Table 4 Results of studies performing conservative strategies

Holmich et al. [14]

To compare an active training (AT) programme with a conventional physiotherapy (PT) programme in the treatment of severe and incapacitating adductor-related groin pain in athletes

AT: 90 min, 3 × a week instructed by a physiotherapist. The active training was divided in 2 modules, made with strength and coordination exercises

PT: 90 min, 2 × a week by one physiotherapist. The PT programme was made with stretching, contract-relax technique, laser, transverse friction massage and transcutaneous electrical nerve stimulation (TENS)

Mean time of 18.5 weeks (13–26 weeks)

AT group: 79% (23/29) subjects returned to sports

PT group: 14% (4/30) subjects returned to sports

There was a significant linear trend towards better effect of the AT treatment

Abduction ROM increased significantly in both treatment groups without difference between then

Adduction strength improved significantly in the AT group compared with the PT group

Treatment was stopped when neither the treatment nor the jogging caused any pain

The subjects and the physiotherapist decided when to stop the treatment

Weir et al. [16]

To compare the new therapy (Multimodal treatment) to the current therapy with the highest level of evidence, for the treatment of long-standing adductor-related groin pain, in a single blinded prospective randomized clinical trial

ETG: Six weeks focus in the exercises for strength and balance. After, phases of the return progressive to sport, witch slow jogging, straight sprints and cutting

MMTG: This group utilizes a paraffin pack to warm the adductor muscle and stretch, finish with manual therapy at the warmed place

ETG: mean time of 17.3 weeks

MMTG: mean time of 12.8 weeks

ETG: 55% (12/22) returned to sports

MMTG: 50% (13/26) returned to sports

The VAS pain scores at 0 and 16 weeks during sports improved significantly in both groups

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Yousefzadeh et al. [17]

Check the effect of the modified version of the Hölmich et al. protocol for the treatment of long-standing adductor-related groin pain (LSAGP) and aimed to evaluate its effects on athletes with this type of injury

The treatment occurred 10–12 weeks, 120–150 min, 3 × a week. Divided in 2 phases, compounded by strength, coordination and balance exercises, utilizing sliding boards, medicine balls, proprioceptive discs and soccer balls

Mean time of 12.06 weeks

86% (13/15) of subjects returned to sports

There was significant improvement in VAS pain scores for the legs adduction, THT and ESST

Meaningful improvements were also found in the T-Test agility scores

Hip abduction and adduction ROM and internal rotation increased significantly at the end of the treatment

Not established, but functional tests (HHD, THT, ESST and T-Test) are used

Schöber et al. [15]

To show the positive effect of a standardised treatment programme for symptomatic pubic overload in athletes with groin pain and osteitis pubis in a prospective randomized controlled study

Standardised nonsurgical treatment consists in a 3 phase program, with manual therapy, mobilization exercise, aerobic exercises, stretching, gradual exposure to sport movements, proprioceptive exercises, and strength exercises

Group 1: shock wave therapy additionally to standardised treatment

Group 2: there were utilized sham shock wave therapy additionally to standardised treatment

Control group: stopped participation in sports activity

Group 1 (Shock wave therapy: mean time of 73.2 days (10 weeks approximately)

Group 2 (Sham shock wave therapy): mean time of 102.6 days

Control group: mean time of 240 days

95% (42/44) of subjects, of both groups, returned to sports

The VAS, Oswestry low back pain and HOOS showed fewer complaints already 1 month after the beginning of therapy (p < 0.001 for both groups)

Subjects of the control group frequently experienced recurrent groin pain during the first year after the beginning of therapy (26/51; 51%)

The return-to-sport decision was made by the subjects, the team coach and the physician

Yousefzadeh et al. [19]

To objectively evaluate the effect of Holmich protocol-based exercise therapy on LSAGP

The treatment occurred 10–12 weeks, 90-120 min, 3 × a week. Divided in 2 phases, compounded by strength, coordination and balance exercises, utilizing sliding boards, medicine balls, wobble board and soccer balls

Mean time of 14.2 weeks

78%% (11/14) of subjects returned to sports

There was significant improvement in VAS pain scores for the squeeze test, THT, ESST, between hip internal rotation before and after treatment in the affected limbs was significant

Meaningful improvements were also found in the T-Test agility scores, for THT and ESST functionality

Not established, but functional tests (HHD, THT, ESST and T-Test) are used

Gore et al. [18]

The aim of this study was to determine if anterior groin pain (AGP) affects kinematics and kinetics during hurdle hop task using a continuous waveform analysis approach and if so, how these affected kinematics and kinetics compare to uninjured controls following return to sport

The exercise program was divided on 3 levels, 4 × per week alternating between, inter-segmental control, strength and running drills, without supervision (physiotherapist assessed each patient’s progress at regular intervals)

Mean time of 9.14 weeks

100% (65/65) of subjects returned to sports

There was significant improvement in maximum adductor squeeze score (at 0°, 45° and 90°)

HAGOS scores improved in 5 out 6 subscales, seven of eighteen kinematic and kinetic variables were no longer significantly different between the two groups

HAGOS

Adductor squeeze test

HHT

The authors suggest the kinematics and kinetics variables may represent the factors most related to return to sport

Paajanen et al. [13]

To compare the efficacy of video-assisted, preperitoneal insertion of polypropylene mesh to nonoperative treatment of suspected sportsman’s hernia in athletes, including magnetic resonance imaging (MRI) studies

Nonoperative treatment: 8 weeks,3 times a week for 90 min, exercise program supervised by a club physiotherapist

The exercise program focus was strength, balance training and reduce pain (with TENS)

Full return to sports activity was achieved in 20% and 27% after 1 and 3 months, respectively

At 12 months 15 (50%) subjects, had achieved full return to sports

1 Month Follow up: (20%)

3 months follow up: (27%)

12 months follow up: (50%)

Of the 60 study subjects, unilateral pain was found in 40 (67%) and bilateral pint in 20 (33%)

Complete relief of pain, after 1 month, was achieved at 14 subjects only in operative group. None of subjects from nonoperative group has reached 0 on VAS

Complete relief of pain, after 3 months, was achieved on 27 subjects at operative group, and 2 at nonoperative group

Complete relief of pain, after 12 months, was achieved on 29 subjects at operative group, and 14 at nonoperative group

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Mazbouh et al. [21]

To evaluate the effect of low intensity of exercise treatment based on MHP on long-standing ALrGP

The treatment consisted of MHP suggested by Yousefzadeh et al. 2018 under the supervision of a trained sport physiotherapist. Note that, the participant will continue his normal pain-free training with the team and he rest if pain is felt at any time during team training. The minimum duration of treatment was 10 weeks. Intensity identification session was held one week before the protocol treatment starts to exclude any effect of muscle fatigue and low exercise intensity was well defined. For applying low resistance in dynamic exercises, we identified the 1RM for each exercise in the pre-treatment session and we applied low intensity exercises at 40% of 1RM. The intensity can be changed to the targeted percentage of 1RM by using weights or elastic bands with different resistances as needed. Note that, 1RM will be assessed every two weeks as a progression of exercise intensity. For balance exercising, in addition to warm-up and stretching exercises, the intensity was not changed because it is considered as functional and overall exercising. In addition to Copenhagen Adduction exercises, where the intensity was identified based on previous studies

Mean time of 17.3 weeks

100% (10/10) of subjects returned to sports

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Not established, but functional tests (Biodex, SEBT) are use, and Pain 2/10 (VAS)