GROIN INJURIES

tion of adductor longus, depending on the site of the individual’s symptoms. Arthrodesis (fusion of bones to eliminate movement) of the symphysis has been performed in chronic cases and although the individual may subsequently be pain free, the lack of movement means they may not regain a full functional recovery. Often further injury occurs in the sacro- iliac or lumbar joints.

Rehabilitation: Modified rest is impor- tant in the initial stages. If this fails to resolve the problem then a period of com- plete rest may be necessary. Biomechanical assessment may demon- strate a gait problem, such as leg length discrepancy, which can be corrected with orthotic control. Functional rehabilitation is similar to that described later in the article in relation to rehabilitation of the posterior abdominal wall repair.

4. Osteoarthritis - degenerative damage Cause: In the older player degenerative changes in the hip joint cannot be dis- counted when trying to diagnose chronic joint pain.

Results of case studies of former soc- cer players suggest that a link exists between playing soccer and osteoarthritis of the hip (3).

Pathophysiology: Degeneration will begin in the non-weight bearing areas of the acetabulum (hip socket), as a degree of compression is necessary for bone cell regeneration. Eventually the weight bear- ing areas are affected and the protective articular cartilage is eroded exposing the subchondral bone. The non-weight bear- ing areas then start to develop osteo- phytes (bony outgrowths) or areas of cal- cification and the articular surface changes into a roughened contour.

Clinical symptoms: The inflammatory symptoms produced and the compensato- ry biomechanical changes will produce subjective, objective and functional symp- toms. Pain is localised to the hip joint or anterior aspect of the thigh. Passive hip flexion, adduction and lateral rotation usually exacerbate the symptoms. Mobility may well be limited, particularly hip extension and rotation. This in turn can affect the running and walking pattern of the player. A true leg length discrepancy

will also contribute to a faulty gait pat- tern and must be corrected if successful rehabilitation is to be achieved.

Examination: Capsular tightening pro- duces limited movement most noticeably in flexion and medial rotation.

FABER’s test (flexion, abduction and external rotation) is often used as a diagnostic and mobilisation tool in the assessment and rehabilitation of hip and groin injuries.

The standard position for FABER’s test is in supine lying (Fig.5a) although it can be performed with the subject lying prone which increases the capacity to mobilise the surrounding adductor muscle tissue and sacroiliac joint (Fig.5b). The hip and knee of the leg to be tested are flexed and the heel is placed next to the knee of the stationary extended leg. The flexed knee is passively moved into abduction and the range of movement and the player’s appreciation of any soft tissue tightness are noted.

In prone lying, the hip and knee of the leg to be tested are flexed and the heel is placed over the proximal aspect of the popliteal fossa of the knee (area behind the knee). The flexed knee is now extend- ed and abducted from the hip, and range of movement and soft tissue tension are recorded.

Management: NSAIDs, corticosteroid injections and the use of electrotherapy modalities may all provide temporary relief to extend the time a player can con- tinue to play weight bearing sport, such as soccer.

Rehabilitation: Active and passive mobilisation work, stretching and specific adaptations to the training programme of the player can all provide temporary relief and extend playing careers. The player must be aware of the need to introduce rest days wherever possible as a daily training programme of weight bearing activity will exacerbate the degenerative symptoms. The introduction of cycling and swimming cardiovascular programmes will help to maintain physical fitness, encour- age mobility and reduce the weight bear- ing stresses of running drills. Any flexibil- ity work must place emphasis on hip extension and rotation, important func- tional components in a sport such as soc- cer, which requires rapid changes of pace and mobility. Biomechanical assessment and orthotic control will be helpful, par- ticularly if a true leg discrepancy is noted on assessment.

5. Bursitis

Localised pain around the greater trochanter (gluteus medius/trochanteric bursitis) or lesser trochanter (iliopsoas bursitis) of the hip joint may present as a groin injury.

Cause: This can be due to direct trauma or repetitive overuse as in pre-season training or fatigue towards the end of the season. Bursae are present to reduce fric- tion between prominent bony structures and overlying soft tissue.

Figure 5: FABER’s test a) patient lying supine

Presentation: Irritation of the bursal tis- sue produces a localised inflammatory reaction with a resulting sensation of ‘toothache’ type pain.

b) patient lying prone

Management: Acute care involves the use of NSAIDs, RICE and localised elec- trotherapy modalities. A modified training programme or complete rest may be nec- essary, depending on the functional limi- tations determined by an objective assessment. Functional assessment of the sport and daily activities is necessary, as the pain is often aggravated by such daily activities as climbing the stairs and get- ting out of a car.

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TIP

TIP