Vivian Grisogono

Groin strain

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Footballer's injury in the groin area.
Q: I am looking for some advice about a sports injury. The following describes how I got the injury and what the symptoms are. Thanks in advance for your time!
I got the injury in April 2007. I was playing football by myself - not in a competitive situation. I stretched my left leg outwards and seemed to pull a muscle in my groin - right above the bone.
It was a little painful but clearly not a big tear. I assumed that the pain would gradually disappear over a few weeks as it healed. However, the next day, there seemed be no pain or inflammation at all, so I decided to try and play again. However, it quickly flared up and so I stopped after a few minutes.
The cycle repeated over the next few weeks. I kept thinking the injury had gone because in the normal course of the day I could feel nothing. However, when I tried to play (once a week) it flared up again.
Only after waiting 6-7 weeks was I able to play again without a flare up. However, I soon realised that I could only play at moderate intensity. Any full sprints caused a gradual increase in the amount of pain. Trying to play in a full competitive match would cause a gradual flare up until the pain would prevent me from walking properly.
This has been the situation ever since.
I have received physiotherapy on the NHS where the physio suggested I might have a weakness in the ITB and glut muscles. I tried strengthening these muscles but no effect was seen. The physio was generally unhelpful and told me she wasn't a sports physio and that her suggestions would be limited.
It is important to let you know that I have slightly bowed legs beneath the knee (as many footballers seem to). This puts pressure on the outer muscles in the leg such as the ITB and has led to my knee caps not tracking properly. This does not cause much pain but is something I try to manage by keeping the muscles as loose as possible to prevent lateral movement of the knee cap. It's effect is that I am more prone to tightness in my hamstring.
Overall however, my muscle flexibility is pretty good and as far as I know I do not have particular tightness in the groin/adductor muscles.
I am slightly flat-footed as well.
My main concern is that I get a proper diagnosis so that I can decide how to proceed. I am not convinced in any way what the actual problem is.
At the moment I am considering that it may be either:
1) a muscle imbalance
2) a structural problem which is stopping the muscle healing
3) some kind of sports hernia (Gilmore's groin etc.)
My own intuition is that it is (2) as I sometimes feel something in the corresponding muscle in the right leg. Whether this is psychological or not I don’t know.
I would be very grateful if you could point me in the direction of any doctors who specialise in groin injuries so I can find out what the problem is.
Male, UK

A: Thank you for your e-mail, and I'm sorry to hear of your ongoing problem.
As you weren't doing anything particularly strenuous or dangerous at the time of your injury, it's possible that your original injury was a muscle or tendon strain, as you thought. You say the pain was just above the bone, presumably referring to the side edge of the pubic bone. This would indicate that it could be the lower end of the abdominal muscles which was injured. If the pain is right on the pubic bone, that indicates it's one of the adductor tendons.
If there is a hernia, with or without a tendon or muscle injury, you would feel a slight lump projecting at times, and it would hurt when you cough or sneeze. From your description, it doesn't sound as though you have these symptoms.
Groin strains can be slow to recover, if you don't treat them properly.
The principles of treatment are simple: you need to massage the injured area or point gently with arnica  or heparinoid cream. Arnica is a natural herbal remedy, heparinoid creams (such as Hirudoid or Lasonil) are the pharmaceutical equivalent to help the circulation.
You need to do gentle stretches for the adductors and the hip flexors. You can sit on the floor and stretch your legs out sideways with the knees straight; sit on the floor with the soles of your feet together and gently press your knees downwards with your hands; stand with your legs apart, shift your weight sideways over one leg and bend your trunk sideways the other way; stand with one leg straight out sideways, and gently bend the the knee until you feel a stretch in the adductors on the straight leg; stand with one leg straight behind you, and bend the front leg until you feel a stretch on the hip flexors of the straight leg; lie on your stomach, take your weight on your hands as though for a press-up, push your trunk upwards, but don't lift your hips up. All the stretches should be very mild, almost so that you feel nothing much is happening. If you over-stretch even to the slightest degree, you will not improve flexibility, and may even cause limitation.
Isometric exercises are invaluable. For these, you press one or both legs against an immovable resistance, hold for a count of 2, then relax completely for a count of 3. For instance, you can sit on the floor, knees straight, with a football between your feet; press your legs inwards against the football to contract the adductor muscles. Experiment with your legs at different angles, and pressing in different directions. if possible, find a position where the isometric contraction causes some, very slight reaction or discomfort: then do the isometric contraction just to the start of the point of pain. This gradually reduces the sensitive area.
You are right to think about muscle balance. You  should certainly keep stretching the iliotibial tract and hip abductor muscles , also the calf muscles and the front-thigh (lying on your stomach and gently pulling the foot towards your buttock, within very comfortable limits).
Can you do bent-knee sit-ups comfortably?
Once you have worked at improving the situation for 2-3 weeks, if there is no pain in any situation, you can re-start trying to run. But do it on a gradually increasing basis. Start with very little, no more than twice a week, and build up in easy stages. The same applies to kicking a football: start by kicking against a wall; gradually increase the distance; then try running and kicking; then doing drills with a partner; and work up gradually to playing in a practice game situation.
I hope these suggestions may be of some use. If you think of any more details that might be relevant, or if you need clarification on any point, just let me know.

Response: Hello - this is a slightly late reply (by about a year or two!) to thank you for your help with my groin injury. My sincere apologies for failing to get back to you sooner after you gave me such a detailed and useful guide to follow. I am very grateful because I decided to follow your suggestions closely, and as a result was able to play again within a few weeks. It took another few months to completely disappear after that, but once I was playing again I had the motivation to keep working at it. I wouldn't say it is 100% perfect, but it is about 98% which is probably on a par with most people who play football regularly. There was a point when I thought I would have to have an operation so you have saved me a lot of worry on that front. You also saved me a lot of money that would have probably been spent on seeing a sports rehab physio. On top of that, I believe I can use the knowledge I have gained from the rehabilitation process and apply that to any other injuries I get in the future. So thank you on all those fronts!