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

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.

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.

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.

The cleft sign may be an independent factor of magnetic resonance imaging findings associated with a delayed return-to-play time in athletes with groin pain

PURPOSE

To investigate the prevalence of magnetic resonance imaging (MRI) findings and define prognostic factors of the return-to-play time in young athletes with groin pain.

METHODS

A total of 1091 consecutive athletes were retrospectively screened; 651 athletes, aged 16-40 years, with pain in the groin regions were assessed using MRI. Of these athletes, 356 were included for analysing the time to return-to-play. Univariate and multiple linear regression analyses were used to determine the associations between the time to return-to-play (primary outcome variable) and the following variables: age, sex, body mass index, type of sports, Hip Sports Activity Scale, clear trauma history, and 12 MRI findings.

RESULTS

Four MRI findings, including cleft sign, pubic bone marrow oedema of both the superior and inferior ramus, and central disc protrusion of the pubic symphysis, appeared together in more than 44% of the cases. The median time to return-to-play was 24.7 weeks for athletes with a cleft sign on MRI, which was significantly longer than the 11.9 weeks for athletes without the sign. The median time to return-to-play was 20.8 weeks for athletes with BMI > 24, which was significantly longer than the 13.6 weeks for athletes with BMI ≦ 24. In multiple linear regression analysis of 356 athletes, in whom hip-related groin pain was excluded, and who were followed-up until the return-to-play, the body mass index and cleft sign were the independent factors associated with a delayed return-to-play. In contrast, iliopsoas muscle strain and other muscle injuries were associated with a shorter return-to-play.

CONCLUSIONS

Multiple MRI findings were present in almost half of all cases. Body mass index and the cleft sign were independently associated with a delayed return-to-play time in young athletes suffering from groin pain.

LEVEL OF EVIDENCE

III.

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.