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

  1. Matheus O Almeida1,*,
  2. Brenda NG Silva1,
  3. Régis B Andriolo2,
  4. Álvaro N Atallah1,
  5. Maria S Peccin3

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 6 JUN 2013

Assessed as up-to-date: 12 MAR 2012

DOI: 10.1002/14651858.CD009565.pub2


How to Cite

Almeida MO, Silva BNG, Andriolo RB, Atallah ÁN, Peccin MS. Conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD009565. DOI: 10.1002/14651858.CD009565.pub2.

Author Information

  1. 1

    Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde, Brazilian Cochrane Centre, São Paulo, São Paulo, Brazil

  2. 2

    Universidade do Estado do Pará, Department of Public Health, Belém, Pará, Brazil

  3. 3

    Universidade Federal de São Paulo, Department of Human Movement Sciences, Santos, São Paulo, Brazil

*Matheus O Almeida, Brazilian Cochrane Centre, Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica em Saúde, R Borges Lagoa, 564 cj 63, Vila Clementino, São Paulo, São Paulo, 04038000, Brazil. mathewsalmeida@hotmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 6 JUN 2013

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Characteristics of included studies [ordered by study ID]
Hölmich 1999

MethodsStudy design: single-blinded randomized controlled trial

Setting: Clinic of Sports Medicine, Department of Orthopaedic Surgery, Amager University Hospital, Copenhagen, Denmark


Participants
  • N = 68 (exercise therapy group, n = 34; physiotherapy without active training group, n = 34)
  • Athletes
  • Age range: 18 to 50 years
  • Gender: males
  • Groin pain at least 2 months
  • Desire to continue sports at the same level of competition as before the injury
  • Pain at palpation of the adductor tendons or the insertion on the pubic bone, and during active adduction against resistance


Interventions1. Exercise therapy (AT): 8 to 12 weeks; 3 times a week

Module 1: first 2 weeks

- Static adduction against soccer ball placed between feet when lying supine (10 rep. of 30s, each)

- Static adduction against soccer ball placed between knees when lying supine (10 rep. of 30s, each)

- Abdominal sit-ups both in straightforward direction and in oblique direction (5 series of 10 rep.)

- Combined abdominal sit-ups and hip flexion, starting from supine position and with soccer ball between knees (5 series of 10 rep.)

- Balance training on wobble board (5 min)

- One-foot exercises on sliding board, with parallel feet as well as with 90 angle between feet (5 sets of 1 min continuous work with each leg and in both positions)

 

Module 2: 2 to 6 weeks

- Leg abduction and adduction exercises performed in side lying (5 series of 10 rep. of each exercise - twice)

- Low-back extension exercises prone over end of couch (5 series of 10 rep. – twice)

- One-leg weight pulling abduction/adduction standing (5 series of 10 rep. for each leg – twice)

- Abdominal sit-ups both in straightforward direction and in oblique direction (5 series of 10 rep. – twice)

- One-leg coordination exercise with flexing and extending knee and swinging arms in same rhythm (5 series of 10 rep. for each leg – twice)

- Training in sideways motion on mini-skateboard (5 min)

- Balance training on wobble board (5 min)

- Skating movements on sliding board (5 sets of 1 min continuous work)

2. Conventional physiotherapy (PT): 8 to 12 weeks; twice a week

- Laser treatment with a gallium aluminium arsen laser. All painful points of the adductor-tendon insertion at the pubic bone received treatment for 1 min, receiving 0·9 mJ per treated point. The probe was in contact with the skin at 90° angle. The laser was fitted with an 830 nm (±0·5 nm) 30 mW, diode beam divergence was 4° and area of probe head was 2·5 mm2

- Transverse friction massage for 10 min on painful area of adductor-tendon insertion into pubic bone

- Stretching of adductor muscles, hamstring muscles, and hip flexors. The contract-relax technique was used. The stretching was repeated three times and the duration of each stretch was 30 s

- Transcutaneous electrical nerve stimulation was given for 30 min at painful area. The apparatus used was a Biometer, Elpha 500, frequency 100 Hz and a pulse width of one and a maximum of 15 mA (100% effect)

Treatment was given or instructed by physiotherapists and in both groups a return to running program was done after 6 weeks.


Outcomes
  • Successful treatment


- No pain at palpation of the adductors tendon or during resisted adduction

- No pain in connection with or after athletic activity in the same sport and at the same level of competition

- Return to sports at the same level without groin pain

If all three measures above were reached, the result was labelled excellent, if two measures were reached, the result was good, if one measure was reached, the result was fair and if no measures were reached, the result was poor.

  • Patients' subjective global assessment
  • Return to sports at the same level without pain


Outcomes were evaluated at 16 weeks and long-term (8 to 12 years) follow-up.


Notes- The participants from AT group were treated in groups with two to four patients, while in PT group the treatment was individual

- A longer- term follow-up of Hölmich 1999 (8 to 12 years from the original study) was included (Hölmich 2011)

- Percentage of lost participants (follow-up of 16 weeks): 13% (9/68); 5 losses from AT group and 4 from PT group

- Reasons for withdrawn (follow-up of 16 weeks): 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 get sufficient time off from work to complete the study (three)

- Percentage of lost participants (follow-up of 8 to 12 years): 31% (21/68); 10 losses from AT group and 11 from PT group

- Reasons for withdrawal (follow-up of 8 to 12 years): 5 individuals could not be located; 4 because of lack of current address 1 because of emigration; 5 were not interested primarily because they would have to take time off work to attend the examination, and 2 could not participate because they had suffered serious disability due to an accident not related to their groin problem


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Patients were randomly allocated by sealed, opaque, and serially numbered envelope to AT or PT group by means of block randomisation (block size four)"

Allocation concealment (selection bias)Low riskQuote: "Patients were randomly allocated by sealed, opaque, and serially numbered envelope to AT or PT group by means of block randomisation (block size four)"

Quote: "The examining physician was not involved in the randomisation procedure and remained unaware of the treatment allocation"

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and physiotherapists could not be blinded to allocation treatment

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskWhile the examining physician was not involved in the randomization procedure and remained unaware of the treatment allocation, there were subjective outcomes (successful treatment and patients' subjective global assessment) assessed by the trial participants, who were not blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskWhile the study participant flow was clear and the missing data were balanced across groups, with reasons for missing data provided, the characteristics of lost participants were not described.

The analyses were not entirely 'intention to treat', nor were sensitivity analyses to address decisions regarding handling missing data.

Quote: "The subjective global assessment of the effect of treatment in the two groups based solely on results from patients completing the study (per-protocol analysis)"

Selective reporting (reporting bias)Unclear riskFunction (an important primary outcome) was not evaluated. No protocol available.

Other biasHigh riskThere was no explicit information about supplementary treatment and physical activity of participants during the follow-up period (8 to 12 years).

Weir 2011

MethodsStudy design: single-blinded randomized controlled trial

Setting: The Hague Medical Centre, Antoniushove hospital, Department of Sports Medicine. Leidschendam, the Netherlands


Participants
  • N = 54 (exercise therapy group, n = 25; multi-modal treatment group, n = 29)
  • Athletes
  • Age range: 18 to 50 years
  • Gender: 53 male/1 female
  • Groin pain during and after sporting activities for at least 2 months
  • Desire to return to active sports participation at pre injury level
  • Pain located at the proximal insertion of adductor muscles on the pubic bone, and during active adduction against resistance


Interventions1. Multi-modal treatment group (MMT): heat + manual therapy + stretching.

- Maximum two sessions of manual therapy and heat, and 15 days of stretching (the stretches were done after a 5 min warming-up using jogging or cycling). Before the manual therapy the adductor muscle group is warmed using paraffin packs for 10 min

- The manual therapy technique consists of: with the patient in a supine position, the contralateral hand is used to control the tension in the adductor muscles while the ipsilateral hand is used to move the hip from a neutral position into flexion, external rotation and abduction while keeping the knee in extension. The treating physician controls the tension subjectively and applies the maximum tolerable stretch to the adductor muscles. After the movement has been performed the adductor muscle group is compressed with one hand while the other hand moves the hip into adduction and slight flexion. This circular motion followed by compressions lasts about 25 s and is repeated three times in one treatment session

2. Exercise therapy group (ET): 8 to 12 weeks; 3 times a week.

Module 1: first 2 weeks

- Static adduction against soccer ball placed between feet when lying supine (10 rep. of 30s, each)

- Static adduction against soccer ball placed between knees when lying supine (10 rep. of 30s, each)

- Abdominal sit-ups both in straightforward direction and in oblique direction (5 series of 10 rep.)

- Combined abdominal sit-ups and hip flexion, starting from supine position and with soccer ball between knees (5 series of 10 rep.)

- Balance training on wobble board (5 min)

- One-foot exercises on sliding board, with parallel feet as well as with 90 angle between feet (5 sets of 1 min continuous work with each leg and in both positions)

 

Module 2: 2 to 6 weeks

- Leg abduction and adduction exercises performed in side lying (5 series of 10 rep. of each exercise- twice)

- Low-back extension exercises prone over end of couch (5 series of 10 rep. – twice)

- One-leg weight pulling abduction/adduction standing (5 series of 10 rep. for each leg – twice)

- Abdominal sit-ups both in straightforward direction and in oblique direction (5 series of 10 rep. – twice)

- One-leg coordination exercise with flexing and extending knee and swinging arms in same rhythm(5 series of 10 rep. for each leg – twice)

- Training in sideways motion on mini-skateboard (5 min)

- Balance training on wobble board (5 min)

- Skating movements on sliding board (5 sets of 1 min continuous work)

In both groups a return to running program was done after treatment.


Outcomes
  • Successful treatment:


- No pain in connection with or after athletic activity in the same sport and at the same level of competition

- No pain during resisted adduction or on palpation of the adductors tendon at the pubic bone insertion

- Return to sports at the same level without groin pain

If all three measures above were reached, the result was labelled excellent, if two measures were reached, the result was good, if one measure was reached, the result was fair and if no measures were reached, the result was poor.

  • Maximum pain during sports (Visual analogue scores, 0-100)
  • Time to return to sports
  • Range of motion of the hip joint (internal and external rotation): It was used a goniometer with the patients lying and the hip and knee flexed to 90º


Outcomes were evaluated at 16 weeks follow-up.


NotesThe participants from exercise therapy (ET) were not supervised while performed the exercises. They were only instructed on how to perform it.

Percentage of participants lost to follow-up: 11% (6/59); 3 losses from ET group and 3 from MMT group

Reasons for withdrawal: did not want the treatment they were assigned (three patients); ankle injury (one patient); low-back pain (one patients); and lost to follow-up (one patient)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "After informed consent and inclusion the athletes were randomised using sealed envelopes.The athlete chose one of 100 opaque envelopes in the presence of the department’s secretary"

Allocation concealment (selection bias)Low riskQuote: "After informed consent and inclusion the athletes were randomised using sealed envelopes.The athlete chose one of 100 opaque envelopes in the presence of the department’s secretary"

Quote: "The examining physician was not involved in the randomisation process and remained unaware of the treatment allocation"

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants and physiotherapists could not be blinded to allocation treatment

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskWhile the examining physician was not involved in the randomization procedure and remained unaware of the treatment allocation, there were subjective outcomes (Successful treatment) assessed by the trial participants, who were not blinded

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAlthough missing data were balanced across groups and reasons for missing data were provided, the characteristics of the lost participants were not described. Furthermore, a per protocol analysis was done

Selective reporting (reporting bias)Unclear riskFunction (an important primary outcome) was not evaluated. No protocol available

Other biasLow riskNo other source of bias was detected

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ekstrand 2001Conservative treatment versus surgical treatment; not in review scope

Paajanen 2011Conservative treatment versus surgical treatment; not in review scope

 
Characteristics of studies awaiting assessment [ordered by study ID]
Backx 2009

MethodsRandomized controlled, parallel group trial

ParticipantsMale athletes, 18 to 45 years old, hip adduction-related complaints, for a period of at least six weeks, strong desire to compete in sports

InterventionsTwo different kinds of physiotherapeutic treatments are given for the population. Both treatment strategies are already in use in daily practice.
Patients are randomized to receive either pelvic-stabilizing muscle training or usual care

Outcomes1. Severity of the pain over the last three days (11-point visual analogue scale (VAS))

2. Participation in sports (11-point VAS)
3. General disability (adapted Quebec low back pain disability scale)

4. Global change (six-point Likert scale)
5. How long before return to full athletic activity
6. Recurrences of the same complaints
Parameters 1, 2, 3 are measured before and directly after the period of treatment and 26 and 52 weeks after the start of treatment.
Parameters 4, 5 and 6 are only measured at 26 and 52 weeks after treatment.

NotesThe author of this study was contacted via email and reported that the trial was not completed as a randomized clinical trial and therefore the results have not been published.

 
Comparison 1. Exercise therapy versus conventional physiotherapy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 'Successful treatment'1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Follow-up 16 weeks, per-protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Follow-up 8 to 12 years, per-protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 Follow-up 8 to 12 years, intention-to-treat analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Patients' subjective global assessment (better or much better)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    2.1 Follow-up 16 weeks, per-protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 Follow-up 16 weeks, intention-to-treat analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 Follow-up 8 to 12 years, per-protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.4 Follow-up 8 to 12 years, intention-to-treat analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Return to sports1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Per-protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Intention-to-treat analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Multi-modal treatment versus exercise therapy

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 'Successful treatment'1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    1.1 Per-protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 Intention-to-treat analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Maximum pain during sports1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 3 Return to sports1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

    3.1 Per protocol analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 Intention-to-treat analysis
1Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Time to return to sports (weeks)1Mean Difference (IV, Fixed, 95% CI)Totals not selected