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Beyond the Pain: A Comprehensive Journey through Groin Strain Recovery

Updated: Dec 5, 2023


Groin strains, a common and painful occurrence often associated with hockey and soccer, are not confined solely to these sports. Activities like cross-country skiing, fencing, handball, and track and field are also predisposed to these injuries due to the intense and regular eccentric contraction of the adductor muscles in the inner thigh, a requirement in these sporting disciplines. (1)


In the National Hockey League (NHL) realm, groin strains constitute roughly 10% of all documented injuries. Interestingly, most strains do not result from direct contact or collision. They are more likely to transpire during the pre-season than during the regular season. (2) This finding has motivated researchers to investigate a correlation between the strength of the adductor muscles situated in the inner thigh and the prevalence of groin injuries, particularly adductor strains. (3)


There is a relationship between the strength of the adductor muscles on the inner thigh and the incidence of groin injuries, specifically adductor strains. (3)


Article Index:

 

What is a Groin Strain


A groin strain refers to damage sustained by the inner thigh and hip muscles, known as the adductor muscles. These muscles stretch from the pelvis and extend to the inner section of the upper leg. The adductor longus is most prone to injuries among the adductor muscle group. (4)


The main functions of the adductor muscles include drawing the leg inward (adduction) and assisting in the bending and rotating of the leg at the hip joint. A strain ensues when these groin muscles are overstretched or subjected to a forceful contraction during stretching, causing muscle fibers to tear.


 

Symptoms Associated With A Groin Strain


Groin strains can trigger various symptoms, largely characterized by discomfort and reduced movement in the impacted region. These symptoms become more pronounced during leg motions, such as walking, or actions necessitating hip bending, like sitting or standing.


The discomfort is often described as an ache but can sometimes be a burning sensation. In certain cases, when nerve irritation is involved, the pain can mimic the jolt of an electric shock. The intensity and ramifications of a groin strain can fluctuate based on the degree of muscle fiber injury. Hence, these strains are typically classified into three grades, each signifying a distinct level of injury and corresponding activity impairment.

  • A Grade I Strain: Considered the least severe form, it involves a minor tear in a small portion of muscle fibers. The pain associated with this grade is generally mild and hardly disrupts one's daily activities.

  • A Grade II Strain: This reflects a moderate injury, with more muscle fibers torn. This leads to moderate pain and a noticeable restriction in certain activities. Moderate bruising and swelling in the groin region might also accompany this strain.

  • A Grade III Strain: This is the most extreme form of a groin strain, featuring a significant or, in some exceptional cases, a total rupture of the muscle fibers. The pain experienced is severe and drastically impedes the individual's capacity to participate in physical activities. This grade is often associated with substantial bruising and swelling.

 

Understanding Hockey Strain Biomechanics


To understand why hockey players are susceptible to groin injuries, it is necessary to analyze the underlying biomechanics of the ice skating stride and the anatomical structures involved in producing this complex movement. A basic ice skating stride encompasses two integral phases:


  • Stance Phase: The initial stage, termed the Stance Phase, involves an individual propelling their body mass forward by executing a forceful push-off with one leg while gliding. Throughout this phase, the adductor muscle group, located within the medial compartment of the thigh, plays a pivotal role in maintaining the equilibrium of forces required for forward propulsion. These forces are generated primarily from the hip, knee, and ankle articulations. As a player engages in the lateral thrust during the Stance Phase, the hip joint exhibits extension and abduction, the knee demonstrates extension, and the ankle undergoes plantar flexion. This orchestrated sequence of joint actions collectively contributes to the propulsion of the skater.

  • Recovery Phase: The subsequent stage, known as the Recovery Phase, is characterized by the leg returning to the central position in preparation for the subsequent push-off. During these transitions, the adductor muscles undergo eccentric contraction while being stretched. This biomechanical behaviour is vital in maintaining postural balance, absorbing reactive forces, and harnessing kinetic energy to facilitate hip flexion and adduction during the Recovery Phase.

This integral process assures that the leg initially utilized for the push-off is effectively repositioned at the center, priming the subsequent push-off with the contralateral leg. This dynamic mechanism promotes a seamless transition between strides and ensures uninterrupted fluidity of movement.


 

The Predisposition of Hockey Players to get Groin Strains


Within the realm of ice hockey, many factors contribute to players' susceptibility to groin injuries.


A primary underlying factor is the prevalent muscular imbalance between the hip abductors, primarily composed of the gluteal muscle group, and the adductors, encompassing the groin muscles. This inherent asymmetry, compounded by muscle fatigue and overutilization, can establish a conducive environment for the manifestation of groin injuries.


Typically, within the biomechanical construct of hockey athletes, the gluteal muscles exhibit superior strength relative to the groin muscles. This power differential often culminates in the overpowering of the groin muscles by the gluteal muscles, engendering an imbalance. This imbalance constitutes a substantial risk factor for injury amidst the dynamic locomotor activities involved in ice skating.


During skating, the adductor muscle group necessitates robust eccentric contractions to counterbalance the lateral leg movements observed in the Stance Phase. Eccentric contractions transpire when a muscle lengthens under the effect of tension, mirroring the behaviour of the groin muscles when mitigating outward leg motion.


However, if the groin muscles display relative weakness vis-à-vis the gluteal muscles, they may be subjected to undue strain during these movements. The overpowering muscular forces exerted by the stronger gluteal muscles can overload the groin muscles. This overload might cause the groin muscles to overextend, culminating in the muscle fibers being pulled and potentially torn, thus precipitating a groin strain.


Thus, the synergistic influence of muscular imbalance, fatigue, and the demanding physical requirements of ice hockey can significantly heighten the propensity of hockey players to groin strains. Regular muscle conditioning and strength training focused on the groin muscles can aid in alleviating these risks and augmenting on-ice performance.


 

Managing Groin Injuries


Groin injuries can induce notable pain, especially during the acute phase. At Kinetic Health, we devise treatment protocols tailored to match the distinct phases of a groin injury. Close collaboration with your healthcare provider across all stages is essential for a full recovery. Our treatment plan is subdivided into three crucial stages:

  1. Acute Phase

  2. Sub-acute Phase

  3. Sports-Specific Training


Managing the Acute Phase of a Groin Injury


During the Acute Phase, it is vital to address the groin injury promptly to facilitate the individual's rapid return to regular activities. The main components of our treatment approach and recommended exercises during the Acute Stage of a groin injury encompass the following:

  1. Implementing the RICE protocol: Rest, Ice, Compression, and Elevation. For additional details on when to apply ice or heat, please refer to Dr. Abelson’s blog, “Ice or Heat – Which Should I Use”.

  2. Providing gentle manual therapy, adjusted as per the patient's tolerance.

  3. Undertaking passive hip range-of-motion exercises strictly within a pain-free range.

  4. Initiating bent knee isometric strengthening exercises with sub-maximal effort and focusing on avoiding straight leg positions to prevent further damage to the adductor muscles.

  5. Introducing non-weight-bearing progressive resistance exercises performed strictly within a pain-free range.

  6. Incorporating flexibility exercises that target muscles uninvolved in the injury.

  7. Promoting strengthening of the lower extremity muscles on the side contralateral to the injury.

 

Treatment During the Sub-acute Phase of a Groin Injury


The transition into the Sub-acute Phase of treatment can commence only when the patient can activate the adductor muscles against gravity without experiencing pain. The primary elements of our treatment approach and suggested exercises during the Sub-acute Stages of a groin injury encompass:

  1. Prolonging manual therapy while expanding the scope to incorporate a broader kinetic chain of involved structures.

  2. Approving activities such as cycling and swimming, with cycling acting as an optimal warmup.

  3. Instituting a flexibility program that extends beyond the adductor muscles. "Sam's Daily Five Stretches" would be a fitting routine.

  4. Incorporating one-legged balance exercises.

  5. Executing progressive resistance exercises, including concentric adduction, strictly within a pain-free range of motion. We recommend standing adduction exercises employing a Theraband. Research indicates that eccentric training can effectively rehabilitate groin injuries.

  6. Including forward lunges paired with reciprocal arm movements in the workout.

  7. Practicing pelvic tilt exercises.

  8. Incorporating goblet squats into the exercise regimen.

  9. Introducing wobble board squats always performed within a pain-free range of motion.

 

Athletic Specific Training for Groin Injuries


The ultimate stage is designed to facilitate the patient's return to their specific sport or activity. The following outlines the principal elements of our treatment approach and the exercises we advise during this stage:

  1. Execution of sport-specific training exercises.

  2. Implementation of advanced balance and proprioception exercises.

  3. Continuation of strengthening and flexibility exercises.

  4. Gradual re-engagement in sports activities, beginning with non-contact drills and progressing towards full contact as tolerated.

Maintaining communication with your healthcare provider about your symptoms and progress is crucial throughout all stages. This helps adjust your treatment plan as necessary, supporting your recovery and preventing re-injury.


During this stage of the recovery journey, the primary objective is to boost the adduction strength on the injured side to 90 to 100 percent, equivalent to the abduction strength on the non-injured side. To fulfill this, heed the following instructions:

  1. Always allocate adequate time for a comprehensive warm-up before any exercise routine. This is a significant step in mitigating the risk of recurrent groin injuries, which are usually prevalent.

  2. Undertake resistance training in a standing position that closely mirrors the particular activity in which the injury occurred. For example, if the injury was sustained while skating, emulate the skating stride or kneel on a surface that simulates ice to perform adductor contraction exercises.

  3. Incorporate multi-directional lunges into your workout regimen. These exercises target multiple muscle groups, bolstering overall strength and stability.

  4. Employ slide boards in multiple directional vectors to boost your balance, agility, and strength. These are highly beneficial tools for rehabilitating groin injuries as they mimic the lateral movements commonly seen in numerous sports.

  5. Execute exercises such as ball squeezes and transitioning from a bent knee to a straight-leg position. These exercises particularly target the adductor muscles, assisting in recovery and preempting future injuries.

Remember that sports-specific training aims not solely to recover from the injury but also to return to your sport with enhanced strength and resilience. Always pay attention to your body's signals and modify your training schedule to avoid overstraining and possible re-injury.


 

Conclusion

In conclusion, although common and often debilitating, groin strains can be effectively managed and prevented through an informed, multi-staged approach. This encompasses early recognition of symptoms, prompt intervention, and adherence to a carefully designed rehabilitation program. As we've outlined, the three-phase approach - from the acute phase through the sub-acute phase and finally to sport-specific training - is paramount in facilitating a complete and expedient recovery.


Remember, the key to preventing re-injury lies in understanding the biomechanics involved in your specific sport, acknowledging inherent muscular imbalances, and fostering a commitment to maintaining balanced muscle strength. Adopting preventative measures, like a regular conditioning program that targets both the adductors and abductors, is critical in safeguarding against future groin strains.


Nevertheless, if a groin strain does occur, it's essential to respect your body's healing timeline and avoid rushing back into full activities. Maintain open communication with your healthcare provider, modifying your treatment and training regime according to your body's feedback and ensuring a slow but sure return to your sport.

While groin strains can be a painful setback, with the right care, prevention strategies, and rehabilitation, you can recover from these injuries and come back stronger, more resilient, and better prepared to enjoy your sport.


 

DR. BRIAN ABELSON DC. - The Author


Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.

 


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References


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  2. Kluin, J., den Hoed, P.T., van Linschoten, R., Ijzerman, J.C., & van Steensel, C.J. (2004). Endoscopic evaluation and treatment of groin pain in the athlete. Am J. Sports Medicine, 32(4), 944-949.

  3. Tyler, T.F., Nicholas, S.J., Campbell, R.J., & McHugh, M.P. (2001). The association of hip strength and flexibility on the incidence of groin strains in professional ice hockey players. Am J. Sports Medicine, 29(2), 124-128.

  4. Kiel, J., & Kaiser, K. (2018). Adductor Strain. StatPearls Publishing, Treasure Island.

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