Groin strains are a very common occurrence on hockey players. We now have lots of evidence that shows that a high percentage of hockey players suffer from groin pain over the course of a hockey season (here, here, here). This may come as no surprise to some, but the mechanics of skating put a lot of stress on the adductor muscle group putting them at higher risk of injury (here).
Treating groin injuries may appear quiet simple at first glance. At the end of the day, it is just another soft tissue injury. However, there is lots to consider when treating groin injuries in hockey players because of the high rates of re-injury and high stress on the adductor muscles while skating.
Here are 4 key assessments that I want to check off when assessing a hockey player complaining of a groin strain.
Groin Pain Assessment
The very first thing, and possibly the most important thing when someone comes to you for groin pain, is a good initial assessment. Without a good initial diagnosis, you might run down the wrong rabbit whole and delay recovery and return to sport. Groin pain can be so many different things, it’s important to rule in and out certain things to give you a better idea of what might be going on. Here are a few things that I look for:
1) Positional Assessment
The first thing I want to see is what’s the starting position of the adductors. A lot of hockey players will tend to fall into a lumbar lordosis and anterior pelvic tilt which could be from tight hip flexors, but could also be from tight adductors. I think we often forget that the adductors are also hip flexors and are in a position to pull the pelvis forward. So the first thing I want to see is what’s the starting point? Are they already tensioned? Are they slack?
3) Movement Assessment
Next, I want to see what they are able to do. Obviously, if someone comes in with an acute groin strain that’s black and purple, this will be for another day. But if someone is complaining of a minor or chronic groin strain, I want to see how well they move from their starting position. Some key movements I’ll look at are standing flexion, standing extension, standing rotation, squat and lateral lunge. I’m looking to see: can they get out of an APT to bend forward? can they extend the hips to extend back? can they rotate through the hips enough to turn? are they able to get into their hips for a squat? can they move in the frontal plane? Based on my movement assessment I may want to break out and look at other areas as well in my kinetic chain assessment, often times some trunk stability, ankle and thoracic mobility for these athletes.
4) Hip Assessment
Finally, I get to my hip assessment. The challenging part about groin pain is that it can have a variety of causes. So if someone comes in with a “pulled groin” and I don’t immediately see bruising or evidence of a soft tissue injury, I need to rule out other things. On my list of things to rule out (other than red flags) are lumbar spine, SIJ and intra-articular pathology. Once that’s done, and I’m confident that I’m dealing with a soft tissue injury, I want to figure out what adductors are injured. This might sound nit picky but it actually does influence my treatment plan.
Ruling in the adductors
Often hip and groin pain can be triggered by multiple tests including impingement tests, resisted tests and mobility tests which can make it challenging to differentiate what’s causing what. I tend to rely on two simple tests to help me run in adductor-related pain.
The first one is the squeeze test (here). As the athlete squeezes, it puts increased strain on the adductor muscles and causes pain suggesting likely adductor-related pain over more intra-articular pain. This test can bring on discomfort in the groin from irritating some deeper tissues, but for this test to be positive it should be painful.
The other test is simply palpating the adductors. Most who don’t have adductor-related groin pain will not necessarily have pain with palpation. Again, it’s important to differentiate between pain and discomfort – where some may have discomfort and tightness from tight muscles. I will typically ask my clients if the spot I’m palpating the same area they get pain and if it is a similar pain.
Anterior adductors (Pectineus, Adductor brevis)
The mechanism of an anterior adductor injury is likely going to be from repetitive flexion from a hip extended position, like in sprinting and skating. It could also come from a single bout of hip hyperextension with abduction, like when field players open up during a change of direction but even these are likely preceded from some repetitive strain leading to tissue weakness.
Anterior adductor strains will often be mistaken for hip flexor strains because of their close proximity and similar functions. To differentiate between the two, I will often use a resisted FABER, where I will put the person in the FABER position and have them resist me pushing their knee further down. My thought is that this will bias more anterior adductor over hip flexor, especially when athletes come in with anterior hip soft tissue injuries made worse with kicking or during the recovery phase of sprinting or skating. These athletes might also be limited in the FABER position, suggesting soft tissue restrictions of the anterior adductors.
Middle Adductors (Adductor Longus, Gracilis)
The middle adductors will often be injured from an over-reaching more in the frontal plane. This is often seen in goalies who overstretch from the butterfly position or when going post-to-post to make a save.
The middle adductors are more classic adductor muscles, so using a squeeze test and resisted adduction can help bias the middle fibers over the other adductors. They might also have more pain and restriction with a lateral lunge and on the table supine abduction.
Posterior adductors (Adductor Magnus)
The posterior adductors, largely the adductor magnus, can mimic a hamstring strain with its adductor fibers and hamstring fibers. Most will have pain when extending in deep hip flexion, like at getting out of the bottom of a squat.
To differentiate a hamstring strain vs a posterior adductor strain, you can use hip flexion in different degrees of hip abduction compared to straight leg raise. Extending the knee will bias the hamstring over the posterior adductors. You might also be able to differentiate simply by the location of the pain, where posterior adductors are more medial than the hamstrings.
4) Kinetic chain assessment
From my movement assessment, I will then breakout other areas that may be problematic, most often trunk stability, thoracic spine and ankle mobility. These limitations can directly or indirectly affect the hip and the adductors. Trunk stability controls the pelvis and forms a tug of war with the adductors. When one is overpowered, we can see pelvic control issues which can lead to groin issues among others.
The thoracic spine and ankle indirectly affect the hip. Ed Ganon described the ankle as the “force transducer of the hip” in this podcast which I think is a great way of the thinking of the relationship between the ankle and hip, especially with skating. I think we could also call the thoracic spine a force transducer of the hip when we think about shooting. I’ve previously written about some of these here and here if you want to check those out.
Final Thoughts
Groin strains can be challenging, so I try to keep a systematic approach of assessing. I’ve outlined 4 key assessments I use when I’m working with someone who has a soft tissue groin injury and that I’ve found to be helpful in coming up with a treatment plan. Check out part 2, where I go over how I approach treating these soft tissue groin injuries.