How to optimise your groin rehabilitation with Dr Stacey Hardin

In this episode with Dr Stacey Hardin, we delve into groin rehabilitation, focusing on patient monitoring, exercise selection, gradual progression, and return-to-play criteria. Stacey shares practical insights for optimising rehabilitation outcomes, making it a must-listen for physiotherapists and sports medicine professionals.

Want to learn more about groin rehabilitation? Stacey recently did an excellent Masterclass with us called, “Mastering Groin Pain: From Injury to Return-to-Play” where she goes into further depth on groin injuries and rehabilitation.

👉🏻 You can watch their class now with our 7-day free trial:
physio.network/masterclass-hardin

Stacey Hardin is a physical therapist and athletic trainer based in the United States. She has worked in elite soccer for over 10 years and currently works as the Director of Medical for Bay FC. In addition to her work in professional soccer, Stacey is actively involved in applied research and education.

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Our host is @James_Armstrong_Physio from Physio Network 

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Transcript

SPEAKER_02 0:00

There are very low cost force gauges that you can use and there are some higher cost ones that are a little bit more robust. And if you don't have access to that or timing with that, you can use something as simple as your arm between the person's ankles, the five second squeeze test, which has been extensively studied and validated as a way to monitor groin pain and function and help give advice on that return to play or participation activity or restrictions.

SPEAKER_01 0:39

In today's episode, We're going to be covering everything from the changes that we expect to see whilst we're rehabbing our groin pain patients and athletes, the return to play frameworks, and proper exercise selection and why that's important, and also the role of pain during our return to play. Now, Stacey is a high-performance practitioner, physical therapist, and athletic trainer specialising in the management of the professional athlete. And after six years in Major League Soccer, she currently works as Director of Medical and Performance at Bay FC in the National Women's Soccer League. Her clinical interests include preventative and rehabilitation strategies in the elite athlete, especially of the lumbopelvic hip complex. In addition to her clinical work, Stacey is committed to the advancement of sports medicine through education and research and volunteering at large scales, athletic events, Boston Marathon, particularly one of those. You're going to love this episode. We've got some real key takeaways as we always do in these short snippets of our episodes. And Stacey really does summarize just a small section of her masterclass in today's episode. So enjoy. I'm James Armstrong, and this is Physio Explained. So Stacey, welcome back to the Physio Explained podcast. It's great to have you back. Lots of changes, new career stuff and changes within what you're doing. And really great news is you've done a masterclass for the Physio Network all about groin pain titled Mastering Groin Pain from Injury to Return to Play. It's out now and I have to say I'm really excited about it actually because it's a big topic of which we're going to discuss. snapshot, take a little bit of it today and talk about some of the rehab if that's all right. So should we dive straight in Stacey about groin pain and groin related pain? Why is it such a big deal?

SPEAKER_02 3:00

Yeah, no, thank you so much. I appreciate you guys inviting me back. And like you said, a little bit of a shift from the men's professional game to the women's professional game, but still doing what I love, which is groin injuries. And so this is perfect. So just how common is groin pain? Well, if you look across the literature, about the fourth most common injury in soccer, about the third most common injury in Australian rules football, there's a really high prevalence in ice hockey of those injuries. There's about a 25% recurrence rate. So really across all sports, a high rate, high prevalence, and a high likelihood that you'll encounter it in your clinical practice as well.

SPEAKER_01 3:44

Brilliant. Yeah. So it's a big topic. It's something that I'm pretty sure most of the listeners will have come across. And it's not always the easiest one to assess, but particularly rehab. And rehab is what we're going to be talking about today. And we're going to kickstart this with what changes we might expect whilst we're rehabbing our patients and how can we monitor those?

SPEAKER_02 4:06

Yeah, no, that's a great question. I think having a realistic expectation and idea of what is normal is key or what is expected throughout a season, throughout a return to play process. So that way we can know when things change, right? So looking at different literature, and this is looking at male professional soccer players and male professional ice hockey players, there really wasn't a lot of change clinically or statistically relevant change in pain or function over the course of their season. So that was really interesting to me because I've seen kind of clinically kind of bigger changes during preseason while people are ramping back up. And then towards the middle end of the season when you have a higher chronic load. But looking across the board, it seems like those were more based on individuals who maybe during the off-season didn't prepare in a way that prepared them to go into pre-season or had some underlying conditions that may predispose them to having groin pain or injury.

SPEAKER_01 5:11

And how are we monitoring this? I mean, it's obviously we're talking about an athletic sporting population. What sort of methods have we got that are valid, reliable, and potentially easy to put in place that we can monitor these athletes? And is it worth doing?

SPEAKER_02 5:23

Yeah, I mean, we have a ton of different ways that we can monitor it. So really depending on what your resources are, time-wise, personnel-wise, financially, there's definitely something to fit every situation. So really, I think the key is not guessing. So trying to quantify changes. That can be as easy as, you know, there are very low cost force gauges that you can use. And there are some higher cost ones that are a little bit more robust. And if you don't have access to that or timing with that, you can use something as simple as your arm between the person's ankles, the five second squeeze test, which has been extensively studied and validated. as a way to monitor growing pain and function and help give advice on that return to play or participation activity or restrictions.

SPEAKER_01 6:17

Brilliant. And perfectly segued there, we talked about return to play. And obviously, this is a hot topic amongst a lot of, particularly in my interest in terms of lower limb rehab and how do we know when players are ready to return to play? And And I suppose from this point of view, the importance of a framework, from your point of view, is that important? And if so, why?

SPEAKER_02 6:40

Yeah, I think absolutely it's important. I like to think of the return to play process as a cross-country road trip. I live in California, so maybe you're going from California to New York. You're going to have a framework. You want to know generally the route that you're going on, maybe how many hours a day you're driving, where you're going to stop, depending on the level of detail involved. that you operate at and how you like to execute things. Maybe you'll figure out what restaurants you're going to, what Starbucks you're gonna stop at, what coffee shop, but you really need to have a plan. And then along that plan, you need to have checks and balances to tell you, am I still going in the right direction? Have I gone off on a detour or have I somehow completely turned way the wrong direction and I'm going backwards? So that plan or that framework is absolutely essential. I think it really gives you as the clinician an idea of what you're doing, which is really important. And likewise, you can communicate that to other stakeholders, whether it's the patient or athlete that you're working with. Maybe management or different people have questions. It's much easier to explain your thought process when you have a plan and actually one that's written out. I know a lot of people say, I've done this lots and lots of times. They're all kind of the same. I can kind of work my way through it. I'm a big advocate of writing down every single one and having that on a piece of paper. continuing to monitor, continuing to check. That's how you can pull in some of your technology and whatever your key indicators are that are important to you. And then you can go along that timeline and that process and say, okay, I've met all of my criteria to progress or criteria to move to the next phase. We can do that in more confidence than just looking at time alone or looking at your gut feeling or the patient maybe saying yeah I'm ready to go. All those things are important but are probably part of the plan and not the entire plan itself.

SPEAKER_01 8:40

Now I suppose also how much of an emphasis do you feel is placed on involving the player, the athlete, the patient in that plan and that process?

SPEAKER_02 8:50

I think it's massively important. Ultimately their body, their choice and I like to educate the people I'm working with a tonne I want people to understand why we're doing what we're doing. I think it gives them some autonomy. It gives them some buy-in. And then particularly in the professional sports realm, their time can be really limited with you. And what they have for their whole career is themselves. They may be Going across teams, across countries, across clubs, across agents, across all these different people who influence them in their life. But if they can really start to understand more about their body, then I think that gives them a better chance to be successful across the course of their

SPEAKER_01 9:30

career. Definitely. So taking that control and that management of themselves and having the buy-in for the rehab process, which isn't going to be easy at all. So I'm going to come back in a second to talking about some of the return to play criteria. Again, we're going to just touch the surface and you go into this a lot more detail in the masterclass. But what about exercise selection? And I suppose linking into this a little bit about how we think about a pain during that return to play. So first of all, exercise selection and how proper exercises are such a thing and are they important?

SPEAKER_02 10:05

That's a great question. Absolutely. There's a ton of high quality research now that's really looking at targeting or helping us understand what muscles are being utilized during which exercises. So if we, through our extensive evaluation, we identify areas of opportunity, then we can say, okay, these interventions or these exercises appropriately dosed in the right reps and sets and with weight they're more likely to give us the outcome that we're looking for. So in the masterclass, there's a link to a couple of different studies that have been done that outline exactly that. So muscles, either glute med, glute min, glute max, that you're more likely to recruit the muscle groups that you're looking for, if again, a dose appropriately. So I would start with those, and maybe we can link them in. So it's Collings work, and a number of different physical therapists and physios across the board have kind of taken it and made different infographics from it. But Colleen's work is outstanding and would be something I would suggest everyone reads to really cue in on what muscles they're looking to help improve over time.

SPEAKER_01 11:13

Yeah. So just having that a little bit more specificity, would you say, in terms of what you're targeting and maybe why? And you mentioned sort of obviously some of the lateral glute structures in that in terms of groin pain. I'm throwing this in here a little bit. So why are we targeting some of those, targeting some of those muscle groups?

SPEAKER_02 11:31

Yeah. I think one of the wonderful parts about the lumbopalmic region and the hip region is there's just so much going on, right? You have your abs that are coming down. You have your adductors that are coming up. You have your glutes that are wrapping around. I always think of it, and especially that pubic symphysis area, kind of like a roundabout. There's stuff coming in and out from every direction and And it all impacts each other. So there's been a lot of research done on the abductor to adductor ratio, so abductor to adductor ratio in strength. So a lot of times if somebody is very acutely injured and maybe they can only tolerate isometric activity of their adductors, we really look at the other parts of the equation, the other parts of the outside. So really focusing on those abductors and the glutes as well. And a lot of times you can load those pretty quickly, pretty early to start to get that stimulus that they need to repair the muscle.

SPEAKER_00 12:32

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SPEAKER_01 12:59

So you mentioned that adductor-abductor ratio there. Can you utilize that? And is that part of any of the return to play testing and monitoring that we talked about earlier?

SPEAKER_02 13:10

Absolutely is. So I try to keep soccer players and footballers around a one-to-one. There is some evidence that Similar to workload ratios, you can go above and you can go below, depending on the strength of the person and maybe some of the activity demands. But really try to monitor them pretty closely to see if they're within that one-to-one

SPEAKER_01 13:32

ratio area. So to clarify, you're looking at the abductors to have an equal strength on testing?

SPEAKER_02 13:40

Yes. And I think that segues nicely. So symmetry is one thing that can be really important. But the other one that I would encourage people to get into is really looking at a relative torque measurement. So making sure that you're looking at what's appropriate force for the person to generate for their height and their leg length and their weight. So basically turning the body into a torque equation. It's pretty popular in ACL literature looking at knee extension, quad strength, but now starting to look a little bit more at the hip as well. So if you think about a car, especially in the wintertime, all the tires may be under inflated because it's cold. They can be pretty close to flat. But if you look at them, they're symmetrical. That's not great for the long term wear and tear of the car. Right. If they're all really their PSI or their their tire pressure is under where it should be. But if you only look at symmetry, you say, hey, great. Like, that's fine. They're symmetrical. They're

SPEAKER_01 14:41

equal. Yes.

SPEAKER_02 14:43

So having both of those measures, that what is appropriate for their size and that symmetry is where I think the next level comes in, especially during a rehab process. Sometimes people may be underloaded. So even comparing to their side that isn't involved may not be that target that we're searching for.

SPEAKER_01 15:04

Absolutely. Yeah. You're sort of measuring against an inadequate strength in the first place. So a one-to-one is... not good enough. It doesn't matter how equal it is. Yeah. So moving through into that return to play and we're monitoring, what's the role of pain and how do we tolerate that? And how do we allow the athlete to measure that themselves?

SPEAKER_02 15:26

Yeah. And I think that wraps into your earlier question about how important it is the athlete or the patient and all of this, especially in This type of brain pain or some injury, sometimes pain can continue on through the process. And that doesn't necessarily mean stop. Everyone's experience with pain is different, but understanding how to safely load somebody. So generally, I obviously the exercise selection needs to target what we're looking to improve. I educate the person I'm working with to say on a zero to 10 scale, zero is no pain, 10 is worst imaginable, six or seven, you would probably pull yourself out of a training or a game. I think a pain level of around three is acceptable depending on how each person experiences the pain, but that pain should go away once you're finished with the activity and the baseline of what you're feeling the next day should not change. Could you have additional muscle soreness? Yes, ideally, if we're working on strengthening your muscles. But that, you know, what is your pain? What are your symptoms? That shouldn't gradually increase over time. So as long as we're still meeting those two criteria and we are prescribing appropriate exercises for them, then I think we're fine. We think sometimes things get a little confusing is when exercises that aren't appropriate for their stage of healing or what they've progressed through, when those are prescribed, then sometimes maybe they have a spike in their pain and you say, well, that probably isn't something they should have been doing in the first place. So making sure that you understand that gradual progression of exercise prescription and their field progression or court progression is really important.

SPEAKER_01 17:09

Brilliant. That's really useful. So we've only got a couple of minutes left of the episode and I thought it'd be really nice to finish on something that the listeners can directly put in practice. And that's this return to play criteria. Because I think as clinicians, we're always looking for these things. What can we test that tells us when that athlete's ready? So for those of us maybe who haven't got access to high level technology, And things like that. What are some of the things that you think are pretty good? And obviously they're going to be amongst lots of other tests and that's fair enough. But what are some of the things that you particularly are a go to for you with athletes that are returning to play from a groin related injury? What sort of things might you utilise or recommend that we put in as part of our return to play criteria?

SPEAKER_02 17:51

Yeah, no, I think the biggest bang for your buck. And by that, I mean, it's free is a five second squeeze test. You throw your arm right between their ankles and you have them squeeze as hard as they can. You know, if they give you a zero to three, they're probably okay to continue their gradual progression. And then, you know, numbers that are up from there, depending on what those numbers are in the activities. You need to modify the activity that they're doing. I think it's very rare that I have somebody completely stop, but I think with a lot of brain pain, they can always do something else. It may not be striking the soccer ball over and over and over again, but can they go for a controlled velocity linear run? Maybe. Help them understand what they can do, but that one I think... Anybody can put your arm between somebody else's lower leg. Anyone can squeeze. You can do that on the pitch. It doesn't take a lot to explain to an athlete how to do that. And they can monitor on their own and send you back that information regardless of where you are.

SPEAKER_01 18:49

Brilliant. That's a really good place to stop and finish the episode there. A positive place as well. And I think there's just so much to this. I think I highly recommend everyone. head over to the masterclass that you've done, Stacey, because I think it encapsulates a lot. I love the roundabout analogy, the year of the hip, because I think it is that, isn't it? There's lots of things going on which can, for many, be exciting, but for others be quite daunting to assess, treat and rehabilitate. So I think the masterclass is really going to help take that roundabout and unpick it a bit and help us work with our athletes that little bit better. So thank you so much for your time, Stacey.

SPEAKER_02 19:24

No, absolutely. Thank you. I love chatting about it. And if anybody else wants to chat, Definitely get in touch and we'll talk soon.

SPEAKER_01 19:32

Brilliant, Stacey. Thank you so much. So a reminder for those of you who want to have a look at this masterclass, which I'm sure pretty much everyone listening to this will want to, please make sure you check out the show notes where we've linked the masterclass below so you can check it out and learn lots more about mastering groin pain from injury to return to play. Stacey, thank you very much.

SPEAKER_02 19:53

Awesome. Thank you. We'll talk to you soon.