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Konservative Maßnahmen zur Behandlung belastungsbedingter muskulotendinöser, ligamentärer und knöcherner Leistenschmerzen

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Referencias

Hölmich 1999 {published data only}

Holmich P, Nyvold P, Larsen K. Continued significant effect of physical training as treatment for overuse injury: 8‐ to 12‐yearoutcome of a randomized clinical trial.. American Journal of Sports Medicine 2011;39(11):2447‐51. [PUBMED: 21813441]
Hölmich P. Personal correspondence (email to Matheus Almeida concerning missing data) April 16 2012.
Hölmich P, Uhrskou P, Ulnits L, Kanstrup I, Nielsen MB, Krogsgaard K. Active physical training is an effective treatment of adductor related groin pain in athletes ‐ results of a randomised clinical trial of two interventions. Acta Orthopaedica Scandinavica 1998;69(Suppl 280):44.
Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, et al. Effectiveness of active physical training as treatment for long‐standing adductor‐related groin pain in athletes: randomised trial. Lancet 1999;353(9151):439‐43. [PUBMED: 9989713]

Weir 2011 {published data only}

Weir A. Personal correspondence (email to Matheus Almeida concerning missing data) April 17 2012.
Weir A, Jansen JA, van de Port IG, van de Sande HB, Tol JL, Backx FJ. Manual or exercise therapy for long‐standing adductor‐related groin pain: a randomised controlled clinical trial. Manual Therapy 2011;16(2):148‐54. [PUBMED: 20952244]

Ekstrand 2001 {published data only}

Ekstrand J, Ringborg S. Surgery versus conservative treatment in soccer players with chronic groin pain: A prospective randomised study in soccer players. European Journal of Sports Traumatology and Related Research 2001;23(4):141‐5.

Paajanen 2011 {published data only}

Paajanen H, Brinck T, Hermunen H, Airo I. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery 2011;150(1):99‐107. [PUBMED: 21549403]

References to studies awaiting assessment

Backx 2009 {published and unpublished data}

Backx FG. Personal communication (email to Matheus Almeida concerning the status of the trial) February 11 2013.
Backx FJ. Longlasting adduction‐related groin injuries in athletes; regular care or a novel treatment approach. http://www.controlled‐trials.com/ISRCTN65462262 (accessed 11/03/2013).

Backx 2013

Backx FGV. Personal communication (email to Matheus Almeida concerning the status of the trial) February 11 2013.

Biedert 2003

Biedert RM, Warnke K, Meyer S. Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes. Clinical Journal of Sport Medicine 2003;13(5):278‐84. [PUBMED: 14501310]

Carnes 2010

Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Manual Therapy 2010;15(4):355‐63. [PUBMED: 20097115]

Cowan 2004

Cowan SM, Scache AG, Brukner P, Bennell KL, Hodges PW, Coburn P, et al. Delayed onset of transversus abdominus in long‐standing groin pain. Medicine & Science in Sports and Exercise 2004;36(12):2040‐5. [PUBMED: 15570137]

Ekberg 1988

Ekberg O, Persson NH, Abrahamsson PA, Westlin NE, Lilja B. Longstanding groin pain in athletes. A multidisciplinary approach. Sports Medicine 1988;6(1):56‐61. [PUBMED: 3175403]

Ekstrand 1999

Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scandinavian Journal of Medicine & Science in Sports 1999;9(2):98‐103. [PUBMED: 10220844]

Emery 1999

Emery CA, Meeuwisse WH, Powell JW. Groin and abdominal strain injuries in the National Hockey League. Clinical Journal of Sport Medicine 1999;9(3):151‐6. [PUBMED: 10512343]

Engebretsen 2010

Engebretsen AH, Myklebust G, Holme I, Engebretsen L, Bahr R. Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study. American Journal of Sports Medicine 2010;38(10):2051‐7. [PUBMED: 20699426]

Hawkins 2001

Hawkins RD, Hulse MA, Wilkinson C, Hodson A, Gibson M. The association football medical research programme: an audit of injuries in professional football. British Journal of Sports Medicine 2001;35(1):43‐7. [PUBMED: 11157461]

Higgins 2011

Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.

Hölmich 2004

Hölmich P, Hölmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. British Journal of Sports Medicine 2004;38(4):446‐51. [PUBMED: 15273182]

Hölmich 2007

Hölmich P. Long‐standing groin pain in sports people falls into three primary patterns, a "clinical entity" approach: a prospective study of 207 patients. British Journal of Sports Medicine 2007 Apr;41(4):247‐52. [PUBMED: 17261557]

Hölmich 2011

Hölmich P,  Nyvold P,  Larsen K. Continued significant effect of physical training as treatment for overuse injury: 8 to 12 year outcome of a randomized clinical trial. American Journal of Sports Medicine 2011;39(11):2447‐51. [PUBMED: 21813441]

Hölmich 2012

Hölmich P. Personal correspondence (email to Matheus Almeida concerning missing data) April 16 2012.

Jansen 2008a

Jansen JA, Mens JM, Backx FJ, Stam HJ. Diagnostics in athletes with long‐standing groin pain. Scandinavian Journal of Medicine & Science in Sports 2008;18(6):679‐90. [PUBMED: 18980608]

Jansen 2008b

Jansen JA, Mens JM, Backx FJ, Kolfschoten N, Stam HJ. Treatment of longstanding groin pain in athletes: a systematic review. Scandinavian Journal of Medicine & Science in Sports 2008;18(3):263‐74. [PUBMED: 18397195]

Lefebvre 2011

Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.

Lloyd‐Smith 1985

Lloyd‐Smith R, Clement DB, McKenzie DC. A survey of overuse and traumatic hip and pelvic injuries in athletes. Physician and Sportsmedicine 1985;13(10):131–41. [EMBASE: 1986011045]

Lynch 1999

Lynch SA, Renström PA. Groin injuries in sport: treatment strategies. Sports Medicine 1999;28(2):137‐44. [PUBMED: 10492031]

Machotka 2009

Machotka Z, Kumar S, Perraton LG. A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009;1(5):1‐10. [DOI: 10.1186/1758‐2555‐1‐5; PUBMED: 19331695]

Maffey 2007

Maffey L, Emery C. What are the risk factors for groin strain injury in sport? A systematic review of the literature. Sports Medicine 2007;37(10):881‐94. [PUBMED: 17887812]

Neumann 2010

Neumann DA. Kinesiology of the hip: a focus on muscular actions. Journal of Orthopaedic and Sports Physical Therapy 2010;40(2):82‐94. [PUBMED: 20118525]

Orchard 2000

Orchard J, Read JW, Verrall GM, Slavotinek JP. Pathophysiology of chronic groin pain in the athlete. International SportMed Journal 2000;1(1):1‐16.

Paajanen 2011a

Paajanen H, Ristolainen L, Turunen H, Kujala UM. Prevalence and etiological factors of sport‐related groin injuries in top‐level soccer compared to non‐contact sports. Archives of Orthopaedic and Trauma Surgery 2011;131(2):261‐6. [PUBMED: 20714902]

Pizzari 2008

Pizzari T, Coburn PT, Crow JF. Prevention and management of osteitis pubis in the Australian Football League: a qualitative analysis. Physical Therapy in Sport 2008;9(3):117‐25. [PUBMED: 19083712]

Rabe 2010

Rabe SB, Oliver GD. Athletic pubalgia: recognition, treatment, and prevention. Athletic Training & Sports Health Care 2010;2(1):25‐30.

Thorborg 2011

Thorborg K, Hölmich P, Christensen R, Petersen J, Roos EM. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according tothe COSMIN checklist. British Journal of Sports Medicine 2011;45:478‐91.

Topol 2005

Topol GA, Reeves KD, Hassanein KM. Efficacy of dextrose prolotherapy in elite male kicking‐sport athletes with chronic groin pain. Archives of Physical Medicine and Rehabilitation 2005;86(4):697‐702. [PUBMED: 15827920]

Verrall 2005a

Verrall GM, Hamilton IA, Slavotinek JP, Oakeshott RD, Spriggins AJ, Barnes PG, et al. Hip joint range of motion reduction in sports‐related chronic groin injury diagnosed as pubic bone stress injury. Journal of Science and Medicine in Sport 2005;8(1):77‐84. [PUBMED: 15887904]

Verrall 2005b

Verrall GM, Slavotinek JP, Barnes PG, Fon GT. Description of pain provocation tests used for the diagnosis of sports‐related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scandinavian Journal of Medicine & Science in Sports 2005;15(1):36‐42. [PUBMED: 15679570]

Verrall 2007a

Verrall GM, Slavotinek JP, Barnes PG, Esterman A, Oakeshott RD, Spriggins AJ. Hip joint range of motion restriction precedes athletic chronic groin injury. Journal of Science & Medicine in Sport 2007;10(6):463‐6. [PUBMED: 17336153]

Verrall 2007b

Verrall GM, Slavotinek JP, Fon GT, Barnes PG. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. American Journal of Sports Medicine 2007;35(3):467‐74. [PUBMED: 17267768]

Vitanzo 2001

Vitanzo PC, McShane JM. Osteitis pubis: solving a perplexing problem. Physician and Sportsmedicine 2001;29(7):33‐38+48. [PUBMED: 20086580]

Weir 2010

Weir A, Jansen J, van Keulen J, Mens J, Backx F, Stam H. Short and mid‐term results of a comprehensive treatment program for longstanding adductor‐related groin pain in athletes: a case series. Physical Therapy in Sport 2010;11(3):99‐103. [PUBMED: 20673858]

Weir 2012

Weir A. Personal correspondence (email to Matheus Almeida concerning missing data) April 17 2012.

Williams 2000

Williams PR, Thomas DP, Downes EM. Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. American Journal of Sports Medicine 2000;28(3):350‐5. [PUBMED: 10843126]

References to other published versions of this review

Almeida 2012

Almeida MO, Gomes Silva BN, Andriolo RB, Atallah ÁN, Peccin MS. Conservative interventions for treating exercise‐related musculotendinous, ligamentous and osseous groin pain. Cochrane Database of Systematic Reviews 2012, Issue 1. [DOI: 10.1002/14651858.CD009565]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Hölmich 1999

Methods

Study design: single‐blinded randomized controlled trial

Setting: Clinic of Sports Medicine, Department of Orthopaedic Surgery, Amager University Hospital, Copenhagen, Denmark

Participants

  • N = 68 (exercise therapy group, n = 34; physiotherapy without active training group, n = 34)

  • Athletes

  • Age range: 18 to 50 years

  • Gender: males

  • Groin pain at least 2 months

  • Desire to continue sports at the same level of competition as before the injury

  • Pain at palpation of the adductor tendons or the insertion on the pubic bone, and during active adduction against resistance

Interventions

1. Exercise therapy (AT): 8 to 12 weeks; 3 times a week

Module 1: first 2 weeks

‐ Static adduction against soccer ball placed between feet when lying supine (10 rep. of 30s, each)

‐ Static adduction against soccer ball placed between knees when lying supine (10 rep. of 30s, each)

‐ Abdominal sit‐ups both in straightforward direction and in oblique direction (5 series of 10 rep.)

‐ Combined abdominal sit‐ups and hip flexion, starting from supine position and with soccer ball between knees (5 series of 10 rep.)

‐ Balance training on wobble board (5 min)

‐ One‐foot exercises on sliding board, with parallel feet as well as with 90 angle between feet (5 sets of 1 min continuous work with each leg and in both positions)

 

Module 2: 2 to 6 weeks

‐ Leg abduction and adduction exercises performed in side lying (5 series of 10 rep. of each exercise ‐ twice)

‐ Low‐back extension exercises prone over end of couch (5 series of 10 rep. – twice)

‐ One‐leg weight pulling abduction/adduction standing (5 series of 10 rep. for each leg – twice)

‐ Abdominal sit‐ups both in straightforward direction and in oblique direction (5 series of 10 rep. – twice)

‐ One‐leg coordination exercise with flexing and extending knee and swinging arms in same rhythm (5 series of 10 rep. for each leg – twice)

‐ Training in sideways motion on mini‐skateboard (5 min)

‐ Balance training on wobble board (5 min)

‐ Skating movements on sliding board (5 sets of 1 min continuous work)

2. Conventional physiotherapy (PT): 8 to 12 weeks; twice a week

‐ Laser treatment with a gallium aluminium arsen laser. All painful points of the adductor‐tendon insertion at the pubic bone received treatment for 1 min, receiving 0·9 mJ per treated point. The probe was in contact with the skin at 90° angle. The laser was fitted with an 830 nm (±0·5 nm) 30 mW, diode beam divergence was 4° and area of probe head was 2·5 mm2

‐ Transverse friction massage for 10 min on painful area of adductor‐tendon insertion into pubic bone

‐ Stretching of adductor muscles, hamstring muscles, and hip flexors. The contract‐relax technique was used. The stretching was repeated three times and the duration of each stretch was 30 s

‐ Transcutaneous electrical nerve stimulation was given for 30 min at painful area. The apparatus used was a Biometer, Elpha 500, frequency 100 Hz and a pulse width of one and a maximum of 15 mA (100% effect)

Treatment was given or instructed by physiotherapists and in both groups a return to running program was done after 6 weeks.

Outcomes

  • Successful treatment

‐ No pain at palpation of the adductors tendon or during resisted adduction

‐ No pain in connection with or after athletic activity in the same sport and at the same level of competition

‐ Return to sports at the same level without groin pain

If all three measures above were reached, the result was labelled excellent, if two measures were reached, the result was good, if one measure was reached, the result was fair and if no measures were reached, the result was poor.

  • Patients' subjective global assessment

  • Return to sports at the same level without pain

Outcomes were evaluated at 16 weeks and long‐term (8 to 12 years) follow‐up.

Notes

‐ The participants from AT group were treated in groups with two to four patients, while in PT group the treatment was individual

‐ A longer‐ term follow‐up of Hölmich 1999 (8 to 12 years from the original study) was included (Hölmich 2011)

‐ Percentage of lost participants (follow‐up of 16 weeks): 13% (9/68); 5 losses from AT group and 4 from PT group

‐ Reasons for withdrawn (follow‐up of 16 weeks): knee injury (one patient); immigration to Australia (one); loss to follow‐up at 4 months (two); did not want the treatment they were assigned (two patients assigned AT); could not get sufficient time off from work to complete the study (three)

‐ Percentage of lost participants (follow‐up of 8 to 12 years): 31% (21/68); 10 losses from AT group and 11 from PT group

‐ Reasons for withdrawal (follow‐up of 8 to 12 years): 5 individuals could not be located; 4 because of lack of current address 1 because of emigration; 5 were not interested primarily because they would have to take time off work to attend the examination, and 2 could not participate because they had suffered serious disability due to an accident not related to their groin problem

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Patients were randomly allocated by sealed, opaque, and serially numbered envelope to AT or PT group by means of block randomisation (block size four)"

Allocation concealment (selection bias)

Low risk

Quote: "Patients were randomly allocated by sealed, opaque, and serially numbered envelope to AT or PT group by means of block randomisation (block size four)"

Quote: "The examining physician was not involved in the randomisation procedure and remained unaware of the treatment allocation"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Participants and physiotherapists could not be blinded to allocation treatment

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

While the examining physician was not involved in the randomization procedure and remained unaware of the treatment allocation, there were subjective outcomes (successful treatment and patients' subjective global assessment) assessed by the trial participants, who were not blinded

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

While the study participant flow was clear and the missing data were balanced across groups, with reasons for missing data provided, the characteristics of lost participants were not described.

The analyses were not entirely 'intention to treat', nor were sensitivity analyses to address decisions regarding handling missing data.

Quote: "The subjective global assessment of the effect of treatment in the two groups based solely on results from patients completing the study (per‐protocol analysis)"

Selective reporting (reporting bias)

Unclear risk

Function (an important primary outcome) was not evaluated. No protocol available.

Other bias

High risk

There was no explicit information about supplementary treatment and physical activity of participants during the follow‐up period (8 to 12 years).

Weir 2011

Methods

Study design: single‐blinded randomized controlled trial

Setting: The Hague Medical Centre, Antoniushove hospital, Department of Sports Medicine. Leidschendam, the Netherlands

Participants

  • N = 54 (exercise therapy group, n = 25; multi‐modal treatment group, n = 29)

  • Athletes

  • Age range: 18 to 50 years

  • Gender: 53 male/1 female

  • Groin pain during and after sporting activities for at least 2 months

  • Desire to return to active sports participation at pre injury level

  • Pain located at the proximal insertion of adductor muscles on the pubic bone, and during active adduction against resistance

Interventions

1. Multi‐modal treatment group (MMT): heat + manual therapy + stretching.

‐ Maximum two sessions of manual therapy and heat, and 15 days of stretching (the stretches were done after a 5 min warming‐up using jogging or cycling). Before the manual therapy the adductor muscle group is warmed using paraffin packs for 10 min

‐ The manual therapy technique consists of: with the patient in a supine position, the contralateral hand is used to control the tension in the adductor muscles while the ipsilateral hand is used to move the hip from a neutral position into flexion, external rotation and abduction while keeping the knee in extension. The treating physician controls the tension subjectively and applies the maximum tolerable stretch to the adductor muscles. After the movement has been performed the adductor muscle group is compressed with one hand while the other hand moves the hip into adduction and slight flexion. This circular motion followed by compressions lasts about 25 s and is repeated three times in one treatment session

2. Exercise therapy group (ET): 8 to 12 weeks; 3 times a week.

Module 1: first 2 weeks

‐ Static adduction against soccer ball placed between feet when lying supine (10 rep. of 30s, each)

‐ Static adduction against soccer ball placed between knees when lying supine (10 rep. of 30s, each)

‐ Abdominal sit‐ups both in straightforward direction and in oblique direction (5 series of 10 rep.)

‐ Combined abdominal sit‐ups and hip flexion, starting from supine position and with soccer ball between knees (5 series of 10 rep.)

‐ Balance training on wobble board (5 min)

‐ One‐foot exercises on sliding board, with parallel feet as well as with 90 angle between feet (5 sets of 1 min continuous work with each leg and in both positions)

 

Module 2: 2 to 6 weeks

‐ Leg abduction and adduction exercises performed in side lying (5 series of 10 rep. of each exercise‐ twice)

‐ Low‐back extension exercises prone over end of couch (5 series of 10 rep. – twice)

‐ One‐leg weight pulling abduction/adduction standing (5 series of 10 rep. for each leg – twice)

‐ Abdominal sit‐ups both in straightforward direction and in oblique direction (5 series of 10 rep. – twice)

‐ One‐leg coordination exercise with flexing and extending knee and swinging arms in same rhythm(5 series of 10 rep. for each leg – twice)

‐ Training in sideways motion on mini‐skateboard (5 min)

‐ Balance training on wobble board (5 min)

‐ Skating movements on sliding board (5 sets of 1 min continuous work)

In both groups a return to running program was done after treatment.

Outcomes

  • Successful treatment:

‐ No pain in connection with or after athletic activity in the same sport and at the same level of competition

‐ No pain during resisted adduction or on palpation of the adductors tendon at the pubic bone insertion

‐ Return to sports at the same level without groin pain

If all three measures above were reached, the result was labelled excellent, if two measures were reached, the result was good, if one measure was reached, the result was fair and if no measures were reached, the result was poor.

  • Maximum pain during sports (Visual analogue scores, 0‐100)

  • Time to return to sports

  • Range of motion of the hip joint (internal and external rotation): It was used a goniometer with the patients lying and the hip and knee flexed to 90º

Outcomes were evaluated at 16 weeks follow‐up.

Notes

The participants from exercise therapy (ET) were not supervised while performed the exercises. They were only instructed on how to perform it.

Percentage of participants lost to follow‐up: 11% (6/59); 3 losses from ET group and 3 from MMT group

Reasons for withdrawal: did not want the treatment they were assigned (three patients); ankle injury (one patient); low‐back pain (one patients); and lost to follow‐up (one patient)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "After informed consent and inclusion the athletes were randomised using sealed envelopes.The athlete chose one of 100 opaque envelopes in the presence of the department’s secretary"

Allocation concealment (selection bias)

Low risk

Quote: "After informed consent and inclusion the athletes were randomised using sealed envelopes.The athlete chose one of 100 opaque envelopes in the presence of the department’s secretary"

Quote: "The examining physician was not involved in the randomisation process and remained unaware of the treatment allocation"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Participants and physiotherapists could not be blinded to allocation treatment

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

While the examining physician was not involved in the randomization procedure and remained unaware of the treatment allocation, there were subjective outcomes (Successful treatment) assessed by the trial participants, who were not blinded

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Although missing data were balanced across groups and reasons for missing data were provided, the characteristics of the lost participants were not described. Furthermore, a per protocol analysis was done

Selective reporting (reporting bias)

Unclear risk

Function (an important primary outcome) was not evaluated. No protocol available

Other bias

Low risk

No other source of bias was detected

rep. = repetitions

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Ekstrand 2001

Conservative treatment versus surgical treatment; not in review scope

Paajanen 2011

Conservative treatment versus surgical treatment; not in review scope

Characteristics of studies awaiting assessment [ordered by study ID]

Backx 2009

Methods

Randomized controlled, parallel group trial

Participants

Male athletes, 18 to 45 years old, hip adduction‐related complaints, for a period of at least six weeks, strong desire to compete in sports

Interventions

Two different kinds of physiotherapeutic treatments are given for the population. Both treatment strategies are already in use in daily practice.
Patients are randomized to receive either pelvic‐stabilizing muscle training or usual care

Outcomes

1. Severity of the pain over the last three days (11‐point visual analogue scale (VAS))

2. Participation in sports (11‐point VAS)
3. General disability (adapted Quebec low back pain disability scale)

4. Global change (six‐point Likert scale)
5. How long before return to full athletic activity
6. Recurrences of the same complaints
Parameters 1, 2, 3 are measured before and directly after the period of treatment and 26 and 52 weeks after the start of treatment.
Parameters 4, 5 and 6 are only measured at 26 and 52 weeks after treatment.

Notes

The author of this study was contacted via email and reported that the trial was not completed as a randomized clinical trial and therefore the results have not been published.

VAS = visual analogue scale

Data and analyses

Open in table viewer
Comparison 1. Exercise therapy versus conventional physiotherapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 'Successful treatment' Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.1

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 1 'Successful treatment'.

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 1 'Successful treatment'.

1.1 Follow‐up 16 weeks, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Follow‐up 8 to 12 years, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Follow‐up 8 to 12 years, intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Patients' subjective global assessment (better or much better) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.2

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 2 Patients' subjective global assessment (better or much better).

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 2 Patients' subjective global assessment (better or much better).

2.1 Follow‐up 16 weeks, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Follow‐up 16 weeks, intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 Follow‐up 8 to 12 years, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.4 Follow‐up 8 to 12 years, intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Return to sports Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 1.3

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 3 Return to sports.

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 3 Return to sports.

3.1 Per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

Open in table viewer
Comparison 2. Multi‐modal treatment versus exercise therapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 'Successful treatment' Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 2.1

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 1 'Successful treatment'.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 1 'Successful treatment'.

1.1 Per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Maximum pain during sports Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Analysis 2.2

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 2 Maximum pain during sports.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 2 Maximum pain during sports.

3 Return to sports Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

Analysis 2.3

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 3 Return to sports.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 3 Return to sports.

3.1 Per protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Time to return to sports (weeks) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Analysis 2.4

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 4 Time to return to sports (weeks).

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 4 Time to return to sports (weeks).

Flow diagram showing the reference screening and study selection.
Figuras y tablas -
Figure 1

Flow diagram showing the reference screening and study selection.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 1 'Successful treatment'.
Figuras y tablas -
Analysis 1.1

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 1 'Successful treatment'.

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 2 Patients' subjective global assessment (better or much better).
Figuras y tablas -
Analysis 1.2

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 2 Patients' subjective global assessment (better or much better).

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 3 Return to sports.
Figuras y tablas -
Analysis 1.3

Comparison 1 Exercise therapy versus conventional physiotherapy, Outcome 3 Return to sports.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 1 'Successful treatment'.
Figuras y tablas -
Analysis 2.1

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 1 'Successful treatment'.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 2 Maximum pain during sports.
Figuras y tablas -
Analysis 2.2

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 2 Maximum pain during sports.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 3 Return to sports.
Figuras y tablas -
Analysis 2.3

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 3 Return to sports.

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 4 Time to return to sports (weeks).
Figuras y tablas -
Analysis 2.4

Comparison 2 Multi‐modal treatment versus exercise therapy, Outcome 4 Time to return to sports (weeks).

Comparison 1. Exercise therapy versus conventional physiotherapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 'Successful treatment' Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.1 Follow‐up 16 weeks, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Follow‐up 8 to 12 years, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.3 Follow‐up 8 to 12 years, intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Patients' subjective global assessment (better or much better) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.1 Follow‐up 16 weeks, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 Follow‐up 16 weeks, intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 Follow‐up 8 to 12 years, per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.4 Follow‐up 8 to 12 years, intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 Return to sports Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 Per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

Figuras y tablas -
Comparison 1. Exercise therapy versus conventional physiotherapy
Comparison 2. Multi‐modal treatment versus exercise therapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 'Successful treatment' Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.1 Per‐protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

2 Maximum pain during sports Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Return to sports Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 Per protocol analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Intention‐to‐treat analysis

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Time to return to sports (weeks) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

Figuras y tablas -
Comparison 2. Multi‐modal treatment versus exercise therapy