Elsevier

The Lancet

Volume 353, Issue 9151, 6 February 1999, Pages 439-443
The Lancet

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

https://doi.org/10.1016/S0140-6736(98)03340-6Get rights and content

Summary

Background

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.

Methods

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.

Findings

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.

Interpretation

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.

Introduction

Groin pain is a problem for athletes in several sports. Among male soccer players the incidence of groin pain is 10–18% per year.1, 2, 3 Groin pain can be ascribed to various disorders, few of which are well defined. There is no consensus on definitions or diagnostic criteria. However, adductor-muscle pain is a frequent cause of groin pain4, 5 and is known to cause long-standing problems.4

The non-operative treatments of groin pain in athletes are not based on randomised clinical trials.6, 7, 8, 9, 10, 11 Most of the studies on operative treatment of groin injuries were retrospective,12, 13, 14, 15, 16, 17 and the few prospective studies were not randomised.18

In sports medicine various training programmes to treat overuse injuries in particular have been designed primarily on an empirical basis. However, the efficacy of training programmes for a few diagnostic entities such as functional instability of the ankle19 and low-back pain,20 has been documented in randomised clinical trials.

Muscular imbalance of the combined action of the muscles stabilising the hip joint could, from an anatomical point of view, be a causative factor of adductor-related groin pain.21 Muscular fatigue and overload might lead to impaired function of the muscle and increase the risk of injury. The adductor muscles act as important stabilisers of the hip joint.22 They are, therefore, exposed to overloading and risk of injury if the stabilisation of the hip joints is disturbed. Laboratory studies have shown that strengthening exercises could protect muscles from injury.23

The purpose of this randomised clinical trial was to compare an active training programme with a conventional physiotherapy programme in the treatment of severe and incapacitating adductor-related groin pain in athletes.

The treatment moralities were: a physiotherapy treatment without active training (PT) with elements of both passive and active therapy put together according to the contemporary practice among physicians and physiotherapists working in the field of sports injuries, and an active training programme (AT) aimed at improving the coordination and strength of the muscles stabilising the pelvis and hip joints, in particular the adductor muscles.

Section snippets

Study population

Potential participants were referred from physicians and physiotherapists. The study was also announced in journals and magazines for athletes and coaches, and on posters in sports-medicine clinics and sports facilities in Copenhagen. The ethics committee of Copenhagen County and the Danish Data Protection Agency approved the study.

Between January, 1991, and November, 1995, 177 patients were referred for interview and examination. 68 (38%) patients fulfilled the entry criteria and gave informed

Results

68 male athletes were included (figure). 59 patients completed the study. Nine patients withdrew before the study was completed, five from the AT group and four from the PT group. Baseline data for these patients did not differ from those for the 59 patients who completed the study. The reasons for withdrawal were: knee injury (one patient); immigration to Australia (one); loss to follow-up at 4 months (two); did not want the treatment they were assigned (two patients assigned AT); could not

Discussion

We found that treatment of long-standing adductorrelated groin pain with an active programme of specific exercises aimed at improving strength and coordination of the muscles acting on the pelvis was significantly better than a conventional physiotherapy programme. Moreover, 79% of the patients in the AT group had no residual groin pain at clinical examination and had returned to sport at the same level or an even higher level of activity without groin pain, compared with only 14% in the PT

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