Physical Therapy for Groin Strains

If you played sports, it is likely that you have experienced a “pulled groin” or “groin strain” at one time or another. This injury is most common in soccer and ice hockey but will frequently occur in other sports such as tennis, rugby, baseball, basketball, and football. Furthermore, a groin strain can limit your ability to perform activities like running, kicking, cutting, or changing direction, and can linger for months if left untreated. Below we will discuss common presentation, cause of injury, and rehab considerations after a groin strain. 

Disclaimer: We recommend for you be evaluated and treated with the supervision of a medical rehab professional, such as a PT, to ensure individualized progression specific to your injury. This blog is meant to be a resource to gather more information about your injury, but should not be substituted for specific medical advice from a qualified professional. 

Anatomy of “Pulled Groin”

Firstly, we must define the muscles that make up the groin. There are several muscles in this area including the adductor brevis, adductor longus, adductor magnus, pectineus, gracilis, and obturator externus. To clarify, these muscles are your adductors. This is because of their function at the hip joint. The most commonly injured muscle of this region is the adductor longus muscle. This injury typically occurs with a rapid deceleration when kicking, cutting, or twisting that causes a quick eccentric contraction of the adductor musculature. Additionally, the adductor longus has a poor mechanical advantage to withstand the forces through the trunk, core, and hips which makes it more susceptible to injury. 

Common Presentation of a Groin Strain

This injury is very common amongst athletes, especially soccer and ice hockey players, due to the high frequency of kicking, cutting, twisting, skating, and changing direction. This injury usually occurs when attempting to resist a rapid hip extension and abduction movement similar to the stride during ice skating. This muscle group attempts to decelerate the leg as it goes into this motion, but fails to do so causing the injury to occur. This injury can be a result of an acute forceful contraction of the muscle, or due to chronic overuse causing microtrauma at the tendon/bone.

Minor groin pain often goes unreported as athletes attempt to play through the pain which can result in chronic changes occurring at the tendon/bone. Patients will typically present with tenderness to palpation of the adductor musculature, painful resisted hip adduction, pain with passive hip abduction, and an inability to kick, jump, sprint/skate, hop, or cut without pain. 

Risk Factors for Groin Strain

Most training and rehab programs place a large focus on strengthening hip abductor musculature to prevent low back, hip, or knee injury, but little effort is placed on strengthening the adductor (groin) muscles. Strength deficits of the adductor muscles compared to the abductors will place an athlete at higher risk for groin or pubic-related pain. Tyler et al found that ice hockey players are 17x more likely to experience a groin injury if there is a strength deficit of greater than 20% between the adductors and abductor muscle groups. This muscle group is often undertrained, but it is important not to ignore the adductors to prevent injury. 

Differential Diagnosis

It is crucial to properly screen for other pathologies to ensure proper diagnosis of the injury. The presence of one of these pathologies may dramatically affect treatment. Because of this, It is imperative to rule out these pathologies to determine the appropriate intervention for recovery. Below are a few examples of pathologies that need to be properly screened for because they may cause pain in the same area or mimic a groin strain:

• Sports hernia or athletic pubalgia
• Osteitis Pubis
• Femoro-Acetabular Impingement (FAI)
• Femoral neck fracture or Avascular Necrosis of the femoral head
• Hip Labral Tear
• Lumbar Spine and Sacroiliac Joint pathology with referred groin pain

Best Physical Therapy Treatment for a Groin Strain

Above all, the best treatment is a comprehensive rehabilitation program supervised by a medical professional. However, for the purpose of this blog, I want to highlight one exercise progression that is highly recommended for recovery, performance, and injury prevention. This exercise progression is called the Copenhagen Side Plank. It is easily scalable to the appropriate phase of rehab or training specific to each athlete. In short, the Copenhagen Side Plank is tremendously effective to improve strength and eccentric control of the adductor musculature. It is an effective exercise to help decrease risk of groin injury when included in training programs. This exercise is key to increasing strength after a groin injury. We still want to train the adductors in hip flexion, extension, and abduction as well, but this exercise provides a great opportunity to build the prerequisite strength required to handle those combined motions at the hip. 

Below is an example of a progression of Copenhagen Side Plank exercises. There are many variations of this exercise. You can scale this exercise further to make it more or less challenging depending on the level of the individual. I typically prescribe them for 2-4 sets of 10-30 seconds on each side. It is important to note that you should not feel stress, pain, or strain on the inside of the knee while performing this exercise. If you are experiencing pain in the inside of your knee, you may need to place more of the leg on the bench to decrease the stress to that area. The exercises below progress in difficulty from easiest (#1) to hardest (#8):

Copenhagen Side Plank

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2.

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8.

I’m not sure why it is associated with Copenhagen in particular, but Tony Gentilcore suggests that it is due to most of the recent research focusing on groin injuries in sport coming from Denmark. I’ll buy into that theory. I always appreciate an exercise with a good name, especially the ones with seemingly random cities or countries attached such as Turkish Get-ups, Bulgarian Split Squats, or Romanian Deadlifts. Copenhagen Side Planks fit right into this group also. I’ll do more research on the origins of these names and write about them soon. 

Further Considerations for a Comprehensive Rehabilitation Program Include:

• Improve Hip ROM and Hip Joint Mobility
• Improve Core Stabilization
• Increase Adductor Strength
• Improve Eccentric Control
• Improve Dynamic Single Limb Stability
• Re-introduce Plyometrics, Sprinting, Cutting
• Return to Sport Drills
• Avoid aggressive stretching during early phases of rehab as it may result in increased pain

It is imperative to be evaluated by a medical professional to rule out any other red flags that may be referring to pain in the groin. It is best to be evaluated and treated with the supervision of a medical rehab professional, such as a PT, to ensure individualized progression if you have suffered from a groin strain. Proper rehab will also help to enhance performance and decrease your risk of re-injury. This injury commonly feels better with rest, but symptoms return as patients resume their sport unless the patient completes a comprehensive rehab program to improve strength, ROM, coordination, stability, power, agility, and endurance. Come in to see us at Symmetry PT and we can create a treatment plan unique to you to get you back as soon as possible. Click here to schedule an appointment to see us today!

References: 

1. Gentilcore T. Exercises you should be doing: Copenhagen side plank shenanigans. 2020 May. Available on https://tonygentilcore.com/2020/05/exercises-you-should-be-doing-copenhagen-side-plank-shenanigans/
2. Groin Strain. Physiopedia. Available on https://www.physio-pedia.com/Groin_Strain
3. Ishøi L, Sørensen CN, Kaae NM, et al. Large eccentric strength increase using the Copenhagen Adduction exercise in football: A randomized controlled trial. Scand J Med Sci Sports. 2016 Nov;26(11):1334-1342.
4. Jackie L Whittaker, et al. Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med 2015;49:803-809
5. Larson CM. Sports hernia/athletic pubalgia: evaluation and management. Sports Health. 2014;6(2):139-44.
6. Serner A, Jakobsen MD, Andersen LL, et al. EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries. Br J Sports Med 2014;48:1108-1114.
7. Thorborg K, Reiman MP, Weir A, et al. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. J Orthop Sports Phys Ther. 2018;48(4):239-249.
8. Tumminello N. Copenhagen hip adduction exercise: the science and unique variations. 2017 Feb. Available on https://nicktumminello.com/2017/02/copenhagen-hip-adduction-exercise-the-science-and-unique-variations/
9. Tyler TF, et al. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. American Journal of Sports Medicine. 2001 Mar-Apr;29(2):124-8