Tackling groin pain in athletes: Return to play guidelines

For physios who treat a lot of sports-related injuries, groin pain can be a common and challenging problem which most often occurs in athletes involved in kicking sports. The management of adductor-related groin pain in athletes is an interesting topic – with many other compensatory structures in such close proximity, athletes tend to be able to continue to play longer with groin pain as compared to other areas (albeit at a lower performance level). So it’s likely that as physiotherapists – unless you work directly with a sporting team – we are not seeing these patients until further down the track, when the adductor-related groin pain becomes untenable and begins to contribute to time off the field. For those who have had to take time off for their adductor-related groin pain, the question is when do we return them to play? Are we able to return them to play sooner as compared to other injuries, knowing there are other structures which can contribute to the overall integrity of the hip and groin area in play? The short answer is that there are a range of factors to consider when making Return To Play (RTP) decisions. Vague, I know! Good news – the long answer is outlined in this blog, it will cover the most recent expert consensus on the RTP criterion for long-standing adductor-related groin pain (2) and tips from expert physio Stacey Hardin on how she implements the RTP decision-making process.

If you’d like to know more from the experts about groin pain in athletes, check out Stacey Hardin’s full Masterclass HERE.

1 – No imaging needed

Before we get into what is needed, it’s important to note the consensus was that for long-standing adductor-related groin pain imaging is not needed to determine an athlete’s RTP readiness. There are some instances in which imaging may be necessary – such as for severe injury where surgery is being considered, or when there may be other structures involved. But for the purposes of long-standing adductor-related groin pain, imaging is not necessary for RTP decision-making.

2 – Strength

This seems like a no-brainer, but there are a few elements to strength which should be considered with the athletes. As Stacey outlines in her Masterclass, you want to make sure there is symmetry in strength from side-to-side. But Stacey points out this is not sufficient in RTP assessment, you also need to make sure the athlete has adequate strength relative to their size by measuring torque – watch the below video taken from Stacey’s Masterclass in which she demonstrates how to calculate torque measurements:

Additionally, it is important to look at both isometric and eccentric strength of the adductors, while concurrently taking into account any reproduction of symptoms. For example, Stacey uses a five second squeeze test to determine the athlete’s pain levels, which she then uses to guide training/play decisions (0-2= continue activities as normal, 3-5 = some modifications to activity, 6-10 = significant modifications to activity).

3 – Performance testing

This includes components of planned and unplanned change of direction testing, athlete feedback and pain levels. Agility testing can include things like the Illinois Agility Test for planned change of direction testing, then adding unplanned/unpredictable change of direction tasks to simulate game play.

Stacey also outlines a useful screening routine she uses with athletes (soccer) including range of motion and functional movement testing, watch the below video taken from her Masterclass in which she explains the screening process:

It’s vital to take into account the athlete’s pain levels, as well as their general feedback when completing performance testing. An athlete’s confidence in RTP is equally as important as their objective performance.

4- Sport-specific skills

This will include assessment of quality of movement, performance analysis and again, the athlete’s feedback and pain levels. This will be very sport-specific. For example, in soccer it may be analysing the athlete’s ability to complete a cross at full speed, taking into account the pain-levels, athlete feedback, speed, power and accuracy.

Honourable mentions

There are a few factors Stacey points out which didn’t make the consensus but can contribute to the overall picture in RTP decision-making. Things such as tenderness on palpation, flexibility, intersegmental control, patient-reported outcome measures and the amount of training load the athlete is under. Obviously, the consensus is not exclusively what you need to follow, but it is a useful framework to guide you in your decision-making. It’s also important to note that while informed by the research, the consensus is also limited by the research – there are still many areas of groin pain which lack sufficient evidence, such as groin pain in female athletes.

Wrapping up

Returning athletes with long-standing adductor-related groin pain to play can be difficult, it’s not as clear cut as things like ligamentous injuries, as many athletes can continue on with some degree of groin pain. This can leave you weighing up a range of factors, such as the timing of the season, the athlete’s level of play, and various other individual lifestyle factors. This is a reminder of how important it is to be guided by athlete feedback, and employ shared decision-making to ensure you’re getting that athlete back at the optimal time with the optimal level needed to perform, as this may be different for everyone depending on their circumstances.

If you’d like to learn more about how the expert physios manage groin pain in athletes, watch Stacey Hardin’s full Masterclass HERE.