groin injuries.pdf

Masculoskeletal for physiotherapy

1. `Sisay.D ( MSc PT)
1

2. Groin injuries
The groin consists of the structures deep to the anterior and
medial intersection of the leg, the lower abdomen, and
includes the structures of the perineum.
The evaluation and treatment of groin pain in athletes is
challenging.
The anatomy is complex.
Multiple pathologies often coexist that may cause similar
symptoms, and
several organ systems can refer pain to the groin.



2

3. Groin structures
the groin muscles consist of three large groups of
muscles that can be injured:
The abdominal
iliopsoas and
adductor group.

3

4. Groin and surrounding structures
4

5. Cont.…..
The abdominal group: The abdominal musculature
comprise the
rectus abdominis
the obliques internus and externs
transverse abdominis.
5

6. Cont.…
6

7. The iliopsoas
The iliopsoas, comprised of iliacus and psoas major muscles.
 is the only muscle directly connecting the spine and the
lower limb.
Innervation:
Iliacus: femoral nerve (L2-L4)
Psoas major: anterior rami of spinal nerves (L1-L3)
Action: main hip flexor
7

8. The adductor group
The adductors of the hip joint
include 6 muscles:
the adductor (longus, magnus
and brevis)
gracilis
obturator externus, and
pectineus.

8

9. Cont.….
INNERVATION:
 All 5 muscles: obturator nerve
Pectineus: femoral nerve.
primary function of this muscle group is
adduction of the thigh
stabilization of the lower extremity

9

10. Cont.….
10

11. Epidemiology
Groin injuries represent 5–10% of all sports injuries.
They are highly prevalent in sports requiring kicking, high-
speed direction changes and/or skating motions.
In these sports groin injuries account for 10–23% of all
injuries.
 In football and ice hockey, groin injuries have an incidence
of 1.1/1000 exposure and 1.3/1000 players exposure,
respectively, during a regular season.


11

12. Cont.…
The hip adductors are the most commonly injured
muscle group in sports-related groin injuries.
This is likely due to the eccentric forces stressing
the muscle–tendinous complex during side-to-side
running, kicking and powerful skating.
12

13. Cont.…
more than 50% of groin injuries are classified as
moderate or severe at elite level, resulting in
substantial periods of absence from football play.
Recent studies showed that the prevalence of hip and
groin pain during a season can be up to 70%.

13

14. Common Types of Groin Injury
There are many types of groin injury, some of which can occur together.
In fact, as many as 90% of athletes experiencing groin pain have
multiple types of groin injuries simultaneously.
Adductor strain (groin strain or pull)
Athletic pubalgia (sports hernia)
Avulsion fracture
Stress fractures of the femoral neck and/or pubic ramus bone
Osteitis pubis








14

15. Adductor strain (groin strain or pull)

A groin strain is an injury or a tear to the muscle or tendon
unit of the adductors.
 that produces pain on palpation of the adductor tendons
or its insertion on the pubic bone with or without pain
during resisted adduction.
Groin muscle strains are encountered more frequently in
ice hockey and soccer than other sport.
 These sports require a strong eccentric contraction of the
adductor musculature during competition and practice.



15

16. Cont.….
Groin strains are common amongst athletes who compete
in sports that involve repetitive twisting, turning, sprinting
and kicking.
Strain injuries to the groin are among the most common
groin injuries in adult male soccer players.
 Groin strain accounts for 11% to 16% of all soccer injuries.
It can happen in other sports also
Such as running, tennis, rugby, American football,
basketball



16

17. Cont.….
The adductor longus muscle is most commonly injured.
The proximal attachment of the adductor longus
contributes to an anatomical pathway across the anterior
pubic symphysis that is likely required to withstand the
transmission of large forces during multidirectional
athletic activities.
 Its lack of mechanical advantage may make it more
susceptible to strain.
17

18. Cont.…..
The exact incidence of groin muscle strains in most sports is
unknown because athletes often play through minor groin
pain and the injury goes unreported.
In addition, overlapping diagnoses can skew the incidence.
Cumulative or single injury seem to be important
etiological factors.
Chronic tendinitis of the adductor muscles/tendons(
adductor longus*) is the most frequently diagnosed.


18

19. Mechanism of injury
Direct blunt trauma:
An acute injury, typically a direct injury to the soft tissues
resulting in muscle hematoma
Micro trauma by repetitive injury:
musculotendinous injuries to the groin are mainly a
consequence of cumulative micro traumas (overuse trauma,
repeated minor injuries) leading to chronic groin pain.
Forceful contraction :
Change of direction and kicking have been described as the
main actions.


19

20. Cont.….
So a rapid muscle activation during a rapid muscle lengthening
appears to be the fundamental injury mechanism for acute
adductor longus injuries.
The adductors attempt to decelerate an extending, abducting leg
by using an eccentric contraction to adduct and flex the hip was
the main cause of injury.
 Change of direction and reaching injuries were categorized as
closed chain movements (59%).
Kicking and jumping injuries were categorized as an open
chain (41%).

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21. Clinical Presentation
intense pain in the groin area
tenderness along the muscle belly, tendon or insertion.
The pain is exacerbated by adduction.
 There is loss of strength or range of movement.
 A popping or snapping feeling during the injury, followed by
severe pain.
21

22. Cont.…..
Tears frequently occur at the myotendinous
junction, which is the weakest part of the muscle-
tendon unit but is also commonly seen in the
muscle belly.
The same mechanism of injury that results in a
muscle tear in an adult may cause an apophyseal
avulsion in an adolescent.
22

23. chronic cases
 a tendency for the pain to radiate out….
 distally along the medial aspect of the thigh or
proximally toward the rectus abdominis.
 symptoms are often vague and diffuse in location.
The most common symptoms are….
pain during exercise
stiffness after exercise and in the morning, as well as
pain at rest.

23

24. Grading of strain
1st degree:
Mild pain, but little loss of strength or movement.
few fibers of the muscle are damaged
2nd degree:
Moderate pain
mild to moderate strength and function loss
 some tissue damage/approximately half of the fibers are torn.
 3rd degree:
Severe pain
more than half of the fibers ruptured to complete rupture of the
muscle.
Both the muscle belly and the tendon can be injured
severe loss of strength and function


24

25. diagnosis
a patient history and an identification of the pain by the
examination of the physiotherapist.
On evaluation
 there is tenderness to palpation with focal swelling of the
adductors and
decreased adductor strength and pain with resisted
adduction.
sonographic and radiographic investigations.

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26. Examination
Bilateral evaluation of adductor muscle-related pain and
strength.
palpation at the adductor insertion at the pubic bone.
Adduction against resistance (squeeze tests)
passive stretching of the adductor muscles.
inspection in a standing position to evaluate the alignment of
extremities.
check the motion of the hip joint and the flexibility of the groin
and hip muscles.

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27. squeeze tests
purpose
diagnosis of groin injuries and
adductor muscles strength.
at 0°, 45° and 90° of hip flexion.
+ve:
if the patient complains of
pain/weakness in the adductor
muscles or bone pain at the
anterior and medial pelvic ring.
27

28. cont.….
 Resistive contraction tests of the knee extensors, knee
flexors, abdominal muscles, and hip rotators,
extensors and flexors, as well as hip adductors and
abductors, should be performed.

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29. Medical Management
NSAIDs
Rest
Ice
Compression
elevation
Adductor tenotomy (after failed conservative
management).

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30. Physiotherapy Management
The primary goal of the treatment program is
Decrease pain
 to minimize the effects of immobilization,
regain full range of motion, and
restore full muscle strength, endurance and
coordination.
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31. Phase 1: acute
First 48 hours after injury: RICE
NSAID
Massage
TENS
Ultrasound
Hip passive range of motion in pain-free range
Submaximal isometric adduction with knees bent → with knees
straight progressing to maximal isometric adduction, pain Free

31

32. Cont.…
Non weight bearing hip progressive resistance
exercises without weight in antigravity position (all
except abduction):
pain free, low load, high repetition
Upper body and trunk strengthening
Flexibility program for noninvolved muscles
Bilateral balance board
Clinical milestone: Concentric adduction against
gravity without pain.


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33. Phase II: Subacute
Bicycling/swimming
squats
Single-limb stance
Concentric adduction with weight against gravity
Standing with involved foot on sliding board moving
in frontal plane.
Adduction in standing on cable column or resistance
band.
Seated adduction machine
Bilateral adduction on sliding board moving in frontal
plane (i.e., simultaneous bilateral adduction)
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34. Cont.…
Unilateral lunges with reciprocal arm movements
Multiplane trunk tilting
Balance board squats with throwbacks
General flexibility program
Clinical milestone :
Lower extremity passive range of motion equal to that of the
uninvolved side and
involved adductor strength at least 75% that of the Ipsilateral
abductors.
34

35. Phase 3: Sports specific training
Phase II exercises with increase in load, intensity, speed
and volume.
Standing resisted stride lengths on cable column to
simulate skating
Slide board
On ice kneeling adductor pull together
Lunges (in all planes)
Correct or modify ice skating technique
35

36. Cont.….
Clinical milestone:
 Adduction strength at least 90-100% of the abduction
strength and involved muscle strength equal to that of
the contralateral side.
36

37. Hernias
 A hernia occurs when an internal organ or other body part protrudes
through the wall of muscle or tissue that normally contains it.
Hernias of the abdominal wall must always be considered in athletes
with groin pain.
 Hernias are frequently overlooked in the athlete.
with only 8% of patients with hernias being detectable on initial
physical examination, but 95% returning to sport after surgical repair
and rehabilitation.
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38. Sportsman's Hernia(athletic pubalgia)
A sportsman’s hernia (or posterior inguinal wall weakness),
Athletic pubalgia, inguinal hernia, Gilmore’s groin.
 is weakness in the deep layer of the abdominal muscles
just above the genitals.
A sports hernia is a strain or tear of any soft tissue (muscle,
tendon, ligament) in the lower abdomen or groin area.
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39. Cont.….
weakening of the muscles
and/or the tendons of
 rectus abdominis
pyramidalis
internal and external
oblique's
transverse abdominis.
39

40. Cont.…..
This weakness allows contents of the abdomen to press
outwards, compressing structures in the groin.
Sports activities that involve planting the feet and
twisting with maximum exertion can cause a tear.
occur mainly in vigorous sports such as ice hockey,
soccer, wrestling, and football.
This is commonly seen in kicking sports.


40

41. symptoms
severe pain in the groin area at the time of the injury.
pain during sports movements—particularly, twisting,
kicking and turning during single-limb stance.
 It is not usually painful at rest; however, the pain returns
immediately if you return to normal activity.
usually radiates to the adductor muscle region and to the
testicles.
The pain is difficult to locate.

41

42. Cont.…
 There may be excessive anterior pelvic tilting and/or
an internal rotation of the ilium on the symptomatic
side concomitant with the adductor pathology.
Without treatment, this injury can result in chronic,
disabling pain that prevents you from resuming sports
activities.

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43. Generally
Pain
dull/burning in nature
reduced range of movement
swelling/inflammation
stiffness
weakness
43

44. Could there be any long-term
effects from a sportsman’s hernia?
Sportsman’s hernia is a condition that does not get
better by itself.
The weakness in the abdominal wall must be surgically
repaired.
Following the surgical repair of a sportsman’s hernia,
recovery usually takes place in a few months and there
are usually no long-term effects.

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45. Physical Tests
To help determine whether you have a sports hernia,
your doctor will likely ask you to do a sit-up or flex
your trunk against resistance.
If you have a sports hernia, these tests will be painful.
Imaging
 ultrasound or magnetic resonance imaging (MRI)

45

46. Nonsurgical Treatment
Rest (In the first 7 to 10 days after the injury)
Ice
If you have a bulge in the groin, compression or a wrap may help
relieve painful symptoms.
non-steroidal anti-inflammatory medicines (ibuprofen or
naproxen)
Physical therapy( 2 weeks after your injury)
Conservative management for a period of between 6–12 weeks.
46

47. Cont.….
Operative management primarily involves re
enforcement of the posterior abdominal wall,
which can either be performed open or laparoscopic
ally.


47

48. Physiotherapy treatment
Physiotherapy treatment is important following the
surgical repair of a sportsman’s hernia.
Your physiotherapist will be able to provide you with a
rehabilitation plan to strengthen your lower
abdominal and pelvic floor muscles.
 This can accelerate your return to participation in
sports and prevent further problems.

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49. Physiotherapy could include:
Electrotherapy: TENS
Hydrotherapy: Hot packs
Mobilizations and ROM exercises
Core Stability Exercises
strengthening of the hip adductors and abdominal muscles, balancing,
and postural training exercises
Soft Tissue Treatment: transverse friction and massage

49

50. Stress fractures
 stress fracture is a small crack in a bone, or severe bruising
within a bone
Femoral neck and the pubic ramus are the most
common stress fractures in the groin region.
Stress fractures are caused by repetitive/overuse trauma
to the bones or through muscular attachments.
 These stress fractures particularly occur secondary to
running related sports.
50

51. Cont.……
additional risk factors can be intrinsic or quite diverse
and include:
 osteoporotic/metabolic bone disease tendency in young
female athletes secondary to nutritional or hormonal
imbalances.
changes in footwear and mode of training, or
 changes in intensity and/or duration of training.
51

52. Cont.…..
The pathophysiology involves repeated loading of the
bone with accumulated microtrauma resulting in the
development of a bony defect.
Femoral neck stress fractures are especially
troublesome because if not treated they may lead to
avascular necrosis of the femoral head which can cause
long- term disability.

52

53. Cont.…
Femoral neck stress fractures (FNSFs) account for 3% of
all sport-related stress fractures.
The commonest causative sports are marathon and long-
distance running.
The most common reported symptom is exercise-related
groin pain.
Femoral stress fractures typically present with hip, groin,
gluteal, thigh, or knee pain, depending on the location.
53

54. Signs and Symptoms

Local pain and oedema
Point tenderness on palpation
Local swelling
Antalgic gait
Painful and limited passive and active ROM of hip and/or
knee (flexion, internal rotation, extension)
Pain increases during activity improves with rest.
Groin pain
Bone marrow oedema
54

55. Cont.…
athletes may identify vague thigh pain accompanied
with diffuse tenderness, particularly for femoral neck
stress fractures.
Regardless of region, athletes typically present with
pain during activity which may be reproducible on
passive range of motion, specifically internal rotation
and when asked to hop on the affected limb.
55

56. Cont.….
 Stress fractures at the pubic rami near the symphysis
are the most common pelvic stress fractures among
runner athletes.
symptoms include low back, buttock, groin, and thigh
pain during activity.
Plain radiographs are typically normal.
 MRI is the best diagnostic test to depict stress
fractures of the femur.

56

57. Cont.….
Pain upon deep palpation of the pubic ramus may
assist in differentiation between affected and an
overlying soft-tissue pathology.
most pelvic stress fractures are non-displaced,
requiring an MRI for diagnosis.
Return to participation ranges from 7–12 weeks with
conservative treatment.
57

58. Treatment and rehabilitation
is dependent on the location and any displacement.
Displacement is the primary indicator for prognosis
with 60% displacement the marker for reduction of
activity level in sport with potential avascular necrosis.
 The majority of femoral stress fractures that lack
displacement respond to conservative treatment
within 8–14 weeks.
58

59. The first phase of a conservative rehabilitation
Rest
maintenance of aerobic fitness
physical therapy modalities( TENS , hydrotherapy)
oral analgesics
weight-bearing as tolerated and ambulation modification if
needed, yet running should be avoided.
Likewise, minimal-impact activities to maintain cardiovascular
fitness should be initiated, such as cycling, pool running,
antigravity treadmill running, , and swimming.




59

60. Second phase
Should begin 2 weeks after the athlete is pain free.
ambulation and cross-training.
 initiation of a running progression.
Focus on muscular endurance training.
Core and pelvic girdle stability.
 balance/proprioception training
60

61. Cont.….
flexibility, and gait retraining
Return to sport activity should coincide with pain free
weight-bearing
 Femoral neck 4–6 weeks and pelvis 7–12 weeks

61

62. Avulsion fracture

An avulsion fracture is a failure of bone in which a bone
fragment is pulled away from its main body by soft tissue
that is attached to it.
An avulsion fracture occurs when the tendons that connect
muscles to bone are torn at the connection site resulting in
pain and muscle weakness.
 Avulsion fractures in the groin are most common in
adolescent athletes because the pelvic growth plates have
not yet solidified.
62

63. Cont.….
growth plates are more prone to trauma compared to the
musculotendinous units having a hormonally induced
increase in strength.
Etiology includes….
 a sudden and forceful contraction or
passive lengthening of the muscles during an acceleration, a
jump or a kick.
Acute trauma is the most common
 less frequently they follow an overuse situation.
63

64. Avulsion fractures involves
the main bundle of the rectus femoris insertion at the
AIIS.
 the Sartorius insertion at the ASIS.
 the hamstring insertion at the ischial tuberosity (IT).
the tensor fasciae latae on the iliac crest (IC) and
the rectus abdominus insertion on the superior corner
of the pubic symphysis (SCPS).
64

65. Cont.…
a simple clinical assessment and a standard AP
radiograph are enough to make a diagnosis.
these injuries are often misdiagnosed as simple muscle
strains leading to ineffective treatments and a delayed
return to sport.

65

66. Mechanism of injuries
Avulsion fractures of ASIS and AIIS
 a forceful contraction of the Sartorius and the rectus femoris,
respectively, with the hip extended and the knee flexed.
AIIS avulsions can occur with a concentric or eccentric
contraction of the rectus femoris.
the most common injury mechanism is concentric
contraction during the acceleration phase of sprinting, a
jump or a kick with sudden-onset groin pain.
66

67. Cont.….
Indirect avulsion fractures of the ischial tuberosity are
the result of a vigorous flexion of the hip joint with an
extended knee and a concomitant activation of hamstring
muscles.
Fractures involving the IC apophysis are
 caused by a massive contraction or repetitive actions of the
tensor fasciae latae.
a sharp pain localized on the antero-lateral side of the pelvis.

67

68. Cont.….
0lder patients are more prone to suffer injuries to the iliac
apophysis (ASIS and iliac crest), while younger are more
likely to sustain a fracture of AIIS or ischial tuberosity.
Why ?
the timing of complete ossification of the apophysis of the
pelvis is probably accountable for these differences, with
the AIIS secondary ossification center closing first and the
iliac apophyses closing last.

68

69. Osteitis pubis
The symphysis pubis is a fibrous joint between the
two halves at the front of the pelvis.
The adductor muscles attach either side and the abdominal
muscles attach along the top of the pubic bones.
It Is an inflammation of the pubic symphysis and surrounding
muscle insertions.
It is painful chronic overuse condition characterized by pelvic
pain and local tenderness over the pubic symphysis.

69

70. Cont.…..
Therefore the symphysis is subjected to significant
shearing forces, especially during alternate single leg
weight bearing with change of direction during
activities like running and kicking
The shearing forces can be increased by biomechanical
limitations, such as restriction of internal hip rotation.

70

71. Cont.….
It commonly affects athletes, especially those who participate in sports
that involve kicking, turning, twisting, cutting, pivoting, sprinting,
rapid acceleration and deceleration or sudden directional changes.
Osteitis pubis has been described in athletes who play sports such as
soccer, rugby, ice hockey, Australian Rules football and distance
running.
Soccer player, hockey player and distance runner are especially
vulnerable to this injuries.


71

72. Cont.….
The etiology is not completely clear.
 Muscle imbalance between the abdominal and hip
adductor muscles is currently considered the most
important pathogenic factor.
In women can also develop after child birth.
A prolonged labor that strain the muscle of the pelvis can
cause inflammation, which will eventually subsides.
 surgery or an injury to the pelvis may also result in osteitis
pubis.`


72

73. Cause/factors cont.…..
Surgical procedures (gynecological or abdominal,
hernia repairs).
Pregnancy and childbirth
Trauma/injury
Spinal malalignment
Pelvic malalignment (the pubic symphysis itself may
be out of line

73

74. cont.….
Leg length difference
Abnormal Foot biomechanics
Technique- walking and /or running
Poor flexibility
Poor muscle strength
Reduced core strength and control of the spine and pelvis
during activity
Poor glut strength and overuse of adductors

74

75. Symptoms of Osteitis Pubis
The most common symptom of osteitis pubis is pain
over the front of the pelvis.
Pain may be unilateral or bilateral.
 it is exacerbated by running, kicking, hip adduction or
flexion, and eccentric loads to the rectus abdominis.
It can also radiate down into one thigh or into the
groin(anterior and medial groin pain).

75

76. Cont.…..
At clinical evaluation, tenderness on palpation of the
symphysis region is common.
oedema (swelling) forming within the pubic ramus.
Weakness
Limping gait
Pain during sport


76

77. Treatment
treatment of this condition is notoriously difficult.
A conservative approach to treatment of osteitis pubis
is considered the first choice of action, while warning
the athlete that prolonged re-stand prolonged absence
from sport is likely.
Pain will often respond well to anti-inflammatory
medication initially.
77

78. Cont.….
However, symptoms often gradually or suddenly
become more acute with pain that inhibits or stops
activity, becoming unresponsive to conservative
management.
Advice to avoid exercising on hard or uneven surfaces.
The player rests from all weight bearing rotational
activities until the squeeze test is negative.
78

79. Treatment can include
Spinal and pelvic alignment work
correct muscular imbalance around the pubic symphysis
Soft tissue work and stretching
Myofascial release
Lower limb and core muscle strengthening
Referral to podiatry if necessary for leg length assessment
and biomechanical analysis

79

80. Cont.….
Postural analysis/correction
Retraining of walking and running technique
Balance retraining
Home exercise program
Breathing retraining
Sport specific training
80

81. Any question?
81