Thursday, November 4, 2010

Resolving Groin Injuries – Part 3

Treating Groin Injuries
Acute stage
The 72-hour phase after an injury is characterized by swelling and pain. During this phase, use ice to reduce inflammation (ice massage), and if required, take an over-the-counter anti-inflammatory medication. Avoid using these medications after the first 72 hours since they can have a negative effect on tissue regeneration. Even during this initial stage, it is important to get some motion into the affected area in order to speed the healing process.
During this stage, I recommend that you get as much rest as possible. I also recommend you use a compression strap which will help to prevent further injury. Elevating the injured leg while doing the ice massage every 2 to 3 hours is also essential (ice only 7 to 9 minutes each time).
Manual Therapy
Manual therapy should be implemented as soon as possible. The longer that the injured person waits for therapy to begin, the longer the resolution time may be. The period of time that you will be unable to perform your usual activities will depend on the cause of injury and the degree of injury.
The first thing practitioners must do in treating a groin injury is perform a biomechanical analysis. In this process they evaluate the patients gait for alteration in movement patterns. This will give them an initial hypothesis as to which structures are involved. Refer to the previous section of this blog to see which muscles are involved.

Then the practitioner will need to examine these areas (hands-on palpation) to confirm that there is a restriction present. The practitioner will feel an alteration in normal tissue consistency, it will feel ropy, rigid, and there will be a lack of tissue glide between adjacent structures. Once the area needing treatment has been identified, manual therapy can begin. There are several forms of therapy that can achieve good results in addressing myofascial adhesions; they include: Active Release, Graston Technique, Massage Therapy, and Fascial Manipulation.
The success rate in resolving a groin injury is very high in the hands of an experienced soft tissue practitioner. As the practitioner work through the soft tissue restrictions they will be looking for changes in tissue consistency, movement and function. Some of these changes are often noted even during the first treatment.
When you are being treated for a soft tissue injury, it is very important to communicate to the practitioner how the treatments are going, and how the condition is improving, if at all. In most cases, improvements in symptoms (decrease in pain) and functionality (ability to perform tasks better) will be noted if the right structures are being treated.
Exercise is essential in the treatment of a groin injury for a complete recovery and to prevent any reoccurrences. In many of my blogs I stress the importance of stretching, strengthening, and balance training for a complete recovery. Without these three essential elements, your injured tissues will not remodel correctly and you will only be setting yourself up for a series of groin injuries.
Stretching Exercises
During the first 48 hours to six weeks after an injury, collagen is formed and laid down to repair the injured area. If the injured person is performing the correct stretching exercises, the majority of the collagen will be laid down in the same direction as the tissue being repaired, making the repaired tissue stronger and more capable of performing its function. If the individual is not stretching, the tissue will be laid down in more random patterns, leading to the development of weaker tissue that is easily re-injured.
  1. Groin Stretch (Core Performance)
  2. Lateral Lunge Moving - Dynamic Stretch (Core Performance)
Strengthening Exercises
Tissue remodeling can last up to 12 months after an injury. During this phase, the collagen fibers increase in size, diameter, and strength. The collagen remodels to withstand the stresses that are placed up on it. In other words, tissue remodeling is dependant on the forces that are applied the tissue. If the injured person is performing appropriate strengthening exercises, the collagen will remodel to withstand the stresses placed upon it. With exercise, this remodeling will lead to a complete recovery of the injured tissue, along with a decreased chance of re- injury. Without appropriate strength training, the possibility of re-injury is very high, no matter what therapy the patient has received.
  1. Lateral Squat - Low (First learned this in martial art - to make harder go lower)
Balance Exercises – Proprioceptive Training
Whenever a groin injury occurs, the injury is usually not restricted to just the ligaments, tendons, muscle fibers, and fascial fibers. Often, the embedded neurological structures within these soft-tissue structures are also damaged. These neurological structures (golgi tendon organs, muscle spindles, and joint receptors) perform an essential role in positional control. Any damage to these structures can have the effect of decreasing stability, which can lead to problems.
Fortunately this damage can be repaired with exercise protocols that involve balance and proprioception. Some of the proprioceptive exercises we use with our patients at the clinic are:
  1. One-legged Stand
· This is a good initial exercise to try, with a slow progression into partial single leg squats. Do all of this exercises within a pain-free range-of-motion.
  1. Wobble board training
· Slowly increase the difficulty of wobble board exercises from the two-legged balance exercises, into a single-leg exercise that combines full-body motions. Once you are ready, you can even try the single-legged version with your eyes closed. Note: The eyes-closed version should only be attempted after you are fully recovered and you are ready to work on increasing athletic performance.

Returning to Activities
In order to return your normal sports and activities (hockey, scoccer etc.), you should be able to perform all movements required by that sport or activity without significant pain.

The time needed to return to a sport will vary depending on the movements required. Distance runners are only required to move in relatively straight lines compared to hockey player who requires constant force changes in direction during normal play. Returning too soon to a particular activity could set an athlete up for a series of injuries.

  1. Emery CA, Meeuwisse WH. Risk factors for groin injuries in hockey. Med Sci Sports Exerc. Sep 2001;33(9):1423-33.
  2. Johnson R. Ice hockey. In: Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. 2nd ed. Philadelphia, Pa: Hanley & Belfus; 1997:851.
  3. Morelli V, Espinoza L. Groin injuries and groin pain in athletes: part 2. Prim Care. Mar 2005;32(1):185-200.
  4. Verrall GM, Slavotinek JP, Barnes PG, et al. Hip joint range of motion restriction precedes athletic chronic groin injury. J Sci Med Sport. Dec 2007;10(6):463-6.

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