Groin injuries are commonly occurring problems in goaltenders. To understand the nature of these sport-related injuries it becomes important to have an appreciation of basic human anatomy. This article will provide a basic overview of relevant human groin anatomy and hockey-related groin injuries.
When discussing groin injuries the principle anatomy of interest is the hip adductor group. Hip adductors are muscles that help draw the legs back to the midline with the knees touching. Conversely, hip abductors are muscles that help move the hips and legs away from the midline. The adductor group consist of the following muscles: Adductor Brevis, Adductor Longus, Adductor Magnus, Iliopsoas, Pectineus and Gracilis. These muscles are located in the upper medial (inner) thigh in superficial (Pectineus, Gracilis, Adductor Longus), intermediate (Adductor Brevis) and deep (Adductor Magnus) layers.
Goaltender-related groin injuries may range from minor stretches in the muscle belly to complete ruptures. Although uncommon, avulsion fractures also occur. These injuries occur due to sudden rapid directional changes and quick acceleration/deceleration type movements. Any activity creating a sudden abduction or adduction can result in a “pulled groin.” Such movements are certainly consistent with what a goaltender encounters both during practice and competition.
Dr. Mike Wilkinson voiced this concern when discussing a groin injury sustained by Roberto Luongo back in 2008 with The Vancouver Sun. He said this injury is not surprising “given the range of movements characteristic of a goalie’s puck-stopping contortions. The goalies constantly going down tend to get those injuries.”
This injury may occur also insidiously based on chronic repetitive strain that is not clinically severe enough to remove the goaltender from competition. As former NHL goaltender Glen Healy said in a 2008 CBC article: “Stand on your driveway and go up and down on your knees on a mattress 300 times a day. Do it for 10 years and see how you feel. It has to affect you physically.”
Groin injuries account for as much as two to five per cent of all sports injuries, according to research from Karlsson, J. et al. Chronic groin injuries in athletes. Recommendations for treatment and rehabilitation. Sports Med 1994; 17: 141-148, and Renstrom, P. et al. Groin injuries in athletes. Br J. Sports Med. 1980; 14: 30-36
The damage most commonly occurs at the junction between the muscle belly and the beginning of the tendon. Anatomically, this is referred to as the musculotendinous junction. All aforementioned muscles may be affected; however, the most commonly affected muscles are adductor longus and gracilis.
When the injury occurs it becomes the body’s duty to respond to the damage incurred. This causes a standard inflammatory cascade to be activated. Numerous cells and fluid enter the affected area along with blood vessel vasodilatation. The area may or may not exhibit swelling; however, discomfort will be present with limited active range of motion (A.R.O.M.). Other potential signs and symptoms include decreased strength, palpation tenderness or an evident mass.
Cells referred to as fibroblasts eventually promote healing with scar tissue developing in the affected area. Although scar tissue becomes quite strong over time, it also results in muscle-tendon shortening referred to as contracture. This limits active range of motion and the desired flexibility to make certain saves. Also of concern is the fact that having a groin injury increases the risk of recurrence. Although not specific to goaltenders, a study of 1292 professional hockey players with one pulled groin found a two fold greater chance of recurrence.
For most athletes amongst us these injuries are usually self-apparent immediately post-event or the following day; however, and if necessary, the diagnosis should easily be made on history and relevant assessment by a competent physician.
At the highest level of the game, where the consequences of player games lost can be significant and cost is not a limiting factor, an MRI (Magnetic Resonance Imaging) is the diagnostic gold standard. Although ultrasound can be used effectively, MRI is choice due to its ability to differentiate tissues (e.g., bone, muscle, blood, edema fluid) from one another based on different tissue densities. They appear different on the image, allowing the radiologist to determine nature and severity of the injury with high accuracy.
When groin injuries occur to weekend warriors and beer leaguers you take your equipment off and potentially limp to the car. You go home, lie on the couch and your spouse laughs at you; however, standard treatment with which you may aid yourself includes the acronyms R.I.C.E. (Rest, Ice, Compression, Elevation) or P.I.E.R. (Pressure, Ice, Elevation, Rest).
This will help limit the inflammatory response and potential swelling. You should demonstrate sound judgement by remove yourself from further aggravating activity until the injury is healed through rest and/or appropriate rehabilitation. In severe cases this may take four to six weeks but each individual is naturally different. You may take an N.S.A.I.D. (Non-Steroidal Anti-Inflammatory Drug) to help with discomfort. The use of steroids is controversial and not clearly proven to be of benefit. Corticosteroids are powerful agents that should not be used when avoidable due to a plethora of undesirable side effects! Other therapeutic modalities exist but will not be discussed herein.
If problems persist beyond a reasonable amount of recovery time please see a physician or suggest this to the goaltenders you train and coach. The possibility exist the presumptive diagnosis of a groin strain is incorrect and that another underlying problem may be the reason for discomfort. It is beyond the purpose and scope of the article to discuss the differential diagnosis or for you to concern yourself with it as a goaltender, trainer or coach. Furthermore, the possibility exists that two medical problems may be present concomitantly (e.g., hernia and groin strain). According to Morelli, V. et al Groin Injuries in Athletes, AM Fam Physician 2001 Oct15: 64(8): 1405-1415, in a study by Ekberg et al. (1988) 19 of 21 patients with groin pain had two or more co-existing disorders.
That which should be of greater interest to us as goaltenders, coaches and trainers is primary prevention. Basic measures include such things as regular flexibility training and a groin specific dynamic warm-up. The days of the static warm-up are basically gone since they result in micro-tears leading to further scarring and contracture. The dynamic warm-up increases capillary blood flow to muscles and tendons, which facilitates muscle lengthening. Primary prevention more so involves strengthening the muscles at risk to minimize the chances of injury. There are numerous exercises present to strengthen the adductor muscle group. These can easily be found through an Internet search.
Groin-related injuries are common occurrences in goaltenders and hockey players in general. In fact, during the 1997-1998 NHL season, 26 per cent of all injuries were associated with the groin musculature (1). The purpose of the article is to provide a general overview of this important topic. The article should allow goaltenders, parents, coaches and minor hockey level trainers to understand and speak with some confidence about the nature, diagnosis and treatment of groin problems in proper terms and advise an injured goaltender to see a physician when things just don’t seem to be getting better.
(1) Clendenin, A. et al. “The Hockey Groin”, Chicago Sports Injury Centers