Short and mid-term results of a comprehensive treatment program for longstanding adductor-related groin pain in athletes: a case series

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.

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.

A Prospective, Randomized, Controlled Trial Comparing Conservative Treatment With Trunk Stabilization Exercise to Standard Hip Muscle Exercise for Treating Femoroacetabular Impingement: A Pilot Study

OBJECTIVE

To assess the efficacy of conservative management of women with femoroacetabular impingement (FAI) using trunk stabilization.

DESIGN

Randomized controlled trial (level of evidence: I).

SUBJECTS

Twenty FAI female patients who met the inclusion FAI criteria.

METHODS

A prospective, randomized, controlled study was performed on 20 female patients with symptomatic FAI comprising 2 groups (10 hips in trunk stabilization exercise group vs 10 hips in control group). We evaluated hip range of motion, isometric muscle strength using a handheld dynamometer (μ-TasMF-01; Anima, Co), and patient-reported outcome measures, including modified Harris hip score, Vail hip score, and international hip outcome tool 12 (iHOT12) before and at 4 weeks and 8 weeks after the intervention.

RESULTS

There was a significant improvement in the range of motion of hip flexion in the trunk training group detected as early as 4 weeks after the intervention compared with the control group (P < 0.05). Hip abductor strength significantly improved in the trunk training group at 4 weeks after the intervention, whereas it did not improve in the control group (P < 0.05). Vail hip score and iHOT12 were significantly increased at 8 weeks after the intervention in the trunk training group compared with the control group (iHOT12: 78.7 ± 22.4 vs 53.0 ± 22.3; P < 0.01, Vail hip score: 81.6 ± 18.5 vs 61.1 ± 11.6; P < 0.05). There was no significant difference in the modified Harris hip score between both the groups at 4 and 8 weeks after the intervention.

CONCLUSIONS

The addition of trunk stabilization exercise to a typical hip rehabilitation protocol improves short-term clinical outcomes and may augment nonoperative and postoperative rehabilitation.

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.

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.

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.

Incidence and clinical presentation of groin injuries in sub-elite male soccer

BACKGROUND

Groin injuries cause major problems in the football codes, as they are prevalent and lead to prolonged symptoms and high recurrence. The aim of the present study was to describe the occurrence and clinical presentation of groin injuries in a large cohort of sub-elite soccer players during a season.

METHODS

Physiotherapists allocated to each of the participating 44 soccer clubs recorded baseline characteristics and groin injuries sustained by a cohort of 998 sub-elite male soccer players during a full 10-month season. All players with groin injuries were examined using the clinical entity approach, which utilises standardised reproducible examination techniques to identify the injured anatomical structures. The exposure time and the injury time were also recorded. Injury time was analysed using multiple regression on the log of the injury times as the data were highly skewed. Effects are thus reported at relative injury time (RIT).

RESULTS

Adductor-related groin injury was the most common entity found followed by iliopsoas-related and abdominal-related injuries. The dominant leg was significantly more often injured. Age and previous groin injury were significant risk factors for sustaining a groin injury. Groin injuries were generally located on the same side as previously reported groin injuries. Adductor-related injuries with no abdominal pain had significantly longer injury times compared to injuries with no adductor and no abdominal pain (RIT 2.28, 95% CI 1.22 to 4.25, p=0.0096). Having both adductor and abdominal pain also increased the injury time significantly when compared to injuries with no adductor and no abdominal pain (RIT=4.56, 95% CI 1.91 to 10.91, p=0.001).

CONCLUSION

Adductor-related groin injury was the most common clinical presentation of groin injuries in male soccer players and the cause of long injury time, especially when combined with abdominal-related injury.

Conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain

BACKGROUND

Musculoskeletal, ligamentous and osseous groin injuries are common in athletes and may result in a delay of several months to resume sports. Even then, this may not be at the former level of sport activity. The treatment of exercise-related groin pain is mainly conservative (non-surgical), using interventions such as exercises, electrotherapy, manual therapy and steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); MEDLINE (1948 to November week 3 2011); EMBASE (1980 to Week 49 2011); CINAHL (1982 to December 2011); LILACS (1982 to December 2011); PEDro (1929 to December 2011), SPORTDiscus (1985 to December 2011), OTseeker (to December 2011), reference lists of papers and conference proceedings (2000 to 2011).

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized controlled trials evaluating conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain were included. Studies comparing conservative with surgical treatments were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and conducted risk of bias assessments. There was no pooling of data.

MAIN RESULTS

Two studies, involving a total of 122 participants who had experienced adductor-related groin pain for at least two months, were included in this review. All but one of the participants were male athletes aged between 18 and 50 years old. Both studies were assessed as 'high risk of bias' for at least one source of bias domain. The 'successful treatment' outcome reported in both studies was based primarily on pain measures.One study, based on an intention-to-treat analysis, found a significant difference favouring exercise therapy (strengthening with an emphasis on the adductor and abdominal muscles and training muscular co-ordination) compared with 'conventional' physiotherapy (stretching exercises, electrotherapy and transverse friction massage) in successful treatment at 16-week follow-up (25/34 (74%) versus 10/34 (29%); risk ratio (RR) 2.50, 95% CI 1.43 to 4.37, P = 0.001). Similarly, of those followed-up significantly more athletes treated by exercise therapy returned to sport at the same level (23/29 (79%) versus 4/30 (13%); RR 5.95, 95% CI 2.34 to 15.09, P = 0.0002). Although still favouring the exercise group, the differences between the two groups in patients' subjective global assessment at 16 weeks and successful treatment at 8 to 12 years follow-up were not statistically significant.The second study (54 participants) found no significant differences at 16-week follow-up between a multi-modal treatment (heat, manual therapy and stretching) and exercise therapy (the same intervention as in the above study) for the outcomes of successful treatment (14/26 (54%) versus 12/22 (55%); RR 0.99, 95% CI 0.59 to 1.66, P = 0.96) and return to full sports participation (13/26 (50%) versus 12/22 (55%); RR 0.92, 95% CI 0.53 to 1.58, P = 0.75). Those returning to full sports participation returned on average 4.5 weeks earlier after receiving multi-modal therapy (mean difference -4.50 weeks, 95% CI -8.60 to -0.40, P = 0.03) than those in the exercise therapy group. This study reported that there were no complications or side effects found in either intervention group.

AUTHORS' CONCLUSIONS

The available evidence from the randomized trials is insufficient to advise on any specific conservative modality for treating exercise-related groin pain. While still low quality, the best evidence is from one trial which found that exercise therapy (strengthening of hip and abdominal muscles) in athletes improves short-term outcomes (based primarily on pain measures) and return to sports compared with physiotherapy consisting of passive modalities. Given the low quality of the available evidence from both included trials, further randomized trials are necessary to reinforce their findings.