Groin pain is a common occurrence in multi-directional field sport athletes. According to a 15-year prospective UEFA injury study¹, groin pain accounts for approximately 12 – 16% of all time-loss injuries in men’s football (soccer). The complex, anatomical nature of the region makes groin pain challenging to diagnose, manage and rehab, with high recurrence rates of ~20% for many football athletes^2,4,5. The most common type of groin injury is acute adductor-related pain (figure 1), which is likely to occur during activities such as change of direction or kicking. Despite acute pain being more common, it is gradual-onset or long-standing pain that is a greater cause for concern. Recent evidence suggests insidious onset pain may be responsible for a high number of undiagnosed or unrecorded groin injuries, which has resulted in athletes playing through pain or discomfort.

Figure 1: Hip and groin injury clinical entities and characteristics in UEFA adapted from Werner et al. 2019 (1).

The major concerns for hip and groin injuries are either insidious onset pain at multiple anatomical sites or long-standing groin pain that results in performance decrements. Decreased hip adduction strength and decreased hip adduction to abduction ratio has been shown to be a risk factor for groin pain². The key to successfully managing groin pain is to develop a monitoring framework that attempts to mitigate the risk of athletes developing insidious groin pain. Performing regular hip adduction and abduction strength assessments to determine an athletes baseline strength level and what constitutes a meaningful change is an important consideration when implementing a monitoring framework, below is a framework of a monitoring system developed by Wollin et al⁸, useful for the early detection and management of groin pain (figure 2).

Figure 2: In-season monitoring and clinical process in soccer from Wollin et al. 2018 (8).

An alternative option to the fixed hip adduction 15% strength deficit alert as shown in Figure 2 would be to use an athletes mean score and have the alert set for a strength deficit of 1 standard deviation, this may allow for individual variation in their response to training or game stimuli. 

Once the strategy to determine a meaningful change has been defined, implementing a successful monitoring framework requires consistent recording of hip adduction and abduction strength following a training or match stimulus. An example of how this monitoring protocol would be implemented for a 6-day turnaround in field-based sports can be found below (figure 3):

Figure 3: A 6-day turnaround monitoring protocol for field-based sports, based on the framework from Wollin et al. (8)

It is common for majority of monitoring or screening tests to occur approx. 48 hours post a match stimulus, it is important to try to maintain consistency with this monitoring structure to eliminate confounding factors and be able to compare results. As can be seen in figure 3 the screening occurs prior to training and if one of the following occurs further assessment if required:

1. Loss of hip adduction strength (group or individual flag eg 15% strength loss)
2. Decreased hip adduction to abduction ratio (group or individual flag eg < 0.9)
3. Pain associated with the assessment 

If any of the above occurs, it would be important to follow up with a physical examination and/or an intervention, the latter may be manual or exercise therapy. The most important component is to re-assess and determine whether there has been a positive change to the strength levels of the athlete, which means they would continue to train or if there is still residual strength loss. If there has been strength loss, a decision will need to be made on whether the athlete requires a modified training load and strength exercise prescription.

The aim of a monitoring framework is to assess an athletes response to training and match stimuli to avoid development of insidious onset of groin pain, the goal shouldn’t be to use the framework to stop athletes from training but to better inform decision making processes on individuals in an attempt to maintain consistent team training to build athlete resilience.

References 

1. Werner, J., Hägglund, M., Ekstrand, J., Waldén, M., (2019), Hip and groin time-loss injuries decreased slightly but injury burden remained constant in mens professional football: the 15-year prospective UEFA Elite Club Injury Study, British Journal of Sports Medicine, 53(9), 539-546. https://doi.org/10.1136/bjsports-2017-097796
2. Weir, Adam, et al. “Doha agreement meeting on terminology and definitions in groin pain in athletes.” Br J Sports Med 49.12 (2015): 768-774.
3. Falvey, É. C., King, E., Kinsella, S., & Franklyn-Miller, A. (2016). Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients—clinical findings, MRI findings and patient-reported outcome measures at baseline. Br J Sports Med, 50(7), 423-430.
4. Waldén, M., Hägglund, M., & Ekstrand, J. (2015). The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med, 49(12), 792-797.
5. Orchard, J. W., Seward, H., & Orchard, J. J. (2013). Results of 2 decades of injury surveillance and public release of data in the Australian Football League. The American journal of sports medicine, 41(4), 734-741.
6. Thorborg, Kristian, et al. “Clinical examination, diagnostic imaging, and testing of athletes with groin pain: an evidence-based approach to effective management.” journal of orthopaedic & sports physical therapy 48.4 (2018): 239-249.
7. Serner, Andreas, et al. “Mechanisms of acute adductor longus injuries in male football players: a systematic visual video analysis.” British journal of sports medicine 53.3 (2019): 158-164.
8. Wollin M, et al. In-season monitoring of hip and groin strength, health and function in elite youth soccer: Implementing an early detection and management strategy over two consecutive seasons. J Sci Med Sport (2018), https://doi.org/10.1016/j.jsams.2018.03.004