The Hip in Ice Hockey Part III: Groin Strain Impostors

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There are many core and hip-related injuries that cause groin pain in ice hockey athletes. Although the groin pain is real, a groin strain may not be the primary cause. Here are a few hip pathologies that oftentimes result in groin pain.

GROIN STRAIN IMPOSTOR 1: FEMOROACETABULAR IMPINGEMENT (FAI)

Although it is an intra-articular hip injury, femoroacetabular impingement (FAI) is the most commonly diagnosed cause of hip and groin pain in ice hockey players at all ages and levels of play [1-3]. FAI has become an increasingly common diagnosis in ice hockey players but is difficult to differentiate from strains because its pathophysiology is poorly understood [4]. FAI refers to pinching between the femur (thigh bone) and the acetabulum (hip socket), caused by bony overgrowth to the femoral head neck offset (CAM-type) or acetabular hood (pincer-type), but the body responds to FAI with inflammation and tightening of the hip capsule, causing compensatory strain to muscles around the hip. FAI is generally associated with hip pain and functional impairments such as limited ROM [5-8], hip muscle weakness [9-11], and compromised athletic performance [3, 11]. Although pincer-type FAI is relevant, CAM-type FAI is the far more common variation that occurs in young athletic males, and is the most commonly diagnosed type in ice hockey players [1, 2, 12-14]. It has been reported that the risk of a CAM-type FAI is ~15x higher in elite male ice hockey players compared with their age-matched counterparts [14], and is 4.5 times higher in ice hockey players 16-19 years old compared with age-matched skiers [13]. In a study of 130 NHL and AHL players during the 2014-15 preseason, 69.4% of hips met radiographic criteria for CAM-type deformity, with 61% of players presenting with CAM-type deformity bilaterally [8].

Image from: https://www.cnos.net/resources/femoroacetabular-impingement-fai

As discussed in Part 1 of this article series, the unique locomotion required in skating is likely a heavy contributor to the array of hip-related overuse injuries. In case you missed Part 1 or Part 2, you can view them here and here. There’s no need to read them now, but when you’re done reading this, I’d strongly advise checking them out!

High physical stresses passing through the hip in skating propulsion such as (1) explosive concentric hip abduction combined with external rotation and stride recovery and (2) eccentric and stabilizing hip flexion combined with adduction and internal rotation may partially explain the relatively high prevalence of FAI and hip strains in ice hockey players [13-19]. Although a paucity of research currently exists in elite ice hockey players, FAI is typically associated with hip muscle weakness [20-22], particularly in the primary stabilizers and eccentric contributors to the ice hockey stride, the hip flexors and adductors [9, 11]. Also, labral tears comprise the majority of intra-articular hip injuries (69.1%) in NHL players [23], and these tears are oftentimes the result of underlying FAI [24]. Diagnosing and addressing FAI, or any source of hip pain at an early stage, may reduce compensatory strategies and prevent subsequent performance decrements and/or injury. Research is limited in ice hockey, but data from other sports imply that continuing to train and play with groin pain has been shown to result in movement compensation strategies, resulting in decreased function and performance [25-30].

GROIN STRAIN IMPOSTOR 2: ATHLETIC PUBALGIA

Core muscle injuries are common in ice hockey; over the course of two seasons in the NHL, abdominal strains were found to account for 23.2% of all groin-related strains [31, 32]. Athletic Pubalgia is a core muscle injury, and is a common cause of chronic groin pain in athletes [33]. The injury is categorized by pain in the lower abdominal wall, with pain, oftentimes, radiating into the groin region [31, 34]. Because of this, it’s labeled as a “core muscle injury,” although there are at least 33 different terms which are used to describe it [35]. Other terms used to describe Athletic Pubalgia include osteitis pubis, hockey groin syndrome, Gilmore’s groin, sportsman’s hernia, and slap shot gut [31, 35].

It’s clear that the abdominal muscles are heavily used and play important roles in successful ice hockey performance. One study on 10 professional ice hockey players found consistent and distinct thinning/tearing in the internal oblique at the inguinal ring [36]. Another group of researchers found extensive tearing of external oblique muscles on the side opposite of the athletes’ shooting side [37]. The authors suggested that this result was caused by the specific biomechanical demands of hockey (i.e. skating, shooting, passing) and other intrinsic factors including muscle fatigue, weak abdominal muscles, and overtraining [37]. It’s easy to see how the constant application of forces by the abdominal wall muscles during twisting, turning and shooting maneuvers may cause tensioning and cordlike bands within the inguinal ligament over time [38]. The forces of the abdominals are transmitted through the inguinal ligament onto the pubic tubercle during ice hockey [38]. The associated groin pain with Athletic Pubalgia becomes apparent when the heavy contribution and force transmission of the abdominal musculature in ice hockey is examined, holistically.

Image from: Larson, C.M., 2014. Sports hernia/athletic pubalgia: evaluation and management. Sports Health, 6(2), pp.139-144.

The most widely accepted theory of Athletic Pubalgia pathogenesis is a disrupted rectus tendon attachment to the pubis and a weakened posterior inguinal wall [39-46]. Given this pathogenesis, it’s no surprise that athletes with adductor and pubic-related groin pain oftentimes present with reduced abdominal muscle strength [29, 47]. The balance in muscle strength between the hips and abdominals may play a pivotal role in preventing Athletic Pubalgia. It has been suggested that weakness of the lower abdominal muscles relative to the hip adductors can be a primary cause [48]. In fact, it’s suggested that treatment for Athletic Pubalgia should include restoring the balance between the forces applied by the abdominal and hip adductor muscle groups [34, 49, 50].

Related: Hip in Ice Hockey Part I

Related: Hip in Ice Hockey Part II

GROIN STRAIN IMPOSTOR 3: HIP FLEXOR STRAIN

In NCAA Men’s Ice Hockey, hip flexor strains were just as frequent as groin strains, as both injuries boast a whopping frequency of 2.47 injuries per 1000 athlete exposures [51]. Hip flexor and groin strains are extremely common in ice hockey; of all NCAA Men’s Sports, soccer was the only sport to have higher injury rates for hip flexor and groin strains [51].

The iliopsoas is the strongest hip flexor muscular complex [52] and is comprised of the psoas major, psoas minor, and iliacus muscles [53]. Although considered the primary hip flexor complex, the iliopsoas does much more than just flex the hip. The iliopsoas is also heavily involved in lumbar posture and pelvic control; strains in this region can also be a cause of groin pain in the ice hockey player [31, 32, 54]. A group of researchers agreed that iliopsoas-related groin pain is more likely if there is pain on resisted hip flexion and/or pain on stretching the hip flexors, which illustrates the close relationship between the groin and hip flexion musculature [55].

Image from: https://www.vivehealth.com/blogs/resources/hip-flexor-strain

The contribution of the hip flexors in ice hockey cannot be overstated. Hip flexion is greater during on-ice sprinting in high-caliber skaters, compared with low-caliber players [56-58]. During hockey treadmill skating, increased treadmill velocity was associated with increased hip flexor activation [59]. Back in 1977, Reid et al. found a relationship between off-ice hip flexion strength and on-ice skating speed in varsity ice hockey players [60]. These results hint that the biomechanical demands of the hip flexor muscles are increased alongside higher level of play and increased speed requirements, on-ice [31]. The multifaceted functionality of the hip flexor muscles in addition to the heavy reliance on these muscles for successful on-ice performance illustrate the frequent association between hip flexor strain and groin pain in ice hockey athletes. 

SUMMARY

Groin pain in ice hockey athletes may not be from a groin strain. Understanding the pathology of the groin pain should play a major role in injury treatment, prevention of injury recurrence, and the strength and conditioning program. There are other pathologies that result in groin pain, including femoroacetabular impingement (FAI), athletic pubalgia, or a hip flexor strain. Watch out for these groin strain impostors when evaluating an ice hockey athlete presenting with groin painIn Part 4 of this article series, I’ll cover the potential financial burden of having unhealthy hips.

 

Coming Up! — Part IV: The Cost of Injury

 

Written by Adam Virgile / @ShakeBotApp

Special to HockeyClan

 

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