Groin Strain

Definition/Description

Groin strains are injuries to the muscle-tendon unit that produce pain on palpation of the adductor tendon or its insertion into the pubic bone and pain in the adductor region during adductor resistance testing. [1] Groin strains are more common in ice hockey and football. [2]

These sports require strong eccentric contractions of the adductor muscles during competition and practice. [3] The underlying injury is usually a muscle or tendon strain when the adductor tendon inserts into the bone. [4] The adductor longus is most commonly injured. [5]

The difference between a groin tendinopathy and a strain is:

• First, strains are acute, whereas tendinosis is chronic. Tendinosis is a repetitive strain injury.
• The second difference is that acute injuries are more often at the tendon junction, whereas chronic injuries are usually at the suprapubic tendon attachment.

See page for adductor tendinitis.

Image: Overview of buttocks and thigh muscles – front and back views. [6]

Clinically Relevant Anatomy

In human anatomy, the groin is the junction of the abdomen and thigh on either side of the pubic bone. This is also known as the inner thigh compartment.

[7]

The groin muscles are made up of three potentially injured muscle groups: the abdominal iliopsoas and the adductors.

Image: front view red pelvis pubis

• Adductors: The adductors of the hip include 6 muscles: the adductor magnus, the obturator externus brevis, and the pectineus. All are innervated by the obturator nerve, except the pubic muscle, which is innervated by the femoral nerve. adductor all Originates from the pubic rami and almost always inserts on the thick line at the posterior part of the femur. The posterior head of the adductor magnus has a proximal attachment point anteroinferior to the ischial tuberosity and distally on the medial side of the distal femur at the adductor tuberosity. Slim Insertion is on the medial border of the tibial tuberosity. The primary function of this muscle group is to adduct the thigh during open-chain motion and to stabilize the lower body and pelvis during closed-chain motion.

In football, most groin injuries involve the adductor muscles. [8] The proximal attachment of the adductor longus facilitates the anatomical pathway across the anterior pubic symphysis, which may be required to withstand high force transmission during multidirectional movements Activity. Its lack of mechanical advantage may make it more susceptible to strain. [9]

• Abdominal Group: The abdominal musculature includes the rectus abdominis, internal obliques, and external abdominals. (see Abs page).
• Iliopsoas Group: The iliopsoas, consisting of the iliacus and psoas major, is the only muscle that directly connects the spine to the lower body. (See page Anatomy of the Hip). [3]

This 17-minute video provides a great overview of the muscles of the buttocks and thighs. [10]

Epidemiology /Etiology

Groin strains are common in athletes who play sports that involve repetitive twists, sprints and kicks, such as Australian ice hockey and Gaelic football. [2] More groin injuries were reported in men than in women soccer players. male injured 4-19% for injuries and 2-14% for females. [11]

The exact incidence of groin muscle strains in most sports is unknown because athletes often compete with mild groin pain and injuries go unreported. In addition, overlapping diagnoses may affect morbidity. [12] Cumulative or single injuries appear to be important etiologies. Chronic Tendinitis of the adductor/tendon, especially of the adductor longus, is most commonly diagnosed. [5]

Injury mechanisms can be divided into 3 groups:

1. Direct blunt trauma: An acute injury is usually a direct injury to soft tissue, resulting in a muscle hematoma.
2. Forced contractions: The most common groin injuries in athletes are muscle and tendon strains of the adductor muscles. Changing direction and kicking were described as the primary actions that lead to adductor longus injury. Video Analysis of Acute Adductor Longus Muscle [13] Injury 17 Professional men’s soccer players have shown that most injuries occur in non-contact situations following quick reactions to changes in play. Injurious behaviors were: changing direction kicking stretch/stretch and jumping. Injury can also occur during strong concentric contractions Muscle.[14] Lower extremity athletes, such as ice hockey players and football players, are naturally more prone to this condition due to repeated twisting, turning, sprinting and kicking. [2]
3. Microtrauma from Repetitive Injuries: Musculotendon injuries in the groin are primarily the result of cumulative microtrauma (repeated minor injuries from overuse trauma) leading to chronic groin pain.

Characteristics/Clinical Presentation

The main sign of a groin strain is severe pain in the groin area. Muscle strains are usually caused by overstretching or stretching when the muscle is activated. When a muscle is pulled, the injury is usually located near the muscle-tendon junction. acute adductor longus The injury may also involve tendon rupture/avulsion primarily at the proximal insertion. [15]

Clinically, with an adductor strain, the patient presents with inner thigh pain and tenderness along the abdominal tendon or attachment point of the muscle. Pain is exacerbated by adduction. [16] Tears often occur at the tendon junction, which is the weakest part of the muscle-tendon unit, but is also Common in muscle belly. The same mechanism of injury that causes a muscle tear in an adult can cause a condyle avulsion in an adolescent. There is a well-established clinical grading system for muscle tears that consists of 3 components:[17]

• Grade 1: No loss of function or strength. Muscle tears can show normal appearance or small areas of focal destruction (<5% of muscle volume), and hematomas and perifascial effusions are relatively common on US and MRI imaging.
• Grade 2: Severe with some weakness. The injury is equivalent to a partial tear with visible muscle fiber disruption (>5% of muscle volume), but does not affect the entire muscle belly. In an acute grade 1 or 2 adductor muscle strain, severe pain in the groin area, like a sudden knife stab If the athlete tries to continue the activity. Local bleeding and swelling can be seen a few days after the injury. A typical history of trauma causes localized tenderness and difficulty contracting the hip abductors.
• Grade 3: The muscle is completely torn with total loss of function. The injury is a complete muscle tear with frayed edges, bunching and/or contraction of torn muscle fibers. Complete muscle tears or grade 3 strains are most common in Insert the femur.

Differential Diagnosis

Groin pain has traditionally been considered complex, with various definitions and terminology, without any diagnostic criteria. [18] In a systematic review of the treatment of groin pain in athletes, more than 30 different diagnostic terms were used to describe groin pain, totaling The complexities of groin injuries in athletes. [19]

To address the different terms and definitions used, a consensus meeting was held during the first World Athlete’s Valley Pain Congress in November 2014 in Doha, Qatar. 24 experts from 14 different countries were invited to agree on standard terminology along with definitions. [1]

The classification system for groin pain was described in three main subheadings during the Doha Accord meeting;

The Doha Agreement Diagnostic Classification [1] defines entities. Other musculoskeletal causes. Should not be missed. Adductor-related groin pain Iliopsoas-related groin pain Groin-related groin pain Pubis-related groin pain Hip-related groin pain Inguinal or femoral hernia Posterior hernia Nerve Obturator entrapment ilioinguinal genital iliac lower abdomen referred pain lumbar sacroiliac joint osteoarthritis or avulsion fracture Epiphysis (juvenile) Perthes disease (children and adolescents) Avascular necrosis/transient osteoporosis Hip arthritis (reactive or infectious) Inguinal lymphadenopathy Abnormal prostatitis Urinary tract infection Kidney stone appendicitis diverticulitis gynecological diseases spondyloarthropathies ankylosing spondylitis tumors testicular tumors bone tumors prostate cancer urinary tract cancer ▸ digestive tract cancer ▸ soft tissue tumors

Diagnostic Procedures

First, there needs to be a patient history and an examination by a physical therapist to identify pain. On evaluation, there was tenderness to palpation, localized swelling of the adductor muscle, decreased strength of the adductor muscle, and pain when adduction was blocked. Diagnosis can be Use the guidelines of the Doha Agreement classification system to perform inspections based on key findings when imaging is not required. [1][20] However, after a comprehensive clinical examination, imaging can be used for exclusion or differential diagnosis. Peripheral Abnormal Radiological Findings Pubic symphysis such as pubic marrow edema is common in athletes with adductor and pubic related pain. These radiographic findings are also common in asymptomatic athletes. Radiological findings should not be used alone to make diagnostic decisions, as morphology does not necessarily mean pathology. [twenty one]

Outcome Measures

Copenhagen Hip and Groin Outcome Score (HAGOS) [22]

Examination

Bilateral assessment of adductor muscles and strength: palpation at the adductor insertion of the pubic adductor against resistance (0° and 45° squeeze tests) and passive stretching of the adductor muscle. [16]

A complete clinical examination should be performed in every patient with groin pain. Injured athletes should first undergo a standing posture examination to assess extremity alignment. The patient should then be asked to lie supine to be able to examine Movement of the hip joint and flexibility of the groin and buttock muscles. The diagnostic classification system provided by the Doha agreement should serve as a guideline for all groin injuries. [1]

Squeeze Test

[23]

1. If the adductor longus is injured, pain in the injured area can be clarified by resisting passive stretching with the leg in adduction and full hip abduction. Tenderness on palpation localized to the origin of the adductor longus tendon or to the site of injury at the tendon junction[1]
2. Assessment of pain intensity and flexibility associated with the iliopsoas: palpation over the isometric strength test of the inguinal ligament and the modified Thomas test during hip flexion [24] Thomas test
3. Abdominal muscle-related pain and strength: joint tenderness on palpation of the abdominal muscles at the pubis and functional sit-up tests and palpation. [twenty four]
4. The location of the injury was based on at least 1 positive finding on palpable stretch or muscle resistance testing. [25]

Medical Management

Management is non-surgical with rest ice compress analgesia and physical therapy. Analgesics include NSAIDs that help reduce pain. [26] Injection into the adductor longus tendon tip is helpful for conservative treatment of refractory patients. [27]

Nonsurgical treatment should be tried for several months and is successful in most cases. However, surgical intervention should be considered if significant limitation of symptoms and presentation persists after an appropriate conservative treatment regimen. Adductor tenotomy recommended As a technique to improve symptoms. [28]

In a recent systematic review comparing surgical versus conservative interventions, athletes who underwent surgical intervention had a faster return to play (RTP) time. However, the nature of surgical interventions varies, and high-quality randomized controlled trials (RCTs) are lacking Meta-analyses make recommending surgical interventions impractical. [29]

Prevention

Subsequent groin strains may cause recurring problems. Therefore, primary prevention and secondary prevention are equally important. In order to identify at-risk athletes and possibly correct predisposing factors, it is essential to understand the intrinsic and extrinsic risk factors for the type of injury. [30]

Previous groin injury reduced hip adduction intensity Higher levels of exercise and lower levels of sport-specific training were associated with increased risk of new groin injuries. [31] Hölmich et al demonstrated that an 8- to 12-week active reinforcement program that included progressive resistance training Abduction and abduction balance exercises for abdominal muscle strengthening and skating on skateboards are effective in treating chronic groin strains. Coordination exercises (focusing on muscles related to the pelvis) core stability and eccentric exercises are also part of the Prevention program [32]

Adductor muscle strain prevention program [12]

Warm-up Cycling Adductor Stretch Sumo Squat Side Lunge Kneeling Pelvic Tilt Strengthening Program Ball Squeeze (leg bent to leg straight) Different sized balls retract sitting position adduction machine standing Affected foot on a skateboard moving in the sagittal plane Bilaterally adducted on a skateboard moving in the frontal plane (i.e., both sides adducted at the same time) Unilateral lunge with reciprocal movement of the arms Sports-specific training Kneeling adduction on ice Muscle pull standing resistance stride Length of simulated ice skating on cable posts Glide skating Cable posts cross pull Clinical target adduction strength is at least 80% of abduction strength

Copenhagen Adductor Exercise

In a cluster randomized controlled trial involving 35 semi-professional Norwegian football teams, a simple adductor strengthening exercise (Copenhagen Adductor Exercises) was used three times a week during preseason (weeks 6-8) in Once a week during the competition, divided into three levels season (28 weeks). The risk of groin problems was significantly reduced compared to a control group that trained normally during the season. The intervention group consisted of 339 players from 18 teams, and the control group consisted of 313 players from 17 teams. The prevalence of groin problems is Both groups were measured weekly during the competition season using the Oslo Center for Sports Injury Research Overuse Injury Questionnaire. [33]

• Copenhagen exx.jpeg

Physiotherapy Management

Treatment of tendon and groin strains is usually conservative. Surgery is rarely required for acute groin injuries. [27]

In the treatment of musculotendon injuries, immobilization should be limited to the shortest possible period of time to avoid the harmful effects of immobilization, including muscle atrophy and loss of function. Immediately after an injury, rest until a diagnosis is made.

• The primary goals of the treatment plan are to minimize the effects of immobilization, regain a full range of motion, and restore full muscular strength, endurance, and coordination. Therefore, it is recommended to use crutches for local cold compresses and anti-inflammatory drugs in the early stage. muscle Exercises can often be started early, but training should be done in the pain range and with careful isometric contractions against resistance.
• After the initial phase, calories are often valuable, especially when starting muscle building. In general, exercise is performed within a pain-free range of motion, and there should be no exacerbation of pain following activity.
• Mild pain during exercise can be tolerated as rehabilitation progresses, but should subside as soon as training stops.
• When full range of motion is achieved, injured muscles and tendons can be subjected to higher loads, and rehabilitation goals should shift to specific strength training exercises designed to restore muscular endurance and full range of motion.
• The final step is a gradual return to physical activity, which may take up to 3 to 6 months in some cases. [14]

Adductor-Related Groin Strain Program

Enda et al. (2018) examined the effect of rehabilitation on intersegmental control in patients with groin pain. Across various diagnostic entities, athletes with groin pain experienced significant improvements in functional performance and time to return to competition. [34]

The intervention consisted of three (3) levels addressing intersegmental control and intensity linear running mechanics, increasing linear running load tolerance and multidirectional mechanics, and transition to high-intensity sprinting. [34]

Level 1: Internode Control and Intensity

StreamsProgressionsHip FlexorSupineStanding Supported Free Standing.Lateral Hip ControlSupported Hip HitchedFree Standing Hip HitchStep UpAbdominalCrook Lying Leg LiftCurved LyingAlternate Leg DropPallofKneelingSplit LungeDouble Leg SquatHigh Cup SquatLow Cup SquatFront SquatLateral Hips Abduction/External Rotation in Power Mini Squats Abduction/External Rotation in Wall Mini Squats Band Squats Deadlifts Hip Hinge 1/2 Deadlifts Deadlifts Floor Deadlifts Lunge Split Lunge Overhead Split Bow step load split lunge enhanced fixed-point jumping skipping rope jumping cone

Level 2: Linear running mechanics

Linear Instructions Marching and jumping rope Jumping rope in place with arms raised overhead, keeping low back pelvis and neutral, and actively touching the ground Barbell/overhead running Overhead running with pegs or barbell straddle, focusing on tall running stance and keeping sticks still legs Ministry changes Single-leg standing exercises focus on quick leg changes to drive alternating leg extensions and swing leg recovery. Complete 3-4 sets of 5-6 repetitions. Complete focus on execution quality

Level 3: Multidirectional Mechanics and Transitions

LinearInstructionsLateral shuffleSide shuffle between 2 cone spare 8 meters arms locked overhead Focus on getting away from the cone as quickly as possible. Race on command or follow your opponent as the Zig-Zag cuts 5 cones in a zigzag formation 5 meters apart from each other. Run and cut around the cone as fast as you can. Add a medicine ball for added resistance and a higher center of gravity. (CoM) 180 degree conical cut. The 5 cones in the semicircle start in the middle, run at any one of the cones, and then cut right back to the start. add a medicine ball Increased resistance and CoM. Complete 3-4 sets of 5-6 repetitions. Complete focus on execution quality

Patients progressed to Grade 2 once they developed a negative cross sign, and from Grade 2 when they performed a painless groin squeeze test with 90 degrees of symmetrical hip internal rotation at 45 degrees and were asymptomatic during a linear running program. Level 3. when they start at level 3 Pain-free multidirectional workouts at maximum intensity. [34]

Modified Hölmich Protocol

Recently published studies suggest that the modified Hölmich protocol [35] may be safer and more effective than the Hölmich protocol for promoting return to sporting activity in athletes with chronic adductor groin pain. Holmich et al. (1999)[36] indicated that therapeutic exercise (focused on buttock and abdominal muscle strengthening) achieved better results in pain reduction and return to physical activity than physical therapy including passive medication (stretching TENS lateral friction massage and laser therapy). Modified Hölmich Ten Weeks Benefit from protocols affecting muscles that affect pelvic core stabilization Hip adductor stretches and high-intensity eccentric exercise of the hip adductors can have a considerable impact on key measures including pain hip adductors and abductor strength hip ROM functional capacity and return to motion. [35]

Stretching Exercises

[37]

Strengthening Exercises

Hip Adductors

• Side lying hip adduction and ball squeeze exercises showed the highest overall activation of the adductor longus muscle. [38]

[39][40]

• Resisted training:

Resists work with heavy objects or elastic bands.

[41]

• Eccentric exercises:[42]

A simple adduction strengthening program based on the Copenhagen adduction exercise reduces the risk of groin problems in soccer players, according to research published in the British Journal of Sports Medicine. [33]

• Squats:

Squats can help strengthen the muscles in your hips and knees, including the adductors. Greater stance width in squats and deadlifts and squeezing the medicine ball between the legs in leg presses may increase adductor longus activation. Studies have shown that the hips are at a 30° angle when squatting External rotation and at least 90° of knee flexion significantly increased hip adductor activity. [43]

[44]

Hip Abductors

Strengthening the hip abductors and hip adductors is important because decreased strength in the hip abductors (glutes medius) has been found in athletes with groin injuries due to reduced activity. [33] Ensure hip abductor strength training is included in rehabilitation Planning is another key element in preventing groin injuries. [45][46]

[47]

Conclusion

Groin strains are common in sports, especially adductor strains. Diagnosis should use the clinical diagnostic entities provided by the Doha agreement meeting. Supports Valuable Injury and Greater Abductor-to-Adductor Strength Ratio and Exercise-Specific Associations Training and preseason sport-specific training as individual risk factors for groin strains in athletes. [31] With proper rehabilitation, most athletes will return to sport without pain and with normal function, and surgery is rarely required. Active training rehabilitation is Found to be very effective in managing groin strains. [25]