Effectiveness of Active Physical Training as Treatment for Long-Standing Adducto
Effectiveness of Active Physical Training as Treatment for Long-Standing Adductor-Related Groin Pain in Athletes
Abstract & commentary
Synopsis: Stretching exercises should be avoided in the treatment of chronic adductor-related groin pain in athletes.
Source: Hölmich P, et al. Effectiveness of active physical training as treatment for long standing adductor-related groin pain in athletes: Randomized trial. Lancet 1999; 353:439-443.
A prospective, randomized trial of the treatment of chronic groin pain in active athletes was conducted among volunteer athletes in Copenhagen. Once a clear diagnosis of simple groin strain was made and other serious causes of chronic groin pain eliminated through the use of careful physical examination, radiographs, and bone scan, the athletes were randomized to two treatment groups. The median duration of pain in the 68 athletes, aged 18-50, had been nine months prior to entering into the study, and almost three-quarters of the athletes could no longer participate in their sport.
One treatment group received a "physical therapy programme," which included laser treatments, transverse friction massage, transcutaneous electrical nerve stimulation, and a strong focus upon stretching of the adductors as well as the hamstring and hip flexor muscles.
The other group was treated with what was described as an "active training programme." This regimen focused upon exercises designed to strengthen the hip musculature, especially the adductors, and trained mucular coordination to improve the postural stability of the pelvis. Specifically avoided in this group were stretching exercises for the adductor muscle group.
The athletes were randomized, 34 to each of the two groups. The outcome of treatment, which lasted a minimum of eight weeks, strongly favored the active training program. The outcomes measured were the elimination of groin pain and a return to athletic activity. Excellent results were obtained in 23 of the 34 active treatment patients and only four of the 34 athletes treated with physical therapy. In contrast, there were six poor results in the active treatment group and 18 poor results in the physical therapy treatment group. Hölmich and colleagues conclude that improving the strength and coordination of the muscles about the hip is a significantly better approach than conventional physical therapy when trying to treat chronic adductor-related groin pain in athletes. They strongly suggest that stretching exercises be avoided in the treatment of this problem despite the fact that many athletes have limited range of motion when they present with complaints of groin pain.
Comment by James D. Heckman, MD
Hölmich et al have carried out an excellent study that is well designed and focuses upon the specific problem of long-standing, adductor-related groin pain in athletes. The randomized, prospective, blinded nature of the study confers a high degree of credibility upon their results. Randomization was into two treatment groups, the elements of which are rather arbitrary. The active treatment program focused upon strengthening of the hip adductors and the abdominal musculature and upon balance training and progressive coordination until the symptoms resolve. It is a graduated, stepwise program that does not use any treatment modalities. On the other hand, the physical therapy group did use some treatment modalities, such as laser and transcutaneous nerve stimulation, which have proved to be marginally beneficial in the hands of others.
It seems to me that the major difference between the two groups was the focus on strengthening of the adductors in the active treatment group and stretching of the adductors in the physical therapy group. But there are many other variables here that may have also had a substantial effect on the outcome. A multivariant analysis was not conducted because the individual treatments, particularly in the PT group, were not given separately. Despite this weakness, the positive results of the active treatment program provide a standard against which other treatment protocols can be compared and measured. Hölmich et al clearly point out that this is a treatment program, and they suggest that the principles of active treatment might be applied to a preventive program in athletes at high risk for developing adductor strain and chronic groin pain.
Long-standing adductor-related groin pain in athletes can most effectively be treated by:
a. strengthening and coordination adductor exercises.
b. laser treatments.
c. transverse friction massage for 10 minutes daily.
d. stretching of the adductor hamstring and hip flexor muscles.
e. transcutaneous electrical nerve stimulation daily for 30 minutes.
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