In part 1 of the 9 keys to dealing with groin strains in hockey players, we talked about the assessment. A quick recap, 4 keys to a good assessment for groin strains arePositional Assessment
- Movement Assessment
- Hip Assessment
- Kinetic Chain assessment
If you haven’t checked out part 1 with keys 1-4 yet, you can find it here.
Part 2 will be all about treatment of groin strains. Groin strains can be thought of as the hamstrings of hockey. They require high eccentric loads at the end of push off to slow the leg down and begin the recovery phase. Like the hamstrings in field sports, they are one of the more commonly injured muscle in hockey players and are prone to re-injury which makes a well thought out rehab plan that much more important.
Here are 5 keys to treating groin injuries in hockey players.
1) Early Loading
In addition to some early mobility, I believe early loading is very important in groin rehab. This sets the foundation for higher loading intensity and volume later in the process.
In fact, Bayer et al. (2018) compared early and delayed rehab in acute strain injuries, where early rehab began 2 days post-injury and delayed rehab began 9 days post-injury. This study found that the early rehab group returned to sport almost 20 days earlier than the delayed rehab group, although they found no difference in muscle tissue quality, muscle size or muscle strength. Interestingly, the only significant finding was in the perception of readiness and confidence in the participants ability to return to sport. So even though healing of the injured muscle takes the same amount of time whether it is loaded early or not, building confidence in the limb through early loading has shown to shorten return to play times.
A discussion point that was mentioned which I believe makes a lot of sense is that loading early using isometrics can have an analgesic effect on the tissue, decreasing the perception of pain and building confidence early in the rehab process. This allows people to do more high-level activity sooner, building confidence early even though the tissue continues to regenerate.
Here are some of my go-to isometric groin exercises for early rehab.
2) Core training
I like to think of the pelvis as the scapula of the hip. A lack of pelvis control can have an impact on hip function, just like poor scapular mechanics influences function of the shoulder. As mentioned in part 1, the core muscles insert very close to the adductors origin but pull in opposite directions, creating opposing forces. Poor pelvic stability and control can potentially lead to problems like athletic pubalgia, inguinal hernias and groin strains. For that reason, a large majority of hip rehab protocols include core strength and endurance training as should any hip rehab treatment.
Multiple studies have shown that the core and pelvis can influence things like hip range of motion. First, Mooreside and McGill found that increasing core muscle endurance and motor control training had significant improvements in hip range of motion. Their conclusion was that creating proximal stiffness allowed for greater hip mobility. Additionally, Ross et al showed that changing in pelvic tilt can influence hip mobility. They showed that by increasing anterior pelvic tilt, there is a reduction in hip flexion and internal rotation by virtue of the orientation of the acetabulum. Considering a lot of hockey players fall into this anterior pelvic tilt, increasing pelvic control and their ability to get out of an anterior tilt could increase their hip range of motion and put less strain on the anterior muscles of the pelvis and hip, including the adductors.
3) Strength in wider ranges
Being strong in wider ranges of motion is important for the hockey players adductors. The length-tension relationship suggests that as we get into larger ranges of motion, we are forming fewer cross bridges simply because the myofilaments overlap less. During the skating stride the hockey player’s adductors reach peak muscle activity at the end of push off, which is near end range of abduction (Upjohn et al). At the end of push-off, we can speculate that this is likely where the greatest load on the adductors also occur as they create the eccentric “braking” force of the leg to transition from push-off to recovery. Based on the length-tension relationship, this position of abduction during the skating stride should be a weak biomechanical position for the adductors which can be a problem for players who are returning after a groin injury.
The reason this is a problem is because a large majority of our groin strengthening exercises are close to midline and aren’t loaded at or near end ranges. So the adductors get strong in tight, or in a similar position as they would be during the stance phase of skating, but not at greater ranges of abduction where they likely need to be stronger as they “brake” the stride push off and transition to stride recovery.
I have started to add more strengthening at wider ranges of hip abduction. I typically start by giving isometrics in abduction (like the picture above) as they begin to improve their range of motion with the eventual goal to get to an elevated Copenhagen. I like elevating the body and the foot simply because it allows them to move through a greater range of abduction. This way they can start building strength near end range abduction where they need it the most.
4) Periodized return to sport
This might be where I see most rehab programs lacking. In general, we tend to a good job of rehabbing groin injuries. But skating is done on ice. So unless you have ice in your clinic (which some might be lucky to have access to), you will never be able to mimic the forces and loads of skating in the clinic. Even though players are strong in the clinic, they need time and a plan to adapt to the loads and demands of actually skating. This is because of the uniqueness of hockey and the skating stride.
Lots of rehab programs in other sports will count reps, like baseball pitches or golf swings, which make it easier to track. In hockey, we are probably not going to count skating strides. But we can track player load. Without some of the technology available to do this, we can calculate a player load in arbitrary units (AU) by multiplying the time on the ice by subjective sessional RPE. Tracking player load over time should show a gradual progression of increasing load to better re-introduce skating as well as gradually re-adapt the groin muscle to the high loads of skating.
5) Maintenance
And finally, once that’s all said and done, players need to continue to take care of their groins even after a full return to sport. Unfortunately, one of the best predictors of a soft tissue injury is a previous injury to that area. Continuing with tissue care, mobility work and strengthening should continue and should become a regular part of the players routine. The way I see it, for a player this is an investment in themselves to reduce their risk of injury or re-injury.
Final Thoughts
There you have it! 9 keys to dealing with adductor strains in hockey players, from assessment to treatment. I hope this has been helpful in guiding you through some of my thoughts around rehabbing groin strains in hockey players.