Conservative treatment for exercise-related groin pain

Exercise-related groin pain is common in sports especially those involving running, kicking and changing directions, such as in soccer and hockey. Athletes may have a delay of several months before being able to resume the sport, and this may not be at their former level of sports activity. Usually the treating clinician deals with the coexistence of two or more disorders, such as muscle, tendon and ligament strains and a bony stress reaction. Conservative interventions are generally the first choice for treatment and include an initial period of rest; strengthening of the muscles stabilising the pelvis and hip joints; stretching the hip muscles; electrotherapy (for example, transcutaneous electrical stimulation (TENS), laser and ultrasound therapy); manual therapy; non-steroidal anti-inflammatory drugs; steroidal injections or prolotherapy (injection of growth factor production stimulants to induce growth and repair of normal tissue).

Two randomized controlled trials, involving a total of 122 athletes with exercise-related groin pain, were included in this review. Participants were aged between 18 and 50 years and all but one were male. They had had groin pain for at least two months. One trial demonstrated positive results in athletes treated by exercise therapy (strengthening of hip and abdominal muscles, and training muscular co-ordination) in comparison with 'conventional' physiotherapy consisting of passive modalities (stretching exercises, electrotherapy and transverse friction massage) 16 weeks after the end of treatment, for 'successful treatment' (based primarily on pain measures) and for the rate of return to sports at the same level without groin pain. The second study compared multi-modal treatment (heat, manual therapy and stretching) with exercise therapy and found no significant difference between groups for 'successful treatment' and return to sports, but did show an earlier return to sport for those athletes who achieved this outcome following the multi-modal treatment.

The available evidence is exclusively related to athletes and is limited because of the low number of studies and low number of participants for each outcome. Further randomized controlled trials are needed to ratify these results.

Authors' conclusions: 

The available evidence from the randomized trials is insufficient to advise on any specific conservative modality for treating exercise-related groin pain. While still low quality, the best evidence is from one trial which found that exercise therapy (strengthening of hip and abdominal muscles) in athletes improves short-term outcomes (based primarily on pain measures) and return to sports compared with physiotherapy consisting of passive modalities. Given the low quality of the available evidence from both included trials, further randomized trials are necessary to reinforce their findings.

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Background: 

Musculoskeletal, ligamentous and osseous groin injuries are common in athletes and may result in a delay of several months to resume sports. Even then, this may not be at the former level of sport activity. The treatment of exercise-related groin pain is mainly conservative (non-surgical), using interventions such as exercises, electrotherapy, manual therapy and steroid injections.

Objectives: 

To assess the effects (benefits and harms) of conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); MEDLINE (1948 to November week 3 2011); EMBASE (1980 to Week 49 2011); CINAHL (1982 to December 2011); LILACS (1982 to December 2011); PEDro (1929 to December 2011), SPORTDiscus (1985 to December 2011), OTseeker (to December 2011), reference lists of papers and conference proceedings (2000 to 2011).

Selection criteria: 

Randomized controlled trials and quasi-randomized controlled trials evaluating conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain were included. Studies comparing conservative with surgical treatments were excluded.

Data collection and analysis: 

Two review authors independently extracted data and conducted risk of bias assessments. There was no pooling of data.

Main results: 

Two studies, involving a total of 122 participants who had experienced adductor-related groin pain for at least two months, were included in this review. All but one of the participants were male athletes aged between 18 and 50 years old. Both studies were assessed as 'high risk of bias' for at least one source of bias domain. The 'successful treatment' outcome reported in both studies was based primarily on pain measures.

One study, based on an intention-to-treat analysis, found a significant difference favouring exercise therapy (strengthening with an emphasis on the adductor and abdominal muscles and training muscular co-ordination) compared with 'conventional' physiotherapy (stretching exercises, electrotherapy and transverse friction massage) in successful treatment at 16-week follow-up (25/34 (74%) versus 10/34 (29%); risk ratio (RR) 2.50, 95% CI 1.43 to 4.37, P = 0.001). Similarly, of those followed-up significantly more athletes treated by exercise therapy returned to sport at the same level (23/29 (79%) versus 4/30 (13%); RR 5.95, 95% CI 2.34 to 15.09, P = 0.0002). Although still favouring the exercise group, the differences between the two groups in patients' subjective global assessment at 16 weeks and successful treatment at 8 to 12 years follow-up were not statistically significant.

The second study (54 participants) found no significant differences at 16-week follow-up between a multi-modal treatment (heat, manual therapy and stretching) and exercise therapy (the same intervention as in the above study) for the outcomes of successful treatment (14/26 (54%) versus 12/22 (55%); RR 0.99, 95% CI 0.59 to 1.66, P = 0.96) and return to full sports participation (13/26 (50%) versus 12/22 (55%); RR 0.92, 95% CI 0.53 to 1.58, P = 0.75). Those returning to full sports participation returned on average 4.5 weeks earlier after receiving multi-modal therapy (mean difference -4.50 weeks, 95% CI -8.60 to -0.40, P = 0.03) than those in the exercise therapy group. This study reported that there were no complications or side effects found in either intervention group.

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