King E, Ward J, Small L, Falvey E, Franklyn-Miller A. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med. 2015;49:1447–1451.
Clinical Question: Does the return-to-play rate and return-to-play time differ between surgical and conservative treatment in athletes with athletic groin pain?
Data Sources: Studies identified from PubMed, Embase, CINAHL, and Google Scholar databases with publications from 1980 to June 30, 2013 were considered. Given the varied terminology used for athletic groin pain, two categories of terms were used. The first category included various diagnoses: groin pain, groin injury, athletic groin pain, chronic groin pain, osteitis pubis, adductor tendinitis, athletic pubalgia, symphysis syndrome, hockey groin, iliopsoas dysfunction, pubic bone stress, incipient hernia, occult hernia, Gilmore's groin, posterior inguinal wall, conjoint tendon disruption, and adductor-related groin pain. The second category included interventions: rehabilitation, physiotherapy, physical therapy, manual therapy, surgical repair, conservative treatment, tenotomy, surgical intervention, and management. Bibliographies were reviewed for missing articles, and the authors contacted colleagues to obtain personal and conference lectures.
Study Selection: Studies were included if they were published in English, were restricted to an athletic population, included surgical intervention and/or conservative treatment, and addressed return-to-play rates and times.
Data Extraction: Two reviewers assessed all studies for eligibility and a third checked for discrepancies. Consensus between all three reviewers was required for a study to be included. One reviewer extracted the data, which was then assessed by a second reviewer. Data included subject numbers, intervention type, and return-to-play time and rate. Studies were then divided into three diagnosis groupings: pubic group, adductor group, and abdominal group. Surgical interventions that included both the abdominal region and a release of the adductors were not analyzed in any of the three diagnostic groups.
Main Results: The search resulted in 585 studies for review and, of those, 56 studies were included in the meta-analysis. The 56 studies included 43 surgical studies, 13 conservative treatment studies, and 1 comparison study. Studies included 3,332 athletes (99% were male); 3,008 athletes underwent surgical intervention, 264 athletes underwent conservative intervention, and 60 athletes underwent both interventions. The results were reported in return-to-play rates and times; all 56 studies included return-to-play rates and 25 studies included return-to-play times. The researchers used the National Health and Medical Research Council hierarchy to evaluate overall evidence and the level of evidence was considered low. The two conservative studies and one comparison study had Level II evidence, one surgical study had Level III evidence, and all other literature used Level IV evidence. Methodological quality and validity were reviewed using Downs and Black's checklist, which found a high risk of bias for surgical studies.
Return-to-play rates for all diagnostic groupings were comparable for both surgical and conservative intervention groups. Return-to-play times were comparable for diagnostic groupings except that of the pubic group, which found return-to-play times of 10.5 weeks (95% confidence interval = 7.81 to 13.19) for conservative treatment and 23.1 weeks (95% confidence interval = 15.04 to 31.12) for surgical treatment.
Conclusions: Currently, few high-quality studies are available to determine whether conservative treatment or surgical intervention is optimal for athletes with athletic groin pain when considering return-to-play rates and times. Regardless of the origin of athletic groin pain, both conservative treatment and surgical intervention showed similar return-to-play rates. When comparing the diagnosis of athletic groin pain in the pubic region, rehabilitation resulted in a much faster return-to-play time compared to surgery. Overall, there is a need for higher quality studies comparing conservative and surgical treatment of athletes with groin pain.
Summary: Although athletic groin pain results in pain and loss of function for the athlete, the numerous differential diagnoses makes it challenging for the clinician to manage. Athletic groin pain is caused by twisting and high force change of direction movements and is common among athletes participating in ice hockey, soccer, American football, rowing, taekwondo, and Australian Rules Football.1 It is difficult to obtain good epidemiologic data on the occurrence rate because of terminology problems. However, de Sa et al.1 reported that the five most performed surgeries for athletic groin pain were femoroacetabular impingement (32%), sports hernia/athletic pubalgia (24%), adductor pathology (12%), inguinal pathology (10%), and labral pathology (5%). To assist with the terminology issue, specific categories of groin pain were identified following the Doha meeting in 2014: (1) clinical entities such as adductor, iliopsoas, inguinal, and pubic-related groin pain, (2) hip-related groin pain, and (3) other causes.2
Athletic groin pain can be attributed to motor control problems, anatomical morphology, or overtraining syndrome causing hernias, contractures, or tears to surrounding soft tissue. The ultimate cause of disruption of anatomical soft tissue structures is strong adductor muscles overpowering weaker abdominal musculature, causing an increase in shear forces at the pubic symphysis disrupting surrounding soft tissue.3 A consensus statement on sports hernias found one or more of the following may be present in individuals with sports hernias: posterior wall weakness causing decreased abdominal tensioning, external ring dilation, conjoint tendon damage, or tears in the inguinal ligament.4 Of those, posterior wall weakness is the most common, reported in 85% of athletes undergoing sports hernia surgery.4
Further complicating the diagnosis and management are regional factors that must be considered. Many hip and groin pathologies coexist, which cause limitations in the current protocols for clinical assessment and diagnostic imaging of the hip and groin. Diagnosis is often achieved by ruling out differential diagnoses through conservative rehabilitation. Five clinical signs have been reported to be indicative of a possible athletic pubalgia injury and could lead to an earlier diagnosis. Those signs include (1) deep groin and/or lower abdominal pain; (2) pain with activity such as sprinting, cutting, and sit-ups that is alleviated by rest; (3) tenderness to touch over the pubic bone where the rectus abdominis and conjoined tendon insert; (4) pain of the external ring with no signs of hernia; and (5) pain with strength test of adduction and abdominal musculature.3–5
In addition to the difficulties with diagnosis and assessment of athletic groin pain, controversy exists regarding the most appropriate treatment approach. King et al.6 found significant improvement of return-to-play times for a conservative rehabilitation group compared to a surgical group for pubic-related groin pain. For all other anatomical groupings, conservative treatment and surgical treatments were not found to be different (Table 1).6
Meta-analysis of Return-to-Play Rates and Times for Conservative and Surgical Treatment of Athletic Groin Pain,
Because of the lack of differences for most causes of athletic groin pain, it would seem prudent to first initiate a conservative rehabilitation program. A multidimensional rehabilitation approach is needed when treating athletes both conservatively and surgically via local and global rehabilitation.5,7 Treatment would include rest, soft tissue mobilization, and joint mobility to decrease restrictions and increase range of motion.5,7 Range of motion for hip rotation needs to be evaluated and addressed. Falvey et al.8 found 85.9% of individuals with chronic groin pain had reduced hip rotation. Local motor control and strengthening includes a focus on appropriate breathing patterns and abdominal, gluteus maximus, and medius musculature.5,7 Later phases should include regional and global strengthening and stability with emphasis on good posture and motor pattern development through progressive load and proprioceptive neuromuscular facilitation.5,7
This type of multidimensional and systematic rehabilitation approach will produce more positive outcomes. Serner et al.7 described return-to-play time to be 12.8 weeks when exercise therapy was combined with manual therapy compared to 17.3 weeks for exercise therapy alone.
Clinicians need to account for pain level, function, impairments, restrictions, performance, and time of season to educate athletes and make appropriate clinical decisions. An additional challenge of this injury is the time of season when the injury is sustained because treatment options may vary depending on whether an athlete is in or out of season. For example, a conservative approach that aims to control symptoms may be used during the season, whereas a more aggressive treatment approach with possible surgery may be considered out of season.
Using specific outcome measures to assess pain, function, athletic performance changes, and long-term outcomes will assist clinicians in educating athletes and making decisions about return-to-play times for both in-season and out-of-season periods. The Copenhagen Hip and Groin Outcome Score patient-reported outcome had good test–retest reliability and statistically significant correlation coefficients for construct validity, and responsiveness was satisfactory.9
The results from this meta-analysis suggest that both conservative and surgical treatments for athletic groin pain can be successful for athletes in regard to both return-to-play rates and times. Early diagnosis and a better classification system of athletic groin pain will assist clinicians to develop a better course of treatment for athletes that includes rest and soft tissue and joint mobilization. In addition to strength exercises, stabilization exercises and movement pattern reeducation should be incorporated first at the regional level of the hip and pelvis and then at global levels incorporating a whole-body approach.
The current body of literature regarding athletic groin pain and return-to-play rates and times is limited, with a high degree of bias and low level of evidence for both treatment approaches. More high quality research needs to be conducted on conservative and surgical treatment of athletic groin pain so clinicians can educate athletes to make better decisions on the appropriate course of treatment for their individual case.
- de Sa D, Hölmich P, Phillips M, et al. Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med. 2016;50:1181–1186. doi:10.1136/bjsports-2015-095137 [CrossRef]
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. 2015;49:768–774. doi:10.1136/bjsports-2015-094869 [CrossRef]
- Elattar O, Choi HR, Dills VD, Busconi B. Groin injuries (athletic pubalgia) and return to play. Sports Health. 2016;8:313–323. doi:10.1177/1941738116653711 [CrossRef]
- Sheen AJ, Stephenson BM, Lloyd DM, et al. ‘Treatment of the sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014;48:1079–1087. doi:10.1136/bjsports-2013-092872 [CrossRef]
- Ellsworth AA, Zoland MP, Tyler TF. Athletic pubalgia and associated rehabilitation. Int J Sports Phys Ther. 2014;9:774–784.
- King E, Ward J, Small L, Falvey E, Franklyn-Miller A. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med. 2015;49:1447–1451. doi:10.1136/bjsports-2014-093715 [CrossRef]
- Serner A, van Eijck CH, Beumer BR, Holmich P, Weir A, de Vos RJ. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Br J Sports Med. 2015;49:813. doi:10.1136/bjsports-2014-094256 [CrossRef]
- Falvey EC, King E, Kinsella S, Franklyn-Miller A. Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients—clinical findings, MRI findings and patient-reported outcome measures at baseline. Br J Sports Med. 2016;50:423–430. doi:10.1136/bjsports-2015-094912 [CrossRef]
- Thorborg K, Holmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med. 2011;45:478–491. doi:10.1136/bjsm.2010.080937 [CrossRef]
Meta-analysis of Return-to-Play Rates and Times for Conservative and Surgical Treatment of Athletic Groin Paina,b
|Region||Treatment||Return to Play (Rate)||# of Subjects||Return to Play Time (Weeks)||# of Subjects|
|Pubic||Conservative||91% (0.76 to 0.97)||60||10.5 (7.81 to 13.19)||8|
|Surgical||86% (0.73 to 0.94)||46||23.1 (15.04 to 31.21)||36|
|Abdominal||Conservative||83% (0.35 to 0.98)||4||7.9 (7.42 to 8.38)||4|
|Surgical||96% (0.94 to 0.98)||2,206||7.2 (5.69 to 8.77)||283|
|Adductor||Conservative||81% (0.57 to 0.93)||190||16.9 (15.02 to 18.68)||157|
|Surgical||84% (0.7 to 0.92)||202||18.3 (16.71 to 19.91)||77|
|Adductor & abdominal||Conservative||N/A||N/A||N/A||N/A|
|Surgical||96% (0.94 to 0.96)||554||21.9 (13.6 to 30.22)||112|