Hip and Core Muscle Injuries in Soccer

October 11, 2018 | Surgery

Benjamin Sherman, DO ; Jorge Chahla, MD, PhD ; William Hutchinson, MD ; Michael Gerhardt, MD

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.

LABRAL TEARS

Labral tears present with groin pain, limited hip range of motion, and symptoms of catching, locking, and instability.²⁵Causes of labral tears include trauma, FAI, hip dysplasia, capsular laxity, and degeneration.⁵⁵ Labral tears rarely occur in isolation and have a high association (87%) with morphologic abnormalities of the hip, most commonly FAI and occasionally dysplasia.^56,57 Physical examination findings include positive anterior impingement tests (flexion-adduction-internal rotation) in athletes with anterior labral tears and, less commonly, positive flexion, abduction, and external rotation tests for athletes with lateral and posterolateral labral tears.⁵⁷ Radiographic imaging is used to evaluate for concurrent morphologic abnormalities of the hip, and MRI arthrogram is used to confirm the diagnosis of a labral tear with a sensitivity of 76% to 91%.⁵⁸ Initial treatment consists of conservative treatment, which includes rest, anti-inflammatory medication, activity modification, and physical therapy. In patient refractory to conservative treatment, arthroscopic surgery is effective with high rates of return to sport.⁵⁹ It is important to note that when treating labral tears surgically, any morphologic abnormality needs to be addressed to prevent recurrence of the tear.

CHONDRAL INJURIES

Focal chondral lesions in the hip are commonly found in athletes with FAI and labral tears during arthroscopic evaluation.⁶⁰ Full-thickness defects and unstable flaps in weight-bearing areas are indications for surgical intervention with microfracture.⁶⁰ There are no studies examining the efficacy of microfracture in isolation; however, Locks and colleagues⁵⁴ have demonstrated a 96% return to professional soccer after an arthroscopic treatment for FAI and found that severe chondral damage with microfracture did not lengthen the return to sport.

RELATIONSHIP BETWEEN INGUINAL-RELATED GROIN PAIN AND FEMOROACETABULAR IMPINGEMENT

The altered biomechanics and restricted range of motion in athletes with FAI cause an increase in compensatory motion at the pelvis and lumbosacral areas, which may contribute to the development of inguinal-related groin pain, bursitis, adductor, and gluteal dysfunction.²⁵ In athletes with concurrent intra-articular hip pathology and inguinal-related groin pain, treating 1 condition in isolation will result in poor results. Larson and colleagues⁶¹ found that when only inguinal-related groin pain or FAI were addressed, return to sport was only 25% and 50%, respectively, while concurrent surgical treatment resulted in a return to sport of 89%.

DISCUSSION AND FUTURE DIRECTIONS

Groin injuries in soccer players can cause significant decreases in athletic performance, result in lost playing time, and may ultimately need a surgical intervention. Efforts are underway to determine the role and efficacy of identifying high-risk athletes that may benefit from targeted prevention strategies. Wyles and colleagues⁴⁸ identified adolescent athletes with hip internal rotation of <10° and found at 5-year follow-up that 95% had abnormal MRI findings compared with 54% in the age-matched control group. Wollin and colleagues⁶² developed an in-season screening protocol using adductor strength reductions of 15%, adductor/abductor strength ratio <0.9, and hip and groin outcome scores <75 as indicators of at-risk individuals. By employing preseason and in-season screening protocols, we can identify high-risk athletes for further workup and close follow-up throughout the season. Pelvic radiographs in these high-risk athletes may help us determine the presence of abnormalities in hip morphology, which would place an athlete into a high-risk group where prevention strategies could then be employed. There are no data available to determine the most effective prevention strategy at this time. However, levels II and III evidence exists indicating that exercise programs may reduce the incidence of groin injuries.⁶³ Additional strategies, like limiting adolescent playing time similar to strategies employed in baseball pitches with pitch counts, could potentially reduce the potential for injury. Further studies on preseason screening and in-season monitoring protocols, targeted exercise therapy, early surgical intervention, and potential biologic intervention are needed to determine the most effective methods of preventing groin injuries in athletes.