The guidelines outlined by the New York State Workers Compensation Board are designed to assist healthcare professionals in evaluating Groin Strains and Adductor-Related Groin Pain. These directives aim to support physicians and healthcare practitioners in determining the appropriate treatment for these conditions.
Healthcare professionals specializing in Groin Strains and Adductor-Related Groin Pain can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable level of care for their patients.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding care should involve collaboration between the patient and their healthcare provider
Groin Strains and Adductor-Related Groin Pain
Groin strains are typically considered genuine strains characterized by disrupted myotendinous junctions, particularly involving the adductor muscles in the upper thigh. In less severe cases, clinical tests may not be necessary. However, for more severe instances, it is advisable to conduct evaluations using x-rays and/or MRI.
These imaging techniques help assess the underlying bony structure and determine the extent of muscle tear. In rare cases, surgical intervention may be necessary based on the findings.
Diagnostic Studies
Ultrasound:
Suggested: for the assessment of groin strains or adductor-related groin discomfort.
Criteria: Individuals experiencing groin strains or adductor-related groin discomfort, typically of at least moderate intensity. Mild strains usually resolve with suitable treatment and without the necessity for diagnostic assessments.
Frequency/Dose/Duration: Generally a singular occurrence.
Justification: Ultrasound is deemed beneficial for assessing and affirming these conditions, hence its endorsement.
X-Rays or MRI:
Recommended: for identifying groin strains or adductor-related groin discomfort in instances of greater severity.
Indications: Severe and specific cases of moderately-severe strains where surgical intervention is under consideration.
Rationale: X-rays contribute to the diagnosis of avulsion fractures, while MRI aids in determining the severity of strains/tears. These examinations are valuable in gauging the extent of severity in more intense cases and establishing suitability for surgical intervention.
Medications
For most patients, the initial recommendation for pain management typically involves suggesting ibuprofen, naproxen, or other conventional NSAIDs. Acetaminophen (or its equivalent, paracetamol) may be considered a viable option for those not suitable for NSAIDs, although current evidence suggests that acetaminophen is marginally less effective. Studies indicate that NSAIDs offer pain relief comparable to opioids (including tramadol) but with fewer impairing effects.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs):
- Recommended: for the treatment of groin strains or adductor-related groin pain.
- Indications: NSAIDs are recommended for treatment, and the use of over-the-counter (OTC) options may be sufficient and should be initially attempted.
- Frequency/Duration: As-needed use may be considered reasonable for many patients.
- Indications for Discontinuation: Cessation of symptoms, lack of efficacy, or the occurrence of adverse effects necessitating discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding:
- Recommended: simultaneous administration of cytoprotective drugs, such as misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors for patients at a heightened risk of gastrointestinal bleeding.
- Indications: Deliberation for patients with a high-risk factor profile who also require NSAIDs, particularly if longer-term treatment is foreseen. At-risk individuals include those with a history of prior gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers.
- Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers are recommended, following the dosage and frequency guidelines provided by the manufacturer. There is generally no substantial belief in differences in efficacy for preventing gastrointestinal bleeding.
NSAIDs for Patients at Risk of Cardiovascular Adverse Effects:
Individuals with a history of cardiovascular disease or multiple risk factors for such conditions should have a comprehensive discussion regarding the potential advantages and drawbacks of NSAID therapy for pain management.
- Recommended: Acetaminophen or aspirin is proposed as the primary treatment, given their perceived safety concerning cardiovascular adverse effects.
- Recommended: If needed, non-selective NSAIDs are favored over COX-2 specific drugs.
- For individuals on low-dose aspirin for primary or secondary prevention of cardiovascular disease, precautions should be taken to prevent potential interference with the beneficial effects of aspirin by NSAIDs. Specifically, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen:
- Recommended: for addressing groin strains or adductor-related groin pain, especially in patients with contraindications for NSAIDs.
- Indications: Applicable to all patients experiencing groin strains or adductor-related groin pain.
- Dose/Frequency: As per the manufacturer’s guidelines; it can be used on an as-needed basis. Caution is warranted, as exceeding four gm/day may lead to hepatic toxicity.
Treatments
Hot and Cold Therapies
Cryotherapy:
- Recommended for groin strains or adductor-related groin pain.
- Indications: Relevant for all patients experiencing groin strains or adductor-related groin pain.
- Frequency/Duration: About 3 to 5 self-applications daily, as needed.
- Indications for Discontinuation: Discontinuation criteria include symptom resolution, adverse effects, or non-compliance.
Heat Therapy:
- Recommended for groin strains or adductor-related groin pain.
- Indications: Appropriate for all patients with groin strains or adductor-related groin pain.
- Frequency/Duration: Roughly three to five self-applications per day, as needed.
- Indications for Discontinuation: Discontinue in case of symptom resolution, adverse effects, or non-compliance.
Rehabilitation Programs
- Recommended: for the treatment of groin strains or adductor-related groin pain.
- Indications: Most patients, particularly those with strength deficits and/or significant functional impairments, can benefit from a therapeutic program. Typically recommended for groin strains and/or adductor-related groin pain of at least moderate severity. Mild cases usually resolve with the elimination of exposures, NSAIDs, and time.
- Frequency/Dose/Duration: The total number of visits may vary, ranging from two to three for patients with mild deficits to 12 to 15 for those with severe deficits. Ongoing documentation of functional improvement is essential. If persistent deficits occur, more than 12 to 15 visits may be needed, especially with documented progress towards specific functional goals. As part of the rehabilitation plan, a home exercise program should be established and performed in conjunction with therapy.
- Rationale: Rehabilitation for work-related injuries should concentrate on restoring functional abilities for daily and work activities, with the goal of returning the patient to pre-injury status to the greatest extent possible.
