{"id":10774,"date":"2023-09-15T06:00:59","date_gmt":"2023-09-15T05:00:59","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=10774"},"modified":"2023-09-12T00:12:35","modified_gmt":"2023-09-11T23:12:35","slug":"groin-pain-into-the-bermuda-triangle-part-1","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2023\/09\/15\/groin-pain-into-the-bermuda-triangle-part-1\/","title":{"rendered":"Groin Pain: Into the Bermuda Triangle Part 1"},"content":{"rendered":"

This blog is part of a series on groin pain by Jim Scanlan, Physiotherapist. \u00a0Keep an eye out for\u00a0monthly releases in this series!<\/b><\/p>\n

Diagnosing, managing & rehabilitating injuries in the Bermuda triangle<\/i><\/b><\/p>\n

Keywords<\/b>: <\/span>Groin Pain; Adductor; Rehabilitation<\/b><\/p>\n

Introduction:<\/b><\/p>\n

Sports involving rapid acceleration, deceleration or sudden changes in direction commonly result in groin injuries <\/span>(1)<\/span><\/a>.\u00a0 This includes football (soccer) <\/span>(2)<\/span><\/a>, <\/span>(3)<\/span><\/a>,<\/span> (4)<\/span><\/a>, <\/span>(5)<\/span><\/a>, <\/span>(6)<\/span><\/a>, <\/span>(7)<\/span><\/a>, <\/span>(8)<\/span><\/a>, <\/span>(9)<\/span><\/a>, <\/span>(10)<\/span><\/a>, <\/span>(11)<\/span><\/a>, <\/span>(12)<\/span><\/a> & <\/span>(13)<\/span><\/a>; rugby league <\/span>(14)<\/span><\/a>; Australian rules football <\/span>(15)<\/span><\/a>; ice hockey <\/span>(16)<\/span><\/a>; Gaelic football and cricket <\/span>(16)<\/span><\/a> & <\/span>(17)<\/span><\/a>.\u00a0 Athletes with a previous groin injury are at a greater risk than those with no previous history (up to 2.4 times greater over consecutive seasons within football) <\/span>(11)<\/span><\/a>.\u00a0 The diagnosis of groin injuries is complex with a multifactorial aetiology <\/span>(18)<\/span><\/a>.\u00a0 This blog is the first in a series discussing some of these complexities, along with management and rehabilitation strategies. Beginning with adductor related groin pain (ARGP).<\/span><\/p>\n

Adductor Related Groin Pain (ARGP):<\/b><\/p>\n

ARGP is defined as adductor tenderness and pain on resisted adduction testing (see Figure 1) <\/span>(18)<\/span><\/a>.\u00a0 ARGP has an incidence of between 3 and 23% <\/span>(19)<\/span><\/a>,<\/span> (20)<\/span><\/a> & <\/span>(21)<\/span><\/a> more commonly affecting young to middle-aged athletic males compared to females.\u00a0 Certain sports, such as football, have a yearly incidence of 10-18% <\/span>(21)<\/span><\/a> with approximately 53% of ARGP within football being from overuse <\/span>(22)<\/span><\/a>.<\/span><\/p>\n

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Figure 1<\/strong>: Groin Pain (<\/span>Weir A, Brukner P, Delahunt E, <\/span>et al, <\/span><\/i>2015) <\/span>(18)<\/span><\/a><\/p>\n

The Copenhagen \u2018Hip and Groin Outcome Score\u2019 (HAGOS) <\/span>(23)<\/span><\/a> is a patient reported outcome measure with six separate subscales, assessing pain; symptoms; physical function in daily living; physical function in sport and recreation; participating in physical activities and hip and \/ or groin quality of life.\u00a0 It has substantial test-retest reliability with adequate measurement qualities for use with physically active, young to middle-aged patients with long-standing hip and \/ or groin pain.<\/span><\/p>\n

As defined by Weir <\/span>et al<\/span><\/i>. (2015) <\/span>(18)<\/span><\/a> ARGP was found to be the most common clinical entity (61% of athletes) <\/span>(24)<\/span><\/a> , with the vast majority of these athletes being male (98%) football (60%) players.\u00a0 There were multiple causes for the ARGP. Unfortunately study quality on groin injury management has been historically low <\/span>(25)<\/span><\/a>.<\/span> This could be because there is a close and complex relationship between ARGP and Pubic Related Groin Pain, along with other aspects of groin pain such as iliopsoas and inguinal.\u00a0\u00a0<\/span><\/p>\n

The most efficacious treatment for long-standing ARGP is exercise therapy.\u00a0 There is insufficient\u00a0 evidence within the literature to recommend a specific exercise protocol or modality <\/span>(19)<\/span><\/a>.\u00a0 However the exercises described in the modules from H\u00f6lmich <\/span>et al<\/span><\/i> (1999)<\/span> (26)<\/span><\/a> and iteration <\/span>(27)<\/span><\/a> appear to be beneficial, regarding reduction in pain and return to sport without groin pain at 16 week follow up in comparison to passive treatments (exercise stretching, electrotherapy and transverse friction massage).\u00a0 <\/span>Emphasis should be paid to adductor eccentric strength in particular <\/span>(27)<\/span><\/a>.\u00a0 Use of The \u2018Copenhagen Adduction\u2019 (CA) exercise <\/span>(see Figure 2) reduced the prevalence and risk of groin problems in male footballers by 41% <\/span>(28)<\/span><\/a>.<\/span><\/p>\n

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Figure 2<\/strong>: The Copenhagen Adduction Exercise (A) starting \/ ending position and (B) mid positions, for the different levels of the adductor strengthening programme (Haroy J, Clarsen B, Wiger EG, <\/span>et al<\/span><\/i>, 2019) <\/span>(28)<\/span><\/a><\/p>\n

Rehabilitation focused on inter-segmental control has been associated with improved HAGOS <\/span>(23)<\/span><\/a> scores and good rates of pain-free return to sport across <\/span>(29)<\/span><\/a> a variety of groin pain diagnoses <\/span>(18)<\/span><\/a>.<\/span><\/p>\n

SSC Sports Medicine Groin Lab – 180 Cut Series – YouTube<\/span><\/a> (29)<\/span><\/a><\/p>\n

For those patients wanting to return to sport the \u2018Strategic Assessment of Risk and Risk Tolerance\u2019 <\/span>(StARRT)<\/span><\/a> Framework, established in 2016 <\/span>(30)<\/span><\/a>, is a good starting point for making return to play decisions post ARGP (see Figure 3).<\/span><\/p>\n

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Figure 3<\/strong> Strategic Assessment of Risk and Risk Tolerance Framework (Ardern CL, Glasgow P, Schneiders A, <\/span>et al<\/span><\/i>. 2016) <\/span>(30)<\/span><\/a><\/p>\n

Conclusions<\/b><\/p>\n