Hindawi

Rehabilitation Research and Practice

Volume 2018, Article ID 8146819, 10 pages
https://doi.org/10.1155/2018/8146819

Clinical Study
The Effect of Therapeutic Exercise on
Long-Standing Adductor-Related Groin Pain in Athletes:
Modified Hölmich Protocol

Abbas Yousefzadeh,1 Azadeh Shadmehr ,1 Gholam Reza Olyaei,1

Nasrin Naseri,1 and Zahra Khazaeipour2
1
Physiotherapy Department, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
2
Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

Correspondence should be addressed to Azadeh Shadmehr; [email protected]

Received 10 November 2017; Accepted 28 January 2018; Published 12 March 2018

Academic Editor: Jae-Young Lim

Copyright © 2018 Abbas Yousefzadeh et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Objective. The Hölmich protocol in therapeutic exercise is the most appropriate method for the treatment of long-standing
adductor-related groin pain (LSAGP). Herein, we evaluated a modified Hölmich protocol to resolve the possible limitations intrinsic
to the Hölmich protocol in terms of the rate of return to sport and the recovery period for athletes with LSAGP. Design. The study
followed a single-blind, before/after study design, where 15 athletes with LSAGP (mean age = 26.13 years; SD = 4.48) performed a 10-
week modified Hölmich therapeutic exercise protocol. Results. Outcome scores related to pain, hip adductor and abductor muscle
strengths, and the ratio of maximum isometric and eccentric hip adduction to abduction strength increased significantly. Likewise,
hip abduction and internal rotation ROM improved significantly compared to that at baseline. Furthermore, functional records
(𝑡-test, Edgren Side Step Test, and Triple Hop Test) showed significant improvement after treatment. Finally, 13 athletes (86.6% of
the participants) successfully returned to sports activity in a mean time of 12.06 weeks (SD = 3.41). Conclusion. The findings of this
study objectively show that the modified Hölmich protocol may be safer and more effective than the Hölmich protocol in athletes
with LSAGP in promoting their return to sports activity. This trial is registered with IRCT2016080829269N1.

1. Introduction muscle strengthening) compared with physiotherapy includ-

ing passive agents (stretching, TENS, transverse friction
Despite the fact that groin injury is prevalent among soc- massage, and laser therapy) leads to better results in terms
cer players, representing 9%–16% of all soccer injuries [1, of reducing pain and returning to sports activity [4, 5, 10].
2], this injury still frequently causes sport physiotherapists In the study by Hölmich et al. (1999), the average time from
trouble due to difficulties in treatment. Groin injuries often the start of treatment to the return to sports activity in
present major problems, such as high rates of recurrence [3], the group treated with therapeutic exercise was 18.5 weeks.
prolonged durations of absence [1], unclear prognosis [4], It seems that this recovery period (18.5 weeks) is too long
and long-term symptoms [4, 5]. Reports indicate that 69% because, in professional sports, there is often a lot of pressure
of groin injuries in soccer players are adductor-related [6, to get an athlete back to his/her sport as soon as possible
7]. When the condition becomes long-standing, the athlete [5, 8, 11].
usually waits a relatively long period of time before returning Since 1999, many studies have been conducted in the
to sports activity [7]. field of musculoskeletal lesion rehabilitation. These results
A review of the studies shows that therapeutic exercise may be useful for resolving the possible limitations of the
is the most appropriate method for treating long-standing Hölmich et al. protocol (regarding the group treated with
groin pain [4, 5, 7–9]. Hölmich et al. (1999) showed that therapeutic exercise) and, as a result, lead to a shortened
therapeutic exercise (concentrated on hip and abdominal period of recovery for athletes with LSAGP [11–15]. The
2 Rehabilitation Research and Practice

potential limitation of the Hölmich protocol and related 2. Method

suggestions are described as follows:
2.1. Subjects. Athletes were called via declaration in sport
(1) Athletes treated with therapeutic exercise were not clubs. Sport physiotherapists and physicians were also asked
allowed to stretch the adductor muscles. Since to refer athletes with LSAGP to the physiotherapy clinic. After
stretching is a standard technique prescribed to rea- interviewing and examining 27 athletes, 18 of them, who
lign the collagen fibers during muscle repair [12], we each signed an informed consent form, were included in the
suggest that stretching should be a component of the study. The Ethics Committee of Tehran University of Medical
exercise protocol. Sciences approved the study. This study was conducted in
(2) In Module 2, Exercise 3 of the Hölmich et al. protocol accordance with the Declaration of Helsinki (1964). The
[5], they used weight-pulling abduction/adduction, included subjects were men aged 18–35 years (mean = 26.13
although it has been claimed that motor unit recruit- years; SD = 4.48) with a history of groin pain for at least
ment when using elastic bands is greater than when two months (mean = 22.53 months; SD = 21.08); they had to
a weight machine or free weights are used [11]. On be motivated to return to their prior level of sports activity;
the other hand, hip adductor strengthening exercises they had to have painful palpation of the adductor tendons
using elastic bands have been introduced as dynamic, and/or their attachment to the pubic bone and, finally, had
high intensity exercises and are some of the best to have groin pain of less than 6 (in our pilot study, the
exercises to be included in preventative and treatment patients who had a pain score of 6 or more than 6 on
plans for groin injuries [13]. Furthermore, elastic the VAS during legs adduction against resistance could not
bands can be used anywhere and in any condition perform functional tests; therefore, we considered this level
[13]. Because of the previous claims, we suggest using of pain as the highest level to participate in the study) on
an elastic band as an external load for hip abduc- adduction of legs against resistance, according to a visual
tion/adduction exercises in the exercise protocol. analogue scale (VAS). Hölmich et al. [18] showed that the
test used to evaluate groin pain is reliable. Moreover, at least
(3) Changes in trunk muscle function [14] and weakness two of the subsequent criteria had to be found: an obvious
of core muscles have been suggested to be factors history of morning groin pain and stiffness, groin pain due to
related to groin injuries in athletes [15, 16]. We suggest sneezing or coughing, night groin pain, pain at the symphysis
that there should be more emphasis on core exercises pubis joint when palpated, or radiological signs suggestive of
in the exercise program. osteitis pubis.
(4) Sliding hip abduction/adduction exercises, used in The exclusion criteria were inguinal or femoral hernia,
Module 1 of the Hölmich et al. protocol [5], were prostatitis or persistent urinary tract disease, backache felt
painful for some participants in our pilot study and from the T10 to L5 segments, pelvic or lower extremity frac-
caused some side effects, so we chose not to use these ture, or any other problems of the lower limbs prohibiting
exercises in the treatment program. the subject from fulfilling the treatment course, with clinical
findings demonstrating genitofemoral or ilioinguinal nerve
(5) Athletes treated with therapeutic exercise after the 6th
entrapment, nonsteroidal anti-inflammatory drug consump-
week of the treatment had permission to jog as long as
tion during the treatment course, osteoarthrosis or other dis-
it did not arouse groin pain. We believe that all partic-
orders of the hip, or any other problem prohibiting the subject
ipants should have an identical running program that
from fulfilling the treatment plan [5, 7]. Furthermore, athletes
teaches them how to progressively increase running
who had performed normative hip adductor strengthening
speed, duration, and other parameters needed for
exercises more than once a week in the 6 months prior to the
returning to sports.
study were excluded [19].
The Copenhagen Adduction (CA), a high-intensity exer-
cise carried out to the hip’s outer range of motion [13, 17], 2.2. Design. The clinical trial was single-blind and was
can be performed at the end stages of the treatment. CA designed as a before/after study. The physiotherapist who pro-
strengthens both the hip adductors and abductors, preparing vided the ratings was not involved in the treatment and was
for muscular stability in the groin area [17]. Serner et al. [13] not informed of the treatment protocol.
described the details of CA. The role of the physiotherapist
during treatment should not only be one of supervision 2.3. Treatment. We have provided the components of the
and instruction but also focus on increasing the intensity or modified Hölmich et al. protocol in Tables 1 and 2. Some of
resistance of the exercises at each successive weekend. the exercises that are described in Tables 1 and 2 are shown
In the current study, according to the above-mentioned in Figure 1. An experienced sport physiotherapist oversaw
points, we developed a modified version of the Hölmich the strict implementation of this treatment protocol. We gave
et al. protocol [5] for the treatment of LSAGP and aimed no therapy other than the therapeutic exercise and we did
to evaluate its effects on athletes with this type of injury. not allow any athletic activity during the treatment. The
The dependent variables in our study were pain, hip adduc- minimum duration of treatment was 10 weeks; however, the
tion/abduction muscle strength, hip abduction and internal athletes could continue their treatment for up to 12 weeks
rotation range of motion (ROM), functional ability, and mean if necessary. During the first two weeks, the participants
time required to return to the sports activity. performed part 1 of our protocol three times a week. From
Rehabilitation Research and Practice 3

Table 1: Modified Hölmich et al. protocol: part 1.

Exercise Amount Rest period

(1) Brief warm-up using a stationary bicycle 10 min (25 W load at 20 km/h) —
(2) Isometric, pain-free adduction against a soccer ball placed 10 sec rest after each rep. and 2 min
3 sets of 10 reps. (each rep. for 10 sec)
between the knees in the crook lying position rest after each set
(3) Bilateral straight leg raising in a seated V position, as in 10 sec rest after each rep. and 2 min
3 sets of 10 reps. (each rep. for 10 sec)
Figure 1(a) rest after each set
(4) Isometric standing hip adduction using elastic bands (both 10 sec rest after each rep. and 2 min
5 sets of 10 reps. (each rep. for 10 sec)
legs should be trained) rest after each set
(5) Abdominal sit-ups in both straight and oblique directions 4 sets of 15 reps. 1 min rest after 15 consecutive reps.
(6) Prone bridging on forearms and toes (the back should be
10 reps. (each rep. for 15 sec) 15–20 sec rest after each rep.
completely straight)
(7) Side bridging on the elbow (the trunk should be in neutral 10 reps. for each side (each rep. for
15–20 sec rest after each rep.
alignment, as in Figure 1(b)) 15 sec)
(8) Unilateral bridge exercise starting from the crook lying
10 reps. of 12 sec (each rep. consists
position (with one knee flexed and the opposite hip and knee
of 6 sec right leg raising followed by 15–20 sec rest after each rep.
extended so that trunk is in neutral spine alignment, as in
6 sec of left leg raising)
Figure 1(c))
(9) Wobble board balance training (beginning with both feet
and gradual increase in difficulty by single leg standing and then 8 min (the legs are switched once a
—
adding some maneuvers like small knee bends to challenge the minute when single leg standing)
balance

(a) (b) (c) (d) (e)

(f) (g) (h) (i) (j)

Figure 1: Some of the exercises that the participants performed during the first and second phases of modified Hölmich et al. protocol.
Descriptions are provided in Tables 1 and 2.

the third week on, they performed part 2 of the protocol and eccentric contractions, as Jensen et al. [19] showed in
three times a week (on even or odd days) and carried out the their study (part 2, Exercise 4). The physiotherapist deter-
exercises from part 1 every other day. The duration of each mined the resistance of the elastic band at the beginning of
session was approximately 120–150 min. the treatment, which was the maximum resistance that could
In the first phase (part 1, Exercise 4), we had participants be performed by the athlete, pain-free, for 10 repetitions. The
do isometric hip adduction using elastic bands (Thera-Band, participants increased this load every treatment week under
Akron, Ohio, USA). The subject moved his body in harmony the supervision of the physiotherapist. In addition to our
with adduction and coming back to the reference position therapeutic exercise protocol, we allowed the participants to
in order to prevent concentric and eccentric adductors ride a bicycle during the first 6 weeks and, from the 6th week
contractions as much as possible (Figure 2). The time under on, their running programs were started according to Hogan’s
tension for the isometric adduction was 10 sec [20]. return to running program [7, 20].
In the second phase of the treatment, the participants After the final assessment at the 10th week, we gave a
performed hip adduction-abduction exercises using elastic similar written document, outlining the unique rehabilitation
bands in three consecutive phases of concentric, isometric, plan, to each athlete. We also conducted weekly telephone
4 Rehabilitation Research and Practice

Table 2: Modified Hölmich et al. protocol: part 2 (from the 3rd week onward).

Exercise Amount Rest period

(1) Brief warm-up using stationary bicycle 10 min (25 W load at 20 km/h) —
(2) Low back extension exercise in the prone position with arms
3 sets of 10 reps. 30 sec rest after each set
at the sides
(3) Abdominal sit-ups, in both straight and oblique directions,
4 sets of 15 reps. 1 min rest after 15 consecutive reps.
while holding a 3 kg medicine ball in hands
(4) Standing hip add-abd. exercise with elastic bands (both legs) 5 sets of 10 reps. for add. and 5 sets
2–5 sec rest after each rep. and 1 min
(Jensen et al., 2014). Figures 1(d) and 1(e) show the starting and of 10 reps. for abd. (concentric phase
rest after each set
end position of hip add. exercise = 1 sec and eccentric phase = 3 sec)
(5) Folding knife sit-ups beginning from the crook lying
position, with a soccer ball located between the knees, 5 sets of 10 reps. 1 min rest after 10 consecutive reps.
simultaneous ab. sit-ups and hip flex (Hölmich et al., 1999)
2 sets of 10 reps. (each rep. consists
(6) In the prone position with arms stretched overhead, partial 6 sec rest after each rep. and 2 min
of 6 sec lift for one side and 6 sec for
lifting of opposite arm and leg for 6 sec and then reverse sides rest after each set
the opposite side)
(7) Prone bridging on forearms and toes with single limb lifting 8 reps. (6 sec for lifting each limb
(Rt. arm, Lt. arm, Rt. leg, and Lt. leg are lifted consecutively, as and total time of 24 sec for each 30 sec rest after each rep.
in Figure 1(f)) rep.)
(8) Side bridging on the elbow plus single hip abd., as in 10 reps. for each side (each rep. for
15–20 sec rest after each rep.
Figure 1(g) 10 sec)
(9) Unilateral bridge exercise. Start from crook lying position
10 reps. of 12 sec (each rep. consists
with one knee flexed and the opposite hip and knee extended
of 6 sec Rt. leg raising followed by 15–20 sec rest after each rep.
while the flexed limb is on an unstable surface such as a Dyna
6 sec Lt. leg raising)
Disc, as in Figure 1(h)
(10) Wobble board balance training including small knee bends,
catching and throwing a ball, hands touching the standing foot
10 min (the legs are alternated)
alternately, and gentle side kicking of the ball (during end
weeks)
(11) Single leg, cross-country skiing (Hölmich et al., 1999) 5 sets of 10 reps. for each leg 1 min rest after 1 set for each leg
Begin with 2 sets of 6 reps., can
(12) Copenhagen Adduction exercise beginning from the 7th
progress to 3 sets of 6 reps. and then
week, if it does not provoke pain (Ishøi et al., 2016; Serner et al., 3–5 min rest after each set
to 3 sets of 10 reps. when it does not
2014), as in Figures 1(i) and 1(j)
provoke pain
(13) Pain-free adductor stretching in a sitting position with
5 reps. of 15 sec
flexed knees and feet together
Note. add.: adduction; abd.: abduction; rep.: repetition; ab.: abdominal; Lt.: left; Rt.: right; sec: second.

follow-up calls with each athlete to determine whether they ratios were included in our primary outcome measurements
had gone back to sports activities or not. The final follow-up for hip muscle strength. We also calculated the percentage
assignment for the athletes at 20 weeks after the start of the gain in muscle strength due to the effect of the treatment. In
treatment was to fill out a new questionnaire regarding their this study, we defined the percentage gain as the difference
symptoms. between the before and after muscle strengths divided by the
before strengths and multiplied by 100. We performed the
2.4. Outcome Measurements. At baseline and 10 weeks after measurements on the affected lower extremity.
that, a trained, single-blind physiotherapist evaluated the The strength measurement procedures for hip adductors
athletes. We did not allow the athletes to take part in any kind and abductors have been explained in detail in previous
of competition or training the day prior to the first evaluation. studies [20–22]. All the participants were recommended to
a 10 min standardized warm-up program prior to the hip
2.4.1. Hip Muscle Strength (Adductor/Abductor). We used a strength measurements. This warm-up program consisted of
hand-held dynamometer (HHD) (Powertrack II Comman- light running, squatting, and hip adduction and abduction
der JTECH Medical, Salt Lake City, Utah, USA) for muscle muscle activation [20]. Using a make test in the supine
strength measurement, which was previously reported to position, we performed our measurements for IHAB and
be valid [19, 21]. Maximal isometric hip abduction (IHAB), IHAD based on Thorborg et al. [21]. The athletes were asked
maximal isometric hip adduction (IHAD), maximal eccen- to fix themselves by taking the sides of the examination table
tric hip abduction (EHAB), maximal eccentric hip adduc- with their hands. The lower limb being tested was in a straight
tion (EHAD), and maximal IHAD/IHAB and EHAD/EHAB position and the knee and hip in the lower limb not being
Rehabilitation Research and Practice 5

(a) (b)

Figure 2: Isometric hip adduction. The subject tries to abstain from concentric or eccentric adductors contraction by moving his body in
harmony with hip adduction (a) and coming back to the reference position (b).

tested were in 90∘ flexion. The assessor exerted resistance most prominent point of the lateral malleol in supine position
in a fixed status 8 cm proximal to the most prominent [21].
point of the lateral malleol (for IHAB and medial malleol
for IHAD) and the participant being tested performed an 2.4.2. Pain. We performed the pain assessment, based on
isometric maximum voluntary contraction (MVC) against the VAS, in two situations: (1) pain during the functional
the dynamometer and the assessor for 5 sec. The rest duration tests: the pain felt by the participants during each functional
between each trial was 30 sec. The standardized command test was recorded and the average earned from the three
by the assessor was “go ahead-push-push-push-push and functional tests was used for data analysis; (2) pain with
relax.” The individual test was performed four times and the adduction of legs against resistance: the participant was in
average of the three highest amounts was reported. According supine position. The assessor physiotherapist stood at the end
to Thorborg et al. [20], using a break test with the athletes of the examination table with hands and forearms between
on their sides, we performed our measurements for EHAB the feet of the participant to hold them apart. The participant’s
and EHAD. The athletes were asked to fix themselves by feet were positioned upward and he pushed them together
taking the sides of the examination table with their hands. with maximal force without elevating the legs or pelvis. The
The lower limb being tested was in a straight position and pain felt by the participant was recorded for data analysis
the knee and hip in the lower limb not being tested were in [3, 18].
90∘ flexion. The assessor exerted resistance in a fixed status
8 cm proximal to the most prominent point of the lateral 2.4.3. Functional Ability. We applied three functional tests
malleol (for EHAB and medial malleol for EHAD) and the including the t-test, Triple Hop Test for Distance (THT), and
participant being tested performed an isometric maximum Edgren Side Step Test (ESST), as reliable and valid measures
voluntary contraction (MVC) against the dynamometer and for the assessment of multiple agility components (unidi-
the assessor for 3–5 sec before the break was carried out by rectional, bidirectional, and multidirectional motions), lower
the assessor. The rest duration between each trial was 60 sec. limb speed, and power [23–26]. All tests were conducted on
The standardized command by the assessor was “go ahead- a natural soccer pitch during the normal working day hours
push-push-push-push.” The single test was repeated till a of 10 a.m. to 1 p.m. and the participants wore a soccer kit
force plateau of less than 5% between two sequential trials to reproduce the playing conditions. All participants became
was attained and the average of these values was reported. The familiar with the testing method used in the current study
rest period between make and break tests was 5 min. Applying before the actual test was applied. Immediately before testing,
the lower limb length and body weight, we presented all force participants carried out a standard 25 min warm-up includ-
amounts as Newton-meters per kilogram of body weight ing 10 min of light running, 10 min of dynamic stretching,
(N⋅m⋅kg−1 ). We measured the leg length from the most and 5 × 30 m of running exercises [27]. During testing, the
prominent point of the anterior superior iliac spine to the air temperature ranged from 19∘ C to 26∘ C. Participants were
6 Rehabilitation Research and Practice

5m 5m

1m
Figure 4: Edgren Side Step Test (ESST).

10 m granted. Disqualification was determined if the participant

failed to keep his body and feet frontward during the test,
crossed his legs, or did not fulfill the course as instructed [26].

2.4.4. Range of Motion (ROM) of the Hip Joint: Abduction and

Internal Rotation. We measured the passive hip abduction
ROM with the participant supine on the examination table.
Figure 3: t-Test.
The starting position was with the legs in contact. The
fixed arm of a goniometer was placed parallel to the line
between the anterior superior iliac spines and the moving arm
asked to do each test twice and the best score obtained from coincided with the longitudinal axis of the femur. The limb
two trials was recorded for data analysis. If the participant under test was passively abducted until rotation of the femur
failed to fulfill a test in two trials due to disqualification, an began, recording the end point of the measurement [22].
extra trial was allowed. The rest duration between each trial We measured passive internal rotation of the hip while the
was 60 sec and between each test was at least 3 min. Prior to participant was in a prone position with knees at 90∘ flexion
testing, participants were given 1 to 3 (self-selected) practice and ankles and knees both in contact. The participant was
trials [26]. then asked to let the feet fall out bilaterally while keeping the
For the t-test, we designed three cones 5 m apart in a row knees at 90∘ flexion. To measure passive hip internal rotation,
and a fourth cone 10 m from the middle cone so that the cones we aligned the moving arm of a standard goniometer with the
form a T (Figure 3). The participants started at the base of long axis of the tibia, while the stationary arm was vertical
the “T” (start line). On the command “go” by the rater, the [28]. We performed all ROM measurements once and on the
participant ran to the middle cone as quickly as possible, then affected lower limb.
sidestepped 5 m to the right cone, next sidestepped 10 m to
the far left cone, after that sidestepped 5 m back to the middle 2.5. Statistical Analysis. We maintained the statistician’s
cone, and finally ran 10 m backwards as quickly as possible to blindness to the treatment protocol and outcomes until the
pass the finish line. The rater began the chronometer on “go” analyses were complete. We used a double data entry process
and stopped when the participant passed the finish line. If the and SPSS Statistics, version 24, for the data analysis. We
participant could not run the path as instructed, crossed his established the alpha level at .05 for all statistical analyses. The
legs more than once during sidestepping, shook any cones, or dependent variables had normal distribution (Kolmogorov-
could not keep his body and feet frontward during the test, he Smirnov test). To ascertain whether there were any consider-
was disqualified and had to repeat the test [25, 26]. able differences between the before and after amounts of the
We measured the THT using a standard tape measure dependent variables, a paired-sample t-test was used.
fixed to the ground perpendicular to a starting line. Each
participant began the test by standing on the affected limb 3. Results
with the great toe on the starting line. The assessor physio-
therapist measured the distance from the starting line to the Eighteen athletes were initially included in the study, with 15
point where the back of the participant’s heel hit the ground completing the treatment protocol. One athlete dropped out
upon completing three sequential hops on the affected limb. due to educational problems, one athlete withdrew because
Disqualification was determined if the participant failed to he had to go to military service, and one athlete was lost to
perform a triple hop without losing balance and contacting follow-up. We have prepared basic characteristics of the study
the ground with the opposite foot [23, 24]. participants in Table 3.
For the ESST, we placed five cones in a line, 1 m apart Weekly follow-ups and a final follow-up at 20 weeks
(Figure 4). The participant stood behind the far left cone and after the start of treatment showed that 13 athletes (86.6%)
was asked not to cross his feet during sidestepping. On the returned to full sports activity without groin symptoms in
“go” command, the participant sidestepped to the right till a mean time span of 12.06 weeks (SD = 3.41). Two athletes
his right foot had contacted or passed the external cone and failed to return to their prior level of sporting activity and
then sidestepped to the left till his left foot had contacted decided to change sports. We have explained the results of
or passed the left external cone. The participant sidestepped the measurements performed at the beginning and end of the
backward and forward to the external cones as quickly as treatment in the following subdivisions.
possible for 10 sec. The rater gave the participant one point
per completion of each 1 m enhancement signed by a cone. 3.1. Hip Adductor and Abductor Muscle Strength. At the end
If the far end cones were not attained, those points were not of the treatment, the mean IHAD, IHAB, EHAD, and EHAB
Rehabilitation Research and Practice 7

Table 3: Baseline characteristics of the participants (𝑛 = 15).

Age (years) 26.13 (SD = 4.48)

Height (meters) 179.67 (SD = 3.47)
Sports Soccer = 14; runner = 1
Preferred limb Right = 11; left = 4
Location of injury Right = 6; left = 9
Duration of injury (months) 22.53 (SD = 21.08)
Elite (>5 times per week) = 4
Level of athletic activity
Subelite (3 or 4 times per week) = 11
Sports activity at baseline Ceased = 2; reduced = 12; unchanged = 1
Pain (VAS∗ ) on legs adduction against resistance 5.07 (SD = 0.59)
Pain (VAS) during functional tests 5.20 (SD = 0.67)
∗
VAS: visual analogue scale (no pain = 0; maximum pain = 10).

Table 4: Dependent variables, before and after values, and significance level after the paired samples t-test.

Percentage gain Paired samples

Dependent variable Before After in muscle test sig.
strength (two-tailed)
VAS pain score (legs add. against resistance) 5.07 (0.59) 0.27 (0.45) 0.0001
VAS pain score (during function) 5.20 (0.67) 0.73 (0.79) 0.0001
Hip Abd. ROM (∘ ) 45.53 (4.10) 48.67 (4.25) 0.0001
Hip Int. rot. ROM (∘ ) 23.40 (8.73) 25.13 (8.21) 0.006
Iso. Add. (N⋅m⋅kg−1 ) 1.26 (0.49) 2.00 (0.46) 58.79% 0.0001
Iso. Abd. (N⋅m⋅kg−1 ) 1.63 (0.33) 2.12 (0.31) 29.53% 0.0001
Ecc. Add. (N⋅m⋅kg−1 ) 1.61 (0.75) 2.49 (0.66) 54.66% 0.0001
Ecc. Abd. (N⋅m⋅kg−1 ) 2.44 (0.54) 3.07 (0.66) 25.97% 0.0001
Ratio of Iso. hip Add. to Abd. 0.77 (0.24) 0.94 (0.15) 0.006
Ratio of Ecc. hip Add. to Abd. 0.67 (0.27) 0.81 (0.16) 0.009
t-Test (sec) 11.51 (0.91) 9.86 (0.51) 0.0001
ESST (m) 23.80 (2.78) 29.80 (2.42) 0.0001
THT (m) 5.30 (0.56) 6.29 (0.39) 0.0001
Note. Abd.: abduction; Add.: adduction; Int. rot.: internal rotation; Iso.: isometric; Ecc.: eccentric; VAS: visual analogue scale; ESST: Edgren Side Step Test;
THT: Triple Hop Test for Distance.

improved considerably compared to the baseline (Table 4). end of the treatment compared to the baseline. For details,
We also found considerable improvements in the ratio of refer to Table 4.
mean, maximum, isometric and eccentric, and hip adduction
to abduction strength, compared to the beginning of the 3.5. Adverse Effects. No adverse effects due to treatment were
treatment (Table 4). We have shown the percentage gain in reported throughout the study.
muscle strength because of treatment in Table 4.
4. Discussion
3.2. Visual Analogue Scale (VAS) for Pain. We found signif-
icant differences in VAS pain scores for the legs adduction The aim of this study was to develop and evaluate a modified
against resistance. In addition, the VAS pain scores during protocol based on exercise therapy for the treatment of
the functional tests improved considerably compared to the LSAGP. Our findings suggest that this modified ten-week
scores at the start of the treatment (Table 4). protocol that benefits from strengthening the muscles affect-
ing the pelvis, core stabilization, hip adductor stretching, and
3.3. Functional Tests. THT and ESST measures increased high intensity eccentric exercise of the hip adductors may
considerably 10 weeks after treatment. Meaningful improve- have a considerable effect on primary measured outcomes
ments were also found in the t-test agility scores. For details, including pain, hip adductor and abductor muscle strength,
refer to Table 4. hip ROM, functional ability, and returning to sport.
After completing our treatment protocol, 86.6% of the
3.4. Hip Abduction and Adduction ROM. The ROM of the hip participants (𝑛 = 13) returned to their previous respective
abduction and internal rotation increased significantly at the levels of sports activity, without groin symptoms. The mean
8 Rehabilitation Research and Practice

time from baseline to completely pain-free sports activity was scores during sports participation were reduced from 58.5 at
12.06 weeks. These results were better than those obtained baseline to 21.0 (VAS of 100 equated to the highest level of
by Hölmich et al. [5] who reported a median time of pain), requiring sixteen weeks for these changes to occur, in
18.5 weeks for 79% of the participants in their therapeutic the exercise therapy (ET) group.
exercise regimen to return to their prior level of sports The major differences that exist between the modified
participation without groin pain. In our study, the higher protocol applied in the current study and the program used
rate of returning to full sports activity (86.6%) and shorter by Hölmich et al. [5] which was subsequently reproduced by
time for recovery (12.06 weeks) could be due to a variety Weir et al. [7] in their ET group could explain the differences
of factors including use of a different method to strengthen in results. Furthermore, the differences in results could be due
hip adductor/abductor muscles (using elastic bands and to differences in supervision. The participants in the study
emphasizing time under tension), use of core stabilization by Weir et al. [7] were instructed by a physiotherapist as to
exercises, institution of high-intensity eccentric training for how to perform the exercises on three separate occasions.
the adductors (Copenhagen Adduction), and hip adductor The method of performing the exercises was controlled in
stretching. Furthermore, we tried to increase the level of these sessions, but the participants were not supervised while
difficulty of the exercises at every possible opportunity, by performing the exercises during the entire treatment period.
utilizing the expertise of a physiotherapist (part 1, Exercises 4 There are some differences between the inclusion and
and 9; part 2, Exercises 4 and 10). We also applied the “return exclusion criteria and also the basic characteristics of the
to running program” [29], whereas, in the Hölmich et al. current study and the study of Weir et al. [7]. For example,
(1999) protocol, there is no defined program for returning unlike the present study, there was no pain limit in the
to running, and the subjects were ordered to begin running inclusion criteria of the study by Weir et al. [7]. In addition,
from the sixth week if it did not provoke groin pain. When most participants (72%) in the study by Weir et al. [7] had
there is no defined running program, the athlete may not be ceased their sports activities prior to the study, but in the
able to plan a graded return without causing further damage present study, most participants (80%) had just reduced their
or he/she may be too cautious, due to fear of reinjury. sports activities at the baseline. On the other hand, duration
It should be mentioned that although the inclusion and of injury in the participants of the present study (22.53
exclusion criteria in the current study are almost similar to months) was much longer than that of the study by Weir et al.
those of the study by Hölmich et al. [5], there are some [7] (32 weeks). As we mentioned before, these differences may
differences between the two studies. The mean age of the influence the results; therefore we should be cautious with our
participants in both studies is in a similar age group but the conclusion.
participants of the current study (mean age = 26.13) are a little Hip joint abduction ROM in the affected limb improved
younger than the participants of the study of Hölmich et al. significantly by the end of treatment (𝑃 = 0.0001). These
[5] (mean age = 30). Furthermore, the athletes had to have results were similar to those obtained by Hölmich et al. [5].
pain less than 6 (based on VAS) on adduction of legs against They suggested that increased muscle strength, coordination,
resistance to be included in the current study, but there was and reduced groin pain can lead to improved ROM. They also
no pain limit in the inclusion criteria of the study by Hölmich declared that adductor stretching might provoke the injury
et al. [5]. In terms of the basic characteristics, there are also by causing pulling at the teno-osseous junction. The results
some differences between the two studies. For example, mean of the current study are not consistent with these suggestions
duration of injury in the participants of the current study because all of the primary outcomes in our study improved
(22.53 months) was much longer than those of the study significantly, despite adductor stretching being practiced
by Hölmich et al. [5] (38 weeks). In addition, most of the by our participants. Furthermore, we did not observe any
participants in the exercise therapy group (71%) of the study adverse effect in the current study. Notable point is that, in
of Hölmich et al. [5] had ceased their sports activities prior to contrast to the present study, most participants in the study
the study, while in the current study, most of the participants by Hölmich et al. [5] had stopped their sports activities prior
(80%) had just reduced their sports activities at the baseline. to the study. The overall flexibility of the participants at the
These differences in inclusion and exclusion criteria and also study baseline may have affected the results. More clinical
basic characteristics may influence the results; therefore, we trials are necessary to study the contribution of stretching
should be cautious in making our conclusion. in the treatment of LSAGP. Taylor et al. [28] declared that a
A higher percentage of participants, in a shorter period decreased range of internal hip rotation might be a potential
of recovery, could return to full sports participation in the risk factor for groin injury [28]. Our findings showed a
current study as compared to the study by Weir et al. [7]. In considerable increase in range of internal hip rotation after
their study, 55% of the athletes in the exercise therapy group the treatment (𝑃 = 0.006). More clinical trials are needed to
could return to full sports activity after a median time of 17.3 further support these results.
weeks. We found considerable improvements in IHAD and
Furthermore, VAS pain scores changed considerably in IHAB strength in the affected limb (by 58.79% (𝑃 = 0.0001)
the current study (from 5.07 to 0.27 in the legs adduction and 29.53% (𝑃 = 0.0001), resp.). EHAD and EHAB strength
against resistance and from 5.20 to 0.73 during the functional also increased considerably in the affected limb (by 54.66%
tests) and were acquired in the relatively short duration of (𝑃 = 0.0001) and 25.97% (𝑃 = 0.0001), resp.). As we did
10 weeks. These findings were better than those obtained by not have a control group in our study, it may be useful to
Weir et al. [7]. In the study by Weir et al. [7], VAS pain compare these results with those obtained by similar studies
Rehabilitation Research and Practice 9

performed in the future. Likewise, measurements related to of Rehabilitation, Tehran University of Medical Sciences.
functional ability improved considerably in the current study The authors would like to acknowledge Editage (https://
(𝑃 = 0.0001). Although we do not have any information www.editage.com) for English language editing.
about the participants’ preinjury functional scores, it might be
useful to compare our findings with those of identical future
studies.
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