Good evening everybody! My name is Maryke. I'm the physiotherapist at sports-injury-physio.com, where
you can get online physiotherapy consultations using Skype or Zoom or any of your favourite
video applications. Tonight's topic is all about groin strains. And what I thought I'd do is, I'll
first explain to you about the anatomy, the things that's actually in the groin that you can injure,
and then I'll discuss my five-step program that I use when I treat runners especially with groin
injuries. Now, if you've got any questions, make sure you pop them in the comments. I'll keep an
eye on them and answer them as they go along. And then, if you're watching this on replay, feel free
to ask them in the comments again, because I'll keep an eye on it and answer them as they come
in. Excellent! So, let's first start by looking at what structures you have around your groin. Now,
if you look at this picture that I've just put up there, that's a picture of your pelvis. It's
the thing that looks as if it's got ears, and you can see that it forms a circle and comes
right together at the pubic bones there at the front. Now, your hip is attaching into the side
of the pelvis on this … on the sides. And you can see that the pelvis is positioned relative to the
hip … can influence that area. Now, you also have all your muscles come in, or quite a few muscles
coming in, attaching in. You've got your … let me just put that one on and then I'll come back
to that one … if we look at this slide, you can see how many muscles cross over the front of the
hip and the groin area. You've got your abdominal muscles coming and attaching into the pubic bone
there. Then, at the bottom of the pubic bone, you've got all your adductor muscles coming and
attaching in. You've got your hip flexors crossing over the front of the groin. And then you also
have a ligament called the inguinal ligament that runs from kind of the top point here,
that you can feel in your pelvis, to your pubic bone again. And underneath that, you've got loads
of nerves and arteries and things running as well. And of course, there are a few other ligaments and
things deep inside as well. Now, I want to go back to this previous picture. So, if you look at this
carefully, that area right there in this area, where a lot of people get their groin pain, you
can see that you've got all your adductors coming and attaching not just to the pubic bone there but
actually to the deep bone right in there. And then at the top bit, you've got your stomach muscles
attaching in, and both of those muscle groups, if you strain them, can actually cause you pain
in that area. So, if we take it one by one: Your hip joint can cause you pain, and one of the most
common causes is when it turns in too much when you run, and you can see if my hip’s gonna turn in
when I run, I'm gonna squash things on the inside, and you can actually squash your bones together or
your hip against the pelvis, and that can make the bones feel really sensitive and sore and inflamed,
and it's called hip impingement. That's a very common cause that I see in runners. And you really
need to strengthen up all the muscles that control the hip and work on your form to get that better.
Then, the second one is, you can strain any of the muscles in that area. So, you can have a hip
flexor strain … let me go back to that one. So, if we look at that, you can have a hip flexor strain.
So, that's either your iliopsoas or your rectus femoris. If we come to the inside, into this bit,
you can strain any of your adductor muscles, and you can even strain your rectus abdominus where
it attaches in there, and that can refer pain into that groin area. What I see is often - especially
with things like footballers - can have a combination of those strains. If it was a
forceful movement, they can actually injure more than one thing. Then, the third condition that's
quite common that I see in practice is Gilmore's groin or sportsmen hernia. Now, they're trying to
move away from the name sportsmen hernia because it's not a true hernia. Normally, you know that a
hernia ... if you cough or sneeze, you can feel a bulge there. With this, you can't feel that,
and they're not actually quite sure yet what causes it. But with the sportsman's hernia,
you can feel the pain really deep inside your groin. And the funny thing about it is, it can
either come on very suddenly as a sharp pain or it can build over several football matches or several
training sessions, that it becomes more and more painful. Now, when they've done scans and things
of the area, they found that often it's actually the ligament - that inguinal ligament - that runs
from there to there, deep in there, that it has tears in it, or even some of the tendons of the
stomach muscles, where they attach into that area, that can have small tears. Now, the big
thing for the Gilmore's groin is, they do often need surgery. But there is a small proportion of
people who can actually get better through rehab, and they always say that you should try 12 to 24
weeks of strengthening exercises specifically for this area before you actually even consider
surgery. So, watch out that you don't go see a surgeon who wants to do any surgery before you've
actually tried to strengthen it up. If we can go back to muscle strains for one moment. A good way
to know that you've got a muscle strain or tear - because remember a strain and a tear really
the same thing - is if the pain comes on suddenly in one training session. So, you usually feel a
sharp pull or something that makes you pull up, that you can't … don't want to run on it again.
That's usually a sign that you've torn something. But it can be a ligament as well that you've torn
or sprained. With a hip joint impingement - that type of pain comes on more gradually again. So,
it's not that sharp sudden pain that you get with that. Okay, so, and the fourth thing is adductor
tendinopathy. Now, if you can look at that - the adductor tendons - you've got quite a few
different adductors that run from the inside of the knee up the middle of the thigh or the inside
of the thigh and come and attach right into that bit. Now, the muscle bellies lie in this nice soft
bit, and then they've got tendons that attach into the bone. When you run, and your stability around
your hip area isn't very good, those tendons will have to take more strain than what they are meant
to, and that can cause a tendon inflammation in the tendon or tendinopathy in that area. It's the
same type of thing that people can get … can get in their Achilles tendons, but it's in their … the
tendons of the adductors. Now, often when runners develop that for the first time, they find that
they can actually run through it, it's just a little bit sore towards the end, or it may be sore
at the beginning of a run, but then as they go on, the sensation goes away. But they often find
that a few hours later or even the next day it's a lot more achy again. Now, if you ignore it for
long enough, you will find that you actually can't run - it will stop you from running. And at that
point, it can take a very long time to recover. So, it's really important to have it diagnosed
quite quickly, and figuring out what it is so that you don't push it to that point where it takes a
long time to recover. Then, the last one I want to talk to you about is, osteitis pubis, which
is a condition where ... it builds … is an overuse injury that builds up over time. Now, with that,
it's not just one structure that’s injured, but it's actually a combination of them. So,
it's usually caused by very poor stability around the pelvis as well as the hips turning in a little
bit too much. And what happens is, because of that you not only strain the adductor tendons,
but you actually strain the pubic bone in that bit as well. And you can even strain your tendons of
your stomach muscles where they attach. And as a result, you get bone or oedema in the bone,
which means … you can see that there's basically swelling in the bone itself, and the soft
tissues … the tendons that attach to it. In severe cases, if you really ignore it for long enough,
you can even get a stress fracture in that bone. Now, unfortunately, if you've got that condition,
it takes months and months and months of careful, careful management and strengthening up before
you can usually go back to pain-free running. So, again, it's really important not to be running on
groin pain for longer than a couple of weeks before you have it checked out. Of course,
some injuries just get better and go away, but if you can see that steadily, it keeps on niggling,
it keeps on being there, I would rather have it checked out. So, just to summarize:
The main five things that I see can cause groin pain in runners are: If you have the hip joint
that impinges because your hip stability and your lumbar pelvic stability isn't good and the
muscles around the hip aren't strong enough. The second is muscle strains or tears. Now,
they’re often not caused by weakness, they’re often caused by if you're not flexible enough. So,
flexibility exercises are more important there. Then, Gilman's groin or sportsman's hernia,
which isn't a true hernia, but actually a small tear of the ligament - the inguinal ligament - and
some of the tendons that attach to that, and again, it's all about improving the stability of
the pelvis. So, how much it moves like that while you're running as well as … like that … and also
improving the stability of the hip joint, that it doesn't move in too much when you run, that's key
to that condition as well. And then you've got the adductor tendinopathy where, because other muscles
aren't strong enough, the poor adductors have to work too hard, and they develop a tendinopathy in
the tendons. And then, lastly, the osteitis pubis, which is often when you've neglected some of these
other injuries, that it's actually escalated to that and it ends up with a stress reaction in
your pubic bone, which can cause a stress fracture if you ignore it. So, how do you go about treating
all of this? The first step is to identify what's wrong. Yes, these conditions are very similar,
but they all need a slightly different approach, and some of them are okay if you train through a
little bit of discomfort, and others, it really isn't. So, your first step should be to look for
either a sports physio, a sports medicine doctor or somebody similar who can help diagnose your
injury, but not just tell you what structure you've injured, importantly also, explain to
you why you've injured it. So, what they've got to do is, they've got to test your muscle strength
for you - they've got a test how well you move. So, analysis on a treadmill for instance. So, for
instance, if I had to do that over Skype, I would get you to do all the testing movements and things
in front of the video and I would get you to film yourself while running so that I can really slow
down your running motion and see what's going on there. Because if you don't identify the cause,
it's just going to come back, isn't it? Or it may not even get better because you keep on carrying
on doing this - the wrong things. The other important thing that you've got to do as part
of identifying the cause is analyse your training. And that's what the person also needs to sit and
do with you - they've got to look at the training you were doing leading up to … before the injury
started, the training you were doing while you had the injury that made it worse, so that you
can come up with a reason from a training point of view. Did you do anything wrong there that
you need to learn from? Are there clues in your current training program of things that you are
actually okay to carry on with and things that you should really really stop? So, that's definitely
key of what should be included when somebody sees you or when you see somebody about it. Okay,
now that you know what's wrong and what has caused it, you ... Step 2 is relative rest. So, remember,
these injuries are now slightly weaker - their capacity to cope with a strain from exercise have
decreased. So, what you need to do is, you need to actually give it a little bit of rest while you
strengthen up key other muscles - and even that muscle – gently, or that area gently, but the rest
is important so that it can produce new fibres and actually recover from the injury. Now, you very …
you very rarely have to completely rest. In most cases, all you have to do is relative rest. Now,
what do I mean by relative rest? It means you identify the things that really aggravate it. So,
for instance, for some people all running, even slow running, aggravates it. For other people,
they can … they may be able to run about three miles at a very slow pace, and they don't feel
any increase in their symptoms. So, for them doing that should be okay. If you can't run,
then finding activities like cycling or swimming or something else to keep your fitness going.
Similarly, with other activities like strength training in the gym, you'll find that there are
certain exercises that really really aggravate it, and you've got to cut it down to a point where you
can do it pain-free. So, it's really important to figure out what exactly you've got to rest it from
and what things are important to do. Now, Step 3 is, build your strength and your flexibility. Now,
how important strength and flexibility is and what ratio of each you need, will all depend on
what type of injury you've got. So, if you've got a muscle strain then, yes, strengthening
it up is important, but it's also important to check if it wasn't caused because you were so
overly tight. Whereas, if you've got adductor tendinopathy or osteitis pubis, it may be more
important to actually check that you create really good lumbo-pelvic stability and core strength in
that area as well as control of that leg. Again, when I see my patients, when I evaluate them,
they all start at very different levels with the strength training program. So, I'm not going to
show you any exercises tonight, because honestly, there's no one-size-fits-all, and you've got to
find the type of exercise that actually works for you. But the muscle groups you want to be
targeting are the core muscles, very important. Strengthening the glutes and the hips up, and then
working on control of the muscles and that area as well, putting it all together. Then, Step 4 is
progressing your exercises over time. So, there's no use in starting with, say, for instance, doing
planks, and six weeks from now you're still doing planks, because you will just be strong enough to
do planks. You've got to progress the exercises, that they become more and more difficult over
time, so that you can keep on growing stronger. Think about it: you wouldn't expect your running
to improve if you just went out for the same old run every single time you went. You play with your
speed, you play with your distance, you play with the difficulty, and that's how you get stronger,
and the same thing for the exercises. So … And then also the other thing that you've got to
progress for the exercises is, you've got to move on from doing simple exercises like your planks
and stuff to a bit more complex things that's actually more specific for the running action and
mimics that. If you’re doing football or a sport where you've got a lot of twisting involved, then
you've also got to add in movements that strain the groin area gently in twisting actions. So,
Step 1 was identify the cause. Step 2 was relative rest. So, only resting from aggravate … the real
aggravating activities. Three was build strength and flexibility. Four was progress your exercises.
Now, the last step, Step 5, is a slow return to running. And I cannot stress this enough. Often
people go through everything and do a really good job of calming the injury down and getting
it stronger, and then they jump into running too quickly, and that load is just too much
for the capacity of that hip to cope with, and it hasn't actually had time to get used to that. So,
always always always, if you're coming back from a groin injury, make sure you start with a run-walk.
You don't just go into a full-on run. And most of my patients that start with a run-walk … and
that means that you start with something like one minute run one and one minute walk. Again,
it's slightly different per person because some people are bit fitter at that stage than others,
but that means that you test it in a very safe way, that if you do aggravate it, it's just
slightly annoyed with you, it's not proper pissed off. So, what it does is, it calms down within a
day or so. But if you go and do a three-mile run, then by the time that it's painful, it's gonna
take a week or more to calm down and you're gonna feel really despondent about it. So, it's really
important at the beginning to do run-walks, look for the 24-hour response, and then two days later
you can see if you can up it a little bit. But as I say, most of my patients get back to 20 minutes
continuous running within two to three weeks if they follow that … this type of program, and they
usually don't have a setback. Excellent! So, let me know if you've got any questions. And remember,
if you would like a bespoke program that's absolutely worked out for you and a diagnosis
of your injury, it can all be done very easily via Skype or WhatsApp, whatever video app you
prefer. Excellent! Take care. Bye-bye. Thank you for watching! If you would like to learn
more about preventing sports injuries, make sure you hit the subscribe button. See you next time!