnosis can be difficult in athletes due the overlapping anatomy in the region. Groin pain can emanate from several closely related structures and is categorised into groin pain arising from these different structures:
- Adductor related groin pain (groin/inner thigh muscles and tendons)
- Iliopsoas related groin pain (hip flexor muscles and tendons)
- Pubic related groin pain (pubic bone, joint and nearby structures)
- Inguinal related groin pain (structures in the groin crease)
- Hip related groin pain (from the hip joint)
A detailed musculoskeletal assessment from your sports physiotherapist or sports physician usually provides the diagnosis. In some cases, scans (ultrasound or MRI) may be used to help clarify the reason for your groin pain. Once your diagnosis is established, it is then important to understand what may have contributed to the cause. Typically, this can be broken into three categories: load, muscle strength and biomechanics (the way you move).
Understanding the onset of groin pain is important for management. Fixture congestion or periods of high game demands will increase chronic overload to the groin region. This is often the case during preseason and towards finals when there are increasing number of games over short time frame. In addition, fluctuations in training patterns or game availability will influence injury risk. Ensuring consistent exposure to agility drills and sprinting in training or games will help reduce variations in loads. Working with your Physio to manage appropriate loads can help reduce overload and help you continue to play through groin pain.
It is rare complete rest will resolve athletic groin pain. Prolonged periods out of training and games will accelerate muscle weakening and reduce tolerance to physical strain across the hip, groin and pelvic region. Instead, modifying training loads to exclude components of training that are provocative (i.e., cutting, small-sided games, kicking) will allow you to maintain fitness and some resemblance of load whilst working on a rehabilitation program to address any strength deficits.
Assessment of hip muscle strength is vital for groin health. One Australian study showed that in A-League & EFL soccer players, increased hip abductor (glute) strength on the kicking leg and higher levels of overall hip abductor and adductor (groin) muscle strength were associated with a reduced likelihood of future injury (Bourne et al. 2020). Using muscle dynamometry, we can profile muscle strength and compare this to normative data available in professional athletes to understand testing benchmarks.
VALD, a leading sport science company demonstrated that the median adductor isometric strength score was 422N (43kg) in professional English and European footballers (over the 2020/21 season). In comparison, AFLW athletes on average, test just over 300N (30kg). Depending on your gender and sporting code, we can refer to research data to help understand how strong you need to be and use this to guide your rehab prescription.
Agility (cutting, pivoting and acceleration) actions are often amongst the most provocative movements for groin pain. Recent research (King et al. 2018) has highlighted the important relationship between how people move their body when changing direction and the load they put on their groin region. Due to the high physical demands of acceleration, being able to control your body during these actions influences how much force is being directed to the groin. Typically, athletes with inefficient strategies change direction with a greater side lean of the trunk, plant their foot too wide and have inadequate control of movement around the hip joint.
The cutting strategy used by a player will be related to the strength and athletic qualities that athlete possesses. One example is of reduced trunk strength (i.e., reduced ability to resist movement with the abdominal and/or back muscles) leading to increased trunk lean over the planted foot. This means the groin muscles have to work harder to push off. Another example is inadequate calf strength and ability to produce fast, forceful movements, resulting in poor ability of the calf to absorb landing forces. These forces are once again transmitted to the groin. Video analysis of cutting technique is used to develop drills and rehab programs to improve efficiency and reduce re-injury risk.
Restoring plyometric ability (explosive jumping) and power are important pieces of the puzzle in restoring effective control of the trunk and pelvis during dynamic movements. Force plates are used to help assess this. Using jump testing, we can break down data about how high you are able to jump, how fast you take off, how much force you generate when leaving the ground and on landing, and your ability to effectively break or stop quickly. These metrics are then used to help ensure the most effective exercise selection and rehab programs.
Treatment of groin pain takes a step-by-step approach. Load management is the initial priority and reducing provocation to the area can help reduce symptoms immediately. Following this, developing muscle strength and resilience to improve the ability of your groin structures to cope with sporting loads is next. Lastly, training cutting technique can be helpful to further reduce stress in the groin region and often has the added benefit of improved performance.
This blog was written by one of our Physiotec Sports Physiotherapists, Kevin Doan
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Bourne, MN, Williams, M, Jackson, J, Williams, KL, Timmins, RG & Pizzari, T 2020, ‘Preseason Hip/Groin Strength and HAGOS Scores Are Associated with Subsequent Injury in Professional Male Soccer Players’, J Orthop Sports Phys Ther, vol. 50, no. 5, pp. 234-242.
King, E, Franklyn-Miller, A, Richter, C, O’Reilly, E, Doolan, M, Moran, K, Strike, S & Falvey, E 2018, ‘Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients’, British Journal of Sports Medicine, vol. 52, pp. 1054-1062.
Thorborg K, Rathleff MS, Petersen P, Branci S, Hölmich P. Prevalence and severity of hip and groin pain in sub-elite male football: a cross-sectional cohort study of 695 players. Scand J Med Sci Sports. 2017 Jan;27(1):107-114.