Treatment of groin injuries

Per Hölmich

Sports Orthopedic Research Center – Copenhagen (SORC-C)

Department of Orthopedic Surgery

Copenhagen University Hospital Hvidovre, Denmark

&

IOC Research Center Copenhagen Research Center for Injury Prevention and Protection of Athlete Health

The epidemiology

- elite and non-elite football players

• 64% (63%) adductor-related

• 10% (8%) iliopsoas-related

• 4% (4%) inguinal-related

• 5% (4%) hip-related

14% of all time-loss injuries

Werner et al; BJSM 2009 & 2018

• 51% adductor-related

• 30% iliopsoas-related

• 19 % inguinal-related

Hölmich et al; BJSM 2013

Clinical diagnosis

Acute injuries

66% - Adductor

25% - Iliopsoas

23% - Rectus Femoris

10% - Abdominal

6% - Sartorius

Andreas Serner et al,

AJSM 2015

Isometric adductor test

Photos courtesy of UEFA Football doctor education program

The best squeeze test to

identify pain related to the

adductor longus

Lovell G et al

Drew M et al

Palpation of the adductor origin

Photos courtesy of UEFA Football doctor education program

Treatment of longstanding

adductor-related groin pain

Treatment of longstanding

adductor-related groin pain

Hölmich et al, The Lancet 1999

Exercise program for adductor related groin pain

– training period 8 to 12 weeks

h.theapp.mobi/adductorprotocol

Created by Roald Otten

Multimodal treatment RCT

Weir et al; Man Ther 2011

Important aspects of the program

• Lots of repetitions

• 3 times a week, 1½ hour duration,8-12 weeks

• No pain provoking/exacerbating activities

• Running allowed after 6 weeks (no pain)

• Good results achieved in 4 months

Hölmich et al, The Lancet 1999

h.theapp.mobi/adductorprotocol

Adductor tenotomy (unsystematic review)

• Five Level 4 studies with great variety in study

design

• Excellent result in 54% - 75%

• Poor results in 8% - 17 %

• Complications 5% - 34%

Active exercise program (Lancet 1999)

• Excellent 79%

• Poor 3%

• Complications 0

h.theapp.mobi/adductorprotocol

8-12 year follow up

Hölmich et al; AJSM 2011

Inguinal-related groin pain - Treatment

• No evidence-based non-surgical treatment

programmes

• The general principles of the treatment programme

used for adductor-related injuries can be used…

- strengthening muscles, training balance &

coordination around the pelvis…

• ..Including a particular focus on specific abdominal

muscle exercises

Strengthening the abdominals

Sundstrup E et al., 2012

Inguinal-related groin pain -

treatment

• With long-standing exercise resistant inguinal-

related groin pain, surgery is an option

• The basic principles of the surgical procedure and

the post-operative regime are identical to those for

manifest hernias – open or endoscopic - apart from

the fact that there is no hernia sac to invert or

remove

Iliopsoas-related groin pain

- Treatment

• No evidence-based rehabilitation programmes

• The general principles of the treatment programme

used for adductor-related injuries can be used…

- strengthening muscles, training balance &

coordination around the pelvis…

• …Including a particular focus on specific exercises

for the hip flexor muscles

• Start with isometric and gentle eccentric exercises

• Continue with heavy slow resistance training

Strength training of hip flexors – a RCT17% strength increase in 6 weeks

Thorborg et al., KSSTA 2015

Iliopsoas-related groin pain

- Treatment

• No evidence-based rehabilitation programmes

• The general principles of the treatment programme

used for adductor-related injuries can be used…

• …Including a particular focus on specific exercises

for the hip flexor muscles

• Start with isometric and gentle eccentric exercises

• Continue with heavy slow resistance training

• If it is too painful to do the strength training

program ultrasound guided cortisone injections

can be helpful

Iliopsoas-related groin pain

- Treatment

• No evidence-based rehabilitation programmes

• The general principles of the treatment programme

used for adductor-related injuries can be used…

• …Including a particular focus on specific exercises

for the hip flexor muscles

• Start with isometric and gentle eccentric exercises

• Continue with heavy slow resistance training

• Return to play in three to six weeks

• Almost never indication for:

Arthroscopic partial iliopsoas tenotomy in athletes

Copenhagen Hip and Groin Outcome Score

- HAGOS

Thorborg, Hölmich et al; 2011 BJSM

• HAGOS is a profile score

• Consists of 6 subscales/scores

• Measuring specific dimensions

and constructs relevant to the

effects of hip/groin impairment

Has been translated into multiple

languages www.koos.nu

AJSM 2018

Methods

Hip arthroscopy for femoroacetabular

impingement syndrome in preceding 6 months to

6 years

Cam resection +

labral surgery

18-30 years old at time of surgery

Danish Hip Arthroscopy Registry

Ishøi et al

AJSM 2018

Return to preinjury sport and HAGOS

Ishøi et al

AJSM 2018

Return to sport following hip arthroscopy

for femoroacetabular impingement

syndrome

89,0%

49,0%

21,0%

74,0%

57,1%

16,9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Any sport Preinjury sport Same/optimalperformance

Wörner et al., 2018 BJSM(N=127)

Ishøi et al., Accepted AJSM(N=189)

Combined

N=316

Ishøi et al

• Groin and hip pain during previous season and at

beginning of current season registered

• HAGOS score at beginning of current season

• Half of the players report pain in the hip and/or groin

during the previous football season

• The football players with the longest duration of pain

in previous season displayed the lowest HAGOS

scores in the beginning of the new season

…..The groin pain carries over to next season

Recommendation

• Use the off-season to focus on treatment and

recovery rather than simply resting

• Examine the athletes at the end of the season

• Use the off-season to improve any muscular deficits

found - combined with sports specific training

The between-group difference for EHAD

strength increase was 13% -

(p=0.044)

The Copenhagen 5-second squeeze

5-second isometric hip-adduction contraction

with extended legs in the supine position

Hölmich et al., 2004

A simple idea

How much

pain

0-10?

Thomee, 1997

Correlation between HAGOS and pain with

The Copenhagen 5-Second Squeeze n=668 football

players

Thorborg K, Hölmich P et al; BJSM 2017

…..and help you decide to give

green or red light for your

soccer-player

Thorborg K, Hölmich P et al; BJSM 2017

The Copenhagen 5-second squeeze

is strongly related to hip- and groin

sporting-function…

Prevention of groin injuries- a joined research project with

Oslo and Copenhagen IOC Research Centres

A cluster RCT

The preventive effect of an

Adductor Strengthening

Program on groin problems in

Norwegian male football players

Copenhagen Adduction

Serner et al; BJSM 2013

Ishøi et al; SJMSS 2015

Significant increase in

eccentric strength

(35.8%)

after 8 weeks training

RCT using the Copenhagen

Adduction as a single exercise

interventionLevel 1 Level 2 Level 3

WeekWeekly

sessionsSet per side Repetitions per side

1 2 1 3-5

2 3 1 3-5

3-4 3 1 7-10

5-6 3 1 12-15

In

season1 1 12-15

Joar Harøy et al

76% gradual onset

37% time loss

Majority in the dominant leg

2500 groin problems reported

Joar Harøy et al

632 players from 34

teams

OSTRC Overuse Injury

Questionnaire (Clarsen et al. 2013)

All groin problems

Mean difference in prevalence: 7.8%

Joar Harøy et al

41% lower injury risk(OR 0.59, p=0.008)

Summary

• Use sufficient exercise stimulation and….time!

- Take another look at the old 1999 Lancet

study – it still works

• Restore the associated pelvic muscular deficits

• Restore the demands and skills needed to participate in sport – including endurance

• Monitor the groin and hip status with HAGOS

Summary

• Use the off season break to avoid continued and

new groin injuries

• Use the Copenhagen 5-Second Squeeze

and HAGOS to monitor players on a regular

basis

• Use the Copenhagen Adduction exercise for

prevention

Thank you