Let's Not Panic About Jason Spezza's Groin

"Doc, it hurts when I do this." - Abelimages

I'm already sick of this Chicken Little mentality.

Well, here we go. I hoped that the return of hockey would simmer Ottawa Senators fans down, and save us from the vitriol and infighting that the summer brought us with Daniel Alfredsson's departure, speculation about Eugene Melnyk's finances, and Mika Zibanejad's AHL stint, among other things.

Sadly, that's clearly not to be. We're just two games in and already some are questioning Bobby Ryan, and are now ready to panic over Jason Spezza.

Is this what it means to be a sports fan in the 21st century? Am I the only one left who actually enjoys, you know, watching hockey? Is all that we have left to do now just seize on any tidbit of information and extrapolate it out to the worst-case scenario like we have any clue what the situation is? What's the benefit of that level of negativity?

"But Mark," you say. "The Senators haven't been forthright about injuries in the past. Why should we believe them this time when last year they told us they were managing Spezza's back one day and then he was having surgery a few days later?"

Well, obviously I don't have more information than you do in this case, but I do have Occam's Razor: The simplest theory is more likely to be true. Was there a secret conspiracy to hide the severity of Spezza's back injury from fans last year, even though they'd find out anyway once he had surgery? Or is it more likely that the team wasn't sure of the severity, did further tests, and then Spezza and his doctors took a few days to determine the best course of treatment, deciding on surgery when he didn't improve?

It's one thing to worry about Spezza's groin. There's no doubt that he's hurt--that's not in dispute. The question is how we react to that news. Do we lock in on words from head coach Paul MacLean like "questionable" and "chronic" and assume the worst? Or do we recognize that we are not doctors, nor is MacLean a doctor--but that having a fully healthy Spezza aligns with his own interests?

Here's what we know about groin injuries: They're more common in sports like hockey, have absolutely nothing to do with a player's conditioning level, and are best treated with rest.

ESPN goes into more depth on those subjects with Dr. Andrew Parker, team doctor for the Colorado Avalanche.

Which activities seem to be most affected by groin pulls?

Dr. Parker: The sports that seem to have the highest incidence of groin injuries are sports where there is cutting side to side, quick accelerations and decelerations and sudden directional changes. You occasionally hear about sprinters with groin pulls, but the typical person we see is not the straight-ahead athlete as much as the side-to-side player in sports such as soccer, hockey and basketball. The thought is that you have a tremendous mass in the upper body and the upper body is going in one direction and the legs are directing the body to do something different either stop, start or turn.

What is the treatment for groin pulls and how long does it take to recover?

Dr. Parker: For the typical muscle strain or pull, including groin injuries, the treatment is always conservative. We use rest and ice, then proceed to a gradual stretching and strengthening program followed with a return to athletics. This works well for the "weekend warrior" up through to the professional athlete. Anti-inflammatory medication and ice help with the swelling, but time is what cures groin pulls more than anything. In higher levels of competition, treatments such as muscle stimulators and ultrasound can help with the healing process. For all the similarities, every groin pull is different, as are the athletes that have them. The recovery depends on a lot of factors. Age, level of fitness, severity of the injury and a diligence with respect to rehabilitation all contribute to recovery times.

Peter Nelson, a former hockey player and strength and conditioning intern with Pennsylvania State University Men’s Ice Hockey Team, wrote an excellent article explaining exactly why perceived poor conditioning doesn't explain how a groin injury can occur:

What the Tyler et al. study did find was that preseason hip adduction strength of the players who sustained groin injuries was 18% lower than that of the healthy players. They also found that adduction strength was 95% of abduction strength in the uninjured players, compared to only 78% in the injured players. This suggests that a muscular imbalance between the weak adductors and the relatively strong abductors plays a large role in groin issues. The Sim et al. study also supports this view, suggesting that "in ice hockey players, adductor strains may be caused by the eccentric force of the adductors attempting to decelerate the leg during a stride." The researchers further went on to state that "a strength imbalance between the propulsive muscles and stabilizing muscles has been proposed as a mechanism for adductor muscle strains in athletes."

The logical conclusion then should be that the solution is to strengthen the adductors and stretch the abductors, right? Well, yes, but a more in-depth look at the problem is necessary to determine exactly why this imbalance is present in the first place, that way we can most effectively remedy the issue. As a sports physician, physical therapist, or strength coach, you are not truly solving the problem unless you address the root cause.

In order to identify the root cause, it is important to first consider three main concepts. First, it is imperative to understand the biomechanics of skating. This brief excerpt from the study by Sim et al. sums it up very well:

"During the powerful skating stride the hip extensors and abductors are the prime movers, while the hip flexors and adductors act to stabilize the hip and decelerate the limb."

Janda Lower Body Cross Syndrome

The second concept to understand is that these specific movement patterns have a profound effect on the relative strength—and consequently length—of the muscles involved. Because hockey players, like most athletes, spend so much time in extension, the spinal erectors become extremely tight. The same is true of the hip flexors, which become tight due to the constant forward lean seen in an "athletic stance" as well as the strength required to overcome the aforementioned eccentric force needed to slow down the leg in the recovery phase of a skating stride.

Consequently, since the hip flexors pull the pelvis down from the front and the spinal erectors pull the pelvis up from the back, the pelvis becomes tilted anteriorly. This lengthens the hamstrings, putting them at a leverage advantage and forcing them to take on more of the load in extending the hips than the glutes. The glutes then become relatively weak, as does the anterior core. The end result is a player with what Janda called "lower-crossed syndrome", illustrated below, who is at risk for both low back and hamstring injuries.

How does this play into groin injuries? In order to make that connection, you need to understand the third concept, which is a central tenet of the Postural Restoration Institute (PRI): while muscles are often prime movers in a single plane, they must actually be considered as having an effect on movement in all three planes—sagittal, frontal, and transverse.

The perfect example of this is the hip extensors. While the hip extensors are mostly responsible for movement generated in the sagittal plane, these same muscles—most notably the gluteus maximus—function as external rotators and abductors. This is relevant to hockey because the nature of a skating stride requires players to have strong abductors—they are prime movers in this movement—as well as spend a lot of time in external rotation. This tightens both the external rotators and abductors and pulls the hips into chronic external rotation and abduction, or in other words causes them to become "flared". Adductor muscles like the adductor magnus, which also contribute to internal rotation, become lengthened and, like the hamstrings in the sagittal plane, are put at risk for injury. This clearly fits the theory of a muscle imbalance as the potential contributor to groin injuries, and it becomes clear from the analysis above that pelvic alignment is important in understanding the root cause of this imbalance.

It also makes it apparent that stretching the groin is not only ineffective; it can actually feed right into the problem!

The Tyler et al. study Nelson refers to is available online, and makes for a fascinating read. Here's the abstract:

Context:

An in-season groin injury may be debilitating for the athlete. Proper diagnosis and identification of the pathology are paramount in providing appropriate intervention. Furthermore, an adductor strain that is treated improperly can become chronic and career threatening. Any one of the 6 muscles of the adductor muscle group can be involved. The degree of injury can range from a minor strain (grade 1), where minimal playing time is lost, to a severe strain (grade 3), in which there is complete loss of muscle function. Persistent groin pain and muscle imbalance may lead to athletic pubalgia.

Evidence Acquisition:

Relevant studies were identified through a literature search of MEDLINE and the Cochrane database from 1990 to 2009, as well as a manual review of reference lists of identified sources.

Results:

Ice hockey and soccer players seem particularly susceptible to adductor muscle strains. In professional ice hockey and soccer players throughout the world, approximately 10% to 11% of all injuries are groin strains. These injuries have been linked to hip muscle weakness, a previous injury to that area, preseason practice sessions, and level of experience. This injury may be prevented if these risk factors are addressed before each season.

Conclusion:

Despite the identification of risk factors and strengthening intervention for athletes, adductor strains continue to occur throughout sport. If groin pain persists, the possibility of athletic pubalgia needs to be explored, because of weakening or tears in the abdominal wall muscles. A diagnosis is confirmed by exclusion of other pathology.

In other words, strengthening the muscle groups is the best possible rehab and best possible prevention method, but does not guarantee a strain will not occur. If one does occur, rest is needed, because aggravation can have serious consequences. The study goes on to further state:

Rehabilitation of the groin should normalize lower extremity muscle balance and protect the groin during energy transfer during sports participation. With the use of an evidence-based rehabilitation program, the athlete may return to sports and prevent further episodes. Although complex at times, the highly skilled clinician can determine if overlapping conditions exist and can localize the primary source of the pain and dysfunction.

In short, Jason Spezza's groin injury can be managed with rehab. We don't know the timeframe of that course of action, because we don't know how severe Spezza's injury is, but we do know that with proper treatment, it will not turn into something more debilitating--a much more promising, but much less sensationalistic, diagnosis than "chronic." And hopefully this information calms everyone down a bit. A player is working through a common injury for his sport. The sky is not falling.

Perhaps Dr. Parker summed up the injury best:

"One of the only common aspects of the injury is the treatment, which in all cases includes rest."

So when Spezza misses time with a groin injury, it's not some sign of a worse hidden injury--it's the proper course of treatment for his injury. It shouldn't be so difficult to accept that at face value, even for the cynics among us.

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