GROIN INJURIES

back muscles; latissimus dorsi, erector spinae, multifidus and semispinalis which play a major role in maintaining an upright posture and working eccentrically to control lumbar flexion (Fig.1).

Differential diagnosis The groin and pelvic area is a minefield for differential diagnosis and in many cases a patient will demonstrate a mixture of clin- ical diagnoses rather than one specific condition. Diagnoses can be divided into acute, degenerative or insidious.

1) Specific muscle strains i) Adductor strain History: The player often complains of acute pain over the musculotendinous junction of adductor longus or at the teno-osseous junction at the pelvis, with pain over the pubic tubercle. This latter site of pain often gives rise to a more chronic injury scenario, a factor to con- sider when asked the inevitable question ‘How long before I am fit to play again?’

Cause: The soccer player will often describe the first symptoms when they had to change direction rapidly or when they had to overstretch to reach a pass that was running away from them. A long diagonal pass or repetitive crossing of the ball may also produce such symptoms.

Presentation: Any visual symptoms will depend on the grade of injury (table 1). Subjectively, the player will describe pain in the adductor region as already stated. Objectively, symptoms may be demonstra- ble on: ● Passive hip abduction ● Resisted hip adduction ● Resisted hip flexion, adduction and lat- eral rotation

Varying degrees of hip rotation may help to determine the specific adductor on the above tests.

Rehabilitation: Following acute manage- ment, full passive and active abduction of the hip joint and resisted hip flexion, adduction and lateral rotation must be pain free. Functional factors such as abrupt changes of direction, acceleration and deceleration and long diagonal kick- ing will place greater and more realistic stresses to the injury site to determine if a full functional recovery has been made.

ii) Rectus abdominis strain History: This tends to occur at the mus- cular insertion of the rectus into the supe- rior ramus of the pubis. A full and detailed history is essential to determine the pres- ence of osteitis pubis or a posterior abdominal wall disruption injury.

Cause: Symptoms often develop during pre-season when coaching staff place a greater emphasis on so-called abdominal work (‘sit-ups’ or ‘leg raises’) and increase the stress on tissues such as rectus abdo- minis by encouraging large numbers of repetitions. Playing or training on heavy pitches during the winter also puts extra stress onto this vulnerable site.

Presentation: Subjectively the player will describe dull pain over the bridge of the pubis, which is aggravated on rising from the sitting position, coughing, sneezing as well as active exercise. Pain is aggra- vated on functional testing such as per- forming a sit-up. The patient should lie on their back and attempt a sit-up in each of the following positions: 1. Hips and knees extended, with ankles fixed

2. Hips flexed to 45 degrees, knees flexed to 90 degrees, ankles fixed 3. Hips and knees flexed to 90 degrees Additional rotation and manual resistance may be necessary to increase the soft tis- sue stress if active movements fail to pre- cipitate the problem.

These three exercises gradually increase the amount of stress on the rectus and decrease the stress on the iliopsoas complex

the physical recovery of the tensile strength of the tissue is important before increasing the workload on the structure.

At the point of injury there is a sudden drop in the tissue’s ability to withstand tensile stress (Fig.3). This is followed by three phases:

a) Inflammatory phase (up to 5 days post-injury) - this is essential for healing and mainly involves protection of the strain and avoidance of tensile stress to encourage a solid foundation from which healing can occur b) Regeneration phase (from day 5 to day 21 post-injury) - gradual tension applied to the strain in the form of manual thera- py techniques encourages early collagen orientation, vital for a full functional recovery and the prevention of injury reoc- currence

c) Remodeling phase (21 days post-injury onwards) - this phase may continue for up

to 18 months and involves continued strengthening of the injury with progres- sive re-alignment of the collagen fibres. The formation of scar tissue must be avoided to prevent the development of a tightened, weaker structure that is more prone to re-injury. The real rehabilitation work only commences once the player has returned to full time training, a diffi- cult point to get across to the supposed fit player!

Injury

Rehabilitation: Once the acute stage has settled, active and passive mobilisations of the pelvic ring and rectus insertion are essential before encouraging strengthen- ing and functional exercise. It should be remembered that all active exercise requires the abdominal wall to contract, so any fitness maintenance must be done carefully. It is very easy for the player to aggravate the condition without realising the indirect damage caused by so-called maintenance work.

AB C

iii) Iliopsoas strain History: The player will often describe a mild, dull ache over the anterior aspect of the pelvis and hip. Due to the deep posi- tion of the muscle tissue, it is very diffi- cult for the player to pinpoint the site of injury.

Time

Figure 3: Change in tensile strength during the healing process (adapted from Hunter, 1994)

Cause: These injuries often result from repetitive work, usually in training, when the player is asked to cross the ball repeatedly during a specific training drill.

SportEX 29

Tensile Strength

TIP