Pulled Groin

What is a pulled groin?

A pulled groin refers to a strain of your inner thigh muscles and can be classified into five categories:

• Adductor related: pain with pulling leg inwards or stretching it outward and tender to touch the groin muscles
• Ilipsoas related: pain with pulling knee towards chest and stretching the hip flexors.
• Inguinal related: pain with using abdominal muscles, coughing or sneezing
• Pubic related: tenderness of the pubic bone
• Hip and other: various conditions such as hip osteoarthritis, nerve entrapment, spine referral, fracture, or some other kind of medical issue.

The muscle known as the adductor longus is the most commonly injured groin muscle and accounts for 62% – 90% of cases.

How does a pulled groin occur?

Most groin strains occur when the inner thigh muscle is forcibly stretched while being contracted, such as an athlete pushing off in the opposite direction. Sudden acceleration in sprinting is the most common mechanism of injury. Groin strains also occur during activities which involve rapid changes in direction, high running loads and kicking. Some  contributing factors which make a person more susceptible to a groin strain include: lumbar spine or sacroiliac joint (SIJ) dysfunction, limited hip range of motion (ROM), decreased lumbopelvic control and/or stability, increased adductor muscle tone, and shortening iliopsoas muscle.

How do I know if I have a pulled groin?

A pulled groin usually presents as a sudden onset of pain in the inner thigh during a specific activity, as opposed to a more gradual onset. Common symptoms include: 

• tenderness at groin region where the adductors attach
• decreased hip abduction ROM
• decreased hip flexor or adductor strength
• pain with resisted hip adduction or flexion
• pain with activities such as running, cutting, and kicking

Could it be serious?

The injury can be graded as follows:

• Grade 1: Pain without significant loss of strength or ROM
• Grade 2: Pain with loss of strength
• Grade 3: Complete disruption of muscle or tendon fibres, with loss of strength

A groin strain can get worse if it is left untreated and activity is not modified. It is worth noting that groin pain may be caused by serious pathologies such as cancer, hernias, appendicitis, or labral tears. It is important to get an assessment from a physiotherapist or another qualified health care provider to rule out other serious pathologies. Once you have a groin strain, you are more likely to re-injure your groin in the future, so treatment is advised. 

Why does a pulled groin hurt so much?

Many daily activities such as walking, getting in or out of the car, and lifting your leg require use of your groin muscles, therefore it can feel very painful and limiting when you have a groin strain. The adductor tendons have a small insertion zone with poor blood supply and rich nerve supply which helps explains an increase in perceived pain.¹

What are the options to help with a pulled groin?

Recommended therapy, treatment and activities depend on the severity of the strain. 

Acute management:

• Activity modification: avoiding activities that put too much load on the groin musculature while continuing aerobic and strength exercises that put less load on the healing tissue
• Compression \  shorts ²
• Modalities to decrease pain and promote healing
• Soft tissue techniques to decrease pain and muscle tension
• Home exercises to address mobility restrictions

Sub-Acute:

• Exercises that progressively load the groin musculature to increase the capacity of the tissue
• Core exercises: pelvis stability is required to prevent control forces at the hip and groin.
• Sport specific exercises: train the hip abductors and adductors to maintain stability of pelvis during the stance phase of running

There are so many websites pushing medications or surgery for a pulled groin, is that really the only way to fix it?

No, but there are times when it is helpful or necessary. Anti-inflammatories may be useful in the initial stages of healing (up to 4 days) to assist with pain management and inflammation. Once pain is under control, it is important to wean yourself off medications to allow for blood flow to the injured tissue.

Occasionally, surgical intervention is indicated. There are no clear guidelines on which injuries require surgical management. Potential indications include: poor recovery with conservative management with full-thickness tears, or avulsion injuries with persistent weakness of the affected limb. For athletes suffering from sportsman’s hernia with/without adductor tendonopathy, there is moderate evidence that surgery results in better treatment success compared with conservative therapy.³

Can a physiotherapist help with a pulled groin?

Yes. A physiotherapist can rule out serious pathologies, educate you on activity modifications and your healing timeframe, provide manual therapy to improve your range of motion, and prescribe specific exercises to assist with healing. Treatments may include: 

• soft tissue treatment and/or dry needling of the adductor muscles
• hip flexor stretching/release (early stretching of the adductors is not advised)
• mobilizations of the lumbar spine/SIJ
• reducing gluteus medias tension
• restoring hip joint range of motion and improving core stability

For athletes with long-standing adductor-related groin pain there is moderate evidence that: 

1. active exercises improve treatment success compared with passive treatments.
2. multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises alone.³ Active exercises include a graduated pain-free muscle strengthening program. A pre-season adductor muscle strengthening program reduced the incidence of adductor muscle strains in ice hockey players who were identified as at risk.⁴

How long will a pulled groin take to heal?

This depends on a number of factors and how the injury is graded but here are some estimates (although further intervention my be required):

• Grade 1: 1-3 weeks
• Grade 2: 4-6 weeks
• Grade 3: 8-10 weeks

Can I play or work with a pulled groin?

Your physiotherapist will identify the stage of healing that you are in and find suitable activities that match your stage. You may be able to continue work depending on the nature of your job. It’s important to follow your physiotherapist’s advice: longstanding groin pain may develop if an athlete continues to play through pain. 

Will a pulled groin get better on its own?

The natural healing of most groin injuries in sport tends to occur after a short period of relative rest.⁴ However, without treatment you may not have optimum healing, and you may be left with range of motion and strength deficits. Also, you are more likely to re-injure your groin if you do not seek treatment.

How soon should I seek treatment?

It is recommended that you see a therapist as soon as possible post injury so you can receive expert advice for optimal recovery and activity modification.

How can a CAMPT-certified physiotherapist help me?

CAMPT-certified physiotherapists are advanced trained physiotherapists who are fellows of the Canadian Academy of Manipulative Physiotherapists and have a designation of “FCAMPT” after their name. Due to the depth of their training, they are particularly skilled at treating more complex injuries, like groin strains.

What should I expect when I see a physiotherapist (or CAMPT-certified therapist)?

You should expect an hour-long appointment and a comprehensive subjective and objective examination. The session will also include hands-on treatment, education and a home exercise program. Depending on your sporting activity, patients may require a running or return to sport program in addition to core and adductor strengthening.

References

1. Tyler TF, Nicholas SJ, Campbell RJ et al. The effectiveness of a preseason exercise program to precent adductor muscle strains in professional ice hockey players. AM J Sports Med 2002; 30 (5): 680-3

2. Otten, R. et all. The effect of compression shorts on pain and performance in male football players with groin pain – A double blinded randomized controlled trial. Physical therapy in Sport. 2019 (38): 87-95

3. Serner A, van Eijck CH, Beumer BR, et al. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med. 2015; 49:813

4. Arnason A, Sigurdsson SB, Gudmundsson A, et al. Risk factors for injuries in football. Am J Sports Med. 2004 32(Suppl.1):5S–16S. 6