Ilya Kovalchuk: The man who finally made me write about the groin.

 

When the Devils announced Ilya Kovalchuk would be missing game 2 in the Devils-Flyers series with a lower body injury, it became clear that the time for an all-groin post was finally upon us. Kovalchuk’s injury was initially rumoured to be a groin pull, and so what better opportunity to explore that magical, mysterious world, and to attempt to keep the inappropriate jokes to a minimum.

No promises though.

The exact nature of Kovalchuk’s injury hasn’t been made clear. Until very recently he was denying he was injured at all. Devils GM Lou Lamoriello revealed yesterday that the lower-body ailment has been an issue since midway through the Florida series, and that Kovalchuk had remained in New Jersey for some sort of mystery therapy. The current rumour is that it’s a lower back injury that has been steadily worsening. As interesting as lower back injuries are (not very), we’ve already had a brief look at those in the Dustin Penner pancake incident. So let’s look at groins. Uh, I mean groin injuries.

What’s a groin, anyway?

The groin (in this context) isn’t as fun as it sounds. It’s the leg version of the armpit: The area between and the leg and the genitals. It’s also very close to a lot of very tricky things, so what may seem like groin problems may actually be hip or abdominal problems (or a combination of any or all of the above).

The groin is a simple way of saying “the leg adduction muscles”. Whaaaaa? Right, sorry. You can abduct or adduct a limb. WHAAAAA? RIGHT, I know. Abduction is the action of moving a limb away from the body (hence the clever name). Adduction is moving a limb towards the body. So the groin muscles adduct the leg – think of the movement you’d make to cross your legs. Okay, now stick your hand in your groin and actually cross your legs. I guarantee you felt your groin muscles at work there. I am also going to leave that alone and move on to a diagram.

 

The groin. It's complicated, it hurts, and it is NOT your friend.

 

The muscles that make up the groin are all of the adductors (brevis, longus, magnus/minimus), pectineus, gracilis, and according to some people, obturator externus (which you can’t see in the diagram, but which I can guarantee exists having been all up in it in anatomy lab).

Sports hernias and an assortment of hip problems are often mistaken for groin injuries, but in the interest of brevity (and keeping the inappropriate jokes to a maximum minimum) we’re only going to look at the most basic, common, meat and potatoes groin problem – the groin strain.

Okay, so what’s a groin strain?

A strain is a stretch or tear in muscle tissue. A groin strain is a stretch or tear in one of the groin muscles, most commonly the adductor longus. Strains are graded based on symptoms and function: Grade 1 is pain but no loss of function, grade 2 is worse pain and some loss of strength, and grade 3 is the ultimate suck with horrendous pain and complete loss of strength (due to a complete muscle tear or detachment). Generally a groin strain can be diagnosed with a good history and physical exam, but MRI can be useful when the source of the injury is unclear.

Groin strains are very common in sports with explosive leg movements, a lot of side-to-side movement, contact, and kicking motions, so you’ll frequently see them in hockey, soccer, football, martial arts, running and dance. Groin strains make up an estimated 10-15% of NHL injuries, although 90% of those groin injuries are from non-contact causes. It’s such a problem within the NHL that they’ve actually done a fair amount of research on prevention through training techniques, and have found strength and flexibility training to be effective.

Groin strain risk factors:

  • Previous groin strain, or incompletely rehabbed strain.
  • Age (the older you are, the more susceptible you are).
  • Muscle weakness (in hip flexors, abductors, adductors, and core muscles).
  • A lack of sport-specific training in the offseason.
That last one is interesting. Hockey players who did less than 18 sport-specific training sessions in the offseason were three times as likely to suffer a groin strain, and the strains were more common in preseason games.

So how do you treat a groin strain?

The best treatment is not to get one. The study linked above found that offseason training aimed at strengthening the adductor muscles significantly reduced the number of groin strains in at-risk players on an NHL team.

If you didn’t do your thigh exercises and ended up with a groin strain, treatment will depend on the severity of the injury. Assuming the muscle is intact (or mostly intact), you’ll start with the usual routine of rest, NSAIDs (like ibuprofen), ice, and the fancier modalities available to the NHL – massage, ultrasound, and electrical stimulation. You’ll progress through a variety of strengthening exercises of increasing intensity until your pain has resolved. Ideally, anyway. Remember a risk factor for groin strains is incompletely rehabbed groin strains, so it’s important that these be well-healed before getting back on the ice. A study using this exercise-based rehab showed that it was very effective, but in athletes with long-term groin pain (we’re talking months), it was an average of 18.5 weeks before they were pain-free and playing at their previous intensity level.

A worst-case scenario would be an avulsion fracture, which is exactly as terrible as it sounds. This is a strain so bad that the muscle pulls away from the attachment to the bone, and takes a bit of bone with it. You’d think that was a surgical repair, but a case study in the NFL showed that a conservative (non-surgical) approach works as well as anchoring the muscle back where it came from, and actually resulted in faster recovery and return-to-play.

The long and the short of the groin

Groin strains are common, they hurt, they can be prevented with proper training, and they’re a pain in the groin to heal properly. This is why we see them over and over again in the same players (my darling DiPietro, I am looking at you). The irony of the groin is that if it’s another condition (a sports hernia, a hip labrum tear) with a surgical fix masquerading as a groin pull, once diagnosed and treated one could conceivably expect a shorter recovery time. The groin pull is therefore awarded a place of honour on my list of truly sucky injuries.