Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

The effectiveness of the Copenhagen adduction exercise on improving eccentric hip adduction strength among soccer players with groin injury: a randomized controlled trial

INTRODUCTION

Groin injuries are common in soccer players and often involve adductor muscle strains. The Copenhagen Adduction Exercise (CAE) is a targeted intervention whose effectiveness in rehabilitation for these injuries warrants investigation.

OBJECTIVE

To investigate the impact of a rehabilitation program, which includes the CAE, on eccentric hip adduction (EHAD) strength, hip joint range of motion (ROM), self-reported disability, and pain among soccer players with adductor-related groin pain. It was hypothesized that the addition of CAE to the rehabilitation program would yield greater improvements.

METHODS

Employing a randomized controlled trial with a two-group parallel design, thirty male soccer players with a mean age of 26.4 ± 3.9 years were randomized into an intervention group (IG) including CAE (n = 15) and a control group (CG) without CAE (n = 15), based on a power analysis to ensure 80% power to detect significant differences. Both groups engaged in their respective rehabilitation programs twice a week for eight weeks. The primary outcome measured was EHAD strength, while secondary outcomes included hip joint ROM, self-reported disability measured by the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain levels.

RESULTS

Significant improvements within groups were observed across all measures (p < 0.001). The IG demonstrated a greater increase in EHAD strength (Mean Difference [MD] = 0.49 Nm/kg, 95% Confidence Interval [CI] [0.31, 0.66]), a more pronounced reduction in pain (MD = -1.60, 95% CI [-2.18, -1.02]), and betterment in all HAGOS subscale scores compared to the CG. There were no significant between-group differences in hip joint ROM.

CONCLUSION

Incorporating the CAE into rehabilitation programs significantly improves EHAD strength, decreases pain scores, and reduces self-reported disability in soccer players with adductor-related groin pain.

REGISTRATION

ClinicalTrials.gov identifier: NCT05589623.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Surgical approaches for core abdominal injuries: a review of the Abdominal Core Health Quality Collaborative database

INTRODUCTION

Core abdominal injury (CAI) is a broad term that describes injuries resulting from repetitive loading of the pubis that leads to inflammation, rupture, or destabilization of the core muscles from the pubic bone. There is no clear recommendation on the surgical approach to CAI. We aimed to describe how hernia surgeons within the Abdominal Core Health Quality Collaborative (ACHQC) address this problem surgically and the short-term outcomes.

METHODS

We queried the ACHQC registry for patients undergoing surgery for isolated CAI and concomitant inguinal hernias (IH) and CAI. Operative approach and quality of life (using EuraHS survey scores) was abstracted.

RESULTS

A total of 29,451 patients underwent surgery for IHs, CAIs, or both within the registry. Twenty patients underwent surgery for isolated CAI (median age 29, 90% males). Eleven patients (55%) underwent surgery with mesh (four Lichtenstein, three TAPP, and four TEP). Nine patients (45%) underwent tissue-based repairs (four closure of floor, one Bassini, one McVay, one Shouldice, one femoral exploration, and one laparoscopic-to-open conversion). There were no postoperative complications or reoperations within 30 days. EuraHS scores showed improvement at 30 days from baseline (median 29 [6.75-41.75] from 42 [29.42-57.61]). Sixty patients had both IHs and CAIs (median age 31, 97% males). All patients received mesh. Thirty-one patients (52%) underwent open surgery (23 Lichtenstein, 1 plug, 7 TREPP) and 29 underwent minimally invasive repairs (23 TAPP, 6 TEP). There was one seroma at 30 days. EuraHS scores showed improvement at 30 days from baseline (median 16 [5.17-27.33] from 37.5 [26.44-46.58]).

CONCLUSIONS

Despite technical variability, CAIs with or without concomitant IH generally undergo operations commonly used for IH repairs. Within our series, there was inconsistency with approach and mesh placement. Future work should be focused on standardizing the approach to CAI and capturing long-term data within the ACHQC.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

The effectiveness of non-surgical interventions in athletes with groin pain: a systematic review and meta-analysis

BACKGROUND

Groin pain is a common pathology among athletes, presenting pain and a reduced range of motion (ROM) as clinical characteristics. Passive physical therapy (PPT) and exercise therapy (ET) interventions are chosen firstly before surgery. The aim of this systematic review and meta-analysis was: (i) to qualitative review the effects of each non-surgical intervention; (ii) to quantitative compare the effects of PPTs plus ET intervention to ET in isolation in pain intensity, and hip ROM in athletes with groin pain.

METHODS

A systematic review and meta-analysis was conducted. Pubmed, PEDro, Web of science, Scopus and Cochrane library were searched. Randomized controlled trials comparing PPT plus ET to ET interventions were included. The methodological quality and risk of bias of the included studies, were assessed with the PEDro scale and the Cochrane risk-of-bias tool. To assess the certainty of evidence the GRADEpro GDT was used. Meta-analyses were conducted using RevMan 5.4 using mean difference analysis to assess the variables pain intensity and hip ROM.

RESULTS

A total of 175 studies was identified from the consulted databases. Five studies were included for systematic- review, from which three studies were meta-analyzed. The methodological quality of the included studies ranged from poor to high. ET compared to PPT plus ET provided statistically significant improvements in pain intensity in the short-term (MD = 2.45; 95% CI 1.11, 3.79; I² :65%). No statistically significant differences between interventions were obtained for hip ROM in the short-term.

CONCLUSIONS

The qualitative review showed that PPTs plus ET and ET seem to have positive effects on pain intensity and hip ROM. The quantitative analysis found very low certainty of evidence proposing a positive effect in pain intensity for ET interventions based on hip muscles stretching, compared to PPT combined with ET, in the short-term.

Current Clinical Concepts: Exercise and Load Management of Adductor Strains, Adductor Ruptures, and Long-Standing Adductor-Related Groin Pain

Adductor-related groin pain is a common problem in sports. Evidence-based management of athletes with adductor strains, adductor ruptures, and long-standing adductor-related groin pain can be approached in a simple yet effective and individualized manner. In most cases, managing adductor-related pain in athletes should be based on specific exercises and loading strategies. In this article, I provide an overview of the different types of adductor injuries, from acute to overuse, including their underlying pathology, functional anatomy, diagnosis, prognosis, mechanisms, and risk factors. This information leads to optimal assessment and management of acute to long-standing adductor-related problems and includes primary, secondary, and tertiary prevention strategies that focus on exercise and load-based strategies. In addition, information on different options and contexts for exercise selection and execution for athletes, athletic trainers, and sports physical therapists in adductor injury rehabilitation is provided.

Nonsurgical Interventions for the Management of Long-Standing Groin Pain in Athletes: A Systematic Review of Randomized Controlled Trials

Groin pain is a common problem in athletes, leading to significant distress and long periods of absence from sports. Nonsurgical interventions are usually the first line of treatment. However, the most effective intervention for groin pain is unknown and recommendations are scarce. The primary objective of this systematic review was to assess the effectiveness of nonsurgical interventions in the treatment of long-standing groin pain in athletes and to provide some guidance for clinical practice and further research. A search strategy was performed in March 2020 in Pubmed, Google Scholar, PEDro, and Cochrane Central Register of Controlled Trials databases, without any time restrictions. Only randomized controlled trials (RCT) were included for full-text analysis. Data on the patient's characteristics, duration of pain, study groups, outcome measures results, follow-up time, and return to play time were extracted. The risk of bias in each study was assessed using the Cochrane risk-of-bias assessment tool. Data for analysis could not be pooled for meta-analysis and, as such, a narrative summary of the outcomes was instead performed. The certainty of the evidence was assessed using a variation of the GRADE approach for when a meta-analysis is not possible to perform. Seven RCTs were included for analysis. Most studies were classified as uncertain risk of bias. All studies provided evidence that nonsurgical interventions have significant positive effects and may lead to good outcomes concerning pain, function, and return to sports at previous levels. The certainty of the evidence was assessed to be low using the modified GRADE approach. Despite the low quality of the available evidence, nonsurgical treatments demonstrated efficacy in the management of groin pain and should probably be the initial approach to treatment. More RCTs of high quality are necessary to provide clear recommendations on the most efficient nonsurgical treatment strategy for groin pain.

Reliability and validity of common hip adduction strength measures: The ForceFrame strength testing system versus the sphygmomanometer

OBJECTIVES

The criterion validity of the sphygmomanometer was evaluated, relative to the Force Frame strength testing system. Test-retest reliability was assessed for both hip adduction and abduction strength.

DESIGN

Test-retest reliability study and criterion validity study.

PARTICIPANTS

50 asymptomatic, field-sport athletes.

MAIN OUTCOME MEASURES

Maximal isometric hip adduction and abduction strength were measured. Interclass correlation coefficient(ICC_2,1) with confidence intervals were calculated to evaluate reliability of peak strength values. A Pearson product-moment correlation coefficient(r) was calculated to examine criterion validity of the sphygmomanometer as a measure of force when compared to the ForceFrame.

RESULTS

Intra-rater reliability for bilateral adduction testing using both ForceFrame and sphygmomanometer values revealed good-excellent reliability for both the 0° (ICC_2.1 = 0.87-0.90) and 45° (ICC_2.1 = 0.81-0.91) positions. ForceFrame values revealed good-excellent reliability for 0° abduction position and 45° abduction position. A good-moderate relationship (Pearson's r = 0.63) for 0° adduction position, and poor relationship (Pearson's r = 0.40) for 45° adduction position, were found between adduction squeeze values on ForceFrame and sphygmomanometer.

CONCLUSION

Excellent reliability in hip adduction squeeze strength testing for both modes. However, there exists a 'good to moderate'-'fair' relationship between the Force Frame and sphygmomanometer.

Return to sport after conservative versus surgical treatment for pubalgia in athletes: a systematic review

Background

To assess the time required to return to sport (RTS) after conservative versus surgical treatment in athletes for pubalgia.

Methods

The PRISMA guidelines were followed. Pubmed, SportDiscus and Web of Science were last accessed on September 2022. All the studies investigating the time to RTS after conservative versus surgical treatment in athletes for pubalgia.

Results

In total, 33 studies were selected for full text assessment, and 10 studies were included in the qualitative analysis. Seven studies reported data on conservative management, two on surgical management and one compared both. A total of 468 subjects were included for analysis. 58.7% (275 of 468) were soccer players, 5.9% (28 of 468) runners, and 3.8% (18 of 468) hockey players. Two studies did not specify the type of sport. The quality of the studies detailing the results of conservative management was higher than surgical procedures.

Conclusion

This review highlights that individuals undergoing surgery for pubalgia may return to sport earlier than those receiving conservative treatment. However, conservative management should be considered before surgical treatment is indicated.

Novel Use of Botulinum Toxin in Long-Standing Adductor-Related Groin Pain: A Case Series

BACKGROUND

Adductor-related groin pain (ARGP) is the most common groin injury in athletes. If conservative treatment fails, then adductor tenotomy to relieve tension can be considered. The use of botulinum toxin A (BoNT-A) has shown good results in other musculoskeletal pathologies.

OBJECTIVE

Assess the effectiveness of BoNT-A injections in ARGP in cases where usual treatment has failed.

DESIGN

Retrospective cohort study.

SETTING

Orthopedic Medicine and Rehabilitation Unit, University of Bordeaux.

PARTICIPANTS

Fifty patients treated by BoNT-A injection in ARGP after failure of medical and/or surgical treatment were included in this study.

INTERVENTIONS

One or several adductor muscles were injected with BoNT-A, according to clinical evaluation using ultrasound and electrical stimulation guidance. Patients were followed up at 1, 3, 6, and 12 months.

MAIN OUTCOME MEASURES

The primary assessment criterion was the improvement of Hip and Groin Outcome Score subscales at day 30. Secondary outcomes included pain intensity and impact on sport, work, and quality of life (QoL), the Blazina scale, and side effects.

RESULTS

All the first 50 injected patients (45 male and 5 female patients) were included. A significant improvement was noted regarding the majority of Hip and Groin Outcome Score subscales at day 30 ( P < 0.05). Pain intensity and its impacts were both significantly reduced ( P < 0.001): less sport and professional disability and lower impact on QoL. Severity of symptoms assessed by the Blazina scale was significantly reduced ( P < 0.001). The improvements remained significant until 1-year postinjection.

CONCLUSIONS

BoNT-A is promising as a new treatment for ARGP but should be fully assessed in a randomized controlled trial.

Frontal plane lower extremity alignment in adolescent athletes with chronic hip adductor-related groin injury symptoms: A case-control study

OBJECTIVE

To compare trunk and lower extremity frontal plane projection angles (FPPA) during single leg squat (SLS) performance, perceived hip and groin function and symptoms, and isometric hip strength of adolescent athletes with chronic hip adductor-related groin injury (HARGI) symptoms and age, gender, and sport-matched healthy subjects.

DESIGN

Case-control study.

SETTING

Junior Olympic Development Training Centre.

PARTICIPANTS

Twenty-six athletes at 59.1 ± 60 weeks (range = 12-208 weeks) post-index grade II HARGI injury who had continued sport training (injury group) and 26 control group subjects.

MAIN OUTCOME MEASURES

SLS trunk, hip, and knee FPPA, isometric hip strength standardized to bodyweight, and Copenhagen Hip and Groin Outcome Scores (HAGOS).

RESULTS

The injury group had greater bilateral knee FPPA, and greater injury side hip FPPA during maximum SLS. Injury group HAGOS subscale scores were lower than control group scores. Hip abductor, adductor, external rotator, and internal rotator strength was lower at the injury side of the injury group compared to the matched control group limb. Forward stepwise multiple regression analysis of the injury group found that 50% of injury side knee FPPA was predicted by hip internal rotator strength and time post-index HARGI; and 47% of injury side hip FPPA was predicted by other side hip flexor strength and the HAGOS function, sport and recreation subscale score (p = 0.002).

CONCLUSIONS

Greater injury side hip and bilateral knee FPPA during maximum SLS, lower self-reported hip symptom and function scores, and less injury side hip abductor, adductor, external rotator and internal rotator strength suggests that adolescent athletes with chronic HARGI symptoms are at an increased risk for sustaining a non-contact knee injury. Impaired hip internal rotator strength at the side of the chronic HARGI was related to increased knee FPPA, and impaired hip flexor strength at the other side of the HARGI was related to increased hip FPPA. Findings support using SLS performance testing in this athlete group to help determine safe return to sport training readiness.

Adductor Muscle Injuries in UEFA Soccer Athletes: A Matched-Cohort Analysis of Injury Rate, Return to Play, and Player Performance From 2000 to 2015

Background:

The effects of adductor muscle injury on performance in soccer athletes are unknown.

Purpose:

To (1) determine the rate and time to return to play (RTP) after adductor muscle injury, (2) investigate the rate of reinjury after RTP, and (3) investigate any long-term effects of injury on elite soccer player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, athletes sustaining adductor muscle injury were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2015. Injured athletes were matched to controls by demographic characteristics and performance metrics from 1 season before the index timepoint. Investigations included the rate of RTP, reinjuries, player characteristics associated with RTP within 2 seasons, player availability, field time, and performance metrics during the 4 seasons after injury.

Results:

A total of 671 players with adductor muscle injury were included. Based on time to RTP, 86% of injuries were mild to moderate (4-28 days missed), and 4% required surgical intervention. Players with adductor muscle injury were absent for a median of 22 days (range, 1-700 days) and 4 games (range, 1-76 games). A total of 521 (78%) players returned at the same level, with no demographic or clinical characteristics associated with RTP on the multivariable regression. Of those returning to play, 143 (21%) experienced adductor reinjury. After RTP, defenders demonstrated decreased field time compared with controls (P < .05). As compared with controls, defenders and midfielders scored more points and goals per game during the season of the injury (P < .01), while attackers recorded more goals and assists per game the season after injury (P < .05).

Conclusion:

Only 3 in 4 players (78%) returned to participate in an official match, and the reinjury rate was high (21%). After RTP, defenders demonstrated decreased field time versus controls. On the other hand, defenders and midfielders recorded more points and goals per game, while attackers recorded more goals and assists per game versus controls. Although the multivariable analysis results did not identify player characteristics associated with RTP, there was a position-dependent association on player performance after RTP.

The Pedicled Flap of Adductor Longus, a New Technique for Inguinal Reconstruction

Introduction: Reconstruction surgeries of the inguinal area pose a challenge for oncological and orthopedic surgeons, especially after radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both. Although numerous surgical procedures have been reported, there is no report about a pedicle adductor longus flap method. The aim of this work is to show our experience about inguinal reconstruction with pedicled adductor longus flap and associated outcomes. Patients and Methods: A retrospective study of 16 patients with localized inguinal region interventions and reconstructed by adductor longus flap from March 2016 to July 2020. Patients' average age was 60.0 years (range = 38-79 years) and had postoperative follow-up of 10 months (ranging 2-19 months). All patients had unilateral inguinal region involvement-seven cases on the left and nine cases on the right. The patients' clinical course, operative course, and postoperative follow-up data were evaluated. Results: All 16 patients recovered well post-operatively and did not require any re-intervention. Four patients experienced negligible discomfort around the groin area. Five patients experienced a minor strength deficit in thigh adduction compared with that of preoperative strength in the same or contralateral leg. The aforementioned complications resolved during the postoperative course and had no functional impact on their activity of daily living. All adductor longus flaps survived, completely filled the inguinal dead space, and wounds healed uneventfully within 3 weeks except for three patients who suffered delayed wound healing for more than 4 weeks. Other common complications such as infection, seroma, or wound dehiscence were not encountered in this series. Conclusion: The adductor longus flap is a reliable alternative method for inguinal region reconstruction following radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both.

Hip Muscle Strength Explains Only 11% of the Improvement in HAGOS With an Intersegmental Approach to Successful Rehabilitation of Athletic Groin Pain

BACKGROUND

Exercise-based rehabilitation targeting intersegmental control has high success rates and fast recovery times in the management of athletic groin pain (AGP). The influence of this approach on hip strength and lower limb reactive strength and how these measures compare with uninjured athletes (CON) remain unknown. Additionally, the efficacy of this program after return to play (RTP) has not been examined.

PURPOSE

First, to examine differences in isometric hip strength, reactive strength, and the Hip and Groin Outcome Score (HAGOS) between the AGP and CON cohorts and after rehabilitation; second, to examine the relationship between the change in HAGOS and the change in strength variables after rehabilitation; last, to track HAGOS for 6 months after RTP.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 42 athletes diagnosed with AGP and 36 matched controls completed baseline testing: isometric hip strength, lower limb reactive strength, and HAGOS. After rehabilitation, athletes with AGP were retested, and HAGOS was collected at 3 and 6 months after RTP.

RESULTS

In total, 36 athletes with AGP completed the program with an RTP time of 9.8 ± 3.0 weeks (mean ± SD). At baseline, these athletes had significantly lower isometric hip strength (abduction, adduction, flexion, extension, external rotation: d = -0.67 to -1.20), single-leg reactive strength (d = -0.73), and HAGOS (r = -0.74 to -0.89) as compared with the CON cohort. Hip strength (d = -0.83 to -1.15) and reactive strength (d = -0.30) improved with rehabilitation and were no longer significantly different between groups at RTP. HAGOS improvements were maintained or improved in athletes with AGP up to 6 months after RTP, although some subscales remained significantly lower than the CON group (r = -0.35 to -0.51). Two linear regression features (hip abduction and external rotation) explained 11% of the variance in the HAGOS Sports and Recreation subscale.

CONCLUSION

Athletes with AGP demonstrated isometric hip strength and reactive strength deficits that resolved after an intersegmental control rehabilitation program; however, improved hip strength explained only 11% of improvement in the Sports and Recreation subscale. HAGOS improvements after pain-free RTP were maintained at 6 months.

Stretching for Recovery from Groin Pain or Injury in Athletes: A Critical and Systematic Review

Stretching is usually used as part of rehabilitation protocols for groin pain or injury, but its specific contribution to and within multimodal recovery protocols is unclear. Our goal was to systematically review the effects of stretching for the recovery from groin pain or injury. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, with eligibility criteria defined according to PICOS: (Participants) athletes with groin pain or injuries; (Interventions) interventions with stretching as the differentiating factor; (Comparators) comparators not applying stretching; (Outcomes) symptom remission or improvement and/or time to return to sport and/or return to play; (Study design) randomized controlled trials. Searches were performed on 26 March 2021, in CINAHL, Cochrane Library, EBSCO, EMBASE, PEDro, PubMed, Scielo, Scopus, SPORTDiscus, and Web of Science, with no limitations regarding language or date, and no filters. Of 117 retrieved results, 65 were duplicates and 49 were excluded at the screening stage. The three articles eligible for full-text analysis failed to comply with one or more inclusion criteria (participants, intervention and/or comparators). We then went beyond the protocol and searched for non-randomized trials and case series, but no intervention was found where stretching was the differentiating factor. We found no trials specifically assessing the effects of stretching on recovery or improvement of groin pain or injury in athletes. Currently, the efficacy of these interventions is unknown, and more research is warranted.

Pubic and adductor related groin pain in an athlete: A case report linking pathology to conservative care

STUDY DESIGN

Case Report.

BACKGROUND

Groin pain in athletes is considered a common condition among males participating in sports that require sprinting, twisting, pivoting and kicking activities. While the condition is considered self-limiting, it often keeps athletes away from sport for a prolonged period of time. Much controversy exists regarding the pathogenesis of groin pain. This conflict translates to disagreement regarding diagnostic criteria, reporting and management strategies.

CASE PRESENTATION

a 28-year old recreational soccer player presented with a five-month history of groin pain that was resistant to passive care. With reference to the current conservative management literature, the athlete was progressed through an individualized multimodal program of care.

OUTCOMES

Following 10-weeks of care, the athlete was able to return to sport participation pain-free.

CONCLUSION

It is suggested that groin pain in athletes is likely multifactorial and therefore the management should reflect its multifactorial nature. Conservative therapy can evidently reduce the time to return to play however the benefits of incorporating plyometrics into the rehabilitation program should be investigated.

The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review

Longstanding (chronic) adductor-related groin pain syndrome is a widely common problem for athletes in many sports activities which often drastically reduces player activity and performance. The first choice in therapeutic treatment is conservative therapy. The objective of this study is to provide a systematic review regarding conservative treatment for longstanding adductor-related groin pain syndrome present in literature today. Furthermore, this study aims to give a critical vision of the current state of the art of the considered topic. After screening 234 articles, 19 studies following the inclusion criteria were included and summarized in this current systematic review and seven different types of therapeutic interventions were described. Compression clothing therapy, manual therapy together with strengthening exercise and prolotherapy were the therapeutic interventions which showed both the greatest level of strength of evidence (Moderate) and grade of recommendation (D). The remaining four types of therapeutic interventions i.e.: corticoid injection, platelet rich plasma therapy, intra-tissue percutaneous electrolysis and pulse-dose radiofrequency, showed both lower levels of strength of evidence (Conflicting) and grade of recommendation (C). In conclusion the literature available on the conservative treatment for longstanding adductor-related groin pain syndrome is limited and characterized by a low level of evidence. Therefore, our recommendation is to refer only to the few studies with higher level of evidence and at the same time to encourage further research in this area. The intervention showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy. Other therapeutic interventions such as intra-tissue percutaneous electrolysis and pulse-dose radiofrequency seem promising but require further studies to confirm their efficacy.

Surgical or conservative treatment in ARGP syndrome? A systematic review

Background and aim of the work: The rectus-adductor syndrome is a common cause of groin pain. In literature the adductor longus is reported as the most frequent site of injury so that the syndrome can be fitted into the adductor related groin pain (ARGP) group. The aim of this study was to define what is the best treatment between surgical and conservative in athletes affected by ARGP in terms of healing and return to play (RTP) time. Methods: A systematic review was performed searching for articles describing studies on RTP time for surgical or conservative interventions for ARGP. A qualitative synthesis was performed. Only 10 out 7607 articles were included in this systematic review. An exploratory meta-analysis was carried out. Due to high heterogeneity of the included studies, raw means of surgery and conservative treatment groups were pooled separately. A random effects model was used. Results: The results showed quicker RTP time for surgery when pooled raw means were compared to conservative treatments: 11,23 weeks (CI 95%, 8.18,14.28, p<0.0001, I^2=99%) vs 14,9 weeks (CI 95%, 13.05,16.76, p<0.0001, I^2 = 77%). The pooled results showed high statistical heterogeneity (I^2), especially in the surgical group. Conclusions: Surgical interventions are associated with quicker RTP time in athletes affected by ARGP, but due to the high heterogeneity of the available studies and the lack of dedicated RCTs this topic needs to be investigated with dedicated high quality RCT studies. (www.actabiomedica.it)

Current trends in sport and exercise hip conditions: Intra-articular and extra-articular hip pain, with detailed focus on femoroacetabular impingement (FAI) syndrome

Musculoskeletal conditions, such as hip pain are leading causes of pain and disability. Hip pain is the second most common cause of lower limb musculoskeletal pain, and is commonly seen in active individuals. Hip and groin pain may have intra-articular and extra-articular causes. Femoroacetabular impingement (FAI) syndrome and the associated pathologies are common intra-articular causes of hip and groin pain in active individuals. There are also a number of extra-articular causes of pain, which include musculotendinous conditions, extra-articular impingements and the clinical entities of groin pain described in the Doha agreement. This chapter will describe these, with a detailed focus on FAI syndrome. Specifically, it addresses: 1. What is and what causes FAI syndrome; 2. How do I diagnose FAI syndrome; and 3. What is the evidence-based approach to managing FAI syndrome?

Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia

Background

Sportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair.

Methods

A randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year.

Results

A total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70–80 to 10–20 in both groups (P &lt; 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408).

Conclusion

Totally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).

Exercise Interventions for the Prevention and Treatment of Groin Pain and Injury in Athletes: A Critical and Systematic Review

BACKGROUND

Groin injury is a common musculoskeletal complaint for athletes competing in a variety of sports. The extent to which exercise interventions incorporating external load are an appropriate option for the treatment and prevention of groin injury in athletes is not yet clear.

OBJECTIVES

The aim of this review was to describe and evaluate exercise therapy interventions and outcomes for the treatment and prevention of groin injury with specific attention to application of external load.

DATA SOURCES

The databases Medline, PubMed, SPORTDiscus, Web of Science, and Cochrane were searched on 18 April 2016.

STUDY ELIGIBILITY CRITERIA

This review was registered as PROSPERO CRD42016037752 and a systematic search was conducted with the following inclusion criteria: any study design evaluating exercise interventions for the prevention or treatment of groin pain in athletes.

DATA ANALYSIS

Two independent authors screened search results, performed data extraction, assessed risk of bias using the modified Downs and Black appraisal tool and determined strength and level of evidence. Reporting standards for exercise interventions were assessed using the Consensus for Exercise Reporting Template (CERT).

RESULTS

A total of 1320 titles were identified with 14 studies satisfying the inclusion criteria, four (29%) of which demonstrated low risk of bias. Ten (71%) studies utilised external load as a component of the exercise intervention. Reporting standards for exercise intervention scores ranged from 0 to 63%.

CONCLUSION

There is limited evidence from level 2 and 3 studies indicating exercise therapy may reduce the incidence and hazard risk of sustaining a groin injury in athletes. There is strong evidence from level 4 studies indicating exercise therapy is beneficial as a treatment for groin injury in athletes in terms of symptom remission, return to sport and recurrence outcomes. However, there are limited studies with low risk of bias, and exercise interventions for the treatment of groin injury are poorly described.

Groin pain in athletes and non-interventional rehabilitative treatment: a systematic review

INTRODUCTION

Groin pain is a common complaint both in high-performance and recreational athletes. Diagnosis is based on the patient's history and physical examination. Imaging assessments are often considered to exclude other pathologies. To date there is no strong evidence to support conservative or surgical treatment options. The purpose of this study is to shed light on the more effective non-interventional rehabilitative treatments for the management of groin pain in athletes and, if possible, provide guidelines useful for clinical practice.

EVIDENCE ACQUISITION

The following electronic databases were searched: PubMed, Physiotherapy Evidence Database (PEDro), Scopus, Web of Science, Google and Google Scholar. Databases were investigated from January 1997 until March 2017.

EVIDENCE SYNTHESIS

The results reported in the randomized clinical trial studies highlight that active treatment is better than passive treatment to improve clinical signs of groin pain. Comparing the active strategy with multi-modal treatment the latter allows a faster return to sport activity. Although the evidence remains poor, all the included literature highlights that an integrated strategy which combines active and passive treatment, the assessment of perceived pain, a return to running program and specific-sport exercises is an effective strategy for management of groin pain in athletes.

CONCLUSIONS

Although we shed some light on common key aspects able to improve the typical signs of groin pain, on the basis of available data we were unable to provide practice guidelines. Further studies are necessary to set the best treatment algorithm for the management of groin pain in athletes.

Effect of Holmich protocol exercise therapy on long-standing adductor-related groin pain in athletes: an objective evaluation

Aim

To objectively evaluate the effect of Holmich protocol-based exercise therapy on long-standing adductor-related groin pain (LSAGP).

Methods

We reproduced the Holmich protocol of exercise therapy and objectively evaluated its effect on 17 male athletes (mean age, 25.07±4.96 years) suffering from LSAGP, of whom 14 participants completed the 10 weeks treatment period. The study was designed as a single-blinded, before-and-after clinical trial. Main outcome measures included pain, functional ability, hip range of motion (ROM), hip abductor and adductor muscle strength, and successful return to sports activity.

Results

Eleven athletes (78.57%) returned to their sports activities in a mean time of 14.2 weeks (range, 10-20 weeks). Visual analogue scale pain score, hip abductor and adductor muscles strength, and function scores improved significantly. Although hip abduction ROM did not show any significant changes (p = 0.609), the extent of progress in the hip internal rotation ROM was significant (p = 0.001). The ratio of hip adduction to abduction strength did not change significantly (p = 0.309 for the isometric and p = 0.957 for the eccentric ratio).

Conclusions

Exercise therapy according to the Holmich programme may be an effective treatment for LSAGP. However, more emphasis should be paid to the hip adductor muscles' eccentric strength.

Trial registration number

IRCT2016080829269N1.

Movement Patterns and Muscular Function Before and After Onset of Sports-Related Groin Pain: A Systematic Review with Meta-analysis

Background

Sports-related groin pain (SRGP) is a common entity in rotational sports such as football, rugby and hockey, accounting for 12–18 % of injuries each year, with high recurrence rates and often prolonged time away from sport.

Objective

This systematic review synthesises movement and muscle function findings to better understand deficits and guide rehabilitation.

Study Selection

Prospective and retrospective cross-sectional studies investigating muscle strength, flexibility, cross-sectional area, electromyographic activation onset and magnitude in patients with SRGP were included.

Search Methods

Four databases (MEDLINE, Web of Knowledge, EBSCOhost and EMBASE) were searched in June 2014. Studies were critiqued using a modified version of the Downs and Black Quality Index, and a meta-analysis was performed.

Results

Seventeen studies (14 high quality, 3 low quality; 8 prospective and 9 retrospective) were identified. Prospective findings: moderate evidence indicated decreased hip abduction flexibility as a risk factor for SRGP. Limited or very limited evidence suggested that decreased hip adduction strength during isokinetic testing at ~119°/s was a risk factor for SRGP, but no associations were found at ~30°/s or ~210°/s, or with peak torque angle. Decreased hip abductor strength in angular velocity in ~30°/s but not in ~119°/s and ~210°/s was found as a risk factor for SRGP. No relationships were found with hip internal or external rotation range of movement, nor isokinetic knee extension strength. Decreased isokinetic knee flexion strength also was a potential risk factor for SRGP, at a speed ~60°/s. Retrospective findings: there was strong evidence of decreased hip adductor muscle strength during a squeeze test at 45°, and decreased total hip external rotation range of movement (sum of both legs) being associated with SRGP. There was strong evidence of no relationship to abductor muscle strength nor unilateral hip internal and external rotation range of movement. Moderate evidence suggested that increased abduction flexibility and no change in total hip internal rotation range of movement (sum of both legs) were retrospectively associated with SRGP. Limited or very limited evidence (significant findings only) indicated decreased hip adductor muscle strength during 0° and 30° squeeze tests and during an eccentric hip adduction test, but a decrease in the isometric adductors-to-abductors strength ratio at speed 120°/s; decreased abductors-to-adductors activation ratio in the early phase in the moving leg as well as in all three phases in the weight-bearing leg during standing hip flexion; and increased hip flexors strength during isokinetic and decrease in transversus abdominis muscle resting thickness associated with SRGP.

Conclusions

There were a number of significant movement and muscle function associations observed in athletes both prior to and following the onset of SRGP. The strength of findings was hampered by the lack of consistent terminology and diagnostic criteria, with there being clear guides for future research. Nonetheless, these findings should be considered in rehabilitation and prevention planning.

Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management

Synopsis Groin pain is common in athletes who participate in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there has been little agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade, the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance; and management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.

Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients

Background

Clinical assessments and rehabilitation in athletic groin pain (AGP) have focused on specific anatomical structures and uniplanar impairments rather than whole body movement.

Objective

To examine the effectiveness of rehabilitation that targeted intersegmental control in patients with AGP and to investigate post rehabilitation changes in cutting biomechanics.

Methods

Two hundred and five patients with AGP were rehabilitated focusing on clinical assessment of intersegmental control, linear running and change of direction mechanics in this prospective case series. Hip and Groin Outcome Score (HAGOS) was the primary outcome measure. Secondary measures included pain-free return to play rates and times, pain provocation on squeeze tests and three-dimensional (3D) biomechanical analysis during a 110° cutting manoeuvre.

Results

Following rehabilitation, patients demonstrated clinically relevant improvements in HAGOS scores (effect size (ES): 0.6–1.7). 73% of patients returned to play pain-free at a mean of 9.9 weeks (±3.5). Squeeze test values also improved (ES: 0.49–0.68). Repeat 3D analysis of the cutting movement demonstrated reductions in ipsilateral trunk side flexion (ES: 0.79) and increased pelvic rotation in the direction of travel (ES: 0.76). Changes to variables associated with improved cutting performance: greater centre of mass translation in the direction of travel relative to centre of pressure (ES: 0.4), reduced knee flexion angle (ES: 0.3) and increased ankle plantar flexor moment (ES: 0.48) were also noted.

Conclusions

Rehabilitation focused on intersegmental control was associated with improved HAGOS scores, high rates of pain-free return to sporting participation and biomechanical changes associated with improved cutting performance across a range of anatomical diagnoses seen in AGP.

The Effect of Therapeutic Exercise on Long-Standing Adductor-Related Groin Pain in Athletes: Modified Hölmich Protocol

Objective

The Hölmich protocol in therapeutic exercise is the most appropriate method for the treatment of long-standing adductor-related groin pain (LSAGP). Herein, we evaluated a modified Hölmich protocol to resolve the possible limitations intrinsic to the Hölmich protocol in terms of the rate of return to sport and the recovery period for athletes with LSAGP.

Design

The study followed a single-blind, before/after study design, where 15 athletes with LSAGP (mean age = 26.13 years; SD = 4.48) performed a 10-week modified Hölmich therapeutic exercise protocol.

Results

Outcome scores related to pain, hip adductor and abductor muscle strengths, and the ratio of maximum isometric and eccentric hip adduction to abduction strength increased significantly. Likewise, hip abduction and internal rotation ROM improved significantly compared to that at baseline. Furthermore, functional records (t-test, Edgren Side Step Test, and Triple Hop Test) showed significant improvement after treatment. Finally, 13 athletes (86.6% of the participants) successfully returned to sports activity in a mean time of 12.06 weeks (SD = 3.41).

Conclusion

The findings of this study objectively show that the modified Hölmich protocol may be safer and more effective than the Hölmich protocol in athletes with LSAGP in promoting their return to sports activity. This trial is registered with  IRCT2016080829269N1.

The effectiveness of manual physical therapy interventions in pediatric patients with anterior hip pain: a retrospective study

OBJECTIVES

The purposes of this study were to: (1) assess the benefit of adding manual therapy (MT) to physical therapy care in pediatric patients with anterior hip pain; (2) assess the relative risk of adverse reactions when MT is used; and (3) report the types of MT used.

METHODS

This study was a retrospective chart review of patients treated in a hospital-based sports medicine clinic. The charts of 201 patients (mean age = 14.23 ± 2.15 years) met the inclusion criteria and were reviewed. Patients were grouped into those who received MT during their episode of care, and those who did not. Pain efficiency (change in pain/number of visits), number and type of adverse reactions, as well as frequency and type of manual therapy interventions used, were the outcomes of interest.

RESULTS

The mean pain efficiency was significantly less if manual therapy was performed (MT = 0.60 [95% CI 0.47-0.72], no MT = 0.80 [95% CI 0.71-0.90] p = 0.01). There was no significant difference between groups in risk of adverse reactions (MT = 5, no MT = 5). The number of visits was significantly different between groups (MT = 9.43 ± 3.9 sessions, and no MT = 7.6 ± 5.2 sessions).

DISCUSSION

MT did not increase the risk of an adverse reaction in pediatric patients with anterior hip pain. While it appears to be a safe intervention, it did not improve pain efficiency or patient adherence. Future research should be performed to assess the effectiveness of MT, when performed by skilled therapists, in pediatric patients with hip pain in a controlled manner.Level of Evidence: 3b.

Spinal Manipulative Therapy and Sports Performance Enhancement: A Systematic Review

OBJECTIVE

The purpose of this study was to review the literature regarding the relationship between spinal manipulative therapy (SMT) and sports performance.

METHODS

PubMed and Embase databases were searched for original studies published up to July 2016. Inclusion criteria were if SMT has been applied to athletes and if any sports performance-related outcome was measured.

RESULTS

Of the 581 potential studies, 7 clinical trials were selected. Most studies had adequate quality (≥6/11) when assessed by the PEDro scale. None of those studies assessed performance at an event or competition. Four studies revealed improvement in a sports performance test after SMT. Meta-analysis could not be performed because of the wide differences in methodologies, design, and outcomes measured. Spinal manipulative therapy influences a wide range of neurophysiological parameters that could be associated with sports performance. Of the 3 studies where SMT did not improve test performance, 2 used SMT not for therapeutic correction of a dysfunctional vertebral joint but to an arbitrary previously set joint.

CONCLUSIONS

Although 4 of 7 studies showed that SMT improved sports performance tests, the evidence is still weak to support its use. Spinal manipulative therapy may be a promising approach for performance enhancement that should be investigated with more consistent methodologic designs.

Conservative management of tendinopathies around hip

BACKGROUND

The anatomy of hip is widely complex and several anatomical structures interact and contribute to its functioning. For position and role, hip and the surrounding tendons, which have their insertion around, are overstressed and often overloaded, especially in athletes. This could lead to the developing of several tendinopathies, among which the differential diagnosis is often complicated. Many conservative treatments are used in clinical practice, while actually, no defined conservative protocol is recommended.

METHODS

This is a review article. The aim of this manuscript is to evaluate the current evidences about the effectiveness of conservative management in hip tendinopathies.

CONCLUSION

Conservative treatment is effective in the management of hip tendinopathies and may be considered the first-line approach for patients affected. However, there is lack of evidences about which is the most effective treatment. Exercise therapy seems to provide long-term pain relief, but the literature is still lacking about the correct type, dose, posology, intensity of exercise prescribed. Further studies about different local approaches, as PRP or hyaluronic acid injections, may be encouraged.

LEVEL OF EVIDENCE

I.

Systematic review: laparoscopic treatment of long-standing groin pain in athletes

OBJECTIVES

No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes.

DATA SOURCES

The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations.

RESULTS

Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266).

CONCLUSIONS

Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.

Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients--clinical findings, MRI findings and patient-reported outcome measures at baseline

Background

Athletic groin pain remains a common field-based team sports time-loss injury. There are few reports of non-surgically managed cohorts with athletic groin pain.

Aim

To describe clinical presentation/examination, MRI findings and patient-reported outcome (PRO) scores for an athletic groin pain cohort.

Methods

All patients had a history including demographics, injury duration, sport played and standardised clinical examination. All patients underwent MRI and PRO score to assess recovery. A clinical diagnosis of the injured anatomical structure was made based on these findings. Statistical assessment of the reliability of accepted standard investigations undertaken in making an anatomical diagnosis was performed.

Result

382 consecutive athletic groin pain patients, all male, enrolled. Median time in pain at presentation was (IQR) 36 (16–75) weeks. Most (91%) played field-based ball-sports. Injury to the pubic aponeurosis (PA) 240 (62.8%) was the most common diagnosis. This was followed by injuries to the hip in 81 (21.2%) and adductors in 56 (14.7%) cases. The adductor squeeze test (90° hip flexion) was sensitive (85.4%) but not specific for the pubic aponeurosis and adductor pathology (negative likelihood ratio 1.95). Analysed in series, positive MRI findings and tenderness of the pubic aponeurosis had a 92.8% post-test probability.

Conclusions

In this largest cohort of patients with athletic groin pain combining clinical and MRI diagnostics there was a 63% prevalence of PA injury. The adductor squeeze test was sensitive for athletic groin pain, but not specific individual pathologies. MRI improved diagnostic post-test probability. No hernia or incipient hernia was diagnosed.

Clinical trial registration number

NCT02437942.

Activation of the hip adductor muscles varies during a simulated weight-bearing task

OBJECTIVE

To investigate the pattern of muscle activation of the individual hip adductor muscles using a standardised simulated unilateral weight-bearing task.

DESIGN

A repeated measures design.

SETTING

Laboratory.

PARTICIPANTS

20 healthy individuals (11 females, 9 males) participated in the study. Age ranged from 20 to 25 years.

MAIN OUTCOME MEASUREMENTS

Surface electromyography recordings from adductor magnus and adductor longus muscles were taken at levels representing 10-50% of body weight during a simulated weight-bearing task. Electromyography (EMG) data were normalised to maximal voluntary isometric contraction.

RESULTS

The adductor magnus was recruited at significantly higher levels than the adductor longus muscle during a simulated weight-bearing task performed across 10-50% of body weight (p < 0.01).

CONCLUSIONS

Adductor magnus and adductor longus muscles are recruited to different extents during a simulated weight-bearing task. This information should be considered when selecting exercises for management and prevention of groin strains. Closed chain exercises with weight-bearing through the lower limb are more likely to recruit the adductor magnus muscle over the adductor longus muscle.

Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes

Background

Groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the efficacy of these treatments is unknown.

Objective

Systematically review the literature on the efficacy of treatments for groin pain in athletes.

Methods

Nine medical databases were searched in May 2014. Inclusion criteria: treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n>10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and two authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Review registration number CRD42014010262.

Results

72 studies were included for quality analysis. Four studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman's hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p<0.001, r=−0.41), but not between study quality and publication year (p=0.09, r=0.20).

Conclusions

Only 6% of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. There is moderate evidence for the efficacy of conservative treatment (active exercises and multimodal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for efficacy of surgical treatment in sportsman's hernia.

The role of eccentric exercise in sport injuries rehabilitation

INTRODUCTION

Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field.

SOURCES OF DATA

A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'.

AREAS OF AGREEMENT

EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation.

AREA OF CONTROVERSY

The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries.

GROWING POINTS

The role of pathology and biomechanics in the response to EE should be further investigated.

AREAS TIMELY FOR DEVELOPING RESEARCH

New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.

A European survey on the aetiology, investigation and management of the "sportsman's groin"

INTRODUCTION

A sportsman's groin has no accepted definition or consensus on treatment. The aim of this study was to assess current opinion among a large body of European surgeons using an online survey.

METHODS

An online questionnaire comprising 16 multiple-choice questions was sent by email to general surgeons in Europe. The survey was live from the 6th to 30th September 2011.

RESULTS

In total 143 responses were received. One hundred and six respondents (74 %) expressed experience in managing this condition. The majority (91 %) managed <26 cases per year. Posterior wall weakness (53 %), pubic tendinitis (43 %), nerve entrapment (37 %) and conjoint tendon injury (36 %) were the commonest aetiological factors described. Preferred diagnostic investigations were ultrasound of the groin (44 %) and MRI of the pelvis (29 %). The most common initial treatment (91 % of respondents) was conservative measures (rest and analgesia) for a maximum of 6-month period. When surgery was undertaken, Lichtenstein repair (29 %), TEP (27 %), TAPP (20 %), and posterior wall repair (21 %) were the commonest procedures. The majority (95 %) of respondents would not offer bilateral surgery for those presenting with unilateral groin pain.

CONCLUSIONS

Most European surgeons see <26 cases of "sportsman's groin" per year, which is in keeping with the low incidence of this condition. There remains wide variation in its investigation and management, which reflects the differences in opinion on its aetiology. The majority of surgeons agree that surgery is not the only treatment option available, but there is little consensus on the optimal management.