The aim of this Delphi study was to achieve an agreement between experts on RTP criteria in LARGP.
The main finding was that assessment of strength, performance tests and sport-specific skills would seem to be a sine qua non in RTP complex process in athletes affected by LARGP.
As reported in Figure 2, it was established that during strength evaluation it would seem crucial to analyse adductors isometric and eccentric strength considering “side-to-side symmetry”.
Planned/unplanned COD analysis seems to be considered as a criterion when performance tests are evaluated; athletes should be confident during completion and totally pain free.
At the same time, during sport-specific skills analysis, athletes should be confident and completely pain free during execution.
Although few items and 4 out of 9 categories reached final agreement, low CV% (mean 18.3%, range 12.9 – 28.7), high %AGR (mean 84.4%, range 65.6% – 96.9%) and W=0.03 (p<0.001) show the robustness of the consensus established.
Strength
Experts agreed on the importance of strength assessment as a RTP criterion (96.9%). Specifically, at the end of 3 rounds, consensus was achieved for the evaluation of hip adductors isometric strength (75%) and eccentric strength (84.4%).
These findings are in line with several studies(32–34) and are supported by evidence that highlights the usefulness of strength both as outcome measure(35,36) and rehabilitation criterion in groin pain.(34,37,38)
Despite no agreement established for strength tests to be used, the squeeze test 0° for isometric strength (66.7% of answers) and eccentric strength assessment in side-lying position (53.3%) would seem to be assessment methods with a wider consensus between experts.
Side-to-side symmetry is a discriminating factor in RTP: 87.6% of participants consider this parameter as a criterion to analyse during RTP process.
Although several studies support strength assessments of other hip muscle groups,(39,40) in our study none of these groups achieved expert consensus.
No final agreement was established for strength analysis of other muscle groups; nevertheless trunk flexors got a high rate of positive response in round 2 (90%). A total of 18 out of the 20 participants consider strength of aforementioned muscle complex important to evaluate. This could be an interesting clinical tip to consider even though no final consensus was achieved.
Imaging
Imaging is the only section that achieved negative consensus (93.7%). In fact, experts strongly agree to not consider or include imaging methods among RTP criteria.
Although imaging can be a valid diagnostic tool to support the clinical examination and identify red flags,(41) to date no study supports its use in RTP decision. Therefore, our finding would seem in agreement with literature.(42,43)
Performance Tests
Experts agree that analysis of performance tests can be considered as a criterion to establish RTP readiness in athletes suffering from LARGP (93.7%).
No specific test reached the 3 rounds agreement, but a strong consensus (96.9%) was achieved on the use of planned/unplanned COD to varying degrees (45-90-110-180°).
Data established seems to strongly agree with the current evidence;(8,44,45) in fact COD is considered an evocative and provocative movement in groin pain(46,47) and both a sport-specific movement and a reliable outcome measure.(48,49)
Experts agree that athletes must be fully asymptomatic (78.1%) and confident (93.7%) during COD execution. This seems to be confirmed by Serner et al.(50) that used COD, absence of symptoms and athlete confidence among RTP criteria, even if their study was on acute adductor injuries.
Sport-specific skills
To date, no study in the literature thoroughly examined the use of sport-specific skills in RTP in LARGP.
However, skills such as “kicking a ball” are considered potential causes of groin pain onset.(51)
Buckthorpe et al.(52) recommended the analysis of sport-specific movements to allow the athletes a full and safe RTS.
In the present study, the sport-specific skills section achieved solid consensus (96.9%). In addition, experts agree that athletes must be asymptomatic (75%) and self-confident (96.9%) during the execution of sport-specific tasks.
Even if parameters such as quality of movement and performance in skills execution did not reach agreement, the percentage obtained among participants (65.6%) suggests that these aspects could play a role as well.
No agreement sections
Three categories that did not achieve consensus (palpation, PROMs and intersegmental control) would seem to be in some way relevant in RTP decision-making although they are not considered as criteria.
It was established 78.1% of experts use palpation in RTP stage but just 68.8% of them uses it as criterion. Despite literature seeming to agree in assuming that pain-free palpation is important during RTP when considering other muscle injuries,(18,53) no expert consensus was achieved for LARGP. In round 1, 56.5% of respondents (13/23) allows pain in palpation, while 43.5% (10/23) requires a complete absence of symptoms.
A total of 71.9% of experts uses PROMs but only 59.4% of them uses it as criteria in RTP. The PROMs most used by clinicians and researchers (91.3% - 21/23) is HAGOS.(54)
Intersegmental Control analysis seems to be useful in managing groin pain.(8) Even if for this category no agreement was established, intersegmental control is used by 71.9% of sample. In particular, 78.3% of respondents (18/23) use single leg squat as a test to assess motor control.
Analysis of flexibility did not reach the consensus in its utilisation. Nevertheless, evidence highlights the importance of getting total hip range of motion to avoid recurrence episodes of groin pain.(55)
Even if training load (TL) cannot be considered a valid tool to assess injury risk,(56) as reported by Cummins et al.,(57) load management could represent a helpful tool to manage RTP progression. However, in the present Delphi study neither internal nor external load parameters reached consensus.