LETTER TO THE EDITOR

Year : 2015  |  Volume : 29  |  Issue : 3  |  Page : 186-187

Efficacy of physiotherapy compared to steroid injection for adductor muscle strain

Sachin Upadhyay¹, Dileep Singh Thakur², Mayank Chansoria^3
1 Department of Orthopaedics, Traumatology and Rehabilitation, NSCB Medical College, Jabalpur, Madhya Pradesh, India
² Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
³ Department of Anaesthesiology, NSCB Medical College, Jabalpur, Madhya Pradesh, India

Correspondence Address:
Dr. Sachin Upadhyay
622, "Poonam" Sneh Nagar, State Bank Colony, Jabalpur - 482 002, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0970-5333.165860

1. The adductor muscle strain in not commonly known as "sportsman hernia (SH)." The "SH or athletic pubalgia" is defined as an injury to the rectus abdominis insertion onto the pubic symphysis, with a concomitant injury to the conjoined tendon insertion and adductor longus attachment to the pelvis. ^[2],[3],[4] The distinguishing feature of this disorder is subtle pelvic instability with compromised transversalis fascia, which in due course leads to the incompetency of the posterior inguinal wall. ^[5] The authors should define an "adductor muscle strain" because it is a stringent inclusion criterion in present clinical research. It is defined as pain on palpation of the adductor tendons, or the insertion on the pubic bone during active adduction against resistance ^[6]
2. Different classification systems are published in the literature concerning muscle injury grading systems. Few related to the amount of tissue damage and associated functional loss ^[7],[8] and other are imaging-based classification systems. ^[9],[10] In the present study, during the clinical assessment, the authors have used "three degrees of strain" while grading the adductor muscle injury. We would like to know from authors that "Is this classification is purely based upon clinical signs?" We believe that grading based on etiology and pathology is more useful than one based on purely clinical assessment
3. The authors included only males. Is this a sex-specific research or is purely coincidental. Clinical research performed with male-only participants differed in nature and size from that performed with female-only participants ^[11]
4. The authors did not mention the degree of adductor strain in the present cohort (in both groups). Whether all are grade one or two or three. Furthermore, patient with grade three injuries (where there is the complete disruption of the muscle tendon unit and loss of muscle function) requires surgical intervention. Furthermore, in true sports hernia, treatment is by surgical reinforcement of the inguinal wall. ^[6] We would like to know from the authors of the present study, that are these treatment algorithms (land condition index [LCI] or PT) used in the present study were same irrespective of grade of injury?
5. The routine use of magnetic resonance imaging for assessment of patients with groin pain cannot be justified owing to its cost. This can be employed in difficult cases to define the anatomic extent of the injury. We believe that plain radiography, ultrasonography, and scintigraphy should be the usual first-line investigations to supplement clinical assessment/observation ^[12]
6. Authors in group one gave "40 mg prednisolone injection in the most painful PT of the groin, and then they were followed up 4 weeks later." We would like to know that during this period besides LCI any rehabilitation program was designed for the patient?
7. The other group underwent PT. We would like to know from the author that this PT is without active training, or it is an active training program aimed at improving the coordination and strength of the muscles, contributing to stability of pelvis and hip joints, in particular, the adductor group of muscle. In present research, the author did not mentioned about the same
8. Were patients in both groups allowed to receive any other treatments for the groin pain before the final follow-up?
9. The conclusion is perplexing. Readers confused about the choice of treatment of adductor muscle strains. The author stated "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." There are two components, the first and foremost is that PT is the choice of therapy irrespective of the grade of injury. Second, the authors recommended steroid as first choice if PT fail. Authors did not clarify the factors that attribute to failure of PT protocol
10. We believe that treatment algorithm should depend upon the grade of the injury. An active training/rehabilitation program should be the first-line therapy for adductor muscle strain. In cases where pain, inflammation is limiting factor, the combination of LCI and active physical training would be the best. We believe that steroid can sometimes hasten the rehabilitation program.

References

1.	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.
2.	Meyers WC, Yoo E, Devon ON, Jain N, Horner M, Lauencin C, Zoga A. Understanding "Sports hernia" (Athletic Pubalgia): The Anatomic and Pathophysiologic Basis for Abdominal and Groin Pain in Athletes. Oper Tech Sports Med 2007; 15: 165-77. [DOI: 10.1053/j.otsm.2007.09.001].
3.	Akita K, Niga S, Yamato Y, Muneta T, Sato T. Anatomic basis of chronic groin pain with special reference to sports hernia. Surg Radiol Anat 1999;21:1-5.
4.	Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med 2001;29:521-33.
5.	Genitsaris M, Goulimaris I, Sikas N. Laparoscopic repair of groin pain in athletes. Am J Sports Med 2004;32:1238-42.
6.	Lynch SA, Renström PA. Groin injuries in sport: Treatment strategies. Sports Med 1999;28:137-44.
7.	O′Donoghue DO. Treatment of Injuries to Athletes. Philadelphia: WB Saunders; 1962.
8.	Ryan AJ. Quadriceps strain, rupture and charlie horse. Med Sci Sports 1969;1:106-11.
9.	Takebayashi S, Takasawa H, Banzai Y, Miki H, Sasaki R, Itoh Y, et al. Sonographic findings in muscle strain injury: Clinical and MR imaging correlation. J Ultrasound Med 1995;14:899-905.
10.	Stoller DW. MRI in Orthopaedics and Sports Medicine. 3 rd ed. Philadelphia: Wolters Kluwer/Lippincott; 2007.
11.	Rogers WA, Ballantyne AJ. Australian Gender Equity in Health Research Group. Exclusion of women from clinical research: Myth or reality? Mayo Clin Proc 2008;83:536-42.
12.	Fon LJ, Spence RA. Sportsman′s hernia. Br J Surg 2000;87:545-52.