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Acute groin injuries

Diagnostics, treatment and return to sports

  • Return to sports after groin injury hard to predict
  • Non-insertional groin injuries recover faster
  • MRI does not seem useful in predicting return to sports

In the majority of athletes suffering an acute groin injury pain resolves within two weeks, so that they are able to resume normal training within three weeks. This does not apply to athletes with a palpable defect as found by a therapist or athletes who experience pain on palpation of the proximal insertion of the adductor longus: most of the times it takes between four and eleven weeks for them to be able to fully participate in training. This was the conclusion of a prospective cohort study of an international research group from Qatar. They intensively supervised 81 male athletes with acute groin injuries according to a rehabilitation programme with established criteria for progressing exercise therapy, sports specific on-field rehabilitation and return to sports. The researchers studied the time athletes needed to resume their sports activities, calculated whether this could be predicted and documented recurrences in the year following rehabilitation.

Pillars

Prior to the study, the scientists established three pillars to assess progress in rehabilitation: 1) clinically pain free, 2) completing a sports specific on field training without any pain; and 3) completing a regular training without any pain. See the frame for criteria for the first two pillars. Of the 81 athletes who started the rehabilitation programme, 61 (75 percent) reached all criteria of ‘clinically pain free’. The others returned to the field while in pain or stopped the rehabilitation programme due to other obligations or surgery, for example. Fifty athletes (62 percent) completed the criteria for ‘controlled on-field training’. Contact by phone every two weeks showed that 75 athletes (93 percent) eventually returned to the training field of their club. 

Non-medical factors

Not all athletes completed the full rehabilitation programme, a portion of them returned to full training at their club while not being completely pain free. According to the authors, this shows that not only medical factors play a role in deciding to resume sports. Sports and commercial factors – such as the moment in the season or the importance of an approaching match – influence the decision to return to the field.

Recurrences 

Six out of 81 athletes (8 percent) suffered a recurrent groin injury the first year after the rehabilitation programme. In five of them this was in the first two months after complete return to sports. According to the authors, it seems that their structured rehabilitation programme can protect athletes from recurrences: in earlier studies, scientists found a recurrence percentage of 18 percent in the first two months after groin injury. Further research is needed to verify this. 

> From: Serner, Am J Sports Med 48 (2020) 1151–1159 . All rights reserved to The Author(s). Click here for the online summary. Translation by Casper Martens

Additional references

[1] Serner A, Weir A, Tol JL, [et al.]. Return to sport after criteria-based rehabilitation of acute adductor injuries in male athletes: a prospective cohort study. Orthop J Sports Med 8 (2020) 2325967119897247

[2] Aspetar Clinical examination and Treatment protocol

Pillars for progression in rehabilitation

Criteria clinically pain free

Criteria controlled on-field training completed

  • Pain free palpation adductors
  • Pain free maximal isometric adduction in maximal abduction 
  • Pain free maximal passive stretch adductors 
  • Pain free maximal hip adduction exercises with elastic band (10 repetitions (reps)) 
  • Pain free Copenhagen Adduction exercise (10 reps)
  • Pain free straight sprint 10x30m at maximum speed
  • Pain free T-test at maximum speed
  • Pain free Illinois agility test at maximum speed
  • Pain free spider-test at maximum intensity
  • Pain free sport training/ test (sports specific), for example for soccer:
    • Changes of direction with or without ball;
    • One or two legged jumps upward or forward;
    • Short and long distance passing;
    • Cross passing (standing and running)
    • Taking corners and penalty kicks
    • Shooting scenarios
    • One-on-one duels

Expert opinion by Maarten Barendrecht

For treatment of adductor related groin injuries, the authors give a good start with these two articles and the freely available addendum [2]. While the exact duration of recovery depends on many factors, this study does provide insight into the criteria that can give direction. The effectiveness of this protocol will still have to be demonstrated in comparative studies. The authors did find a smaller chance of recurrence in athletes who were clinically pain free at pillar 1 compared to athletes who progressed a step despite pain. It seems sensible to follow the described criteria for progression to achieve optimal recovery. This advice can be considered in shared decision making.

When interpreting the results, do take the setting of the study (competitive athletes who came to a sports medical clinic with complaints) into account. Athletes with mild complaints might recover faster. It seems wise to use the same criteria for progression to avoid underestimation of their complaints. During rehabilitation the load intensity was kept at a pain level of NRS 2 at all times. During intensive supervision this can be monitored better than when practicing independently. In that case, explicit instructions are very important. Frequency and intensity of the rehabilitation should be tuned to the demands of the individual athlete. 

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