Long-standing Adductor-related Groin Pain Research Articles

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.

Exercise interventions on athletes with longstanding adductor-related groin pain: a critically appraised topic

Exercise interventions on athletes with longstanding adductor-related groin pain: a critically appraised topic

Return to Play in Long-Standing Adductor-Related Groin Pain: A Delphi Study Among Experts

BackgroundGroin pain is a very common injury in multidirectional sports such as soccer, ice hockey, rugby and Australian football. Long-standing adductor-related groin pain is a persistent clinical condition and a frequent complaint in athletes involved in sports that require multiplanar movement patterns (change of direction, high-speed sprinting and kicking). To date, the lack of rehabilitation guidelines and return-to-play criteria makes this clinical entity difficult to manage. The aim of the present Delphi was to suggest, based on opinion and practical experience of a panel of experts, potential criteria that could be taken into consideration by clinicians in the RTP decision-making process in athletes suffering from long-standing adductor-related groin pain.MethodsThirty two out of 40 experts participated to a 3-Round Delphi questionnaire. In round 1, open-ended and closed questions about 9 different sections (palpation, flexibility, strength, patient-reported outcome measures, imaging, intersegmental control, performance tests, sport-specific skills, training load) were proposed to investigate return to play evaluation criteria used by each expert. Responses were analysed and coded to produce round 2 questionnaire that investigated only the sections and the items that reached the cut-off value (≥ 70%). Round 3 questionnaire was based on sections and items that reached cut-off value in previous rounds and experts rated their agreement for return to play criteria with a 5-point Likert Scale. Descriptive statistics enabled interpretation of consensus.ResultsHigh participation rate (80%) and response rate across the 3 rounds (100%) were recorded. 6 sections reached positive consensus in round 1, 1 section reached negative consensus. In round 2 positive consensus was confirmed only for 3 sections and negative consensus for 1 section. In round 3, positive agreement was established for strength (3 items), performance tests (3 items) and sport-specific skills (2 items) sections. Negative consensus was confirmed for imaging section.ConclusionExperts agreed that strength, performance tests and sport-specific skills can be used to support RTP decision, while imaging cannot be used. These findings could be useful in assisting clinicians in the RTP decision making.

Evaluation of the bent knee fall out test pre- and post- an adductor longus tenotomy

ObjectiveTo investigate the immediate effect of an adductor longus tenotomy on the results of the bent knee fall out test, and whether there was a correlation between pre-tenotomy measures and the magnitude of change. DesignObservational study. MethodsWe included recreational to elite athletes with longstanding adductor-related groin pain (specifically adductor longus insertion pain) undergoing unilateral or bilateral full adductor longus tenotomy. The bent knee fall out test was performed immediately prior and immediately after the surgical procedure. We used Wilcoxon signed-rank test to compare test results pre- and post-tenotomy, and Spearman’s rho (rs) to analyse correlation between pre-tenotomy values and the magnitude of change in the bent knee fall out test. ResultsWe consecutively included 60 male adult athletes. There was a statistically significant difference (p < 0.001) in the bent knee fall out result from pre-surgery (median 11.5 cm [IQR 9–15], range 5–25 cm) to post-surgery (median 8 cm [IQR 6–10], range 3–15 cm). The mean difference was 3.9 ± 2 cm, range 0–11 cm, corresponding to a large effect size, d = 1.92. There was a moderate correlation between the bent knee fall out measurement pre-tenotomy and the difference from pre-to-post, rs = 0.75, p < 0.001. ConclusionThe bent knee fall out measurements changed considerably immediately after an adductor longus tenotomy, showing that the test is assessing adductor longus flexibility in male athletes with longstanding adductor-related groin pain. There was a moderate correlation between the bent knee fall out measure pre-tenotomy and the magnitude of change.

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.

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

AimTo objectively evaluate the effect of Holmich protocol-based exercise therapy on long-standing adductor-related groin pain (LSAGP).MethodsWe reproduced the Holmich protocol of exercise therapy and objectively evaluated its effect on 17...

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.

A new clinical test for measurement of lower limb specific range of motion in football players: Design, reliability and reference findings in non-injured players and those with long-standing adductor-related groin pain

ObjectiveThe association between groin pain and range of motion is poorly understood. The aim of this study was to develop a test to measure sport specific range of motion (SSROM) of the lower limb, to evaluate its reliability and describe findings in non-injured (NI) and injured football players. DesignCase-controlled. Setting6 Dutch elite clubs, 6 amateur clubs and a sports medicine practice. Participants103 NI elite and 83 NI amateurs and 57 football players with unilateral adductor-related groin pain. Main outcome measuresSport specific hip extension, adduction, abduction, internal and external rotation of both legs were examined with inclinometers. Test-retest reliability (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated. Non-injured players were compared with the injured group. ResultsIntra and inter tester ICCs were acceptable and ranged from 0.90 to 0.98 and 0.50–0.88. SEM ranged from 1.3 to 9.2° and MDC from 3.7 to 25.6° for single directions and total SSROM. Both non-injured elite and amateur players had very similar total SSROM in non-dominant and dominant legs (188–190, SD ± 25). Injured players had significant (p < 0.05) total SSROM deficits with 187(SD ± 31)° on the healthy and 135(SD ± 29)° on the injured side. ConclusionThe SSROM test shows acceptable reliability. Loss of SSROM is found on the injured side in football players with unilateral adductor-related groin pain. Whether this is the cause or effect of groin pain cannot be stated due to the study design. Whether restoration of SSROM in injured players leads to improved outcomes should be investigated in new studies.

A manual muscle manipulation and early return to sports in footballers with long-standing adductor-related groin pain; A prospective case series

A manual muscle manipulation and early return to sports in footballers with long-standing adductor-related groin pain; A prospective case series

Sports hernia and femoroacetabular impingement in athletes: A systematic review

To investigate the association between sports hernias and femoroacetabular impingement (FAI) in athletes. PubMed, MEDLINE, CINAHL, Embase, Cochrane Controlled Trials Register, and Google Scholar databases were electronically searched for articles relating to sports hernia, athletic pubalgia, groin pain, long-standing adductor-related groin pain, Gilmore groin, adductor pain syndrome, and FAI. The initial search identified 196 studies, of which only articles reporting on the association of sports hernia and FAI or laparoscopic treatment of sports hernia were selected for systematic review. Finally, 24 studies were reviewed to evaluate the prevalence of FAI in cases of sports hernia and examine treatment outcomes and evidence for a common underlying pathogenic mechanism. FAI has been reported in as few as 12% to as high as 94% of patients with sports hernias, athletic pubalgia or adductor-related groin pain. Cam-type impingement is proposed to lead to increased symphyseal motion with overload on the surrounding extra-articular structures and muscle, which can result in the development of sports hernia and athletic pubalgia. Laparoscopic repair of sports hernias, via either the transabdominal preperitoneal or extraperitoneal approach, has a high success rate and earlier recovery of full sports activity compared to open surgery or conservative treatment. For patients with FAI and sports hernia, the surgical management of both pathologies is more effective than sports pubalgia treatment or hip arthroscopy alone (89% vs 33% of cases). As sports hernias and FAI are typically treated by general and orthopedic surgeons, respectively, a multidisciplinary approach for diagnosis and treatment is recommended for optimal treatment of patients with these injuries. The restriction in range of motion due to FAI likely contributes to sports hernias; therefore, surgical treatment of both pathologies represents an optimal therapy.

MRI findings in soccer players with long-standing adductor-related groin pain and asymptomatic controls

BackgroundSoccer players are commonly affected by long-standing adductor-related groin pain (ARGP), but the clinical significance of MRI findings in these athletes is largely unknown. Our aims were (1) to evaluate...

Paper 149: Ten Years Follow Up of Longstanding Adductor-related Groin Pain in Athletes

Paper 149: Ten Years Follow Up of Longstanding Adductor-related Groin Pain in Athletes

Continued Significant Effect of Physical Training as Treatment for Overuse Injury

Background: The treatment of exercise-related injuries is often a problem, and recurrent injuries are common. Two recent systematic reviews found only one high-quality paper on the treatment of long-standing groin pain. In this randomized clinical trial, a training program including strength training resulted in a return of 79% of the athletes to the previous level of sport without any groin pain. The long-term effect of this exercise program was evaluated. Hypothesis: The effect of the exercise program for adductor-related groin pain is long lasting. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Forty-seven (80%) of the 59 original participants of the study agreed to participate in this 8- to 12-year follow-up. They were all interviewed and examined using a standardized and reproducible protocol, identical to the one used in the original trial. The investigating physician (P.N.) was not involved in the original study and was unaware of the original treatment allocation. Results: A significant effect of the active training treatment still existed for the whole group (P = .047) and even more for the subgroup of 39 (83%) soccer players (P = .012). No significant differences were found regarding age, present sports activity, reasons for activity reduction, or time to follow-up. Conclusion: The beneficial short-term effect of the exercise program used in the primary randomized clinical trial for treating long-standing adductor-related groin pain in athletes was found to be lasting, both for the whole group and even more for the large subgroup of soccer players. This is the first time an exercise treatment for overuse injuries to the musculoskeletal system has been shown to have a long-lasting effect (8-12 years).

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

Hypothesis A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain. Study design Single blinded, prospective, randomised controlled trial. Methods Patients: Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months. Interventions: ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program. Primary outcome: time to return to full sports participation. Secondary outcome measures: objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks. Results Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p = 0.043). Only 50–55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome ( p = 0.72) or VAS during sports ( p = 0.12). Conclusions The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective.

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

Objective To evaluate short and mid-term results of active physical therapy in athletes with longstanding groin pain. Design Case series. Setting Primary care physical therapy practice. Participants A total of 44 athletes suffering longstanding adductor-related groin pain. Intervention A combination of passive (joint mobilization) and active (exercises) physical therapy interventions. Main outcome measurements Return to (the same level of) sports, restriction in sports, and recurrence. Results Directly after treatment, return to the same level and type of sport was successful in 38 athletes (86%), and without symptoms in 34 athletes (77%). At 6.5–51 months follow up, 10/38 (26%) of those that returned to sports had experienced a relapse; 22 (50%) athletes were able to participate in sports without any restrictions at the mid-term follow-up. Conclusions For athletes with longstanding groin pain, short term results of physical therapy seem positive, whereas mid-term results are moderately positive. The risk for recurrence is high.

Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain

ObjectiveA decreased range of motion (ROM) of the hip joint is known to predispose to athletic groin injury. Femoroacetabular impingement (FAI) of the hip leads to a reduced ROM. This...

Active Physical Training for Long-Standing Adductor-Related Groin Pain

Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomized trial. Lancet 1999; 353:439–443.

Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial

Groin pain is common among athletes. A major cause of long-standing problems is adductor-related groin pain. The purpose of this randomised clinical trial was to compare an active training programme (AT) with a physiotherapy treatment without active training (PT) in the treatment of adductor-related groin pain in athletes. 68 athletes with long-standing (median 40 weeks) adductor-related groin pain--after examination according to a standardised protocol--were randomly assigned to AT or PT. The treatment period was 8-12 weeks. 4 months after the end of treatment a standardised examination was done. The examining physician was unaware of the treatment allocation. The ultimate outcome measure was full return to sports at the same level without groin pain. Analyses were by intention to treat. 23 patients in the AT group and four in the PT group returned to sports without groin pain (odds ratio, multiple-logistic-regression analysis, 12.7 [95% CI 3.4-47.2]). The subjective global assessments of the effect of the treatments showed a significant (p=0.006) linear trend towards a better effect in the AT group. A per-protocol analysis did not show appreciably different results. AT with a programme aimed at improving strength and coordination of the muscles acting on the pelvis, in particular the adductor muscles, is very effective in the treatment of athletes with long-standing adductor-related groin pain. The potential preventive value of a short programme based upon the principles of AT should be assessed in future, randomised, clinical trials.