Let’s Talk About the Groin Area: No More Taboos

Chicago Bulls’ Wendell Carter, Jr., Major League Baseball’s Cliff Lee and the National Football League’s Donovan McNabb, what do they have in common besides being elite athletes? They have all suffered core muscle injuries that required surgical intervention. Despite how debilitating these injuries can be and these athlete’s star power, core muscle injuries don’t get the same billing as other type of sports injuries like anterior cruciate ligament tears or an injury to the ulnar collateral ligament.

William Meyers, M.D., founder of the Vincera Institute in Philadelphia, and a leader in core muscle injuries, told OTW that a big reason for this is what he calls the sex distraction. Because the core includes the pubic bone, people get uncomfortable and sometimes giggly when talking about it. Hence the popularization of the term sports hernia to refer to core muscle injuries, despite the fact there is actually no hernia involved at all.

Meyers prefers the term “athletic pubalgia.” He explained that the core which he identifies as from mid-thigh to mid-chest is very complex covering a lot of organs, blood vessels, bone and muscles, and when an injury here is left undetected it can be career-ending for an athlete.

Another reason these injuries don’t get much attention in mainstream medicine he said was because of how doctors are trained. He explained that there is too much focus on specialties like orthopedics, gynecology or dermatology and not enough of cross-training or bridging of specialties.

“Orthopedic doctors are afraid to get in there because they were not trained on blood vessels or the bladder for example,” he said.

“This has been a no-touch area of medicine and we just need to get over it. Orthopedic surgeons working with athletes need to be more aware of how weakness and injury in the core has repercussions in other areas of the body.”

The Complexities of the Core

First, what are core muscle injuries? They generally involve small tears of the muscles attached to the pubic bone. They can result from a trauma or from overuse. Dancers can experience one from hyperextending during a split.

Pain can present in different ways too. For some patients, it is a shooting pain in one area and for others it is a pain that moves around.

Common symptoms according to the Vincera Institute website include: “Abdominal or groin pain after an acute injury, Abdominal or groin pain that worsens (or gets progressively worse) over weeks, months or even years, Chest or rib pain, Fleeting pain that appears or disappears on one or two sides, Pain that moves from abdomen to groin or thigh, Increased pain or discomfort with exertion such as sprinting, kicking, sidestepping or light or heavy lifting, Increased pain or discomfort when coughing, sneezing or turning over in bed.”

The most common core muscles injuries include tears to the rectus abdominus, otherwise known as the abdominals, tears to the adductor (thigh muscles) and iliotibial tract syndrome where you experience pain around the iliotibial band on the outer sides of the thigh. Core muscle injuries are complex because there are over a hundred different combinations of them and just as many variations on the types of surgeries needed to treat them.

Link Between Core and Other Injuries

Meyers who has been performing core muscle surgeries since the late 80s, continues to push for more research on these types of injuries and how they can contribute to problems in other parts of the body.

Because of the complexity of the core anatomy, patients with groin pain often find themselves being passed from one specialist to another before the right diagnosis is made.

The research body on core muscle injuries is growing though. “Mini-Open Incision Sports Hernia Repair: A Surgical Technique for Core Muscle Injury” published in August 2017 in Arthroscopy Techniques has offered up a new surgical technique for core muscle injury where not only is the rectus abdominis repaired to the pubis, but the adductor longus is also elongated.

Another study, “Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine” published in May 2017 in the Arthroscopy Journal offered positive news on athletes’ recovery after core muscle surgery. The researchers found that when treated correctly, these injuries don’t have any long-term impact on an athlete’s performance. The authors wrote, “Athletes with a history of successful athletic pubalgia surgery invited to the NFL Combine and those with persistent pathology on the MRI are not at increased risk for diminished performance in the NFL.”

Studies have also shown that while core muscle injuries/athletic pubalgia and femoroacetabular impingement have always been considered separate conditions, they can actually both play a role in why an athlete experiences groin pain.

One of the most recent studies conducted so far has even explored the connection between core muscle injuries and extremity injuries. “Impaired Core Stability as a Risk Factor for the Development of Lower Extremity Overuse Injuries: A Prospective Cohort Study,” which was published in the June 2019 issue of The American Journal of Sports Medicine suggests that core stability issues are a risk factor for lower extremity overuse injuries.

During the study, participants went through baseline testing for dynamic postural control, isometric core and hip muscle strength, core muscle endurance, core neuromuscular control and proprioception, and functional movement. Then they were followed for 1.5 years.

According to the results, 34 of the 139 participants experienced a lower extremity overuse injury during the follow-up period. An increased side-by-side difference in dynamic postural control (p = .038), decreased isometric hip extension:flexion strength ratio (p = .046), and decreased abdominal core muscle endurance (p = .032) were also found to be significant risk factors for lower extremity overuse injuries.

Meyers who was not involved in the study said that this concept that core instability leads to lower extremity injuries is a real finding.

“My definition of the core (mid-thigh to mid-chest) is different though and therefore some of the injuries they identified are actually part of the core because they defined the core from pubic bone up. Therefore, my interpretation of their findings is that weakness in one part of the core leads to weakness in other parts of the core and the lower extremities.”

Despite these differences, he still feels though that “this is the sort of data we should be looking for. “I deal with this every day. The longer the core injury, the higher the likelihood of upper or lower extremity injury.”

It’s a musculoskeletal system. Not the other way around.

Meyers believes strongly in the interconnectedness of the core with the rest of the body just like Leonardo da Vinci did. Da Vinci in his drawing Vitruvian Man labeled the pubic bone as the center of the body’s universe.

“All skeletal muscle like the rectus abdominus muscle (abs) and adductor muscles (thighs) pass by or are attached to pubic bone, creating a tension above and below and side to side. This is the harness of power, especially in the athlete,” he said.

He added that often underlying core weakness or injuries go undiagnosed, and that probably half of the people in a gynecological office have untreated core injury, which can lead to an increased susceptibility to falls. He emphasized the importance of teaching core stability in elderly, especially considering the direct correlation between longevity and falls.

As part of his mission to bring core muscle injuries into mainstream medicine, Meyers wrote and edited a book, Introducing The Core: Demystifying the Body of an Athlete, which was published by SLACK Incorporated, He and his fellow expert contributors explain not only how the core functions, but also how it particularly influences the body the athlete.

Meyers is also working on a study looking at how MRIs can better identify risks for core injuries in athletes. The study involves conducting MRIs on entire teams before, during and after season, to look for imaging results that might help identify core muscle injuries earlier.

“The more data the better,” he said.

For Meyers, the most important thing is to bring different specialties together to treat the complexities of core muscle injuries. At The Core Muscle Injury Center at Vincera he works with orthopedic and general surgeons, medical acupuncturists, physiatrists, pain management physicians, physical therapists, yoga and nutritional specialists and massage therapists to find the right treatment for each patient.