Groin Injuries in Football Player

1. Groin Injuries in
Football Players

2. Overview
• Groin anatomy
• Main groin issues experienced by football players
• Clinical and imaging assessments
• Treatment and Rehabilitation Options

3. Groin Anatomy

4. A Complex Area

5. DOHA Consensus

6. Acute Groin Injuries

7. Chronic Groin Pain
Usually due to three causes that are often combined;
• Pubic overload / osteitis pubis.
• ‘Inguinal disruption’ / Sportsmans hernia arising
from a secondary weakness of the posterior wall of
the deep inguinal ring
• Musculotendinous / Enthesopathic lesions of the
adductors or rectus abdominus

8. Pubic bone stress /
Osteitis Pubis
Osteitis pubis is an overuse injury caused
by biomechanical overloading of the pubic
symphysis and adjacent parasymphyseal
bone with subsequent bony stress reaction.
The pain is usually aggravated by running,
cutting, hip adduction and flexion against
resistance, and loading of the rectus
abdominis. The pain can progress such
that athletes are unable to sustain athletic
activity at high levels.

9. Pubic Apophysitis

10. Inguinal-related groin
pain

11. Sports Hernia
What pathology if any is present?
Abnormal tension exists in the inguinal canal due to
varying degrees of inguinal disruption and this is
recognised as posterior wall weakness, external ring
dilation, conjoint tendon damage and tears in the
inguinal ligament. Not all of the features are present
in any one individual and other pathologies involving
the muscles, ligaments and joints may also be
affected.
What appropriate nomenclature would be
acceptable for this condition?
The agreed term to be used for this condition is
inguinal disruption as this was thought to accurately
describe the condition which tends to present with an
increase in tension in the groin area due to the high
level of ‘twisting, turning, sprinting and kicking’ the
athletes undertake in their sporting activity.

12. Signs of Sports Hernia

13. Prepubic Aponeurotic
Complex (P-PAC)
The PPAC is formed by
interconnection between the
tendons of the adductor
longus, adductor brevis,
gracilis and pectineus
muscles, the aponeurosis of
rectus abdominis,
pyramidalis and external
oblique muscles, the articular
disc, the anterior pubic
periostium and by the
superior, inferior and anterior
pubic ligament;

14. Adductor
Tendinopathy

15. Secondary Cleft
Diagram shows development of secondary
cleft (arrow) due to tear at conjoined tendon
attachment to inferior margin of
fibrocartilage and at conjoined tendon
enthesis.
The secondary cleft sign is a marker of short
adductor (gracilis, adductor brevis, and
pectineus muscles) attachment injury.

16. Superior Cleft
Rectus abdominis–
adductor longus
attachment
microtearing

17. Pyramidalis-anterior pubic
ligament-adductor longus complex
(PLAC)
Studies by Prof Ernest Schilders
demonstrates a strong direct connection
between the pyramidalis muscle and
adductor longus tendon via the anterior
pubic ligament.
This introduces the new anatomical
concept of the pyramidalis-anterior pubic
ligament-adductor longus complex
(PLAC).
A classification system of 6 types of PLAC
injuries has been developed.
MRI imaging should be employed for all
proximal adductor longus avulsions to
assess the integrity of the PLAC.

18. Combined Injuries
• DOHA consensus is a useful
framework, but groin injuries in
football players are often
combined as shown in this
study
• Pain provocation tests are
often positive and multiple
clinical entities is often present
in male football players with
longstanding groin pain.
• Both the number of positive
pain provocation tests and the
number of clinical entities
correlate with pain intensity
and disability in male football
players with longstanding groin

19. Red Flags

20. Assessment

21. Per Holmich
Groin Assessment
How to Examine the Groin by Per Holmich -
YouTube @PerHolmich

22. James Noake
Groin Assessment
@DrJN_SportsMed

23. Clinical Tests for Groin Pain

24. Imaging
MRI and dynamic ultrasound
identified as the primary
methods for identifying the
majority of issues.
Selective nerve blocks can be
used to rule out and identify
specific causes of pain.
X-ray, CT and small field of
view DEXA useful in some
cases.

25. Treatment Options

26. Conservative Management

27. Prof Schilders - Acute groin injuries
– any indications for surgery?
Acute groin injuries – any indications for
surgery? Ernest Schilders - UK (youtube.com) @e_schilders

28. Prof Sheen – Sports Hernias &
Chronic Groin Pain
28. HerniaTalk LIVE Q&A: Sports Hernias &
Chronic Groin Pain (youtube.com)
@aalisheen

29. Is surgery required?

30. Dr Muschaweck – Sports Hernia
& Minimal Repair Technique
113. HerniaTalk LIVE Q&A: Sports Hernia & Minimal Repair
Technique (youtube.com)

31. Rehab

32. Rehabilitation of Groin
Injuries
Rehabilitation of Groin Injuries (youtube.com) @aserner

33. Groin Rehab Exercises

34. Groin Rehab Continuum
@enda_king

35. Groin Rehab Concepts
@KThorborg

36. Strength Testing
Measure Hip & Groin Strength | VALD
Performance ForceFrame - YouTube
@JoClubbSportSci

37. Holmich Protocol

38. Modified Holmich Protocol

39. Osteitis Pubis Rehab
@Steeve_McAleer

40. Iliopsoas Rehab

41. Sports Hernia Rehab

42. Return To Play Criteria