The Adolescent Female And The Athlete Triad


Many RMTs, Athletic Therapists and Physios start their career wanting to work with athletes, I know I did.

I had dreams of spending my days in the locker room and on the field, being part of a team and sharing in the glory of winning (having never been talented enough to compete myself!).

For many years, I did just that.

I worked in a sports clinic with my physical therapy “hat” on treating sports injuries and my evenings and weekends covering athletic events wearing my athletic trainer “hat.”  During my time at an all-girls high school, I became involved in female athlete triad research and bone stress injuries.

It opened my eyes to how athletics can affect females differently than males.

Since then, how we view the triad and how we treat it has changed.

Can you recognize and screen for the signs of the triad?  Do you know who is at risk?

What Is The Triad, And How Do We Recognize It?

Adolescent girls should participate in sports.  I want that to be clear.

Girls participating in sports have better communication with their parents, are less likely to get pregnant, have more positive body image and are 20% less likely to get breast cancer later in life.

But they are at risk for injury,  48% of female athletes will have injury severe enough for them to miss playing time.

Bone stress injuries are common in adolescent females, occurring in up to 21% of competitive females.  Injuries can range from a stress reaction to a stress fracture and occurs from a disturbance in osteoblastic bone formation and osteoclastic resorption.  The most common places are the foot, lower leg and pars in the spine.  Risk factors include endurance sports, sudden changes in training (duration, intensity, equipment) and inadequate recovery time.

90% of peak bone mass is gained by 18 years of age and research shows athletes have approximately 10% more bone density than non-athletes.  So any non-traumatic bone injury is cause for concern.  

It is imperative that the underlying cause is investigated and treatment includes resolving more than just the fracture.

Any time there is a bone stress injury, the other components of the Female Athlete Triad should be considered.

The Female Athlete Triad was first described in 1992 as disordered eating, amenorrhea (specifically missing more than 3 periods in a row) and osteoporosis.  The triad has now been expanded to include a spectrum of each pathology.  Screening should include having less than 6 periods a year (not necessarily consecutive missed cycles), dietary counselling and a DEXA bone density scan that compares the Z-scores, which matches the athlete to others her age. A  -2.0 standard deviation or greater is concerning.

The crux of the triad seems to be low energy availability due to disordered eating.

The athlete doesn’t necessarily try to restrict their calories, although some do in body-conscious sports, or if they are concerned about their weight.  Many are just unaware of the amount of food it takes to fuel their daily activity.  Sometimes they are just eating poorly: fast food, processed food, you know….they are teenagers!  This low energy availability leads to hypoestrogenism and disrupts menstrual cycles.

Estrogen normally inhibits bone turnover and maintains a balance between resorption and formation.  When there is a nutritional deficit and a lack of estrogen, this balance is disrupted.

Back when we started the research, we thought the best thing to do was replace the estrogen. Makes sense right?  Studies now show that using oral birth control does not change the bone density, even with prolonged use.  The first treatment should be nutritional counselling and improving caloric intake.  There are great resources online at www.femaleathletetriad.org that includes a nutritional calculator to get you started.

Also, find a nutritional counsellor in your area used to working with athletes.

Photo by: KeithJJ

What Can We Do?

So what do you do as a healthcare professional?

Know the signs….an athlete presenting with even one component has a 3x greater risk to develop one of the other components.  The Female Athlete Triad Coalition has a great screening tool that is non-confrontational and can easily be done as part of pre-participation screens.

Have information available.  Adolescent females need 1300mg of calcium a day and the best source is spread out throughout the day with food.  Raw green leafy vegetables, broccoli, almonds, canned sardines with bones, low-fat milk products are the best sources.  Certain medications can also impact bone health and may predispose your athlete to bone injuries.

Antiseizure medications (also used for migraine control), prednisone, SSRIs, thyroid medications are common medications for adolescents to be taking for a variety of disorders.

Female Athlete Triad is primarily hormonal and dietary driven.  It’s important to have a multidisciplinary approach to diagnosis and treatment.  It’s also important to be a nonjudgmental place for your athlete.  Athletes are a lot of fun to work with and you are part of a much larger team, especially when dealing with the triad.



  • Goolsby M, Boniquit N. Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones. Sports Health[serial online]. November 7, 2016
  • Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985-996
  • De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43:140-14
  • Liu SL, Lebrun CM. Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review. Br J Sports Med. 2006;40:11-24
  • Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4:302-311
  • O’Connor D, Blake J, Bell R, Bowen A et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause and Beyond. J Obstet Gynaecol Can 2016;38(6):508-554
  • femaleathletetriad.org

Travelling In Sport As A Massage Therapist


When I decided to go back to school to be a Massage Therapist, the one thing that made me decide on this new profession was the chance to work with athletes and sports teams.

The whole idea of working with teams always had a certain lure to me, getting to be part of that team environment always seemed more appealing than strictly working in a clinic.

While in college I was lucky enough to start working with our local Junior A hockey club and continued working with them for seven years, even being the head trainer and medical director for one season. During that season, I did some travel with the team to other parts of the province and got the feel of what it’s like to be on the road with a team, dealing with transport, setting up dressing rooms, loading and reloading the bus with equipment and all the other issues that happen on the road.

Because of putting in the time volunteering with that team, some other great opportunities have come my way. I got to spend a year working with our Rugby 7’s men’s national team, and in 2016 I got my first opportunity to work with our national women’s development program in hockey.

Since working with the women’s development program, I’ve had two opportunities to travel internationally with them. I thought I knew the work and effort it takes to work with a team from my past experience, but working and travelling internationally takes on a whole other level of work and work ethic to be successful.

I know many of our readers are interested in this type of work, so I’ll try to outline what an average couple of days looks like work-wise, so you’ll know what you’re getting into if this is your chosen area of interest.

Daily Schedule

While I’m sure it’s different for every sport and probably every venue, it takes a ton of work to get things set up at hotels, dressing rooms, and whatever venue you are using to help the athletes throughout a tournament.

You aren’t doing strictly massage therapy when you’re on the road, you’re helping out wherever is needed, plus covering some aspects you may not have thought of (keep in mind this is just three days of a three-week trip).

Pretournament Game

5:00 amLight snack

5:30 amAthlete exercise routine  

6:00 amTeam meetings/presentations

6:30 amTeam practice/dryland

7:00 amRegular breakfast

7:30 amMorning session with S&C coach

7:45 – 9:10amPractice session for some athletes  

10:00am – 12:00pmPhysio & Massage Therapy treatments

1:30 pmPregame Meal

3:10 pmAthletes and coaches meeting

3:45 pmDryland warmup

4:30 pmOn ice warmup for both teams

5:00 pmGame time

5:10 pmAthlete cool down  

8:20 pmDinner

9:00 pmStaff meeting

Travel Day

5:00 amLight snack

5:30 amAthlete exercise routine

5:45 amTeam meetings/presentations

6:30 amBreakfast

6:50 amAthletes and coaches meeting

7:15 amDryland warmup

8:00am – 9:15amTeam practice

9:30 amAthlete cooldown 

9:30 am – 10:15 amHelp equipment manager pack up the dressing room and load all equipment on the bus

10:30 amLunch

12:15 pmLoad all team luggage on the bus

12:30 pmLeave for airport

1:45 pmCheck all baggage and equipment in through airport security

5:05 pmFlight leaves

6:30 amLand for connecting flight

10:10amConnecting flight departs

3:25 pmLand in destination, collect luggage, load bus

6:00 pmCheck into hotel

6:30 pmDinner

7:00 pmAll support staff (medical, logistics, equipment manager etc) set up athletes dressing room, medical room, and all associated equipment.

9:10 pm Staff meeting (time depending on dressing room setup completion)


8:15 amBreakfast

8:45 amAthlete and coaches meeting

9:30 amDryland warmup

10:00 am – 11:45 amPractice

12:00 pmAthlete cool down

12:40 pmLunch

1:15 pmTeam meetings/presentations

2:00 pm – 4:00 pmPhysio and Massage Therapy treatments

4:30 pmLight meal

5:30 pmDryland warmup

6:00 pm – 7:15pmPractice

7:25 pmAthlete cool down

8:30 pmDinner

9:00 pm – 10:00 pmTreatment window for Physio and Massage

10:10 pmStaff meeting


7:15 amBreakfast

7:45 am – Athlete and coaches meeting

8:15 amDryland warmup

9:00 am – 9:45 amPregame Skate

9:55 amAthlete cool down

11:00 amLight lunch

12:00 pm – 2:00 pmPhysio and Massage Therapy treatments

3:30 pmPregame Meal

4:50 pmAthlete and coaches meeting

5:45 pmDryland warmup

6:30 pmOn ice warmup for both teams

7:00 pmGame time

9:10 pmAthlete cool down

10:30 pmDinner

11:00pmStaff meeting

So when you look through this schedule, everywhere it talks about dryland warmup, athlete cool down, and practices, at least one member of the medical team is expected to be in attendance. Typically one member attends while the other therapist tends to some other tasks like filling game water bottles, getting ice, making up ice bags, or helping the equipment manager if needed (essentially doing the background work that isn’t typically thought about). Sometimes the practices and warmups etc. overlap each other depending on how the schedule is set, so you could be covering one practice and another medical staff member is covering the other one.  

During game times I would go up and help the video coach by shooting video during the game, while the physiotherapist is on the bench. Essentially everyone has a job description, so each members time is utilized and productive. 

If you’ve followed this blog for very long, you’ve seen articles stressing the need for us as a profession to be certified in First Aid training. In sports, it’s even more important to be trained as a First Responder. In cases like this, anytime there is an emergency with one of the athletes, the Massage Therapist is part of the emergency action plan and is expected to take part in the injury or emergency, whether it’s on the ice, or off. 

I can’t stress enough how important it is to get this training if working in sports is your interest!

The Team Within The Team

All of the staff are literally another team, within a sports team, it’s not just about the athletes working together.

As I mentioned before, you could be tasked with some menial work (filling water bottles etc.) while another member of the medical staff is working directly with the athletes at a warm up or cool down.

You can’t have an ego about this! 

Even if you work with a team at home and you’re the head trainer, that may not be your role when you travel with a national team. They will have a specific job description for you, and it’s important you adhere to it. There are some really long days where you could be setting up a dressing room, or loading equipment for travel (and not actually do any massage), while the coaches are doing their prep work, logistics are organizing travel, and other members are filling the role for whatever their responsibility is.

But just like the athletes who may be playing a smaller role on the team than they play at home, everyone comes together as a team to accomplish a goal. EVERYONE is filing a different role than they are used to. There will be days you get frustrated, you’ll be tired, and maybe even annoyed with other staff members. But part of being on a team is the ability to put that aside, come together, and work for the benefit of the athlete, it’s about them, not you. 

However, if you are willing to work, put your ego aside and do this kind of work, the benefits are phenomenal. The friendships you’ll make, the pride of not only helping the athletes performance but also representing your country (or whatever organization you’re working with) is incomparable. Plus, you may even end up with a cool picture and a medal at the end of it all.


Red Flags For Low Back Pain, Or Clinical Decision Making?

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital. 

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

  • Mechanism of injury
    • Fall from greater than 20ft
    • High-speed accident
    • Pedestrian struck at speeds higher than 30 km/hour
    • Broken windshield damaged steering wheel, or airbags deployed
    • A rollover accident
    • Severe crush injuries
    • Any other people involved in the accident that result in a fatality
    • Electrical injuries (we always assume spinal damage with electrocution)
  • Anatomy of injury
    • Severe brain injury
    • Penetrating injuries to anything but the limbs
    • Depressed skull fracture
    • Pregnant woman with fairly moderate trauma
  • Findings in the Primary Survey
    • Decreased level of consciousness
    • Cardiac arrest
    • Suspected heart attack
    • Poisoning
    • Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening. 

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

  • Fever/chills
  • Use of corticosteroids or immunosuppressant therapy
  • IV drug use
  • Pain worse at night
  • Night and rest pain
  • Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness)  and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

  • A belief that back pain is harmful or disabling
  • Fear of pain and movement avoidance
  • Tendency to low mood and withdrawal from social interaction
  • Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.

Massage Therapists, Athletes, And Mental Health

In the athletic community we are inundated with ways to improve physical strength; endurance; nutritional intake; psychological advantage. We have done a tremendous job of ensuring the physical health of our athletes, which is critical to their performance and physical well being.

One area that has been overlooked for quite some time, however, is their mental wellbeing.

As a Psychotherapist, I have had the opportunity to work with young athletes both individually and in group settings. Through this work, it became very apparent that there exists a need for athletes to have a safe space to consider, explore and discuss their mental health.

It is time to enlighten the sporting community to the benefits of supporting athletes’ mental wellbeing. As helpers in this area, we have the power to do so.

The reality is that with the amount of pressure our athletes experience in managing their sport as well as their individual lives they are being asked to cope with a tremendous amount. Research has informed us that 63% of student athletes struggle with mental health but only 10% seek help…10%!

That means the majority of athletes struggling with their mental health are doing so on their own. There are many reasons this occurs but basically, we can sum it up with stigma. Seeking help has a bit of a stigma to it, doesn’t it? Especially for athletes who are supposed to be strong and mentally tough.

Consider this: While working with a group of 11-year-old rugby players we were enlightened to see their fear at the thought of dealing with mental illness. Now when 11-year-olds are concerned about the stigma surrounding mental health, imagine how that looks as we get older and society continues to paint it with a dark brush.

Ways To Recognize An Athlete Needs Help

As helpers, we need to be even more vigilant in supporting those dealing with mental illness.

We need to be open and non-judgemental. We need to encourage complete wellness in our athletes and support, rather than inadvertently shame, those who need us.

As Massage Therapists, you are trusted professionals to those who seek your help. I mean what other professionals do people allow to put their hands on them; move their bodies in different ways, all with complete faith that you will help their condition?

Basically what I am so eloquently saying is: you’re in! You are an ally. You are someone who has the opportunity to be a change agent.

Think for a moment what you talk about with some clients while working on them.

I have had the opportunity to work closely with amazing Massage Therapists. I have witnessed them explore the physical concerns being presented and beautifully ask questions about what happened: where the pain is; what causes the pain; and skilfully inquire.

I have also witnessed the creation of trust, relationships, and a general camaraderie that exists between two people investing in one another for even a short period of time. This creates an incredible opportunity for you to explore further.

Does your athlete appear to be:

  • Withdrawn
  • Unable to concentrate
  • Not getting things done
  • Overwhelmed
  • Irritable
  • Unhappy
  • Indecisive
  • Tired/sick/run down
  • Experiencing recurring injuries
  • Recovering from concussion

Plain and simple does something just seem off?

You are accustomed to working with athletes so trust yourself. If something seems off it likely is. You may be hearing or seeing something in an athlete you know that you do not usually see or hear; you may be hearing or seeing something in a new client that seems unusual. Again, trust that feeling and ask some questions.

This can be done in a variety of simple ways:

Be Aware…Notice Opportunity

  • An event in the media can provide an opening to discuss something you may suspect is relatable to your athlete.
  • An experience a teammate or someone in their sport is going through can provide a nice opening.
  • A question they may ask you can provide an excellent opportunity to further inquire.

Pay Attention

  • Know their preferred method of communication. This will allow you to notice when something is different.

Start the Conversation

  • Please help me understand more about…
  • Be Curious!!!

Photo by: lindahaynes13

Creating Support Systems

If you have the opportunity to connect with coaches or parents this can also provide you with clues that something is not okay with your athlete. Take the time to inquire about any noticeable changes in behaviour. In doing so you may inadvertently create a support system for the athlete that otherwise may not have existed. How incredible is that?

What you might hear from parents or coaches:

  • Perfectionist tendencies
  • Lack of confidence
  • Preoccupied with failure
  • Making poor choices
  • Not being themselves
  • Unable to rebound
  • Struggling to cope

Seems easy enough, right?! Don’t let this list scare you away and prevent you from going there. Some of you may have noticed these things in the past but were not sure where to put them or perhaps, upon reflection, you are thinking of specific athletes where something felt off.

Without fail we come across coaches and parents who may have identified a potential mental health concern but have cautiously sidestepped the questions for fear of what to do next.

Well, I am about to let you in a little therapy secret I will keep no longer…ready for it? Here it is… You do not have to have the answers. Seriously.

Simply asking questions and showing individuals that you are paying attention and are concerned about their wellbeing is an amazing start. How refreshing for an individual who may be struggling to hear you say “I don’t know”. There is one thing you must do, however (perhaps I should have told you there was a catch before the big secret reveal) if you are going to take the opportunity to inquire, you have to follow up. Let them know that while you may not know how to ‘fix’ things you are going to connect them with someone who can help.

Have the name of a psychotherapist or psychologist on hand; support them in reaching out; refer them out to an appropriate professional. Whatever you choose to do just be sure to be a positive social responder who does not ignore, who does not judge, and who allows them to maintain their dignity in this difficult time.


Understanding And Managing Groin Pulls

I felt a little tweak on the inside of my leg, but kept playing anyway.

It was the final game of the tournament that weekend, so I knew I just had to get through the last period.

As the game continued, the pain in my inner thigh was getting worse.

Each time I pushed off and my skate cut into the ice it felt like a shock going up into my groin.

As soon as the game was over, I pulled some ice out of the beer cooler, wrapped it up and put it on the inside of my leg. It helped a little, (or it could have been the beer) but I had never felt something like this before.

The next day I had a snowboard trip booked for a week.

By the time I got up to the chalet, I could barely lift my leg. Going up a flight of stairs was almost impossible.

Just getting up out of a chair was excruciating. I was basically limping for 5 days.

I have never pulled my groin before, but holy was this painful.

Contributing Factors To A Groin Pull

A groin pull is common among athletes, especially in sports where the athlete is required to change directions quickly or where explosive movement is part of the sport.

Hockey and soccer seem to be the sports where a groin strain/pull is most common with athletes, but are also found in fencing, handball, football, cross country skiing, hurdling and high jumping.

A groin strain can be graded into three classifications and can involve any one of the six adductor muscles

There has long been a belief that Janda’s lower cross syndrome played a major role in what contributed to groin strains in athletes. 

In fact I did a case study in college on a marathon runner experiencing hip pain and based a lot of the treatment on this syndrome. But in talking to many of my pain science friends, it appears that this syndrome is not as accurate as we once thought. 

However there are parts to it, which I believe plays a role in an athlete experiencing a groin strain (this is where my pain science friends will probably want to correct me).

Essentially the thought was a muscle imbalance, or strength imbalance between the gluts and adductors and the strength of the gluts was pulling on the adductors, thus causing a groin pull.

Some of the research back then was pointing to this being a specific cause in hockey players (most hockey players have big butts from skating) and this being a major contributor to groin pulls in these athletes, although I couldn’t find any current research to support that, so we’ll just leave it in the past for now.

However there is a strong indication that weak adductors are a major contributor to these injuries. 

One systematic review compared 17 studies and found limited evidence to support the theory of weak adductors but it was dependant on positioning. At 45° during a squeeze test there was strong evidence of adductor weakness. 

A study done on Australian Rules Footballers demonstrated that weak adductors could be a factor in groin injuries. Their adductor muscle strength was tested weekly. Of the seven players that suffered a groin injury (over a two season period), they all demonstrated decreased strength in hip adduction two weeks prior and the week of their injury.(1)

While this is a very small study, it helps to support weak adductors as a possible contributor to groin injuries. 

Some other studies have shown there to be several other risk factors involved. With hockey players there was a greater chance of having a groin strain if you had a previous injury to the same area and less likely to suffer the injury if they had practiced in the off season.

When it came to soccer players, previous injury was also a risk factor but so was limited hip abduction. Groin strains were most common during the action of kicking the ball.

Either way it seems that weak adductors can be one of the contributing factors to suffering a groin strain. 

I also think (and this is strictly opinion) the motion of skating is also a contributor as the legs are continually going into extension, external rotation and abduction placing a greater strain on the adductors, but again, just opinion.

It would also be interesting to see the significance between player positions, if I even tried doing what the goalie in the picture below is doing, I probably wouldn’t walk for a month. 


By Mike Salvucci (Flickr) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Treatment Of Groin Injuries

During the acute stage you are going to follow your R.I.C.E protocol and rest the area.

  • R – rest
  • I – ice
  • C – compression
  • E – elevate

As the healing progresses (keep in mind if walking is difficult the person may be on crutches) manual therapy and exercises can begin, in the acute stages the injury will be too painful (depending on grade) to do much in the way of hands on therapy.

The acute phase should be getting better in about five days. If there is no progress, they should be referred to their doctor to check for other possible injuries like osteitis pubis, myositis ossificans or nerve entrapment.

Once it settles down, then try and determine which muscles specifically are having the issue by doing some manual muscle tests, although it may be tough to determine as it could be a group of muscles, not just one.

There aren’t many research articles I could find that specify exact methods or provide a treatment outline.

One recommends using muscle energy techniques, but it was referring to the sacrum for an anterior rotated innominate because of a positive standing flexion test, but research has since shown us that doesn’t happen.(2)

Another one demonstrated placing tension on the muscle with one hand while the other hand is used to take the leg into abduction and external rotation while the knee is fully extended, for use with chronic injuries.(3)

With the management of strains once the pain of the acute phase is gone, doing some manual therapy along with pain free stretching is recommended. As we have seen, some strengthening is going to have to happen as well. Having the patient begin some strengthening (if it is within your scope of practice) will be crucial in getting over the injury. Doing some balance exercises, lunges or walking up and down stairs pain free are some easy ones to start with. One of our biggest goals is to prevent this from becoming a chronic injury. As we have seen in some of the research, once someone experiences a groin pull it is then easier to re-injure the area again. Although I haven’t pulled my groin since that hockey tournament, I will never forget how painful it was. If I had gone somewhere for manual therapy, there is no way I would have let someone work on it during that first five days. Fortunately it didn’t become a chronic issue. And even though some may disagree, I’m still going to work into my hockey players gluts if they pull their groin!


  1. Turk P. IS THERE A RELATIONSHIP BETWEEN HIP ADDUCTOR STRENGTH AND GROIN INJURIES IN AUSTRALIAN FOOTBALL LEAGUE FOOTBALLERS?. Journal Of Australian Strength & Conditioning [serial on the Internet]. (2016, Oct), [cited January 9, 2017]; 24(5): 21-28. Available from: SPORTDiscus with Full Text.
  2. Brumm L, Carrier D, Nogle S, Johnson S. Looking beyond the soft tissue: illustrative case studies of groin injuries. Athletic Therapy Today [serial on the Internet]. (2001, July), [cited January 9, 2017]; 6(4): 24-64. Available from: CINAHL Complete.
  3. Weir A, Veger S, Van de Sande H, Bakker E, de Jonge S, Tol J. A manual therapy technique for chronic adductor-related groin pain in athletes: a case series. Scandinavian Journal Of Medicine & Science In Sports [serial on the Internet]. (2009, Oct), [cited January 9, 2017]; 19(5): 616-620. Available from: SPORTDiscus with Full Text.

Is The Use Of Oxygen A Placebo?

Forgetting to use it could be the difference between passing and failing a Sport First Responder test.

It has a wide range of uses in an emergency care setting, especially when dealing with your athletes in an acute injury or emergency.

Using supplemental oxygen therapy has been a major part of Sport First Responder courses over the years with various reasons for application including:

  • Shock prevention
  • Cardiac Arrest
  • Anaphylaxis
  • Carbon Monoxide poisoning
  • Asthma

However recently I have been hearing rumblings, the use of oxygen may be on it’s way out as an intervention and I recently worked with a sport med doctor who doesn’t use oxygen and downplayed its effectiveness.

But this practice is so hard grained into us, that with pretty much every patient we see in an emergency setting, they get oxygen.

But do we really need it in all cases?

Why The Use Of Oxygen

The biggest reason oxygen is used in these emergency scenarios is to prevent hypoxemia, which is a decreased level of oxygen in the blood, which then leads to hypoxia (oxygen supply which is insufficient to support life).

However there is also a risk of using too much oxygen which results in hyperoxia (too much oxygen in the system), if oxygen therapy is not used properly it can lead to complications, which also depends on the condition your patient is dealing with.

It turns out that hypoxia (which is determined by using a pulse oximeter) is the only evidence based reason to give oxygen to a patient.

The other reasons are based on the assumption that it will help prevent hypoxia and relief of symptoms in an emergency setting.


I’m sure we all remember what shock is from our time in college, but there is more than one type of shock and we should all be familiar with the various types.

Medical shock is the type we are mainly worried about as opposed to emotional or psychological shock resulting from a traumatic experience or an emotional event.

When someone is suffering from or going into shock, the body is redirecting blood to service the internal organs and keep them alive, which is why you will often see the persons skin turn pale, cool and clammy.

The extremities are not getting the blood supply they’re used to.

But within the classification of “medical shock” there are further classifications of types of shock:

  • Anaphylactic
    • life threatening allergy to a substance
  • Caridiogenic
    • failure of the heart to pump sufficient blood to the body, usually occurs with cardiac arrest
  • Hypovolemic
    • lack of blood in the body
  • Neurogenic
    • failure of the nervous system to control the size of blood vessels causing dilation, common with head and spine injuries
  • Respiratory
    • the lungs fail to get sufficient oxygen into the bloodstream, common with breathing emergencies, respiratory arrest
  • Septic
    • intake of a poison causes blood vessels to dilate

Within the license of a Sport First Responder we would treat all of these types of shock the same way, by putting the patient on oxygen at a 10L flow along with keeping them warm.

In the case of someone having a heart attack (caridogenic shock) there are studies showing the use of oxygen in the first 12 hours may be unwarranted, however would still be appropriate for the sport first responder or until the patient reaches the hospital.

But in some cases with angina attack, oxygen can help with pain relief.

This is also because in the stressful environment of being a first responder, to determine exactly when it is appropriate to administer oxygen (signs of dyspnea or heart failure), so would more efficient to give it to everyone until arrival at hospital.

Common breathing emergencies like breathlessness or asthma should only be treated with oxygen if there is hypoxia present, this is one of those areas where we have always put oxygen on a patient .

In dealing with traumatic injuries that would typically cause hypovolemic shock a study showed that only half of adult trauma patients actually required the use of oxygen in pre-hospital care, yet it was still being administered to everyone.

When it comes to using oxygen therapy for shock it looks like a bit of a mixed bag as to when it’s appropriate to use it and when it is not.

However our Sport First Responder guidelines at this point still say that oxygen should be used to either help prevent or to deal with shock.


Photo by: Offutt Air Force Base

Photo by: Offutt Air Force Base

Strokes, COPD And Other Emergencies

I know these aren’t typically seen in the Sport First Responder setting but it’s still important information to know in case you ever have to deal with it.

Again, these are all instances where oxygen would always be put on a patient having an emergency.

New research is showing us that it may not be the best approach.

In patients having an acute COPD (Chronic Obstructive Pulmonary Disease) we have always been told that high flow oxygen is the method to treat the situation.

Studies have shown that using reduced flow oxygen actually decreased the risk of mortality by 58% (1) and leads to worse clinical outcomes. (2)

Using oxygen with someone who is suffering a stroke is also coming under skepticism even though it too has always been promoted as an acute therapy. I’ve used it on patients several times because of the recommendations.

But newer studies are saying that unless there is hypoxia present, the use of oxygen should be avoided (although it is also referring to the first 24 hours of hospitalization).

The same article points out that unless hypoxia is present with a pregnant woman or someone experiencing breathlessness, oxygen should be avoided.

However there is still hope for our friend Oxygen.

Someone with carbon monoxide poisoning should still be given Oxygen. It reduces the level of carbon monoxide in the blood in 40 min compared to 4-5 hours just breathing regular air. 

Even though studies have started to question the use of oxygen in emergency settings, it is still imperative to stick to your local guidelines when responding to an emergency with your athletes. Most of the studies outlined in this post were based on the reading of gas exchange in the bloodstream using a pulse oximeter. Your average Sport First Responder probably doesn’t have one of these in their kit, so it is ALWAYS better to err on the side of caution. Another caveat for the use of oxygen (that I have seen first hand at emergency scenes) is distracting your patient. Having a mask on that is delivering oxygen brings some comfort to a patient, especially with breathing emergencies. I’m not sure it could be considered a placebo effect, but it definitely helps to calm a patient down. The point of this post wasn’t to tell you not to use oxygen anymore, you most certainly should. It was more just to make you aware that there could be changes coming down the road and the next time you re-certify, things might be a little different. In the meantime continue using your O2 cylinders and keep those athletes safe.



1. Ntoumenopoulos G. Using titrated oxygen instead of high flow oxygen during an acute exacerbation of chronic obstructive pulmonary disease (COPD) saves lives. Journal Of Physiotherapy [serial on the Internet]. (2011), [cited September 12, 2016]; 57(1): 55. Available from: MEDLINE with Full Text.

2.Cameron L, Pilcher J, Weatherall M, Beasley R, Perrin K. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgraduate Medical Journal [serial on the Internet]. (2012, Dec), [cited September 12, 2016]; 88(1046): 684-689. Available from: CINAHL Complete.