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
([Link] 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
​endaking@​hotmail.​com 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
Published Online First associated with improved cutting performance: greater the relationship between the centre of mass and
17 March 2018 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
been made to group painful structures by both of a rehabilitation programme focusing on interseg-
To cite: King E, Franklyn- anatomy4 and entity,2 but the descriptive termi- mental control, in consecutive patients who presented
Miller A, Richter C, nology in use remains both wide and confusing,5 with a variety of anatomical diagnoses relating to AGP.
et al. Br J Sports Med and there have been recent attempts to simplify The primary outcome measure used was the HAGOS
2018;52:1054–1062. using expert consensus.6 questionnaire. Secondary measures included RTP

King E, et al. Br J Sports Med 2018;52:1054–1062. doi:10.1136/bjsports-2016-097089    1 of 10

 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.

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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).

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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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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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 Original article

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 groin pain.29 This pattern of recovery has been identified in
hip abduction and knee flexion angle. The centre of mass similar cohorts previously.37 Quality of life and participation in
was more anterior relative to the centre of pressure during physical activities scores remained below this normal distribu-
the eccentric phase of cutting, more towards the direction of tion on discharge (table 2). Recovery of quality of life scores
intended travel throughout stance phase after rehabilitation have been shown to be inversely associated with longer dura-
and ground contact time was reduced. There was no differ- tion of symptoms.37 These lower scores may reflect ongoing
ence in the centre of mass velocity (approach speed) at initial self-driven or coach-driven load management and psychological
contact before (2.14 m/s (±0.3)) and after rehabilitation (2.16 factors relating to the long duration of symptoms, which may
m/s (±0.29)) (p=0.434). continue to improve over time as the patient makes a successful
Kinetic analysis demonstrated increased ankle plantar return to sport.
flexion moment post rehabilitation and reduced hip extensor This study examined both HAGOS and pain provocation tests
moment as well as reduced hip adduction moment during with reported pain-free RTP to improve outcome validity. The
push-off (table 5). Analysis of total work done at each joint demonstrated pain-free RTP rates (73%) and times (9.9±3.4
showed a large increase in total work done at the ankle, a weeks) compare favourably with anatomically specific rehabil-
moderate reduction in the total work done at the hip and a itation protocols used by Hölmich (68% RTP, 18.5 weeks)11
small reduction at the knee after rehabilitation. This primarily and Weir (48% RTP, 17.3 weeks),10 as well as surgical proto-
was affected by large increases in work in the sagittal plane of cols for adductor (63%–76% RTP, 14–18 weeks)38–40 and pubic
the ankle and moderate reductions in work in all three planes pathology (100% RTP, 13–28 weeks).41 42 Both rehabilita-
at the hip and frontal plane at the knee (table 6). tion papers are randomised control trials,10 11 not prospective
case series as in this case; a higher level of evidence ensuring
Discussion their outcomes did not occur by chance. Of those who made a
We describe a rehabilitation programme for patients with AGP, pain-free RTP, seven patients demonstrated residual symptoms
regardless of clinical entity. The programme was designed to on squeeze test at discharge, suggesting a clinical lag between
target intersegmental control (across strength, linear and multi- pain-free RTP and pain-free squeeze at 0°, 45° and 90°. As the
directional drills) and optimise the biomechanics of maximal median duration of symptoms prior to rehabilitation was over 8
effort change of direction cutting. The post rehabilitation cohort months, the authors consider the mean time to RTP of 9.9 weeks
demonstrated significantly different change of direction strate- encouraging and believe the intervention may have influenced
gies during the cutting manoeuvre. outcomes.

Clinical outcomes (HAGOS, RTP, squeeze test) Biomechanical changes in cutting

HAGOS subscores for pain, symptoms, activities of daily living Following rehabilitation, patients demonstrated changes in
and sports/recreation all returned to normative levels36 but various biomechanical variables post rehabilitation, which
remained reduced compared with athletes who have never had have been shown to be related to cutting performance. These

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
include reduced ground contact time,21 43 44 increased centre of Limitations
mass distance to the centre of pressure in the frontal plane,20 This was not a randomised trial and there is no explicit control
reduced trunk side flexion towards the stance leg,21 43 reduced group. The results are impacted by a loss to follow-up rate of
knee flexion,44 and increased ankle power and plantar flexion 27% and additionally a further 14% returning to play without
moment.21 These changes also concurrently reduced the load final 3D comparison. An omission was made in the registration
around the hip and groin as work in all three planes of the hip of the study in the non-inclusion of an additional secondary
and the adductor moment were reduced. outcome measure of RTP.
Future studies should look at the relationship between changes
Components of rehabilitation in specific biomechanical variables and outcome measures such
Exercise selection was based on individual patient competency as HAGOS and RTP to allow for more targeted rehabilitation
and progressed according to improvements in segmental control. strategies, as well as compare the current rehabilitation approach
Without appropriate execution of any exercise, the patient may with previously published anatomical specific protocols.
not achieve the desired training effect or change in segmental
control, leading to delayed recovery and commonly an aggra-
vation of symptoms despite appropriate dosage. This approach Conclusion
ensured the programme was set at a level specific to the patient This study demonstrated that a rehabilitation programme
and progressed as quickly or slowly as the individual compe- focused on intersegmental control improved patients’ HAGOS
tency and symptom levels allowed, ensuring the most appro- scores and pain provocation tests, and allowed 73% of patients
priate exercise selection and recovery time. to return to play pain-free faster than in previous trials. In this
Level 1 focused on intersegmental control and strength. study, successful rehabilitation effected a change in cutting
Reduced gluteal and iliopsoas activation during hip exten- biomechanics, which reduced mechanical work across the hip as
sion has been suggested to increase anterior hip joint forces, well as variables associated with improved cutting performance.
and thus restoring function in both is essential to optimising An approach to rehabilitation based on intersegmental control
load distribution in the region.45 Loss of lumbopelvic control may offer an alternative to strategies based on specific anatom-
into anterior pelvic tilt has been shown to increase dynamic ical diagnoses, and warrants further comparison in randomised
femoroacetabular impingement and load across the symphysis control trials.
pubis,46 47 and changes in pelvic position relative to the femur
have been shown to influence hip muscle action and joint What are the findings?
loading at the hip.48 49 Hip strength and rate of force develop-
ment relative to body weight have been shown to correlate posi- ►► A rehabilitation programme focused on intersegmental
tively with cutting performance and biomechanics.50 51 Level 1 control was associated with improvement in a range of
included exercises that focused on control between individual outcome measures (return to play, Hip and Groin Outcome
segments and combined them with compound movements such Score, squeeze test) in patients with diverse (and multiple)
as deadlift, squat and lunge, which targeted multisegmental anatomical diagnoses for athletic groin pain.
coordination while developing strength. It is noteworthy that ►► Rehabilitation focusing on intersegmental control elicited
this study demonstrated a significant improvement in adductor changes in the change of direction biomechanics associated
strength in the absence of any isolated adductor strengthening with improved cutting performance.
during rehabilitation, perhaps demonstrating the efficacy of ►► Three-dimensional (3D) biomechanical examination can
restoring pain-free function to the area in improving adductor provide new insights into understanding rehabilitation
function. interventions.

Linear and multidirectional mechanics How might it impact on clinical practice in the future?
Acceleration, sprinting and change of direction are the most
commonly reported aggravating activities for AGP; therefore, ►► Focus attention towards identifying movement strategies as a
early incorporation of rate of force development and running risk factor for athletic groin pain.
mechanics, through linear and multidirectional drills, was ►► Allow the focus of rehabilitation to be on intersegmental
deemed important.52 53 The linear running drills addressed coordination control rather than specific anatomical
overstride and dynamic anterior pelvic tilt. Overstride may structures.
increase anterior hip joint forces at end range extension54 ►► Identify specific targets for rehabilitation through 3D motion
causing increased hip joint load,52 55 while anterior pelvic tilt analysis.
may increase femoroacetabular contact and pubic symphysis
stress.46 47 The linear running programme A and B gradually
increased patients’ load tolerance and exposure to avoid injury Contributors EK was involved in the creation of study design and hypothesis,
data collection, carrying out rehabilitation intervention, data analysis, and drafting
associated with acute spikes in training load on resumption of and revising submission. AFM was involved in the creation of study design and
playing.53 Change of direction drills have been shown to be hypothesis, data collection, and drafting and revising submission. CR was involved in
more effective at improving change of direction performance the creation of study design, data collection, data analysis and drafting submission.
than strength training or sprint training alone.56 Progression to EOR was involved in the creation of study design, data collection and carrying out
the multidirectional drills focused on the rate of force devel- rehabilitation intervention, and revision of submission. MD was involved in study
design, data collection, data analysis and revision of submission. KM was involved
opment across all three planes and reactive agility to prepare in study design, data interpretation and revision of submission. SS was involved in
the patient for sports-specific movements with the associated study design, data interpretation and revision of submission. EF was involved in the
enhancement in cutting mechanics and performance outlined creation of study design and hypothesis, data collection, and drafting and revising
above. submission.
Funding This research received no specific grant from any funding agency in the
public, commercial or not-for-profit sectors.

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Competing interests Sports Surgery Clinic is a private orthopaedic and sports 22 Kristianslund E, Krosshaug T. Comparison of drop jumps and sport-specific sidestep
medicine clinic and operates an athletic groin pain programme. cutting: implications for anterior cruciate ligament injury risk screening. Am J Sports
Med 2013;41:684–8.
Patient consent Obtained.
23 Franklyn-Miller A, Richter C, King E, et al. Athletic groin pain (part 2): a prospective
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