Fact: Forms of athletic hip and groin pain are incredibly complex, and require a highly individualised and sports specific rehabilitation program.
The contributing factors to an athletes pain will be completely different to the next person. As a result, a generic rehabilitation program will not suffice. In fact, if not carefully constructed a program may make an individuals symptoms worse, by overloading already struggling muscle groups, or stressing irritated tissues with provocative positions. It can also be incredibly disheartening for an individual to complete months of rehabilitation only to see no improvement, because a key movement pattern specific to this individual’s injury and sport, was not addressed. Be it hip joint, abdominal, adductor, or pubic in origin, each athlete needs careful assessment of their biomechanics, movement patterns, and tissue health. Incorporating the resulting findings into a carefully constructed gym program, whilst considering the individuals goals, should see success.
Fact: Radiological findings are only a small part of the picture.
Many of our clinical tests give us valuable information without the need for imaging. For example, studies have shown greater than 90% accuracy in locating acute injuries to the adductors (Serner et al 2015). This gives a great opportunity for re-testing to gauge recovery and treatment effectiveness, without the clouding of various incidental imaging findings that can often instill fear of further injury and negative beliefs. Many incidental imaging findings that are not the pain source are often found in athletes with and without groin pain, including low grade pubic bone marrow oedema and signs of tendon overuse. In relation to hip joint pathology identified via imaging, Kemp et al (2019) found labral tears in 54% of asymptomatic individuals, cam deformity (FAI) in 25% of asymptomatic non-athletes, and within 66% of athletes regardless of symptoms. Often, these findings can instill fear of movement, and maladaptive patterns without significant benefit to the individuals management plan, and as a result, should be considered carefully, and results discussed tactfully.
Fact: Principles of load management and strength training should be introduced at a young age within the athletic population.
The old myth that lifting weights stunts growth, is completely false and outdated. The facts are that completing some strength and conditioning work in these rapid skeletal growth phases (~ages 10-14) is the optimal time to start. Not only will their body be the most responsive to training stimulus, this conditioning work improves their tissue tolerance to load, and instills safe and effective movement patterns when it is most needed. During these phases, we now know that playing significant amounts of impact sport/running (>4-5 nights weekly) can result in extra bony formation around areas of high stress, such as the femoral head/neck. In some individuals this can result in a ball socket joint less capable of absorbing load, with the potential to cause pain and dysfunction later in life. The historical fear of the gym in juniors, but the ‘go for your life’ attitude towards sport, needs a rethink. Perhaps more careful consideration of a junior athlete’s sporting load, and making room for some strength training in the weekly routine, is the way moving forward.
Myth: My muscles are tight because they are weak.
Indeed muscles can be tight when they are weak, as they fatigue more easily. However, muscles can also be tight when they are indeed strong but doing all the work for weaker areas or compensating. Muscles that are ‘hypertonic’, or always switched on, also tend to be tight however would likely be quite strong if they were able to rest and recover properly. In these scenarios, if we get this wrong, prescribing exercises for these ‘weak’ muscles can just fatigue them further, and exacerbate symptoms. Sometimes this is clear on assessment for the physio. Other times we need to gauge how that muscle adapts to the exercise over time. If it isn’t getting stronger, progressing through the exercise as a healthy muscle should, it warrants further investigation.
Myth: That pain at the front of my hip is just a tight hip flexor.
Your hip flexors are quite likely tight, however when your physio is assessing your hip into flexion (knee coming towards chest) and therefore shortening your hip flexors, what you are feeling at the front of your hip is very unlikely to be your hip flexors. More likely, this sensation is hip impingement sign wherebay the ball is approaching the roof of the socket and starting to ‘pinch’. This will certainly tend to occur sooner in flexion ranges with tight hip flexors (to go with quads, adductors), and goes for all flexion tasks you are feeling such a sensation, eg squatting, lunging.
Myth: My MRI shows degenerative changes, I should stop exercising and playing sport.
Joanne KempAlison GrimaldiJoshua HeereyDenise JonesMark ScholesPeter LawrensonSally CoburnMatthew King (2019). Current trends in sport and exercise hipconditions: Intra-articular and extra-articularhip pain, with detailed focus onfemoroacetabular impingement (FAI) syndrome. Best Practice & Research Clinical Rheumatology 33 (2019) 66e87, https://doi.org/10.1016/j.berh.2019.01.016