In field based sports such as football, rugby, and AFL hip and groin injuries occur at a rate of 14%, making them one of the most commonly reported injuries (Walden et al, 2015). Chronic athletic hip and groin pain (CAHGP) presents several challenges to physiotherapists as it is generally insidious in onset. Until their performance is affected, athletes commonly don’t present for treatment. This results in the loss of initial diagnostic information, complicating the assessment process.
A systematic review on CAHGP by Serner et al (2005), reported 33 different terminologies utilized in 72 studies, resulting in difficulties managing this condition. The Doha Agreement set out to standardise the terms for the diagnosis of CAHGP (Weir et al,2015) and should be used in the clinical management of patients. The following summary outlines the risk factors, assessment processes, and recommended rehabilitation protocols for the management of CAHGP.
Risk Factors
The following have been identified as risk factors: muscular weakness and imbalance; reduced muscular activity; reduced range of motion; increased training load; genetic anatomical variation; and deviation of movement pattern (Gore et al 2019, Franklyn-Miller 2015). These factors influence kinematics resulting in excessive or unevenly distributed loading or reduced capacity to cope with repetitive multidirectional movements. Segmental timed muscle coordination is intrinsic to an athlete’s ability to control change of direction, produce power, and provide endurance. A loss of this muscle coordination may lead to tissue injury if this load exceeds tissue tolerance (Franklyn- Miller et al, 2015).
Assessment
A wealth of literature over recent years has highlighted the importance of gluteal strength in the prevention and rehabilitation of lower limb injuries.
In addition to this it is hypothesized that the deep lateral rotators, internal rotators, and Iliopsoas are pain inhibited with CAHGP. Assessing the athlete’s ability to actively move their hip through full passive range in multiple planes without compensating assesses their basic motor control.
Strength of these muscles is then best assessed with the use of a handheld dynamometer, with decreased muscle strength a consistent finding amongst athletes with groin pain (Thorborg et al,2018). Muscle strength testing is either concentric (make test) or eccentric (break test) in nature. Which test you utilize depends on a number of factors including but not limited to setup, strength of patient and therapist, stage of day/training week as well as the irritability of the patient’s pain.
Gore et al, 2018 reported that hop height is not significantly different in the population with CAHGP in comparison to controls. Whilst power production may not be affected Gore, 2019 reported longer contact time and less power absorption in the athletic groin pain population. This is where the use of readily available technology in clinic such as the “My jump 2” ap can be utilized to ensure functional objective data is assessed
Change of direction strategies must also be assessed. These have been shown to be individual rather than grouped relating to anatomical diagnoses (Franklyn-Miller, 2015).
The ankle has been shown in previous research to contribute up to 45% of total energy dissipation during single leg landings (Gore et al, 2015). Franklyn-Miller (2015) also highlighted the importance of the ankle joint in determining how ground reaction forces travel to proximal joints. What is unknown currently is whether ankle dysfunction is a risk factor for the development of athletic groin pain or a subsequent protective mechanism. What is essential is that examination of ankle function must be part of the athletic groin assessment and rehabilitation.
Rehabilitation
In order to rehabilitate CAHGP there must be a progression from motor control, to increasing strength, progressing onto increasing power, speed and finally into change of direction (Gore et al 2018). As we have seen in running based research change in strength alone is insufficient to alter movement patterns and coaching intervention and cueing is required (Franklyn-Miller et al, 2015).
It is imperative that the athlete learns to absorb impact as without this they are unable to decelerate with appropriate technique when changing direction which not only further loads the painful site but also leaves an unstable base for acceleration affecting performance. Other factors that may need to be addressed with change of direction technique and performance are reducing excessive side flexion and rotation of the lumbar and thoracic spine to the stance leg (King et al, 2018).
Conclusion
CAHGP is a complex condition with a number of clinical entities that may be present individually or combined. What is essential is that for conservative management to be successful the rehabilitation programme must address all biomechanical impairments that have led to or resulted from this condition.
References
Falvey, E, King, E, Kinsella S, Frankyn-Miller A. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients – clinical findings, MRI findings and patient-reported outcome measures at baseline. British Journal Sports Medicine. 2016:50: 423-430.
Frankyn-Miller A, Richter C, King E, Gore S, Moran K, Strike S, Falvey E. Athletic groin pain(part 2): a prospective cohort study on the biomechanical evaluation of change of direction identifies. Three clusters of movement patterns. British Journal of Sports Medicine. 2017: 51: 460-468.
King E, Franklyn-Miller A, Richter C, O’Reilly E, Doolan M, Moran K, Strike S, Falvey E. Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients. British Journal of Sports Medicine. 2018:0:1-9.
Gore S, Franklyn-Miller A, Richter C, King E, Falvey E, Moran K. The effects of rehabilitation on the biomechanics of patients with athletic groin pain. Journal of Biomechanics. 2019: 1- 9.
Gore S, Franklyn-Miller A, Richter C, Falvey E, King E, Moran K. Is stiffness related to athletic groin pain? Scandinavian Journal Medicine and Science in Sports. 2018:28:1681-1690.
Thorborg K, Reiman. M, Weir A, Kemp J, Serner A, Mosler, A, Holmich P. Clinical Examination, Diagnostic Imaging, and testing of athletes with groin pain: An evidence-based approach to effective management. Journal of Orthopaedic and Sports Physical Therapy. 2018: 48:4, 239 – 249.
Walden M, Hagglund M, Ekstrand J. The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med. 2015;49:792–7.
Serner A, van Eijck CH, Beumer BR, et al. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med 2015;49:813.
Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan K, Lovell G, Meyers W, Muschaweck U, Orchard J, Paajanen H, Philippon M, Reboul G, Robinson P, Schache A, Schilders E, Serner A, Silvers H, Thorborg K, Tyler T, Verral G, de Vos RJ, Vuckovic Z, Holmich P. Doha agreement meeting on terminology and definations in groin pain in athletes. British Journal of Sports Medicine. 2015:49:768-774.
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