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1 Objective To identify and evaluate the evidence
Faculty of Kinesiology, Sport
Injury Prevention Research
Centre, University of Calgary,
Calgary, Alberta, Canada
2
Pure Sports Medicine,
London, UK
3
Faculty of Medicine, Division
of Sport Medicine, University of
British Columbia, Vancouver,
British Columbia, Canada
4
School of Rehabilitation
Science, McMaster University,
Canada
5
Faculty of Kinesiology, Sport
Injury Prevention Research
Centre, University of Calgary,
Calgary, Canada
6
Department of Pediatrics and
Department of Community
Health Sciences, Alberta
Children’s Hospital Research
Institute for Child and
Maternal Health, Cummings
School of Medicine, University
of Calgary, Calgary, Canada
Correspondence to
Dr Jackie L Whittaker, Sport
Injury Prevention Research
Centre, Faculty of Kinesiology,
University of Calgary, 2500
University Dr NW, Calgary,
Alberta, Canada T2N 1N4;
jwhittak@ucalgary.ca
Received 1 October 2014
Revised 9 March 2015
Accepted 11 March 2015
To cite: Whittaker JL,
Small C, Maffey L, et al. Br J
Sports Med Published Online
First: [ please include Day
Month Year] doi:10.1136/
bjsports-2014-094287
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
Risk factors for groin injury in sport:
an updated systematic review
Jackie L Whittaker,1 Claire Small,2 Lorrie Maffey,3,4 Carolyn A Emery5,6
ABSTRACT
Background The identification of risk factors for groin
injury in sport is important to develop and implement
injury prevention strategies.
examining risk factors for groin injury in sport.
Material and methods Nine electronic databases
were systematically searched to June 2014. Studies
selected met the following criteria: original data; analytic
design; investigated a risk factor(s); included outcomes
for groin injury sustained during sport participation.
The Preferred Reporting Items for Systematic reviews and
Meta-Analyses (PRISMA) guidelines were followed and
two independent authors assessed the quality and level
of evidence with the Downs and Black (DB) criteria and
Oxford Centre of Evidence-Based Medicine model,
respectively.
Results Of 2521 potentially relevant studies, 29 were
included and scored. Heterogeneity in methodology and
injury definition precluded meta-analyses. The most
common risk factors investigated included age, hip range
of motion, hip adductor strength and height. The
median DB score across studies was 11/33 (range
6–20). The majority of studies represented level 2
evidence (cohort studies) however few considered the
inter-relationships between risk factors. There is level 1
and 2 evidence that previous groin injury, higher-level of
play, reduced hip adductor (absolute and relative to the
hip abductors) strength and lower levels of sport-specific
training are associated with increased risk of groin injury
in sport.
Conclusions We recommended that investigators focus
on developing and evaluating preparticipation screening
and groin injury prevention programmes through high-
quality randomised controlled trials targeting athletes at
greater risk of injury.
BACKGROUND
Groin injuries are common in many sports that
involve rapid acceleration and deceleration, sudden
changes in direction and kicking such as soccer,1–12
rugby,13 Australian rules football,14 ice hockey,15
Gaelic football and cricket.15 16 In addition to fre-
quent occurrence, prospective collection of injury
data over consecutive soccer seasons has demon-
strated that those with a previous groin injury are
at a 2.4 (hazard ratio; 95% CI 1.2 to 4.6) times
greater risk of groin injury than payers with no pre-
vious history.10 This vicious cycle of injury and
re-injury may result not only in reduced perform-
ance and missed training/competition but chron-
icity, the end of an athletic career and future
mobility disability.
According to van Mechelen,17 the prevention of
sport injuries occurs through a four-step process
Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287
Review
beginning with establishing the extent of the spe-
cific injury through a validated injury surveillance
system. This is followed by identifying injury risk
factors and causal mechanisms through prospective
analysis of specific injury patterns, development
and introduction of preventative strategies and
evaluation of these strategies by determining their
impact on injury incidence. Throughout this
process it is important to acknowledge that a sport
injury is unlikely to result from a single risk factor
but rather as a consequence of complex interactions
of multiple risk factors and inciting events.18 Thus,
studies aimed at identifying risk factors for groin
injuries in sport should utilise a prospective design
and ensure an adequate sample size to facilitate bio-
statistical methods that consider the interrelation-
ships between various risk factors.19
Consensus regarding the risk factors for groin
injury is lacking and this may be due, in part, to
methodological limitations and heterogeneity of
previous studies. Our 2007 systematic review of
risk factors for groin strain injury in sport reported
a deficiency in prospective studies.20 Based on the
studies available at that time (n=11; 2 cross-
sectional and 9 prospective), there was support for
an association of previous injury and greater hip
adductor to abductor strength ratio, sport specifi-
city of training and amount of preseason sport-
specific training as individual risk factors in groin
strain injury. Although this review did not include a
formal assessment of the quality or level of evi-
dence of the included studies, it reported significant
concerns regarding the internal validity of the
included studies. Further, it recommended that any
future studies examining risk factors for groin
strain injury in sport employ consistent injury defi-
nitions, use validated and reliable injury reporting
systems to quantify outcome measures and consider
the inter-relationships between risk factors by con-
trolling for potential confounding variables (eg,
player exposure and previous injury).
As identification of risk factors and their causal
mechanisms is a precursor to the development of
effective prevention strategies, the lack of consensus
related to risk factors for groin injury in sport has
likely hindered the process of developing and
evaluating groin injury prevention strategies in
sport. The objective of this review was to update
this previous systematic review and summarise the
evidence related to risk factors for groin injury in
sport, including critical appraisal of the literature.
METHODS
This review was conducted according to the
Preferred Reporting Items for Systematic reviews
and Meta-Analyses (PRISMA) guidelines.21
1
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Review

Data sources and search
Relevant studies were identified by searching nine online data-
bases, selected based on their relevance to the research topics,
from inception to June 2014. These databases included:
MEDLINE (1966-present), CINAHL (Cumulative Index to
Nursing and Allied Health Literature; 1982–present), Cochrane
database for Systematic and Complete Reviews (1975–present),
Cochrane Controlled Trials Registry (1975–present), Cochrane
Injuries Group Trials Register, Sport Discus (1980–present),
EMBASE (Excerpta medical databases; 1974–present), PubMed
(public Medline) and SCOPUS. A combination of medical subject
headings (MeSH) and text words were used to execute each
search. Table 1 outlines the search terms used by injury, anatom-
ical region or tissue type and risk concept along with the combi-
nations of search terms that formed each search strategy. The
only limits set were that studies be published in a peer-reviewed
journal. The Cochrane database for Systematic and Complete
Reviews was included to identify any systematic reviews and/or
meta-analyses such that their reference lists could be manually
searched alongside those of all selected studies to identify relevant
articles not identified by the search strategies. Manuscripts were
organised using the reference management software package,
EndNotes V.7.1 (Thomson Reuters, 2013). The number of refer-
ences obtained from each search strategy for each database was
recorded and a running total constructed. After accounting for
duplication, the titles and corresponding abstracts of all returned
records were reviewed by ( JLW) to identify potentially relevant
studies. Finally, the full text of all potentially relevant studies was
reviewed to determine final study selection by ( JLW, CAE).
Study selection
Studies were included if they investigated the association
between any potential injury risk factor (defined as any factor
that may increase the potential for injury) or injury prevention
strategy with groin injury (defined as any or all of the following;
groin or hip adductor injury or muscle strain, tenderness on pal-
pation of the hip adductor or flexor muscles, adductor bone-
tendon junction or pubic symphysis and/or pain on resisted hip
adduction). Additional inclusion criteria included: primary
research of original data, analytic design (eg, experimental,
cohort, case–control or cross-sectional), an outcome measure of
groin injury sustained during sport participation, an objective
exposure measure of one or more potential risk factor or injury
prevention strategy for groin injury in sport and study partici-
pants who were involved in any sport that involved rapid accel-
eration and deceleration, sudden changes in direction and
kicking. The definition of groin injury was modified slightly
(omitted lower abdominal muscles) from the original systematic
review to be consistent with clinical entity of adductor-related
pain proposed by Holmich et al22 and, as a greater number of
studies focusing on the hip adductors and adductor bone-
tendon junction were available than at the time of the original
review.
Studies were excluded if the injury outcome was only
described in general terms such as thigh or hip injury, were not
written in English or involved animal models or cadavers.
Further, conference proceedings/abstracts, review articles (sys-
tematic and narrative), case series or case studies, editorials,
commentaries and opinion-based papers were excluded.
Data extraction and study rating process
Data extracted from each study included; study design, study loca-
tion and population (sport, level, age, sample size), injury outcome
(definition), injury estimates (incidence proportion, incidence rate,
prevalence), measures of risk (difference in means, correlations,
OR, incidence rate ratios; IRR and risk ratio; RR), risk factors and

Table 1 Search strategy and results of the systematic literature search, with total number of unique articles per database
Sport
MeSH or text words* MEDLINE PubMed CINAHL EMBASE Discus Scopus CCTR CDSR References

1 and 6 269/269/17 170/2/0 177/87/0 24/3/0 1/1/0 193/3/0 6/0/0 1/0/0

1 and 7 4/1/0 37/4/0 0/0/0 10/0/0 0/0/0 28/0/0 0/0/0 0/0/0
1 and 8 1/1/ 0 1/0/0 1/0/0 278/57/0 1/0/0 224/3/0 0/0/0 1/0/0
1 and 9 1053/860/4 545/93/1 2/0/0 1542/647/0 18/1/0 636/28/0 23/0/0 40/39/0
1 and 10 133/0/0 487/62/0 3/0/0 34/0/0 0/0/0 120/0/0 1/0/0 3/0/0
2 and (3 OR 4) and 6 47/0/0 3/0/0 4/0/0 2/0/0 1/0/0 18/1/0 0/0/0 2/0/0
2 and (3 OR 4) and 7 2/1/0 0/0/0 5/0/0 0/0/0 2/0/0 6/1/0 0/0/0 0/0/0
2 and (3 OR 4) and 8 0/0/0 0/0/0 6/0/0 12/2/0 3/0/0 22/3/0 0/0/0 2/0/0
2 and (3 OR 4) and 9 195/167/3 25/1/0 7/0/0 147/64/0 4/0/0 90/19/0 6/1/0 8/6/0
2 and (3 OR 4) and 10 4/0/0 19/4/0 8/0/0 0/0/0 5/0/0 0/0/0 0/0/0 1/1/0
5 and 6 39/9/0 38/0/0 9/0/0 7/0/0 6/0/0 41/0/0 0/0/0 1/0/0
5 and 7 0/0/0 15/3/0 10/0/0 1/1/0 7/0/0 6/1/0 0/0/0 0/0/0
5 and 8 0/0/0 1/1/0 11/0/0 49/4/0 8/0/0 56/3/0 0/0/0 1/0/0
5 and 9 58/14/0 76/8/0 12/0/0 112/20/0 9/0/0 85/5/0 0/0/0 1/0/0
5 and 10 2/0/0 57/3/0 13/0/0 0/0/0 10/0/0 2/2/0 0/0/0 0/0/0
1 and (6 OR 7 OR 8 OR 9 OR 10) and 11 75/0/0 29/0/0 14/0/0 63/0/0 11/0/0 48/0/0 2/0/0 11/0/0
2 and (3 OR 4) and (6 OR 7 OR 8 OR 28/0/0 1/0/0 15/0/0 3/0/0 12/0/0 9/3/0 0/0/0 2/0/0
9 OR 10) and 11
5 and (6 OR 7 OR 8 OR 9 OR 10) and 11 4/0/0 3/0/0 16/0/0 4/0/0 13/0/0 5/4/0 0/0/0 1/0/0
Individual Database Totals 1914/1322/24 1507/181/1 183/87/0 2288/798/0 26/2/0 1589/76/0 38/1/0 75/46/0 8/8/4
No. of articles included in systematic review 24 1 0 0 0 0 0 0 4
Cell values represent potentially relevant/unique (eg, not a duplicate)/included in systematic review.
*1=Groin (MeSH), 2=hip (MeSH), 3=adductor (tw), 4=flexor (tw), 5=osteitis pubis (tw), 6=athletic injuries (MeSH), 7=sprain, 8=strain (MeSH), 9=sport injur×(tw), 10=injur×(tw),
11=wounds and injuries (MeSH), 12=risk factors (MeSH); CCTR, Cochrane central register of controlled trials; CDSR, Cochrane database for systematic and complete reviews; CINAHL,
Cumulative index to nursing and allied health literature; EMBASE, Excerpta medical databases; MeSH, medical subject heading; tw, text word.

2 Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287

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results (significant and non-significant). If available, injury esti-
mates (injury rates) were used to calculate point estimates of IRR
(IR exposed/injury rate in unexposed). Two authors (lead author
and one of three coauthors) independently assessed the quality
and level of evidence of each study. Quality of evidence was evalu-
ated based on criteria for internal validity (study design, quality of
reporting, presence of selection and misclassification bias, poten-
tial confounding) and external validity (generalisability) using the
Downs and Black (DB) quality assessment tool which assigns an
individual score calculated out of 33 total points for each study
(10 points for reporting, 3 points for external validity, 7 points for
bias, 3 points for confounding and 1 for power: see online supple-
mentary appendix 1).23 The level of evidence represented by each
study was categorised based on the Oxford Centre of Evidence
Based Medicine (OCEBM) model (see online supplementary
appendix 2).24 As per study exclusion criteria, levels 1a, 2a, 3a
(systematic reviews), 4 (case series) and 5 (opinion-based papers)
were not included. Discrepancies in DB scoring or OCEBM
categorisation were resolved first by consensus between the
two reviewers who rated the study and if required, by the senior
author (CAE).
Data synthesis
Extracted data, quality and level of evidence were summarised
for each study. The quantity, quality and level of evidence for
the most commonly investigated modifiable and non-modifiable
risk factors for groin injury in sport were collated.
RESULTS
Identification of studies
An overview of the study identification process is provided in
figure 1. The initial search yielded 7760 articles (including eight
identified through reference list search), 5239 duplicates were
removed leaving 2512 potentially relevant articles. Following the
Figure 1 Study identification Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow sheet.
Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287
Review
removal of studies not meeting inclusion criteria based on
abstract review (eg, injury and injury risk were not investigated,
population or dance form did not match criteria) this was nar-
rowed to 70. Subsequent to further manuscript evaluation by the
two independent reviewers ( JLW and CAE), 41 were excluded
leaving 29 studies deemed appropriate for inclusion to the sys-
tematic review. Electronic or hard copies of two potentially rele-
vant articles were not available for review and as they had not
met similar inclusion criteria for the previous review, published
in 2007, they were excluded.25 26 One study27 included in the
previous systematic review was excluded as it did not provide an
independent estimate of groin injury (eg, combined low back,
groin and hamstring injuries), while another study included in
the previous review,15 that included abdominal muscle strain in
the injury definition, was included as 83% of the reported injur-
ies were related to the adductor muscles. Owing to inconsistent
methodology and injury definition as well as the heterogeneity of
the risk factors examined meta-analysis was precluded (see online
supplementary table S1).
Study characteristics
Characteristics of the 29 included studies are summarised in
online supplementary table S1. These consisted of 2 intervention
studies (1 randomised controlled trial, 1 quasi-experimental),
21 cohort (19 prospective, 1 historical, 1 pilot), 5 case–control
and 1 cross-sectional study representing approximately 14 differ-
ent countries. The median number of participants per study was
219 (range 18–2299) and the combined total number of athletes
investigated across studies was 12 131 (9925 males and 2206
females). Twenty-eight of the studies are believed to have
included male athletes (11 of these did not specify the sex of
their participants however based on the sport investigated it is
likely the participants were male) spanning the ages of
12–38 years, while five studies included female athletes (age
3
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Review
range 15–41 years). Among the 23 follow-up studies 13 had a
follow-up time greater than one season (range 9 weeks—9
seasons), 7 had at least 50 injury cases (range 4–672) and 9 uti-
lised a multivariate statistical approach to identify risk factors for
groin injury in sport. Of the 19 studies published since 2007, 1
was a randomised controlled trial, 14 were cohort (12 prospect-
ive, 1 historical and 1 pilot) and 4 were case–control. Six of these
19 studies utilised multivariate statistical approaches and 5 had at
least 50 injury cases.
Injury estimates
Descriptions of injury estimates (incidence proportion, incidence
rate, prevalence), effect estimates (IRR, RR, OR) and significant
and non-significant groin injury risk factors are presented in
online supplementary table S1.
Quality and level of evidence
The highest level of evidence demonstrated by all reviewed
studies was level 1b (Individual randomised controlled trial).
The majority (21/28) of studies were classified as level 2b which
corresponds to cohort studies.
The median methodological quality for all 29 studies, based
on the DB criteria, was 11/33 (range 6–20) with an initial mod-
erate between rater agreement of 65.5% (κ=0.62).43 The aim
of the DB criteria is to assess scientific study methodological
quality (inclusive of randomised and non-randomised interven-
tion as well as observational studies). Owing to the majority of
included studies being observational in nature, seven items (4, 8,
14, 19, 23, 24 and 27; totalling 10 points) on the DB checklist
were not applicable. Therefore, 27 of the 29 articles did not
have the opportunity to achieve a full score due to their study
design. Areas in which the included studies were consistently
limited included: incomplete description of how the sample was
representative of the population of interest (eg, insufficient
description of participant characteristics such as sex, history of
previous groin injury, training exposure), limited description of
the characteristics of those lost to follow-up, use of invalid or
unreliable measures, insufficient reporting of how participants
lost to follow-up and differing length of follow-up were
accounted for in statistical analyses, inadequate sample size and
lack of adjustment for potential modification and confounding
by factors such as exposure and previous injury. Further, several
of the case–control studies that report a matched design did not
account for matching in their analyses (eg, independent t tests
vs paired t tests).
Synthesis of results
The quantity, quality and level of evidence for the most com-
monly investigated modifiable and non-modifiable risk factors
for groin injury in sport are summarised in table 2. The most
common risk factors investigated included age, hip range of
motion, hip adductor strength, height and weight. There is level
1 and 2 evidence that previous groin injury, higher level of play,
reduced hip adductor strength (isolated and relative to hip
abductor strength) and lower levels of sport-specific training are
associated with increased risk of groin injury in sport. Further,
there is consistent evidence to suggest that older age, higher
weight or body mass index (BMI), height, reduced hip range of
motion (ROM) and performance on fitness tests such as jump
height, leg power (squat), 40 m sprint, sidestepping, kicking and
VO2max estimated from a shuttle run are not associated with
groin injury in sport.
4 Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287
DISCUSSION
To our knowledge, this is the first systematic review examining
risk factors for groin injury in sport that considers both a
formal evaluation of study quality and level of evidence. Overall
the quality and level of evidence investigating risk factors for
groin injury in sport has improved in the past 7 years since our
systematic review in 2007.20 Specifically, there are a greater
number of prospective studies with larger sample sizes employ-
ing multivariate statistical techniques.
Key findings—risk factors
Consistency across the literature support previous groin injury,
higher level of play, reduced hip adductor strength (absolute
and relative to the hip abductors) and lower levels of
sport-specific training as risk factors for groin injury in sport. To
date, many authors have speculated on the mechanisms under-
lying these risk factors. The general consensus regarding the
mechanism by which previous injury is a risk factor is inad-
equate rehabilitation following the initial injury and/or inherent
physiological risk in certain individuals that puts them at greater
risk of both the initial and subsequent injuries.2 10 15 31 The risk
associated with higher level of play may result from a higher
intensity in training and game play as well as a greater number
of training hours.32 Decreased levels of hip adductor strength
(both absolute and in comparison to the hip abductors) may
result in decreased muscle capacity, imbalances between the syn-
ergistic functions of hip adductor and abductor muscles, and
increased risk of muscle injury during movements involving
side-to-side cutting, striding, quick acceleration/deceleration and
sudden direction changes.9 15 Sport-specific training (specifically,
pre-season) may address muscle weakness and imbalance as well
as promote function specific recruitment resulting in more
effective utilisation and less muscle fatigue.20 Consequently
reduced sport-specific training may place an athlete at higher
injury risk when faced with an increase in training load as the
playing season begins.
Although there have been valuable contributions made to the
evidence base related to identifying risk factors for groin injury in
sport in the past 7 years the conclusions of this systematic review
and that of the previous20 are surprisingly similar. Specifically:
▸ previous groin injury,
▸ reduced relative hip adductor strength and
▸ reduced sport-specific training
were all identified as risk factors for groin injury in sport previ-
ously. Previous groin injury, and reduced hip adductor strength
have also been identified as risk factors for groin/hip injury in
field-based sports in a recent systematic review of seven
studies.44
In addition, Ryan et al44 reported that older age, higher BMI
and reduced hip abductor ROM are risk factors for groin/hip
injury in field-based sport. The discrepancies between these
findings and those of the current review are likely due to the
limited scope of sports considered and the inclusion of studies
investigating both hip and groin injuries in the field-based sport
review. Of the 29 studies included in the current review, 12
investigated older age as a risk factor for groin injury in sport
(see online supplementary table S1). Of these, all but two
studies (including one randomised controlled trial (RCT), eight
cohort) found no association between older age (both as a
dichotomous and continuous variable) and groin injury in sport
(see table 2). Similarly, five of six included studies investigating
BMI and six of nine investigating hip ROM found no associ-
ation between the exposure variables and groin injury.
 Table 2 Summary of significant and non-significant groin injury risk factors by quantity, quality and level of evidence
1 2 3 4
5
b: High-quality b: True or quasi b: Retrospective Pilot cohort
Level of evidence* RCT experimental b: Prospective cohort cohort b: Case–control cross-sectional
a c a c a
Risk factor Risk factor SIG NOT SIG NOT SIG NOT SIG NOT SIG NOT SIG NOT Total studies

Modifiable Weight 1 (11) 4 (13–19) 1 (9) 1 (12) 7

BMI 5 (13–18) 1 (9) 6
Body fat 3 (11–18) 3
Hip ROM 1 (10) 5 (9–18) 1 (7) 1 (11) 1 (12) 9
Hip Add strength 1 (12) 3 (9–18) 2 (11–15) 2 (7–11) 1 (9) 9
Hip Abd strength 1 (12) 1 (11) 1 (9) 1 (11) 4
GMd activation 1 (7) 1
TrA thickness/activation 2 (9–11) 2
Knee muscle strength 1 (11) 1
Knee ROM 1 (9) 1
Calf flexibility 1 (9) 1
Clinical tests† 1 (18) 1 (11) 1 (11) 3

Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287

Fitness tests‡ 1 (18) 4 (11–18) 5
GrOS/function 2 (16–18) 1 (11) 3
Exposure§ 3 (16–18) 1 (10) 4
Stretching and cross-training 1 (10) 1
Sport specific training 1 (15) 1
Non-modifiable Age 1 (20) 2 (10–13) 6 (13–18) 1 (9) 2 (10–12) 12
Sex 1 (18) 1 (16) 1 (9) 1 (10) 4
Height 6 (11–18) 1 (9) 1 (12) 8
Previous injury 1 (20) 4 (15–18) 5
Game play 1 (13) 1 (18) 2
Level of play 1 (20) 2 (11–18) 3
Player position 1 (20) 1 (11) 2 (11–18) 1 (9) 5
Years of sport experience 1 (15) 2 (11–16) 1 (9) 4
Occupational demands 1 (20) 1
Skeletal maturation 1 (10) 1
Leg morphology 1 (11) 1
Cell values represent number of studies (range of Downs and Black quality assessment tool scores/23 for cohort studies and/32 for RCT’s). As per exclusion criteria, systematic reviews (1a, 2a and 3a), case series (4) and opinion-based papers (5) were not
included (shown in dark grey).
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*Level of evidence is based on the modified Oxford Centre for Evidence-Based Medicine Model.
†Including tenderness on palpation, pain, joint stability (knee and ankle) and positive active straight leg raise test.
‡Includes jump height, leg power (squat), 40 m sprint, sidestepping, kicking and VO2max estimated from a shuttle run.
§Includes measures of training and match exposure as well as weekly sports participation.
Abd, abduction; Add, adduction; ASLR, active straight leg raise test; BMI, body mass index; GMd, glutaeus medius; GrOS, groin outcome score; IO, internal oblique; LE, lower extremity (knee and ankle); NOT, not significant finding; RA, rectus abdominins;
RCT, randomised control trial; ROM, range of motion; SIG, significant finding; TrA, transversus abdominis.
Review

5
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Review
What can we learn from other injuries?
Looking beyond the groin injury literature, the current findings
are relatively consistent with a recent systematic review and
meta-analysis (including 34 studies) of risk factors for hamstring
injury in sport45 which identified previous hamstring injury,
quadriceps peak torque and older age as the exposure variables
most consistently associated with hamstring muscle strain-type
injury. The discrepancy in findings regarding increasing age as a
risk factor for groin and hamstring injury may be related to the
relatively narrow age range (mean age ≤25.8 years with SDs
ranging between 0.8 and 4.6 years) represented in the 12 studies
that have investigated age as a risk factor for groin injury.
Further, the conclusion that increasing age is a risk factor for
hamstring injury45 is potentially influenced by the findings of one
study by Arnason et al2 Accordingly additional consideration of
the prospective relationship across between age and injury risk
across a wider age span for both muscle groups is recommended.
Limitations
Meta-analyses were not possible due to inconsistent method-
ology and heterogeneity of the definition of groin injury in the
included studies. Further, despite a comprehensive search strat-
egy and rigorous approach to study selection it is important to
acknowledge the possibility of omitting a relevant study and
inclusion of only English language manuscripts.
As the conclusions and recommendations contained within
this review are based on a synthesis and evaluation of existing
literature they are limited by its inadequacies. In several
instances (eg, game play, fitness tests) there was a lack of consist-
ent high-quality evidence to support nominating a particular
exposure variable as a risk factor due to inadequate reporting of
concepts essential to establishing internal and external validity.
The biggest threats to internal validity were related to the possi-
bility of selection bias and potential confounding. Specifically,
due to the lack of reporting of participant characteristics it was
often difficult to determine if the athletes selected for a study
differed systematically from those in the source population
(selection bias). Equally important was the consistent omission
of the characteristics of those lost to follow-up, which made it
impossible to determine if those lost to follow-up were systemat-
ically different from those retained in the study. The inability to
assess for selection bias not only questions the internal validity
of several studies, it impacts the degree to which the findings of
these studies can be generalised to the larger athletic population
from which the sample was drawn (external validity).
As stated earlier, it is highly unlikely that a groin injury is a
result of a single risk factor, but rather the consequence of
complex interactions between multiple risk factors and inciting
events.18 Multivariate biostatistical techniques can be used to
explore these complex interactions given an adequate sample
size. Bahr and Holme19 estimated that 50 injury cases are
needed to detect a moderate to strong association between a
risk factor and sport injury. Of the 29 studies included in this
review only nine employed these techniques, of which only
three had 50 or more injury cases and were able to assess these
interactions.9 15 31 As a result, the association between the
potential risk factor and groin injury reported in the studies that
did not employ these techniques may be biased as they failed to
consider any potential confounder (eg,. extraneous variables
that may have distorted the relationship between the exposure
variable and groin injury).
The last point of consideration is that studies to date may not
have considered all possible risk factors for groin injury in
6 Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287
sport. For example, a recent systematic review and position
statement released by the American Medical Society for Sports
Medicine highlights that although there is a lack of clinical data
a high ratio of workload-to-recovery time may lead to overuse
injuries and burnout in youth sport.46 To the best of our knowl-
edge the relationship between measures of over training or
physiological fatigue and groin injury and sport have yet to be
investigated.
Recommendations
Both prospective cohort and intervention study designs are
important for identifying potential risk factors for injury in
sport.19 While prospective cohort studies are critical for estab-
lishing temporality between a risk factor and subsequent injury,
RCTs provide the strongest evidence for the causal nature of a
risk factor (eg, hip abductor and adductor strength, decreased
levels of sport-specific training) and the effectiveness of modify-
ing that factor on injury outcomes. Based on the additional pro-
spective studies undertaken in the past 7 years (involving larger
samples and employing multivariate statistical techniques), con-
sistency of the finding of the current review with those of the
previous review20 and the challenges and high cost of undertak-
ing high quality prospective cohort studies, it is recommended
that investigators shift their focus from prospective cohort to
high quality RCTs. Specifically, future research should include
RCTs that target athletes at greater risk of groin injury during
sport (eg, high levels of play, previous injury) with prevention
programmes that include interventions targeting the hip
abductor and adductor muscles in conjunction with off and pre-
season sport specific training.
To date two separate intervention studies aimed at addressing
modifiable risk factors (eg, dynamic balance, muscle strength
and agility), for sport-related lower extremity and groin injuries
have been undertaken.32 47 Engebretsen et al47 investigated the
effectiveness of an injury prevention programme on high-risk
(eg, previous injury and/or reduced function) soccer players,
while Holmich et al32 selected a cluster (soccer team) design to
facilitate implementation. Unfortunately both studies lacked suf-
ficient statistical power to demonstrate a significant effect of the
proposed intervention on the occurrence of sport-related groin
injuries and Engebretsen et al47 report that player compliance to
the training programmes was poor with only 19.4% of the
groin injury high-risk group carrying out the minimum recom-
mended training volume. Other reasons for null findings in
these studies may be that the intervention did not sufficiently
address the risk factors present. For example, there is a body of
evidence suggesting that persistence of neuromuscular changes
post-injury may have detrimental long-term consequences that
contribute to re-injury through increased joint load, decreased
movement, and decreased loading variability.48–53 Consequently,
prevention programmes focused on purely building strength
without restoring coordinated motor control (eg, eliminating
protective cocontraction) may not prove as effective. Regardless
of the lack of effect detected in these two landmark intervention
studies, valuable lessons can be learned from both, the least of
which is the importance of developing an implementation strat-
egy and then tracking and accounting for adherence to the pre-
vention programmes in the analysis.
SUMMARY
The quality of studies investigating risk factors for groin injury
has improved in the past 7 years.
 Downloaded from http://bjsm.bmj.com/ on April 19, 2015 - Published by group.bmj.com
There is relatively consistent level 1 and 2 evidence to suggest
that previous groin injury, higher level of play, reduced hip
abductor and adductor strength and lower levels of
sport-specific training are associated with increased risk of groin
injury in sport.
Further, there is consistent level 2 evidence suggesting that
higher weight, BMI or height, reduced hip ROM and perform-
ance on fitness test such as jump height, leg power (squat),
40 metre sprint, sidestepping, kicking and VO2max
estimated from a shuttle run are not associated with groin injury
in sport.
Based on the work performed in the field in the past 7 years
and the challenges and high cost of undertaking high-quality
prospective cohort studies aimed at identifying risk factors for
groin injury in sport it is recommended that investigators turn
their focus to high-quality randomised controlled trials targeting
athletes at greater risk of injury (those at a high level of play
with a previous injury) with prevention programmes targeting
the hip abductor and adductor muscles in conjunction with off
and preseason sport-specific training.
What are the new findings
▸ There has been an improvement in the quality (eg, larger
sample size, employing multivariate statistical techniques)
and level of evidence of studies investigating risk factors for
groin injury in sport in the past 7 years.
▸ There is level 1 and 2 evidence that previous groin injury,
higher level of play, reduced hip adductor strength and
lower levels of sport-specific training are associated with an
increased risk of groin injury in sport.
▸ Based on the work performed in the field, it is recommended
that investigators turn their focus to high-quality randomised
controlled trials targeting athletes at greater risk of groin
injury in sport with prevention programmes targeting the hip
abductor and adductor muscles in conjunction with off and
preseason sport-specific training.
Twitter Follow Jackie Whittaker at @jwhittak_physio
Acknowledgements The authors would like to acknowledge the assistance of the
University of Calgary, Faculty of Kinesiology librarian Alex Hayden as well as research
assistants Lisa Loos, Leticia Janzen and Rhys Johnson.
Contributors JLW and CAE were responsible for the conception and design of the
study. JLW and CAE independently reviewed the literature. JLW extracted data from
the included studies, while all four authors were involved in rating the literature. JLW
was the primary author in preparing the manuscript however all authors contributed
to the interpretation of the findings, critical revision of the manuscript and reviewed
the document prior to submission.
Funding The Sport Injury Prevention Research Centres is supported by an
International Olympic Committee Research Centre Award. JLW is funded through
an Alberta Innovates Health Solutions Postdoctoral Clinician Fellowship. CAE
holds a Professorship in Pediatric Rehabilitation Alberta Children’s Hospital
Foundation.
Competing interests None.
Provenance and peer review This paper was commissioned by the 1st World
Conference on Groin Pain in Athletes, Doha, Qatar, November 2014; externally peer
reviewed.
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8 Whittaker JL, et al. Br J Sports Med 2015;0:1–8. doi:10.1136/bjsports-2014-094287

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Risk factors for groin injury in sport: an

updated systematic review
Jackie L Whittaker, Claire Small, Lorrie Maffey and Carolyn A Emery

Br J Sports Med published online April 1, 2015

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