Wednesday, November 3

Groin injuries

When Buffalo Sabres goalie Dominik Hasek stretched awkwardly to stop an opponent's slap shot in a game early in November, he said he heard it "pop." That pop was a torn groin muscle and it is serious enough to keep the star goaltender from dominating the ice for at least two months.

Although it is at the extreme end of the spectrum, Hasek's injury is part of the range of groin injuries, from mild strains to painful tears. "Across all sports, every groin pull is different, as are the athletes that get them," says Dr. Andrew Parker, a member of the Association of Professional Team Physicians (PTP) and team physician for the Colorado Avalanche of the NHL. "One of the only common aspects of the injury is the treatment, which in all cases includes rest."

We asked Dr. Parker to comment on the basic causes of groin muscle pulls and review why this misunderstood ailment can be so difficult to treat.

What exactly is a groin pull?

Dr. Parker: It's an interesting question. Over the years, groin pulls have encompassed a lot of different diagnoses, one of which is the commonly classified muscle pull in the groin area. But as we try to make a more accurate assessment, things tend to not be as clear. For example, what particular muscle are we talking about? Typically, the muscle that most people injure in a groin pull is the adductor longus muscle, a long muscle on the inside of the thigh. A groin pull occurs when the thigh bone or leg is pulled out causing the leg muscle to overstretch. The tear or pull usually occurs either at the junction of the tendon and the muscle, which is located about three inches below the pelvis, or at the junction of the tendon and the pelvic bone itself.

Other types of injuries can mimic the pain associated with groin pulls, making a diagnosis a little difficult. Is this a pull of the adductor longus muscle? Or is it a pull or strain of the upper quadriceps muscle, which inserts around the hip joint. Maybe it's a bony injury to the groin? An older athlete playing tennis falls and comes in with what he thinks is a groin pull when, in fact, he may have a small fracture in the pelvic region. There are also number of different types of hernias around the groin that can be very painful; thus, a number of different pelvic injuries can possibly be mistaken for groin pulls.

Do groin pulls fall into grading categories like sprains?

Dr. Parker:Grading systems, although used, are fairly arbitrary. In muscle injuries, there are many different grading systems to try to help physicians, trainers and recreational athletes classify the severity of the injury. Grading systems are used to predict how quickly people are going to recover, how aggressive the treatment needs to be and when the athlete can be expected to return to play. But in reality, you can't tell how severe an injury is and therefore how aggressive you may need to be unless you examine the injury through surgery. If you examine the patient five minutes after the injury happened, your exam is going to be quite different than it would be an hour later, so from that standpoint, grading systems are a little overrated.


Q: I have recently come back from a severe stress fracture in my right foot. I am a three-sport athlete in college. How do I help prevent the chance of this happening again during my sports seasons?
-- Shana Olsen, St. Paul, Minn.

A: Dr. Robert Gotlin, PTP member physician: "The first step in preventing future stress fractures is to identify the cause of the first stress fracture (if possible). While most are due to 'overtraining' or 'over doing it', some are resultant to poor biomechanics or pre-existing medical conditions. First, a training schedule must be established, with guidance. Many people are time-locked and try to do too much in a very limited time frame. This is the most common scenario for a stress fracture. Also, poor footwear, falling arches, or leg-length discrepancies can be an inciting factor. Lastly, bone-density abnormalities can be a precursor to stress fractures. Usually one is prone to repeat episodes and if this is the case, a bone density study should be done.

In general, sticking to the 10 percent rule is often helpful. Training should not progress any more than 10 percent per week for either distance or time. "

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How would you diagnose a groin pull?

Dr. Parker: The two most useful tools in making any diagnosis are the patient's history and the physical exam. The history ought to point you to the type of specific structure that is injured. From that, you come up with what is called a differential diagnosis, a list that outlines your first best guess followed by your next best guess, etc. Then you use the physical exam to prove or refute one of the options. For example, if someone has a pull of the adductor muscle, it's a very easy muscle to feel. The history that you're probably going to hear is one where the leg was pulled out away from the body or was stretched suddenly. The patient will complain of pain in that area. So our first diagnosis would be that this appears to be an adductor muscle injury and if it's accurate, the physical exam will show a lot of tenderness around that area as well as a lack of tenderness in other areas. Beyond that, there are a number of tests we use if we are still unsure of the diagnosis. An X-ray will usually rule out a bone injury. We also use MRI, which can show the internal bleeding to an injured area, but the problem with an MRI test is that it looks at the injury statically.

Which activities seem to be most affected by groin pulls?

Dr. Parker: The sports that seem to have the highest incidence of groin injuries are sports where there is cutting side to side, quick accelerations and decelerations and sudden directional changes. You occasionally hear about sprinters with groin pulls, but the typical person we see is not the straight-ahead athlete as much as the side-to-side player in sports such as soccer, hockey and basketball. The thought is that you have a tremendous mass in the upper body and the upper body is going in one direction and the legs are directing the body to do something different either stop, start or turn.

What is the treatment for groin pulls and how long does it take to recover?

Dr. Parker:For the typical muscle strain or pull, including groin injuries, the treatment is always conservative. We use rest and ice, then proceed to a gradual stretching and strengthening program followed with a return to athletics. This works well for the "weekend warrior" up through to the professional athlete. Anti-inflammatory medication and ice help with the swelling, but time is what cures groin pulls more than anything. In higher levels of competition, treatments such as muscle stimulators and ultrasound can help with the healing process.

For all the similarities, every groin pull is different, as are the athletes that have them. The recovery depends on a lot of factors. Age, level of fitness, severity of the injury and a diligence with respect to rehabilitation all contribute to recovery times.

Dr. Andrew Parker, a member of the Association of Professional Team Physicians (PTP), is currently team physician for the Colorado Avalanche of the NHL. He is a member of the American Academy of Orthopaedic Surgeons and is also a consulting physician for the Denver Nuggets. Dr. Parker received his undergraduate degree from Occidental College in Los Angeles and his medical degree from Northwestern University in Chicago. He also completed his residency in Orthopedic Surgery at Northwestern University Medical School and was a Knee and Sports Medicine Fellow at Louisiana State University.

The information, including opinions and recommendations, contained in this website is for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. No one should act upon any information provided in this website without first seeking medical advice from a qualified medical physician.

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