Commonly termed groin strain, it refers to the tearing of the adductor muscles located at the groin in the inner side of the thighs.
A strain of the groin occurs when pulling one or more adductor muscles. This group of muscles originates in the pelvic ring and attach along the inner side of the femur. They are the adductor brevis, adductor longus, adductor magnus gracilis, obturator externus, pectineus, which together form the hamstrings. These muscles are used when flexing and bending the hip joint when running and kicking. The damage can be minimal or result into a complete rupture of the muscle and avulsion. The pathology is graded as:
Grade 1: tear of few muscle fibres causing light pain and minimal functional impairment
Grade 2: damage to significant number of fibres resulting in moderate loss of function (most common)
Grade 3: complete rupture (avulsion) of a muscle and severe functional loss.
The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:
Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand
Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist
Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint
Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.
Intra-articular fracture extends to the wrist joint (or articulation)
Extra-articular fracture is located outside of the wrist joint
Open fracture when bone fragments perforate the skin
Comminuted fracture when the bone breaks into multiple fragments
Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.
Melone’s classification describes the characteristics of intra-articular fractures of the radius:
i Stable fracture
ii Unstable "die-punch"
iii "Spike" fracture
iv Split fracture
v Explosion injuries
These fractures are divided into:
Anterior pillar (not weight bearing part of joint)
Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)
Comminuted involving both column type
Sacral / coccygeal fractures
The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.
Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.
A groin strain is a frequent pathology encountered in 10-30% of soccer and hockey players when the contraction of the adductor muscles (more frequently in the adductor longus) is so intense to cause a tear with external rotation of the abducted leg. Such tears occur with sudden muscle contraction while accelerating (springers) or as a muscle pull with intense stretching (long distance ball kick). A groin strain is frequent in sports such as:
Long jumper athletes
By being a typical sports injury the risk for a groin strain is enhanced with poor warm up without stretching prior to training. The pathology is more frequent in older athletes. Overuse and repetitive groin muscle activities can lead to adductor tendinopathy and eventually to muscle tears. The sports mentioned previously increase the risk of a groin tear. Additional risk factors are:
Lack of groin flexibility
Muscle weakness (groin, pelvis, core muscles)
Muscle strength discrepancy
Inadequate training technique
Incorrect posture during activity
The symptoms for a groin tear become evident at the time of injury and are particularly felt with activities of the adductor muscles. The typical symptoms include:
Sudden sharp pain to the groin area and inner thigh
Pain increasing with movement
Pain when squeezing the legs
Pain after cooling down
Inability to walk or play sport
Walking with a limp
The diagnosis of a groin tear is mostly obtained with clinical examination. Tenderness sensations at the site of a muscle tear and through the pubic area are clear signs of the pathology. In more severe tears, decreased muscle strength is observed while the examiner adducts the leg and the patient fails to resist the pressure. Due to the nature of this pathology, mostly MRI and ultrasound suffice to detect muscle tears in the region, swelling, haemorrhage and oedema.
An X-ray may be recommended in groin tears with suspected injury of the bony structures around the pelvis.
A groin tear is mostly treated conservatively beginning with a phase of rest followed by a rehabilitative regime. The prognosis varies from 3 weeks in mild tears to 6 weeks or longer in more severe cases. With muscle avulsion the prognosis may last for months. Additional conservative treatment includes:
Pain management with analgesics
Anti-inflammatory drugs (NSAIDs)
Local steroid injection
Reduced weight bearing if necessary
Surgical treatment of a groin tear is rare and only performed in case of larger muscle ruptures and total muscle avulsion that includes the detachment of the bony area of muscle insertion. Open surgery is the method used and involves an incision over the area of tear to allow suturing the torn muscle or to reattach the tendon origin to the bone. Following surgery the patient may require the use of crutches for a few weeks. Occasionally symptoms may last for up to 6 months.
Physical therapy is indicated following a short period of rest. The rehabilitation program consists of gentle stretching and physical exercise of increasing strength. The therapist will also guide the patient to a planned return to sport including education in modifying those activities that may cause recidivism. A groin strain strapping can be applied immediately after injury to reduce swelling by compression as well as a preventative tool after recovery. Physiotherapy management includes:
Local compression to reduce swelling
Anti-inflammatory therapy (NSAIDs)
Use of crutches
Activity modifying regime
Return to activity plan
Groin strains have a high rate of recidivism. Therefore it is critical to maintain the improved physical condition achieved with weeks of rehabilitation. The following rules will assist in preventing a groin tear:
Avoid premature return to sport
Gradual resume of sport by reducing activity time, and vigour (e.g. slower running speed)
Practicing movements posing stress to the adductor muscles
Including stretches and warm-ups for proper preparation to sport
Use groin straps, brace and groin shorts during activities.
Wear proper fitting shoes