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


Hip Impingement

 

Hip pain is a very topical issue within GAA players at the moment. In the past year there has been some high profile articles within the media, with often misleading information and scaremongering being circulated, confusing the patients that we see in our clinic.

 

So what is it?

For years there has been a poor establishment of diagnostic criteria and management of this injury, however the Warwick Agreement on Femoroacetabular Impingement Syndrome has outlined the consensus of world experts.  Femoroacetabular syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum. The main symptoms that people present with in the clinic is hip or groin pain during certain movements or positions e.g. changing direction or cutting during training/match. Pain may also be felt in the buttock and thigh.

Patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way.

In clinic, GAA players often report an increase in training load, playing with multiple teams and multiple age groups, general increase in stiffness in the hips and groin over a sustained period.

Diagnosis of FAI syndrome does not depend on a single clinical sign. Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used test, flexion adduction internal rotation (FADIR), is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion. There will be strength deficits around the joint on testing, especially in Hip Abduction and Hip Flexion. Hip flexion deficits were associated with a decrease in function as shown by the association with the greater loss in range of motion and patient reported outcomes.  It is well established that large strength deficits are found in people who have chronic hip pain, leading to weakness of the hip rotators and hip abductors.  There is suggestion of impairments in hip frontal, sagittal and transverse plane ROM during gait, squatting and stair climbing.  A recent research paper showed that during a squat movement, participants with FAI had decreased hip internal rotation and increased anterior pelvic tilt compared to a normal group. The study also showed the FAI group had decreased gluteal and hamstring strength compared to the normal group. In theory, decreased activation of the gluteus maximus and/or hamstring muscles may contribute to the lack of posterior pelvis tilt. Hypothetically, relative posterior tilt of the pelvis during this phase of squatting would limit the potential for impingement in the presence of cam morphology.

The average age of symptomatic hip pain in this group is about 28 years, with nearly a 50/50 split in male and females, however this is a North American population,

with very little research been done in GAA.  Studies of adolescents have made it apparent that the development of FAI may also be due to developmental adaptations during skeletal maturation as a result of activities that involve repetitive hip motion, such as field based sports. Recent research demonstrates an increased prevalence of FAI type-deformities in elite adolescent athletes compared to their age-matched non-athletic controls.

This suggests that the morphological changes of FAI may be a response to repetitive stress at the hip joint secondary to sporting activity during periods of skeletal growth.

Research has shown that in particular, adolescent males who participate in ice-hockey, basketball and to a lesser extent soccer, whilst performing a minimum of three training sessions and games per week are currently at greatest risk of developing a boney deformity in the hip and potentially progressing to symptomatic hip impingement.  So from a practical point of view, parents and coaches need to be aware of the amount of training load that young adolescents are participating in, especially during times of growth spurts. While physical activity is hugely important, a 15 year old boy playing three different sports up to 9 or 10 times a week while going through a growth spurt needs to be properly managed.

 

Rehabilitation aims to reduce patients’ symptoms by improving hip stability, neuromuscular control and movement patterns. However, for optimal results in returning the player to pain free play it is important that all confounding variables are explored.

  • Activity Modifications to reduce pain
  • Training Load education
  • Range of Motion deficits
    • Especially Internal Rotation
  • Strength deficits
    • Sagittal plane
    • Frontal plane
    • Transverse plane
  • Movement patterns
    • eg. modifying squat and deadlift mechanics to prevent pain and increase glute/hamstring strength
  • Correct poor mechanic mechanics
    • Change of Direction
    • Cutting
    • Acceleration/Deceleration

One of the most important things that patients need to understand is there is no one size fits all to these problems. Each case has different challenges and rehabilitation needs to target the presenting persons deficits so a suitable tailored programme can be prescribed.

Thomas Divilly MSc MISCP 

 

References: 

 

Griffin et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med. (2016). 50

Hayes et al. Persons With Chronic Hip Joint Pain Exhibit Reduced Hip Muscle Strength. Journal of Orthopaedic & Sports Physical Therapy. (2014). 44 (11).

Nepple, J.J. et al. Hip Strength Deficits in Patients With Symptomatic Femoroacetabular Impingement and Labral Tears. Arthroscopy: The Journal of Arthroscopic and Related Surgery. (2015). Vol 31, No 11 ,

Diamond et al. Isometric and Isokinetic hip strength and agonist/antagonist ratios in symptomatic femoroacetabular impingement. Journal of Science and Medicine in Sport. (2016) 696-701.

Bagwell et al. Hip kinematics and kinetics in persons with and without cam femoroacetabular impingement during a deep squat task. Clinical Biomechanics. (2016). 87-92.

Clohisy JC et al. Descriptive epidemiology of femoroacetabular impingement: a North American cohort of patients undergoing surgery. Am J Sports Med. (2013). 41(6)

de Silva et al. Does high level youth sports participation increase the risk of femoroacetabular impingement? A review of the current literature. Pediatric Rheumatology. (2016). 14:16

 


hiparticle

 

How To Fix Hip Injuries in Runners

Hip injuries are commonly seen in runners regularly by physiotherapy clinics throughout Dublin, especially after the recent Dublin marathon. These injuries are quite often caused by poor running techniques. Hip injuries are amongst the most common, usually from a result of too much pressure exerted on the hip on landing during running. This can cause injury to the joint, which leads to inactivity and pain  surrounding hip and pelvic muscles.

The way we run is quite ofter determined by imbalances or tightnesses in our hips and legs. Your body will find the most efficient way to run that suits your specific hip tightness. I often use a river flowing through a rocky valley as am example. The water can’t get through hard rocks so it finds an easier way. This is the same for running, the body will other methods and compensate, if your hips are tight or your hamstrings won’t allow you lift your legs which can lead to poor or imbalanced running techniques.

When dealing with hip injuries in runners at Sports Physio Ireland, we look into the person’s specific restrictions, tightnesses and imbalances when moving in the gym, running and on the physiotherapy bed. It is important to identify the runners specific characteristics so that we can then put in place exercises and a running technique development programme that are specific to our injured client.

Posterior hip development is one of our best ways to cure hip pain in runners. Exercises such as one leg deadlift, lunges and barbell deadlifts all help develop muscular and neural feedback in this area. This helps our injured runners in four ways;

1) Builds muscle

2) Improves sensory feedback

3) Improves hip stability

4) Realigns the hip

The above four benefits of posterior chain exercises are key to any runner who needs physiotherapy on a hip injury, some may need more than others. We also use these exercises on our uninjured runners to help prevent injuries in the future

Joey Boland
BSc Physiotherapy MSc Sports Medicine

www.sportsphysioireland.com

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The Hip Flexor Stretch

The Hip Flexor stretch is a common exercise used in both gym and rehab settings. Personally I use it a lot in conjunction with many other movements, in the treatment of musculoskeletal disorders and sports-related injuries.

While it can be an excellent prescription for many individuals, it is very often performed wrong. Some simple queues to help make sure your technique is spot on are:


– Tighten your tummy
– Squeeze your bum (glutes) on the side being stretched
– Try not to arch through your lower back
– ‘Spread the ground’ with your feet

Hip
Once your form is correct you can play around with the angle of the stretch for even greater results. Because of the oblique orientation of the iliopsoas muscle (hip flexor) I find that adding a slight degree of rotation towards the opposite knee can allow for further lengthening of the muscle and a better all around stretch.

This stretch, when prescribed in conjunction with good strength-based rehab exercises, can help to improve reduced hip mobility. And improved hip mobility has strong links to decreasing low back and knee pain.

Give it a try and let us know how you get on.

Riain Casey, M.I.S.C.P.


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