Groin injuries in Athletes

Groin injuries are typically associated with athletes involved in multi-directional fast paced sports such as Hurling and Football.

The incidence of groin injuries in elite Gaelic footballers was shown to be as high as 9% (Murphy et al, 2012).

There are many different causes of groin pain in the sporting athlete, the most common diagnoses including acute groin strains, adductor tendinopathy and osteitis pubis. It can be an extremely debilitating injury associated prolonged periods on the sideline. There are many structures around the hip and groin region that must be considered when managing a groin injury, for instance there are 5 different muscles that act as adductors of the hip. When too much pressure is put on a certain part of the pelvis during movement this can lead to failure of other local tissues. This is often seen in sport when players have an unusual way of cutting/turning which can become problematic over time, thus leading to a groin injury as an example.

Red flags for groin injury often seen in GAA are limited hip ROM, reduced groin strength (groin squeeze) and poor lumbopelvic control, characterised by a player leaning excessively over their planting foot during a cutting movement.

Treatment begins with accurate diagnosis of the pathology as without clarifying the exact cause it is hard to implement a fully functional rehab programme due to the complexity of the hip/groin region. Muscle control and de-loading of affected tissues are two components that I like to focus on when approaching these injuries initially. It is important to introduce sports specific drills when suitable especially in multidirectional sports as the groin muscle has a massive role in decelerating the hip movements during quick turns.

 

Paddy Hannon, MISCP


Groin Injury Screening In Gaelic Football

 
The role of musculoskeletal screening has been a hot topic in recent time, see here, with the debate on the validity and efficacy of some tools. It can cause serious confusion for some clinicians on whats the most effective strategies to put into place, what is worth measuring etc.
The past 10 years clinicians have been sold false promises on the role of the FMS and other such tools in predicting and preventing injuries.
And while we shouldn’t abandon the screening process to reduce injuries, we need to be a bit more aware on what they actually measure and does it even help the clinician? 
 
A recent paper by the group led by Dr. Eamonn Delahunt has looked at the adductor squeeze test and the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire to assess its ability to identify Gaelic Football players at risk of developing groin injury. There was 55 players within the cohort and they where followed over a 9 month period. The chartered Physiotherapist during pre-season as part of an injury screening evaluation included both the adductor squeeze test and HAGOS. No groin injuries or other injuries where found during the pre-season testing. 
 
Results revealed a significant difference in pre-season adductor squeeze test scores between those players who did (median = 210 mmHg, n = 10) and did not (median = 260 mmHg, n = 45) sustain a groin injury, U= 107.5, z =  2.58, p = 0.01, r = 0.35.
The optimal cut point for the squeeze test to discriminate between players who did and did not sustain a groin injury, to be 225 mmHg. 
 
Results of the Mann-Whitney Test revealed a significant difference in pre-season HAGOS function,sport and recreation subscale scores between those players who did (median=76.56, n=10) and did not (median=96.87, n=45) sustain a groin injury, U=114.5, z=2.48, p=0.01, r=0.33. With regard to the HAGOS function,sport and recreation subscale score, the cut point with maximal sensitivity (0.70) and specificity (0.73) to discriminate between players who did and did not sustain a groin injury was 87.50.
 
What should be of great interest to clinicians when reading this study is both the ease to administer of both tests and the cost-effectiveness. Unlike many studies which look at expensive and time-heavy methods, these are available to all clinicians with no heavy burden also. While the relative sample size was small, it does give clinicians both some normative data and cut off points to make some meaningful decisions within the team setting. It may also allow the clinicians to individualise both Strength and Conditioning programs and injury prevention methods within a group setting. 
Thomas Divilly

Acute Groin Injuries in Gaelic Football

We recently had the pleasure of having Mark Roe present on the “Managing Injury Risk when Performance is the Focus” in Sports Physio Ireland as part of our Educational Seminars. A lot of the data presented was related to the GAA, which is highly relevant as they would make up most of the sporting population that Physiotherapist’s and Sport Therapist’s would see in the clinic setting. A few things really stood out in the seminar, mainly the injury burden that some injuries have on Gaelic Football and Hurling.

Mark presented data that showed that Groin injuries accounted for 14% of the total injury incidence in Gaelic Football, with adductor related accounting for 39% of those groin injuries. What was interesting to note was that out of all those groin injuries 72% where acute in on-set. This goes against the popular belief out there that all groin injuries are chronic in nature, with only 28% of groin injuries classified as chronic in this population. Of the groin sub-classification of injuries (based on the Doha Consensus Statement), pubic-related pain accounted for the greatest time-loss of player availability (Mean Time-Loss 49 days). Thus, knowing that adductor related injuries account for a large portion of injuries in Gaelic Football it’s important to consider injury reduction strategies for this group.

This data follows on nicely from some of Andreas Serner work on acute adductor related injuries. His work has looked at the anatomical location of acute adductor related injuries in a sporting population and found that the adductor longus was involved in 87% of all cases. Isolated injuries accounted for 65% of athletes with multiple muscle injuries in 35% of cases, these with a combination of adductor grevis, pectineus etc. The majority of injuries were graded as 1 or 2 (83%) with 17% grade 3 injuries. Of the avulsion injuries, all where proximal adductor longus avulsions, which where combined with at least two other adductor injuries in all cases. Thus a relatively severe injury.

So as a professional working with GAA teams, knowing that groin injuries account for a large portion of lower limb injuries and which the adductor longus will largely make up the majority of those, putting in strategies looking at training load, strength, hip mobility etc to help reduce these injuries is vital.

 

Thomas Divilly


Fatigue Markers in Sport

Following on with some of our most recent posts on training load and injury/illness as we prepare to welcome Mark Roe for our August Seminar “Minimising Injury Risk and Maximising Performance in the GAA”, we will look at fatigue as a useful marker to monitor the athletes that we work in day to day, especially within the team setting.

Management of fatigue is important in mediating adaption to training and ensuring the athlete is prepared for competition. These training responses can be both positive and negative, and helps both the Strength and Conditioning and Medical staff see how the athlete is responding to the training load prescribed.

Different times of the year, different objectives will always make these slightly open to interpretation of the support staff e.g. during a period of planned overreaching,

the support staff will expect to have changes in fatigue markers that may be negative. Fatigue can also give us a better ability to reduce the athletes’ susceptibility to nonfunctional over-reaching, injury, and illness, by picking up signs and symptoms of difficulties to the training load early.

An excellent recent systematic review in Sports Medicine highlighted the role of fatigue on injury rates and illness in athletes. Below I have outlined some of the main findings from the review on fatigue markers and injury within that paper.

Fatigue Markers and Injury

The review showed that only 9 studies investigated fatigue–injury relationships, seven of which used perceptual wellness scales.

  • In soccer players 3 studies showed greater daily hassles to be associated with increased injury, using the Hassles and Uplifts Scale (HUS) (Ivarsson et al., 2010; Ivarsson et al., 2013; Ivarsson et al., 2015)
  • Laux et al. (2015) further support the positive perceptual fatigue– injury relationship in their findings, which reported that increased fatigue and disturbed breaks, as well as decreased sleep-quality ratings, were related to increased injury.

However, In contrast rating of perceptual fatigue showed slightly different findings in other studies:

  • Killen et al. (2010) found increased perceptual fatigue (measured via worse ratings of perceptual sleep, food, energy, mood, and stress) was associated with decreased training injury during an elite rugby league preseason.
  • Similarly, King et al. (2010) showed increased perceptual fatigue (measured via various REST-Q factors) was associated with decreased sports performance training injuries and time-loss match injuries.

The authors theorise that these unexpected findings may be due to the fact that when players perceive themselves to be less fatigued they may train/play at higher intensities, increasing injury likelihood.

Most of the studies used wellness scales that take approximately 1–4 min to complete. These are extremely practical to administer to athletes and are quick and not too time consuming. The Rest-Q has been also well-validated within the literature.

The review also showed that current self-report measures fare better than their commonly used objective counterparts. In particular, subjective well-being typically worsened with an acute increase in training load and chronic training load, whereas subjective well-being demonstrated improvement when acute training load decreased. Using quick subjective questionnaires and “knowing” the athletes is vitally important. Earning the trust of the athlete and building a strong relationship over a period of time, is just as useful as any expensive monitoring system.

The authors also noted the poor investigation within the literature of the relationship between sleep and injury.

Sleep is a vital part of the body’s recovery process and has been well highlighted in recent times on it’s relationship to productivity, chronic pain and depression (Rosekind, (2010); Smith (2004); Tsuno (2005). The review showed that three studies assessed sleep–injury relationships via sleep quality ratings, with only Dennis et al. (2015) investigating objective measures of sleep quality and quantity in relation to injury. No significant differences in sleep duration and efficiency were reported between the week of injury and 2 weeks prior to injury.

fatigue

While the number of studies is quiet limited in the review, evidence of the use in the team setting to monitor the role of fatigue on injuries is supported. However, anecdotally and from experience within the field the importance of speaking to people, building strong relationships and creating a supportive environment cannot be underestimated. An athlete who trusts your role and job in helping their performance and having their wellness as a priority will often speak to you sooner than any subjective or objective marker can pick up.

So while using these tools is of great importance, don’t forget the strength of building personal relationships with your athletes.

Thomas Divilly

  • Ivarsson A, Johnson U. Psychological factors as predictors of injuries among senior soccer players: a prospective study. J Sports Sci Med. 2010;9(2):347.
  • Ivarsson A, Johnson U, Podlog L. Psychological predictors of injury occurrence: a prospective investigation of professional Swedish soccer players. J Sport Rehabil. 2013;22(1):19–26. 93.
  • Ivarsson A, Johnson U, Lindwall M, et al. Psychosocial stress as a predictor of injury in elite junior soccer: a latent growth curve analysis. J Sci Med Sport. 2014;17(4):366–70
  • King D, Clark T, Kellmann M. Changes in stress and recovery as a result of participating in a premier rugby league representative competition. Int J Sports Sci Coach. 2010;5(2):223–37.
  • Kinchington M, Ball K, Naughton G. Reliability of an instrument to determine lower limb comfort in professional football. Open Access J Sports Med. 2010;1:77–85.
  • Kinchington M, Ball K, Naughton G. Monitoring of lower limb comfort and injury in elite football. J Sports Sci Med. 2010;9(4):652.
  • Killen NM, Gabbett TJ, Jenkins DG. Training loads and incidence of injury during the preseason in professional rugby league players. J Strength Cond Res. 2010;24(8):2079–84.
  • Laux P, Krumm B, Diers M, et al. Recovery-stress balance and injury risk in professional football players: a prospective study. J Sports Sci. 2015;33(20):2140–8.
  • Rosekind, Mark R., et al. “The cost of poor sleep: workplace productivity loss and associated costs.” Journal of Occupational and Environmental Medicine52.1 (2010): 91-98.
  • Smith, Michael T., and Jennifer A. Haythornthwaite. “How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature.” Sleep medicine reviews 8.2 (2004): 119-132.
  • Tsuno, Norifumi, Alain Besset, and Karen Ritchie. “Sleep and depression.” The Journal of clinical psychiatry (2005).
  • Dennis J, Dawson B, Heasman J, et al. Sleep patterns and injury occurrence in elite Australian footballers. J Sci Med Sport. 2015;19(2):113–6.

Groin Rehab

Groin rehab

Groin Injury Rehab

Rehabilitation for groin injuries

A groin injury is one of the most complex injuries we see at Sports Physio Ireland. It’s location and anatomy is one of the main reasons for this. This area consists of the adductor longus, magnus, brevis and gracilis, all of which insert to the underside of the pelvis.  The primary role for these group of muscles as a whole is the stabilisation of the pelvis during motion (running, jumping, cutting). These muscles also play a role in swinging the leg when turning and twisting during movement in scenarios such as game play.

When designing a rehabilitation program, it’s important not to only focus on the area of pain. You have to look at the overall balance between both groin areas, left and right. Tension or restriction of movement in one can directly effect the forces and pressures on the other side.

It is also important to assess and analyse the areas above and below the injured groin. Lack of ankle balance or stiffness can cause an overload in the groin when cutting or tackling. Quite often I see groin injuries in players who have had a history of bad ankle sprains or achilles injuries in the past. Strength in the core muscles above the area of pain and stiffness in the hip also have a huge impact on the cause and the design of the rehab program at SPI.

It is for this reason that we choose whole body movement exercises to rehab groin injuries. By doing so, you improve your overall movement and offload any imbalances that have contributed to developing the injury. The key thing with exercises such like side lunges, squats or single leg deadlifts is the attention to detail. I see many players performing these exercises in a rushed environment which can actually just compound the imbalances that are already there.

 

Key Messages

  • The groin has multiple roles for an athlete.
  • Don’t focus on the pain, look at the overall movement pattern.
  • Find your imbalances.
  • Attention to detail with your rehab.

 

Joey Boland,

Head Physiotherpaist

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Speed For GAA Players

Speed is defined as the rate at which someone moves.  We can divide speed into an explosive phase and a knee drive phase. A lot of GAA players spend far too much time developing muscles to move slowler, simply because this is an easier way to train during a gym session. We have to look at the relationship between gym sessions and the game played. GAA involves a lot of acceleration and deceleration, but many gym programs don’t reflect the two patterns.

There is a huge role for both strength and hypertrophy in athletic development but speed is often ignored. Reasons for this include;

It’s Time Consuming

In order to train absolute speed it can take up to 40 minutes to properly warm up and activate the muscles and patterns required. This can be slow and tedious. Quite often this part is skipped or sped up in order to get to ‘the good stuff,’ such as sprinting. Athletes can be resting for up to 4 minutes between exercises which can result in sessions lasting up to 2 hours . These sessions are regularly omitted from training plans because of an already busy schedule.

It Is Perceived As A Light Session

There is a ‘if its not hard its not worth doing’ mentality in GAA. Quite often coaches would rather see teams out of breath rather than doing a pure speed session. Athletes don’t get their heart rates up too high or break a sweat. For coaches and some athletes the temptation to work hard can be too much. Working smarter is better for athletic development.

Too Tired After Heavy Training Loads

Heavy weights, long training sessions and matches make it hard to fit speed work into a training regime. You need to prioritise it in your training week for when you are at your freshest. Typically GAA matches are on a Sunday so a speed session would be optimum on a Wednesday. Pitch sessions and gym sessions are regularly prioritised ahead of this, with pitch sessions regularly on a Tuesday and Thusday and gym sessions on Mondays and Wednesdays.

Joey Boland,

Head Physiotherpaist

www.sportsphysioireland.com

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Podcast 1 – GAA Pre Season

As the GAA pre season gets under way for clubs around the country, Inter County hurler and Physio Joey Boland and Physio Thomas Divilly discuss what they see as the rights and wrongs seen in your usual pre season and how you can improve what you’re doing.

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6 Tips to improve your speed in GAA

1. Mobility:

It is essential to have mobility in your muscles and joints to allow your legs to produce power through the whole motion while sprinting, cutting and turning.

This is best done through foam rolling, dynamic stretches and last but not least static stretches of areas that are particularly tight or limited.

2. Single leg control:

Is key component of speed, while sprinting and changing direction quickly only one foot is in contact with the ground at a time. The better your single leg control, especially around hip the greater the transfer of power through your body to the ground. Poor single leg control lead to lead to inefficient use of the power your muscles are producing.

3. Running Mechanics:

Your running technique also plays an important part, ideally you should be generating power and driving through the strong glutes muscles and not through your knees and calfs. Keeping light on your feet and preventing your heels from touching the ground on cuts and turns always you spring back in the opposite directing as quickly as possible.

4. Explosive Power:

Developing your explosive power is one the key components to increasing your speed on the pitch. Simply put explosive power refers to an athletes ability to exert a maximal amount of force in the shortest possible time interval. Enhancing your explosive power can be done through a variety of different training systems and exercises such as plyometric work and using a prowler.

5. Repeat sprint ability:

In sports such as gaelic football and hurling an athletes Repeat Sprint Ability (RSA) is an important component of their fitness. RSA describes the ability of an athlete to recover and maintain maximal effort during subsequent sprints. This type of fitness is commonly trained using interval sprints and Maximal Aerobic speed (MAS) runs.

6. Body Fat Percentage:

Decreasing your % Body fat is another factor in increasing your speed on the pitch. Imagine what it would be like to run around a pitch with a weighted vest or carrying dumbbells and how that would affect your athletic performance. Keeping an optimal % body fat decreases the workload on your joints and muscles while also allowing you to to maximise your speed.