3 of 12 Top Hip Papers of 2024 | Clinical tests for adductor and pubic-related groin pain
Welcome to day 3 of my 12 Top Hip Papers of 2024 series of miniblogs. If you missed Day 2, you'll find a link at the bottom of this page to take you back. On day 3, we'll be looking at the value and relevance of clinical tests for adductor and pubic-related groin pain.
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3 of 12 Top Hip Papers of 2024: Clinical tests for adductor and pubic-related groin pain: reliability & positive test prevalence1
Background:
- Most clinicians use a fairly standard set of tests for groin pain, usually including palpation, stretch and resistance tests. But just how reliable are these tests in long-standing groin pain? Reliability is an important concept tightly linked with how confident we can be in our diagnosis. Previous studies have only included small numbers of participants, reducing our ability to generalise these results.
Study Aim:
- This study aimed to evaluate inter-examiner reliability of pain provocation tests for hip adductor-related groin pain and pubic-related groin pain in athletes with longstanding groin pain, and to determine the prevalence of positive tests.
What was done:
- Two highly experienced groin pain experts performed a range of physical tests on 44 male athletes (with 69 symptomatic sides).
- Median pain duration was 4.5 months.
- Participants were classified into one or more of the DOHA consensus groin pain entities, with focus on adductor related groin pain and pubic related groin pain.
- A 'likely' diagnosis was made when not all criteria were met but the diagnosis was considered likely.
- Positive test prevalence was determined and examiner agreement on each test assessed.
Key Findings:
Long Standing - Adductor Related Groin Pain (LS-ARGP)
Classification of Clinical Entity:
- Was diagnosed on 22 and 27 sides by Examiners A and B.
- Was considered likely in 18 and 11 sides by Examiners A and B.
Clinical Test Reliability & Prevalence of Positive Findings
- Tenderness on palpation was most prevalent at the adductor longus (ADL) origin (94%), with moderate reliability at this site.
- Palpation, other than at the ADL origin, had limited reliability.
- The Adductor Stretch Test was moderately reliable but positive in only 55%.
- Pain on Resisted Hip Adduction in maximum hip abduction was the most prevalent positive resistance test (72%) and reliability was substantial.
- Squeeze tests were positive in 62-70% and reliability was moderate.
Long Standing - Pubic-Related Groin Pain (LS-PRGP)
Classification of Clinical Entity:
- Was diagnosed in 7 and 2 cases by Examiners A and B.
- Was considered likely in 6 and 0 cases by Examiners A and B.
Clinical Test Reliability:
- Examiner agreement on palpation findings was only fair.
Clinical Implications:
Reliability of clinical tests for groin pain was lower in this study than previously reported, with one of the factors being more robust methods. The most reliable and prevalent positive tests in those with long-standing adductor related groin pain were palpation of the adductor longus origin and resisted adduction in a position of maximum abduction.
Tenderness on palpation in other areas apart from the adductor longus origin and tendon, had only slight to fair inter-tester reliability, and tenderness in other locations was much less prevalent. In cases of long-standing groin pain, these findings suggest that palpation of the adductor longus origin would appear to be most relevant to an entity classification.
Use a test battery that includes resisted adduction in maximum hip abduction and other squeeze tests. This will help ensure you don't miss a positive test in a flexed hip position, when loading the hip adductors in hip extension is negative.
The classification of pubic related groin pain was made on the basis of patient interview features and palpation of the pubic symphysis and the adjacent bone. The relatively low examiner agreement suggests a high level of uncertainty exists in classifying patients with the clinical entity of pubic related groin pain. However, there were only a small number of athletes with pain in the pubic region in this study.
Further research on a larger group of patients with pubic pain is warranted, and other physical tests might need to be considered - for example the 'Pubic Symphysis Stress Test' - achieved at the same time as performing hip extension/abduction and resisted hip flexion/adduction in the modified Thomas Test.
Area of pain provocation will be key when performing all stretch or resistance tests. Pain is often felt in other locations, as a broad area is being loaded.
It is important to note that this study was performed only on males athletes. There may be different or additional considerations in females and the non-athletic population.
Like to learn more about assessing and managing patients with groin pain?
In this course, you can find detailed information on pathoaetiology, assessment and management of groin and anterior hip pain conditions. To learn more, take the anterior hip and groin pain online course, or join me in a face to face or practical anterior hip and groin pain workshop.
This online course is included in Hip Academy and Hip Academy members receive discounts for online workshops.
I hope you enjoyed the infographics and key learnings from Day 3 of my 12 Top Hip Papers of 2024. There are 9 more papers to come! So keep an eye on the graphics below, to see what other top papers and infographics I have prepared for you!
Missed paper 2? Click above to read it!
Paper 4 comes out tomorrow!
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