The Role of Exercise Therapy in Exercise-Related Groin Pain by Athletes

Exercise related groin pain are very common in high intensity athletic activities, especially in sports, that require running, changes in direction, repetitive kicking and twisting [1]. The groin region contains a lot of anatomical structures and different issues. Because of the numerously pathologies several comparable diagnostic signs and symtoms are called by different diadnoses. In consequence there exist a lot of variable suggestions for therapy and rehabilitation. Therefore in 2014 a consensus statement about 'Treatment of the Sportsman's groin' was published to evaluate the available evidence on the effectiveness of exercise therapy [2]. At the same time a Cochrane review about evidence level of exercise therapy was published [3].

The first step, before treating an athlete with exercise related groin pain ist he exclusion of other pathologies and provide the correct diagnosis.

Tab. 1: [7]

	Exercise	Prescription
Module 1 (first 2 weeks)	Static adduction against ball (knees extended)	30 secs, 10 reps
	Static adduction againts ball (knees bent)	30 secs, 10 reps
	Abdominal sit ups straight and in oblique directions	5 sets, 10 reps
	Combined abdominal sit up and hip flexion with ball between knees	5 sets, 10 reps
	Balance training	5 mins
	Sliding board with feet parallel and apart at 90 degree angle	1 min, 5 sets, each leg
Module 2 (from 3rd week performed twice each session)	Leg abduction and adduction side lying	5 sets, 10 reps
	Low back extensions prone over a couch	5 sets, 10 reps
	Standing one leg weight pulling abduction and adduction	5 sets, 10 reps, each leg
	Abdominal sit ups straight and in oblique directions	5 sets, 10 reps
	Cross country skiing exercis on one leg	5 sets, 10 reps, each leg
	Lateral training on 'fitter'	5 mins
	Balance training	5 mins
	Skating movements on sliding board	1 min, 5 sets
	Eccentric strengthening using weight machines for hip adduction, adduction, flexion and abdominals	20 rep max progressed to 10 rep max
(Holmich et al 1999; Holmich et al 2011; Weir et al, 2011; Thorborg et al, 2013)

Hölmich [4] described three primary patterns of groin pain in athletes, that suggest pathology in the adductors, the ilopsoas and the rectus abdominis. Based on these clinical entities exercise programs have been developed and successfully applied. Cowan et al. [5] again showed a delayed onset of transversus abdominis in long standing groin pain. Ekstrom [6] measured electromyografically the amount of activation of several muscles while doing different exercises. The results showed that some exercises can be used for strengthening certain muscles and, that consecutively, exercises have therapeutical benefit.

Based on this knowledge several treatment algorithms [7] have been established and practiced, even if the evidence for any specific conservative modality for treating exercise- related groin pain is insufficiant [3] how is mentioned in the cochrane review:“ Further randomized controlled trials are needed to confirm or refute the possible favourable effects of exercise therapy, multi-modal treatments, and other conservative modalities for treating patients diagnosed with exercise-related groin pain.

References:

[1] Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med 2009;43:213 – 20.

[2] 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. 2013. doi: 10.1136/bjsports-2013 – 092872.

[3] Conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain. Cochrane Database Syst Rev. 2013 Jun 6;6:CD009565. doi: 10.1002/14651858.CD009565.pub2.

[4] Hölmich, Long-standing groin pain in sportspeople falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients. Br J Sports Med. 2007 Apr;41(4):247 – 52; discussion 252. Epub 2007 Jan 29.

[5] Cowan SM, Schache AG, Brukner P, Bennell KL, Hodges PW, Coburn P, Crossley KM: Delayed onset of transversus abdominus in long-standing groin pain. Med Sci Sports Exerc 2004, 36(12):2040 – 5.

[6] Ekstrom R, Donatelli R, Carp K. Electromyographical analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. J Orthop Sports Phys Ther. 2007;37(12):754 – 762.

[7] http://paulhead.co.uk/wp-content/uploads/2015/04/table-1.jpg