Author Names
Short, S., Short, G., Strack, D., Anloague, P., & Brewster, B.
Reviewer Name
Arienne Sauvignon Howard LAT, ATC, SPT
Reviewer Affiliation(s)
Student within Duke’s Doctorate of Physical Therapy Program Class of 2025
Paper Abstract
Background/Purpose Athletes experiencing hip, groin, and low back pain often exhibit similar clinical characteristics. Individuals with hip, groin and low back pain may have the presence of multiple concurrent pathoanatomical diagnoses. Regardless, similar regional characteristics and dysfunction may contribute to the patient’s chief complaint, potentially creating a sub-group of individuals that may be defined by lumbopelvic and hip mobility limitations, motor control impairments, and other shared clinical findings. The purpose of this case series is to describe the conservative management of elite athletes, within the identified aforementioned sub-group, that emphasized regional manual therapy interventions, and therapeutic exercise designed to improve lumbopelvic and hip mobility, stability and motor control. Case Descriptions Five elite athletes were clinically diagnosed by a physical therapist with primary pathologies including adductor-related groin pain (ARGP), femoral acetabular impingement (FAI) with acetabular labral lesion and acute, mechanical low back pain (LBP). Similar subjective, objective findings and overall clinical profiles were identified among all subjects. Common findings aside from the chief complaint included, but were not limited to, decreased hip range of motion (ROM), impaired lumbopelvic motor control and strength, lumbar hypomobility in at least one segment, and a positive hip flexion-adduction-internal rotation (FADIR) special test. A three-phase impairment-based physical therapy program was implemented to resolve the primary complaints and return the subjects to their desired level of function. Acute phase rehabilitation consisted of manual therapy and fundamental motor control exercises. Progression to the sub-acute and terminal phases was based on improved subjective pain reports and progress with functional impairments. As the subjects progress through the rehabilitation phases, the delivery of physical therapy interventions were defined by decreased manual therapies and an increased emphasis and priority on graded exercise. Outcomes Significant reductions in reported pain (>2 points Numeric Pain Rating Scale), improved reported function via functional outcome measures (Hip and Groin Outcome Score), and continued participation in sport occurred in all five cases without the need for surgical intervention. Discussion The athletes described in this case series make up a common clinical sub-group defined by hip and lumbopelvic mobility restrictions, lumbopelvic and lower extremity motor control impairments and potentially other shared clinical findings. Despite differences in pathoanatomic findings, similar objective findings were identified, and similar treatment plans were applied, potentially affecting the movement system as a whole. Subjects were conservatively managed allowing continued participation in sport within their competitive seasons. Conclusion Comprehensive conservative treatment of the athletes with shared impairments, as described in this case series, may be of clinical importance when managing athletes with hip, groin, and low back pain.
NIH Risk of Bias Tool
Quality Assessment of Case-Control Studies
- Was the study question or objective clearly stated?
- Yes
- Was the study population clearly and fully described, including a case definition?
- Yes
- Were the cases consecutive?
- Yes
- Were the subjects comparable?
- Yes
- Was the intervention clearly described?
- Yes
- Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?
- Yes
- Was the length of follow-up adequate?
- No
- Were the statistical methods well-described?
- Yes
- Were the results well-described?
- Yes
Key Finding #1
By the completion of the 3-phase program, reduction within reported pain was noted by greater than 2 points via the Numeric Pain Rating Scale. Improved reported function was detected via functional outcome measures such as Hip and Groin Outcome Score. Return to sport including continued participation within the respective seasons occurred for all 5 cases.
Key Finding #2
By the 2nd phase of the 3-phase rehabilitation program; the Sub Acute phase, 4 out of the 5 subjects returned to sport participation and/or competition. “All subjects were managed conservatively within their competitive seasons and training cycles. Players were able to maintain sport performance at or above their prior levels of function with significant reductions in reported pain upon returning to participation and competition” (Short, S. et al. 2017).
Key Finding #3
Subject Response To Manual Therapy:
- Subject 1- The application of soft tissue mobilization and dry needling resulted in reports of decreased groin ‘tightness’ and overall pain reductions on the Numeric Pain Rating Scale. In addition to this, along the course of the 3-phase rehabilitation program, graded hip mobilization was introduced which resulted in decreased pain with single leg squatting.
- Subject 2- Responded well to soft tissue mobilization as well as graded joint mobilization of the lumbar spine that resulted in the improved capability of abdominal drawing-in exercises, which decreased reported pain in the groin.
- Subject 3- The application of spinal manipulation and graded lumbar mobilization resulted in visual and palpable improvements in motor control during the performance of a posterior pelvic tilt. These manipulations and mobilizations also provided a decrease in the patient’s report of ‘pinching’ in his groin during the performance of a double leg squat and forward lunge. In addition to this, along the course of the 3-phase rehabilitation program, hip joint mobilization and using mobilization with movement techniques along with soft tissue mobilizations resulted in pain-free performance of the double leg squat, forward lunge and single leg squat.
- Subject 4- The application of spinal manipulation and graded lumbar and hip mobilizations were utilized throughout the 3-phase rehabilitation program.
- Subject 5- The application of soft tissue mobilization, hip mobilization with movement, followed by a long axis hip thrust manipulation, and supine lumbopelvic manipulation technique resulted in immediate reduction in both his inferior lumbar and medial hip symptoms.
Please provide your summary of the paper
“A combined treatment approach emphasizing impairment- based manual therapy and exercise for hip-related compensatory injury in elite athletes: A case series.” by Short, S. et al. ( 2017), was based on five male athletes between the ages of 19-27 years-old who participate in contact sports varying between collegiate to the professional level that have been experiencing signs/symptoms of discomfort within the low back, hip and/or groin. In addition to common findings regarding the chief complaints, additional examinations included palpation, range of motion, strength assessment and special test all of which confirmed correlation between each subject as they had similar diagnoses. With the information gathered during the beginning of examination, a three-phase rehabilitation program was developed and implemented as a comprehensive conservative treatment approach to assist in return to sport for each subject within their respective seasons. Within each phase the incorporation of exercise and manual therapy was utilized to ensure improvements with lumbopelvic and hip mobility, stability, and motor control. By the end of the program, reduction within reported pain was noted by greater than 2 points via the Numeric Pain Rating Scale, improved reported function was detected via functional outcome measures such as Hip and Groin Outcome Score, and return to sport including continued participation occurred for all 5 cases. Though return to sport occurred with subjects missing at least 1 game and practice to at most subjects returning 12-weeks post-injury, during the 1 year follow up it was recognized that 2 out of the 5 subjects encountered re-injury 6 months to a year following the completion of the 3-phase rehabilitation program.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
The study presented within the article, “A combined treatment approach emphasizing impairment- based manual therapy and exercise for hip-related compensatory injury in elite athletes: A case series.” by Short, S. et al. (2017), impacts clinical practice by giving insight on how to approach similar instances in the future more effectively by understanding what worked and what could have been done better in respect to treatment of elite athletes. Expanding on this insight allows for clinicians to take a more targeted approach towards allowing for the success of conservative management of elite athletes (within the identified aforementioned sub-group) with an emphasis on regional manual therapy interventions and therapeutic exercise designed to improve lumbopelvic and hip mobility, stability, and motor control.
Regarding execution, results can be implemented via recognition of two important key components; addressing the body as a whole and continuation of rehabilitation/intervention after signs/symptoms have subsided. Addressing the body as a whole and not just focusing on what or how the patient presents themselves is pivotal as “asymptomatic findings and concurrent pathoanatomical diagnosis make treating specific structures challenging” and complex. For instance, for those who had chronic pathologies within the study, taking into consideration biomechanics as well as other coexisting diagnoses are crucial factors as they can also be why/how the patient presents themselves. Furthermore, ensuring the continuation of rehabilitation is important to warrant the prevention of injury recurrence as already stated in the article “once symptoms are improved, continuing an individualized program may be beneficial in further reducing this risk” Short, S. et al. (2017).
