Doha agreement meeting on terminology and definitions in groin pain in athletes

Groin pain in soccer players: anatomy, clinical presentation, biomechanics, pathology and imaging findings

Groin pain is extremely common in soccer players, especially male soccer players, with nearly a third experiencing groin pain over the course of their careers. Despite its high prevalence, there continues to be some confusion and controversy regarding the detailed anatomy and recommended terminology related to groin pain in athletes. This article will review the anatomy, clinical presentation, biomechanics, pathology and imaging findings most commonly associated with groin pain in soccer players.

Imaging-detected sports injuries and imaging-guided interventions in athletes during the 2022 FIFA football (soccer) World Cup

OBJECTIVE

To describe imaging-detected musculoskeletal injuries and image-guided interventional procedures during the 2022 FIFA football (soccer) World Cup.

MATERIALS AND METHODS

Retrospective analysis of all radiologic examinations performed in a central medical facility for athletes was performed by two board certified musculoskeletal radiologists. Data on muscle, tendon, ligament, cartilage, and bone injuries were collected according to imaging modality and body part.

RESULTS

A total of 143 radiology examinations in 94 athletes were evaluated at the central medical facility. Magnetic resonance imaging (MRI) was the most utilized modality (67%), followed by radiography (12%), ultrasonography (9%), and computed tomography (4%). Image-guided interventions corresponded to 8% of all radiological examinations. There were 112 injuries described, affecting muscles and tendons (42%), ligaments (25%), cartilage (21%), and bone (12%). Most injured body parts were thigh (27%), foot and ankle (23%), knee (23%), and hip/groin (8%). Most injured players were within the age range of 24-35 years old (71%).

CONCLUSION

Imaging was utilized in 11% of players who participated in the 2022 FIFA World Cup in Qatar. MRI was the most utilized modality, and acute muscle tears were the most diagnosed type of injury. Diagnostic imaging played an important role in diagnosing sports-related injuries during the 2022 FIFA World Cup.

Neuropathic causes of groin pain in athletes: understanding nerve involvement

PURPOSE

Groin pain in athletes, particularly inguinal-related groin pain, remains a diagnostic and therapeutic challenge despite recent consensus on terminology. This study aims to explore nerve disorders as a key contributor to groin pain in athletes, focusing on the anatomy, aetiology, diagnosis, and management options.

METHODS

A comprehensive review of the literature was conducted, focusing on the anatomical variability of the ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerves, clinical presentations, diagnostic methods, and conservative and surgical treatments for nerve-related inguinal pain. Key studies on nerve entrapment, neuropathic and nociceptive pain mechanisms, and surgical outcomes were analyzed.

RESULTS

Variability in nerve pathways and sensory overlap complicate diagnosis and management. Neuropathic pain often presents with burning or electric sensations due to nerve compression or entrapment, while nociceptive pain manifests as dull or stabbing pain. Conservative treatment, including exercise-based rehabilitation and nerve blocks, offers relief in many cases. For refractory cases, surgical treatment can provide significant pain resolution, with nerve identification and potential neurectomy improving outcomes.

CONCLUSION

Nerve disorders play a critical role in inguinal-related groin pain in athletes. Accurate diagnosis relies on detailed clinical examination and targeted imaging. Conservative treatments are first line, but surgical interventions addressing nerve entrapment or compression are effective for persistent cases. Future research should focus on the role of collagen deficiencies, nerve histopathology, and long-term outcomes of different treatment modalities.

Clinical assessment and treatment of patients presenting with longstanding hip and groin pain in primary care: a survey study among physical therapists and general practitioners in Sweden

BACKGROUND

Methods of assessment, treatment and referral rates of patients presenting with longstanding hip and groin pain (LHGP) are not well documented. The aim of this study was to investigate assessment and treatment of patients with LHGP among general practitioners (GPs) and physical therapists (PTs) in primary care.

METHODS

An anonymous web-based survey was developed specifically for this study and distributed to GPs and PTs at primary care centers in the southern part of Sweden. The survey covered the use of different methods of assessment and treatment for LHGP, the perceived importance these methods, and referral rates to orthopedic care. Responses from clinicians were reported in frequencies and percentages, and differences in assessment methodology between professions were examined with chi-square tests.

RESULTS

PTs (n = 104) and GPs (n = 62) referred less than 25% of patients with LHGP to orthopedic care. Both professions used clinical assessments as range of motion tests, but PTs were more likely to use specific clinical tests (PTs 76% vs. GPs 19%, p = < 0.001), GPs used more imaging (GPs 98% vs. PTs 58%, p = < 0.001) and neither profession used validated patient-reported outcome measures (GPs 2% vs. PTs 11%, p = 0.134). GPs and PTs ranked patient history and range of motion as the most important factors for diagnosis. GPs and PTs both reported providing patient education and advice on physical activity as part of the treatment. GPs commonly prescribed pain medication, including NSAIDs (97%), paracetamol (100%), and opioids (69%). 77% of PTs reported treatment duration less than 3 months, with treatment consisting of combinations of exercise therapy and manual therapy.

CONCLUSIONS

GPs and PTs in primary care referred 25% or less of patients with LHGP to orthopedic care. Both professions generally used assessment for LHGP in line with clinical recommendations. However, some assessment methods differed between GPs and PTs, and neither used validated patient-reported outcome measures. Treatment strategies mainly included pain medication (GPs), exercise and manual therapy (PTs), and education (both professions). Inconsistent with clinical recommendations, GPs commonly prescribed opioids as part of pain management, and PTs report treatment duration of less than 3 months.

CLINICAL TRIAL NUMBER

NA.

Does Core Training Improve Agility Performance in Soccer Players With Groin Pain? A Randomized, Single-Blind Study

CONTEXT

Agility is crucial for soccer players, and core training can improve it. One study showed significant agility improvements after an intervention including core training for athletes with groin pain. However, it is unclear if these improvements resulted specifically from the core exercises or the entire program. Additionally, the study lacked a control group, making the findings inconclusive.

PURPOSE

The current study aimed to explore the effect of core training, previously reported in the context of groin-pain rehabilitation, on agility performance in soccer players with groin pain.

METHODS

Twenty soccer players with groin pain volunteered to participate. They were randomly assigned to a core training group (n = 10) and a control group (n = 10). Before and immediately after that period, agility performance (T test and Edgren Side Step Test) and self-reported outcomes (Copenhagen Hip and Groin Outcome Score) were assessed in both groups.

RESULTS

No significant session × group interaction was observed in agility T test (F = 2.55; P = .12; ηp2=.12) and Edgren Side Step Test (F = 3.18; P = .09; ηp2=.15) performances. Besides, Copenhagen Hip and Groin Outcome scores showed significant improvements (P = .007 to <.001) in the core training group following the 12 weeks of core training and compared with the control group.

CONCLUSION

The results showed that soccer players with groin pain who received or did not receive core training showed similar agility performance. However, significant improvements in self-reported outcomes were observed in soccer players compared with the control group. Clinicians and coaches should therefore consider core training when designing training and rehabilitation programs for this population to enhance recovery.

Running biomechanics in people with femoroacetabular impingement syndrome: A cross-sectional analysis of sex differences and relationships with patient reported outcome measures

OBJECTIVES

(i) Investigate if lower-limb running biomechanics differ between women and men with femoroacetabular impingement syndrome, and (ii) explore whether sex-specific relationships between lower-limb running biomechanics and symptom severity and sport-related concerns exist.

DESIGN

Cross-sectional.

SETTING

Gait laboratory.

PARTICIPANTS

Twenty women and 22 men enrolled in a clinical trial of physiotherapist-led treatments for femoroacetabular impingement syndrome.

MAIN OUTCOME MEASURES

Kinematics and kinetics of hip, knee, and ankle joints during the stance phase (calculated from three-dimensional biomechanics data) were compared using statistical parametric mapping. The International Hip Outcome Tool-33 and Copenhagen Hip and Groin Outcomes Score quantified hip-related symptom severity and sport-related concerns.

RESULTS

Women had larger hip adduction angles (34%-44% of stance,p = 0.045) than men. For kinetics, women displayed larger external hip extension moments (77%-100%,p = 0.001), smaller knee extension moments (80%-100%,p = 0.007), and smaller ankle dorsiflexion moments (26%-67%,p < 0.001) than men. Worse sport-related concern was associated with a larger peak hip extension angle (0.18, 95%CI 0.05,0.31) and smaller hip flexion moment impulse (0.14∗10-2, 95% CI 0.02∗10-2,0.25∗10-2) in women, and smaller hip external rotation moment impulse in men (0.06∗10-2, 95% CI 0.01∗10-2,0.11∗10-2).

CONCLUSIONS

Women and men with FAI syndrome display differences in lower-limb running biomechanics and relationships between symptom severity and running biomechanics are sex-dependent, warranting consideration in future analyses.

Core Muscle Injuries: Preoperative Imaging and Postoperative Considerations

Core muscle injuries constitute a significant source of pain and functional impairment among elite athletes. Understanding the anatomy and biomechanics centered at the pubic bone joint is necessary to interpret imaging findings. Dedicated athletic pubalgia magnetic resonance imaging (MRI) plays a crucial role in accurately diagnosing and assessing injuries affecting the pubic plate and associated muscular attachments. Preoperative findings can include harness muscle injury, pubic plate detachment, and/or osteitis pubis. Various surgical approaches are used for core muscle repair, requiring close collaboration with the referring surgeon during the interpretation of postoperative MRI. Although postoperative MRI can indicate healing progress, its primary usefulness lies in detecting new or exacerbated tears that may signify potential reinjury or surgical complications.

Image-guided Interventions for Core Muscle Injury and Other Disorders in the Pubic Symphysis

Formerly termed sports hernia or athletic pubalgia, core muscle injury (CMI) encompasses abnormality of structures within the so-called core, which is essentially the hip, abdomen, and pubis. Compared with data on image-guided procedures of other joints, information regarding procedures performed to address CMI and other disorders of the pubic symphysis is lacking. These procedures can be daunting given the joint's small size, surrounding critical neurovascular structures, and three-dimensional anatomy. Nonetheless, various diagnostic and therapeutic image-guided interventions in this region can be successfully performed by the astute radiologist. Diagnostic symphyseography provides a contrast agent map that allows detection of symphyseal cleft injuries. Although largely supplanted with MRI, which can help depict additional findings such as bone marrow edema and atypical cleft injuries, symphyseography performed alongside local anesthetic and steroid injection remains a valuable conservative therapeutic strategy in the treatment of CMI. US-guided percutaneous dry needling (tenotomy) is thought to promote tendon healing by using repeated needle passage to convert chronic degeneration of tendinosis into an acute inflammatory condition; the distal rectus abdominis and/or proximal adductor longus may be targeted. Other perisymphyseal procedures include joint aspiration, biopsy, and osteoplasty. Fluoroscopic- or US-guided joint aspiration aids in evaluation of arthropathies. While bone and soft-tissue biopsies are best performed under CT guidance, fluoroscopy and US are viable alternatives in the evaluation of lesions with significant extraosseous components. Percutaneous osteoplasty is a minimally invasive palliative procedure that stabilizes pubic metastases by injecting bone cement; it can be performed under fluoroscopic or CT guidance by itself or with thermal ablation to maximize pain relief. ©RSNA, 2025 Supplemental material is available for this article.

Imaging on the painful and compressed nerve: lower extremity

Entrapment neuropathies of the lower extremity are often underdiagnosed due to limitations in clinical examination and electrophysiological testing. Advanced imaging techniques, particularly MR neurography and high-resolution ultrasonography (US), have significantly improved the evaluation and diagnosis of these conditions by enabling precise visualization of nerves and their surrounding anatomical structures. This review focuses on the imaging features of compressive neuropathies affecting the lumbosacral plexus and its branches, including the femoral, obturator, sciatic, common peroneal, and tibial nerves. Key conditions such as meralgia paraesthetica, piriformis syndrome, and tarsal tunnel syndrome are discussed, highlighting findings such as nerve thickening, T2 hypersignal, fascicular changes, and associated muscle denervation patterns. The ability to detect structural causes, including anatomical variations, fibrous bands, and space-occupying lesions, underscores the value of these imaging modalities in facilitating early diagnosis, guiding therapeutic interventions, and improving patient outcomes.

Narrative review of long-standing groin pain in athletes. Retrospective analysis of over 12 000 patients

PURPOSE

This article critically examines long-standing groin pain (LSGP) in physically active adults related to sports overload by analyzing terminology, pathophysiology, and treatment.

METHOD

This review is based on data from over 10,000 patients managed through a multidisciplinary algorithm. (LSGP) has been variably labeled, using terms that have led to inconsistencies in understanding its origin and management. Terms such as "Pubic Inguinal Pain Syndrome," "Sportsman's Groin," and "Athletic Pubalgia" have been proposed to standardize terminology and unify the classification of (LSGP). Pathophysiologically, (LSGP) is often due to tendinopathies affecting major tendons in the groin region, such as the adductors, iliopsoas, conjoint tendon, and inguinal ligament, often associated with weakness in the posterior wall of the inguinal canal. This condition frequently arises in sports involving abrupt directional changes and high-energy loads in the groin. Tendinopathies progress through reactive, reparative, or degenerative stages of tendinosis.

RESULTS

Literature supports a multidisciplinary approach involving surgeons, physiotherapists, sports medicine physicians, and orthopedists for accurate diagnosis and effective treatment. Our algorithm focuses on both anatomical and functional factors in managing (LSGP). Initial conservative therapies aim to support tendon regeneration and load correction, while surgical interventions, such as laparoscopic hernioplasty, are reserved for non-responsive cases. From 2004 to 2024, 12,144 patients completed this protocol, with only 14% requiring surgery. Long-term follow-up demonstrated a low recurrence rate of tendinopathy and an absence of severe complications.

CONCLUSION

Standardizing terminology, understanding pathophysiology, and utilizing a multidisciplinary approach are essential for optimizing the diagnosis and management of sports-related (LSGP).

The effects of TECAR therapy on pain, range of motion, strength and subscale of HAGOS questionnaire in athletes with chronic adductor related groin pain: a randomized controlled trial

INTRODUCTION

Groin pain is a common issue among athletes. Adductor-related pain is known as the most common cause of groin pain. Although, non-operative treatments have limited efficacy, Capacitive and Resistive Energy Transfer (TECAR), can be used in the treatment of musculoskeletal conditions. The objective of the present study is to explore the effect of TECAR therapy on pain, range of motion (ROM), strength, and subscales of the "Copenhagen Thigh and Groin Assessment Scale"(HAGOS) questionnaire in athletes suffering from adductor-related groin pain (ARGP).

METHODS

This study was a two arm parallel groups randomized sham-controlled superiority trial. A total of 22 male professional athletes (mean age 21.36 years) were randomly assigned to either the real TECAR therapy (n = 11) or sham TECAR therapy (n = 11) group, using block-balanced randomization. Both groups received stretching exercises. Intervention group received 10 sessions of TECAR therapy while, the control group received sham TECAR therapy. Primary outcome was pain that was measured by Visual Analogue Scale (VAS). Secondary outcomes included ROM, strength, and HAGOS questionnaire subscales. All outcomes were assessed at baseline, after 5 sessions, after 10 sessions, and one month after treatment. Analysis of Variance (ANOVA) and Analysis of Covariance were used to compare between-group mean differences. P-value was set at 0.05. Effect size Cohen's d was also reported. This study took place from September 2022 to August 2023 at the Rehabilitation Clinic at Iran University of Medical Sciences.

RESULTS

A total of 22 male athletes were included (11 in each group), with a mean age of 21.09 years in the TECAR group and 21.63 years in the sham group. TECAR therapy was associated with significant reductions in pain intensity across all evaluation sessions. Specifically, after 5 sessions, there was a large effect size for pain reduction (p = 0.01, Cohen's d = -1.09 [95% CI: -0.195 to -1.987]); after 10 sessions, the effect was even larger (p = 0.001, Cohen's d = -2.153 [95% CI: -1.103 to -3.203]); and at the 1-month follow-up, the pain reduction persisted (p = 0.001, Cohen's d = -1.96 [95% CI: -0.944 to -2.978]). In terms of secondary outcomes, there was a significant improvement in hip adduction ROM at the 1-month follow-up (p = 0.03, Cohen's d = 0.908 [95% CI: 0.03 to 1.78]). However, no statistically significant differences were found for other secondary outcomes, with effect sizes ranging from no effect to intermediate.

CONCLUSION

The results of this study suggest that TECAR therapy may reduce pain and improve hip adduction range of motion in athletes with adductor-related groin pain.

TRIAL REGISTRATION

This trial was registered at the ( https://www.irct.ir ), (IRCT20220622055250N1) on 18/09/2022.

Incidence, Prevalence, and Burden of Health Problems in Elite Female Ice Hockey Players-A One-Season Prospective Study

Introduction: Epidemiological studies on elite female ice hockey players are lacking but needed to tailor preventive efforts in this growing group of athletes. Therefore, the aim of this study was to describe the incidence, prevalence, and burden of health problems in elite female ice hockey players. Methods: In this prospective cohort study, we asked all Swedish Women's Hockey League (SWHL) players (N = 207) to report their health status on the OSTRC-H2 weekly throughout the 2022/2023 season (28 weeks). Reported problems were categorized as injuries (acute or overuse) or illnesses and presented as incidence per player season and mean weekly prevalence. Results: A total of 129 players (62% of all SWHL players) provided 2286 health reports with a mean weekly response rate of 67%. Mean weekly prevalence of health problems was 21% (95% confidence interval [CI]: 19-23) (injuries: 15% [95% CI: 14-17] and illnesses: 6% [95% CI: 5-8]). Injury incidence was 2.1 (95% CI: 1.8-2.4) per player season (acute: 1.2 [95% CI: 1.0-1.5] and overuse: 0.8 [95% CI: 0.7-1.1]). Illness incidence was 1.3 per player season (95% CI: 1.1-1.6). Most reported health problems were acute injuries (59.4% of reported injuries). Most common among acute injuries where to the shoulder (15%), head (13%), and knee (11%). The hip/groin was the most reported (35%) and burdensome (49% of severity score) region among overuse injuries. Reported illnesses were mostly represented by respiratory infections (75%). Conclusions: In average, one in five elite ice hockey players reported a health problem at any given time during the season. Results of this study highlight the need to develop and test primary prevention strategies for shoulder, head, and knee injuries and secondary prevention strategies for hip and groin problems.

Sportsman's Hernia repair using Nesovic procedure, a 13-year single-center experience

Sportsman's hernia is very frequent in some sports, particularly in football. This painful syndrome is reported by high-level athletes as well as amateurs. There is no consensus about the management of sportsman's hernia, because of the heterogeneity in anatomoclinic forms. In case of surgical indication, the Nesovic procedure, also named "fasciomyoplasty", is one of the recommended procedures for the abdomino-parietal forms. Our objective was to report our experience with this procedure in terms of short- and mid-term results. All the patients who underwent Nesovic procedure between January 2009 and December 2022 in our center were retrospectively reviewed. 43 patients (98% men; mean age: 29.5 ± 9.2 years) were included. 37% of patients were professional athletes. The median time from symptoms' onset to diagnosis was 3 months (range = 1-72 months). The median time from diagnosis to surgery was 7 months (range = 1-58 months). Postoperative overall morbidity occurred in six patients (14%), including scrotum swelling (n = 2), hematoma (n = 1), serous collection (n = 1) and acute urinary retention (n = 2). No major complication occurred. At the end of follow-up (median: 1 year; range = 1 month-11 years), 84% of patients recovered their previous sports activity, after a mean delay of 2 months. Nesovic procedure is efficient in more than 80% of sports patients without any major morbidity.

Is limb asymmetry an intrinsic risk factor for time-loss groin injury in professional male soccer players?

OBJECTIVES

To provide normative values for between-limb asymmetry of hip strength and range of motion (ROM) in professional male soccer players and evaluate the relationship between these asymmetries and groin injury.

DESIGN

Secondary analysis of a prospective cohort study.

METHODS

A total of 438 professional male soccer players underwent musculoskeletal screening, injury and exposure surveillance over two consecutive seasons. Between-limb asymmetry for two hip strength (eccentric adduction and abduction) and six ROM measures were calculated, and normal asymmetry considered within 1 standard deviation (SD) of the mean. Cox proportional hazard regression analysis estimated the association between asymmetry and time-loss groin injury.

RESULTS

Normal asymmetry ranged between 0.3% and 27.3% across strength and ROM variables. No association was found between groin injuries and asymmetry in eccentric hip adduction (HR = 0.99, 95%CI = 0.98-1.00; p = 0.167) or abduction strength (HR = 1.00, 95%CI = 0.99-1.01; p = 0.745). For five of the six ROM measures, no association with groin injuries were determined. A statistically significant, though likely clinically irrelevant, association was found between groin injury and dominant leg total hip rotation ROM (HR = 1.03, 95% CI = 1.00-1.05; p = 0.040).

CONCLUSION

Normal hip strength and ROM asymmetry ranged between -27 and +20%. No clinically relevant associations were found between asymmetry in hip strength or ROM and time-loss groin injuries.

LEVEL OF EVIDENCE: 2

Ultrasound of Groin Pain in the Athlete

Groin pain is a common cause of disability in athletes. Imaging is crucial in a clinical diagnosis, given the multiple associated etiologies. The main sites of groin pain are the adductors, iliopsoas muscles, inguinal ring, hip joint, and pubic symphysis. Although magnetic resonance imaging is the gold standard to image groin pain, ultrasound (US) offers excellent accuracy in pinpointing muscle injuries, inguinal disruption, and hernias. US requires a detailed knowledge of anatomical landmarks; imaging pitfalls, and pathologic patterns. We review the complex anatomy of the groin region, the sonographic appearance of the involved structures, and the strengths and weaknesses of US.

Is hip adductor or abductor strength in healthy athletes associated with future groin pain? A systematic review and meta-analysis

OBJECTIVE

To systematically review the association between hip adduction and abduction strength, and adduction-to-abduction strength ratio in healthy athletes with the occurrence of future groin pain and time-loss groin injuries.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

PubMed, Web of Science, SPORTDiscus, PEDro, Embase, and Scopus.

ELIGIBILITY CRITERIA

Studies included had to (1) measure hip adductor or abductor strength in healthy athletes, (2) conduct a follow-up period to assess the occurrence of groin pain, (3) present strength data separately for participants who remained uninjured and those who suffered an injury and (4) use a prospective design. Risk of bias was assessed according to the Quality in Prognosis Studies tool. The certainty in the evidence appraised was measured using the Grading of Recommendations Assessment Development and Evaluation approach.

RESULTS

Thirteen prospective cohort studies met the inclusion criteria. Overall study risk of bias was rated as low. Players who remained uninjured had stronger adduction strength compared with players who subsequently suffered groin pain (standardised mean differences with 95% CIs (SMD=-0.5, 95% CI -0.92 to -0.09)) and time-loss groin pain (SMD=-0.68, 95% CI -1.31 to -0.06). Trivial effects were observed for abduction strength (groin pain SMD=0.03, 95% CI -0.11 to 0.17; time-loss SMD=-0.07, 95% CI -0.25 to 0.11) and adduction-to-abduction strength ratio (groin pain SMD=-0.02, 95% CI -0.55 to 0.51; time-loss SMD=-0.11, 95% CI -1.11 to 0.89). Age and diagnostic criteria were not significant moderators of the relationship between adductor strength and groin pain (p=0.72 and p=0.12).

CONCLUSION

There is a moderate effect of hip adductor strength on the occurrence of groin pain, while there is no relationship between either abductor strength or the ratio of adductor-to-abductor strength with the occurrence of groin pain.

PROSPERO REGISTRATION NUMBER

CRD42024548630.

Assessment of hip abductor and adductor muscle strength with fixed-frame dynamometry: Considerations on the use of bilateral and unilateral tasks

OBJECTIVE

To examine the specificities and limitations of bilateral and unilateral tasks for the assessment of hip abductor and adductor strength with a commercially-available fixed-frame dynamometer.

DESIGN

Correlational/validity study.

METHODS

Maximal voluntary isometric strength of hip abductors and adductors was evaluated in 130 healthy participants using unilateral and bilateral tasks. Surface EMG activity of agonist and stabilizer muscles was concomitantly recorded in a subgroup of 15 participants.

RESULTS

For both muscle groups, bilateral tasks resulted in higher strength values than unilateral tasks (∼25%; p < 0.001). The correlation between left- and right-side data was higher for bilateral than unilateral tasks (p < 0.05), thereby resulting in lower interlimb asymmetries (p < 0.001). Agonist EMG activity was lower for unilateral than bilateral tasks (p < 0.01). Stabilizer EMG activity (external abdominal oblique) was higher for unilateral than bilateral tasks (p < 0.05) on the ipsilateral and contralateral side for hip abductors and adductors, respectively.

CONCLUSIONS

A large (25%) and quasi-systematic bilateral facilitation of strength was observed for both hip abductors and adductors. Bilateral testing led to an underestimation of interlimb asymmetries, due to higher side equivalence than unilateral tasks. Unilateral testing resulted in lower agonist EMG activity and higher stabilizer activity than bilateral tasks, especially in weaker subjects.

Monitoring hip adductor strength in professional women's football players over a season: A prospective study

OBJECTIVES

To describe the changes in hip adductor strength of professional women's football players over a season.

DESIGN

One-season prospective study.

SETTING

Facilities of a national first division club.

PARTICIPANTS

Professional women's football players.

MAIN OUTCOME MEASURES

Maximum hip adductor isometric strength in the long-lever and short-lever positions at four timepoints: early preseason, early season, mid-season, and end-season.

RESULTS

Twenty-two players completed the study. Hip adductor strength values in early preseason (134 ± 29 N in the long-lever position and 317 ± 68 N in the short-lever position) were significantly lower than in the early season (171 ± 29 N and 363 ± 54 N) and mid-season (163 ± 23 N and 369 ± 53 N). By the end of the season (150 ± 19 N and 345 ± 39 N), strength values had significantly declined from both early and mid-season levels. Visual inspection of individual athletes' strength evolution over time reveals heterogeneous responses, with some players showing trajectories opposite to the group at specific time points.

CONCLUSIONS

Hip adductor strength increased from the preseason to the start of the women's football national league, remained stable during the first half of the league, but slightly declined in the second half. The heterogeneous responses among athletes underscore the importance of individualized monitoring throughout the season.

Prevalence of Asymptomatic Changes in the Groin Region Among Adult Professional Soccer Players and Their Association With Limb Dominance

OBJECTIVE

To investigate the prevalence of asymptomatic radiologic groin region findings in adult professional soccer players using magnetic resonance imaging (MRI) and examine the influence of age and limb dominance on their occurrences.

DESIGN

Cross-sectional trial.

SETTING

Soccer club medical service, private practice.

PARTICIPANTS

Forty-seven male professional soccer players.

INTERVENTIONS

Players underwent a groin presigning MRI scan with a magnetic field induction of 1.5 Tesla. Image analysis of their pubic bones was performed according to The Copenhagen Standardized MRI protocol to assess the pubic symphysis and adductor regions of players.

MAIN OUTCOME MEASURES

The prevalence of various changes in the symphysis, pubic bone, and adjacent areas.

RESULTS

Fifty images of pubic bones and adjacent regions (53.2%) highlighted 1 to 4 changes, while another 44 images (46.8%) demonstrated 5 or more changes. The most frequent changes observed in the pubic bone were joint surface irregularities (100%), symphyseal sclerosis (93.6%), pubic bone swelling (56.3%), parasymphyseal high-intensity line (55.3%), fatty infiltration in bone marrow (38.3%), and adductor tendinopathy (34%). When comparing the prevalence of different changes in the dominant and nondominant limbs, no statistically significant differences were found.

CONCLUSIONS

In adult professional soccer players with no prior groin pain complaints in recent history (12 months), asymptomatic changes are extremely common in the pubic joint and adjacent areas, including those that are very likely to be considered the main cause of pain when investigated in soccer players with groin pain. None of these changes were associated with limb dominance.

The association between hip adductor and extensor strength, and hip-related patient-reported outcomes in patients with longstanding hip and groin pain: An exploratory cross-sectional study

OBJECTIVE

The objective of this study was to assess the association between hip muscle strength and hip-related patient-reported outcome measures (PROMs) in patients with longstanding hip and groin pain (LHGP).

DESIGN

Cross-sectional design.

SETTING

Orthopedic care.

PARTICIPANTS

Eighty-one patients with LHGP were consecutively recruited.

MAIN OUTCOME MEASURES

Hip muscle strength was measured in adduction and extension. Hip-related PROMs was measured with the Copenhagen Hip and Groin Outcome Score (HAGOS) which includes six subscales (Symptoms, Pain, Activity in Daily Living (ADL), Physical Function in Sports and Recreation (Sport/Rec), Participation in Physical Activities (PA), and Quality of Life (QoL). Linear regression examined the association between hip muscle strength and each HAGOS subscale.

RESULTS

Greater isometric hip muscle strength in adduction was associated with better HAGOS score for Pain and ADL (p ≤ 0.037), but not for Symptoms, Sport/Rec, PA, or QoL (p ≥ 0.154). Greater isometric hip muscle strength in extension was associated with better HAGOS score for Symptoms, Pain, and ADL (p ≤ 0.034), but not for Sport/Rec, PA, or QoL (p ≥ 0.084).

CONCLUSIONS

In patients with LHGP, greater isometric hip muscle strength seems to be associated with less symptoms and pain, and better function in ADL. No association was found for Sport/Rec, PA, or QoL.

Hip adduction and abduction strength in different test positions and their relationship to previous groin injuries in women footballers

Hip strength has been shown to influence the incidence of injury in women's football. The first objective of our study was to examine the differences in isometric strength of the adductors and abductors between two test positions (0° vs. 45° hip angle). Our second objective was to verify the sensitivity of the two test positions in discriminating between women footballers with and without a history of groin pain in the last twelve months. One hundred and one elite players from the Slovenian women's football league were tested. The isometric strength of the adductors, abductors, and the ratio between hip abductor and adductor strength in two different test positions were assessed. We found statistically significant differences (p < 0.05; effect size range 0.12-0.13) between the two test positions in hip adduction, abduction strength, and abductor/adductor strength ratio. The ROC analysis showed that only the abductor/adductor strength ratio at the 0° hip angle position can differentiate between players with and without a history of groin pain, with an optimal cut-off point of ≤ 1.01 (p < 0.05; AUC = 0.734). The results should help practitioners plan hip strength training for returning to sport or preventing groin pain among women football players.

Hip and Groin Problems in Female Team-Sport Athletes: A Cross-Sectional Study

Background

Hip and groin problems are common among team-sport athletes. However, few studies have been conducted in female athletes that have used the Doha Agreement classification system to categorize these problems.

Purpose

The purpose of this study was to examine the preseason point prevalence of hip and groin problems in elite female team-sport athletes. Secondary aims were to categorize the groin problems according to the Doha Agreement classification system and to explore the association between hip muscle strength and self-reported hip and groin function.

Study Design

Cross-sectional study.

Methods

Female athletes who participated in various sports underwent preseason assessment of isometric hip adduction and abduction strength, with pain levels recorded during respective contractions, and self-reported function on the Copenhagen Hip and groin Outcome Score (HAGOS). If any athlete reported current hip and groin problems during this screening assessment, a full, standardized clinical hip and groin examination was undertaken. These hip and groin problems were then categorized according to the Doha Agreement classification system. Comparisons between the participants with vs without hip and groin problems were made, and correlational statistics were used to examine relationships between strength and HAGOS scores.

Results

Ninety-one elite female athletes from six different sports were included in the study. Thirteen athletes reported current hip and groin problems, with an overall prevalence rate of 14.3%. Iliopsoas-related groin pain was the most common category diagnosed, accounting for 58.8% of cases, followed by hip-related groin pain (17.6%), adductor-related (11.8%), and inguinal- and pubic-related pain (both 5.9%). No association was found between strength and function.

Conclusion

The hip and groin point prevalence in female athletes documented during preseason appears to be similar to those reported in male athletes. Iliopsoas-related groin pain was the most common clinical entity reported in female athletes in this study. There was no association between hip muscle strength and self-reported hip and groin function.

Level of Evidence

3b.

An Evaluation of the Design of Multimedia Patient Education Materials in Musculoskeletal Health Care: Systematic Review

BACKGROUND

Educational multimedia is a cost-effective and straightforward way to administer large-scale information interventions to patient populations in musculoskeletal health care. While an abundance of health research informs the content of these interventions, less guidance exists about optimizing their design.

OBJECTIVE

This study aims to identify randomized controlled trials of patient populations with musculoskeletal conditions that used multimedia-based patient educational materials (PEMs) and examine how design was reported and impacted patients' knowledge and rehabilitation outcomes. Design was evaluated using principles from the cognitive theory of multimedia learning (CTML).

METHODS

PubMed, CINAHL, PsycINFO, and Embase were searched from inception to September 2023 for studies examining adult patients with musculoskeletal conditions receiving multimedia PEMs compared to any other interventions. The primary outcome was knowledge retention measured via test scores. Secondary outcomes were any patient-reported measures. Retrievability was noted, and PEMs were sourced through search, purchase, and author communication.

RESULTS

A total of 160 randomized controlled trials were eligible for inclusion: 13 (8.1%) included their educational materials and 31 (19.4%) required a web search, purchase, or direct requests for educational materials. Of these 44 (27.5%) studies, none fully optimized the design of their educational materials, particularly lacking in the CTML principles of coherence, redundancy, modality, and generative activities for the learner. Of the 160 studies, the remaining 116 (72.5%) contained interventions that could not be retrieved or appraised. Learning was evaluated in 5 (3.1%) studies.

CONCLUSIONS

Musculoskeletal studies should use open science principles and provide their PEMs wherever possible. The link between providing multimedia PEMs and patient learning is largely unexamined, but engagement potential may be maximized when considering design principles such as the CTML.

The effectiveness of the Copenhagen adduction exercise on improving eccentric hip adduction strength among soccer players with groin injury: a randomized controlled trial

INTRODUCTION

Groin injuries are common in soccer players and often involve adductor muscle strains. The Copenhagen Adduction Exercise (CAE) is a targeted intervention whose effectiveness in rehabilitation for these injuries warrants investigation.

OBJECTIVE

To investigate the impact of a rehabilitation program, which includes the CAE, on eccentric hip adduction (EHAD) strength, hip joint range of motion (ROM), self-reported disability, and pain among soccer players with adductor-related groin pain. It was hypothesized that the addition of CAE to the rehabilitation program would yield greater improvements.

METHODS

Employing a randomized controlled trial with a two-group parallel design, thirty male soccer players with a mean age of 26.4 ± 3.9 years were randomized into an intervention group (IG) including CAE (n = 15) and a control group (CG) without CAE (n = 15), based on a power analysis to ensure 80% power to detect significant differences. Both groups engaged in their respective rehabilitation programs twice a week for eight weeks. The primary outcome measured was EHAD strength, while secondary outcomes included hip joint ROM, self-reported disability measured by the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain levels.

RESULTS

Significant improvements within groups were observed across all measures (p < 0.001). The IG demonstrated a greater increase in EHAD strength (Mean Difference [MD] = 0.49 Nm/kg, 95% Confidence Interval [CI] [0.31, 0.66]), a more pronounced reduction in pain (MD = -1.60, 95% CI [-2.18, -1.02]), and betterment in all HAGOS subscale scores compared to the CG. There were no significant between-group differences in hip joint ROM.

CONCLUSION

Incorporating the CAE into rehabilitation programs significantly improves EHAD strength, decreases pain scores, and reduces self-reported disability in soccer players with adductor-related groin pain.

REGISTRATION

ClinicalTrials.gov identifier: NCT05589623.

Relationship Between Hip and Groin Pain and Hip Range of Motion in Amateur Soccer and Australian Rules Football Players

Background

The relationship between hip/groin pain and hip range of motion (ROM) is unclear.

Purpose

To explore the relationship between hip/groin pain and hip joint ROM and examine the influence of sex and cam morphology on this relationship.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were 184 amateur soccer and Australian Rules football players (276 hips; 20% women; median age, 26 years; interquartile range, 24-30 years) with hip/groin pain >6 months and a positive flexion-adduction-internal-rotation (FADIR) test, and 50 matched asymptomatic control players (98 hips; 28% women, median age, 26 years; interquartile range, 23-31 years). Hip ROM measures were flexion, internal and external rotation at 90° of hip flexion, total rotation (internal and external), and bent-knee fall out (BKFO). Cam morphology was determined from anteroposterior pelvis or 45° Dunn radiographs, defined by an alpha angle ≥60°. Linear regression models with generalized estimating equations were used to examine the relationship between group (symptomatic and asymptomatic) and each ROM measure. Interaction terms (group × cam morphology or group × sex) were included to examine if relationships between group and hip ROM were influenced by cam morphology or sex. Where appropriate, models were adjusted for sex, age, and cam morphology.

Results

An interaction between the relationship between group × cam and internal rotation ROM was found. Symptomatic players with cam morphology had lower internal rotation ROM than controls with cam morphology (adjusted mean difference [AMD] = -4.5°; 95% CI, -7.4° to -1.6°). Hip/groin pain was not associated with internal rotation ROM if cam morphology was absent. A significant interaction was also found for group × sex and BKFO and total rotation ROM. Symptomatic women had lower total rotation ROM than control women (AMD = -8.2°; 95% CI, -14.1° to -2.2°), but no difference was seen in men. BKFO range was lower in men with hip/groin pain compared with control men (AMD = 1.6 cm; 95% CI, 0.3-3.0 cm), but no difference was seen in women. Flexion and external rotation ROM did not differ between symptomatic and control hips.

Conclusion

Cam morphology was an effect modifier of the relationship between hip/groin pain and internal rotation ROM. Sex-related differences were also observed in the relationship between hip/groin pain and hip ROM.

Hip Sideline Emergencies and Hip Injuries in Elite Athletes

PURPOSE OF REVIEW

Hip injuries in elite athletes are an increasingly recognized problem and range from chronic overuse injuries, such as adductor strains and labral tears, to acute traumatic injuries such as hip dislocations. In this article, we review common hip pathology experienced by elite athletes and sideline management of emergent hip injuries.

RECENT FINDINGS

Elite athletes are subject to unique physical and mental stresses and therefore must be evaluated and treated in a unique manner. Hip and groin injuries account for approximately 6% of sport injuries overall and 3-15% of all injuries in professional sports. Hip sideline emergencies were rare but can include hip dislocations, subluxations, and avulsion fractures. Hip and groin injuries represent an important subset of injuries which can greatly impact an athlete's ability to perform. Understanding the physiology and types of hip/groin injuries, which athletes are prone to injuries, the impact on recovery time, recurrence risk, and the potential need for surgery aid sports medicine physicians in decision-making.

The epidemiology of hip and groin pain and Femoroacetabular Impingement Syndrome (FAIS) in male and female Gaelic games players

OBJECTIVES

Hip and groin pain is common in Gaelic games players, but data are limited to elite males with poor representation of females. The aim of this study was to examine the prevalence, severity and factors associated with hip and groin pain and Femoroacetabular Impingement Syndrome (FAIS) in male and female Gaelic games players.

METHODS

A representative national sample of Gaelic games players completed a survey providing demographic information and details related to self-reported episodes of hip and groin pain and FAIS diagnosis within the last year. Players from multiple age grades, codes (Football/Hurling/Camogie) and levels of Gaelic games were included.

RESULTS

A total of 775 players responded to the survey. The annual prevalence of hip and groin pain was 54.8%. Almost half of players (48.8%) continued to participate in sport, while 18.7% ceased participation and 32.5% reported reduced participation. Although 40% of episodes lasted no longer than 3 weeks, there was a high recurrence rate (33.5%). FAIS was reported by eight players, representing 1.9% of hip and groin complaints. Logistic regression models indicate male sex, playing both codes of Gaelic games and participating in additional sport were significant factors in predicting hip and groin pain.

CONCLUSION

Hip and groin pain is prevalent in Gaelic Games with FAIS accounting for a small proportion of cases. However, consideration of indicators of severity (participation impact/symptom duration/medical attention) is essential in understanding the context and magnitude of these hip and groin issues. Male players and players engaging in multiple sports are more likely to experience hip and groin pain.

Association between Hip/Groin Pain and Hip ROM and Strength in Elite Female Soccer Players

Background/Objectives: Hip strength and range of motion have been compared in soccer players with and without hip and groin pain but only in male footballers or gender-combined samples. In female soccer players, the biomechanics contributing to this injury remain poorly understood compared to other sporting injuries. The aim of the present study is to investigate whether differences exist in adductor and abductor isometric test values and hip joint range of motion between elite female soccer players with longstanding groin pain and injury-free controls. Methods: Ten female elite soccer players with current longstanding hip and groin pain and twenty-five injury-free controls from the same teams were included in the study. Hip adductor and abductor isometric strength were evaluated with a hand-held dynamometer. A bent knee fall-out test was also utilized to examine the hip joint range of motion. Results: A significant difference in abductor isometric test values was observed between the control group (2.29 ± 0.53 N/Kg) and the hip and groin pain group (2.77 ± 0.48 N/Kg; p = 0.018). Furthermore, the injured group showed a decreased adductor/abductor ratio compared to the control group (1.00 ± 0.33 vs. 1.27 ± 0.26; p = 0.013). No differences were observed in the bent knee fall-out test (p = 0.285). Conclusions: Female elite soccer players with current longstanding hip and groin pain exhibited higher abductor isometric strength and lower adductor/abductor ratio compared to non-injured women players. There were no differences in the BKFO test between groups.

Cleft Sign in MRI May Represent the Disruption of Cartilage Structure within Pubic Symphysis and Pubic Plate: A Cadaver Case Report

BACKGROUND/OBJECTIVES

Long-standing groin pain is a severe issue for athletes, often associated with the cleft sign on magnetic resonance imaging (MRI) scans, yet its underlying causes are poorly understood. The purpose of this study is to histologically examine the pubic plate structure in cadavers with and without the cleft sign on MRI, shedding light on the pathology behind the cleft sign.

METHODS

Three fresh human pelvic cadavers underwent 3.0T MRI to detect the cleft sign before histological dissection of pubic plates. Pubic plate tissues were fixed in formalin, decalcified, and processed. Of the two cleft sign-negative specimens, one was cut into sagittal sections, and the other was cut into coronal sections for histology. For the cleft sign positive specimen, a sagittal section was cut. Moreover, 5 µm thick sections were cut at different axial levels for each orientation. Sections were subjected to Safranin O, Alcian blue, and Herovici's staining or hematoxylin and eosin staining.

RESULTS

MRI confirmed that one specimen had a cleft sign in the inferior region on both sides of the pubis and that two specimens had no cleft sign. Both sagittal and coronal sections showed the presence of a cartilage structure continuing from the pubic symphysis to 3 mm laterally within the pubic plate. In the specimen with a positive cleft sign, cartilage damage within the pubic symphysis and pubic plate was identified as revealed by Safranin O staining, Herovici's staining, and H&E staining.

CONCLUSIONS

This study elucidated the existence of a cartilage component extending from the pubic symphysis to the pubic plate. The cleft sign in MRI correlated with a disruption in the cartilage component in histology within this specific area.

The Translation, Cross-Cultural Adaptation and Validation of the Italian Version of the Hip and Groin Outcome Score Questionnaire for a Young and Active Population

The HAGOS (Hip and Groin Outcome Score) questionnaire is a valid and reliable measure of the self-assessment of symptoms, activity limitation, participation restriction, and quality of life (Qol) of subjects with hip and/or groin pain. The aims of this study are to translate and transculturally adapt the HAGOS into Italian (HAGOS-I) and to assess its internal consistency, validity, and reliability in physically active, young, and middle-aged subjects. The translation and transcultural adaptation of (HAGOS-I) was carried out according to international guidelines. Eight-one subjects (mean age 28.19) were included in this study. All the participants completed the HAGOS-I, the Lower Extremity Functional Scale (LEFS-I), the Oxford Hip Score (OHS-I), and the Short Form 36 Health Surveys (SF-36-I). The Cronbach's α for the six HAGOS subscales ranged from 0.63 to 0.87. Statistically significant correlations were obtained between the six HAGOS-I subscales and the LEFS-I (rs = 0.44-0.68; p < 0.01). Only one HAGOS-I subscale (Participation in Physical Activities) did not reach statistical significance with the OHS-I, while the remaining five had a moderate correlation (rs = 0.40-0.60; p < 0.01). The test-retest reliability (Intraclass Correlation Coefficient) ranged from 0.57 to 0.86 for the six HAGOS-I subscales. The HAGOS-I is a valid and reliable instrument that can be used in clinical settings with young and middle-aged subjects with hip and/or groin pathologies.

Athletes With Adductor-Related Groin Pain: A Narrative Review

Adductor-related groin pain is extremely common among athletes, and despite its high prevalence and impact, there is no consensus regarding taxonomy, anatomy, physiopathology, or treatment. We performed a comprehensive literature review and tried to demystify this pathology and its treatment. The Doha agreement classification and its impact are scrutinized as well as the complexity of the proximal adductor longus (AL) insertion and its relationship with the pyramidalis-anterior pubic ligament-AL complex. The stress-shielding and compression theories for the origin of AL tendon pathology are exploited along with how this knowledge translates into injury prevention protocols and surgical techniques. The importance of active rehabilitation protocols and intersegmental control-focused programs is highlighted. The role of an enthesis injection in the treatment algorithm is discussed along with when to perform a tenotomy. The differences between selective and complete tenotomy are highlighted.

Femoroacetabular Impingement and Groin Injuries Among Soccer Players

Groin injuries and femoroacetabular impingement are common among soccer players and can provide a challenge in diagnosis, as well as treatment. Nonoperative and operative measures are the 2 predominant treatments. This current review investigates the recent literature on groin and femoroacetabular impingement injuries in soccer players, as well as potential treatment modalities.

Predicting the occurrence of in-season groin pain in male high school soccer players: a cohort study

[Purpose] This study investigated whether pre-season HAGOS (Japanese Copenhagen Hip and Groin Outcome Scores) and eccentric muscle strength of the hip muscles predict in-season groin pain incidences in high school soccer players. [Participants and Methods] This study had a cohort design. The participants were male high school players under 18 years playing in the Japan Soccer League, which is an elite-level soccer league of that age category in Japan. The HAGOS and the strength of hip abductor and adductor muscles in eccentric contraction were measured before the season, and hip and groin pain incidences were recorded during the season. Multiple logistic regression analysis was performed to investigate the factors derived from the pre-season HAGOS and hip muscle strength tests, presumably pertaining to the development of in-season groin pain. [Results] The eccentric adductor muscle strength of the dominant leg and the HAGOS were selected as factors associated with groin pain during the season. [Conclusion] Low pre-season HAGOS and weak dominant-leg eccentric adductor muscle strength were suggested as factors to predict in-season groin pain occurrence in male high school soccer players.

Effectiveness of 12-Week Core Stability Training on Postural Balance in Soccer Players With Groin Pain: A Single-Blind Randomized Controlled Pilot Study

BACKGROUND

Core stability training (CST) is effective in improving postural balance, core endurance, and self-reported outcomes in different populations. This study aimed to investigate the effect of CST in soccer players with groin pain (GP).

HYPOTHESIS

CST would improve postural balance performance, core endurance, and self-reported outcomes in soccer players with GP.

STUDY DESIGN

Randomized controlled trial.

LEVEL OF EVIDENCE

Level 2.

METHODS

Soccer players with GP who met the selection criteria were assigned randomly to a CST (CSTG, n = 10) or a control (CG, n = 10) group. The CG undertook no additional physical activity program besides their usual training. The CSTG performed a 12-week CST comprising 76 ~75 min sessions. Static (force platform) and dynamic (Y-Balance test) postural balance, core endurance (McGill trunk endurance tests), and self-reported outcomes (Copenhagen Hip and Groin Outcome Score [HAGOS]) were assessed before and immediately after the 12-week CST.

RESULTS

Significant improvements were seen in dynamic postural balance (P = 0.04 to <0.01), HAGOS scores (P = 0.02 to <0.01), and core endurance measures (P < 0.01) in the CSTG in posttest compared with pretest session and compared with CG. Static bipedal postural balance measures showed significant improvements (eyes open, P = 0.02; eyes closed, P < 0.01) in the CSTG in posttest compared with pretest session. However, no significant differences (P > 0.05) were observed between CSTG and CG after the training period.

CONCLUSION

A 12-week CST improved static (foam surface) and dynamic postural balance, core endurance measures, and HAGOS scores.

CLINICAL RELEVANCE

The beneficial effect of CST on improving postural balance, core endurance, and self-reported outcomes in soccer players with GP suggests that this training would be an important feature of rehabilitation programs for these players. Coaches and clinicians should prioritize CST training when designing rehabilitation programs.

Core stability is associated with dynamic postural balance in soccer players experiencing groin pain without time-loss

Objectives

The study sought to evaluate possible relationships between dynamic postural balance and pain, core stability, and hip range of motion in soccer players who were experiencing groin pain (GP). Furthermore, the study aimed to compare these measurements in symptomatic and asymptomatic players.

Methods

The study included 42 male soccer players experiencing GP and an equal number of asymptomatic players. Dynamic postural balance, pain, hip range of motion and trunk endurance were measured.

Results

The GP group revealed reduced dynamic balance performance (p < 0.01-0.001) in injured and non-injured limbs compared to control group. Further, players experiencing GP demonstrated lower hip range of motion in internal (p < 0.05) and total rotations (p < 0.01) in the injured limb, and lower trunk endurance (p < 0.001) compared to their asymptomatic peers. In general, core stability was associated (r = 0.13-0.61, p < 0.05-0.001) with the poor dynamic balance performance in the GP group while standing on injured and non-injured limbs. No significant correlations between dynamic postural balance, pain and hip range of motion were observed.

Conclusion

Poor core endurance was found to be associated with dynamic balance disorders in soccer players experiencing GP. This information can aid in the development of targeted strategies to enhance dynamic postural balance in these players.

Is hip capsule morphology associated with hip pain in patients without another structural correlate?

OBJECTIVE

The goals of this study were (i) to assess the association between hip capsule morphology and pain in patients without any other MRI abnormalities that would correlate with pain and (ii) to investigate whether hip capsule morphology in hip pain patients is different from that of controls.

METHODS

In this study, 76 adults with hip pain who did not show any structural abnormalities on MRI and 46 asymptomatic volunteers were included. Manual segmentation of the anterior and posterior hip capsules was performed. Total and mean anterior hip capsule area, posterior capsule area, anterior-to-posterior capsule area ratio, and medial-to-lateral area ratio in the anterior capsule were quantified. Differences between the pain and control groups were evaluated using logistic regression models.

RESULTS

Patients with hip pain showed a significantly lower anterior-to-posterior area ratio as compared with the control group (p = 0.002). The pain group's posterior hip capsule area was significantly larger than that of controls (p = 0.001). Additionally, the ratio between the medial and lateral sections of the anterior capsule was significantly lower in the pain group (p = 0.004).

CONCLUSIONS

Patients with hip pain are more likely to have thicker posterior capsules and a lower ratio of the anterior-to-posterior capsule area and thinner medial anterior capsules with a lower ratio of the medial-to-lateral anterior hip capsule compartment, compared with controls.

CLINICAL RELEVANCE STATEMENT

During MRI evaluations of patients with hip pain, morphology of the hip capsule should be assessed. This study aims to be a foundation for future analyses to identify thresholds distinguishing normal from abnormal hip capsule measurements.

KEY POINTS

• Even with modern image modalities such as MRI, one of the biggest challenges in handling hip pain patients is finding a structural link for their pain. • Hip capsule morphologies that correlated with hip pain showed a larger posterior hip capsule area and a lower anterior-to-posterior capsule area ratio, as well as a smaller medial anterior capsule area with a lower medial-to-lateral anterior hip capsule ratio. • The hip capsule morphology is correlated with hip pain in patients who do not show other morphology abnormalities in MRI and should get more attention in clinical practice.

MR imaging spectrum of adolescent pubic symphyseal injuries/athletic pubalgia

BACKGROUND

Magnetic resonance imaging (MRI) findings associated with athletic pubalgia are well documented in the adult literature.

OBJECTIVE

To describe the spectrum of MRI findings in adolescents with pubic symphyseal injuries/athletic pubalgia.

MATERIALS AND METHODS

This is an institutional review board approved, retrospective study of all patients < 18 years who were referred for MRI, over the last 10 years. Two pediatric musculoskeletal radiologists evaluated the MRI in consensus for the following findings: Chronic Salter-Harris (SH)-I equivalent fracture or asymmetric parasymphyseal ossific fraying, non-retractile muscular tear or retraction, and edema of the aponeurosis and arcuate ligament. Radiographs were also reviewed for Risser stage.

RESULTS

Fifteen patients were identified (100% male, median age 17 years, IQR 16-17.6). Most patients (14/15, 93%) had either asymmetric parasymphyseal ossific fraying (4/15, 27%) or chronic SH-1 equivalent fracture (10/15, 67%) of the pubic symphysis, and all patients (15/15, 100%) had aponeurotic and arcuate ligament edema. Few patients had rectus abdominis muscular retraction (2/15, 13%), non-retractile muscular tear of the rectus abdominis (2/15, 13%), and/or adductor muscle (4/15, 27%). Risser stage was as follows: stages 0 (13%), 3 (7%), 4 (47%), and 5 (33%). The injuries in our limited data set were independent of skeletal maturity with no statistically significant association between any of the MRI findings and Risser stage.

CONCLUSION

The MR imaging spectrum of adolescent athletic pubalgia differs from the described findings in adults due to skeletal immaturity. The cleft sign described in adults manifests in adolescents as asymmetric parasymphyseal ossific fraying and chronic SH-1 equivalent fractures.

High Prevalence of Seasonal and Current Groin Problems in Rink Hockey Players

Groin problems are common in multidirectional sports. The aim of the present study is to assess seasonal, current, and trends for groin problems in rink hockey players, irrespective of their playing position, age, or gender. Rink hockey players from three countries [n=446 (162 female, 284 male)] were invited to participate in an online questionnaire. This form evaluated the prevalence of groin problems (time-loss and non-time-loss) for the 2022-2023 season, as well as monthly prevalence of groin problems (time-loss and non-time-loss). All groin problems were compared between playing position, gender, and age to assess between-group differences. Senior males reported the highest time-loss (25%) and non-time-loss (51%) for seasonal prevalence; while U-17 males reported the lowest in both categories of groin problems (time-loss 9%, non-time-loss 27%). No significant differences between playing position or gender were found for any of the groin problems analyzed. In-season prevalence (9-15.7%) of groin problems was significantly higher than pre-season (7.4%) prevalence (p<0.01). Seasonal prevalence of groin problems is common in rink hockey, regardless of gender, playing position, or age. Preventive efforts should be directed towards all players, regardless of their individual characteristics.

A New Clinical Examination Algorithm to Prescribe Conservative Treatment in People with Hip-Related Pain

Hip-related pain is a common issue in active adults affecting their quality of life, mobility, and overall function, and it can lead to persistent disability. However, diagnosing hip-related pain is challenging due to the many potential sources and causes, including intra-articular and extra-articular pathology, and referred pain from other areas (lumbar or groin related pain). To address this, there is a need for a clinical algorithm based on the best available evidence and expert consensus. This algorithm could guide healthcare professionals in assessing and managing patients with hip-related pain, during the diagnosis, test selection, intervention, monitoring, and promoting collaboration among various healthcare providers. This clinical algorithm for hip-related pain is a comprehensive, flexible, adaptable to different settings, and regularly updated to incorporate new research findings. This literature review aims to establish a clinical algorithm specifically for prescribing exercise treatment to patients with hip-related pain, addressing their individual needs and enhancing their overall care.

New Anatomical Concepts regarding Pubic-Related Groin Pain: A Dissection Study

OBJECTIVE

Pubis-related groin pain remains a difficult topic in orthopedic and sports medicine. A better understanding of the anatomy of the adductors and the pubic ligaments is necessary. The aim of this study is to map all the musculotendinous attachments to the pubic ligaments and to investigate in detail all the possible inter-adductor fusions.

METHODS

The pubic symphyses were dissected in eight male and fourteen female embalmed cadavers (mean age 85 years), focusing on the fusion between the adductors, pubic ligaments, and musculotendinous attachments at the pubic ligaments. The 95% confidence intervals for the prevalence of the different conjoint tendons and tendon attachment to ligament were calculated.

RESULTS

The presence of three types of conjoint tendons was found: adductor brevis and gracilis (AB/G) 90.9 [72.2 - 97.5]%; adductor brevis and adductor longus (AB/AL) 50.0 [30.7 - 69.3]%; adductor longus and gracilis (AL/G) 50.0 [30.7 - 69.3]%. The AL, AB and G were in every cadaver attached to the anterior pubic ligament (APL). 64% of the AB and 100% of the G were attached to the inferior pubic ligament (IPL).

CONCLUSION

The proximal anatomy of the adductors is more complex than initially described. This study identified three possible conjoint tendons between the proximal adductors. The AB/G conjoint tendon was significantly more present than the AB/AL or AL/G conjoint tendon. The IPL has attachments only from the AB and G. Rectus Abdominis (RA) and AL were not attached to IPL. Mapping the musculotendinous attachments on the pubic ligaments creates more clarity on the pathophysiology of lesions in this area.

Ozone Therapy for a Soccer Player With Osteitis Pubis: A Case Report

CONTEXT

Osteitis pubis (OP), which occurs as a result of excessive use of the symphysis pubis and parasymphysis bones, is more common in long-distance runners and kicking athletes, especially football players. Due to the poor results of commonly used treatments for OP, there is a need for investigation of more effective treatments, such as ozone therapy. Ozone therapy is used to treat a variety of diseases, including musculoskeletal conditions.

CASE PRESENTATION

A 30-year-old amateur soccer player diagnosed with OP received conservative treatment with traditional physiotherapy and analgesic medications. After 6 months and no resolution of symptoms, the patient presented to the sports medicine outpatient clinic seeking alternative therapy options.

MANAGEMENT AND OUTCOMES

The patient received ozone injections in 3 sessions administered at 10-day intervals. At 1, 3, 6 and 12 months after the treatment, the patient's complaints and pain levels were re-evaluated and examined. The patient was able to return to competition at the same level after the first injection. No recurrence was revealed at a minimum of 12 months of follow-up.

CONCLUSION

In this article, we present a case in which OP was successfully treated with ozone injection.

Groin injuries in women's premier league football in Norway: A two-season prospective cohort study describing clinical and imaging characteristics

OBJECTIVE

To describe the prevalence, incidence, and burden of groin injuries in the Norwegian women's premier football league and to describe their clinical and imaging characteristics.

METHODS

During the 2020 and 2021 seasons, players in the Norwegian women's premier league reported groin injuries weekly, using the Oslo Sports Trauma Research Centre Questionnaire on Health Problems (OSTRC-H2). We calculated weekly prevalence, incidence, and burden of groin injuries. The team physical therapists classified the player-reported injuries based on the Doha classification system. Injuries with more than 3 days' time loss or reported in 2 consecutive weeks were eligible for magnetic resonance imaging (MRI).

RESULTS

On average, 3.9% (95% CI: 3.4-4.4) of players reported a groin injury at any time; of which 78% caused time loss. The incidence rate was 1.6 injuries/1000 h (95% CI: 1.3-2.0) and their burden was 11 days lost/1000 h. The physical therapists examined 67 of 124 player-reported groin injuries (53%). Adductor-related injury was most common (55%) followed by iliopsoas (15%) and rectus femoris-related (12%). Pubic-related injuries caused most time loss (median: 24 days, IQR: 5-133). In this study, 42 injuries were investigated with MRI; 8 (19%) showed no changes, 6 (14%) an acute musculotendinous lesion, and 32 (76%) a nonacute finding (e.g., central symphyseal disc protrusion, tendinopathies).

CONCLUSION

The incidence rate and burden of groin injuries were high. Adductor-related injuries were most common, but pubic-related injuries caused most time loss. Most MRI examinations demonstrated nonacute findings.

Comparison Between Movement Pattern Training and Strengthening on Kinematics and Kinetics in Patients With Chronic Hip-Related Groin Pain

The purpose of this study was to compare the preliminary effects of movement pattern training (MoveTrain) versus strengthening/flexibility (standard) treatment on hip and pelvic biomechanics in patients with chronic hip-related groin pain. This is a secondary analysis of data collected during a pilot randomized clinical trial. Thirty patients with hip pain, between the ages of 15 and 40 years, were randomized to MoveTrain or standard. Both groups completed 10 treatment sessions over 12 weeks along with a daily home exercise program. Three-dimensional motion analysis was used to collect kinematic and kinetic data of the pelvis and hip during a single-leg squat task at pretreatment and immediately posttreatment. Compared with the standard group, the MoveTrain group demonstrated smaller hip adduction angles (P = .006) and smaller hip external adduction moments (P = .008) at posttreatment. The desired changes to hip joint biomechanics, as found in this study, may require specificity in training that could allow health care professionals to better customize the rehabilitation of patients with hip pain. These findings can also be applied to the design and implementation of future clinical trials to strengthen our understanding of the long-term implications of different rehabilitation techniques for patients with hip pain.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement

ABSTRACT

Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement

ABSTRACT

Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Clinical examination tests for adductor- and pubic-related groin pain in athletes with longstanding groin pain: Inter-examiner reliability and prevalence of positive tests

OBJECTIVES

Evaluate the inter-examiner reliability of pain provocation tests for hip adductors (palpation, stretch and resistance) and for pubic symphysis (palpation) in athletes with longstanding groin pain, and to determine the prevalence of positive tests.

DESIGN

Inter-examiner reliability.

SETTING

Orthopaedic and sports medicine hospital.

PARTICIPANTS

Male athletes with longstanding groin pain.

MAIN OUTCOME MEASURES

Inter-examiner reliability, absolute/positive/negative agreement, and the mean prevalence of positive tests for athletes classified with adductor- and pubic-related groin pain were calculated.

RESULTS

We included 44 male athletes with longstanding groin pain (61 symptomatic sides). The mean age was 29 years (±6) and 70% were soccer players. Inter-examiner reliability was slight to moderate for adductor palpation (Cohen's Kappa statistic(κ)) = 0.02-0.54) and pubic palpation (κ = 0.37-0.45); moderate for the adductor stretch test (κ = 0.50), and fair to substantial for adductor resistance tests (κ = 0.22-0.74). Palpation pain was most prevalent at the adductor longus origin (94%) in athletes classified with adductor-related groin pain.

CONCLUSION

The inter-examiner reliability of palpation tests varied from slight to moderate. The adductor stretch test had a moderate reliability, and adductor resistance tests a fair to substantial reliability. Adductor longus origin is the main site for palpation pain. Adductor palpation tests not related to the adductor longus have limited inter-examiner reliability. The adductor stretch test did not assist in classifying adductor-related groin pain.

Dynamic Magnetic Resonance Imaging (MRI) in Inguinal-Related Chronic Groin Pain (CGP): Comparison With Systematic Surgical Assessment

Objective This study aimed to assess the performance of dynamic MRI in Chronic Groin Pain (CGP) related to the inguinal region, comparing it with surgery as the gold standard. Materials and methods A cohort of 25 consecutive patients exhibiting persistent clinical inguinal-related CGP underwent a pre-surgical pelvis MRI. Imaging encompassed strictly axial Fast Spin Echo (FSE) T1 sequences, both without (static sequence) and with Valsalva Maneuver (VM, dynamic sequence), alongside axial-oblique Proton Density weighted with Fat Saturation (PDFS). Evaluation of these sequences focused on identifying Abdominal Wall (AW) injuries. A consistent surgical approach was employed by the same surgeon across all patients (34 AW injuries in 25 patients). Specificity (Sp), Sensitivity (Se), Negative Predictive Value (NPV), Positive Predictive Value (PPV), and overall accuracy of MRI sequences and their combinations for detecting AW injuries were computed by comparing them to surgical findings. Results Ninety sequences were obtained, revealing that the axial PDFS oblique sequence emerged as the most singularly reliable (Accuracy: 58.82%). The optimal sequence combination was found to be axial T1 combined with axial T1 VM, exhibiting an accuracy of 75.00% (Se: 85.71%, Sp: 70.59%, PPV: 54.55%, NPV: 92.31%, with an average duration of 4 minutes and 31 seconds). Conclusion Based on our findings, we advocate for the adoption of the axial FSE T1 combined with Valsalva Maneuver as a dependable protocol for inguinal-related CGP, characterized by a highly reasonable examination duration.

Is there a relationship between static postural control and core stability? A cross-sectional study in soccer players with groin pain

Background

Static postural control disorders have been documented in soccer players suffering from groin pain (GP). Understanding the mechanisms of these disorders is crucial in designing rehabilitation programs.

Objectives

To (i) assess static postural control and core stability in soccer players suffering from GP compared to their peers and (ii) explore the relationship between these two parameters.

Methods

This cross-sectional study involved 42 male soccer players suffering from GP (GP group: GPG) and 42 healthy players (control group: CG). Static postural control (stabilometric platform) and core stability (core endurance tests) were assessed.

Results

Center of pressure velocity in the GPG was significantly higher compared to the CG during bipedal stance on the firm surface with eyes closed (2.66 [95 % CI: 0.86-3.67]; p < 0.01) and on the foam one (p < 0.001) in both conditions; eyes opened (2.88 [95 % CI: 1.42-4.43]) and closed (5.88 [95 % CI: 2.66-9.10]), and on the IL in eyes closed (12.54 [95 % CI: 4.27-20.80]; p < 0.01). Besides, GPG revealed significant (p < 0.001) lower core stability measures compared to CG. No significant associations (p > 0.05) were observed between static postural control and core stability in GPG.

Conclusion

Soccer players suffering from GP showed static disorders of postural control compared with their peers. These impairments were not associated with measures of core stability. These findings provide insight into the direction of future research exploring the mechanisms underlying deficits in static postural control in soccer players suffering from GP.