Groin Strains, Rehab, Ice and Stretching

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Rebecca Barclay is a Physical Therapist at the English Institute of Sport. Based at Loughborough University she works with Team Great Britain athletes to help them prepare for the upcoming winter and summer Olympics. Previously she worked for the professional clubs Reading FC and MK Dons, working at different times with their academy, reserve and first teams. She has a master’s degree in Advanced Physiotherapy in Sport and Performance from Kings College, London. 

Groin strains are a relatively common injury in soccer. Are there specific movements within the game that are frequently responsible?

If you took current Premier League footballers and scanned their hips you would probably find chronic degeneration in all of them. The movement patterns that they recreate on the pitch give them hip impingements and groin strains as a matter of course. The injury is quite complex though and often overlaps with other issues. The classic groin strain often comes from the player jumping up to collect a ball with leg outstretched, having that open chain contact and putting pressure on the long lever of the limb to the top of the hip. This can cause a pulling of the tendon from the pubic symphysis bone, damaging the enthesis (the connective tissue between the tendon and bone). Professional footballers have pretty powerful muscles, but their flexibility is often very poor, which means the tendon at the attachment takes the brunt of the movement as the striker reaches out for the ball.

The other common cause is changes in direction, due to the unpredictable nature of the sport. Running in one direction then suddenly turning and swiveling on the hip joint and pushing away can cause impingement injuries in the groin. A very high percentage of Premiership players have had groin surgery where the inguinal ligament is cut (which roughly follows the underwear line). This reduces the strain and tension placed on this area. The surgeon then places a mesh over the ligament and surrounding area to act to strengthen the inguinal region and dissipate the load placed there.

Is a large part of the problem from chronic injury that builds up over time?

We screen the athletes during the preseason using objective measures such as the Adductor Squeeze Test. They are asked to put pressure on a biofeedback machine which allows us to assess the strength of their groin. You can then retest it after every training session to look for changes. If players are showing a poor test result then they are potentially at risk of injury, even if they are not presenting with any symptoms. Many athletes will have injury prevention strategies in place that they have to do every day to make sure their groins are as strong as they can be.

The combination of load placed on the hip/groin complex over time contributes to many factors such as impingement in the hip, poor core stability, inguinal ligament tension and general overuse will mean somewhere in the season they will have issues.

If poor flexibility is a factor, should players try to improve it to avoid groin injuries?

As a general rule you can increase your flexibility, which is great, but if don’t apply extra strength and control training over the top of it, you can actually be making them more prone to injury. If you make an elastic band more flexible it becomes weaker, so you need to increase the fibrous content of the band to make it stronger. Without learning how to control their new-found flexibility they’ll just be a bit of a floppy mess on the pitch! Footballers are generally tight compared to many other sports, but that gives them the speed and technical ability that they need, so you have to be careful not to tip the balance and take that away. The goal is to make them as strong as they can be so they don’t come back with different injuries.

How long does it take a professional athlete vs a normal person to recover? It seems like people sometimes come back too early and reinjure themselves?

A professional athlete will generally always recover more quickly compared with a non elite athlete. This is due to a multitude of factors, but mainly down to the medical care they receive from day one of injury. I have seen that footballers tend to be more protected than Olympic athletes, as the club can wait until they are 100% better before bringing them back into the team. They also have more frequent treatment and care – which is directly linked with funding! In football, players are at the training ground more than healthy ones because of the amount of rehabilitation work they have to do though. It’s one of the reasons they hate being injured – the amount of extra time they have to spend at the training ground!

As we have so much time with the athlete we are in a better place to know when they are ready to come back, but that isn’t always possible outside of the elite athlete environment. We rely on objective markers to rate a player’s progress. If coaches can test all of their players before the season on basic abilities then you have a marker to work with when they are injured. The tests could be jump mat testing, sprint testing, agility testing, and so on. Then when we rehabilitate injuries we can compare the results with those that were taken before the season. This also gives the players goals to aim for, which helps them be motivated to get through it.

Unfortunately the nature of the sport is that it is unpredictable, and there is no way of knowing if they will damage something else, or if they had another injury brewing already. So even if they meet all of the objective test scores there is no guarantee that the injury won’t reoccur when they go back to playing.

We heard recently that Gabe Mirkin who in 1978 coined the acronym R.I.C.E. (Rest. Ice. Compression. Elevation.) is now saying that ice and complete rest might delay recovery. What is your position on that?

If that research is out there regarding ice, then I haven’t read it yet, but I do agree that compression and ice should be used for a finite period of time only. The first part of healing is for your body to create inflammatory markers that will kick start the next phase of healing. If we completely stop inflammation then we are stopping what the body wants to naturally do. So some inflammation is fine, but too much can be damaging to the cells, which is why we say to use compression. For ice there is evidence of different things in different studies, so it is important to read them in their entirety, understand who wrote them, who sponsored them and so on. For ice there is something called the Hunting Reaction where the body uses vasoconstriction and vasodilation in extremities exposed to cold – like when your nose goes red in the cold. If you use ice for too long there is a suggestion that you can reverse the benefit of using ice as the body tries to combat it by increasing the temperature. As a rule we don’t use it for more than ten minutes as after that that you could be doing more damage than good. To some degree ice is a pain reliever, but in the elite athlete setting we really use it to prevent further cell damage. In a major knee injury the inflammation will go on for days and weeks, so if you can restrict it you could potentially reduce the amount of healing that needs to take place down the line.

It has long been known that rest is not always an effective way of managing an injury. Delaying movement in an injured limb can create long term movement restrictions for example which can be very hard to restore later down the line. With elite athletes’ particularly, you also need to be aware of their general fitness, flexibility, core etc and be mindful of keeping on top of this during an injured phase. So rest is definitely not advocated!

How about static and dynamic stretching before and/or after exercise? Is there benefit to it?

Our school of thought is that static stretching has a place, but as a standalone program. They will do it, but not pre or post-training, it will be at home for thirty minutes in their own time. The purpose is to lengthen the fascia and muscle fibers to improve the pliability of the tissues. Anything you do around the game itself has a ballistic element in the way that you see Barcelona doing their pre-game movement patterns. Everything there is on a jog and has elements of improving flexibility even though players don’t necessarily see that it is doing that. So for example with speed skaters we do movement patterns that recreate what they will be doing on the ice – lung walking and so on that will be a functional form of groin stretch without the risk of injuring it. You are connecting the brain with the muscle tissue, which is exactly what you want to do before the competition.

Players often repeat the same injury several times. How much is physical vs mental, and is there anything they can do about it?

It is very difficult to tie the new injury to a mental factor, but the biggest predictor of injury is previous injury. Once you injure it something, you are likely to do it again because you have changed the whole tissue structure of that part of the body and it is never going to behave the same way again. Even once you have rehabbed it and your balance could even be better than it was before, you have a chronic injury and scar tissue that will be a risk for you. It’s horrible for the medical team to see when they rehab a player for nine months after ACL surgery and when they go back on the pitch they might do it again, or do the other knee. One of my colleagues had a training camp and three girls all tore their ACLs in one game. It is incredible bad luck and you can analyze forever why it happened – did the last two do it because they saw the first girl do it? You just don’t know. The mental aspect certainly comes into play but I believe that once a tissue is damaged the athlete can never perform in exactly the same way again.      

At what point should an athlete consider stopping playing a sport in the face of mounting injuries? When should their own safety overrule their desire to play?

It’s hard to say. We have a player who has had a lot of surgery on his shoulder, but he wants to get to Rio [de Janeiro for the 2016 Olympics]and you can’t get in the way of that goal. If he didn’t have that he would probably retire. At the end of the day it has to come from the athlete. If they can pass the fitness tests and the coach wants them, then they carry on as long as they want to try, and the vast majority will do that because it is their life. They don’t think beyond the game and their immediate future because they don’t worry about what happens after that.

When it is a non-musculoskeletal issue like concussion, it is different. I worked with a player who had MS [Multiple Sclerosis] and he was not allowed to play because he wasn’t medically fit enough for it. I’ve seen players in the past who had concussion and played on for twenty minutes but don’t remember any of it, which is frightening. At that time we have to step in and protect them from serious medical issues.

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