|Year : 2015 | Volume
| Issue : 2 | Page : 96-99
Efficacy of physiotherapy compared to steroid injection for adductor muscle strain
Asadollah Amanollahi1, Mohammad-Taghi Hollisaz1, Keramatollah Askari2, Amin Saburi3
1 Department of Physical and Rehabilitation Medicine, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
3 Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
|Date of Web Publication||15-Apr-2015|
Dr. Amin Saburi
Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Mollasadra St, Vanak Sq, Tehran
Source of Support: None, Conflict of Interest: None
Introduction: Adductor muscle strain or sportsman hernia (SH) is one of the most common disorders in cases who underwent heavy physical activity. An injection of corticosteroids is used to treat inflammation on the last step. Recently, physiotherapy (PT) considered as one of the most effective treatment for muscle strain. The aim of this study was the evaluation of the efficacy of steroid injection compared physiotherapy in adductor muscle strain. Materials and Methods: This cohort study was conducted on the patients who have presented to the physical medicine clinic of Baqiyatallah hospital with chronic groin pain definitely diagnosed SH. Other cause of unilateral groin pain was overruled, and the patients were divided into the two groups accidentally. Patients at the first group underwent 40 mg prednisolone injection and follow-up of 4 weeks later, and at the second group, the patients underwent PT containing stretching adductor muscle lasting 30 seconds 3 times per week for 2 weeks. Results: Seventy-six male patients with the mean age of 24.62 ± 3.49 including 24 athletes, 26 soldiers, and 26 martials were enrolled whom 37 of them divided into the first group and 39 into the second one. The mean ± SD of Visual Analogue Scale (VAS) before and after treatment in first group was 7.784 ± 0.492 and 3.340 ± 0.836, respectively and in second group equals to 8.008 ± 0.457 and 3.370 ± 0.297, respectively. These differences between and within groups were statistically significant. (P < 0.05). Conclusion: Both therapeutic protocols were effectively repressed the pain scores (VAS) although PT protocol was more effective than prednisolone injection. We suggest PT protocol as the first choice of SH treatment.
Keywords: Adductor muscle strain, corticosteroids, groin pain, physiotherapy, sportsman hernia, visual analogue scale
|How to cite this article:|
Amanollahi A, Hollisaz MT, Askari K, Saburi A. Efficacy of physiotherapy compared to steroid injection for adductor muscle strain. Indian J Pain 2015;29:96-9
|How to cite this URL:|
Amanollahi A, Hollisaz MT, Askari K, Saburi A. Efficacy of physiotherapy compared to steroid injection for adductor muscle strain. Indian J Pain [serial online] 2015 [cited 2020 Feb 17];29:96-9. Available from: http://www.indianjpain.org/text.asp?2015/29/2/96/155178
| Introduction|| |
Adductor muscle strain or groin pain or sportsman hernia (SH) is one of the most common disorders in athletes. In addition to athletes, people who are engaged with heavy physical activity and tension on groin and thigh such as soldiers and millenarians can frequently be suffered by SH. The frequency of SH was estimated as equal as 10-18% in athletes.  After a sudden over abduction or over external rotation, SH was presented by groin pain while adductor muscles were strained (and micro tearing in muscle and ligament happen).  SH presents itself with internal groin pain that refer to internal surface of thigh. , This acute injury can be treated completely, but in many cases, this injury progresses to an advance chronic disorder with debilitating pain, especially in exercise. ,, This chronic pain can affect sport life and occupation of cases and creates a remarkable downfall in their function. 
Treatment for patients with acute phase of SH includes elastic bands, local ice, physiotherapy protocol, which used according to the degree of damage.  Regarding to the inflammatory mechanism of SH, corticosteroids administration (local injection or systemic prescription) is used to treat SH on the last step or in severe degrees.  Recently, physiotherapy (PT) is considered as the first-line treatment of SH after the initial resting and movement limitation.  But there are many controversies in efficacy of these two protocols including PT and local corticosteroid injection (LCI). The aim of this study was the evaluation of the efficacy of LCI compared to PT in patients with chronic adductor muscle strain.
| Materials and Methods|| |
Study design and Participants
This study was conducted as cohort study on patients who were presented to the physical medicine clinic of Baqiyatallah hospital, Tehran, Iran during 2010-2011. Male subjects who had suffered by unilateral chronic groin pain were randomly studied and after excluding patients with other causes of groin pain (such as direct trauma, lymphadenitis, femoral or inguinal hernia, referral pain), the patients with definite diagnosis of SH were recruited. Chronic SH was defined as a pain locating at groin area under the inguinal ligament from 6 months ago. Imaging studies including MRI, laboratory test including CBC, ESR, CRP, RF, and ANA and also physical examinations were used for assessing all cases to exclude other cause of groin pain. The patients were allocated into the two groups using block randomization for more effective matching groups.
Interventions and Assessments
Patients at the first group (LCI) underwent 40 mg prednisolone injection in the most painful point of groin, and then they were followed up 4 weeks later and at the second group (PT), the patients underwent PT containing stretching adductor muscle lasting 30 seconds 3 times per week for 2 weeks. The patients were assessed by Visual Analog Scale (VAS) before and after intervention. The VAS is an international and valid scale for assessment of pain according to patient's statement. 
Usually three degrees are used in the examination. In the first degree, the patient feels a little pain and tenderness. While there is no walking and examination and no limitation in moving and swelling. In the second degree, the patient feels a little swelling and pain in his muscles during the movement and disorder in activities in the range of 3-14 days and mild movement disorders. Finally in the third degree, the patient feels severe pain and swelling in his leg and uses crutches to move. He has limitations in walking, and disability occurs from a few weeks to a few months. ,,
Ethic Approval and Statistical Analysis
This study was approved by ethical committee of Baqiyatallah University of Medical Sciences, Tehran, Iran, and all of the patients have filled the informed consent before enrollment. Moreover, as an open-labeled clinical trial study, all cases were free to continue or leave the study whenever they want. Data were analyzed using 16th edition of SPSS software (SPSS Co, Chicago, U.S.) using chi-squared and McNemmar tests for qualitative variables and t-test and ANOVA for quantitative variable.
| Results|| |
Finally, 76 male patients including 24 athletes, 26 soldiers, 26 military personnel's were enrolled of whom 37 cases were divided into the LCI group and 39 cases in the PT group. The overall mean age was 24.62 ± 3.49, and the mean age of LCI and PT group was 24.56 ± 3.37 and 25.68 ± 3.68, respectively. (P = 0.891) The mean VAS score before and after treatment in first group was 7.784 ± 0.492 and 3.340 ± 0.836, respectively, and the mean VAS score in second group was 8.008 ± 0.457 and 3.370 ± 0.297, respectively. These differences between and within groups were statistically significant. (P < 0.05) [Table 1].
|Table 1: Clinical and baseline characteristics in two therapeutic groups|
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The mean age of athletes, soldiers, and armed forces personnel were 24.75 ± 2.5, 20.88 ± 0.81, and 28.23 ± 1.47 years, respectively. (P = 0.001) The average duration of pain in patients who were treated with PT was 110.6 ± 25.28 days and in patients who were treated with prednisone was 108.8 ± 23.52 days. (P = 0.742) The average duration of pain in athletes was 110.46 ± 25.56 days, in soldiers was 103.2 ± 25.28 and in armed forces personnel 119.23 ± 30.55 days. There was a significant difference in terms of duration of pain between the three groups of athletes, soldiers, and armed forces personnel. (P = 0.040) [Table 2].
The mean score of VAS in the group treated with PT was 8.008 ± 0.457 before the treatment and 3.370 ± 0.297 after the treatment. The mean score of VAS in the group treated with prednisone was 7.784 ± 0.492 before the treatment and 6.340 ± 0.836 after the treatment. There was no significant difference in the mean score of baseline VAS between two groups (P = 0.073), but it was significant after the treatment. (P = 0.001) In the group treated with PT, the mean score of VAS changes was significantly different in comparison with the group treated with prednisone. (P = 0.001).
According to the occupation categories, 13 athletes were treated with PT and their mean score of VAS was 7.23 ± 0.54 before the treatment and 3.15 ± 0.72 after the treatment. Also, 13 athletes were treated with prednisone, and their mean score of VAS was 7.63 ± 0.44 before the treatment and 6.03 ± 0.72 after the treatment. Total 11 soldiers were treated with PT, and their mean score of VAS was 8.18 ± 0.38 before the treatment and 3.45 ± 0.31 after the treatment; 25 soldiers were treated with prednisone, and their mean score of VAS was 7.81 ± 0.58 before the treatment and 6.56 ± 0.54 after the treatment; 13 armed forces personnel were treated with PT, and their mean score of VAS was 8.14 ± 0.27 before the treatment and 3.35 after the treatment; 13 armed forces personnel were treated with prednisone, and their mean score of VAS was 7.87 ± 0.42 before the treatment and 6.36 ± 1.36 after the treatment [Figure 1] and [Figure 2].
There was no significant difference in response to treatment (based on the VAS score changes) according to the type of patients (soldier, athlete, and military personnel) in both groups (P = 0.323 in the LCI group and P = 0.452 in the PT group).
| Discussion|| |
Regarding the results, we found that both therapy protocols were effectively repressed the pain score (VAS) although PT protocol was more effective than local prednisolone injection. There are few investigations like our studies in the literature review, and most of the similar studies assessed the efficacy of each therapeutic protocol solely.
In 1997, Homlich et al. stated the efficacy of PT in athletes with chronic SH as 79% and the athletes came back to their professional sports after 18.5 weeks of treatment.  They did not compare their PT results to corticosteroids therapy results, and therefore, their findings are not comprisable with our findings. In another study in 2008 in Netherlands, Weir et al treated 30 athletes who suffered by chronic SH with multi-model treatment program consisting massage and heat therapy, and the rate of success was 90% and they came to sport after 18 weeks. 
Also, Weir & Jansen conducted an investigation on 44 similar cases that were treated by a short period of resting followed by PT, and they concluded that 86% of patients had a good response to this treatment protocol. They stated that only 50% of cases came back to professional sport after 51 weeks of treatment.  It seems that PT can be effective to relief chronic SH pain, but it seems that the therapeutic effect of PT may indicate at the longer time than drug medications although our results were different.
Weir and his colleagues conducted a research in the Netherlands in 2011 on 54 athletes with chronic groin pain caused by adductor. They showed that patients after (MMT) multi model treatment program with heat and massage and exercise and Van den Akker were improved sooner than the ET group and returned to their sports activities after 12.5 weeks. (12 weeks vs. 17 weeks). 
P-value on VAS was significant based on occupational groups before treatment (P = 0.03), but it did not become significant after the treatment( (P = 0.32), which indicates that the athletes and soldiers may have more physical activity and stronger muscle tissue than the armed forces personnel. And its significance after the treatment means that the kind of job and treatment are not related to each other.
There was no significant difference in terms of age between the two treated groups. (P = 0.89). So, age does not have any influence on the type of process of treatment, and the two groups were similar for age in this study. There was no significant difference In terms of treatment duration (P = 0.74), the result is that the duration of treatment did not affect the outcome. There was a significant difference in terms of pain duration between three groups of athletes, soldiers, and armed forces personnel. (P = 0.04), and it could be due to differences in muscle mass and strength in different jobs.
Elastic bandages, local ice, and PT activities that vary depending on the degree of injury are used for the treatment of acute phase. Corticosteroid injection is used as the last line of treatment in cases of severe and acute inflammation, and PT vary depending on the degree of injury. For example, for acute cases muscle stretching is done five times a day for 10 seconds to three times a day using foot massager twice a day for 5-10 minutes in the third degree (3). Currently, exercise therapy is used for the first-line treatment of this lesion after initial recovery and movement limitation.
In conclusion, it seems that both therapeutic protocols effectively repressed the pain scores (VAS) although PT protocol was more effective than prednisolone injection. We suggest PT protocol as the first choice of SH treatment. We recommend local corticosteroids injection for patients with SH if the PT protocol was not effective at the first time because PT was more effective than LCI for these cases in our research.
| Acknowledgment|| |
The authors would like to thank patients for their kind collaboration.
| References|| |
Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, et al
. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: Randomized trial. Lancet 1999;353:439-43.
Weir A, Jansen JA, van de Port IG, Van de Sande HB, Tol JL, Backx FJ. Manual or exercise therapy for long-standing adductor-related groin pain: A randomised controlled clinical trial. Man Ther 2011;16:148-54.
Spencer JE. Groin strain: Chiropractic rehabilitation. J Bodywork Movement Ther 1998;2:154-60.
Nam A, Brody F. Management and therapy for sports hernia. J Am Coll Surg 2007;7:37-48.
Fricker PA. Management of groin pain in athletes. Br J Sports Med 1997;31:97-101.
Farber AJ, Wilckens JH. Sports hernia: Diagnosis and therapeutic approach. J Am Acad Orthop Surg 2007;15:507-14.
Richardson WS, Jones DG, Winters JC, McQueen MA. The treatment of inguinal pain. Ochsner J 2009;9:11-3.
Misailidou V, Malliou P, Beneka A, Karagiannidis A, Godolias G. Assessment of patients with neck pain: A review of definitions, selection criteria, and measurement tools. J Chiropr Med 2010;9:49-59.
Weir A, Jansen J, van Keulen J, Mens J, Backx F, Stam H. Short and mid-term results of a comprehensive treatment program for longstanding adductor-related groin pain in athletes: A case series. Phys Ther Sport 2010;11:99-103.
Restram P, Peterson L. Groin injuries in athletes. Br J Sports Med 1980;14:30-60.
[Figure 1], [Figure 2]
[Table 1], [Table 2]