Return to play in long-standing adductor-related groin pain: a delphi study among experts

Key Points

1. The assessment of strength (isometric and eccentric), performance tests (planned and unplanned change of direction), and sports-specific skills should be included as criteria for return to play (RTP) in athletes with long-standing athletic-related groin pain.
2. Imaging should not be used as a RTP criterion but may have use in ruling out red flag conditions.
3. Although the group of experts did not reach consensus, other criteria such as load management should be further explored.

BACKGROUND & OBJECTIVE

Groin pain (with or without time-loss injury) is a common challenge in sport, especially those that require multi-planar movement. Researchers and clinicians continue to work to identify the best injury prevention, intervention and treatment methods. Several frameworks have been suggested to help clinicians organize return to play (RTP) decisions; however, RTP criteria supported by scientific evidence is lacking.

The objective of this Delphi study was to identify criteria that could be considered by practitioners in the RTP decision-making process for athletes with long-standing adductor-related groin pain.

Groin pain (with or without time-loss injury) is a common challenge in sport, especially those that require multi-planar movement.

Performance testing should include planned and unplanned change of direction to evaluate the athlete’s level of confidence and pain during completion.

METHODS

• The survey was created by a five-member committee (four sports physiotherapists and one sport physician).

• 32 experts who met the established definition of expert were identified directly or by the “snowball method” of invitation from other experts and were invited to participate in the study.

• Three rounds of questionnaires were sent to the participants. Round one consisted of investigating:

  • The characteristics of the expert participants
  • Nine different criteria (palpation, flexibility, strength, patient-reported outcome measures, imaging, intersegmental control, performance tests, sports-specific skills, training load) that may be considered during the RTP process

• Responses from round one were analyzed to form round two questions which aimed to further investigate RTP criteria.

• Round two responses were analyzed and RTP criteria that met the cut-off value were included in round three, which asked experts to identify their degree of confidence in the different RTP criteria using a Likert-scale.

RESULTS

Expert demographics:

• 3 regions - Europe, USA, Australia
• 3 affiliations - clinical, academic, team
• 4 professions – physiotherapists, physiologists, physicians, and surgeons
• Mean experience - 20.8 years
• Peer reviewed publications on groin pain in total - 15.7

Round 1

• Positive consensus was achieved on: palpation, strength, PROM, intersegmental control, performance testing, and sports-specific skills.
• Negative consensus was achieved on imaging.

Round 2

• Positive consensus was confirmed on: strength, performance tests, sports-specific skills.
• Negative consensus was confirmed on imaging.

Round 3

• Positive consensus was established on: strength, performance tests, sports-specific skills.
• Negative consensus was confirmed on imaging.

LIMITATIONS

• A Delphi study provides a lower level of evidence than other study designs.

• In this study specific groups may have been over-represented, including 87.5% of experts identifying as European with only three geographic regions represented.

• 75% of experts identified as affiliated with clinical setting, and 65.6% of participants identified as physiotherapists.

• Participants were limited by their ability to complete the survey in English.

CLINICAL IMPLICATIONS

The RTP decision in athletes with long-standing adductor-related groin pain is a complex one. This study provided agreement on the inclusion of three criteria – strength tests, performance tests, and sports-specific skills. And the exclusion of one criteria – imaging.

It is recommended that strength testing include adductor isometric and eccentric testing for symmetry. Full agreement was not achieved regarding testing positions, however the widest consensus was a squeeze test at 0 degrees for isometric strength and a side-lying eccentric assessment. Although consensus was not achieved in this group, strength assessment of other muscle groups, specifically the abductors and their resulting adductor:abductor ratio, and the trunk flexors should be considered (1).

In addition to symmetry, consideration should be given to size-adjusted strength values to ensure that individuals are both symmetrical and appropriately strong for their height and weight (2).

Performance testing should include planned and unplanned change of direction (COD) to evaluate the athlete’s level of confidence and pain during completion. No specific test reached consensus, however it was strongly agreed upon that the COD should take place at varying degrees (45-90-110-180) and the athlete should complete the COD without pain and with self-confidence.

Sports-specific skills analysis should also be completed with confidence and in a pain-free manner. Selected movements should be appropriate to the demands of the athlete’s sport and completed with good quality.

The experts strongly agreed imaging should not be considered as a RTP criteria but may have use in ruling out red flag conditions.

Palpation, passive range of motion and intersegmental control did not achieve consensus among the experts as RTP criteria. However, experts did report using these criteria in their assessment and progression through the RTP continuum and recent literature continues to support their use (3).

A summary of the physical assessment can be seen in Figure 1.

+STUDY REFERENCE

Vergani L, Cuniberti M, Zanovello M, Maffei D, Farooq A & Eirale C (2022) Return to Play in Long-Standing Adductor-Related Groin Pain: A Delphi Study Among Experts. Sports Medicine - Open, 8 (11).

SUPPORTING REFERENCE

1. Rodriguez, R. (2020). Measuring the hip adductor to abductor strength ratio in ice hockey and soccer players: A critically appraised topic. Journal of Sport Rehabilitation, 29(1), 116–121.
2. Thorborg, K., Branci, S., Nielsen, M. P., Tang, L., Nielsen, M. B., & Hölmich, P. (2014). Eccentric and Isometric Hip Adduction Strength in Male Soccer Players With and Without Adductor-Related Groin Pain: An Assessor-Blinded Comparison. Orthopaedic journal of sports medicine, 2(2), 2325967114521778.
3. Baida, S. R., King, E., Richter, C., Gore, S., Franklyn-Miller, A., & Moran, K. (2021). Hip muscle strength explains only 11% of the improvement in hagos with an intersegmental approach to successful rehabilitation of athletic groin pain. The American Journal of Sports Medicine, 49(11), 2994–3003. https://doi.org/10.1177/03635465211028981