Injuries to the groin or inguinal region -the area of the body that joins the lower abdomen to the upper thighs -are common among football players.
They usually occur progressively, starting as a mild complaint, although they can also occur abruptly, in the form of a tear or rupture, producing intense pain immediately.
Is It Only a Groin Injury When There is Training/Play Loss
In epidemiological studies in soccer, the definition of training/football loss (“time-loss”) has traditionally been used to record injuries, including groin injuries.
Recent research has shown that the use of this definition carries the risk of underestimating the impact of injuries that usually appear progressively, such as groin injuries. In this regard, a Danish study inelite men’s soccer showed that only one third of the injuries in the groin that required medical attention did not result in loss of training/playing time.
Recording the severity of injuries in terms of number of training sessions or games missed has also been assessed. It has been argued that the number of training/matches missed does not necessarily reflect the extent of symptoms or limitations in sporting function, which in this type of injury may fluctuate over time. For this type of injury, it has been recommended that the assessment of the severity of the injury severity should be considered with the level of sports-related function or capacity -such as reduced sporting performance -and not with training or matches loss alone.
A Study Beyond Training/Play Loss
The number of prospective studies exploring the extent of groin injuries beyond the training/match-loss approach is low. In this setting, one of the most recent studies called Prevalence and severity of groin problems in Spanish football (Ernest Esteve et al., 2020) tackled the extent of groin problems besides the training or play-loss approach through self-reported/reported pain and sports function records
In this study, 407 players from 17 Spanish amateur male soccer teams were evaluated during the 2015-2016 preseason. During 39 consecutive weeks, the footballers answered two questionnaires, one on groin pain and the other on limitations in their sporting function in relation to hip and/or groin problems. Injuries and their severity according to the definition training/match-loss were also recorded. From these records, groin problems were classified as follows:
- A player was considered to have a groin problem if he/she answered (YES) to the question “Have you experienced groin pain during the last week?” on the pain questionnaire and/or had missed training/matches due to a groin injury during the same week.
- A player was classified as having a groin problem without loss of training in the case of an affirmative response to the pain questionnaire but no loss of training.
- A player was classified as having a groin problem with time loss when at least one training session/match was missed, regardless of his response on the pain questionnaire.
- The results of the lost training/match log for groin injury and the groin pain questionnaire were combined to calculate the average weekly prevalence of all groin problems.
- Sports function/ability related to hip and/or groin problems were recorded every 4 weeks using a subscale of the HAGOS (Hip and Groin Outcome Score) questionnaire, a tool designed specifically to assess hip and groin pain and function.
Results: The Actual Extent of Groin Problems
- In total, 216 players (53.1%) reported a groin problem. This means that groin problems were highly prevalent and affected more than one out of two players.
- The average weekly prevalence of all groin problems was 11.7%, consisting of 1.3% groin problems with training/match loss and 10.4% without training/match loss. In other words, one in ten players experienced groin problems and reduced sporting function, but most players continued to train/compete.
- Players with groin problems reported lower scores on the HAGOS subscale compared to players without problems, while there was no difference between players reporting groin problems with and without training/match loss. That is, the extent of the groin injury problem in a male football season is far greater than the training/match-loss definition approach may detect.
- Measuring an injury quantified as “training/match loss” only detected 10% of all groin problems.
Conclusions of the Study on Groin Injuries
These results show that despite causing pain and significant impairments in sporting function, the majority of groin problems do not lead to training/match loss. Therefore, if we focus on training/match loss as a measure of severity in football players with groin problems, we may be underestimating the impact of these injuries.
This also indicates that football players continue playing regardless of having their sporting function impaired, which fits well with the clinical experience that players with severe overuse symptoms may ignore such symptoms and continue to play. Evidence has suggested that injured football players decide to continue to play for several reasons mainly related to economic aspects or football player idiosyncrasy, such as a sense of guilt of being injured or pressure from managers to continue playing.
Since training/match loss is not related to hip-and groin-related sporting function, it seems highly relevant to implement other tools to rate injury severity and prevalence. For this purpose, the HAGOS questionnaire would allow for close monitoring of a player’s function and early detection of abnormal scores.
Due to the high prevalence of on-going groin problems, future interventions should aim not only at preventing new groin problem episodes but also at reducing pain and the duration of symptoms of already existing problems. Strength-training interventions for the hip adductor muscles have proven effective both in reducing the prevalence of groin problems, and in treating long-standing groin pain cases.
These conclusions emphasize the need for contextualization of sports-injury definitions, including not only perspectives from athletes and researchers, but also from coaches, clinicians and physiotherapists, as they are key for implementing successful injury prevention interventions.
References:
- Waldén M, Hägglund M, Ekstrand J. The epidemiology of groin injury in senior football: a systematic review of prospective studies. Br J Sports Med. 2015;49(12):792-797. doi:10.1136/bjsports-2015-094705
- Mosler AB, Weir A, Eirale C, et al. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. Br J Sports Med. 2018;52(5):292-297. doi:10.1136/bjsports-2016-097277
- Werner J, Hägglund M, Ekstrand J, Waldén M. Hip and groin time-loss injuries decreased slightly but injury burden remained constant in men’s professional football: the 15-year prospective UEFA Elite Club Injury Study. Br J Sports Med. 2019;53(9):539-546. doi:10.1136/bjsports-2017-097796
- Hölmich P, Thorborg K, Dehlendorff C, Krogsgaard K, Gluud C. Incidence and clinical presentation of groin injuries in sub-elite male soccer. Br J Sports Med. 2014;48(16):1245-1250. doi:10.1136/bjsports-2013-092627
- Bahr R. No injuries, but plenty of pain? On the methodology for recording overuse symptoms in sports. Br J Sports Med. 2009;43(13):966-972. doi:10.1136/bjsm.2009.066936
- Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: the Oslo Sports Trauma Research Centre (OSTRC) overuse injury questionnaire. Br J Sports Med. 2013;47(8):495-502. doi:10.1136/bjsports-2012-091524
- Roderick M. Adding insult to injury: workplace injury in English professional football. Sociol Health Illn. 2006;28(1):76-97. doi:10.1111/j.1467-9566.2006.00483.x
- Roderick M, Waddington I, Parker G. PLAYING HURT: Managing Injuries in English Professional Football. Int Rev Sociol Sport. 2000;35(2):165-180. doi:10.1177/101269000035002003
- Wollin M, Thorborg K, Welvaert M, Pizzari T. In-season monitoring of hip and groin strength, health and function in elite youth soccer: Implementing an early detection and management strategy over two consecutive seasons. J Sci Med Sport. 2018;21(10):988-993. doi:10.1016/j.jsams.2018.03.004
- Harøy J, Clarsen B, Wiger EG, et al. The Adductor Strengthening Programme prevents groin problems among male football players: a cluster-randomised controlled trial. Br J Sports Med. 2019;53(3):150-157. doi:10.1136/bjsports-2017-098937
- Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet Lond Engl. 1999;353(9151):439-443. doi:10.1016/S0140-6736(98)03340-6
- Bolling C, Delfino Barboza S, van Mechelen W, Pasman HR. How elite athletes, coaches, and physiotherapists perceive a sports injury. Transl Sports Med. 2019;2(1):17-23. doi:10.1002/tsm2.53
- Bolling C, van Mechelen W, Pasman HR, Verhagen E. Context Matters: Revisiting the First Step of the “Sequence of Prevention” of Sports Injuries. Sports Med Auckl NZ. 2018;48(10):2227-2234.doi:10.1007/s40279-018-0953-x
- Verhagen E, Voogt N, Bruinsma A, Finch CF. A knowledge transfer scheme to bridge the gap between science and practice: an integration of existing research frameworks into a tool for practice. Br J Sports Med. 2014;48(8):698-701. doi:10.1136/bjsports-2013-092241
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