Athletic Groin Pain
The terminology that is used in this condition is confusing you may have heard of Osteiitis Pubis, Athletic Pubalgia or the terms Sportsman’s hernia, Gilmore’s Groin or even Inguinal disruption. In some countries it is called Hockey Players Groin or Slapshot groin. Dependent on who you have seen you may have been told you need an operation, or actually have had an operation or several. Many Hip surgeons will tell you that the condition will only be ‘cured’ by Hip surgery and hernia surgeons that they will either tension (Insert a mesh or sutures’ into a defect – you may have been examined for a hernia or not – it doesn’t always seem to matter OR have been offered a de-tensioning operation where a surgeon will cut the adductor tendon or abdominal tendon.
I offer an alternate view:
Athletic groin pain (AGP) is a term I will use to start this discussion to include all the above – it is not really accurate but we will get there. AGP commonly presently slowly – you may have pain after training but it wont stop you, a period of rest seems to settle it but it comes back. It can move from lower abdominals to thigh to groin to feeling very much in pubic bone. Cutting, turning, rotation under load all aggravate it , and kicking sometimes. As it worsens you can get pain when you wake up – sitting up in bed, putting on socks, standing on one leg, and coughing and sneezing.
You will probably have had massage, strengthening, physiotherapy, and maybe injections to keep playing. Steroid injections to the adductor muscles, pubic bone and symphysis are commonly used, but do not ‘cure’ or fix, neither does rest – it is not treatment.
Now lets look at the forces.
I am going to argue that this is a ‘Biomechanical overload’ – not some guru treatment or diagnosis, just the end result of overload. In our research we have seen that most commonly this results in overload to the Lower abdominal muscles as they attach to the pubic bone. The lack of control increases the compression load in the pubic bone and usually – but not always leads to stress at the lower abdominal aponeurosis and adductor longus.
In less than 0.5% of patients have we seen evidence of hernia, of course I see patients with hernia all the time – but this is not in the athletic groin pain category. A palpable bulge with pain in the groin is a hernia unless otherwise proven – but needs a scrotal examination to confirm.
MRI is essential including a sagittal view – to rule out other causes and to get a idea of severity – this can help suggest whether this has been longstanding or acute, and early work we are doing suggests that the MRI may help in overall time in rehabilitation estimates – not yet though! It can suggest that there is some contribution from the hip joint – but recent studies have highlighted that 60% of athletes have some change in the hip – without any pain – and as such we are much less likely to revert to surgery here than ever before.
See the animation we have designed to show what happens when you change direction at speed. As you will see unless your posterior chain (Butt/Gluteals – Lumbar extensors and Hamstrings all work in synchronous stability – your torso can tip forward, or your lumbar spine can become lordotic – ie stick your butt out like a duck. This decreases hip range of motion and results in an increased load on the hip flexor and upper quad muscles. In fact some people move this way all the time – and certainly give themselves less room for error.
This in turn is likely to mean an increase in bone load across the pubic bone and lower abdominal muscle. Yu can see the lower abs and adductors form a sling and if this is overloaded it hurts.
Recent work we have submitted to the British Journal of Sports Medicine suggests that Pelvic Biomechanical overload would be a better term – rather than the multitude of named diagnosis.
In order to make a diagnosis we put our patients through a battery of 3D movement tests – these are not subjective like FMS or movement screens – and they are not static – you need to run and change direction, as visualized in the following video.
The idea is that we can identify groupings of particular movement patterns you use to change direction. These are the target of rehabilitation – not a standard clam and squeeze program and certainly not an operation. Our data shows that three groups are common and guide the process.
We focus on individual gains for you – any strength training will improve various aspects of your condition but this is false economy, as is rest – ‘Rest never equals treatment’.
Rate of force development is critical for our programs – You can never recruit all your available muscle, it requires the activation of motor units, and they cannot be all recruited quick enough, but to generate power you need to train this ability – we feel it is more important than strength alone – but you of course need both. Posterior Chain work is critical along with rotational work – you will see torso sway and lean in cutting patterns and the less lower limb compression and more stiffness the faster you will cut.
Our latest Return to play rates are around 9 weeks in recreational athletes and under 3 in professional athletes – not because you are any different – but a professional athlete usually stays with us for residential rehabilitation.
What About Surgery?
Groin Surgery may be divided according to procedures designed to tension structures around the groin, or to detension these same structures. Detensioning interventions include Adductor tenotomy, Rectus aponeurosis tenotomy and Inguinal ligament release. Tensioning interventions are targeted at potential ‘weakness’ or ‘bulging’ of the posterior inguinal wall and Gilmore, Mushaweck and Brannigan describe interventions in detail to mesh, suture or a combination of both. You wouldn’t let someone cut your ACL so why your groin? And given the hip bony FAI and labral changes in normal hips – we have found only a very small number of our patients benefit form debridement.