Optimising groin pain management: Practical strategies for a tricky condition

Groin pain can be tricky to manage because it can have multiple causes and often occurs with hip pain. Due to the multiple factors and potential structures influencing groin pain, it can be difficult to know which path to go down in its management. This blog will outline expert physio Andrea Mosler’s Practical on the management of groin pain, with the aim of helping you master your management and optimise outcomes for your groin pain patients

If you’d like to be a fly on the wall for how expert physio Andrea Mosler manages groin pain, watch her full Practical HERE.

Assessment

The first step to managing groin pain involves identifying the associated impairments and categorising the type of groin pain – you can learn more on this in Andrea’s groin pain assessment Practical. Broadly speaking, groin pain can be categorised as one or more of the below five categories (1):

• Adductor-related groin pain
• Inguinal-related groin pain
• Iliopsoas-related groin pain
• Pubic-related groin pain
• Hip-related groin pain

After a thorough assessment, you can start the management process using strategies including:

• Manual therapy
• External aids
• Activation exercises
• Proprioceptive training
• Strength training
• Plyometrics and return to sport training

Manual therapy

Manual techniques help improve range of motion and decrease pain to enhance the patient’s capacity to participate in rehab exercises. Hands on techniques are more likely helpful for acute situations, or where high levels of pain make exercise challenging.

Soft tissue mobilisation can be used on the adductors, hip flexors and/or gluteal muscles, as these areas tend to get irritated in athletes with groin pain. Also, for athletes who have a component of femoral nerve or obturator nerve-related pain, techniques such as soft tissue mobilisation and joint mobilisations of the hip and spine may be indicated.

External aids: Taping, groin straps, compression shorts

To better participate in rehab and to return to sport, many athletes benefit from wearable equipment that decreases pain in weight bearing. This can include taping, groin straps, and compression shorts. See the below snippet taken from Andrea’s Practical, in which she demonstrates the use of some of these aids:

Activation exercises

Now that we’ve covered ways to decrease pain and get moving, let’s move to the core of our management plan – exercise.

Initial rehab exercises should focus on re-establishing lumbopelvic control and reducing stiffness. These introductory exercises should include transverse abdominis activation, as well as pelvic tilts to develop an understanding of neutral pelvic positioning. When starting these lumbopelvic exercises it’s best to use positions that simplify coordination of the movement, such as quadruped and supine.

The next step is performing isometric contractions of the hip and pelvic region to decrease pain and activate areas that have been inhibited due to pain. Examples of this include supine adduction ball squeezes and seated hip flexion with manual resistance.

The final step in this early activation phase is developing lateral pelvic control in weight bearing. Lateral hip hikes are an excellent exercise to develop control, which Andrea demonstrates in the below video taken from her Practical:

Proprioceptive training

This can often be introduced early on, as it requires minimal motion of the hip. Initially, the athlete will perform static balance training such as standing on a compliant surface, and then progress to eyes closed. Dynamic balance would then be addressed by introducing movements such as multi-directional lunges on a compliant surface.

Proprioceptive training can be progressed in a variety of ways, including adding external loads or rotating the body to alter the athlete’s center of mass. For example, when performing a lunge, trunk rotation can be added to shift the athlete’s center of mass.

Strength Training

In addition to redeveloping balance, isolated hip exercises, trunk strengthening and multi-joint exercises (e.g. squats) need to be performed.

Hip strengthening

The patient should be progressed from isometric to isotonic training as quickly as they can tolerate. This is where you can integrate the early-rehab lumbopelvic activation cues to strengthen the hip in abduction/adduction, flexion/extension and internal/external rotation.

In her Practical, Andrea demonstrates how to progress the Copenhagen plank, which is especially important for adductor-related groin pain. See this snippet from her Practical below:

Initially these exercises may need to be performed in supine, side-lying, or quadruped. However, standing variations need to be added to improve closed kinetic chain motor control, and develop strength in athletic positions. An important recommendation is to use cable machines in order to standardise loads. Resistance bands do not offer constant resistance through a full range of motion, and the resistance varies due to factors such as the age of the band.

Trunk strengthening

Trunk weakness is commonly seen in athletes with hip and groin pain. From clinical experience, I find this is one of the most neglected elements in rehab programs. The primary exercises to focus on are sit-ups, leg raises, plank variations, and eventually sit-ups with rotation for certain athletes (e.g. throwing athletes). In the below video from her Practical, Andrea provides a sit-up progression that strengthens the trunk while minimising irritation of the hip:

Multi-joint strength training

This refers to larger compound movements like lunges, squats, and deadlifts (the unilateral variations of these can help improve lateral pelvic control). A vital consideration for some athletes will be to limit end range hip flexion. Many athletes with groin pain (especially those with femoroacetabular impingement) feel pain in deep hip flexion. By performing squats and deadlifts in a smaller range of hip flexion, we can load these movements with substantial weight while avoiding irritation.

Plyometrics and returning to sport

Plyometric training

Plyometric training bridges the gap from rehab to return to sport. The exact programming varies based on factors such as the type of injury, and the athlete’s sport. However, there are some high level principles to follow.

In general, the least intense/complex exercises are: low amplitude (i.e. low height and/or horizontal distance), bilateral, concentric focused (minimal eccentric landing loads), single repetition, performed on compliant surfaces with rebound, and/or performed in the sagittal plane. In the chart below, the left column outlines where to start with plyometric training and provides progressions through each variable as you move to the right:

NOTE: It is important to progress cautiously into frontal and multiplanar movements, as these can be particularly aggravating for patients with groin pain.

Return to sport training

As the athlete demonstrates sufficient control and minimal irritability with plyometric training, they can begin their return to sport training.

The fundamental introduction to return to sport is straight line running. Running provides the repetitive, continuous tissue loading that an athlete needs to tolerate the demands of sport. When the athlete demonstrates proper mechanics and can run continuously (e.g. 15 minutes), they should increase movement complexity by performing zig-zag running. The next progression is performing cutting drills.

As the athlete masters cutting drills, they can start performing some of the drills with sports equipment (e.g. a soccer player performing cone zig-zag drills while dribbling). Introducing equipment helps the athlete get back to warm-ups with the team, which is highly motivating and marks a major milestone in the rehab process.

Wrapping Up

Excellent groin pain management requires the right tools for every stage of rehab. This blog showcased some of the powerful tools physios have, including:

• Manual therapy
• External aids
• Activation exercises
• Proprioceptive training
• Strength training
• Plyometrics and return to sport training

For a full rundown on how to master your assessment and management of groin pain in athletes, check out expert physio Andrea Mosler’s full groin pain assessment and management Practicals HERE.