Groin Pain Treatment

MECHANISM OF GROIN PAIN

Groin strain can be sudden or gradual onset. Pain may come from bones, joints, muscles, tendons and nerves. The injury occurs when the tissues in the pelvis and upper thigh are stressed beyond their capacity to absorb the load. This causes micro failure in the tissues that may progress to tearing. Pain occurs as a protective mechanism to prevent continuing the activity and causing further tissue damage.

In the common presentation of muscle injury the adductor muscles in the inner part of the thigh, which act as important stabilisers for the hip joint, are strained due to a powerful contraction such as kicking, accelerating or when changing direction when running. Groin pain can also increase gradually when the muscle/tendon attachment to the bone is repetitively loaded. This is often due to increased or high workload levels, lack of recovery between training sessions, incorrect technique, or poor biomechanics due to muscle tightness, weakness or reduced motor control.

PRESENTATION OF GROIN PAIN

The main reason for attending our clinic for assessment and treatment is the inability to continue with sporting activity or training due to pain.  In our experience running and ball sports predominate as causes but groin pain secondary to strength training, personal training in boot camps can also be a factor.

In acute cases walking can be difficult as well as simple movements such as sitting to standing and using stairs.  With the sudden onset of pain the athlete often reports a sudden pull in the muscle which may prevent them from continuing.  Often muscle spasm pain and weakness is present in the cool down.  There are reports of localised pain and bruising or swelling may be evident.  Stretching and resisted muscle tests such as pulling the leg toward the midline reproduce or increase the presenting pain.  
With the chronic onset the athlete reports a period of pain usually associated with training that they may tolerate for a period.  Early in the training session they report stiffness and discomfort that eases as they warm up but they have increased pain and stiffness for 24 hours following the session.  Usually they reach a stage when they find it difficult to participate in activities involving kicking or agility work and have to significantly reduce their training levels or stop altogether and seek assistance.  Early intervention is critical to resolving the strain which is due to overuse and cumulative strain.
  

GROIN PAIN ASSESSMENT

1. Observation:  Walking, squat, stairs.  Looking for muscle guarding and asymmetry in movement
2. Quick tests:  Sit to stand, lunge, side lunge, knee lunge, heel raises, jog on spot, hop on spot, depending on severity of pain.  Looking for compensatory movements and contributions from joints such as the knee and ankle
3. Standing movement tests of active lumbar, thoracic and shoulder movement and noting restrictions of movement, muscle guarding or compensatory movements
4. Range of hip knee and ankle movement active and passive. Resistance tests at the hip joint particularly hip flexion, adduction and rotation and lower leg muscles. Mobility testing for hamstring, quads, iliotibial band, calf, adductors and psoas assessing for restriction of movement and pain provocation
5. Trunk stability testing in lying or 4 point kneeling to assess the capacity of the deep stabilising muscles of the spine to support the back and hip joints in movement, standing and running 
6. Specific provocation tests for the groin and palpation of the adductor muscles, pubic bone and abdominal region for tenderness, tightness or asymmetry in findings between sides
7. Neural testing for restriction in gliding and the neural system and specific nerve tests if indicated
8. Sports specific tests such as running on a treadmill, jumping, landing, knee tucks and cutting and planting when changing direction.

GROIN PAIN TREATMENT

Comprehensive assessment leads to a treatment plan with clearly identified aims and specific tests used to gauge improvement. The aims must be measurable and clear so the athlete can monitor their own progress and avoid overloading the injured tissues during recovery.

The foundation of treatment for any injured muscle or tendon is to initially decrease loading. Stop the activity that is aggravating the injury or causing pain. Initially pain relief and rest is important in the early stages of treatment. Using crutches, ice, supportive taping and modifying work or training is important in the early stages of recovery.

When the level of pain has eased manual therapy is integral to correcting underlying dysfunctions found during the assessment.

1. Decreased range of movement in the lumbar and thoracic spine, hips, knee and ankle joints
2. Poor awareness of posture, malalignment of the spine both statically and with movement and decreased lumbar stability
3. Muscle recruitment patterns – often weakness or delays in activation of gluteals, hip rotators and adductors with overactivity of the low back muscles and hip flexors and hamstrings 
4. Inability to maintain posture and balance in more challenging positions such as standing on a single leg or with side to side movements
5. Tightness in specific muscle groups, often hip flexors, adductors, hamstring and calf
6. Neural tissue tension and altered nerve gliding.

 
Progressive local muscle strengthening must be addressed during the treatment phase. Muscles that often need strengthening are hip adductors which pull the leg toward the mid line hip rotators, gluteals and pelvic stabilisers. Lack of endurance or weakness in core strength and spinal stabilising function need to be improved. Strengthening starts in a non weight bearing position such as laying on the back and can progress to standing and more functional positions relating to sports such as in a squat and wide based stance.

Monitoring exercise intensity and load as well as pain is essential in safely progressing to full training.

RETURN TO SPORT AFTER GROIN PAIN TREATMENT

In preparation for a return to sport isolated strength training must be progressed to strength relating to function in sports specific environment. During the assessment after identifying which activities increase groin pain, such as kicking or changing direction in running or prolonged running need to be improved.  A program with controlled resistance applied to strengthen the damaged tissues and increase their capacity to absorb more load is necessary to prepare for returning to sport. 
If kicking is an aggravating action progressive resistance work need to be introduced both for the kicking leg and stance leg. Resuming running is based on established protocols and careful progression of time, speed and constant reassessment.
 
A physiotherapist can assist in the assessment and treatment phases and monitoring a return to sport as well as treating any underlying dysfunctions that may have contributed to the injury. 
To be fully fit to return to sport you must have:
1. Minimal or no pain during an exercise activity
2. Minimal levels of pain or stiffness the day following and exercise session
3. Negative testing on specific provocation tests such as the “squeeze test” where the knees are squeezed together and also pubic stress tests which can be monitored independently by the athlete
4. No tightness or increased tension in the muscles around the groin region such as adductors, abdominals, quads and gluteals

Muscle injury causing groin pain can be managed well with careful assessment, initial rest and icing, muscle release/stretches, progressive strengthening and returning to full activity. If your groin is not resolving with appropriate rest, acute care and a gradual increase in exercise levels there may be an underlying coexisting pathology. 

There are a number of pathologies mentioned in literature including osteitis pubis, sports hernia, hip degenerative change, chronic adductor tendon injury, stress fractures in the pelvis and hip joints, nerve entrapment and referral from the lumbar spine.

Persisting groin pain that is not resolving would benefit from a careful assessment of the pelvis, lumbar spine and hips. Improving hip and lumbar movement, muscle recruitment strategies, strength and biomechanical assessment can get you back moving well and returning to your sport. 

The team at Northwest Physiotherapy can organise a referral for specialist investigation or opinion if that is also needed to resolve your groin injury.  We have worked closely with experts in sports medicine and orthopaedic surgeons.

CONCLUSION ABOUT GROIN PAIN TREATMENT

Groin pain is a common presentation in physiotherapy and medical clinics and requires a thorough musculoskeletal assessment to achieve optimal results.  
At Northwest Physiotherapy Group we have over 40 years of combined experience and we routinely manage patients who have elbow pain and dysfunction.  Our groin pain treatment philosophy is based on a comprehensive assessment of the whole musculoskeletal system and a results based hands approach.

There are good research studies that have demonstrated the effectiveness of Physiotherapy in the treatment of groin pain, especially in the long term.

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