2011 Longstanding Adduction-related Groin Pain in Athletes Jaap Jansen

8/4/2019 2011 Longstanding Adduction-related Groin Pain in Athletes Jaap Jansen

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Experience from work in my thesis.

Jaap Jansen


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} Theoretical framework considering groin pain} Practice!} Fundamental (explanatory) theory} Recommendations

Consistent terminology during symposium:longstanding adductor-related groin pain (LAGP)

?


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} Symptom of pain during forceful adduction (Mens et al., 2006) Similar as in patients with post partum pelvic pain.

} Active Straight Leg Raise test (ASLR) sometimes positive(Mens et al., 2006) Similar as in patients with post partum pelvic pain.

} Wearing a pelvic belt decreases both symptoms (Mens et al.,2006) Similar as patients with post partum pelvic pain.

} Transversus abdominus (TA) as stabilizer of the pelvis (Richardson2002)


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} TA recruitment isdelayed in athletes withLAGP (Cowan et al., 2004)


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} Ultrasonography of deep abdominal musclethickness in patients compared with controls

Rest ASLR Hip adduction

} TA resting thickness decreased in patientswith LAGP


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} What are the effects of physical therapy with specificabdominal exercises compared to physical therapywith general hip-trunk stabilizing and strengtheningexercises in athletes with LAGP?

1. Randomized controlled trial

- Ultrasonographic measures

- Sports related outcomes

2. Identification of prognostic factors associated

with recovery


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Control treatment Intervention treatment1 Information on injury insight

Mobilization/ manipulation hip, sacroiliac

joints/lumbar spineInformation on injury insightMobilization/ manipulation hip,

sacroiliac joints/lumbar spineMotor control training for TA function

2 Low intensity cardiovascular exercise(bike, swimming)Low load hip adduction/ abduction training.Straight/ oblique sit up training

Low intensity cardiovascular exercise(bike, swimming)Low load hip adduction/ abductiontraining with TA contraction.

Straight/ oblique sit up trainingBridging exercises while maintaining TA

contraction3 Continuation of adduction/ abduction

exercises; increased load. Balance

exercises using Swiss ball/ wobble board.Return to running starting with 5 minutes

jogging. Increase one minute per run

Continuation of adduction/ abductionexercises with TA contraction and

avoidance of Valsalva maneuver;increased load. Balance exercises

using Swiss ball/ wobble board. Returnto running starting with 5 minutes

jogging; focus on breathing pattern.

Increase one minute per run4 Sport specific exercises (kicking, sprinting, turning); gradual increase in intensity5 Return to sports at own club, starting with training and gradual progress to match


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Baseline 14 weeks follow up P-values from ANOVAC (n=9) I (n=22) C

(n=9)I

(n=22)Main effect

timeInteraction

effect

TAResting thickness (mm)

4.1 (1.0) 4.1 (0,8) 4.6 (1.2) 4.5 (0.87) 0.006 0.83Relative thickness ASLR (%)

15.1 (12.8) 2.9 (12.1) 2.9 (15.2) 4.3 (14.5) 0.14 0.067Relative thickness adduction

(%) 56.6 (45.6) 53.8 (41.4) 54.0 (38.8) 69.5 (55.2) 0.59 0.45

OI

Resting thickness (mm)11.9 (3,0) 11.4 (1.6) 12.1 (2.9) 11.75 (2.0) 0.41 0.81

Relative thickness ASLR (%)4.9 (9.9) 3.9 (8.4) 4.6 (7.4) 4.7 (9.2) 0.88 0.80

Relative thickness adduction

(%) 28.6 (27.2) 27.6 (24.5) 33.9 (22.4) 30.8 (24.7) 0.44 0.85


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Sports restriction at follow

up (numeric Likert scale 0-10)N =35 (100%)

0123456789

10

7 (20%)9 (25.7%)8 (22.8%)1 (2.9%)0 (0%)

3 (8.6%)2 (5.7)0 (0%)

3 (8.6%)2 (5.7%)

0 (0%)


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0

1

2

3

4

5

6

7

8

9

10

before intervention after intervention

selfreported

sportsr

estriction

control

intervention*

*


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Return to sports Odds ratio Confidenceintervalyes no

Control (n=12) 6 60.44 0.104 -1.84Intervention

(n=23) 16 7

No significant differences between control &intervention groups on abdominal and sports-

related outcome measures!


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Unstandardized

coefficient BetaStandardized

coefficient Beta P=

back pain (presence =1)2.76 0.47 0.002

ASLR test score -0.934 -0,35 0.022Duration of complaints 0.016 0.31 0.049

A positive value for Beta indicates that a higher score is associated with

more sports restriction at follow up i.e. poorer prognosis.

Presence of back pain is associated with poorer prognosis.


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} Both general exercise and specific exerciseprograms are equally (in-)effective inchanging abdominal muscle thickness(behavior) as measured with ultrasonography Poor sensitivty of ultrasonography to detect small

changes in muscle activity

No measurements of changes in timing


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} Both general exercise and specific exerciseprograms are equally effective for athleteswith LAGP in the short term!

} Indications that low back pain, ASLR testscore and duration of complaints are relevantpredictors!

} Limitation: underpowered!


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} Does pain itself affect abdominal musclerecruitment?

} 14 volunteers to study the effects ofexperimental groin pain using

electrostimulation!} Ultrasonography


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} Pain anticipation leads to adaptions in deepabdominal muscle recruitment

} Pelvic instability not required to alterabdominal muscle behaviour (Jansen et al. Clin J Pain 2010) Might explain lack of difference between groups No need for specific stabilization!


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} Effects on hip/ groin proprioception} Repositioning error measured by a pulley

apparatus using video analysis With and without painful electrostimulation Verbal estimate of the magnitude and direction ofthe error


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} 15 healthy volunteers} No significant difference between

repostioning error with (14.0 (5.9) or withoutpain (13.2 (5,69)) pixels (p=0.56).

} Pain affects association between verbalestimate of error and true error

Correlation P-valueverbal estimate-trueerror

Rho=0,29 0,05

Verbal estimate-trueerror pain condition

Rho=-0,01 0,995


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Pain

Motor output

Previous muscleactivity

Memory

Signal integration

Proprioception


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} Specific exercises for deep abdominals Only data on short term follow up!

} Efficacy at long term follow up?}

Altered recruitment of TA may not changewithout specific exercise potential riskfactor for recurrence!


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Patients:

} Dont wait too long consulting a sports medicalexpert on groin pain!

} Strengthen your back muscles!Therapists:

} Use the ASLR test to prognose effectiveness ofexercise therapy

} Strengthen the hip flexion kinetic chain} Graded activity or pain contingent approach for

exercise in LAGP? Given the effects of pain on muscle recruitment patterns

and its possible influence on proprioception, pain shouldnot be ignored!

A. Weir, PhD


23/23Thank you!

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2011 Longstanding Adduction-related Groin Pain in Athletes Jaap Jansen