Article Summary: Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial

Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial

Objective: 

• "To determine whether an active rehabilitation program that involves repetitive effortful muscle contractions, including core stability, balancing exercises, progressive resistance exercises, and running activities, after a sports hernia, is effective."

Population: 

• 40 male soccer players age 18-25 with groin pain with sport for at least 2 months.

Methods: 

• Study Design: Single Blind RCT
• Group A: Active Rehabilitation Program (also received Group B intervention)
• Group B: Conventional Treatment Program
• Randomization via envelope method.  Staff therapist drew an envelope and handed to treating therapist.
• Both groups instructed to perform stretching exercises for adductor, hamstring, and hip-flexor musculature on days between treatment days.
• Did not specify if there were different treating therapists.
• Did not specify any training to provide consistency of interventions.
• Treatment 3x/week for a total of 8 weeks
• Progression of exercise was performed when the following criteria were met: 
• In the absence of pain during exercises 
• The acquisition of functional control 
• The ability to complete a functional exercises or a set number of repetitions of an exercise.
• Patients in both groups were instructed to return to a running program at the 6th week of the study which progressed from slow jogging to straight sprints and finally ended with cutting.
• Did not specify dosing or description of any running interventions
• Examining therapist was not aware of which treatment group the patients were assigned.
• Athletes instructed not to reveal treatment group to examining therapist.

Inclusion:

• Male soccer player age 18-25
• Groin pain with sport for at least 2 months
• 3 of 5 clinical findings
1. Tenderness at the insertion of the conjoint tendon (lower part of the aponeurosis of the TA and the internal oblique at or near their insertion on the pubic crest / pectineal line).
2. Palpable tenderness over the deep inguinal ring .
3. Pain and/or dilation of the external ring with no obvious hernia present.
4. Hip adductor longus muscle pain at its origin.
5. Dull diffuse groin pain often radiating to the perineum and inner thigh or across midline.
• Examiners also used two special tests to confirm diagnosis:
1. Resisted sit-ups.
2. Single or bilateral resisted leg adduction tests.

Exclusion:

• Palpable inguinal or femoral hernia
• Evidence of lumbar radiculopathy
• Sacroiliac dysfunction
• Nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves
• Hip joint disorders such as: osteoarthritis (OA), osteochondritis dissecans (OCD), bursitis, and femoroacetabular impingement (FAI)

Outcomes:

• VAS: pain assessed with valsalva maneuver and a resisted sit-up with the mean counting as their pain score.
• Internal Rotation ROM: assessed with goniometer in 90 degrees of hip flexion
• External Rotation ROM: assessed with goniometer in 90 degrees of hip flexion

• Successful outcome was defined as:
1. No pain at palpation of the adductor tendons and the adductor insertions at the pubic bone
2. No pain during active adduction against resistance
3. No groin pain in connection with or after athletic activity in the same sport at the same level of competition as before the onset of groin pain and return to the same sport and at the same level without groin pain
• Excellent = all 3 met
• Good = 2 met
• Fair = 1 met
• Poor = 0 met

Treatment:

• Group A: (See table 2 for description of individual exercises)
• Weeks 1-2
• Static adduction with soccer ball between feet: 10 x 30"
• Static adduction with soccer ball between knees in supine: 10 x 30"
• Posterior pelvic tilt (dosing not provided)
• Bridging: 5 x 10
• Sitting on ball maintaining neutral pelvis, hands on thighs
• Abdominal sit-up in straight forward direction and oblique direction: 5 x 10
• Folding knife (sit up and hip flexion w/ ball b/n knees): 5 x 10
• Balance training on wobble board: 5 minutes
• Weeks 2-6
• Cardio warm up: bike or elliptical (time not provided)
• Side lying hip abduction and adduction: 5x10 each
• Single-leg weight-pulling abduction and adduction in standing: 5 x 10 each leg
• Abdominal sit-up in straight forward direction and oblique direction: 5 x 10
• Legs elevated on physioball bridging (dosing not provided)
• Hip conditioning and core stabilization exercises:
• Raise arm and march hip on same side and push on elevated thigh with opposite upper extremity
• Quadruped hip extension with neutral spine: 2 x 15
• Bird-dogs: 2 x 15
• Half kneeling with perturbations: 3 x 30"-60"
• Forward / backward walking lunges with medicine ball lift: 2-3 sets of 10-15 lunges each direction
• Single leg balance on 360 degree balance board with hips and knees flexed
• Weeks 6-8
• Cardio warm up: bike or elliptical at higher speed and resistance than previous phase
• Clamshells: 5 x 10
• Standing cable hip abduction: 5 x 10
• Physioball bridging with single leg lift (dosing not provided)
• Plank (dosing not provided)
• Side Plank (dosing not provided)
• Pelvic stability on unstable surface: seated on balance disc and maintains balance with a single leg lift, progressed to a double leg lift, then progressed to include a ball toss
• Forward / backward walking lunges with medicine ball lift: 2-3 sets of 10-15 lunges each direction
• Single leg balance on 360 degree balance board with hips and knees flexed
• Group B: (See table 1 for description of mobilization techniques)
• Heat: hot pack for 10 minutes to painful groin area
• Transverse Friction Massage: 10 minutes at painful area of adductor tendon insertion into pubic bone.
• TENS: 30 minutes to painful area
• Mobilization Techniques:
• Anterior ilium rotation mobilization
• Posterior ilium rotation mobilization
• Hip anterior glide mobilization
• Hip posterior glide mobilization
• Stretching exercises using "contract-relax" technique
• Adductors: 3x30"
• Hamstrings: 3x30"
• Hip Flexors: 3x30"

Results: (See tables 3 and 4 for full results)

• VAS:
• Group A: decreased from average of 7.85 to 1.55 (80.25% improvement)
• Group B: decreased from average of 7.75 to 4.50 (41.93% improvement)
• Notes: 
• Standard deviations of all outcome measures was fairly small
• There were no differences in any outcomes pre-treatment
• Internal and external rotation
• Both groups improved but no difference between groups
• Successful Outcomes
• Group A: 
• Excellent: 13
• Good: 2
• Fair 2
• Poor: 3
• Group B:
• Excellent: 3
• Good: 4
• Fair: 4
• Poor: 9

Potential Limitations:

• Successful treatment did not include anything involving abdominal contraction.
• No objective strength measures taken.
• Did not specify their return to running progression.
• Exercise group got a lot more total time of treatment.
• Fairly small sample but with a difference in VAS of almost 3 full points and an excellent outcome in 13 in group A vs. 3 in group B allows us to be pretty confident with the results of this study.
• No long term follow up.

Authors Conclusions:

• "Active rehabilitation was effective for sports hernia management measured by a decrease in pain and the return to sports."

My Summary / Conclusion:

• I liked the fact that being able to return to their sport pain free was a large part of a successful outcome.
• I liked the fact that the exercises seemed to be dosed at a level that it may actually produce muscle fatigue and seemed fairly logically progressed and is easily reproducible in almost any physical therapy clinic.
• I am a little concerned that some of the pain may come back and I may incorporate a little bit more anterior sling and anterior line eccentric training though I really like the fact that they work the overhead med ball into their lunges which help to target the anterior line.
• The amount of improvement in the exercise group was so superior to the conventional group that we can be confident that exercises targeting the adductors and core must be part of our sports hernia rehab.  With 75% of patients having an excellent or good outcome in exercise group, I think that this article is also a good foundational piece to guide exercise prescription in the lack of significant experience or expertise in exercise prescription for sports hernia rehab.

Table 1: Conventional Treatment Program

Table 2: Active Rehabilitation Program

Table 3: Comparison of outcomes between groups

Table 4: Comparison of outcomes between groups

Citation:

Abouelnaga, W. A., & Aboelnour, N. H. (2019). Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial. Annals of rehabilitation medicine, 43(3), 305.