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. 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.

Changes in abdominal muscle thickness measured by ultrasound are not associated with recovery in athletes with longstanding groin pain associated with resisted hip adduction.

STUDY DESIGN: Longitudinal single-cohort study. BACKGROUND: Athletes with longstanding groin pain associated with resisted hip adduction have been shown to have abnormal activation of the transversus abdominis (TA). Therefore, exercises targeting the TA to help stabilize the lumbopelvic area are generally used in the rehabilitation of these athletes. OBJECTIVES: To investigate if (1) changes in abdominal muscle resting thickness and changes in relative thickness during lower extremity tasks after 14 weeks of intervention are related to changes in clinical status and (2) the changes in abdominal muscle resting/relative thickness are significant postintervention. METHODS: In 21 athletes with longstanding groin pain associated with resisted hip adduction, ultrasound imaging of the abdominal musculature on the right side was performed at rest, during the active straight-leg raise (left and right), and during bilateral isometric hip adduction. Athletes then followed a 14-week rehabilitation protocol. Clinical outcome measured by self-reported sports restriction and change in abdominal muscle resting and relative thickness during lower extremity tasks were evaluated. RESULTS: There was an overall significant decrease in self-reported sports restriction after intervention for this group of athletes. Apart from a significant negative correlation for changes in TA resting thickness, no significant association between changes in abdominal muscle thickness and change in self-reported sports restriction were found. Postintervention, TA resting thickness was significantly increased but relative thickness during the lower extremity tasks was found not to be statistically different for all muscles, except for a decreased relative thickness of obliquus externus abdominus (OE) during the active straight-leg raise for the left lower extremity. CONCLUSION: There was no association between changes in abdominal muscle resting thickness and relative thickness during lower extremity tasks, and change in self-reported sports restriction after a period of physical therapy in athletes with longstanding groin pain associated with resisted hip adduction. Although this study was designed as a single-cohort longitudinal study, the data suggest that the intervention described can change TA resting thickness. The intervention did not influence abdominal muscle relative thickness during lower extremity tasks.

Diagnostics in athletes with long-standing groin pain.

Chronic adductor dysfunction, osteitis pubis and abdominal wall deficiency are mentioned as pathologies explaining long-standing groin pain (LGP) in athletes. The main objective of this study was to evaluate the validity of diagnostic tests used to identify these pathologies in athletic OKE. Additionally, starting points for intervention were searched for. A systematic literature search was performed to retrieve all relevant diagnostic studies and studies describing risk factors. The methodological quality of the identified studies was evaluated. Seventeen studies provided an insight into pathologies; eight provided relevant information for intervention. Adduction provocation tests are moderately valid for osteitis pubis. A pelvic belt might provide some insight into the role of the pubic symphysis during adduction provocation. Palpation can be used for provocation of adductors and symphysis. Roentgen, bone scan and herniography show poor validity. Bilateral abdominal abnormalities on ultrasound appear to be a valid marker for LGP. Magnetic resonance imaging (MRI) can visualize edema and other abnormalities, although the relation to groin pain is not unambiguous. The methodological quality of the studies ranged from poor to good. MRI and ultrasound should be the primary diagnostic tools after clinical examination.

Treatment of longstanding groin pain in athletes: a systematic review.

The aims of this study were to determine (1) the kinds of treatments applied for longstanding groin pain (LGP) in athletes; (2) the results; and (3) the levels of evidence for the interventions. Digital databases P were searched for articles describing the effects of interventions for LGP in athletes. Treatment of LGP in athletes can consist of conservative measures such as rest or restricted activity, active or passive physical therapy, steroid injections or dextrose prolotherapy. Studies describing surgery generally mention failure of conservative measures, although a description of these conservative measures is mostly lacking. During surgery, a reinforcement of the abdominal wall is applied in most cases, using an open or laparoscopic approach. There is level I evidence that physical therapy aiming at strengthening and coordinating the muscles stabilizing hip and pelvis has superior results compared with passive physical therapy. For patients with a positive herniography and/or positive ilioinguinal or iliohypogastric nerve block tests, there are indications (level II) that surgery results in earlier return to sport compared with exercise therapy. Possibly, laparoscopic intervention might result in an earlier return to sport compared with open approach surgery (level III). For different clinical diagnoses, the same or similar surgical interventions were performed.