[Physio Discussed] Mastering groin pain with Dr Stacey Hardin and Dr Adam Weir

In this episode, we discuss the assessment and management of injuries to the groin. We explore: 

• Differential diagnosis of groin pain
• Key clinical tests for groin pain
• The role of imaging in this population
• Specificity of strength tests
• Relationship between groin weakness and injury
• Practical load management strategies
• Managing recurrent groin pain
• Unrealistic expectations in elite sport

Want to learn more about groin pain? Dr Stacey Hardin recently did a brilliant Masterclass with us called “Mastering Groin Pain: From Injury to Return-to-Play” where she goes into further depth on this topic. 

👉🏻 You can watch her class now with our 7-day free trial: https://physio.network/masterclass-hardin1

Stacey Hardin is a Doctor of Physical Therapy and athletic trainer with an extensive background working in professional soccer in the United States. Previously, Hardin was the Senior Director, Player Health and Performance for Minnesota United in Major League Soccer and the Director of Medical and Performance for Bay FC in the National Women’s Soccer League. Currently, Stacey is a PhD student at Teesside University studying fatigue in the female athlete.

Dr Adam Weir is a British-trained sports medicine physician specialising in groin injuries, who completed his training and PhD in the Netherlands before working internationally, including a leadership role at Aspetar in Doha. He is a key contributor to research and terminology in groin pain, holds clinical and academic roles in the Netherlands, and has broad interests in sports injury management, education, and research.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio

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Transcript

SPEAKER_02 0:04

Welcome back to Physio Disgust, the Physio Network podcast where we sit down with leading experts and unpack the clinical topics that challenge and shape modern physiotherapy practice. In today's episode, we're diving into one of the most complex and frequently misunderstood areas in sport and MSK care: groin pain. Whether you're working with elite athletes or active patients in everyday practice, groin presentations can be notoriously difficult. Overlapping pathologies, confusing imaging, persistent symptoms, and high reoccurrence rates all make this a real clinical puzzle. I'm joined by two outstanding guests. First, Stacy Hardin, a doctor of physiotherapy and athletic trainer with extensive experience working in professional soccer in the United States. Stacy has held senior leadership roles in player health and performance with Minnesota United in Major League Soccer and Bay FC in the National Women's Soccer League. She's currently completing her PhD at Teesdale University, focusing on fatigue in female athletes with a strong passion for prevention, rehabilitation and performance strategies in elite sport. Alongside Stacy, we're also joined by Dr. Adam Weir, a British sports medicine physician and one of the world's leading authorities on groin pain in athletes. Adam completed his PhD on the treatment of groin injuries and has played a central role in advancing the field, including as lead author of the landmark Doha Agreement on Terminology and Definitions in Groin Pain. He worked in the Aspatar Sports Groin Pain Centre in Doha and now coordinates the Academic Centre for Groin Injuries at Erasmus University Hospital in Rotterdam, whilst also serving as an associate editor for the British Journal of Sports Medicine. So together, in this episode, we explore how clinicians can approach groin pain with greater clarity, from early differential diagnosis across a doctor, illitous, inguinal and pubic-related presentations, to the role of imaging and key rehabilitation milestones, return-to-play decision making, and load management strategies to reduce risk. We also dig into what to do when groin pain becomes persistent and recurrent and the common pitfalls that can derail even the best rehab programs. This is a conversation packed with practical takeaways and expert insight. So let's dive in. I'm James Armstrong and this is Physio Disgust. Stacey Adam, welcome to the Physio Disgust podcast. It's great to see you both and thanks for joining us. Thanks very much for having me on.

SPEAKER_00 2:37

Great to be part of this. Looking forward to it.

SPEAKER_01 2:39

Yeah, likewise. Thank you so much.

What is groin pain?

SPEAKER_02 2:41

So we're going to be talking today in a lot more detail around groin-related injuries management and lots of tips and tricks for listeners in terms of everything from assessment to return to play. And I thought, what better way to start is with a definition? Let's get on the same page on what we're talking about here. So many listeners, I'm sure, are probably quite accustomed to what we're talking about in terms of groin pain. But just to make sure, Stacey, do you want to kick us off in terms of when we talk about groin pain? How would you summarize that as a term and what that might include?

SPEAKER_01 3:16

So I think you know the inclusion of groin pain can come from multiple structures. So we can consider rip is more adapter related, illiosobos related, inguinal, pubic related. And that's really one of our first big tasks is to figure out where we think it's coming from. And you should also consider whether there are intraarticular causes of the pain as well. So looking at the hip joints itself, low back referral patterns. So there's a lot going on in a small space, which is, I think, one of the big challenges for clinicians.

SPEAKER_02 3:45

I think it was Alison Grimaldi once, I don't know if it's her term, but she used it as the as the roundabout of the body, the crossroads of the body, where everything seems to come in. And as a new clinician, it can seem really daunting, can't it? Where there's just so much going on. Adam, anything to add to sort of our term groin related?

SPEAKER_00 4:04

I think it's really nice from my side. Ten years ago, I was involved in the the Doha agreement and invested uh uh quite a large proportion of my career in trying to reach a kind of a common language and a terminology when you have a clinical approach, and it's great to hear Stacy speaking the same language. The terms are ductur-related, iliozoas-related, inguinal-related, pubic-related are the four kind of major clinical categories that I think you'll see a lot in athletes. And just to reinforce as well, never never forget the hip, that's obviously part of the groin as well. So I think it's going to be nice to do the podcast together as we seem to be using the same terminology.

Differential diagnosis of groin pain

SPEAKER_02 4:47

Absolutely. I think it helps, doesn't it? And I think when clinicians use the same terminology, that often helps our patients and our clients, athletes, start understanding what's going on as well. It's it's confusing when they hear different terms and and relate those to different things. So the first element to this is we've just talked there through sort of keys key structures, the Doha Agreement, which kind of looked at how we might separate those out. In your experience, how might you approach that assessment in terms of your differential diagnosis? Now, obviously, this could be a podcast in its own right, but are there any tricks and tips that you found help you negate that differential diagnosis? Adam, we'll start with you.

SPEAKER_00 5:30

I think the history is the key part in your assessment. You're two major modes of onset. The first is acute during an explosive kind of physical activity. I commonly see that during sprinting change of direction or kicking, the athlete feels in a sudden onset of pain, or the gradual onset where they've started with a grumbling groin that's perhaps sore during the warming up, then jaw soaring the warming up and off. And in the end, if they keep on playing and training, it gradually worsens. So you've got those two kind of mechanisms, acute versus gradual. And then the location of the pain, the athletes are really trying to tell you where it hurts. So don't be satisfied with them just waving the hand around wishy-washy, it's the groin somewhere, get them to dial that in, point to it. And they're trying to help you. We've done some research with pain mapping and how the location of pain depicted by the athlete themselves maps to a clinical diagnosis, and the adductors, the athletes just point to their adductors and say, It's sore there. Typically, it'll be up on the insertion on the pubic bone. But they're really trying to help you if you get them to be specific on the location. So the mechanism of onset onset and the location of the pain would be two real important things to drill down into on the history. The the character of the pain is less important, perhaps we didn't find a clear relationship between the specific characteristic of pain and a specific clinical diagnosis.

SPEAKER_02 7:01

Yeah, so that's a good one. So the patient helping you with where that location is. Stacey, anything else in terms of your your assessment and trying to dial in on where this pain's potentially coming from and to help us manage that feature treatment.

SPEAKER_01 7:16

Yeah, I think that subjective report and listening to the patient is really important, and you can get a lot of really good information from that. I think the other piece is sometimes patients will do the whole hand wave over and say that this is the area that hurts. And I think that's when it's really our role also to help guide them through. And for us to do a thorough exam, sometimes it's tempting to say, great, pinpoint, here's the one spot, found it. This is my familiar pain. But especially in hip and groin pain, there can be multiple occurrences of it. Location can change, it can change between session to session, depending on the injury. So really making sure you do that thorough exam. There can also be some areas that maybe are painful, but still the patient hasn't identified them yet as a primary area of pain. So making sure that we really do that thorough exam to help guide our treatment is really important.

SPEAKER_02 8:14

Definitely. And we we talk about that waving of the hand. Do you think some of that comes from the embarrassment? I mean, we're talking about an area of the body that a lot of people maybe are are quite protective or private around. And that could mean point into areas that they might just don't feel comfortable to do. So in terms of making them feel more comfortable, is that part and parcel of it, do you think?

SPEAKER_00 8:32

I think that that obviously depends upon the clinical setting and cultural context as well. But you're right, in in general, the groin is a a kind of a region of your body that you're not used to having checked by doctors or physiotherapists all the time, and it does with a physical examination, meaning getting into your underwear, lying on a bed, and you're feeling a bit sort of exposed. So that that could be a factor. I also think as Stacy points out, sometimes athletes have multiple entities, so they may often pain may start in the adductors if it's been long there for long enough, and the complaints are getting worse, it can often track up into the the inguinal region as well. So as you correctly point out, the the groin pain can kind of move around over time as well. And the alongside your history, that the clinical examination is key. So screening the lower back side joints, screening the hip. And then in my mind, I sort of run through the the clinical entities of Doha in terms of my physical approach with the resistance testing, stretch testing and palpation. And that gives me a sort of a clinical framework. How are the adductors, how's the iliozoas, how's the inginal canal, and what's the pubic bone like?

Key tests in the objective assessment

SPEAKER_02 9:50

As always, uh in terms of the assessment, I g it is something that always crops up as especially I think with with newly graduated physiotherapists, we're quite often looking for an easier way to find the answer, uh, a recipe of assessments, something quick that will tell us and I think hence why special tests are often the people want those, maybe, and we're drawing away from them in some respects. But are there any simple assessments that you've have found that are relatively reliable in terms of some of the elements in terms of say a ductor related, ileus oasis and and pubit-related? Is there ways that we can test those in our objective assessment after we've gathered our subjective, Stacey?

SPEAKER_01 10:31

Yeah, I think the five-second squeeze test has been studied well, and that's a simple one to do without any equipment. So that's a I think a great one to add into your examination, palpation in terms of tenderness on the pubic bone, and then resisted hip flexion in that supine position at 90 degrees. I think another one that I've been looking at more recently, especially with higher level athletes, I think can typically give you one or two good reps, whether it's against manual resistance or then an external force frame type device. But what I've I've seen more recently is when you have them go through an eccentric component or of the movement that you're looking for, I've seen almost like a drop foot type presentation where they their motion and their resistance isn't isn't smooth. It's more kind of hitchy on the way down on the eccentric component of the muscle action. So that's been one anecdotally that I I've been adding in a little bit more. But Adam, what have you seen?

SPEAKER_00 11:32

Yeah, I think for me, the simple sort of clinical skills of pulpation, know your anatomy, your surface anatomy. We've had recent research from Willem Hybor's PhD where he really had a deep dive into the clinical findings in long-standing adductor cases. And there you see that most of the time the pain is up on the insertion of the adductor longus. If you get them to rest their leg upon your thigh on the bed, so they're lying kind of in a figure four position, that brings a certain tension into the adductors, and you can pulpate them really nicely, and the adductor longus kind of stands up, you feel it just below the skin like a finger, and it's a simple landmark to identify. You obviously have to be comfy enough then to follow it up to the proximal insertion onto the pubic bone. Whenever you're palpating in the groin, if they have unilateral complaints, I'll always start with the asymptomatic side to give them a sense of what's just the discomfort of having your pubic bone pulpated because there are nicer things to do on a any given afternoon. So then you're looking when you go to the symptomatic side to try and get them to differentiate. Is this just pain from me pushing, or is this your recognizable injury pain? You know, I think if I had a euro for every time I've said that phrase, I'd probably be retired now. But that yeah, so have a good good thorough palpation, but all the time you want them to give you a sense is that they're injury pain, or is that just discomfort because it's an unpleasant test? And then you back that up with your resistance testing, and I would just do a quick against the ankles, have them push out A B duction, hands between the ankles, A deduction, hip flexion, and then a couple of sit-ups with their legs straight as a as a kind of a global check to see what's happening. And you can do that in 30 seconds if you're convinced it's an adductor, but there's no pain on just squeezing in neutral long lever. You can always bring them into outer range, like you say, get them to push against your thigh, and you'll be able to break everybody's adduction strength like that. And I do recognise what you say, that's kind of jerky motion, whether that's reflex inhibition through because of the pain, I'm not sure, but it's it's definitely, I think, something in general with painful conditions that you lose the kind of fluidity of motion.

Role of imaging

SPEAKER_02 13:57

We see that across a lot of joints, don't we, in terms of that quality of movement. It's why we look at not just range, not just not just strength, but also that quality and and inhibition or or apprehension potentially that that we might see. Moving on to another element I think that's always comes back in conversation is when to image? When do we want to be looking more? And we often will talk about when it might change our management. But with these this patient group, are there any things that would lead you to think this is someone who actually I want to to send for imaging? Uh is there anything that's gonna stand out from previous experiences or your assessment?

SPEAKER_00 14:37

Uh when to image or not is gonna be really context specific. I work in an academic hospital, nearly everybody I see will have had the imaging before they even get to the phase of seeing me. But in general, I would say that one of the main kind of pitfalls with imaging is that there's a real underappreciation of the amount of changes on imaging in healthy athletes. So if you do a simple x-ray of a male football or soccer player, the chance that they'll have a camorphology of the hip is going to be about two-thirds to three-quarters. If you do an MRI of the same football player, about 50% will have some degree of bone marrow edema, 70% will have some changes in their reduct tendons. So I'd say the the main challenge with imaging is if you don't have a good idea of the clinical picture and you just request some imaging, you're gonna find lots of stuff. But if you didn't have a clinical picture beforehand, it won't help you. So I'd say that yeah, then then you end up creating vomits. So the victims of modern imaging technology, and that really it really sits in people's heads. Everybody looks up their imaging reports, they put their MRI reports into Chat GPT, and it can be terribly depressing for athletes to read all these awful things they supposedly have while often it's completely unrelated to their clinical condition, I'd say.

SPEAKER_01 16:08

I like that that vomits. We we say over here sometimes, well, you're you're going fishing and you're gonna catch something. So what do you what are you gonna catch? I think you know, in the pro sport environment, like you said, imaging is customary. So that's the expectation, really. If if you miss a match or have more than just a couple of days of some type of presentation that requires modification, there will be imaging, but we know with information that you cited, that there will be findings. It is very rare to have an MRI come back and have nothing that's commented upon. So outside of trying to rule out something potentially more systemic, I I like to treat the person in front and put that clinical picture together. Otherwise, creating those moments of doubt, those moments of fear are very real, especially in the professional athlete and in the younger athlete.

SPEAKER_00 17:29

Yeah. And I think that the the the pre-imaging counselling is really useful. If you're performing it yourself, it's up to you how you're gonna frame that beforehand. You can address the things you'd expect to see because of the certain sport they do, the duration of sports they do. But if I think about my own practice, when would I request imaging? You can assess the maturation of the pubic bone very nicely. So if as a clinician I'm trying to decide with a long-standing adducted case in the age category between 18 and early twenties, we know that that's often due to a pubic apophysitis. So with even with a simple X-ray, you can check the maturity of the pubic bone, because I would uh give a different clinical approach to an apophysitis compared to a more adult, which you might consider being like an insertional tendinopathy kind of underlying problem. So assessing the maturation of the pubic bone, I'd find it to be useful. If I'd suspect a stress fracture, that would be something I'd certainly think about getting uh imaging for in those cases. The red flags you mentioned, systemic underlying problems. There'd all be times when you're gonna use imaging and the the hip joint, I think I'd have a fairly low threshold with imaging if I'm considering the groin pain being more hip-related, hip dysplasia, or CAM or pinsomorphology or things that are very easily detectable again on simple x-rays.

SPEAKER_02 19:02

And Stacey, are there any sort of standouts that you think that that presentation is something that I would I'd want to image?

SPEAKER_01 19:08

Yeah, I I think like Adam mentioned, the suspicion for stress-related, bone stress-related injury, especially in well, and in both genders, but especially in the the female athlete, we see those a lot more. And so catching those early on and and not, you know, the wait and see approach and the monitoring approach that sometimes can be appropriate with other types of injuries, they that would be one where I would move quicker to imaging.

SPEAKER_02 19:32

Okay. In terms of sort of our more traumatic adductor related, if we're starting to think of anything else, is is there a point whereby you would wait till image or would you image maybe more quickly with those ones?

SPEAKER_01 19:44

I think just one is if there's suspicion of an abulsion or abulsion fracture, having an idea of that and then the level of retraction to see if there is potentially an indication for surgery or not. We know that surgery, although popular, you can achieve similar, if not better, outcomes with non-surgical management in in some of those cases, but having an idea of whether there is that abulsion, abulsion fracture, and then whether there's a level of retraction that's associated with it.

Objective tests for return to play

SPEAKER_00 20:13

Maybe you want to add to add to that one, Adam. No, I think uh the sort of more serious uh avortions around the groin and avortion of the adductors is by far the most common. You can have an avortion with a minimal retraction or the entire proximal enthesis of the adductor longus avorsor, sometimes with concominant muscles around it. There are big differences geographically to the clinical approach. In nearly all cases in Holland we'll treat a complete adductor avortion even with retraction with a rehab program. And typically the that three to five centimetre retraction, they have hematoma that gradually congeals and then over the course of the coming months becomes like a neo tendon. So it's absolutely amazing. They have a palpable gap, and then a few months down the line and it's it's completely filled up, and they generally will return to sports between two to four months after the initial injury. And we found out to be quicker than a surgical approach where they'll need a long postoperative rest period to let the anchors and what have you deal. They'll often be able to do a speed ladder by the end of the first week if they don't take large lateral steps, so they're able to kind of maintain their general conditioning pretty well as well. But I've seen people from other countries who've had surgery very quickly for identical injuries. Yeah.

SPEAKER_02 21:36

Brilliant, brilliant. So we we we've got sort of down to the nitty-gritty of a sort of assessment and and and now we're gonna move on to our management. And when we're looking at progression of sort of our athletes and particularly return to play, are there any sort of objective tests or strength ratios that you you think we should be aware of and be prioritize when we look at the milestones? Stacey, we'll go straight to you on this one in terms of what are we looking for when we push our patients forward and and get them back?

SPEAKER_01 22:06

Yeah, I I think their relative strength is of important. So we'll look at symmetry. I think everybody does that, but then their strength relative to their height, weight, and their leg length. So how much work they can generate. Before people return back to any multi directional movement, I like to have them at least at 2.0 newton meters per kilogram, getting them above 2.5. As we progress through the rehab process. And then looking at their AB doctor to AD doctor strength ratio, starting them out anywhere between the 0.8 and 1.2, but then trying to close that gap and get them closer to one as we progress through that on-field return to play piece of it. And then the other piece that I think a lot less likely gets looked at or less often gets looked at is that top-end speed. People consider that a lot, obviously, in hamstring injuries, but looking at can they generate that force that they're going to need to run very quickly? And then layering that on top of can they do that with a change of direction afterwards? But I think early on I spent a lot of time really interested in their cutting in a 510-5, the moving really quickly side to side, and didn't really appreciate the contribution during something like just top end, hot top and running.

SPEAKER_02 23:21

And when you talk about the the forces you talked about just at the beginning there, are there a particular muscle group that you're you're looking at there? You mentioned the two, I think, newton meters per kilogram. How do you measure that more specifically or where are you measuring that?

SPEAKER_01 23:33

Yeah. So you can use a handheld dynamometer or an external force frame of sorts, whichever one you like. So I'll measure down towards the lateral or medial malleolis and look at abductor and adductor strength. In recurrent grain pain, I'll also test them out in that end-range abiducted position, because sometimes, especially in more recurrent cases, I've found that we're really good at getting them strong at middle range. But when they bring their leg away from their body, all of a sudden they they can't do that. And you look at their sport where they're really not operating their legs right next to each other very often, if ever, miss the boat on that one a number of times. So they'll get their leg abducted as well and test out.

SPEAKER_02 24:18

Yeah, good that that those different ranges. And and the other thing to mention that is you talked about the ratio between A-Duction and A-bduction strength in our field athletes, maybe when they are multi-directional cutting. Is there a difference in that ratio compared to other athletes and other sports where you might be more in a different plane of movement? Is there a where the ratio is different?

SPEAKER_01 24:43

Yeah, I think Adam's probably had more experience in in other schools. I've been pretty much soccer football my entire career. So if you want to take that, I want to go for it.

SPEAKER_00 24:52

Yeah, firstly, I'll just back up your kind of plea to use a dynamometer, all these kind of subtle differences in ratios. You're not going to pick up with your bare hands if someone's really weak just with a simple resistance test, then you know there's something going on there. But a dynamometer is a great piece of kit, and I'd encourage any aspiring physiotherapist to consider spending the money to buy one because it gives you great data and will be a valuable addition to your objective testing. And then coming back to what you said before about various sports, we've done work ourselves looking at football, also female football, with male field hockey. There are subtle differences if you're involved looking after athletes in a specific sport, have a look around in the literature. But in general, most high-end athletes are stronger on the A-Ductus than they are on the A B ductus. So as a kind of a rule of thumb, you'd want the ratio to be one or or higher, and it can be as high as 1.2 to 1.4.

SPEAKER_02 25:55

So as you say there, that that use of dynamometry giving more specific strength measurements rather than us just using our hands and who I see still, unfortunately, in the NHS where those resources aren't necessarily there, we're still using the sort of manual muscle testing and not really necessarily finding those nuances in different muscle groups.

SPEAKER_00 26:17

But we perhaps have to be realistic there that not everybody has a dynamometer and not all athletes that I see in clinic have access to physiotherapy or very limited access as well. And there you can resort to more kind of practical testing. If I'd see a recreational football player who is going to follow a YouTube tutorial or a printout in terms of their exercise program, I'd speak to them.

SPEAKER_02 27:09

I love that. And that's always nice, isn't it, when we can give athletes a self-test, depending on which setting, of course. But yeah, it's quite nice for them to be able to test themselves. People like usually testing themselves. Yeah, and you're right, not everywhere has access to all of these things. Yeah, definitely. Is Stacey anything else on those, on that really, or on where we don't necessarily have access, any other cheats, as it were, or on assessing some of these athletes.

SPEAKER_01 27:33

Yeah, I think that three sets of tens great. And I'd be curious, we we've done an isometric hold before, and I'd be curious your thoughts on the reps versus the ISO hole. But that's been a 45-second isometric hold. And then also looking at lateral core and av ductor strength, having them in a side plank 45 seconds to begin with as they start through their return to play progression, but then up to 90 seconds. And I think there's some pretty good paper that looked at the recurrence of hip and grain pain in APL athletes, saying 90 seconds, was there cutoff for a lateral plank or a side plank? So we'll have folks test that as well.

SPEAKER_00 28:12

I could see how that would track clinically as well. I don't have experience with it myself, but when you say it, it it makes perfect intuitive sense as to how that would carry over. And certainly a lack of ability to do something on that kind of basic level would make you question their readiness. Yeah.

Predictive factors for groin injury

SPEAKER_01 28:29

I think it's an easy screen in a team setting too. You set everyone up, you pop everybody up and say, all right, go hold it. You know, isometrics are easier to s to scan for form in a whole group as well. So potentially another thing that somebody could add.

SPEAKER_00 28:43

And you know for sure if you do that in a team setting, the competitive spirit will dominate. So they're not gonna just give up too easily when everyone else is watching, for sure.

SPEAKER_02 28:53

Yeah. And do you do you find in terms of that low tolerance, does that carry over into, dare I say, any likelihood of increased likelihood of of injury? So almost preempting someone who might be at risk of is there any carryover with that, or is there anything that we can be looking at in terms of prediction?

SPEAKER_00 29:13

I think there's it there's good literature out there that would support the weakness of the uh adductors to be one of the risk factors for getting injured in the groin in the in the future. So it doesn't track one-to-one, of course. There are people with weaker adductors who are never gonna pick up an injury, but at the group level, there's a an association between adductor weakness and subsequent groin injury. And we also know that from randomized control trials, that the performing even one set a week in season of Copenhagen adductor exercises can reduce the risk of developing groin pain as well. So I think that the a certain level of strength and kind of baseline robustness is is kind of essential and works protectively as well. Yeah.

SPEAKER_02 30:01

The next bit is it kind of link links onto that in terms of load management, because a lot of the time we'll see heighter season and this because it it I think goes into the amateur sport as well, in terms of where there's maybe less structure within season. But what what are your practical tips, I suppose, we're looking at in here in terms of practical load management strategies that you think we as physiotherapists could prioritize to reduce risk or reduce that growing injury? Is that is there anything because obviously we've returning these athletes back to play, it's always good to be able to give some advice to them to reduce that risk of occurrence in the future. What sort of yeah, practical strategies have have you found will work in your practice, Stacey?

SPEAKER_01 30:43

Yeah, I I think finding the little pockets where you can make a difference. You know, if somebody doesn't practice, yes, I think their growing will feel better in the moment, but that's just not really practical most of the time unless there's an acute injury. So really finding those little pockets where you can do your maintenance Copenhagen exercises and it takes you two minutes before you start training. Those are really important habits to carry out throughout the season. So either working with your staff or or by yourself, depending on what your setup is, to continue your strengthening, to dial back a little bit if you're in a period where you know you'll have three matches and in eight games. You know, what are other things that you can tweak? Little changes. We're not looking for big sweeping changes. I don't think that's sustainable. Um, it can be a good short-term solution, but certainly not in the long battle, especially of long-standing growing pain. Those strategies don't work. So we we look to make small, sustainable changes over time.

SPEAKER_02 31:42

As you know, that sustainability is key, isn't it, for them to be actually consistently carry those on. Adam, anything uh in terms of practical strategies for you from yourself?

SPEAKER_00 31:51

Yeah, a lot of the people I see in clinic will be recreational athletes or amateur athletes. Certainly here in Holland, they have a very long summer break. A lot of people kind of over the season cumulatively pick up groin pain and intuitively a lot of them spend the summer resting. I'm gonna rest this injury away. And then for us, the kind of the peak of the year in terms of busyness in clinic is always after that summer break when people have had the summer off, rested sometimes for two or even three months, and it feels great, and then they return to pre-season camp, sometimes double trainings, and then it's just kind of flares everything again. And we've got data to show that resting in the summer is not the best strategy. So, there in terms of them using their summer wisely, that's the window of opportunity that they have to work on issues that are ongoing and not spend it just resting.

SPEAKER_02 32:49

Yeah, rest isn't all well, is rarely best. But education around what they can and can do to help that. That's interesting, isn't it, with that that long-term break and I suppose almost an effective deconditioning and then the expectation of returning instantaneously to a pre-level of training, potentially having a stress of trying to catch up again. It's not a great combination, really, is it?

Power and speed in rehabilitation

SPEAKER_00 33:13

Yeah, really like what you said, Stacy, about kind of scheduling exercise sessions as well. If you've got three matches in eight days, maybe that's not the time to go hard on your reductor work or any other structure because you're gonna be getting your load from the match play itself. And that's completely different if an athlete's removed from play or is only training or playing partially. So you've got to, I'd say that's the art of medicine or good rehab is is thinking about this scheduling and the and the dosing of the exercises you're gonna be doing.

SPEAKER_02 33:45

A quick question just suddenly come to my mind is we we taught, I mean, I'm gonna go back a little bit here in terms of when we talked about uh measuring strength, so our force production. What about power? So the ability, so the rate of force development, does that come into a rehab, but also testing and return to play, Stacy?

SPEAKER_01 34:06

That's a good question. I think the more work's been done around the quadricep specifically, especially in in football. I don't think as much work has been done with the groin, but like anecdotally it it makes sense, especially for a football athlete where you're striking the ball versus an athlete where they're not making contact, where they're making contact just with the ground. So I think that's a great area to have to look into, certainly.

SPEAKER_02 34:30

Could think it as well in in terms of that change of direction, that change of direction force happens very quickly. So that absorption of loads and production of force is is all quick. Any thoughts on around that from you, Adam?

SPEAKER_00 34:44

I'd say it's something that we're definitely kind of behind the curve there in terms of the science, specifically related to the groin, when you compare it to other areas of medicine or sports medicine at the moment. So I've been more sort of looking around what are other people doing and how could we potentially kind of translate that across to work in the groin? Because at the moment most of the strength measures are either isometric or eccentric brake tests, but we're not really measuring power like that.

SPEAKER_02 35:12

I suppose it maybe a little bit in terms of Stacey. You talked about top-end speed. Is that in some way looking at our ability to produce a force very quickly to get up to speed and maintain a high speed? I suppose ground contact time, etc. There might be something in there somewhere indirectly.

SPEAKER_01 35:27

Yeah. And even just the recurrence or the recurrence of that injury and then preventing injury to the another muscle group that's in a similar area. Yeah, the number of times that you kind of see folks that get back to play and then now their calf's bugging them or their hip flexors bugging them, just making sure we're considering that entire conditioning component.

Managing athletes with recurrent groin injury

SPEAKER_00 35:47

Yeah, really important point. And when we followed up athletes, Andrea Cerna, for part of his PhD, followed a cohort of athletes returning after acute adductor injuries. And in the first 12 months after they came back, it was actually more common for them to pick up another injury rather than a recurrence of their original adductor injury. So that's yeah, the kind of evidence backing up the clinical idea that they they've got to be generally fit and ready to go back as well.

SPEAKER_02 36:16

Yeah, definitely. Sort of recondition the athlete, not just the injury. Or the groin, yeah. Or the just the groin, yeah. And it it kind of leads us really nicely onto our sort of main final point, really, about managing athletes with persistent or or that recurrent groin injury and groin pain, if they're not necessarily responding well to standard rehab. What are the some of the pitfalls you see in not just management, but I suppose maybe the rehab, but also then the management that you feel may lead these players and and people to be more recurrent and more and come back? Are there any things that you've seen that you think could be improved?

SPEAKER_00 36:53

Yeah, I'd say one of the key factors based on my experience in clinics is just the lack of understanding or the lack of awareness about realistic time courses. If an athlete ruptures an ACL, everybody understands immediately, oh, that's gonna take many, many months to get back. We've had data since the 90s that a long-standing adductor insertion or issue is a question of multiple months, but there's some somehow people don't accept that, be that managers, v- that coaches, because with a growing, if your life depended on it, you probably could still play and one more match. So the athletes could be out there running around and people see that, and then there's just a complete sort of disconnect. Okay, they're out there on the pitch, they can run around a little bit, therefore, this should be better in two weeks, four weeks, or six weeks. And these very unrealistic time frames are, I think, a root cause of a lot of the problems that people have.

SPEAKER_01 38:20

Yeah, I think along those same lines, the compliance, once somebody has an initial injury, especially with the the weaker athletes where you potentially met your criteria to progress, but then things drop off pretty quickly and they're already a little weaker than we would like them to be normally. And so they can go down into those danger zones again and feel like we're almost walking that tight rope until something else comes up. So, and I think that's where there's been some really good work and what is the minimal effective dose? What do we have to do? What have we studied that have been tons and tons and tons of Copenhagens? What have we studied that have gone down to again that minimal effective dose? So I think figuring out what that is and being compliant with that can take people a long ways.

SPEAKER_00 39:06

In the professional setting as well, because athletes are often able to keep playing and would like to keep on playing, if they use analgesics, a lot of support measures they're often able to play for considerable periods. And obviously, my bias is I only see the ones where that ends badly. But then people can really end up with quite severe pain in the in the end that affects them in daily life. So they they played through it for weeks or months and months to come to the point where they've actually accumulated quite a severe injury. But once again, there's often a complete lack of understanding. Okay, we played through it for two months to get to the cup final or to avoid relegation or whatever, and then afterwards, okay, this has to be better in a fortnight, and they're just not realistic time frames. So that that kind of lack of awareness in the literature, you look at a rehab program for long-standing adductor related, you're talking three to five months, would be a ballpark figure, especially for recreational athlete. They're not going to be back fit in a in a month.

SPEAKER_01 40:09

I think that's a great point. I had an athlete once tell me, I'd rather just blow out my knee because then at least people would get it. Something I think about a lot, where you know, some of these more long-standing issues, be it groin pain or ankle pain, where they're things that people are burdening a lot and playing through a lot, but have real implications on their life during their career and afterwards.

SPEAKER_00 40:33

And I think that's important as you know, in physical therapists are often the four first point of contact in terms of setting realistic expectations. So, yeah, it's possible to keep playing and training a little bit, but it will delay recovery. That's a a choice that you can make. But also if they've decided, okay, I'm going to remove myself from play and focus on rehab, give them a realistic time frame about how long this is going to take, because otherwise they'll end up being either disappointed or upset if they don't get back within the time frame that was initially laid out for them.

Advice for your younger Physio self

SPEAKER_02 41:09

I think that kind of it transcends to many, many things that we see as physios is being honest, upfront, and realistic with patients so they can set their own expectations of what they might achieve. I literally had a patient today that had been phenomenally poor expectations of Achilles tendon rupture and was expecting to be back walking across the moor within six weeks and they completely missed misheard because I'm sure they've been told, but uh it was then setting their expectation and and they were fine once they knew it. But I think it's the same with this. If people know and and can understand those time frames, they can work with them in their own minds as well as physically in in their rehab.

SPEAKER_00 41:48

So yeah, really so often reassuring as well if they've been told, Oh, this is going to take six weeks and they're coming to see me after ten weeks, and you say, Well, actually, you know, you're not even at the halfway mark for a normal recovery. They're sort of like, Phew, okay, well, there's actually nothing wrong with me. I'm doing the right things, but I just need to do them for longer.

SPEAKER_02 42:08

Yeah.

SPEAKER_00 42:08

And that that can give them also a sense of relief, and I'm not the worst case in the world, or there's not something disastrously wrong with Michael Royne that's not going to recover if we if we keep doing what we're doing. Yeah.

SPEAKER_02 42:21

Absolutely. It builds confidence in what they're doing. Uh, last thing, I'm gonna ask you both to to answer this individually. We're gonna go through it. I I'm gonna ask you the question of if you were to go back and meet your newly qualified or or more junior self, what tips would you give yourself when treating groin pain?

SPEAKER_00 42:40

Ah, the retrospectroscope, yeah. I wish I had one. For myself, I'd learn a lot earlier on about the concept of pubic apophysitis with the retrospectroscope. I've seen athletes in the past before 2012 where we didn't understand that the pubic bone is the last bone in the human body to ossify, and that I have seen even Olympic athletes in the run-up to the Olympics in London 2012, and we looked at imaging and diagnosed them with all kinds of scary stuff, and then later on I learned about pubic apophysitis, and in retrospect, that was just an immature pubic bone that was uh normal, so like they had the Ojkudschlutter of the groin, I'd say, and I had no conception that you could have that at 18 or 19 years old. So that'll be my my tip to younger Adam. Yeah.

SPEAKER_02 43:34

Great, really good. You were very quick on that one as well, Adam. That was that's clearly very further forefront of your mind. Stacy, what about yourself?

SPEAKER_01 43:45

That's that's a really good one. I I think for me, just acknowledging like some things take time. So whether it's treatment of the athlete, but for you as a clinician, I think combining seeing lots of cases with what's available in the literature, maybe it's because in the United States football isn't as popular, and so we're not as like growing crazy, I would say, as Europe is. I think some things you just you have to live them, you have to look at the research and and you have to have experience with them. So I would make sure you're in a setting where you can get a lot of exposure to a lot of reps. And and sometimes pro sports isn't that just because you're limited to you know 26, 28 folks who are on the roster, you can go multiple seasons without, hopefully with without an ACL tear. But if you really want to get good experience, you need the reps. And I think that's where somewhere like a university based healthcare system can or a university college can be really helpful because you see more of that volume and more of the just a variety of cases.

SPEAKER_02 44:51

Definitely. Yeah, that we go from classic. a patient mileage see them lots and you get you get better at treating them because you see see the variety one as well.

SPEAKER_00 45:00

Oh good the other one I I think as a as a young clinician your idea of evidence based medicine is to follow the protocol the holy protocol back in when I started out that was the Holmick protocol for longstanding adductor and I think I'm glad we've kind of evolved as a field but still I often get emails or requests for do you have a protocol for A, V, C, or D, you name it. We've developed a lot of protocols over the years, but the longer you work the more you begin to understand before recommending any protocol you'll speak with an athlete how many days a week would you be able to invest in your rehab? What do you do normally? Are you playing football just in the weekend as a match? Do you normally train twice a week and play in the weekend or is it a professional athlete who's training multiple times a day? The ideal protocol for an adductor is going to look entirely different depending on the athlete in front of you. So that sort of the evidence based is what would the patient like to do? What does the literature say and what's your clinical experience but there's not one holy protocol for all adductors. It's going to be hugely varying depending on their individual kind of level of sports. Yeah.

SPEAKER_01 46:12

Yeah. I think ultimately at the end of the day it's not your decision. It's their body it's their choice and so making sure that they have things that we've talked about like a realistic understanding of the injury and timelines affiliated with that risks and benefits. We've all been in situations where our clinical recommendation was hey this probably isn't uh the smartest idea to play and they come back and say great it's playoffs or I need to have two more games under my bell because I'm trying to extend my contract. There are a lot of other circumstances that can play into it but ultimately our job is to give them the information and their job is is to make the choice.

SPEAKER_00 46:51

Definitely yeah I'd fully agree there and I love the way you framed that it it's not our choice. And I think that's probably different in terms of the relationship of being a team physician than it is when you're in clinic. When you're in a clinic is very easy to give advice and sit back and I'm not in the setting on a day-to-day basis. I don't work with the coach or or the managers or the rest of the stuff I I can imagine that that will be much harder as a team physician because you're in the setting with the athlete but you're also in there with all the other personnel and see them on a day-to-day basis as well.

SPEAKER_02 47:25

Absolutely both settings have their challenges absolutely well both of you it's been a a fantastic chat today there's been lots we've covered and I think it's been really insightful and some real key key aspects which our listeners will be able to take away and and utilize so so thank you so much Stacy Adam for your time on the podcast today. Thanks very much it was really nice.

SPEAKER_01 47:48

Awesome thanks for having us