Why are groin pain, sports hernias, and adductor strains so difficult to rehabilitate? Probably because groin pain has many so variables that limit complete recovery. The Clinical Journal of Sports Medicine outlined a complex range of functional deficits that may either cause or accompany groin pain. (1) During surgical exploration of 98 elite hockey players, 100% had co-existent external oblique tears, nerve entrapment of the ilioinguinal nerve, and strain to the adductor longus. Groin pain ceased after surgical reconstruction of the lesions. (1)
Groin pain can arise from any number of isolated diagnoses, all with nearly identical presentations. Groin pain is often elusive and multifactorial. Evidence-based chiropractors must be able to select appropriate tests, evaluate functional core and hip stability, then efficiently treat all of the variables involved.
The following video will dive a little deeper into the causative functional deficits behind core and hip instability as they relate to groin pain. Check out this quick review of why groin pain is difficult to treat, and learn one potent exercise to help the most stubborn of cases.
* The Copenhagen Adductor Strengthening Exercise demonstrated in this video is challenging and, like any other higher intensity functional exercise, should be reserved for players about to return to play or as a preventive measure for improving the adductor/abductor strength ratio in a healthy population.
Functional “stability” is required for joints to bear loads, move, and perform optimally while at the same time avoid injury and pain. (2,3) More specifically, local joint stability requires three basic components: the strength of the supporting musculature, adequate bony and ligamentous architecture, and precise dynamic CNS coordination of these muscles. (4) Athletic activities challenge each of these components. Athletes require a rapid transfer of load through joints for quality global movement. For example, injury-free running requires activation of the core, hip, knee, and foot with precise control to avoid overloading. A compromised joint will not remain in a neutral or centered position (centration). Joints are designed to reduce mechanical strain to passive structures, including the ligaments, capsule, cartilage, and joint surfaces- and allow the muscles to perform at their greatest mechanical advantage. (5) However, deficiency, injury, or weakness in one joint stabilizer requires compensatory recruitment of other muscles – resulting in an altered global movement pattern. (5,6) Compensatory muscle activation leads to strain and overuse injury, with ongoing problems creating “learned” dysfunction. (5-8)
Our core should be the foundation upon which the upper and lower extremities provide purposeful and injury-free movement. The muscles of the core allow the hip to provide lower extremity functional alignment. (9-12) While weakness in some hip muscles (hip extensors and knee extensors) is tolerated, deficiency or imbalance in others can have a profound effect on gait and biomechanical function throughout the lower half of the body. (12) Weakness of the hip abductors, particularly those that assist with external rotation, has the most significant impact on hip and lower extremity stability. (13,14) The thigh adductors are a frequently overlooked group of muscles in the pelvis. Adductor strains may be the origin of hip dysfunction or a consequence of compensation.
If an athlete develops weakness in their core or hips, eventually some other tissue will be stressed beyond its capacity during movement. Insufficient adductor strength complicated by global weakness often leads to groin pain. The adductor muscles function to approximate the thigh in open chain motion and stabilize the pelvis during closed chain activities. (15) The adductor group is called upon to generate substantial force during complex athletic movements. Injuries often occur during explosive movements that require the adductors to contract eccentrically; i.e., decelerate an abducted and extended thigh. (16) The adductor longus has a relative mechanical disadvantage for these types of movements and, not surprisingly, is the most frequently strained adductor muscle. (17,18) Predisposing factors for groin strain include a history of prior injury or inadequate physical conditioning. (19) Athletes with a thigh adductor: abductor strength ratio of less than 4:5 are at risk. (15,20,22) While many clinicians and at least one author regard limited abduction as a risk factor, (23) several studies have found no relationship between adductor flexibility and groin strain. (24-26)
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- Brown, Rea A MD; Mascia, Anthony MD; Kinnear, Douglas G MD; Lacroix, Vincent MD; Feldman, Liane MD; Mulder, David S MD An 18-Year Review of Sports Groin Injuries in the Elite Hockey Player: Clinical Presentation, New Diagnostic Imaging, Treatment, and Results Clinical Journal of Sport Medicine: May 2008 – Volume 18 – Issue 3 – p 221-226
- Clare Frank, Alena Kobesova, Pavel Kolar Dynamic Neuromuscular Stabilization and Sports Rehabilitation. The International Journal of Sports Physical Therapy Volume 8, Number 1 February 2013 Page 62
- N. Peter Reeves, Kumpati S. Narendra, Jacek Cholewicki Spine stability: The six blind men and the elephant Clinical Biomechanics 22 (2007) 266–274
- Kolar P: Facilitation of Agonist-Antagonist Coactivation by Reflex Stimulation Methods In: Craig Liebenson: Rehabilitation of the Spine – A Practitioner’s Manual. Lippincott Williams & Wilkins, 2nd edition 2006, 531-565.
- Janda V. Muscles, central nervous regulation and back problems. In: Korr IM (ed). Neurobiological mechanisms in manipulative therapy. Plenum Press, New York, 1978, pp 27-41.
- Janda V. Muscles and motor control in cervicogenic disorders. In: Grant R (ed). Physical therapy of the cervical and thoracic spine. 1st edition. Churchill Livingstone, Edinburgh. 1994, pp 195-215.
- Page P, Frank C, Lardner R: Asessement & Treatment of Muscle Imbalances. The Janda Approach. Human Kinetics. 2010.
- Cholewicki, J., McGill, S.M., 1992. Lumbar posterior ligament involvement during extremely heavy lifts estimated from fluoroscopic measurements. J. Biomech. 25, 17–28.
- Szu-Ping Lee, Powers C. Description of a Weight-Bearing Method to Assess Hip Abductor and External Rotator Muscle Performance. JOSPT. Volume 43, Issue 6
- Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM. Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med. 2011;39:866-873.
- Presswood L, Cronin J, Keogh JWL, Whatman C. Gluteus medius: applied anatomy, dysfunction, assessment, and progressive strengthening. Strength Cond J. 2008;30:41-53.
- Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG. Effect of a home program of hip abductor ex- ercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial. Phys Ther. 2010;90:895-904.
- van der Krogt MM, Delp SL, Schwartz MH How robust is human gait to muscle weakness? Gait Posture. 2012 Feb 29.
- Laurie Stickler, Margaret Finley, Heather Gulgin Relationship between hip and core strength and frontal plane alignment during a single leg squat Physical Therapy in Sport Available online 2 June 2014
- Tyler TF. et al. Groin Injuries in Sports Medicine. Sports Health. 2010 May; 2(3): 231–236.
- Delahunt E, Thorborg K, Khan KM, et al. Minimum reporting standards for clinical research on groin pain in athletes. Br J Sports Med 2015;49:775-781.
- Davis JA, Stringer MD, Woodley SJ. New insights into the proximal tendons of adductor longus, adductor brevis and gracilis. Br J Sports Med 2012;46:876—971.
- Norton‐old, Kimberley J., et al. Anatomical and mechanical relationship between the proximal attachment of adductor longus and the distal rectus sheath. Clinical Anatomy 26.4 (2013): 522-530.
- Emery CA, Meeuwisse WH. Risk factors for groin injuries in hockey. Med Sci Sports Exerc 2001;33:1423—33.
- Crow JF, Pearce AJ, Veale JP, VanderWesthuizen D, Coburn PT, Pizzari T. Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players. Journal of Sciences and Medicine in Sport 2010;13(2):202e4.
- Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility on the incidence of groin strains in professional ice hockey players. Am J Sports Med. 2001;29(2):124-128
- Ekstrand J, Gillquist J. The avoidability of soccer injuries. Int J Sports Med. 1983;4(2):124-128
- Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clin J Sport Med. 1999;9(3):151-156
- Emery CA, Meeuwisse WH. Risk factors for groin injuries in hockey. Med Sci Sports Exerc. 2001;33(9):1423-1433
- Tegner Y, Lorentzon R. Ice hockey injuries: incidence, nature and causes. Br J Sports Med. 1991;25(2):87-89
About the Author
Dr. Brandon Steele
Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.