Original articleManual or exercise therapy for long-standing adductor-related groin pain: A randomised controlled clinical trial
Introduction
Groin pain is a frequent complaint in athletes. It occurs commonly in sports involving repeated sprinting, twisting, kicking and cutting such as soccer, rugby, Australian rules football and (ice-) hockey (Bradshaw and McCrory, 1997, Jansen et al., 2008b). In football groin injuries have been reported to account for about 10% of all injuries (Hawkins et al., 2001). Most of these injuries will recover quickly and in one study only three of 22 groin injured athletes still had complaints after three weeks (Arnason et al., 2004).
When groin pain does go on to be long-standing it can be hard to treat, with a relatively long period for return to full sports activity (Hölmich et al., 1999). Adductor-related groin pain has been reported to account for 58% of groin injuries in all sports and 69% of groin injuries in footballers (Hölmich, 2007).
Exercise therapy (ET) is recommended as the first line of treatment after a period of rest or restricted activity (Jansen et al., 2008a). In a recent systematic review (Machotka et al., 2009) on the effect of ET only one randomised controlled trial (Hölmich et al., 1999) was identified. Both reviews noted the lack of randomised controlled studies on the treatment of athletic groin injuries and recommended that more trials be performed in this area. The study of Hölmich et al. showed the value of ET (level 1 evidence) for athletes with long-standing adductor-related groin pain. 79% of athletes who underwent ET were able to resume sports at their pre-injury level. The median time to return to sport was 18.5 weeks (range 13–26). At present ET can be considered the therapy with the highest level of evidence (usual care) for the treatment of adductor-related groin pain.
The results of a multi-modal treatment program (MMT) using heat, Van Den Akker manual therapy method, stretching and a return to running program have been studied previously retrospectively (Weir et al., 2008). The study reported promising results with 27 of the 30 athletes (90%) being able to return to sporting activities after treatment. A weakness of the study was the retrospective design and the lack of a control group. The aim of the study was to compare the new therapy (MMT) to the current therapy with the highest level of evidence (ET (usual care)), for the treatment of long-standing adductor-related groin pain, in a single blinded prospective randomised clinical trial.
Section snippets
Subjects
Athletes were referred to the sports medicine department of a large district hospital by local physiotherapists, general practitioners and sports medicine physicians. All athletes were assessed for suitability to participate by a single sports physician, experienced in the field of athletic groin injuries, who used a structured examination protocol. The inclusion and exclusion criteria are shown in Table 1. Physical examination was used to assess for the presence of adductor pain and has been
Results
One hundred athletes were referred for inclusion. Forty six athletes were not suitable for inclusion (hip joint problem 12, primary iliopsoas pain 10, pain above the conjoined tendon 10, current lower back pain 8, unwilling to participate 6). There were 53 males and one female included in the study. Fig. 3 shows the allocation of the athletes in the study.
Thirty seven (69%) played soccer, three (6%) played rugby, three (6%) did distance running, three (6%) played field hockey, two (4%) were
Discussion
In this study the athletes (50%) who were successfully treated with the MMT were able to return to sporting activities more quickly (12.8 weeks) when compared to those treated with the ET (55%) program (17.3 weeks). There was no significant difference in the number of athletes able to return to sporting activities between the two treatment groups. The objective treatment outcome and pain scores during sporting activities did not differ between the two treatment groups.
The results of the MMT in
Conclusion
This single blinded randomised controlled clinical trial showed that the MMT was safe and equally effective treatment for athletes with long-standing adductor-related groin pain as an ET program. After 4 months both groups showed significant decrease of VAS pain scores during sport. The athletes in the MMT group who made a full return to sports did so significantly quicker than those who performed ET. Further studies should evaluate if a combination of all treatments would improve effectiveness
Acknowledgements
Many thanks to Aad Scheffer for making the balance boards for the exercise therapy group. Many thanks to Ton Kraan and Marcel Thomas for instructing the athletes in the exercise therapy group. Many thanks to Cora Van der Heijden, Ank de Vries and Pauline Verschoor for coordinating athletes through the study.
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