Physiotherapy for Groin Pain
Groin pain is one of the most common complaints among the football codes, particularly soccer and AFL. Within the soccer world, it doesn’t hold the crown for the injury causing the most time loss, which belongs to the hamstring strain, but it does hold the crown for the most detrimental from a performance standpoint. Often players are still able to continue playing and training with groin pain but they report performance deficits such as a reduced ability to kick, cross the ball, and go into 50/50 challenges.
Groin pain often pops up as either an acute groin strain or as the gradual onset of groin pain, surprisingly the slow gradual onset is the more common of the two in my experience. Often players play with this for a period of weeks or months before they report it to anyone, that is how common groin pain can be in soccer players, it’s just seen as “normal” sometimes. This is so far from what should be the case, as a sport, and as a profession as physiotherapists, we should be educating people better.
Groin pain doesn’t just affect athletes though, it can be a common presentation in everyday life as well. But sometimes what feels like groin pain isn’t always groin pain. The hip can be a common referral source for groin pain, and sometimes it could be a hernia that is causing groin pain, or maybe the abdominals. The hip and groin area is a bit confusing sometimes, with a lot of things referring to a lot of different areas, a thorough subjective and objective testing battery with the aim of determining a clear diagnosis is a necessity.
What we will discuss:
As with every other presentation and injury, discussing how it all started is where we will begin. Whether it be an acute injury that started things, or we are delving into a 3-month history of groin pain I’m here for it all. In acute injuries I want to know all about how it happened, what were you doing and what was the gameplay situation, as physios we need to have a good grasp of the initial injury to understand the tissue stresses that occurred as well as understand a potential differential diagnosis from the outset. In longer standing gradual onset style groin pain, we will be digging right into the nitty gritty of what you have been doing, often going back to a month or two before the symptoms started. Together we will be looking for something that changed, maybe your coach added in a lot of shooting practice at training, or maybe they added in a lot of change of direction and agility work you weren’t doing before. Often there will be something that has changed that has precipitated the onset of symptoms.
Next, we want to understand the symptoms, how they have developed and what aggravates them. Without this understanding of particularly what aggravates them, we cannot develop a picture of what you are able to comfortably perform either on the training field, in an exercise program, or even just in day-to-day life. For example, some clients may find straight-line running and sprinting fine, but a change of direction drill will aggravate it immediately. But others may find it only starts to get sore doing change of direction drills after 10mins. All three of these clients can be managed differently, this is what individualised care truly looks like. Next, we need to understand how quickly the symptoms develop and how long they are sore, this gives us an insight into how irritable the pain is. The less irritable it is the more we can load it, so long as it isn’t too sore afterwards.
I will also often want to know if you have had a previous history of either gradual onset groin pain or groin strains in the past. If you have, I want to know what you did for them, did you just rest up for a few weeks, did you see a physio and just get a few massages, or did it also include a comprehensive exercise program that you completed religiously? Understanding what has worked and what hasn’t worked in the past means we either won’t repeat the same mistakes or gives us an idea of what may be missing and why you have had another episode of groin pain.
What we will assess:
Assessing pain around the groin is complex, often I will utilise the findings from the Doha Agreement to begin. This was a consensus statement a few years ago that experts determined clinical entities that can cause hip and groin pain and provided the best diagnostic tests for each entity. The entities include the hip joint, the hip flexor, the adductors, the pubic symphysis, and the inguinal canal. Just because you fit the criteria for one doesn’t mean you can’t fit the criteria for another, and that was the whole point, hips and groins are complex. The assessment is designed to come to an area-specific diagnosis rather than a specific structural diagnosis. So what’s the point then I hear you ask? From this we are then able to perform further more specific testing of those structures, we can perform more specific hip joint tests, or perhaps we refer on for imaging to assess for a potential hernia, it is designed to guide clinicians and clients in a complex region.
Specifically, with regard to the adductors, there are a few specific tests that we can perform that have shown good clinical utility from a diagnostic perspective. As with pretty much every other muscle injury they don’t like three things – contraction, stretch and being pushed on. So for the adductors, we can perform a squeeze test where I put my forearms between my client’s ankles and get them to squeeze, I am looking for both reproduction of pain as well as whether the client is hesitant to contact or not. The testing can be changed slightly if needed to put less stress on the adductors, but between the ankles is the best position to test in. Next up we look at lengthening the adductors, for that, we simply just abduct the leg and take it straight out and away from the body and assess for the range of motion and pain response. When palpating the region, we will assess the muscle belly of the adductor muscle group for tenderness and increased muscle tone as well as palpate the adductor tendons and tendon insertions for a pain response.
Assessing your functional capacity is the last portion of the assessment, this can include a range of different activities and will depend upon your chosen sport and the demands it will place upon the adductors. Commonly the range of assessments I will perform with clients include:
- Squat
- Single leg squat
- Lunge
- Side lunge
- Squat jump
- Hopping
- Hopping forwards
- Side-to-side hopping
- Multi-directional hopping
- Running
- Sprinting
- Change of direction
- Deceleration
This isn’t designed as an exhaustive list and often with most clients we won’t get close to assessing all of these on an initial consult but it is designed to display a spectrum of activities that load the adductors that we will work through throughout the rehabilitation process.
How we treat it
Treating groin pain should be simple, with an emphasis on should, unfortunately, that’s not always the case. Whether it be a long history of groin pain that has caused movement adaptations that we need to correct, or whether it be an acute strain that requires precise hands-on treatment and specific exercise programming. Groin pain always keeps me on my toes but it’s an interesting challenge.
Often the most common thing I will be doing when treating these clients is doing hands-on work through both hips and adductor complexes. Often I find, even in single-sided groin pain, that the opposite set of adductors increases in muscle tone, I believe it is often a compensation to try to stabilise the region with one side not doing as much work. Often, reducing this muscle tone can assist in improving pain symptoms as well as improving freedom of movement. I also find the hip flexors are the other very common area that I treat, most commonly it is on the same side as the pain is on, but occasionally I will work on both sides. I find the hip flexor often tightens up in an attempt to try to protect the hip as the athlete starts to load the opposite side up more. Occasionally I will have to work through the lateral hip and the glutes with some clients but that is less often than I am working through the front of the hips.
Last but not least, an exercise program to strengthen the adductors, hips, and abdominals is vital. Without a strengthening program, returning to sport will either be unsuccessful, you will not be able to perform to your normal standards, or you will risk re-injury. Particularly in soccer players, adductor weakness is rife, and not many athletes tend to spend too much time focusing on them. Specific and isolated strengthening of the adductors is always needed. But we also need to consider the role that the hip flexors and gluteal play in maintaining stability and producing power through the hips. The abdominals and core is the other key, maintaining a stable core and trunk means we are able to produce more power due to having a more stable base to work from, this improves our efficiency of movement when looking at movements such as kicking and changing direction.
Return to Training and Sport
Injury Prevention
Prevention is always better than a cure, so what can you do to prevent groin pain or groin strains in the first place? Strengthening your adductors is 100% the best bang for your buck method for reducing your risk. In most cases of long-standing groin pain, they have weak adductors. If you’ve suffered a groin strain, you don’t want any residual weakness sticking around, so keeping a background strengthening program going is your best avenue.
Outside of the obvious answer, there are a few other avenues you can look at. Keeping your hip flexors and abdominals strong would be another good tip. This helps to stabilise the pelvis and provides a strong base for you to operate from as an athlete. When looking at the core though we need to do a bit more than just planks and side planks. We need to develop the capacity for the core to work as a powerhouse and develop the capacity for the obliques to rotate the trunk. Using exercises such as medicine ball throws to the side is a great way to develop this capacity.
The last tip would be load management. Performing what your body is prepared for and not deciding to go racing out of the blocks on the highway to get an injury is often the best avenue. Slowly working your way up to what you need to be able to perform is the best avenue, it’s not the end of the road that dictates your injury risk, it’s the road there that gets people into trouble. The 10% rule is a little overstated, particularly in the early days of returning from injury or coming back from an injury, you can progress a little bit quicker than that early on. But once you start to have a decent amount of training load the 10% rule is quite good. Most importantly though, listen to your body, and not just physically, sometimes increases in stress, poor sleep, and mood irritability, can all be signs that you are overtraining.
Treatment Packages
3 Week Program
Our 3-week program was designed for clients who have suffered an acute injury and want to get out of pain ASAP. This package could be suitable for clients who have sustained a low-grade adductor strain or the recent onset of gradual onset groin pain less than a month into symptom onset.
Our 3-week program is inclusive of the following:
- 3xweekly 45min physiotherapy consults
- $40 equipment allowance for bands, trigger point balls, foam rollers etc.
Package price: $770
6 Week Program
Our 6-week program is designed for clients who have sustained a higher-grade injury and want to not only rehabilitate their injury but also address causative factors and ensure a safe return to sport. Injuries such as a moderate-grade groin strain or up to a 2 to 3-month history of groin pain would be suitable presentations for this program.
Our 6-week program is inclusive of the following:
- 2xweekly 45min physiotherapy consults
- $80 equipment allowance for bands, trigger point balls, foam rollers etc.
Package price: $1050
12 Week Program
Our 12-week program is designed for clients who have sustained higher-grade injuries and want to address causative factors but also want to return to sport as a more complete athlete than what they were when they got injured. Injuries such as a moderate to a higher grade groin strain as well as more prolonged cases of groin pain such as 3 months or longer would be suitable presentations for this program.
Our 12-week program is inclusive of the following:
- 2xweekly 45min physiotherapy consults
- $150 equipment allowance for bands, trigger point balls, foam rollers etc.
Package price: $2050