This 18-year-old young man 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 of last year when he started developing left-sided groin pain, although the right was occasionally achey as well

Initially, the pain was present early on in a game 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 game. After three or four weeks, he decided to rest for one week, but found the pain was worse when he attempted to resume training, or even when running. He persisted until one particular game in mid-December when the pain became so sharp that he had to stop playing. Finally, he sought help at our Sports Injury Centre

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 movement caused pain, whether active or passive; internal rotation and adduction were the most painful and restricted, with resisted tests for the adductors also being very weak and painful. Palpation further revealed a small mal-alignment of the pubic symphysis and general muscle tenderness but no evidence of conjoint or adductor tendon disturbance, 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 antero-medial 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 on in order to maximise the speed of his recovery and return to competitive sport

Though very fit and muscular, it was found that he had very poor muscle control around his pelvis and trunk, especially of gluteus maximus. He had compensated 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, particularly NSAIDs, were used right up until he began light 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 progressing hip range of movement to finally gaining full internal rotation, flexion and ad/abduction. The success of the treatment hinged on gaining and maintaining full hip range of movement, especially when he began running, and then full training. He would only be progressed to the next level of activity if it was pain-free during and after, and if his muscle control and endurance was improving to match the level of the activity

3. The principles of muscle and movement rehabilitation were initially 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 or he'd never be the union player he wanted to be

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 your focus from 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 these problems has not been sufficiently dealt with

Ulrik Larsen

Groin Pain Causes and treatments


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