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BJSM Online First, published on March 17, 2018 as 10.1136/bjsports-2016-097089
Original article

Clinical and biomechanical outcomes of rehabilitation

targeting intersegmental control in athletic groin
pain: prospective cohort of 205 patients
Enda King,1,2 Andrew Franklyn-Miller,1,3 Chris Richter,1 Eamon O’Reilly,1 Mark Doolan,1
Kieran Moran,4,5 Siobhan Strike,2 Éanna Falvey1,6

►► Additional material is Abstract No clear differences in outcomes on return

published online only. To view Background Clinical assessments and rehabilitation to play (RTP) times or rates, between surgical
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​ in athletic groin pain (AGP) have focused on specific intervention and rehabilitation, were found in a
bjsports-​2016-​097089). anatomical structures and uniplanar impairments rather recent systematic review.7 The success of exer-
than whole body movement. cise-based rehabilitation for AGP has been docu-
1
Sports Medicine Research Objective To examine the effectiveness of rehabilitation mented.8 9 Programmes targeting lumbopelvic
Department, Sports Surgery
that targeted intersegmental control in patients with control and muscle strength, focusing on adductor
Clinic, Dublin, Ireland
2
Department of Life Sciences, AGP and to investigate post rehabilitation changes in strengthening, have been compared with manual
University of Roehampton, cutting biomechanics. therapy10 and with rest and active recovery11 with
Roehampton, UK
3
Methods Two hundred and five patients with AGP good outcomes at long-term follow-up.12 These
Centre for Health, Exercise and were rehabilitated focusing on clinical assessment of studies commonly included patients with a single
Sports Medicine, University of
Melbourne, Melbourne, Victoria, intersegmental control, linear running and change of anatomical presentation: adductor-related groin
Australia direction mechanics in this prospective case series. Hip pain. This limits their generalisability in treating
4
School of Health and Human and Groin Outcome Score (HAGOS) was the primary athletes presenting with other entities.7 10 11
Performance, Dublin City outcome measure. Secondary measures included pain- Outcome measures used to assess interven-
University, Dublin, Ireland
5 free return to play rates and times, pain provocation on tions in AGP include patient-reported outcome
Insight Research Centre, Dublin
City University, Dublin, Ireland squeeze tests and three-dimensional (3D) biomechanical measures such as the Hip and Groin Outcome
6
Department of Medicine, analysis during a 110° cutting manoeuvre. Score (HAGOS), and strength and pain prov-
University College Cork, Cork, Results Following rehabilitation, patients ocation measures such as adductor squeeze
Ireland demonstrated clinically relevant improvements in testing.13 14 To date, despite multiplanar move-
HAGOS scores (effect size (ES): 0.6–1.7). 73% of ment patterns (such as change of direction and
Correspondence to
patients returned to play pain-free at a mean of 9.9 high-speed sprinting) being reported as provoca-
Mr Enda King, Sports Medicine
Research Department, Sports weeks (±3.5). Squeeze test values also improved tive activities in athletes with AGP,15–18 these have
Surgery Clinic, Santry Demesne, (ES: 0.49–0.68). Repeat 3D analysis of the cutting not been used as outcome measures. The physical
Dublin 9, Republic of Ireland; movement demonstrated reductions in ipsilateral trunk demands of acceleration and braking (common
e​ ndaking@​hotmail.c​ om side flexion (ES: 0.79) and increased pelvic rotation in in field sports) are not evenly distributed across
Accepted 31 December 2017 the direction of travel (ES: 0.76). Changes to variables the hip, knee and ankle but depend heavily on
associated with improved cutting performance: greater the relationship between the centre of mass and
centre of mass translation in the direction of travel centre of pressure.19 20 This complex relationship
relative to centre of pressure (ES: 0.4), reduced knee is not controlled by a single muscle group that can
flexion angle (ES: 0.3) and increased ankle plantar flexor be targeted in isolation.
moment (ES: 0.48) were also noted. Three-dimensional (3D) motion analysis enables
Conclusions Rehabilitation focused on intersegmental the evaluation of complex multiplanar, multi-
control was associated with improved HAGOS scores, joint movements.21 22 While performing a cutting
high rates of pain-free return to sporting participation manoeuvre, patients with AGP could be character-
and biomechanical changes associated with improved ised into three distinct movement strategies (clus-
cutting performance across a range of anatomical ters). These biomechanical clusters did not correlate
diagnoses seen in AGP.
with a specific site of groin pain.23 An individual
athlete’s risk of developing AGP is likely linked
to a combination of individual risk factors such as
Introduction training load, recovery and sport/position.24–26 We
Athletes with athletic groin pain (AGP) frequently hypothesise that an athlete’s movement strategy
present with single or multiple painful anatomical may also be part of this equation, leading to a
sites in the groin.1 2 Coexisting painful structures biomechanical overload resulting in symptoms. As
along with a lack of histological pathology studies3 a result, an intervention focusing on intersegmental
make it challenging to identify a specific diagnosis control is a novel approach to rehabilitation in AGP.
on which to focus treatment.1 Attempts have The aim of this study was to describe the outcome
To cite: King E, Franklyn- of a rehabilitation programme focusing on interseg-
been made to group painful structures by both
Miller A, Richter C, et al.
Br J Sports Med Epub ahead anatomy4 and entity,2 but the descriptive termi- mental control, in consecutive patients who presented
of print: [please include Day nology in use remains both wide and confusing,5 with a variety of anatomical diagnoses relating to AGP.
Month Year]. doi:10.1136/ and there have been recent attempts to simplify The primary outcome measure used was the HAGOS
bjsports-2016-097089 using expert consensus.6 questionnaire. Secondary measures included RTP

King E, et al. Br J Sports Med 2018;0:1–9. doi:10.1136/bjsports-2016-097089    1

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Original article

Figure 1 Flow chart of patient inclusion in study. 3D, three-dimensional; HAGOS, Hip and Groin Outcome Score; RTP, return to play.
rates and times, pain provocation tests (squeeze test) and 3D biome- consent. The methodology of the study reported is in keeping
chanical analysis of cutting. It was hypothesised that the rehabili- with the Strengthening the Reporting of Observational Studies
tation intervention would be effective across all clinical outcomes in Epidemiology guidelines.27
irrespective of anatomical diagnosis.
Diagnostic assessment
Methods A sports and exercise medicine physician performed an injury
Three hundred and twenty-two male patients who presented to history (including sport participation and duration of symptoms)
the sports medicine department of Sports Surgery Clinic, Dublin, and clinical examination, which included initial interpretation
from January 2013 to May 2015 were assessed for eligibility in of MRI to make an anatomical diagnosis and exclude pathology
this study. Patients presented to the clinic independently or by unsuitable for rehabilitation. The clinical assessment, radio-
third-party referral. Of the 322 patients, 205 were eligible for logical findings and differential diagnostic process have been
inclusion in the study (figure 1). All patients signed informed detailed elsewhere.1

Figure 2 110° change of direction test.

2 King E, et al. Br J Sports Med 2018;0:1–9. doi:10.1136/bjsports-2016-097089

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Original article

Figure 3 Level 1: intersegmental control and strength rehabilitation streams (the figure identifies the plane of intersegmental control each stream
influenced).

Inclusion criteria Patients eligible for inclusion completed the HAGOS question-
All patients reported pain in the anterior hip and groin area naire as the primary outcome measure on initial assessment and on
during their chosen sporting activity, and symptom duration discharge to RTP, which has been shown to be a reliable measure
was greater than 4 weeks. All patients had a stated intention of (Intraclass Correlation: 0.82–0.91), with a smallest detectable
returning to the same level of preinjury participation in compet- change at group level of 2-7-5.2 and an SE of measure of 6.4–12.2.29
itive multidirectional sport. All patients with an anatomical diag-
nosis falling under AGP (iliopsoas, adductor, pubic aponeurosis Clinical assessment
and hip) were included as per Falvey et al.1 Those patients eligible for inclusion underwent a physical assess-
ment with a senior physiotherapist documenting pain provoca-
Exclusion criteria tion tests using crossover test17 and squeeze tests at 0°, 45° and
Patients with hip joint arthrosis (grade 3 or higher on MRI28); 90°,30 and the symmetry of hip internal rotation at 90° hip flexion
those who did not intend to return to preinjury activity levels; with a goniometer (Saehan). The pressure (mm Hg) at onset of
those who could not commit to completing the rehabilitation the patient’s groin pain and maximum pressure achievable were
programme as prescribed due to time or equipment/facility recorded using a sphygmomanometer (DS66, Welch Allyn), which
constraints; and those with underlying medical conditions such was set at a pretest pressure of 20 mm Hg. The reliability of the
as inflammatory arthropathy or infection were excluded. squeeze test has been shown previously (ICC: 0.89–0.92) with an

Figure 4 Level 2: segmental control focus of linear running drills (the figure demonstrates the intersegmental control the drills targeted).

King E, et al. Br J Sports Med 2018;0:1–9. doi:10.1136/bjsports-2016-097089 3

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Original article

Figure 5 Intersegmental control focus of multidirectional drills (the figure demonstrates the intersegmental control the drills targeted).

SE of measurement between 1.6% and 3.3%,30 and these tests have in angle multiplied by change in moment) for all three anatom-
been reported as valid for use in clinical research on groin pain.31 ical planes. Details regarding the method of calculation of these
variables have been described previously.23
Biomechanical assessment
Subsequently patients underwent 3D biomechanical analysis Intervention
of a 110° cut (figure 2). The cutting task was performed at the The rehabilitation programme consisted of three levels.
patient’s perceived maximal effort for each trial. The approach Level 1 addressed intersegmental control and strength (figure 3),
speeds are reported to demonstrate comparability. The reliability level 2 involved linear running mechanics and increasing linear
(ICC >0.85), validity and methodology of this test have been running load tolerance (linear A) (figure 4), and level 3 targeted
reported previously.21 23 32 The biomechanical variables included multidirectional mechanics and the transition back to high inten-
in the analysis were joint angles and internal joint moments, joint sity sprinting (linear B) (figure 5). The rehabilitation interven-
powers (rate at which joint work is done) and joint work (change tion is reported in detail in accordance with the Template for

Figure 6 Components of rehabilitation and key performance indicators for progression.

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Original article

Table 1 Patient demographics Table 3 Changes in squeeze test pre-rehabilitation and post-
Time (IQR) Range rehabilitation (n=112) (P<0.001)
Duration of symptoms 32 weeks (20–52) 4–416 weeks Squeeze (mm Hg) Initial mean (SD) Discharge mean (SD) Effect size
Total Percentage 0° p1 81 (±28) NA
Diagnosis r2 123 (±29) 135 (±32) 0.68
 Pubic aponeurosis 132 64 45° p1 159 (±43) NA
 Iliopsoas 8 4 r2 223 (±41) 234 (±40) 0.65
 Adductor 35 17 90° p1 122 (±45) NA
 Hip 30 15 r2 177 (±41) 209 (±38) 0.46
Side p1 is pressure at initial onset of patients’ groin pain symptoms; r2 is maximum
 Left 75 37 pressure achieved; Na, not applicable.
 Right 88 43
 Bilateral 42 20
Sport Statistical analysis
 Gaelic Football 131 64 Data analysis was carried out using SPSS V.21.0 to report
 Hurling 29 14 descriptive statistics for patient data. Spearman’s rank correla-
 Soccer 25 12 tion was used to correlate RTP time and duration of symptoms
 Rugby 15 7
prior to rehabilitation. One-way analysis of variance was used
to calculate the difference in RTP time between anatomical
 Hockey 5 2
diagnoses and movement clusters at initial assessment. Paired
3D biomechanics
samples t-test was used to analyse the change in HAGOS and
 Cluster 1 88 43
squeeze test scores after rehabilitation. To examine if differences
 Cluster 2 44 21
exist between the kinematic and kinetic measures post rehabil-
 Cluster 3 74 36 itation, statistical parametric mapping (1D, paired t-test) was
used.34 Effect sizes were calculated in a point-by-point manner,
and reported according to Cohen’s d (d>0.3 = small; d>0.5
Intervention Description and Replication checklist and guide33
= medium; d>0.7 = strong).35 Data processing and statistical
in online supplementary appendix A. The exercise selection
parametric mapping were performed using MATLAB (R2015a,
was dictated by the patient’s physical competency (ie. ability to
MathWorks, Natick, MA, USA).
perform the exercise with appropriate technique), and progres-
sion through the programme was individualised according to
each patient achieving key goals for progression (figure 6). Results
Patients whose symptoms were not improving during reha- Two hundred and five patients entered rehabilitation (24.9 ± 5.1
bilitation in spite of improving segmental control were referred years; 179.4 ± 5.8 cm; 80.4 ± 9.2 kg), with a median duration
back to the sports medicine physician for review and were of symptoms of 32 weeks (IQR: 20–52 weeks) and participated
considered to have failed rehabilitation. Patients who withdrew across a range of field sports (table 1). The most commonly
were contacted regarding their reason for withdrawal. identified anatomical diagnoses were pain or tenderness at
Patients completed the HAGOS questionnaire after rehabili- the pubic aponeurosis (64%), which was superior to the pubic
tation and pain-free RTP, and where possible pain provocation symphysis, with 17% adductor, 15% hip and 4% iliopsoas, with
testing and 3D biomechanics were also repeated. Patients were 20% reporting bilateral symptoms.
cleared to RTP in their chosen sports once they had passed Fifty-five patients (27%) commenced the rehabilitation
through the three rehabilitation levels and demonstrated symp- process but did not complete repeat Hip and Groin Outcome
tom-free completion of linear A and B and multidirectional Score. Eight of these patients’ symptoms failed to resolve during
drills. Time to RTP was to their first full participation in training/ rehabilitation and were removed from the study (pubic aponeu-
competition after being cleared. Where secondary testing rosis=5; adductor=2; hip=1.) Reasons reported for dropout
revealed symptoms on squeeze testing or residual biomechan- prior to discharge included desire to return to play in spite of
ical asymmetries during cutting, in spite of pain-free completion remaining symptoms (n=6), geographical travel issues to clinic
of the running programme, further follow-up was performed. for review (n=7) and other commitments (n=8), with the rest
This was to ensure complete resolution of these deficits before non-contactable for reason of non-return (n=26) despite efforts
discharge from the programme. to do so by email and telephone (figure 1).

Table 2 Changes in HAGOS scores pre-rehabilitation and post-rehabilitation (n=150) (p<0.001)

95% CI
Std error mean
HAGOS Initial mean (SD) Discharge mean (SD) Mean change (SD) change Lower Upper Effect size
Pain 72.9 (+/−14.7) 88 (+/−11.9) 15.1 (+/−15.7) 1.29 12.55 17.63 0.96
Symptoms 60.3 (+/−17.4) 89.1 (+/−10.2) 28.8 (+/−17.2) 1.40 26.10 31.64 1.68
ADL 73.9 (+/−18.9) 93.2 (+/−10.9) 19.2 (+/−18.6) 1.52 16.23 22.24 1.03
Sports 50.7 (+/−16.7) 86.3 (+/−13.7) 35.6 (+/−20) 1.63 32.38 38.81 1.78
PA 42 (+/−38) 66.3 (+/−31.4) 24.3 (+/−41.4) 3.38 17.57 30.93 0.59
QOL 36.5 (+/−14.7) 66 (+/−21.2) 29.5 (+/−21.6) 1.77 26.04 33.03 1.36
ADL - activities of daily living; HAGOS - Hip and Groin Outcome Score; PA - participation in physical activity; QOL - quality of living; Sports - sport and recreational activities.

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Table 4 Kinematic changes in cutting after rehabilitation (n=112)

Variable Start End Initial mean (SD) Discharge mean Direction Finding Effect size
Thorax Angles Frontal (°) 0 100 −0.91 (5.7) 6.06 (6.6) Contralateral side flexion Post>Pre −0.79
Pelvis Angles Transverse(°) 0 100 −0.135 (4.4) 6.19 (4.6) Contralateral rotation Post>Pre −0.76
Pelvis Angles Frontal(°) 0 100 16.05 (1.8) 19.48 (1.4) Contralateral side flexion Post>Pre −0.62
Ankle Angles Sagittal(°) 9 75 17.39 (8.2) 22.11 (8.1) Dorsiflexion Post>Pre −0.58
Thorax on Pelvis Angles Frontal(°) 16 100 16.46 (4.3) 12.34 (5.2) Ipsilateral side flexion Pre>Post 0.56
Thorax Angles Transverse(°) 0 100 −6.02 (8.2) −1.25 (8.8) Ipsilateral rotation Post>Pre −0.54
Hip Angles Sagittal(°) 0 100 42.03 (14.5) 36.59 (14.7) Flexion Pre>Post 0.51
Thorax on Pelvis Angles Transverse(°) 0 90 5.51 (4.0) 8.23 (4) Ipsilateral rotation Post>Pre −0.46
Hip Angles Frontal(°) 67 100 −19.91 (2.1) −17.64 (1.8) Abduction Pre>Post −0.36
Knee Angles Sagittal(°) 57 100 50.85 (11.4) 47.76 (11.3) Flexion Pre>Post 0.33
COM to COP Sagittal (mm) 4 41 507 (12) 527 (16) Anterior Post>Pre −0.36
COM to COP Frontal (mm) 0 95 -58 (101) -108 (10) Contralateral Post>Pre 0.40
Ground Contact Time (seconds) 0.38 (0.06) 0.36 (0.06) Pre>Post 0.30
Start—% point in stance phase when difference started to occur; End—% point in stance phase when difference ended.
COM, centre of mass; COP, centre of pressure.

HAGOS questionnaire Changes in 3D biomechanical analysis of cutting

A significant improvement across all subsections of HAGOS was Biomechanical analysis of a 110° cutting manoeuvre (n=112)
seen post intervention (table 2). using the previously described cluster analysis23 during initial
assessment placed 43% in cluster 1, 21% in cluster 2% and 36%
Squeeze test in cluster 3, with no significant difference in RTP times between
A significant improvement in squeeze tests was demonstrated at the clusters (p=0.57).
all three angles, with 94% (105/112) of patients achieving pain- Comparative analysis displayed significant changes in post-
free squeeze at 0°, 45° and 90° on RTP (table 3). rehabilitation kinetic and kinematic variables (figure 7). The
strongest effect size was for increased pelvic rotation towards
RTP rates and times the direction of intended travel, and greater trunk side flexion
The pain-free RTP rate of those who entered the study was 73% towards the direction of intended travel throughout stance
(150/205), with patients attending 5.1 (±1.5) appointments phase (table 4). There were medium effect sizes for changes
prior to RTP. There was no difference in time to RTP based on in pelvic tilt towards the direction of intended travel, reduced
anatomical diagnosis (p=0.56), and there was no correlation trunk-on-pelvis side flexion towards the stance leg, reduced
between duration of symptoms prior to rehabilitation and time hip flexion and increased ankle dorsiflexion. There were small
to RTP (p=0.17). effect sizes for a number of variables, including increased

Figure 7 Biomechanical changes in cutting mechanics after rehabilitation (grey figure). COM, centre of mass; COP, centre of pressure.

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Table 5 Kinetic changes in cutting after rehabilitation

Variable Start End Initial mean SD Discharge mean SD Direction Finding Effect size
Ankle moment sagittal 6 71 19.62 8.11 22.60 8.29 Plantar Post>Pre −0.48
Ankle power sagittal 1 24 −0.03 0.03 −0.05 0.03 Eccentric Post>Pre 0.46
Ankle power sagittal 57 83 0.05 0.04 0.07 0.04 Concentric Post>Pre −0.46
Hip power sagittal 68 87 0.04 0.02 0.02 0.02 Concentric Pre>Post 0.43
Hip moment sagittal 50 89 15.31 9.95 10.57 9.98 Extensor Pre>Post 0.41
Knee power sagittal 43 58 0.00 0.02 0.02 0.02 Concentric Post>Pre −0.4
Hip moment frontal 78 95 −7.75 0.95 −5.48 0.68 Adductor Pre>Post −0.39
Power units—watts; moment units—Newton-metres/kg; Start—% point in stance phase when difference started to occur; End—% point in stance phase when difference
ended.

thoracic rotation in the direction of intended travel, reduced distribution on discharge (table 2). Recovery of quality of life
hip abduction and knee flexion angle. The centre of mass scores have been shown to be inversely associated with longer
was more anterior relative to the centre of pressure during duration of symptoms.37 These lower scores may reflect ongoing
the eccentric phase of cutting, more towards the direction of self-driven or coach-driven load management and psychological
intended travel throughout stance phase after rehabilitation factors relating to the long duration of symptoms, which may
and ground contact time was reduced. There was no differ- continue to improve over time as the patient makes a successful
ence in the centre of mass velocity (approach speed) at initial return to sport.
contact before (2.14 m/s (±0.3)) and after rehabilitation (2.16 This study examined both HAGOS and pain provocation tests
m/s (±0.29)) (p=0.434). with reported pain-free RTP to improve outcome validity. The
Kinetic analysis demonstrated increased ankle plantar demonstrated pain-free RTP rates (73%) and times (9.9±3.4
flexion moment post rehabilitation and reduced hip extensor weeks) compare favourably with anatomically specific rehabili-
moment as well as reduced hip adduction moment during tation protocols used by Hölmich (68% RTP, 18.5 weeks)11 and
push-off (table 5). Analysis of total work done at each joint Weir (48% RTP, 17.3 weeks),10 as well as surgical protocols for
showed a large increase in total work done at the ankle, a adductor (63%–76% RTP, 14–18 weeks)38–40 and pubic pathology
moderate reduction in the total work done at the hip and a (100% RTP, 13–28 weeks).41 42 Both rehabilitation papers are
small reduction at the knee after rehabilitation. This primarily randomised control trials,10 11 not prospective case series as in
was affected by large increases in work in the sagittal plane of this case; a higher level of evidence ensuring their outcomes
the ankle and moderate reductions in work in all three planes did not occur by chance. Of those who made a pain-free RTP,
at the hip and frontal plane at the knee (table 6). seven patients demonstrated residual symptoms on squeeze test
at discharge, suggesting a clinical lag between pain-free RTP and
Discussion pain-free squeeze at 0°, 45° and 90°. As the median duration of
We describe a rehabilitation programme for patients with AGP, symptoms prior to rehabilitation was over 8 months, the authors
regardless of clinical entity. The programme was designed to consider the mean time to RTP of 9.9 weeks encouraging and
target intersegmental control (across strength, linear and multi- believe the intervention may have influenced outcomes.
directional drills) and optimise the biomechanics of maximal
effort change of direction cutting. The post rehabilitation cohort Biomechanical changes in cutting
demonstrated significantly different change of direction strate- Following rehabilitation, patients demonstrated changes in
gies during the cutting manoeuvre. various biomechanical variables post rehabilitation, which
have been shown to be related to cutting performance. These
Clinical outcomes (HAGOS, RTP, squeeze test) include reduced ground contact time,21 43 44 increased centre of
HAGOS subscores for pain, symptoms, activities of daily living mass distance to the centre of pressure in the frontal plane,20
and sports/recreation all returned to normative levels36 but reduced trunk side flexion towards the stance leg,21 43 reduced
remained reduced compared with athletes who have never knee flexion,44 and increased ankle power and plantar flexion
had groin pain.29 This pattern of recovery has been identified moment.21 These changes also concurrently reduced the load
in similar cohorts previously.37 Quality of life and participa- around the hip and groin as work in all three planes of the hip
tion in physical activities scores remained below this normal and the adductor moment were reduced.

Table 6 Changes in joint work during cutting after rehabilitation

Variable Initial mean, % SD Discharge mean, % SD Finding Effect size
Total ankle work 29.57 6.89 34.84 7.68 Post>Pre −0.68
Total knee work 40.43 6.40 38.88 5.55 Pre>Post 0.26
Total hip work 30.00 7.66 26.28 7.25 Pre>Post 0.48
Ankle work sagittal 26.10 6.65 31.38 7.45 Post>Pre −0.70
Knee work frontal 7.89 3.18 6.79 2.89 Pre>Post 0.36
Hip work sagittal 22.43 7.10 19.64 6.31 Pre>Post 0.41
Hip work frontal 4.01 1.82 3.57 1.90 Pre>Post 0.24
Hip work transverse 3.56 1.59 3.07 1.45 Pre>Post 0.32
%, percentage of total work done at lower limb.

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Original article
Components of rehabilitation strategies, as well as compare the current rehabilitation approach
Exercise selection was based on individual patient competency with previously published anatomical specific protocols.
and progressed according to improvements in segmental control.
Without appropriate execution of any exercise, the patient may
not achieve the desired training effect or change in segmental Conclusion
control, leading to delayed recovery and commonly an aggra- This study demonstrated that a rehabilitation programme
vation of symptoms despite appropriate dosage. This approach focused on intersegmental control improved patients’ HAGOS
ensured the programme was set at a level specific to the patient scores and pain provocation tests, and allowed 73% of patients
and progressed as quickly or slowly as the individual compe- to return to play pain-free faster than in previous trials. In this
tency and symptom levels allowed, ensuring the most appro- study, successful rehabilitation effected a change in cutting
priate exercise selection and recovery time. biomechanics, which reduced mechanical work across the hip as
Level 1 focused on intersegmental control and strength. well as variables associated with improved cutting performance.
Reduced gluteal and iliopsoas activation during hip extension An approach to rehabilitation based on intersegmental control
has been suggested to increase anterior hip joint forces, and thus may offer an alternative to strategies based on specific anatom-
restoring function in both is essential to optimising load distri- ical diagnoses, and warrants further comparison in randomised
bution in the region.45 Loss of lumbopelvic control into anterior control trials.
pelvic tilt has been shown to increase dynamic femoroacetab-
ular impingement and load across the symphysis pubis,46 47 What are the findings?
and changes in pelvic position relative to the femur have been
shown to influence hip muscle action and joint loading at the ►► A rehabilitation programme focused on intersegmental
hip.48 49 Hip strength and rate of force development relative control was associated with improvement in a range of
to body weight have been shown to correlate positively with outcome measures (return to play, Hip and Groin Outcome
cutting performance and biomechanics.50 51 Level 1 included Score, squeeze test) in patients with diverse (and multiple)
exercises that focused on control between individual segments anatomical diagnoses for athletic groin pain.
and combined them with compound movements such as dead- ►► Rehabilitation focusing on intersegmental control elicited
lift, squat and lunge, which targeted multisegmental coordina- changes in the change of direction biomechanics associated
tion while developing strength. It is noteworthy that this study with improved cutting performance.
demonstrated a significant improvement in adductor strength in ►► Three-dimensional (3D) biomechanical examination can
the absence of any isolated adductor strengthening during reha- provide new insights into understanding rehabilitation
bilitation, perhaps demonstrating the efficacy of restoring pain- interventions.
free function to the area in improving adductor function.
How might it impact on clinical practice in the future?
Linear and multidirectional mechanics
Acceleration, sprinting and change of direction are the most ►► Focus attention towards identifying movement strategies as a
commonly reported aggravating activities for AGP; therefore, risk factor for athletic groin pain.
early incorporation of rate of force development and running ►► Allow the focus of rehabilitation to be on intersegmental
mechanics, through linear and multidirectional drills, was coordination control rather than specific anatomical
deemed important.52 53 The linear running drills addressed structures.
overstride and dynamic anterior pelvic tilt. Overstride may ►► Identify specific targets for rehabilitation through 3D motion
increase anterior hip joint forces at end range extension54 analysis.
causing increased hip joint load,52 55 while anterior pelvic tilt
may increase femoroacetabular contact and pubic symphysis
Contributors EK was involved in the creation of study design and hypothesis,
stress.46 47 The linear running programme A and B gradually data collection, carrying out rehabilitation intervention, data analysis, and drafting
increased patients’ load tolerance and exposure to avoid injury and revising submission. AFM was involved in the creation of study design and
associated with acute spikes in training load on resumption of hypothesis, data collection, and drafting and revising submission. CR was involved in
playing.53 Change of direction drills have been shown to be more the creation of study design, data collection, data analysis and drafting submission.
EOR was involved in the creation of study design, data collection and carrying out
effective at improving change of direction performance than rehabilitation intervention, and revision of submission. MD was involved in study
strength training or sprint training alone.56 Progression to the design, data collection, data analysis and revision of submission. KM was involved
multidirectional drills focused on the rate of force development in study design, data interpretation and revision of submission. SS was involved in
across all three planes and reactive agility to prepare the patient study design, data interpretation and revision of submission. EF was involved in the
for sports-specific movements with the associated enhancement creation of study design and hypothesis, data collection, and drafting and revising
submission.
in cutting mechanics and performance outlined above.
Funding This research received no specific grant from any funding agency in the
public, commercial or not-for-profit sectors.
Limitations Competing interests Sports Surgery Clinic is a private orthopaedic and sports
This was not a randomised trial and there is no explicit control medicine clinic and operates an athletic groin pain programme.
group. The results are impacted by a loss to follow-up rate of Patient consent Obtained.
27% and additionally a further 14% returning to play without Ethics approval The Sports Surgery Clinic Hospital Ethics Committee approved the
final 3D comparison. An omission was made in the registration study (Ref 25EF011), which was registered at ​ClinicalTrials.​gov (NCT02437942).
of the study in the non-inclusion of an additional secondary Provenance and peer review Not commissioned; externally peer reviewed.
outcome measure of RTP.
Open Access This is an Open Access article distributed in accordance with the
Future studies should look at the relationship between changes Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
in specific biomechanical variables and outcome measures such permits others to distribute, remix, adapt, build upon this work non-commercially,
as HAGOS and RTP to allow for more targeted rehabilitation and license their derivative works on different terms, provided the original work

8 King E, et al. Br J Sports Med 2018;0:1–9. doi:10.1136/bjsports-2016-097089

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King E, et al. Br J Sports Med 2018;0:1–9. doi:10.1136/bjsports-2016-097089 9

 Downloaded from http://bjsm.bmj.com/ on March 17, 2018 - Published by group.bmj.com

Clinical and biomechanical outcomes of

rehabilitation targeting intersegmental
control in athletic groin pain: prospective
cohort of 205 patients
Enda King, Andrew Franklyn-Miller, Chris Richter, Eamon O'Reilly, Mark
Doolan, Kieran Moran, Siobhan Strike and Éanna Falvey

Br J Sports Med published online March 17, 2018

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