– Written by Anthony Hogan, Australia

THE PROBLEM

Groin pain during (or after) running is the most common functional limitation experienced by athletes with a groin injury. At the initial assessment (and at each subsequent re-assessment) the clinician needs to make a clinical decision about running i.e. whether the athlete should cease, commence or continue running. The decision to ‘commence running’ is considered one of the most important milestones in groin pain rehabilitation. For the sports medicine clinician, the ‘running decision’ is unusually difficult because there are few guidelines and there is an associated risk of an exacerbation or recurrence of groin pain.

WHY IS THE RUNNING DECISION SO DIFFICULT?

1. It can be difficult (often very difficult) for the clinician to diagnose the specific patho-anatomy responsible for the groin pain because:

• there are a large number of patho-anatomical conditions¹,
• there is usually more than one source of groin pain^2,3,
• there are no clinical tests or radiological investigations currently recognised as a ‘gold standard’ diagnostic test.

2. Radiological findings do not appear to predict the capacity to run⁴
3. It is difficult to decide if running is contraindicated by any of the following musculoskeletal problems that are commonly associated with athletic groin pain:

• insufficient core stability,
• insufficient strength in single leg stance,
• insufficient hip flexor function,
• increased tone in adductor longus, psoas, tensor fascia latae/anterior gluteus medius etc and
• decreased range of motion at the hip joint.

Careful assessment of these musculoskeletal problems will predict what rehabilitation is required but does not predict when the athlete can safely resume running. The rehabilitation timeline for these problems can take weeks or months, so it would be useful for the clinician to know whether the athlete could be running while these problems are being rehabilitated. Trial and error (i.e. asking the athlete to run and then report the groin pain experience) is a very crude method of answering this important clinical question. In addition, there is a risk that the athlete will lose faith in the clinician if a wrong decision is made and groin pain recurs. What the clinician needs is one or more clinical tests that indicate when the athlete can resume or continue running without risk of increased groin pain or further groin injury.

THE SOLUTION

In 1998, Hogan and Lovell presented a paper to the 4th World Football Symposium that reported the successful use of objective and reliable clinical tests to decide when a footballer could safely return to running during a groin rehabilitation programme. This decision-making process has stood the test of time and has been successfully used in many football clubs and elite sporting organisations throughout the world since.

The groin pain provocation tests used in the running decision:

• Walking/dynamic warm-up.
• Squeeze test.
• Resisted Hip Adduction test.
• Pubic Stress tests.

Walking/dynamic warm-up

To be considered ready for running, the athlete needs to demonstrate an unlimited capacity for pain-free walking. For example, to be able to walk at a normal pace for 2 km (on grass) without groin pain during walking, after walking or walking the next morning. In addition, the athlete needs to complete a 10-minute dynamic warm-up without groin pain during the warm-up, after the warm-up or the next morning.

The Squeeze test

The Squeeze test is the ‘traditional’ groin pain provocation test. The clinician places their fist (or crossed hands) between the knees of the athlete and asks them to squeeze as hard as possible (i.e. adduct both legs at the same time) and to report any groin pain. The Squeeze test can be done in various degrees of hip flexion with 0 degrees, 45 degrees and 90 degrees hip flexion being popular choices. Hogan (1996) used a sphygmomanometer to measure the Squeeze test, arguing that this device could almost always be found in medical rooms (unlike dynamometers).

Based on clinical experience over the past 15 years, the Squeeze test seems to indicate the real time status of the groin pain, i.e. the relative status of the groin pain today compared to a previous measure, say yesterday, or the same time last week. A noticeably higher max effort, P1 or P1% is associated with better function and less pain during rehabilitation exercises, running or training/playing. A noticeably lower value for these measures indicates there has been an adverse load on the groin during rehabilitation exercises, running or training/playing. It is my clinical experience that the Squeeze test is more helpful for adductor-related and pubic-related groin pain than hip-related (including hip flexor) or abdominal-related groin pain. Fortunately for clinicians, the adductor-related and pubic-related are more common in the professional football codes.

Resisted Hip Adduction tests

The Resisted Hip Adduction test allows the clinician to assess pain and adductor muscle strength in a simulated running position with one hip flexed and the other hip in relative neutral flexion/extension (comparable to the mid-stance phase of running). The Resisted Hip Adduction test can be performed in two positions:

1. Modified Thomas test position (on the edge of the bed).
2. Side lying (on the ground).

The magnitude of the hip adduction contraction can be assessed manually or with a dynamometer. A clinical rating of ‘weakness’ must consider all of the following possible explanations:

• true muscle weakness (i.e. insufficient, de-conditioned),
• pain inhibited weakness,
• associated with pain anticipation.

The Pubic Stress tests

The Pubic Stress test allows the clinician to assess the athlete in the simulated running position with one hip flexed and the other leg in relative neutral hip flexion/extension (comparable to mid-stance phase of running). The neutral hip is passively moved into positions that are comparable to the mid-stance phase of straight-line running (hip extension) or cutting (combined hip extension/abduction).

Putting it all together: the ‘stop light’ analogy

As previously stated, the clinician needs to make a clinical decision regarding running at the initial assessment and at each subsequent reassessment. In other words, the clinician must decide whether the athlete should cease, commence or continue running. No single test is adequate to make this decision, so the general consensus of the tests is used. The athlete gets to know these tests and the meaning of ‘red’, ‘yellow’ and ‘green’ lights as general indicators of their ability to run.

CASE STUDY

Our footballer has been assessed using the guidelines described in Table 1 and a clinical decision has been made to commence running. In my opinion, the key to a successful running programme is to monitor the response to the running session. The Squeeze test is the preferred test because it can be measured and (based on clinical experience) the Squeeze test seems to indicate the real time status of the groin pain. If the max effort or P1 has decreased by more than 20 to 30 mmHg (10 to 15%) compared to the pre-run value, this indicates that the groin pain has been irritated by the running session. While this is interesting information, no clinical decisions about running should be made at this time.

The most important Squeeze test is the one taken before the next running session. Ideally, the Squeeze test will have recovered to normal values, and resisted adduction and Pubic Stress tests will give the ‘green light’ to continue running.

In Figure 8, the Squeeze test has been assessed on four occasions:

• Day 1: before run
• Day 1: after run
• Day 2: pre-treatment
• Day 3: post-treatment

The results are shown for three separate running sessions. Each running session demonstrates a different response and recovery pattern.

After the first running session, the recovery process is slow (48 hours) and relies heavily on therapy. This indicates that the footballer was only just ready to start running. Provided the resisted adduction and Pubic Stress tests are no worse, the running decision will be to repeat the same running session (with caution) and stop if any adverse sign, e.g. groin tightness, is experienced.

After the second run, the recovery is spontaneous and not reliant on therapy. This pattern indicates that the footballer coped well with the running session. Provided the resisted adduction and Pubic Stress tests are comparable, the running decision will be to repeat the running session with extra running repetitions added if there are no adverse signs.

The third running session is substantially different from the first two running sessions. There is no adverse response to running as measured by the Squeeze test. The running decision will be to increase the number of running repetitions and consider controlled change of direction running.

The key point of Figure 8 and Table 2 is that recovery from a running session is a better indicator for planning the next running session than the immediate response to that running session.

SUMMARY OF KEY POINTS

The running decision:

• Commence running
• Continue running (decrease/same/increase repetitions)
• Cease running

This is an important (and difficult) decision that clinicians have to make every time they assess an athlete with groin pain.

Key groin pain provocation tests:

• Walking/dynamic warm-up (if not started running,)
• Squeeze tests
• Resisted adduction tests
• Pubic Stress tests

are recommended to make the running decision (Table 1).

The green, yellow, red ‘stop light’ system (Table 1) is very useful when explaining the running decision to an athlete.

The Squeeze tests can be used to monitor the different responses to running (Figure 8) but the response to running is not as useful as the recovery from running.

The Squeeze test (max effort and P1) can be used to monitor the recovery from running and this is proving to be more helpful (than the response to running) when making the next running decision.

Anthony Hogan B.Sc.

APA Sports Physiotherapist

Clinical Director, GroinREHAB

Adelaide, Australia

Contact: anthony.hogan@hotmail.com

References

1. Brukner P, Khan K. Bruckner and Khan’s Clinical Sports Medicine 4th Edition. Mcgraw Hill, Sydney 2012.
2. Ekberg O, Persson NH, Abrahamsson PA, Westlin NE, Lilja B. Longstanding groin pain in athletes. A multidisciplinary approach. Sports Med 1988; 6:56-61.
3. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport 1995; 27:76-79.
4. Lovell G, Galloway H, Hopkins W, Harvey A. Osteitis Pubis and assessment of bone marrow edema at the pubic symphysis with MRI in an elite junior male soccer squad. Clin J Sports Med 2006; 16:117-122.
5. Hogan A, Lovell G. Pubic Symphysis Stress tests and rehabilitation of osteitis pubis. In: Spinks W, Reilly T, Murphy A, eds. Science and Football IV. London: Routledge 2002.