Clinical examination tests for adductor- and pubic-related groin pain in athletes with longstanding groin pain: Inter-examiner reliability and prevalence of positive tests.

OBJECTIVES: Evaluate the inter-examiner reliability of pain provocation tests for hip adductors (palpation, stretch and resistance) and for pubic symphysis (palpation) in athletes with longstanding groin pain, and to determine the prevalence of positive tests. DESIGN: Inter-examiner reliability. SETTING: Orthopaedic and sports medicine hospital. PARTICIPANTS: Male athletes with longstanding groin pain. MAIN OUTCOME MEASURES: Inter-examiner reliability, absolute/positive/negative agreement, and the mean prevalence of positive tests for athletes classified with adductor- and pubic-related groin pain were calculated. RESULTS: We included 44 male athletes with longstanding groin pain (61 symptomatic sides). The mean age was 29 years (±6) and 70% were soccer players. Inter-examiner reliability was slight to moderate for adductor palpation (Cohen's Kappa statistic(κ)) = 0.02-0.54) and pubic palpation (κ = 0.37-0.45); moderate for the adductor stretch test (κ = 0.50), and fair to substantial for adductor resistance tests (κ = 0.22-0.74). Palpation pain was most prevalent at the adductor longus origin (94%) in athletes classified with adductor-related groin pain. CONCLUSION: The inter-examiner reliability of palpation tests varied from slight to moderate. The adductor stretch test had a moderate reliability, and adductor resistance tests a fair to substantial reliability. Adductor longus origin is the main site for palpation pain. Adductor palpation tests not related to the adductor longus have limited inter-examiner reliability. The adductor stretch test did not assist in classifying adductor-related groin pain.

Clinical examination for athletes with inguinal-related groin pain: interexaminer reliability and prevalence of positive tests.

Objectives: To evaluate the interexaminer reliability of abdominal palpation and resistance tests in athletes with longstanding groin pain, and to identify the prevalence of positive clinical tests in athletes classified with inguinal-related groin pain. Methods: Male athletes (18-40 years) with longstanding groin pain were prospectively recruited between March 2019 and October 2020 at a sports medicine hospital. Two examiners performed history taking and standardised clinical examination (including abdominal palpation, scrotal invagination and abdominal resistance tests) blinded to each other's findings. Interexaminer reliability was calculated using Cohen's Kappa statistic (κ). Examiners classified groin pain using the Doha agreement meeting terminology. A differentiation was made between 'defined inguinal-related groin pain' (according to recommended definition criteria) and 'likely inguinal-related groin pain' (expert-based application of the Doha agreement classification when not all recommended criteria were present). Results: Overall, 44 athletes were included (61 symptomatic sides). Interexaminer reliability of inguinal palpation pain provocation tests varied from fair to moderate (κ=0.35-0.49). Reliability of posterior wall structure palpation (firm/soft) was slight (κ=0.01), and posterior wall bulging (yes/no) fair (κ=0.29). Reliability for abdominal resistance tests varied from fair to substantial (κ=0.35-0.72). In athletes classified with defined inguinal-related groin pain, recognisable injury pain on palpation during scrotal invagination when athletes performed a Valsalva manoeuvre was the most prevalent positive palpation test (79%). Abdominal resistance tests were positive in 21%-49% of these cases. Conclusion: The interexaminer reliability for clinical examination tests used to classify inguinal-related groin pain in athletes varies from slight to substantial. There is no single perfect clinical examination test. Trial registration number: NCT03842826.

Inter-examiner reliability of the Doha agreement meeting classification system of groin pain in male athletes.

The Doha agreement classification is used to classify groin pain in athletes. We evaluated the inter-examiner reliability of this classification system. We prospectively recruited 48 male athletes (66 symptomatic sides) with groin pain between 10-2017 and 03-2020 at a sports medicine hospital in Qatar. Two examiners (23 and 10 years of clinical experience) performed history taking, and a standardized clinical examination blinded to each other's findings. Examiners classified groin pain using the Doha agreement terminology (adductor-, inguinal-, iliopsoas-, pubic-, hip-related groin pain, or other causes of groin pain). Multiple entities were ranked in order of perceived clinical importance. Each side was classified separately for bilateral groin pain. Inter-examiner reliability was calculated using Cohen's Kappa statistic (κ). Inter-examiner reliability was slight to moderate for adductor- (κ = 0.40), inguinal- (κ = 0.44), iliopsoas- (κ = 0.57), and pubic-related groin pain (κ = 0.12), substantial for hip-related groin pain (κ = 0.62), and slight for "other causes of groin pain" (κ = 0.13). Ranking entities in order of perceived clinical importance improved inter-examiner reliability for adductor-, inguinal-, and iliopsoas-related groin pain (κ = 0.52-0.65), but not for pubic (κ = 0.12), hip (κ = 0.51), and "other causes of groin pain" (κ = 0.03). For participants with unilateral groin pain classified with a single entity (n = 7), there was 100% agreement between the two examiners. Inter-examiner reliability of the Doha agreement meeting classification system varied from slight to substantial, depending on the clinical entity. Agreement between examiners was perfect when athletes were classified with a single clinical entity of groin pain, but lower when athletes were classified with multiple clinical entities.

Digital body mapping of pain quality and distribution in athletes with longstanding groin pain.

Groin pain is common in athletes, but remains a challenge to diagnose. Self-reported pain quality distribution may facilitate differential diagnoses. We included 167 athletes with groin pain (≥ 4 weeks). All athletes received a standardized clinical examination. Athletes could choose multiple quality descriptors and intensity, and drew these on a digital body map. Overlay images were created to assess distribution and area visually. Intensity, duration, and qualities were compared between each clinical entity and multiple entities. Top three quality descriptors were electric (22%), pain (19%), and dull/aching (15%). There were no differences in the frequencies of quality descriptors (p = 0.893) between clinical entities. Areas of the mapped qualities were similar between the single clinical entities (χ2(3) = 0.143, p = 0.986) and independent of symptom duration (ρ = 0.004, p = 0.958). Despite a considerable overlap, the mapped pain qualities' distributions appear to differ visually between single clinical entities and align with the defined clinical entities of adductor-related, inguinal-related, and pubic-related groin. In iliopsoas-related groin pain, pain extended more medially. The overlap between the drawn areas underscores a challenge in differentiating groin pain classifications based only on self-reported pain. The prevalence of pain quality descriptors varied and individually do not associate with one particular clinical entity of groin pain.

A Delphi survey and international e-survey evaluating the Doha agreement meeting classification system in groin pain: Where are we 5 years later?

OBJECTIVES: To evaluate the adoption of and opinions on the Doha agreement meeting classification in groin pain in athletes. DESIGN: Delphi survey and e-survey. METHODS: A 2-round Delphi survey among the Doha agreement meeting expert group, and a separate international e-survey among clinicians who regularly assess athletes with groin pain. Clinical cases were presented, and participants provided their preferred terms for the diagnoses. All participants reported if they had adopted the Doha agreement meeting classification system in their practice. The Doha agreement meeting experts also shared opinions on amendments to the classification system, and reported their level of agreement with suggested statements. RESULTS: In the Delphi survey, the Doha agreement meeting experts (n = 21) reported 8-11 different terms for their primary diagnosis of each presented case. The Doha agreement meeting terminology was used by 50-67% of these experts. In the international e-survey (n = 51), 12-15 different diagnostic terms were reported in each clinical case, and 43-55% of clinicians used the Doha agreement meeting terminology. Adoption of the Doha agreement classification system in practice was reported by 73-82% of the Doha agreement meeting experts and 57-69% of the clinicians in the international e-survey. The experts suggested 49 statements regarding amendments to the classification system. Seven of these reached >75% agreement or disagreement. CONCLUSIONS: Five years after publication, the majority of the Doha agreement expert group and independent international clinicians report adopting the Doha agreement meeting classification system. There is still considerable heterogeneity in diagnostic terminology when clinical cases are presented, and disagreement on statements related to amendments of the current classification system.

The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review.

Longstanding (chronic) adductor-related groin pain syndrome is a widely common problem for athletes in many sports activities which often drastically reduces player activity and performance. The first choice in therapeutic treatment is conservative therapy. The objective of this study is to provide a systematic review regarding conservative treatment for longstanding adductor-related groin pain syndrome present in literature today. Furthermore, this study aims to give a critical vision of the current state of the art of the considered topic. After screening 234 articles, 19 studies following the inclusion criteria were included and summarized in this current systematic review and seven different types of therapeutic interventions were described. Compression clothing therapy, manual therapy together with strengthening exercise and prolotherapy were the therapeutic interventions which showed both the greatest level of strength of evidence (Moderate) and grade of recommendation (D). The remaining four types of therapeutic interventions i.e.: corticoid injection, platelet rich plasma therapy, intra-tissue percutaneous electrolysis and pulse-dose radiofrequency, showed both lower levels of strength of evidence (Conflicting) and grade of recommendation (C). In conclusion the literature available on the conservative treatment for longstanding adductor-related groin pain syndrome is limited and characterized by a low level of evidence. Therefore, our recommendation is to refer only to the few studies with higher level of evidence and at the same time to encourage further research in this area. The intervention showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy. Other therapeutic interventions such as intra-tissue percutaneous electrolysis and pulse-dose radiofrequency seem promising but require further studies to confirm their efficacy.

Classifying radiographic changes of the pubic symphysis in male athletes: Development and reproducibility of a new scoring protocol.

PURPOSE: To develop a specified radiographic scoring system for the pubic symphysis and adjacent bones, and to examine the intra- and inter-rater reproducibility of this system. METHOD: Development of the scoring protocol was performed in three stages using AP pelvis radiographs of 102 male adult athletes. The final protocol included 5 overall scoring items, which included further specification of locations: 1) bone lucency (erosion-like configuration and cysts), 2) proliferation, 3) fragmentation, 4) sclerosis, and 5) joint space width. Intra- and inter-rater reproducibility were determined using Cohen's kappa statistic (κ) and intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and minimal detectable difference (MDD) were also determined. RESULTS: We present a radiographic scoring protocol with clear definitions and examples to improve clinical usability. Intra-rater reproducibility was: bone lucency (erosion-like configuration or cysts): κ = 0.67 (95 %CI 0.56-0.78), proliferation: κ = 0.54 (95 %CI 0.38-0.70), fragmentation: κ = 0.80 (95 %CI 0.67-0.93), sclerosis: κ = 0.60 (95 %CI 0.49-0.71), and joint space width: ICC(2.1) 0.85 (95 %CI 0.78-0.89), SEM 0.4 mm, MDD 1.2 mm. Inter-rater reproducibility was: bone lucency: κ = 0.61 (95 %CI 0.50-0.72), proliferation: κ = 0.34 (95 %CI 0.20-0.48), fragmentation: κ = 0.67 (95 %CI 0.50-0.84), sclerosis: κ = 0.30 (95 %CI 0.17-0.43), and joint space width: ICC(2.1) 0.72 (95 %CI 0.59-0.81), SEM 0.5 mm., MDD 1.5 mm. CONCLUSIONS: The Aspetar pubic symphysis radiographic scoring protocol contains five overall scoring items, with additional specifications. These five items showed moderate to almost perfect intra-rater reproducibility, and fair to substantial inter-rater reproducibility. This protocol provides the basis for use in clinical practice, and will allow future investigations of the clinical significance of radiographic changes at the pubic symphysis in athletes.

Multidisciplinary Assessment of 100 Athletes With Groin Pain Using the Doha Agreement: High Prevalence of Adductor-Related Groin Pain in Conjunction With Multiple Causes.

OBJECTIVE: To examine the prevalence of different causes of groin pain in athletes using the recent Doha consensus classification of terminology and definitions of groin pain in athletes. DESIGN: Descriptive epidemiological study. SETTING: Multidisciplinary sports groin pain clinic at Aspetar Orthopedic and Sports Medicine Hospital, Doha, Qatar. PATIENTS: The clinical records of 100 consecutive athletes with complaints of groin pain who attended the multidisciplinary sports groin pain clinic between January and December 2014 were analyzed. MAIN OUTCOME MEASURES: The causes of groin pain were categorized according to terminology and definitions agreed upon at the Doha consensus meeting on groin pain classification in athletes. The classification system has 3 main subheadings; defined clinical entities for groin pain (adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain), hip-related groin pain, and other causes of groin pain in athletes. RESULTS: The majority of athletes were male (98%) soccer players (60%). Multiple causes for groin pain were found in 44% of the athletes. Adductor-related groin pain was the most prevalent defined clinical entity (61% of athletes), and pubic-related groin pain was the least prevalent (4% of athletes). CONCLUSIONS: Adductor-related groin pain is the most commonly occurring clinical entity in this athlete population in mainly kicking and change of direction sports and frequently, multiple causes are found. CLINICAL RELEVANCE: This is the first study to use the Doha agreement classification system and highlights the prevalence of adductor-related groin pain and that often multiple clinical entities contribute to an athlete's groin pain. Consequently, prevention programs should be implemented with these factors in mind.

Doha agreement meeting on terminology and definitions in groin pain in athletes.

BACKGROUND: Heterogeneous taxonomy of groin injuries in athletes adds confusion to this complicated area. AIM: The 'Doha agreement meeting on terminology and definitions in groin pain in athletes' was convened to attempt to resolve this problem. Our aim was to agree on a standard terminology, along with accompanying definitions. METHODS: A one-day agreement meeting was held on 4 November 2014. Twenty-four international experts from 14 different countries participated. Systematic reviews were performed to give an up-to-date synthesis of the current evidence on major topics concerning groin pain in athletes. All members participated in a Delphi questionnaire prior to the meeting. RESULTS: Unanimous agreement was reached on the following terminology. The classification system has three major subheadings of groin pain in athletes: 1. Defined clinical entities for groin pain: Adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain. 2. Hip-related groin pain. 3. Other causes of groin pain in athletes. The definitions are included in this paper. CONCLUSIONS: The Doha agreement meeting on terminology and definitions in groin pain in athletes reached a consensus on a clinically based taxonomy using three major categories. These definitions and terminology are based on history and physical examination to categorise athletes, making it simple and suitable for both clinical practice and research.