Physical Therapy in Sport 14 (2013) 3e16Contents lists available at SciVerse ScienceDirect Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp Masterclass A suggested model for physical examination and conservative treatment of athletic pubalgia Eric J. Hegedus a, Ben Stern b, Michael P. Reiman c, Dan Tarara d, Alexis A. Wright a, * a High Point University, School of Health Sciences, Department of Physical Therapy, 833 Montlieu Ave., High Point, NC 27262, USA b 360 Physical Therapy, 13215 N Verde River Drive Suite 5, Fountain Hills, AZ 85268, USA c Duke University Medical Center, Department of Community and Family Medicine, Division of Physical Therapy, DUMC 104002, Durham, NC 27705, USA d High Point University, School of Health Sciences, Department of Exercise and Sports Science, 833 Montlieu Ave., High Point, NC 27262, USA a r t i c l e i n f o a b s t r a c t Article history: Background: Athletic pubalgia (AP) is a chronic debilitating syndrome that affects many athletes. As Received 13 December 2011 a syndrome, AP is difficult to diagnose both with clinical examination and imaging. AP is also a challenge Received in revised form for conservative intervention with randomized controlled trials showing mixed success rates. In other 12 March 2012 syndromes where clinical diagnosis and conservative treatment have been less than clear, a paradigm Accepted 6 April 2012 has been suggested as a framework for clinical decision making. Objectives: To propose a new clinical diagnostic and treatment paradigm for the conservative Keywords: management of AP. Athletic pubalgia Sports hernia Design: Relevant studies were viewed with regard to diagnosis and intervention and where a gap in Diagnosis evidence existed, clinical expertise was used to fill that gap and duly noted. Treatment Results: A new paradigm is proposed to assist with clinical diagnosis and non-surgical intervention in Review patients suffering with AP. The level of evidence supporting this paradigm, according to the SORT taxonomy, is primarily level 2B. Conclusions: Further testing is warranted but following the suggested paradigm should lead to a clearer diagnosis of AP and allow more meaningful research into homogeneous patient populations within the AP diagnostic cluster. Strength-of-Recommendation Taxonomy (SORT): 2B Ó 2012 Elsevier Ltd. All rights reserved. 1. Introduction “hernia” appear to be losing favor since often, a hernia is not distinguishable (Davies, Clarke, Gilmore, Wotherspoon, & Connell, Athletic pubalgia (AP), broadly defined as pain in the groin and 2010; Zoga et al., 2008). Further, imaging including bone scintig- pubic region, is a relatively common entity in competitive athletes raphy, radiographs, and magnetic resonance (MR) are prone to false and considered one of the most common injuries in hockey (Agel, positive reports (Davies et al., 2010; Silvis et al., 2011). One recent Dompier, Dick, & Marshall, 2007), soccer (Arnason, Sigurdsson, author referred to this region of the body as, “the Bermuda triangle Gudmundsson, Holme, Engebretsen, & Bahr, 2004), and Austra- of sports medicine”(Bizzini, 2011). The implication of this state- lian rules football (Orchard & Seward, 2002). For such a common ment is that navigating through diagnosis and intervention is entity, relatively little is known about this syndrome. Similar to challenging, with a great probability of misdiagnosis driving inef- other syndromes, AP is a collection of signs and symptoms arising ficient treatment. One reason for this difficulty may be the reliance from multiple pathologies that are difficult to distinguish from one on a pathology-based diagnosis to drive intervention. another (Nam & Brody, 2008). Evidence of this fact are the multiple Two randomized controlled trials (RCTs), using the same active labels associated with AP (Table 1) and that as many as 90% of intervention protocol on heterogeneous patient populations, report athletes with chronic groin pain have multiple pathologies (Caudill, conflicting levels of success with conservative intervention in Nyland, Smith, Yerasimides, & Lach, 2008). Names using the term patients with AP (Holmich et al., 1999; Paajanen, Brinck, Hermunen, & Airo, 2011). Similar diagnostic and treatment issues have been reported relative to low back pain syndrome (LBPS). New classifi- * Corresponding author. Tel.: þ1 336 841 9270; fax: þ1 336 888 6394. E-mail addresses:
[email protected] (E.J. Hegedus),
[email protected] cation schemes have been proposed to help improve the diagnostic (B. Stern),
[email protected] (M.P. Reiman),
[email protected] process and create smaller, homogeneous patient groups where the (D. Tarara),
[email protected] (A.A. Wright). effectiveness of treatment can better be examined in patients with 1466-853X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ptsp.2012.04.002 This process. the psoas directly from the lumbar reality is that these intervention approaches are often parallel. Delitto. 2004). osteitis pubis (Smodlaka. & Bismil. & Mandlebaum. will aide in arriving at a diagnosis that the tendons. Piva. with AP. Foley. the operational definition in 4. external rather. Inklaar. and transverse abdominus muscles receive innervations Fritz. 2. & Eustace. Esrailian. Inner. 2000). Koes. Altered load tolerance in this Thackeray. Bradshaw & McCrory. espe- region. This biomechanical theory stated simply is Gracilis syndrome that an imbalance between normal anatomic structures can Groin disruption change the ability of those structures to dissipate load (Biedert. has been advocated in other difficult-to-diagnose definition of AP.. For this paper. 1. Meyers. & Erhard. 2) From digm presents evidence-based criteria to help isolate the diagnosis below. impairments like pain. and recalcitrant entity like AP. or pubic region that presents in painful. & Whitman (2004). and a refinement of thoughts from the distal thoracic/upper lumbar spine (Akita. eventually focusing on AP Persson. & Bowling. Dimitrakopoulou. Robinson. MacMahon. 1988). Sward. Talley. Fritz. 1995. the pubic symphysis resses to a regional approach and finally to a whole body approach. 1993. & Chang. for simplicity. Holmich et al. the reader is referred to Falvey. Proposed paradigm for clinical examination and treatment any clinical review of the topic is important to establish. professional colleagues and students. or sheaths in our defined region exempting will drive efficient and effective conservative intervention. / Physical Therapy in Sport 14 (2013) 3e16 Table 1 3.J. Theories of pain and dysfunction in AP Synonyms for athletic pubalgia. Hall. and cially in the absence of definitive diagnostic criteria. the pectineus. oblique.. there are many structures with process often changes from diagnosis by exclusion to criteria-based the potential to cause pain associated with athletic pubalgia: 1) diagnosis. 1995). Ebmer. Farid. 2010). internal oblique. The inguinal canal is formed by contributions The second part of the paradigm. presents a linear from the external oblique (anterior wall and base). Erhard. we hope. internal oblique. the rectus abdominus by the thoracoabdominal nerve not linear.4 E. The purpose region may cause pelvic instability (Garvey. & Stam. 2001). 1997). In the presence of such uncertainty with regard to a complex. Bennell. Thomas. This inability to transmit LBPS (Delitto. but not exclusively. Schilders et al. Niga. 2009). Brennan. compiled over the years and obtained from interaction with Muneta. Williams. Theoretically. a focus primarily. O’Neill. 1999. medial thigh. into 2 halves: Schilders. examination leading to diagnosis. From the pubic symphysis medially to the anterior. 2. In addition to helping que. (1995). motion loss. & Dellon. Gibbon. Karlsson. of this review is to propose a new paradigm which will serve as Mens. Yamato. This paradigm will serve as the framework Captured by our operational definition of athletic pubalgia are upon which to lay the evidence about diagnosis and treatment of tendinopathies (Kalebo. the adductor group of muscles. treatment for patients with AP. 2010. The review may assist in guiding future their bony interface (Cook & Purdam. We inguinal hernia and inflammation of the pubic bone from systemic present this paradigm in Fig. clinically useful in diagnosis of a syndrome. and the internal oblique. Talbot. As more is discovered about a syndrome. McIntosh. load is key since the pelvic bone and pubic symphysis are vital 2009). Garrett. . Warnke. of AP. 2006. diagnoses that refer pain to this region. 2007. 1999. a skeletal framework for clinical diagnosis and conservative 2000) as well as damage to tendons and other soft tissues and management of AP. This paradigm is not the invention of the authors but (originating partially from L1-2). & Peterson. intervention. lower abdomen. A brief review of as the “only diagnosis left standing”. and plexus (L1-3). Abrahamsson. Athletic pubalgia Because of the complex innervation of this region. 1980). 2009). Childs. & Garlick. and nerve entrapments in the inguinal region (Ekberg. Hunter. greater detail hereafter. the Again. The resultant pain my further compromise the motor control of this region (Cowan. The examination component begins with insufficiency (Hackney. called diagnosis the anatomy of this region will further elucidate our operational by exclusion. is innervated by the genitofemoral and pudendal nerves. Franklyn-Miller.. Orchard. & Boyle. Criteria-based diagnosis is a list of items that are From above. Read. Lohnes. and the iliopsoas. research and improving patient outcomes with conservative O’Connell. Cunningham. we would like to propose athletes and may encompass the following pathologies: damage to a paradigm that. for simplicity. the diagnostic superior iliac spine (ASIS) laterally.. as is the case McCrory (2009). Brukner. Rab. & Sato. 2006. 2003. For a more thorough review of the anatomy of this syndromes (Spiegel. fascia. (stage-based) sequence which starts with addressing local and the transverse abdominus (posterior wall and ceiling). we will define athletic pubalgia as pain in the groin region. 1999. external obli. & Downes. AP. 1992. intervention leading to 2009). Because of the complexity of AP. Operational definition and brief anatomy review Coburn. the gracilis. 2009). Hall et al. joint (Dalstra & Huiskes. Read. 2009. and transverse abdominus muscles/tendons/sheaths as well as the clinician to rule out competing diagnoses.. Neophyton. 1 and describe the paradigm in disease or fracture. posterior inguinal wall return to function. Westlin. and strength loss then prog- vation of the area varies but generally speaking. Gilmore groin Adductor-related groin pain The second and most prevalent theory is more biomechanical Prehernia complex in nature and may also explain the weakness in the posterior wall Symphysis syndrome of the inguinal canal. & Lilja. These classification schemes have shown promise in the links in transferring forces from the lumbosacral region to the hip form of improved patient outcomes (Brennan. the proposed para- the inguinal ligament (the fold of the external oblique). Hegedus et al. & Turner. & Meyer. the pectineus from impairment-based to multi-modal treatment but the clinical and iliacus by the femoral nerve. one theory is Sports hernia that nerve entrapment is a potential source of pain in AP (Falvey et al. the rectus abdominus. The paradigm can be sub-divided. Hodges. Schache. the sequence is presented in a linear fashion adductor group and gracilis by the obturator nerve. is based on original work by Delitto et al. the most frequent nerve entrapment Sportsmen hernia Sportsmen’s groin in this region is that the cutaneous branches of the ilioinguinal or Pubic inguinal syndrome the genitofemoral (genital branch) nerves become entrapped Osteitis (Os) pubis secondary to weakness in the posterior wall of the inguinal canal Chronic groin pain (Akita et al. on ruling out more common 1998). There are multiple ways to capture a pain intensity rating. The sport in which the athlete participates is likely to population. and valid understanding of outcomes in patients with AP. Verrall. Holmich. & Barnes. sensory components can be captured by the Short Form McGill Pain Holmich. The LEFS contains region-specific outcomes measures for the hip revealed only one 20 questions about a person’s ability to perform everyday tasks and questionnaire for the groin region (Thorborg. but instead. sensory. A recent review of setting (Binkley. reflects that the use of these measures in 2009). An Emery & Meeuwisse. Schilders et al. contributory (Bradshaw & McCrory. Moen. Foster.. and dimension- Fon. 2007). Petersen. specific (AP). Long... all are needed to provide more inclusive multiple pain episodes and/or chronic pain (Arnason et al. Holmich. Meyers et al. dimension-specific (pain). Patient report outcomes measures are widely used in an attempt 1986) is an 11-point (0 ¼ no pain. The LEFS can be used by lower quality and was used only in post-operative patients. 1999). as well as to set functional goals. Lott. 2008). or hockey The chief impairment to capture in patients with AP is pain (Arnason et al. Gabbe et al.. Mackintosh. 1994). Stratford. Ekstrand & given that pain is generally what drives the patient to seek care. A proposed paradigm for examination and treatment of patients with athletic pubalgia (AP). measure of lower extremity function validated in an outpatient Schmidt. an outcomes measure which uses 6 subscales to capture toward 0 represents functional losses.. E. Because the lower abdominals (Ekstrand & Gillquist. et al. Hegedus et al. although 2 of those studies Katz. 2007). Slavotinek. As the condition important note is that our level of evidence rating for this category worsens. 2007. 2005) instru- suggested that other sources of pain from the hip joint were ment. Verrall. measures. 2001. & Fitzpatrick.. condition. This measure was found to be of a disorder of one or both lower extremities. & Tol. 2010). A higher score developed and validated the Hip and Groin Outcome Score toward 80 represents excellent function whereas a lower score (HAGOS). symptoms may present bilaterally and refer into the does not reflect the evidence supporting the following outcomes testicular region (in males)(Meyers et al. Fon. 10 ¼ worst possible pain). 5.J. Bush. 1987) which is a valid (Melzack & were a likely group to suffer from AP. 2011. 1983. 2000. Roos. Examination sequence not only the patient’s disability but also the patient’s perception of his or her disability. but a highly competitive athlete (Meyers et al. Gillquist. to capture results from treatment that are meaningful to patients consistent measure of pain intensity that can be adapted to ask and to address constructs like function and readiness to return to about pain at rest. and pain sport. rugby. 2010). generic (health profile). 2001) and reliable (Grafton. based on 101 subjects. such. 2004. pain during regular daily activities. 1997. Thorborg. The affective and 2008). More clinicians as a measure of patients’ initial function. & Holmich. Bradshaw & McCrory. & Roos (2011) ress and outcome.. American or Australian Rules football. generic. The patient is likely to report that they are not only an a population with AP is recommended based on our clinical expe- athlete. Independent validation has yet to be performed on the HAGOS. Slavotinek. Zoga et al. Interestingly. we believe it prudent to recommend the use of dimension- contact related unilateral pain in the adductor region and/or specific. / Physical Therapy in Sport 14 (2013) 3e16 5 Fig. be soccer. These measures can be region-specific (hip). 2002). & Riddle. & Harkins. Bartels. 2000. 3 studies (Bradshaw & McCrory. Test-retest reliability of the . ongoing prog- recently. & Wright. 1997. and 2007. individualized. 2000.1. Holmich. can be used to evaluate the functional impairment of a patient with Petersen. Karoly. Further questioning is likely to reveal specific measures differ. 5. 1997. Pain is a multidimensional construct with affective. and individualized measures. The Numeric Pain Rating Scale (NPRS)(Jensen. Christensen. during sport (Price. 2004... de Vos. The authors concluded. as The patient with AP will most often report insidious or non. & Braver. 1983... The Lower Extremity Functional Scale (LEFS) is a generic or individualized (patient chooses items of importance)(Garratt. 2010). conceptual frameworks for generic.. intensity components (Hegedus et al. Weir. Zoga et al. Zoga rience rather than the actual validation of these measures in this et al. 1. 2008) demonstrated that runners Questionnaire (SFMPQ)(Melzack. Patient history and self-report outcomes measures that the questionnaire had “adequate” measurement qualities. & Taylor. male athlete.. Hegedus et al. endometriosis. adaptation to symptoms. the gender difference may be related a modification of that screen that adds sensitive tests that. Signs of more serious pathology are setting and targeted treatment interventions to achieve pre. the usual report is that more males than (Grimes & Schulz.. Uhorchak. certainly room for greater understanding of the risk factors asso- tients with lower-extremity musculoskeletal dysfunction (Binkley ciated with AP. establish patient perception of overall results. In one study involving Australian Rules football players. the age. or level of performance. fever. there is very little from a local Another generic measure is the Single Assessment Numeric observational perspective that can be considered a hallmark sign of Evaluation (SANE)(Williams. 1997.. Holmich. 2001) found groin (Bradshaw. Fon & Spence. gynecological. functional outcome scale used to evaluate changes in disability over musculoskeletal causes of groin pain must be ruled out before time (Chatman et al. pelvic or hip stress fracture..86) in outpa. assist in ruling out pathology with similar signs and (Bradshaw & McCrory. & Snyder. the first step in detecting specified goals. reality. and possible upper motor involvement. a study of professional soccer players reported that those lower quarter screening examination. clinicians to further understand the process of recovery within In order to make the decision to refer. 2002).. rheumatologic. Further. there may be no gender difference at all (Schick & sacral spine. While the term athlete is an accurate descriptor in the romusculoskeletal sources of groin pain. was more common in the young (Orchard. & Falvey. However. Arciero.. Any (2nd most injured)(Ekstrand. in a study of National Hockey League players. experience. 1997. referred to as “red flags” and generally.. injury or problem”) scale. Triage and screening would you rate your hip today as a percentage of normal (0e100% scale with 100% being normal)?”. more serious pathology. 1999) and the LEFS was also found to be valid. 2000). when to sport. Boissonnault. These sources of groin pain majority. 16 of 17 females with groin represents the ability to perform the activity well with lower scores pain were found to have another source of pain beyond AP further representing a lower level of function. 1997. Traditionally. lumbosacral pathology. and gender of the athlete are less may include but are not limited to hip osteoarthritis. We . focusing on the concept of expected pathology that is outside the practice scope of that practitioner. other non-urgent. Therapeutic success can thus be defined at pathology that requires imaging or lab testing in order that the the individual level (i.. An affirmative Observation is defined as the process of looking at the patient as response to any of these questions or a report of any of these a whole. with the final score determined by ankylosing spondylitis. the examiner must the multiple dimensions that exist.6 E. the lower aged 16e21 years were least likely to have a groin injury when quarter screen consists of testing of dermatomes. and true inguinal hernia (Caudill et al. 1997). Seward. Observed findings like ecchymosis. A higher score toward 10 and genital herpes. 2009). epididymitis. questions should broach urological. In our clinical experience. Other red flags include a history with knee dysfunction (Chatman et al. The SANE is a patient-based outcome measure used to or an antalgic gait have been inconsistent or non-existent. 1998). Thompson. Haj-Hassan. Because most of the studies we examined additions to the lower quarter screen can be found in Table 3 and we consisted of relatively small samples of convenience. Of note. Observation Leerar. 2010). Young. A detailed ties that they are having difficulty with or are unable to perform medical questionnaire is beyond the scope of this article.2. 5. 2007.J. 1999). averaging the three activity scores. The SANE is time-efficient and reconcile with the fact that any clinical examination is imperfect correlates well with other established outcomes measure but has and that serious pathology or pathology that requires further not been studied in patients with AP. 2007. The patient rates each activity on a 0 (“unable to perform oncologic.. of trauma. needs to be ruled out before a diagnosis of AP can be suspected Emery and Meeuwisse (Emery & Meeuwisse. 2000. In fact. responsive the young male who plays a cutting sport may not be entirely and reliable in an inpatient orthopedic setting (Yeung. inflammatory bowel disease. Wood. deep compared to 22e30 year olds (most injured). this picture becomes less clear when the evidence is The next step is to attempt to discern among the various neu- examined. 2000. 2007) and in competitive symptoms to AP: intra-articular hip pathology. prostatitis. night pain. Gangel. or treat acceptable at the end of the care. accurate nor all encompassing. the hip may that those with AP are mostly under the age of 40 (Zoga et al. & Macdermid. and fractures and stress fractures. 2008). Aguilera. Zoga et al. AP roacetabular impingement.e. A second study with a broader sample population confirmed 2008. There is also reason to suspect that the stereotype of et al. screening exam should be composed of tests with high sensitivity With regard to gender. Hegedus. 1997). symptoms would require more in-depth questioning and may The stereotypical patient with AP is a young. Pietrobon. 2003). followed by inspection of the localized area of symptoms. 2010. 2007). but these (Chatman et al. differentiate the many potential pain referral sources is through the Finally. The definition of SANE is based on Triage and screening is defined as the process by which the the personal experience of the patient including satisfaction and examiner rules out. 2011). 2009). Bundy. and those over 30 tendon reflexes. Female runners may have a higher incidence of AP negative. Suggested sensitive Meeuwisse. & Roddey. AP. & Broad. an obvious inguinal bulge. Test-retest reliability of the suggesting the need for a detailed screen as part of the clinical PSFS has been demonstrated to be excellent (R ¼ 0. Wessel. 2008). and inflammatory sources of groin pain including activity”) to 10 (“able to perform activity at same level as before testicular seminoma. The SANE rating is determined by patient response to the following question: “How 5. Cleland. Meyers sensitive (Cook. The PSFS may assist clinicians in goal arriving at a diagnosis of AP. Domholdt.3. Tibor & Sekiya. the lumbo- hockey. Michener. / Physical Therapy in Sport 14 (2013) 3e16 LEFS has been demonstrated to be excellent (R ¼ 0. red flags is a standardized medical questionnaire. burning with urination. we suggest et al.84) in patients examination (Meyers et al. treat independently. hip labral tear. since AP is a syndrome. This step is critical in a syndrome like AP. and prolonged corticosteroid use (Gabbe et al. Van den Bruel.. there is will discuss the screening examination in greater detail here. 2008). testing beyond physical examination can mimic the signs and The Patient-Specific Functional Scale (PSFS) is an individualized symptoms of AP. in one study. & Goode. Holmich. & Mant. for each patient) as achieving a state following decision can be made: refer. myotomes. Stratford. femo- clear. appendicitis. hip OA. In result in immediate referral or further medical testing or imaging. While there seems to be good support for (Table 2) actually is composed of tests that are specific rather than this statement (Bradshaw & McCrory. The PSFS requires patients to identify three activi. & Walden. Since the traditional neurological “screen” females are prone to AP. An efficient way to begin to pain to be more common in older. Buntinx. more experienced players. Hagglund.. be the main source of referred pain to the groin and so hip pathology 2008). unexplained weight loss. via clinical examination. The SANE method enables and refer. Femoroacetabular impingement Pubic Percussion (PPP) Test is helpful in ruling out a fracture (FAI) and labral tears often are found together on imaging and both between the patella and pubic bone when negative (Adams & can refer pain that is similar to that experienced with AP.. myotome. Dillingham. If this test is positive. encourage clinicians to adapt the order in which we present this in ruling out both impingement and labral tears when negative. SP ¼ specificity.. A positive test means refer down on to the forearm. Cadoux-Hudson. the examiner’s forearm placed under the thigh. LR 0. & Belandres. LRþ 1. The patient should be referred for further testing. & Limke.. 2005) The patient is supine and the hip and knee SN 88..0 Great toe extension with flexion of the remaining neuron (UMN) testing 4 toes is considered positive for an UMN lesion. The Fulcrum Test (Johnson. LRþ 4. 2003) suspicion of spine or upper motor neuron L4-5 Heel walking pathology and be combined with dermatome. Even if ROM is limited in only 1 plane. 2000a) SP 84.. 2008) of flexion. there is generally (Birrell et al. LR 0. LRþ 8. SP ¼ specificity. SN 92. 1998) L5 e web space of great and 2nd toe (Kerr. the practitioner should refer Flexion Adduction Internal Rotation (FADIR) test has been studied for imaging (Adams & Yarnold.reflexia compared to the L4-5 Achilles (Lauder et al.0 pain from the spine and be combined with L4 e Medial malleolus (Peeters. & Soballe. while not necessarily an intra-articular pathology. the FADIR test has high sensitivity which is helpful but for cases of stress fracture of the femur. & Silman.. then a femoral stress fracture can be The examiner pushes the patient’s leg ruled out. 1988) Myotome testing L1-2 Resisted hip flexion (Lauder et al. and upper motor neuron (UMN) testing Reflex testing L2-3 Quadriceps (Lauder et al. Leunig. 2001). LR 0. Gralla. If ROM is limited in 1 or less planes. ITEM Description Key metrics INTERPRETATION Repeated lumbar motion The patient repeats forward. / Physical Therapy in Sport 14 (2013) 3e16 7 Table 2 Traditional components of a lower quarter screening examination. then FAI and/or a torn Sink. Hosie. E. then femoral neck fracture tuning fork on the patella. Bolvig. The Yarnold.88 uninvolved side in any of these deep tendon L5-S1 Extensor Digitorum Brevis SP 91. Finno. 1995) upper motor neuron pathology and be combined with dermatome. & Ganz. Cooper. Sensitive tests of the hip: 1. The examiner moves SN 96 to 100 If the FADIR does not reproduce the Test (FADIR)(Ito.0 Hyper. OA. reflex. 2000b) SP 92. LRþ ¼ positive likelihood ratio. An important point to Table 3 Additional sensitive components of the lower quarter screen for patients with AP. & Dayton. 2007). LRþ 4. Fractures and stress can be ruled out (Birrell.or hypo. fractures. 1997). for imaging SIJ ¼ Sacroiliac Joint. LRþ 2.06 bilaterally. 2001) a loss of ROM in 2 or more planes. myotome. backward. adduction. 2004. . Aufdemkampe. Macfarlane. Flexion Adduction Internal Rotation The patient is supine. the patient’s leg into the combined motions patients pain.56 reflexes should cause suspicion of spine or (Marin. Chang. Hip ROM Lack of limitation in any hip motion SN 100 With OA of the hip. Patellar Pubic Percussion (PPP) Test A stethoscope is placed on the pubic bone SN 94. LRþ 1.0 Decreased or loss of sensation in any of these L2 e inner thigh SP 86. The Patellar contributor (Birrell et al. Jacobsen. active population.. SN ¼ Sensitivity. & Wheeler. can be ruled out. 1994) is used in a like fashion to the PPP Test Hegedus. labrum 2.J. LRþ ¼ positive likelihood ratio. 1997) while the examiner either taps or places a LRþ 20. hip OA is an unlikely a concern in a relatively young. the lumbar spine is ruled out Thigh Thrust Test (Laslett et al.14 dermatomes should cause suspicion of referred L3 e medial knee SP 86. motion (ROM) is not limited in any plane. the sacroiliac joint compression along the long axis of the is ruled out femur using a hand under the patient’s sacrum as a wedge to create shearing force at the SIJ. 2002) SP 90.. SP 95 If auscultation produces like sounds (Adams & Yarnold. regardless of severity Gelineck. Jouve. Ryba. Hegedus et al.38 Weakness compared to the uninvolved side L2-3 Single leg sit to stand in any of these myotomes should cause (Rainville. & Adams.17 If the thigh thrust does not reproduce are flexed to 90 . LR ¼ negative likelihood ratio. 3.12 If repeated motions don’t reproduce the (Donelson et al. The examiner provides the patient’s pain. Different sounds means refer for imaging. the sensitivity was only 59% (Troelsen.. and upper motor neuron (UMN) testing & Oostendorp. support this use of the FADIR test with some caution since the The first steps in the screening examination for suspected AP is specificity of the FADIR test has been reported in only one study and to rule out the hip joint and lumbosacral region. We screen for the convenience of individual patients and circumstances. 1997) and side bending pain. LRþ 1. 1994) The patient is seated at the end of a table with SN 100 If the patient’s pain is not reproduced. Croft. 2009). LRþ 3. 1988) S1 e underside of foot (Kerr et al. 2000b) SP 96. If hip range of in this study. Item Description Key metrics Interpretation (if available) Dermatome testing L1 e inguinal SP 88. and upper motor neuron (UMN) testing Upper motor Babinski (Berger & Fannin. 1997). Mechlenburg. 4. are still 2001). and internal rotation labrum can be ruled out FAI. ROM ¼ range of motion. L5-S1 Toe walking reflex. Fulcrum test (Johnson et al. ROM ¼ range of motion. multiple times and according to one comprehensive source (Cook & Weiss. OA is unlikely. The evidence correlating AP and ice hockey players. and the psoas muscle to further used early in the examination and that their value is in being localize the source of pain (Holmich. logical step is to continue with a focused clinical examination Several studies have correlated hip weakness or pain with resisted involving motion testing. tion of the pubic region including the pubic ramus and symphysis.3. No studies groups in the groin and lower abdominal region to include the hip were found examining the correlation between accessory motions (flexors. the lower abdominals. For this review. & McHugh (2002) found adductor strength actively or passively. 2001) reported no associ- tests are important since AP is a diagnosis of exclusion.4. (2004) reported delayed contraction of Ekstrand & Gillquist. the transversus abdominus in a small sample (n ¼ 10) of compet- Verrall et al. While there certainly is no harm ROM testing. but the majority of evidence supports a correlation of strength loss with AP (Crow. One study (Emery & Meeuwisse.. (2010) re- ported decreased hip adductor strength both prior to and during an 5. Eighty-seven percent of the subjects 2003). function and recruitment.2. strength testing. 2001). Ibrahim. fractures. Barnes. Nicholas. there is no research to support this statement.. and tant factor. One study found tenderness over the pubic Once the decreased likelihood of referral from the hip joint has bone in 75% of Australian Rules Football players with groin pain been established. The decreased strength compared to the uninvolved side. et al. and AP but one case series did report decreased anterior and posterior rectus abdominus) musculature. Hemingway. extensors.8 E. uninjured simplified abbreviation of ROM.. Others have correlated oblique or rectus abdominus weakness or 1973). Crossley. 2003. Veale. still other studies have found flexibility to be no (2003) described the bent knee fallout test with abdominal issue (Emery & Meeuwisse.4. Danneels. Slavotinek. Diagnosis of AP VanderWesthuizen. The clinician is also encouraged to perform passive hernia was reported in one study (Meyers et al. Another study found repeated flexion. which . 2004. Slavotinek. Intra- accessory intervertebral motion testing of the lumbar spine for observer agreement for pain provocation over specific structures symptom reproduction as described by Maitland (Maitland. We also believe that pain reproduction with accessory in testing for delayed transversus abdominus or oblique contraction. 2005). (Verrall. the next a ratio of one muscle group to another. We have captured this combination by using the to be 18% less than the abductor strength in injured vs. is generally found to be good (K > 0. 2003. Palpation As the clinician arrives at the end of the systematic physical Experts have recommended palpation over specific structures examination process. & Blower. Asselman.J. external rotation.. 2003. authors of the papers included in measurement of isolated adductor strength alone. Strength testing in patients with AP is recommended. rotation. we perhaps more importantly. Verrall. and side bending of the lumbar spine can superior pubic ramus pain with palpation in 85% of subjects rule out the lumbar spine as a contributor (Donelson.. Nicholas. Strength has generally Assuming that the clinician has effectively ruled out the been tested against resistance provided by an examiner with the lumbosacral spine. Lack of flexibility has been found to be correlated with AP in pain with resisted testing with AP (Hemingway et al. & Cambier. Hogan. lack of symptom reproduction following season (Slavotinek. 2001. there will be some been questioned (Malliaras.. 2001. ation of strength deficit with AP. Tyler. The same study reported an athlete as 17 times ROM is conflicting.. 5. Esterman. D’Have. pubic symphysis high specificity and a high positive likelihood ratio (LRþ). specific special tests for AP.4. as other sources of referred symptoms to the groin region. Strength testing specificities meaning a positive test cannot be used to rule in AP. 2001). 2000). 2008).. A positive finding with any of these tests is less helpful since all have lower 5. Donellan.. Campbell. the lumbosacral region should be ruled out. Delahaye et al. 1983. Tyler. Tyler et al. Aprill. intra-articular hip pathology. tests that are falsely negative. Medcalf. 2004. Witvrouw. & Banks. Murrell. hip testing with AP (Crow et al. Fon. adductors) and abdominal (obliques. formed to rule out the sacroiliac joint (SIJ)(Laslett. or as a motor control issue. 2007). Oakeshott. The clinician should take note of glide of the hip in patients with AP (Kachingwe & Grech. rectus abdominis muscle. Delahaye et al. we recommend a detailed palpa- a potential contributor. Motion testing episode of AP suggesting weakness as both a causative and resul- Motion testing includes active (AROM). extension.. chief complaint of pain.. Based Hengeveld. Muscle strength imbalance has been considered accessory motions. itive Australian Rules football players with AP. Meyers et al. the lack of a palpable & Grant. Despite their imperfection. Cowan et al. This the reliability of testing internal and external rotation of the hip has imperfection means that in daily clinical practice. Some have hypothesized that AP is caused by more likely to experience an adductor muscle strains if their overstretching of the hip into abduction and external rotation which adductor strength is less than 80% of their abductor strength. McDonald.. Coburn. / Physical Therapy in Sport 14 (2013) 3e16 reiterate is that the benefit of most of these tests is that they are joint. Also.4. Further. If the patient does not report reproduction of the reproducing the patient’s complaint of pain. 2010. 5. Hegedus et al. 2002) to further clear the lumbar spine as on this moderate level research. negative which helps rule out hip pathologies. & drawing in and a pressure biofeedback cuff to assess oblique McHugh. 2003. & Bjerg. Holmich. 2004). 2007. implies a lack of flexibility in these two motions (Merrifield & Cowan. 2005). 2007). Tyler numerous studies (Arnason et al. Herrington.. special tests should exhibit the metrics of such as the adductor longus muscle insertion. 2003.4. palpation.. 2000). and the adductor region with the intent of & Young. Delahaye et al.80)(Holmich et al. Hemingway et al.4. screening 2009). & Schache. & Knapman. Crow et al. we have combined the evidence a greater risk factor in developing sports related groin pain than the on AROM and PROM since.. Special tests 5. et al. and finally. the reproduction of the patient’s pain suggest that the detailed examination of patients with AP include with testing (Meyers et al. the ratio of debate of the importance of ROM as a contributing factor to AP will abduction to adduction strength regardless of side tested. & Sage. Hemingway et al. & Pizzari. the sensitive Thigh Thrust Test is per. The motions most often reported as limited are hip internal with AP due to posterior abdominal wall deficiency failed the test. passive (PROM). often. our review did not specify whether the assessed motion was tested Campbell. 2010. although these tests are imperfect in that their sensitivities are not 100%. Nawrocki. motions of the pubic symphysis may be an important finding but the evidence supporting this testing is limited in patients with AP. abductors. Aprill. & Spriggins. 2005. and continue but due to the findings in some studies of limited motion. 2000). and abduction implying that the hip We recommend resisted strength testing of the major muscle rotators and adductor group exhibit decreased flexibility. Pearce. Verrall. 1997). Fon. and results classified as pain or loss of strength in a single plane. which was strongly correlated with training restriction during the According to the literature. 2003).1. then the SIJ has been ruled out. Next. Hegedus et al.. The probability fist between the patient’s knees and instructs of detecting AP with a positive test the patient to squeeze maximally. or easier than the lifts to instability in the pelvic ring. & Rayens. with a positive test is increased 2.. 2005) flexed to 90 . decreased quad strength. formed as a complement to self-report measures to capture both Alcock. 2005) exhibits the maintaining single leg stance. Snijders. Reid. The examiner is a positive test for AP. The Squeeze (Verrall. & Hewett.96 (Ageberg. LRþ 4. is increased 4 Single Adductor (Verrall. If the patient is value of >90% prior to reintegration into sport. ankle instability. et al. strength and The modified agility T-test (MAT) is used to evaluate side to side balance (Filipa. SP 92. et al. SP ¼ specificity. defined as activities distance.0 cm with an ICC (2. SP 94. However. and poster- Test (Mens... Slavotinek. The MAT is impairments related to musculoskeletal injuries including chronic a timed performance test utilized for sports that require quick starts. without the belt Valsalva The patient bears down forcefully as in a difficult In patients with AP.. Caborn. and if cients (ICC 2. (2002) on pelvic pain in pregnancy and not AP. and efficient movement.. 1999. single hop for Physical performance measures (PPMs). Bolgla & Keskula. & Giffin. LRþ 2. Petschnig. produce greater force in the leg lift The process is repeated on the opposite leg.. Barnes.08 Reproduction of the patient’s pain Slavotinek. the sensitivity and specificity of the ASLR test in patients In addition to the Y Balance Test. The single hop for way. this Reproduction of the patient’s pain bowel movement test is positive in less than: is a positive test for a hernia.67 Reproduction of the patient’s pain Slavotinek. as difficult. The 10% (Meyers et al. ruled in postural stability in athletes post ACL reconstruction compared to AP. 2010) Researchers differences in lower extremity agility performance specific to have provided evidence that the SEBT is sensitive for screening cutting and running maneuvers (Myer et al. 5. Gustavsson et al. Paterno. a Active Straight Leg Raise The patient is supine with legs 20 cm apart and asked to SN 87. Brosky. a less strenuous PPM can be chosen or recreational athletes have been reported in the range of testing can be deferred until follow-up.96 (Filipa et al. Kiesel. Baron. 2011.k) of 0. controls (P < 0. a These statistics come from a study by Mens et al. The authors recommend a minimum LSI baseline physical function and to gauge recovery.5e195. The probability of detecting AP The process is completed on the contralateral side also. & Elkins.J.. Kinzey this test detects that instability. . 2003). and patellofemoral pain dynamic changes in direction. SN ¼ Sensitivity. then the test would have value. The Active Straight Leg Raise (ASLR) lower extremity dysfunction (anterior. & have been tested in populations exclusively with AP.. and has a good idea of the patient’s pain level. One The Star-Excursion Balance Test (SEBT) or the modified SEBT (Y final addition to the Gustavsson et al. Ronchetti. 1998. The Y Balance Test Adductor (Verrall. Byrnes. SP 88. et al. The test is Table 4 Specific Physical Examination Tests (Special Tests) for Patients with Athletic Pubalgia (AP). (2006) battery is the triple balance test) is a useful functional screening tool developed to hop for distance which has been reported to have a large effect size assess an athlete’s dynamic balance and postural control. LRþ 14. et al. These measures are best performed at the end of the exami. LR ¼ negative likelihood ratio. Vleeming. Birmingham.. 2006). hips flexed to 45 and knees SN 49.5. 2002) raise one leg while rating the difficulty of the lift. the patient reaches with the free best metrics and is the only specific test for AP we would recom. we would recommend a hop with AP is unknown.4. 2005) abducted. 2007). The list of specific special tests syndrome (Gribble & Hertel.1) ranging from 0. and pathologies. are assessed in a very standardized. Normal values for unable to perform the PPM. 1997. Physical performance measures (2006) found that if 1 of 3 hop tests (vertical hop. and slightly internally rotated. Zatterstrom. 1998). et al. Nitz.001)(Myer et al. While adductor test (Verrall. posteromedial. distance is a useful tool to identify persistent deficits in lower limb nation process since the clinician has ruled out more serious performance including functional power. Single leg hop tests have been studied mostly in an ACL-injured population. repeatable detecting an ACL reconstructed knee was 91%.. 2011). The patient is supine with both hips flexed to 30 . ruled out contribution of other hip pathology. & Olmsted-Kramer. & Albrecht. Plisky. Malone. the bilateral patient standing on one leg at the center of the “star”. Braham. Stratford. E. The examiner places his or her is a positive test for AP. Test Description Key metrics Interpretation Squeeze test (Verrall.67 to 0. 2011). A belt is with a stabilizing pelvic belt in place. 2002) is olateral)(Hertel. & Fon. Slavotinek. Athlete lays supine. 2006. The test is performed with the for patients with AP is short (Table 4) and currently. Butler. timed side hop) showed a deficient limb symmetry index performed by the patient in order that the examiner is better able (LSI) (involved score O uninvolved score 100).. The SEBT has the inability to effectively transfer load from the lumbar spine to demonstrated good intra-rater reliability with reliability coeffi- the hip causes pain. 1998). & Stam.13 Reproduction of the patient’s pain Slavotinek. placed securely around the pelvis and each leg lift is then the patient with AP has impaired repeated and the patient is asked whether the lift was load transfer through the pelvis due more difficult. 2010. Hale. LRþ ¼ positive likelihood ratio. PPMs are per. the sensitivity for to assess function. Myer.. 2011) AP is dubious. 2009). The patient is supine and flexes the test leg to 30 . The probability places their forearms on the patient’s medial foot arches of detecting AP with a positive and instructs the patient to resist the examiner’s attempt test is increased 8 to abduct the patient’s hips.5 If the patient has less pain or can (Mens et al. If pelvic ring instability is one cause of AP. force attenuation. so the use of Moritz. slightly SN 65. 2005) and Single gressing clockwise) in relation to the stance foot. The SEBT (Myer et al. Underwood. SN 32. limb in eight different directions (starting anteriorly and pro- mend. flexibility. test battery (Gustavsson et al. & Armstrong. Slavotinek. There are no PPMs that 173. 2000) use of this test in patients with 30% (Weir et al. LRþ 8. SP 88. the examiner’s attempt to abduct the patient’s hips. / Physical Therapy in Sport 14 (2013) 3e16 9 will help rule in the diagnosis of AP. intriguing especially since one theory of the etiology of AP is that Gorman. requires lower extremity coordination.7 Bilateral adductor (Verrall. 2005) tests are appropriate but was developed to standardize performance of the SEBT incorpo- with worse metrics and there is no need to perform redundant tests rating those directions with the greatest accuracy in identifying that increase the patient’s pain. 2005) The examiner places their hand on the medial aspect regardless of the lower extremity of the patient’s heel and instructs the patient to resist tested is a positive test for AP. the following PPMs is based on our clinical opinion. AP. controlled trials. 2004. Appleyard. Koes. The sequence is presented in a linear We encourage the reader to remember that while many of these fashion from impairment-based to multi-modal treatment but the tests have been assessed for reliability and validity. 2009). Therefore. 1996. treatment does not result in improvement. 2008. Delitto et al. Recall that within our definition of AP falls tendinopathy of the adductor group or the abdominal group. Appleyard. The athlete is likely to report a slow onset of pain in motion. particularly if the patient is an elite athlete. Although no research exists to support the use of dermally applied glyceryl trinitrate in patients with AP. These categories taken to complete the task (Myer. referred classification categories should be added.1) of biological rationale. 90-degree cuts isolated to a single Specific interventions paired with these priority impairments direction during the trial to evaluate a potential unilateral deficit. Price.825 (Hickey. 2007). Khan. 2002. have been selected based on a combination of earlier research. this group includes populations who are acute.. Paterno. the level of evidence is 3C 6. Kamper et al. and not linear. 6. 2004. number to reduce the likelihood of Type I error (chance findings due to multiple comparisons) in follow-up studies examining 5. Fig. strength) have not been established in this patient pop- a defined area from the groin to the pubic symphysis. Multiple interventions have been described for the treatment of includes a subgroup of patients who rate their pain >7/10 and have higher levels of disability (Childs et al. / Physical Therapy in Sport 14 (2013) 3e16 designed to incorporate four. Subgroup classification (Stage 1). Lewis. the clinician should rule out hip and pelvis & Lohnes. We made the decision not to categorize this subgroup based on duration of symptoms since there is little known about AP in the gating conservative treatment of AP are of limited quality... the battery of tests that we have recommended been tested as a group on any population. Nelson. Toro-Velasco. We included manual interven- symptoms consistent with our operational definition of AP can initially be classified into subgroups based on clinical features.. 2010). Fon. Delitto et al. Maher. there is great doubt about the effectiveness of . & Hewett. After these two steps have excluded competing diag. compile criteria associated with AP with a focus on the diagnosis of These treatment groups are to facilitate the initiation of an efficient AP.. et al.5. subacute. Hegedus et al. Souvlis. Ismail. which we classify as the Pain Control Group. Larson When diagnosing AP. Fig. If. motion loss. and George (2009) cited several studies suggesting a potential mecha- nism of action of manual therapy on musculoskeletal pain medi- ated by both the peripheral and central nervous system. Paoloni. This lack acute stages. 2008. Nelson. Holmich et al... Delitto et al.1. Croft. conservative 2005) and common elbow extensors (Paoloni. Clinical examination summary treatment effect (Childs et al. the individual clinical reality is that these intervention approaches are often tests have not been studied in a patient population with AP nor has parallel. Paoloni. 2009). 2007).. and chronic overuse patients of conservative intervention evidence was the driving force behind the development of our new paradigm. Hancock.1. Further research will determine whether additional cologic systems. 2011). Ford. 1999. & Warren. patients who fit our definition of AP. Slavotinek. Intervention sequence As pain is generally what drives patients with AP to seek care. Sorensen. & Murrell.. Therefore. 2004. manipulation. We recognize that pre-injury norms (range of players. Slavotinek. We understand that this is (Knight. then conservative treatment should be continued following Stages 2 (Kane. and 3 of our proposed intervention sequence. Farber & Wilckens. Bialosky. as with previous sources of pain from the hip and lumbosacral region should be authors (Childs et al. most of which are surgical and mention specific conservative treatments only in passing. & Graven-Nielsen. Simonsen. After eliminating red flag sources of pain. Cleland. Also. 2006). 2 is designed to assist in the allocation of patients to a specific treatment category and to 2008. Criteria of note are highly competitive male athletes who play treatment program based on impairment (pain. Verrall. If & Murrell. Ford. Robinson. Fernandez-de-Las-Penas. 1999. Arroyo-Morales... 2008). Hoeksma et al. allow treatment providers to address the impairments of a more homogenous subgroup of patients. et al. Hip determining who is at greater or less risk for injury as well as more motion may be limited but the clinician is more likely to find focused management of impairments. systematic physical examination should be undertaken to may fall into more than 1 treatment group (Stanton et al. some patients noses. 1995). lacking evidence from high quality randomized. not meant to be mutually exclusive and therefore. chronic recurring. & Barrero-Hernandez. Pain Control Group 6. 1995). & Calder. 2009.. 2010. a cutting sport with the exception of female runners and hockey strength deficit). especially of the urologic and gyne.. 2007. and whole-body issues. & Murrell. Lynch & Renstrom. Bishop. Verrall. over the course of 6e8 weeks. Mortensen. comprise an initial list that may be worth investigating as potential The goal of the athlete is to attain a symmetry within 10% in the time treatment effect mediators in patients with AP. there is evidence of an analgesic effect in tendinopathies of the rotator cuff (Berrazueta et al.. Myer.10 E. Quatman. For tions in this phase citing evidence of improved perception of symptoms after their use in other regions of the body (Childs et al. Treatment in this group consists of manual inter- ventions to decrease pain and modification of activity to decrease only the initial step of a process that should include controlled trials to examine the effect of treatment on subgroups and replication of loading through the lumbopelvic-hip complex (Fricker. and clinical experience and are also limited in 0. Nelson. An intriguing intervention for AP that has been studied in other ten- dinopathies is the glyceryl trinitrate patch. 2003) with mixed findings in the Achilles tendon progress is noted. sometimes ulation and further development of such norms would be useful in with radiation into the testes or lower abdominal region.1. 1995. 2. the first category. 2010. studies investi. 1997. Strickland. We believe that individuals suffering from include joint mobilization. & Sterling. passive range of motion (ROM) and soft tissue techniques. & Hewett. Manual interventions those findings in further studies (Kamper. other treatment options should be discussed (Anderson. Fon. The MAT test has shown excellent reliability at ICC (3. these categories are ruled out. Quatman. With rare exception. 2001). Appleyard. 2004). The intervention sequence weakness of the adductor group (when compared to the abductor then progresses to a multi-modal intervention addressing regional group) and pain with either the squeeze or bilateral adductor test. Nielsen. fractures and other red flags. Conversely.J. Stage 1 e local intervention based on our collective clinical opinion. Brosky. & Hay. Mahieu.. abdominal Iliopsoas stretching** obliques. Oberg. 2006). Hun- gerford. 2007. nation of both. Serner. McNair. Larson & Lohnes. the natural controlled trial. limited range-of-motion (ROM). 2002). The rationale for the Strength and Stability Cameron. 2007). authors suggest a relationship between limited hip ROM and long. 2002. Stage 1 e local intervention condition (Depledge. Nicholas & Tyler. 2008).. 1997. 1997. Barnes. 6. standing groin pain (Fricker.2. Supine. abdominal muscles. Walker. one set of exercises for ized controlled trial suggests that an active exercise program may the first two weeks and the second to be performed from week improve abduction range of motion without specifically stretching three until discharge. Vanderstraeten.. & Williams. we recommend a program (Table 6). or a combi. Training frequency was program and as part of an injury prevention program have been three times per week for 90 min and included groups of two to four suggested in patients with AP (Fricker.5 weeks. Stage 1 e local intervention dysfunction here may create discomfort (Mens et al. Oberg. & Stam. & Danneels. Williams et al. Evidence supports that Successful completion of Stage 1 is indicated by the patient in patients with AP. a stability program is the theory that the pelvic ring is instrumental in transferring load from the lumbosacral region to the hip and 6. Exercises targeting the adductors of ommended a group of exercises. Tyler et al. active individuals with thought would be passive ROM or stretching to improve ROM. The ROM category includes interventions designed Strength and Stability is a combined group since there is not to restore full. 2004. and/or abduction range of abductors (Tyler et al. back extensors. 2006. E. decreased hip motions include primarily hip achieving pain-free adductor strength of at least 80% that of the internal rotation. Although pelvic instability has been a described and treated 6.. ** decrease discomfort (Cowan et al. Damen. Seventy-nine percent of the participants returned to sport appear to improve ROM in the lower extremity (Moller. Backx. Slavotinek. Petersen. without discomfort (Fritz & George.. more robust evidence from a random. Strength and stability group Pas. 1999). Strength and Stability is designed to safely any direct conservative interventions focused on stability in improve strength in the muscles surrounding the hip and pelvis athletes having AP...2. several differ much between legs (Thorborg. some hip ROM may be at a greater risk for AP (Verrall. Restoration of ROM is important since athletes with limited dominant leg may be less strong than the dominant.1. Holmich et al. 2002). Skating on slide board* Therefore. Madsen. The Tyler et al.. Ekstrand.1. Hodges & Suggested program to restore hip ROM in patients with AP.. 2004. Krogsgaard. Exercises 2008. external rotation. (Motion. rectus abdominus. Instability in this study was defined in the sense of limited joint mobility. In addition. exercises were divided into two modules. Mens et al. which may restore hip ROM athletes with adductor-to-abductor strength ratios of less than 80% (Table 5) with the understanding that the specific exercises are may be an effective means of decreasing incidence of groin strains a mixture of SORT evidence levels 1. & Holmich. Further. without increasing pain..3. 2002.. which consists of Sitting adduction and abduction** strengthening of the hip adductors. Strength and Stability) and expediently. Richardson. While strength testing of the non- motion.. demonstrated that young. 2 of our paradigm. feet together.. Magnusson. hip the adductors (Holmich et al. Hegedus et al. we were unable to find The third category. 2002. (2002). generally by comparing strength ratios of the involved to Passive internal and external ROM the uninvolved side and of ipsilateral hip abductors to adductors. 1999). Larsen. 2005. Exercises targeted the hip adductors. Reggars. 2002. 2009. Motion group instability in a small subgroup of athletes with osteitis pubis (Zoga The motion or mobility classification includes patients who have et al. However. & in an average of 18. program as a framework for their successful exercise intervention 1983) but active stretching appears to have greater benefit (Holmich. some authors have proposed training Side-lying abduction and adduction* for the transverse abdominus and obliques as well as other muscles One-leg Coordination Exercise Flexing and Extending Knee and acting to stabilize the pelvis may improve hip strength and Swinging Arms in Same Rhythm (mimic cross country skiing on one leg)*.J. The reason for incorporation of (regional) stage of treatment. 2. The goals of this successfully incorporated strength-based treatments in pop- stage are to decrease pain and disability as quickly as possible so ulations of individuals suffering from impairments related to the that the patient can move into one of the other classifications pathologies captured by our definition of AP (Holmich et al. Keal-Smith. 2007). 1985. and transverse abdominus since each of these muscle Unilateral lungesþ groups has been implicated in AP. Keeping these facts in mind. Verrall... (1999).. 2000). 1997. Wiktorsson-Moller. 2011). 2000). Snijders. & Gluud. Stage *Holmich et al. & Storm. Richardson. Jansen. Weir et al. magnetic resonance imaging has demonstrated pubic 6. Hamilton. Delayed firing of the transverse abdominus and obliques is a common issue in patients with instability or pelvic injuries and is generally addressed by a program promoting pelvic Table 5 strengthening and core stability (Cowan et al. research suggests adductor-to-abductor strength ratios should not 2005.. balance and coor- to discount passive stretching and ROM completely since they dination. (Holmich et al. & Esterman. Tyler et al. 2009. 1999. in a randomized With the obvious impairment of limited hip ROM. et al. et al.. 2011). **Holmich et al. Bouche. passive ROM and stretching as an early portion of a recovery benefited from supervised active training. Kolfschoten. Wollin & Lovell. Vleeming. (Maffey & Emery. Stevens. and 3. 2002). 2004. muscle disruption/defect/detachment from the pubic bone. Further. & Lee. Regarding strengthening. into the second Tyler et al. Hides. 2006). Sumo squatþ Side lungeþ As the patient shows signs of improvement in strength and Kneeling pelvic tiltþ stability. There is not enough evidence abductors. butterfly wings (active ROM) the patient should be progressed to a more regional program. þTyler et al. 2010. / Physical Therapy in Sport 14 (2013) 3e16 11 modalities on pain and so we cannot recommend their use (French. . Both hip adductor pain who were not able to participate in sport. 2006).. pain-free motion of the hip complex and to ensure currently enough evidence to support instability alone as a major the patient’s ability to perform low to moderate intensity activities cause or effect of AP. Others have utilized this original Gillquist. classification is based on evidence derived from studies that have Rutjes et al.3. (1999). 2008).. patients who were supervised by one physical therapist. 2002). Mens. Gilleard. & Gillquist. Kroeling et al. we have rec. (2010). Yousefi-Nooraie et al. Mirasola. Hunter. the lumbar spine. was recently labeled “regional interdependence”(Wainner.J. This view of the body as 2006. Therefore the progression from local to regional interventions. frequency) necessary to induce pathology is not clear. Blanch. & Padua (2009). (Schache. There Kneeling reach out with sliders are various normative values for these tests published elsewhere The above exercises are recommended based on our clinical experience and (Reiman & Manske. The clinician should carefully consider several variables when Exercises rehabilitating the athlete with AP in Stage 3. & Lee. 6. Skovgaard. Stolen. & Siegler. 2005). 2000). AP.5. Stolen et al. & Fowles. providing sufficient time between loadings to allow for ventions. & Young. Babb. McTaggart. football) Front squat Slalom pole drills with sport related object Roman chair lumbar extensions Visual cueing change of direction drills with sport related object 2 Legged plyometrics Audible cueing change of direction drills with sport related object 1 Legged plyometrics Sport specific drills with emphasis on anaerobic capacity Position specific drills performed at appropriate work: rest ratios The above exercises are recommended based on our clinical experience and work by Distefano. and hop battery. Table 8 Suggested program to restore sport related function in patients with AP. Regional interventions in patients load may be critical in the capacity of both normal and pathological with AP can be directed at the remaining muscle groups of the hip not tendons to tolerate load (Langberg. Further. sacrum. we believe that an integral part of the rehabilitation of patients intensity. lower extremity and total body anaerobic power (Arnold. their tolerance of progression. Crosbie. Farlinger. work by Escamilla. side-throws) Exercises Repetitive box drill plyometrics Bracing or drawing in of abdominals wit hip extension in quadruped Anaerobic capacity drills Resisted hip internal/external rotation in sit Yoeyo/beep test Body-weight squats with band resistance around knees Running/skating line drills Single leg deadlift Sport specific drills with emphasis on total body anaerobic power Single leg squat Acceleration/deceleration running drills with ball (soccer/rugby/football) Single leg chest press Acceleration/deceleration skating drills with puck (hockey) Single leg row Sport specific drills with emphasis on speed and quickness Standing cable hip extension Progression from form drills (A and B walks/skips) to sprints of Standing cable hip abduction sport related distances Sliding board Sport specific drills with emphasis on changes-of-direction/agility Cable diagonal chops and lifts Cone drills with sport related object (soccer ball. multiple changes of direction the groin and pelvis. 2005. 2007. 1988. strength.. catabolic for tendons (Benjamin. et al. & Dempsey. There is ample evidence of the intricate relationship between (Iosia & Bishop. Y balance test. Sawyer. Cleland. and the position requirements Curl up within that sport.4. The amount of load (volume. 1996. Repetitive energy storage Whitman. Variables to consider include the patient’s re- Active Straight Leg Raise with abdominal bracing examination findings. we advocate a more regional approach to inter. 2008). 2007). pelvis and hip and that the ratio Chamari. and proper work to rest ratio integration vention. a major contributor to AP. Medicine ball throws (overhead forward and back. Brown. The PPMs previously described. Proper assurance of readiness to return to Standing cable hip adduction their sport is not an exact science. & Kjaer. Montgomery. 2006. but also to avoid excessive loading of interconnected regions. clinically. Full sit-up the MAT. 2002). as well as excessive compression appear to be key that have examined regional intervention specifically in patients with factors in the onset of tendinopathy. (2006). Bennell. & Wrigley. 2008. One area that requires found with limb movements in athletes who played sports that some greater discussion is work to rest ratio since tendinopathy is involve cutting along with hip and trunk rotation (Scholtes. can provide the clinician Pike position on theraball with some means of objectivity but also a method of training. however. Micheli. Hegedus et al. and stability in patients with AP. 2009). 2008. Gombatto. (Baker & Newton. Kiger. with AP is the progression from local treatment to regional inter. Castagna. The above exercises are recommended based on our clinical experience.12 E. Barnette. motions of the lumbar region. 2005) are all components of a prop- of these motions is changed in the presence of pain (Esola. A point worth reiterating is that although we have outlined tendon response is important (Cook & Purdam. 2007). 2009). A sample of suggested exercises can be found in Table 7. 2004. & Coker. these volume (hours) and frequency (sessions per day or week) of intense interventions operate in parallel. Stage 3 e global interventions Suggested program to restore local motion. While there have been no studies and release. & Flynn. Asp. 2009). Kruisselbrink. Rhea. & Hunter. Further. Baker & Newton. to their sport. Blackburn. perhaps held by holistic practitioners for the involved tissue. .. Escamilla. Exercises Table 7 Suggested program to restore regional strength and stability in patients Total body anaerobic power drills with AP. Shum. Designing a proper work to rest ratio for & Van Dillen. Recall that most athletes who suffer with Crunch Reverse curl up symptoms of AP are likely to play sports that primarily involve Standing cable hip flexion sprinting and cutting. 1980. (2006). Load has been shown to be both anabolic and decades. & Wisloff. / Physical Therapy in Sport 14 (2013) 3e16 Table 6 6. After addressing the chief complaints in the primary local region of Ostarello. Table 8 provides a sample of exercises and tests that Perhaps most important to this paper is that this altered ratio was also will provide the necessary components. et al. there is evidence that forces applied the rehabilitating athlete with AP is important not only to most distally in the kinetic chain while running can cause proximal pain closely replicate the demands of the particular sport (Rhea et al. already addressed with local intervention (abductors and extensors). and the lower extremities. McClure. hockey puck. Marshall. the sport in Side plank hip adduction which the athlete participates. Suess. 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