Case study 3 - groin pain

A rugby-union player with groin pain

This 18-year-old is a rugby-union player in his final year at school, having been chosen to play for a national junior squad and poached by a prestigious premier club as a fly half or winger. All was going well until October the year before last when he started developing left-sided groin pain, although the right was occasionally achy as well.
Initially, the pain was present early in a match or training session, but gradually the ache developed into a sharper pain, especially before being fully warmed up, for two-to-three days before a match. After three or four weeks, he rested for one week, but found the pain was worse when he resumed training. He persisted until one day in December when the pain became so sharp he had to stop playing. Finally, he sought help at our injury clinic.
He presented with constant pain on any movement of his hip; walking was difficult. His pain seemed centred at a point halfway between the pubic symphysis and the ASIS (hip bone) and deep inside. Almost every hip move-ment caused pain, whether active or passive; internal rotation and adduction were the most painful and restricted, with resisted tests for the adductors also being weak and painful. Palpation further revealed a small mal-alignment of the pubic symphysis and general muscle tenderness but no evidence of a conjoint or adductor tendon distur-bance, or of a hernia. Negative x-rays and bone scan ruled out stress fractures, slipped femoral epiphysis, or early degenerative or rheumatic changes. As ice, rest and NSAIDs quickly reduced the pain and inflammation, it became clear that the primary restrictions were in the hip joint capsule, and the diagnosis was made: an anteromedial hip joint impingement and capsulitis, with major muscle imbalance factors directly relating to the hip dysfunction.
Biomechanical assessment of his trunk/pelvis/hips and lower limbs revealed an interesting pattern of dysfunction that had to be addressed early in order to maximise recovery speed and his return to competitive sport.
Though very fit and muscular, it was found that he had poor muscle control around his pelvis and trunk, especially of gluteus maximus. He had compen-sated for this by (1) gaining his sprint propulsion from very large calves, and (2) the piriformis and gluteus medius muscles had become very tight and weak, causing dysfunction around the hip joint and severely limiting his straight-leg raise/hamstring flexibility on that side. There was also an inability to recruit/use transverse and oblique abdominal muscles to control the movement of his pelvis in running, although his rectus abdominis ('six-pack') muscles were great!

Treatment progressed on three levels:
1. Anti-inflammatory agents, par-ticularly NSAIDs, were used up until he began training again, with gradual reduction, and then he was carefully weaned off.
2. Hip mobilisation was achieved by using seat belts to gain a gradually firmer distraction element, and then progres-sing hip range of movement to finally gain full internal rotation, flexion and ad/abduction. The success of the treatment hinged on gaining and maintaining full hip range of movement, especially when run-ning, and then full training. He would only progress to the next level of activity if it was pain-free during and after, and if his muscle control and endurance were improving in line with the level of activity.
3. The principles of muscle and movement rehabiliation initially were to use static holds and then add in movement - first with concentric, then eccentric loading, without losing the neutral pelvic positions. A flexibility routine was established early on, which he always carries out before any activity. However, strength and re-education exercises were only to be done AFTER a run in order not to fatigue the postural muscles and thereby sabotage his running technique. However, the bottom line, literally, was that 'that little butt' had to grow.
He is back in full training now and aiming to play at the earliest opportunity. The lesson to be learnt from a situation such as this is that you must never lose focus of what you are aiming to achieve with treatment, be it any one or more of the three above problems that need to be addressed. If the results are not forthcoming, particularly with groin injuries, you have to ask which of the problems has not been sufficiently dealt with.

Ulrik Larsen