Hip and Core Muscle Injuries in Soccer
TAKE-HOME POINTS
- Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need surgical intervention.
- Groin pain can be separated into 3 categories: (1) defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related [sports hernias/athletic pubalgia], and pubic-related groin pain), (2) hip-related groin pain (hip morphologic abnormalities, labral tears, and chondral injuries), and (3) other causes of groin pain.
- Acute groin pain in soccer players is most commonly caused by muscle strain involving the adductor longus, the iliopsoas or the rectus femoris.
- Inguinal-related groin pain is a common cause of chronic groin pain and typically is the most challenging to treat with a complex pathophysiology and a high association with femoroacetabular impingement.
- Hip-related groin pain (femoroacetabular impingement, labral tears, and chondral injuries) usually respond well to surgical intervention and has high rates of return to sport.
PUBIC-RELATED GROIN PAIN
Pubic-related groin pain is defined as tenderness to palpation over the pubic symphysis and adjacent bone.6 Osteitis pubis is a chronic overuse injury characterized by localized pain to the pubic symphysis and is believed to be caused by repetitive microtrauma from a dynamic rotation of the sacroiliac joint with suggested imbalances between the rectus abdominis and the adductor musculature.12,38 In soccer players, the condition may be related to the constant torsional stresses of kicking, running, or twisting.12 If performed, radiographs often show lytic areas of the pubic symphysis, widening of the symphysis, sclerosis, and cystic changes, while bone marrow edema may be present on MRI.38Management consists of rest, anti-inflammatory medication, and corticosteroid injections with gentle stretching once asymptomatic.12,39
RECTUS FEMORIS INJURIES
The most common injury to the rectus femoris is a strain as a result of an eccentric overload while a soccer player is hit trying to extend his or her leg to kick a ball.12 In pediatric soccer athletes, an avulsion of the anterior inferior iliac spine from the direct head of the rectus femoris is the second most common avulsion injury.40 Radiographs are diagnostic and can help determine treatment. Most avulsions are minimally displaced and can be treated conservatively, but surgical intervention should be considered for an avulsion >2 cm.12
PROXIMAL HAMSTRING INJURIES
Proximal hamstring injuries are important causes of acute posterior hip pain and are caused by an eccentric overload in hip flexion and knee extension.25 In soccer players, the typical mechanism is that the planted leg slipping on the playing turf creates a sudden violent flexion of the hip with the knee in an extended position. While relatively uncommon, when a significant avulsion occurs in a professional athlete, surgical intervention is often necessary. In general, these injuries may involve partial or full avulsions off the ischial tuberosity or separation of the bony apophysis in pediatric athletes. A physical examination in the acute setting typically demonstrates massive posterior thigh ecchymosis, a palpable defect, and/or weakness with knee flexion. Imaging is helpful to confirm the diagnosis and evaluate for surgical repair. Radiographs may show a bony avulsion, which is more commonly seen in pediatric apophyseal avulsions. MRI can be used to differentiate a complete tear (involving all 3 tendons) vs a partial tear and evaluate for retraction of the tendon distally. Complete and partial tears of 2 tendons with retraction of >2 cm should be surgically repaired.25 Partial tears without tendon retraction may be treated conservatively with rest, anti-inflammatory medication, and physical therapy and then followed later by a hamstring prevention program.25 We have found that biologic augmentation with platelet-rich plasma can help accelerate healing in partial thickness injuries; however, the evidence is conflicting.
GLUTEAL INJURIES
Chronic overuse injuries of the gluteal musculature are common causes of lateral hip pain. Abductor overuse caused by weakness in the gluteus medius with a normal tensor fascia lata can cause pain with sitting and side-lying.25Overuse of the gluteal muscles with muscular imbalances along with increased tension on the iliotibial band can lead to greater trochanteric pain syndrome.25 A physical examination may demonstrate tenderness over the greater trochanter bursa and positive flexion, abduction, and external rotation testing.25 Abductor overuse syndrome and greater trochanteric pain syndrome are best treated with anti-inflammatory medication and physical therapy to balance the core/pelvic musculature.41
PIRIFORMIS INJURIES
Piriformis syndrome is a compressive neuropathy of the sciatic nerve. The mechanism of injury in the athlete is through a minor trauma to the buttock or pelvis.25,42,43 Presenting symptoms include pain with sitting and internal rotation of the hip.12 Zeren and colleagues42 published the only study that includes 2 cases of bilateral piriformis syndrome in professional soccer players. The diagnosis was confirmed with electromyography that was negative at rest and positive when measured after running.42 The athletes exhausted conservative treatment with physical therapy, anti-inflammatory medications, injections, and rest and were treated with surgical decompression.42 Both players returned to professional soccer after 6 months and played for an average of 7 years.42
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