Groin pain occurs frequently in sporting activities such as running, kicking, soccer, rugby, and ice hockey which involve quick accelerations, decelerations and sudden rapid directional changes (Cowan et al., 2004 and Verrall et al., 2005). Hormon (2007) suggested that, groin pain may be caused by a sports hernia, osteitis pubis, nerve entrapment, adductor and Iliopsoas muscle strain or any combination of these entities. The most common location (>50%) of groin pain reported in athletes is the adductor muscle tendon region (Holmich. 2007). The assessment and treatment of groin pain in athletes is difficult as the anatomy of the groin region is complex and the ability to imagine the anatomy of the groin area is important for both physical examination and the differential diagnosis (Vincent and Victoria, 2001). Holmich (2007) reports that the cause of chronic groin pain left in debate and systematic clinical assessments using reliable examination methods were not carried out in studies and well-defined diagnostic entities are not reported.
Please find the appendix i (a) for some of the terms used frequently.
Janda (1992), reports that in any sport the first part of injury management is injury prevention. Emery (2003) describes that, to develop and evaluate the sport injury prevention strategies, a good understanding of injury rates, the participant population at risk and the risk factors associated with injury for the population need to be first identified. In athletic population; groin strain injury incidence definition may be obtained by using a standardised exposure of actual player hours separated between training time and game time. The risk of injury is different for different sports (Junge et al, 2006). When taking the severity of the injury into account in a English Football Association team that the overall risk to professional athletes is profoundly high approximately 1000 times higher among professional football players than for high-risk industrial occupations (Drawer and Fuller2002). The high rate of injury incidence among different sports may have lead researchers to attempt to identify risk factors and preventive methods for different sport injuries.
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Meeuwisse and Bahr (2009), defines risk factors are ‘the ones which causes the athletic injury or sufficient enough to cause injury”. The risk factors for groin injury in sport are considered as intrinsic risk factors like age, gender and physical fitness, level of play, anatomical alignment of structures, previous injury and body composition. The extrinsic risk factors such as protective equipment, sports equipment, environment factors like weather, surface of play, and human factors like opponent behavior, playing situation and also biomechanical description make the athlete susceptible to injury.
These risk factors were further classified by Meeuwisse and Bahr (2009), as modifiable or non modifiable. Endurance, strength, balance and decreased levels of sport-specific training are some of the modifiable risk factors. These risk factors can be altered to reduce the groin injury rates through the implementation of injury prevention strategies. Age, gender, previous groin injury are considered as non modifiable risk factors for groin injury. These factors cannot be altered to reduce injury rates through the implementation of injury prevention strategies but facilitate the identification of the sport population at risk.
See Appendix ii for injury causation model by Meeuwisse (2006)
The groin region is a highly mobile area consists of where abdomen meets the legs and contains the structures of the perineum (Timothy and Steven, 2008).Therefore, it includes the lower rectus abdominal muscles, the inguinal region, the symphysis pubis, the upper portions of the adductor muscles of the thigh, and the genitalia, also the scrotum in males. Falvey et al, (2008) described the groin region by setting out borders which comprises of groin, gluteal and greater trochanter of femur called 3G triangle, for sports medicine professionals to help understand the diagnosis of groin pain easier by the origin of symptoms.
(Adapted from Falvey et al, 2009. The groin pain: patho- anatomical approach to the diagnosis of chronic groin pain in athletes).
The anterior superior iliac spine (ASIS) and pubic tubercle forms the apex of groin triangle, as this point refers to the 3G point. The land marks of the superior border of the triangle forms by the line between the pubic tubercle and ASIS, whereas line from the pubic tubercle inferiorly forms the medial border and line from ASIS superiorly forms the lateral border.
See appendix i (b) for diagram for muscles of the groin region.
The body’s center of gravity is located within the pelvis, anterior to the second sacral vertebra; thus, the loads that are generated or transferred through this area are important in virtually every athletic effort (Anderson, et al 2001).Loads of up to eight times body weight has been demonstrated in the hip joint during jogging, with potentially greater loads may present during vigorous athletic competition (Crowninshield, et al 1978), the structures around the hip are uniquely adapted to transfer such forces. The most common fracture is to the femur may caused by the force transmitted from the hip joint, when subject to a combination of axial compression, torsion, shear and bending loads which can cause fracture at various sites. Imbalance between the loads applied to the pelvis and the integrity of the pelvic structures, resulting into overuse problems. Pubic symphysis displays its greatest mobility when it is exposed to shear forces. Pizzari et al (2008) reports that the imbalances may be occurring from inadequate pelvic integrity which is intrinsic risk factor and alterations in the loads as extrinsic risk factor or sometimes combination of these two can cause osteitis pubis, which in turn contributes to groin pathology. Therefore, in prevention of osteitis pubis sometimes involves early recognition of risk factors at the beginning of the season may be appropriate.
Having known the complexity of anatomy and biomechanics groin region, it may be useful to develop comprehensive understanding of risk factors causing the groin pain to develop effective preventive measures among different sports.
The first step in the process of any research study is to form a research question. Four components should be considered when forming a research question (Meade and Richardson 1997). These include the client group being investigated, interventions, comparative interventions and the outcomes used to measure the effect.
Is identifying risk factors and causes help athletes in preventing groin pain? a literature review.
Objective of the study
This review examines the studies on identifying the risk factors and causes of the groin pain and does this helped in preventing groin pain, and aims to develop new insights based on current knowledge on the topic by reviewing the literature.
Aims of the study
The aim of this study is to review the evidence to see if there are positive benefits (decreasing the incidence of injuries) of identifying risk factors for causing groin pain. These positive outcomes may help health care professionals involved to prevent athletes groin pain.
Chapter 1– Preliminary Literature Review
In this review there will be a broad preliminary literature review on groin pain, where incidence, epidemiology, risk factors and causes in relation to groin pain will be discussed. Importance and principles of injury prevention are discussed in detail.
Epidemiology of groin injuries in athletes
Injury was defined as “any event that kept a player out of a practice or a game or required the attention of the team physician” (Molsa, et al 1997). In professional soccer, groin injuries comprises of up to 10% of all the injuries (Hawkins et al, 2001), but are responsible for a much larger proportion of time lost from training and play (Muckle, 1982). Brooks et al (2005) have reported on match injuries associated with 546 rugby union players at 12 English Premiership clubs in two seasons. They found that incidence, severity of groin, hip and buttock injuries as per every 1000 player hours and severity in number of day’s absence. In elite level soccer, groin strain injuries have been reported to account for 20% of all muscle strain injuries and more than 40% in ice hockey and they also account for >10% of all injuries in elite levels of ice hockey, soccer, and athletics.
In Australian Rules football (AFL), the number of games lost was more at all levels of the game due to hip and groin injuries. AFL statistics for seasons 2001-2006 saw groin pathologies accounting for an average of 13.0 missed games per club per season involving an average of 3.25 players per team. Over this same period these groin injuries had a 23% recurrence rate. Walden et al (2007) studied in professional sports, and have found groin injury to be the fourth most common injury affecting soccer players. Orchard and Seward (2002) consider groin injury the third most common injury in Australian Rules football and it also has a high prevalence in ice hockey and rugby. But in considering time lost from injury, groin pain plays only next to fracture and joint reconstruction (Brooks et al, 2005). Groin injury is among the top one to sixth most common cited injury in the Olympic sports of ice hockey, speed skating, soccer, and athletics. Groin injuries account for 3-11% of all injuries in some Olympic sports including ice hockey, speed skating, soccer, swimming, and athletics.
Causes of groin injuries
Groin pain in athletes can be classified into athletic and non athletic causes. (Please find a table in appendix iii for causes of groin pain). Adductor muscle strains and osteitis pubis are the most common musculoskeletal causes of groin pain in athletes, which are often difficult to distinguish (Morelli and Smith, 2001). Hip injuries associated with sports participation often refer pain to the groin. Exclusion of rare differential diagnoses is often the focus of clinical testing and imaging.
Awareness of overlapping pain referral patterns from the hip joint, the lumbar spine, lumbar facet joints, and sacroiliac joint and abdominal structures is important for accurate diagnosis of the cause of groin pain (Katherine, 2008). Katherine also reports, the common condition that may be associated with acute or chronic groin pain due to Iliopsoas myofascial pain which can be persists as primary problem or secondary problem and suggests Iliopsoas muscle should be included in the assessment of groin pain. Ekberg et al. (1988), found the difficulty in diagnosing the groin pain as it presented with more than one diagnosis in 19 of 21 athletes with longstanding groin pain. Holmich et al. (1999) noticed signs for osteitis pubis in over 60% of their athletes who were primarily diagnosed as suffering with adductor complaints.
Please find the table for differential diagnosis for groin pain in appendix iv
1.3 Principles of Injury prevention
Bahr et al, (2006) described the sports injury prevention program into ‘primary’, ‘secondary’ and ‘tertiary’ (Bahr, 2006 for Clinical sports medicine). They defined primary prevention as health promotion and injury prevention by means of application of external supports for body parts to protect from injury, even for those without any previous injury. Secondary prevention included early diagnosis and intervention to limit the development of disability or reduce the risk of re- injury and this is considered as treatment for any acute injury. Lastly, the tertiary prevention is the focus on rehabilitation to reduce and to correct an existing disability in relation to an underlying disease. This may refer to the process of rehabilitation following any sports injury and bringing back to the level of normal sport.
The successful injury prevention strategies consist of a model developed by Van Mechelen et al (1997). The first step is to determine the incidence and severity of the sport injury problem, needs to be established prior to identifying risk for injury. Van Mechelen (1992) developed a model that follows “sequence of prevention” which is widely used from past decade. Four steps of Van mechelen strategies are: (a) identify the incidence of specific sports Injury (b) secondly, identifying the risk factors and mechanism of injury considered (c) finally, develop the interventions likely to reduce the risk of injury should be introduced and their efficacy monitored and (d) by repeating the step (a) monitor the efficacy of preventive measures.
Further to Van Mechelen model, Finch (2006) came up with six staged approach to Translating Research into Injury Prevention Practice framework which is widely known as Finch TRIPP prevention framework. This approach suggests, those research studies that include sports participants, bodies and coaches can prevent injuries, but this may be only possible in broad research studies that may lead to real world injury prevention benefits.
1.4 Importance of injury prevention
Bahr et al (2002) reports that in Scandinavia, sports injuries are the main cause for hospitalization among children in every one third and injuries seen by a physician, every sixth is caused due to sports participation. During 1997 and 1998, in the United States, annually an estimated 3.7 million (approximately 11%) sports and recreation-related injuries visited emergency department. In these, 2.6 million visits were persons aged 5-24 years and the medical charges for these visits were 500 million US$ annually (Bahr et al., 2002). Injury prevention in sport has several benefits; some of them may include greater health of the individual, long-term in the activity and reduced costs to the individual, the sport, the health care system, and the society. The ultimate benefit would be the potential for better performance. The treatment of sports-related injuries can be time consuming, difficult and expensive, thus making preventive strategies justified, not just from a medical perspective but also economically (Scanlan and MacKay 2001). The significance in knowing about risk factors and preventive strategies may help athletes in decresing the chances of any fresh injuries, reduces training absences, financial burden on sports clubs, authorities, and society and most importantly avoids re-injury (Chalmers, 2002).
Chapter 2 – Methodology
This chapter discusses literature reviews as a research methodology in relation to research paradigms and the rationale for conducting a literature review. Also discussed are different types of literature reviews, advantages and disadvantages of performing a literature review and the process of conducting a literature review including ethical considerations.
2.1 Research Methodology:
Hart (1998) defined research methodology as a system of methods and rules to facilitate the collection and analysis of data. A literature review that is performed in a systematic way is a research methodology (Aveyard 2007).
2.2 Research Paradigm
The first consideration when addressing any research question is the research paradigm. Paradigms can be defined as the framework that has unwritten rules but directs actions. The term paradigm describes a system of ideas or world view used by the community of researchers to generate knowledge. It is a set of assumptions, research strategies and criteria for rigour that are even taken for granted by the community (Guba and Lincoln 1994). So paradigms are the ways of understanding reality and they contain some assumptions about the reality and find the ways to know the reality. Guba (1990) suggested that paradigms can be characterized by the way their proponents respond to three basic question, they are ontological, epistemological, and the methodological questions. There are many paradigms, but positivism and constructivism are considered as main paradigms.
2.3 Rationale for conducting a literature review
The electronic databases with healthcare literature were easily accessible for the author from University of Central Lancashire. These databases consisted of all up- to- date studies on Groin pain and prevention. A literature review is a suitable methodology for identifying, evaluating, and interpreting the existing body of recorded work produced by researchers, scholars, and practitioners (Cormack 1991). Steward and Kamnis (1993) recommended that literature review is a useful tool to compare already existing data to analyse and generate new ideas on topic of interest and also not expensive and time consuming.
As a research tool, the literature review has few disadvantages, because it uses previous research developed in different conditions and different backgrounds, and there is a possibility of unintended bias when collecting data (Stewart and Kamnis 1993). Accuracy of the synthesis of findings depends on the person who is critiquing and drawing up the synthesis of the literature (Burns and Grove 1995).
Ethical consideration for a literature review
Literature review is a secondary research (Aveyard 2007), during which participants do not come in direct contact with the researcher. Hence literature reviews do not require an ethical approval. But some ethical aspects have to be considered during literature review. One should treat people’s research with respect and ensure that the studies included are represented accurately in the review.
2.5 Literature review
The literature review is defined as “the selection of available documents (both published and unpublished) on the topic, which contain information, ideas, data and evidence written from a particular standpoint to fulfill certain aims or express certain views on the nature of the topic and how it is to be investigated, and the effective evaluation of these documents in relation to the research being proposed” (Hart 1998, p27). Rees (1997) defined literature review, as the critical examination of a representative selection of published literature on a particular topic or issue. The literature review might identify gaps in the previous literature that new research can address, or might suggest research to be replicated (Aveyard 2007). A comprehensive and competently carried out review enables a health care practitioner to apply a body of research evidence to practice rather than to rely on individual studies (Aveyard 2007). This emphasizes the place of a literature review in building the evidence based practice.
2.6Types of literature review
Gill (2000) suggests that there are three types of literature review. They are: a general survey of the literature, a focused survey of the literature and a systematic review. In a general survey the researcher is aimed at comprehensive search of literature within certain clear parameters (Gill 2000). A focused survey is a comprehensive search of literature with emphasis on the selectivity of the literature in terms of its appropriateness to the author’s approach to their research study (Gill 2000). A systematic review follows a strict protocol which includes precisely defining the research question, an exhaustive literature search of all the studies that address the question, assessing the quality of those studies using predefined criteria, exclusion of studies that fail to meet the criteria and provide an overview of the results of the included studies (Gill 2000). The type of literature review used in the current review is focused survey.
Chapter 3- Methods
This chapter explains how data was searched for this project, how the inclusion and exclusion criteria were selected and what key words were used to search the articles. The research question for this current review is: Is identifying risk factors and causes help athletes in preventing groin pain?
3.1 Search strategy
A comprehensive search strategy was developed to identify and locate the key literature on published material on groin pain. As much as possible literature relevant to the topic was identified. Search terms ‘Groin pain in athletes’, ‘risk factors’, ’causes’ and ‘prevention’ were used to help select articles for the review.
3.2 Inclusion criteria
The following inclusion criteria were used,
Risk factors and causes of groin pain
Prevention of groin pain
Articles published up to till date from 2000
Age of participants between18-65 years
Articles written in English
3.3 Exclusion criteria
Not relevant to groin pain and prevention
Articles published before 2000
Excluded were non-English publications
Articles on non athletic population
3.4 Search results
Literature search was performed using the key words with inclusion and exclusion criteria in mind. A literature search was carried out electronically in SPORTdiscus, MEDLINE with full text (Medical Literature Online), OVID (??) healthcare databases using the University online library. A manual search was also performed to identify articles related to risk factors, causes and prevention of groin pain.
The number of studies included and excluded from the literature search for the review is summarized in the table below.
SPORTdiscus full text
MEDLINE with full text
Chapter 4 — Results
This chapter focuses on the findings of the articles in database. The electronic literature search initially identified 191 suitable articles. After reading the abstracts and applying inclusion and exclusion criteria, 10 studies were identified as suitable for the current literature review.
The articles included for the review are:
Tyler, T.F., Nicholas, S.J., Campbell, R.J., Donellan, S., and McHugh, M.P., 2002. The Effectiveness of a Preseason Exercise Program to Prevent Adductor Muscle Strains in professional ice hockey players, American journal of sports medicine, 30, 5, 680-683.
Holmich, P., 2007. Long-standing groin pain in sportspeople falls into three
primary patterns, a ”clinical entity” approach: a prospective study of 207 patients, British journal of sports medicine, 41, 247-252.
Knowles, S.B., Marshall, S.W., Guskiewicz, K.M., 2006. Issues in Estimating Risks and Rates in Sports Injury Research, Journal of athletic training, 41, 2, 207-215.
Engebretsen, A.H., Myklebust, G., Holme, I., Engebretsen, L., and Bahr, R., 2008. Prevention of Injuries Among Male Soccer Players : A Prospective, Randomized Intervention Study Targeting Players With Previous Injuries or Reduced Function, American journal of sports medicine, 36, 6, 1052-1060.
Emery, C.A., Meeuwisse, W.H., 2001. Risk factors for groin injuries in hockey. Medicine and Science in Sports Exercise, 33, 9, 1423-1433.
Harmon,K.G., 2007. Evaluation of groin pain in athletes, Current sports medicine reports, 6, 354-361.
Macintyre, J., Johson, C., Schroeder, E.L.,2006. Groin pain in athletes, Current Sports Medicine Reports, 5,293-299.
Ibrahim, A., Murrell, G.A.C., Knapman, P., 2007. Adductor strain and hip range of movement in male professional soccer players, Journal of orthopaedic surgery, 15, 1, 46-9.
Biedert, R.M., Warnke, K., Meyer, S., 2003. Symphysis Syndrome in Athletes Surgical Treatment for Chronic Lower Abdominal, Groin, and Adductor Pain in Athletes, Clinical journal of sport medicine, 13, 5, 278-284.
Maffey, L., Emery, C., 2007. What are the Risk Factors for Groin Strain Injury in Sport? A Systematic Review of the Literature, Sport medicine, 37, 10, 881-894.
Chapter 5 -Analysis
Holmich et al (2009), classified risk factors of the groin injury as intrinsic or extrinsic to the athlete, and also suggested that groin injury prevention strategies may be developed and evaluated if there is a good understanding of the athlete population at risk of groin injury. Similary, Parkkari et al (2001) informed that there has not been thorough identification of the risk factors or adequate surveillance of groin injury, such that injury prevention strategies can be scientifically implemented and evaluated. Due to high incidence of groin pain in hockey, a prospective cohort study by Emery and Meeuwisse (2001) surveyed 1292 National Hockey League players and found that abduction flexibility, peak adductor torque was not predicted as injury, but low levels of offseason training, sport specific training and previous injury were predicted as risk factors for groin injury. But the above risk factors are potentially modifiable intrinsic risk factors. Emery and Meeuwisse (2001) also found that the in-season sport specific training may not act as strong risk factor for groin injury.
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Tyler et al (2002) suggested that, adductor muscle weakness was identified as a strong risk factor compared to flexibility in Professional Ice Hockey players. The authors of the study identified that, if the adductor to abductor muscle strength ratio is less than 80%, it is predicted as a strong risk factor for adductor muscle strain. In addition to the above statement Tyler et al (2001) also identified similar findings. The player with adductor to abductor muscle strength ratio less than 80% is 17 times more likely to have an adductor muscle strain and authors recognised adduction strength was 95% of abduction strength in non injured players, but only 78% of abduction strength was found in injured players. The authors in their (Tyler et al 2001) prospective study, apart from above findings, the preseason strength of hip adduction was 18% less in players with adductor muscle strains when compared with that of uninjured players.
Engebretsen et al (2008) have performed a randomized controlled trial in soccer players, identified the players and divided into high risk and low risk group. The inclusion criteria for the study were previous injury or reduced function identified through questionnaire. However, the introduction of individual specific preventive training programs to the divided groups such as ankle, knee, hamstring and groin has been resulted poor compliance with the prescribed training programs. So, the authors believe that the study did not affect the injury risk in this intervention group. Although the intervention followed in the above study was ineffective in affecting risk of injury, but players who may be able to gain from preventive exercises could be identified and reports that risk of injury was approximately twice as high in athletes with a history of previous injury or in reduced function.
Chapter 6 -Discussion
In this current review, the author describes that evidence shows, to develop an effective strategy for injury prevention only possible by first determining the incidence of injuries and identifying the risk factors to the athlete. Engebretsen and Bahr (2009) reports, Injury prevention in sports is a complex process, by supporting Van mechelen sequence of prevention. Researchers first try to identify one or several risk factors that causes the injury, the mechanisms of injury and develop an effective intervention to modify it, implement the intervention with sufficient compliance, and study the outcome of the intervention to detect reductions in the injury rate which are clinically applicable to make it an effective strategy. However, sometimes eliminating the risk factor may not necessarily prevent injury if there is no cause present.
Evidence shows that a few well designed prospective studies exist on reviewing the literature regarding the prevention strategies in sport. Caroline Finch (2000) argued at 5th world conference on injury prevention and controls saying that sports injuries should be given considerable recognition as a public health issue. Finch also argued for the need for origin of sports injury epidemiology as a sub discipline and has seen considerable effort targeting surveillance activities. In supporting the above, Engebretsen and Bahr (2009) reported a PubMed search on athletic injury in May 2000 and showed that out of 10,691 papers, only six randomized controlled trials (RCTs) were found on sports injury prevention. In last 7 year period the number of studies on athletic injuries has gradually increased by 43% but sports injury prevention has seen a gradual improvement on number of studies and RCTs by 200-300%.
There is a gap in the literature examining groin injury specifically in female sport; gender has not been identified as a risk factor for groin strain injury. But in contradiction to the above, Leetun et al (2004) identified that female athletes have significantly reduced hip abduction and external rotation strength than their male counterparts. The authors suggest that hip and trunk weakness reduces the ability of females to stabilize the hip and trunk. Therefore females may be more vulnerable to large external forces experienced by these segments during athletics, particularly forces during the transverse and frontal planes. Holmich (2007) prospective study describes on 206 athletes about the importance of the adductor related groin pain, the most common primary cause of groin pain in foot ball, but in runners the most common was iliopsoas related one, which was found in 58% of the athletes which may be of important to consider in developing and implementation of prevention strategies. In the area of injury prevention in sport, there are very few studies with a strong prospective research design addressing risk factors, there need to
6.1 What are the Implications for injury prevention?
Injury prevention should be the ultimate goal of the sports medicine professionals. Karlsson (2009) believes, prevention should be the starting place for sports injuries unlike treatment, but prevention is not always easy to implement in the daily routine practice. Coaches, trainers involve in the games may not be interested on taking time off from the ordinary team and individual training for prevention, because coaches sometimes may have short term goals, due to various reasons and often aim players to the next match, not to the next season. Therefore, it may be mostly up to the team doctors, physiotherapists and others working with player’s health over the season to give long-term prevention a thought (Karlsson, 2009).
McHugh (2004) suggests, in many sports the period of preseason training may be a good opportunity for sports medicine professionals to implement injury prevention strategies. However, the sports medicine professional may have only limited ability to implement strategies without the involvement of other team successfully, to reduce injuries. The pre-season period also offers an excellent opportunity to identify potential players at risk for particular injuries through pre-season screening and testing which can provide the baseline measures for sports medicine professionals to develop individual injury prevention strategies.
Chapter 7 — Conclusion
It has been well documented that randomized Controlled Trials (RCTs) are the best and most useful, appropriate and reliable studies aiming to evaluate the effectiveness of healthcare intervention. Studies identifying risk factors for injury are essential before assessing potential prevention strategies for injury in sport.
Anderson, K., Strickland, S.M., Warren, R. 2001. Hip and groin injuries in athletes. American Journal of Sports Medicine, 29, 521-533.
Aveyard, H., 2007. Doing a Literature Review in Health and Social Care. A practical gu
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