#IOCprev2017 Engagement, Evidence & Practice Blog Series

Nirmala Perera (@Nim_Perera) with contributions from Kristian Thorborg (@KThorborg)

Groin injury prevention and management

Evidence for groin injury prevention has been limited.[1] A recent systematic review indicates that hip and groin injury can be reduced by up to 40% using the FIFA 11+ programme,[2] but these results are based upon only two studies with heterogenic populations. More research is needed in this area.

Interested to learn more about whether it is possible to reduce groin injuries with an exercise-based building up resilience in the preseason? A PhD scholar from the Oslo Trauma and Research Center Joar Haroy will present his findings of a recent RCT which included the Copenhagen Adduction Exercise at the IOC World Conference on Prevention of Injury and Illness in Sport in Monaco (in two weeks!!). This exercise has shown great promise by activating and targeting the adductor muscle complex and increasing football players’ eccentric hip adduction strength.[3, 4] This is relevant in both players with current and previous history of groin pain, as both of these groups show an impaired hip adduction strength capacity and reduced function.[5, 6]

Backround on Groin injuries

Groin injuries are debilitating for athletes.[7] The majority of groin injuries (90%) sustained by elite footballers (soccer) result in less than a four week time-loss from the sport.[8] However, for many football players symptoms persist following return to play.[9] Treating these injuries is a major challenge for clinicians. The source of groin pain can be hard to define, being a region where a number of muscles converge (including the six muscles of the adductor group, iliopsoas and the abdominals), as well as an area in which pain can be generated from the hip joint, pelvis and spine.[8, 10, 11]

The vague reporting of pain in this region as groin injury/pain/strain makes comparisons across epidemiological studies difficult.[8, 12] Groin injuries are complex and the taxonomy used is heterogeneous. To overcome this limitation a consensus statement into groin pain was developed, namely the Doha agreement.[13]  Based on clinical entities of origin, groin pain was grouped into: adductor-related; iliopsoas-related; inguinal-related; pubic-related and hip-related groin pain. The most common type of groin injuries are believed to be adductor related as reported by between half and 2/3 of footballers (soccer) with groin injury.[8, 11]

Severity of muscle related groin injuries can range from minor strain (grade 1) to a severe strain (grade 3)[14] where grade 3 injuries can lead to complete loss of muscle function.

Knowledge of the epidemiology of groin injuries in sub populations such as female athletes and youth is also limited. The existing evidence relates predominately to male athletes. However, the available evidence suggests that prevalence is less in female athletes, potentially related to differences in anatomical structure.[15]

The most common mechanisms of groin injuries are kicking, sprinting, and sudden changes of direction.[16] In addition, actions that activate and/or stretch the muscle during forceful contraction can also contribute to groin injuries.

As well as being both an anatomical ‘lion’s den’ and difficult to treat, the recurrence rate for groin injuries and pain is high. It could be argued that the complications alluded to lead to poor clinical management and premature return to sport, associated with the development of more longstanding issues and recurrent or ongoing impairments of, athlete’s performance.[10, 11] Persistent symptoms can lead to the development of secondary problems as identified by existing evidence of more than one anatomical structure being involved in the presentation of 33% of athletes with a longstanding groin pain. [10-12]

When considering risk of injury, we know that previous injury carries considerable impact in relation to the potential for re-injury. Risk has been demonstrated to be >6 times more likely in youth AFL players compared to their peers who have not suffered an injury.[17] Further risk factors may include low levels of sports-specific fitness in the off-season[18] and adductor weakness.[18, 19]

Looking for more cutting-edge information on this topic? Including the Copenhagen five-second squeeze which is a new valid and practical clinical tool to evaluate sports-related hip and groin function.[20]

Make sure to sign up for the IOC World Conference on Prevention of Injury and Illness in Sport in Monaco (#IOCprev2017). Notably, leading experts including Per Hölmich, Thor Einar Andersen,  Joar Haroy and Kristian Thorborg will share latest research in the groin injury symposium.

References

1. Esteve, E., et al., Prevention of groin injuries in sports: a systematic review with meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 2015. 49(12): p. 875-891.
2. Thorborg, K., et al., Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. British Journal of Sports Medicine, 2017.
3. Ishøi, L., et al., Large eccentric strength increase using the Copenhagen Adduction exercise in football: A randomized controlled trial. Scandinavian journal of medicine & science in sports, 2015.
4. Serner, A., et al., EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. British journal of sports medicine, 2013: p. bjsports-2012-091746.
5. Thorborg, K., et al., Eccentric and isometric hip adduction strength in male soccer players with and without adductor-related groin pain: an assessor-blinded comparison. Orthopaedic journal of sports medicine, 2014. 2(2): p. 2325967114521778.
6. Thorborg, K., et al., Copenhagen hip and groin outcome score (HAGOS) in male soccer: reference values for hip and groin injury-free players. British journal of sports medicine, 2013: p. bjsports-2013-092607.
7. Waldén, M., M. Hägglund, and J. Ekstrand, The epidemiology of groin injury in senior football: a systematic review of prospective studies. British Journal of Sports Medicine, 2015.
8. Werner, J., et al., UEFA injury study: a prospective study of hip and groin injuries in professional football over seven consecutive seasons. British Journal of Sports Medicine, 2009. 43(13): p. 1036-1040.
9. Thorborg, K., et al., Prevalence and severity of hip and groin pain in sub‐elite male football: a cross‐sectional cohort study of 695 players. Scandinavian journal of medicine & science in sports, 2015.
10. Hölmich, P., Long‐standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. British Journal of Sports Medicine, 2007. 41(4): p. 247-252.
11. Hölmich, P., et al., Incidence and clinical presentation of groin injuries in sub-elite male soccer. British Journal of Sports Medicine, 2014. 48(16): p. 1245-1250.
12. Thorborg, K. and P. Hölmich, Advancing hip and groin injury management: from eminence to evidence. British Journal of Sports Medicine, 2013. 47(10): p. 602-605.
13. Weir, A., et al., Doha agreement meeting on terminology and definitions in groin pain in athletes. British Journal of Sports Medicine, 2015. 49(12): p. 768-774.
14. Tyler, T., et al., Groin Injuries in Sports Medicine. Sports Health, 2010. 2(3): p. 231-236.
15. Schache, A.G., et al., Anatomical and morphological characteristics may explain why groin pain is more common in male than female athletes. British Journal of Sports Medicine, 2016.
16. Serner, A., et al., Diagnosis of acute groin injuries: a prospective study of 110 athletes. The American journal of sports medicine, 2015. 43(8): p. 1857-1864.
17. Gabbe, B., et al., The association between hip and groin injuries in the elite junior football years and injuries sustained during elite senior competition. British Journal of Sports Medicine, 2010. 44(11): p. 799-802.
18. Whittaker, J.L., et al., Risk factors for groin injury in sport: an updated systematic review. British journal of sports medicine, 2015. 49(12): p. 803-809.
19. Engebretsen, A., et al., Intrinsic Risk Factors for Groin Injuries Among Male Soccer Players: A Prospective Cohort Study. The American Journal of Sports Medicine, 2010. 38(10): p. 2051-2057.
20. Thorborg, K., et al., Copenhagen five-second squeeze: a valid indicator of sports-related hip and groin function. British Journal of Sports Medicine, 2016.

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Nirmala Perera (@Nim_Perera) is an epidemiologist and a PhD scholar at the Australian Centre for Research into Injury in Sport and its Prevention (@ACRISPFedUni). She is the @IOCprev2017 #SoMe campaign coordinator.

Kristian Thorborg (@KThorborg) is a physiotherapist and associate professor at Amager-Hvidovre Hospital, in Denmark. He works for the Sports Orthopedic Research Center in Copenhagen (SORC-C), which is part of the IOC Sports Injury Prevention Research Center in Copenhagen.