xPeerd (AI review)

September 23, 2026

AI Review (xPeerd — DAReview)

Summary

This case report describes a 43-year-old recreational cricket player with combined pubic- and adductor-related groin pain syndrome (GPS), managed with a five-phase, criterion-based physiotherapy program over ten weeks. The manuscript’s main strengths are its clinically relevant focus on a recreational athlete population, clear phase-based rehabilitation structure, and serial use of HAGOS to document functional change over time. The observed trajectory—baseline improvement, transient deterioration after premature competition, and later recovery—adds practical value to rehabilitation planning. The manuscript is also appropriately cautious in acknowledging several limitations. However, the work remains constrained by the intrinsic limits of a single-case design, incomplete diagnostic workup, limited methodological detail for reproducibility, and some overstatement in the conclusion relative to the evidentiary base. The paper is clinically readable and potentially useful as a case-based contribution, but it would benefit from stronger diagnostic justification, more explicit reporting of clinical decision thresholds, clearer differentiation between observation and inference, and tighter language around generalizability and effectiveness.

Potential Major Revisions

1. Diagnostic certainty remains limited and should be discussed more rigorously. The manuscript states that “Dynamic ultrasonography during Valsalva manoeuvre excluded inguinal hernia” and that the case was “consistent with a combined pubic- and adductor-related GPS subtype, with intra-articular hip pathology not excluded in the absence of MRI” in the Case Presentation section on page 3. This is an important admission, but the manuscript still builds a relatively confident diagnostic narrative despite the absence of MRI or radiographic imaging. Because the authors also acknowledge in the Discussion on pages 4–5 that “No hip imaging (MRI or radiograph) was performed, so structural pathology such as femoroacetabular impingement or labral tear cannot be excluded,” the diagnostic framework should be reframed as provisional rather than clinically settled. The paper should explain more explicitly why the chosen diagnosis was sufficiently actionable without further imaging and what competing diagnoses remained plausible throughout rehabilitation.

2. The manuscript makes effectiveness claims that exceed the strength of a single-case design. In the Discussion, the authors write that “GPS in a middle-aged recreational athlete can be effectively managed through a structured, phase-based physiotherapy programme” and in the Conclusion they state that “A five-phase, criterion-based physiotherapy programme produced clinically meaningful improvement in GPS in a recreational cricket player, with full return to sport.” For a single uncontrolled case, these statements should be softened. Improvement may reflect natural recovery, regression to the mean, rest, reduced exposure, nonspecific therapeutic effects, or combined intervention effects rather than the specific superiority of the five-phase program. The article would be more methodologically sound if it described association rather than implying intervention efficacy.

3. Reproducibility is limited by insufficient reporting of exercise prescription details. The intervention phases are described in broad terms, such as “graded isometric adductor loading,” “dynamic neuromuscular control,” and “ground-based running with incrementally increased pace, distance, and step length,” but dosage variables are not adequately reported on page 4. To support reproducibility, the paper should specify session frequency, sets, repetitions, hold durations, running distances, pace thresholds, rest intervals, pain-monitoring rules, and progression/regression criteria for each phase. “Pain-free completion” is too vague unless accompanied by a quantified pain threshold or decision algorithm.

4. The progression criteria are not operationalized enough for clinical replication. The manuscript states that progression was “contingent on pain-free completion of current-phase exercises” and that Phase 4 began “following an 80% symptom reduction.” The paper does not explain how “pain-free” was measured, whether this refers to pain during exercise, after exercise, or next-day response, nor how “80% symptom reduction” was calculated. Was this based on numeric pain rating, HAGOS domain change, clinician judgment, or patient impression? These ambiguities reduce the utility of the case report for clinicians seeking to implement the protocol.

5. Outcome interpretation needs more caution, especially regarding HAGOS use in a single patient. The manuscript claims that “serial HAGOS assessment proved a sensitive tool for monitoring both progress and event-related functional decline” in the Abstract and later that it “provided a sensitive framework for monitoring recovery” in the Conclusion. While the observed score changes are clinically interesting, one case cannot establish measurement sensitivity in a generalizable sense. The authors can say HAGOS appeared useful in this patient, but broader psychometric implications should remain tied to prior validation studies rather than inferred from this report alone.

6. The temporal narrative suggests a meaningful setback, but causality is asserted too directly. The manuscript reports that “After two days of unstructured competitive participation, the patient experienced a transient symptom flare and was regressed to Phase 2” and later notes a decline in mean HAGOS “from 66.3 to 36.5.” The event is plausible, but the causal interpretation should be expressed more cautiously. It should be clarified whether other contributing factors were considered, whether any interim treatment changes occurred, and whether symptom flare was documented with additional clinical findings beyond HAGOS.

7. The paper insufficiently separates Case Report from Discussion, reducing structural clarity. The section heading “Case Report and Discussion” on page 3 combines descriptive reporting and interpretation. For scholarly clarity, especially in a clinical case report, the manuscript would benefit from distinct sections for Case Presentation, Intervention, Outcomes, and Discussion. This would improve logical flow and make it easier for readers to distinguish observed facts from comparative interpretation.

8. Anti-fraud / coherence check: low concern, but citation-context alignment should be verified carefully. I do not see strong paper-mill signals such as incoherent jargon, impossible methods, fabricated-style grandiosity, or internally contradictory timelines. The clinical story is coherent and the limitations section is a positive sign of authenticity. However, the manuscript cites a 2026 article by Ayhan et al. with very strong outcome figures (“98.8% achieving complete or partial resolution”) used to contextualize this case. Because that comparative citation carries interpretive weight, the authors should verify that the cited population, definitions, and treatment context are closely comparable to this case. Overextended comparison would weaken evidentiary coherence even if the citation itself is real.

Potential Minor Revisions

1. Section labeling and organization The merged heading “Case Report and Discussion” on page 3 is structurally awkward for a scientific case report. Separate headings would improve readability and conformity to reporting norms.

2. Hyphenation and style consistency The manuscript alternates among compound modifiers such as “evidence￾based,” “patient￾reported,” “phase-based,” and “sport-specific.” Some instances appear to contain encoding or hyphenation artifacts rather than standard typography, especially in phrases like “Evidence￾based physiotherapy protocols” and “patient￾reported outcome measure.” These should be cleaned throughout.

3. Formatting artifact in pagination/text flow The extracted text shows page-number collisions and layout interruptions, such as “HAGOS).[3]3 Case Report and Discussion” and “sport/recreation, 4 physical activity, quality of life).” These may be PDF conversion artifacts, but the final manuscript should be checked to ensure page numbers or figure/table anchors do not interrupt sentence flow in the submitted version.

4. Abbreviation consistency “HAGOS” is introduced appropriately, but related abbreviations in Table I such as “ADL,” “Rec.,” and “QOL” should be checked for consistency between text, table, and figure captions. Table I defines them, which is good, but the prose should mirror the same terminology consistently.

5. Table presentation Table I is informative, but it would be stronger if it also stated whether score changes exceeded any known minimal clinically important difference, if such thresholds are available and appropriate for the domains used. At present, the table is descriptive but not interpretively anchored.

6. Wording precision The phrase in the Abstract that outcome tracking is “often limited to symptom resolution rather than validated patient-reported measures” is plausible, but it reads as a broad field-level claim. Consider either citing this more directly or softening the wording.

7. Typographic/grammatical issues identified | Location | Issue | Suggested Revision | |---|---|---| | Page 1, Abstract | “Evidence￾based” shows encoding/hyphen artifact | Replace with “Evidence-based” | | Page 3/4, Outcomes | “patient￾reported” shows encoding/hyphen artifact | Replace with “patient-reported” | | Page 5, Conclusion | “event￾related” shows encoding/hyphen artifact | Replace with “event-related” | | Page 3 | “one￾month history” shows encoding/hyphen artifact | Replace with “one-month history” | | Page 5, Table/figure transition | “Serial HAGOS 5 assessment” suggests page-number intrusion into sentence flow | Correct page layout so “5” does not split sentence | | Page 2/3 transition | “HAGOS).[3]3 Case Report and Discussion” suggests pagination/layout interruption | Repair formatting before submission |

8. AI content analysis for this post-2021 manuscript Estimated percentage of AI-generated content: low to moderate probability, approximately 20–35%.

Rationale: The prose is highly uniform, polished, and formulaically structured, with repeated balanced sentence construction and stock scientific phrasing such as “This case demonstrates that…,” “producing HAGOS gains across all domains,” and “highlights HAGOS as a sensitive tool…” These features can occur in human-edited medical writing, so they are not evidence of misuse by themselves. I do not see obvious semantic incoherence, fabricated terminology, or abrupt stylistic shifts that would strongly indicate machine-generated drafting. The text is coherent and internally consistent. Therefore, any AI-use concern here is modest and primarily stylistic rather than evidentiary.

Highlighted sections with elevated AI-like patterning:

• Page 1 Abstract, especially the compressed structure from problem statement to intervention to quantified outcome to conclusion.
• Page 4 Discussion opening paragraph, which is polished but somewhat template-like in phrasing and rhetorical balance.
• Page 5 Conclusion, which is concise and generic in a way often seen in assisted drafting.

Assessed epistemic impact: Even if AI-assisted drafting was used, the main issue would not be authorship style but whether claims are appropriately calibrated to the evidence. In this manuscript, the larger epistemic concern is not AI style; it is inferential overreach from a single case and incomplete diagnostic exclusion. That impact is more significant than any probable AI-writing influence.

Recommendations

1. Reframe the diagnosis more cautiously. Explicitly present the diagnosis as a clinically reasoned working diagnosis rather than a fully confirmed one, given that “intra-articular hip pathology [was] not excluded in the absence of MRI.”

2. Strengthen reproducibility. Add a supplementary rehabilitation table with exercises, dosage, progression thresholds, regression criteria, pain-monitoring rules, and weekly loading targets. This would substantially improve clinical transferability.

3. Calibrate causal and efficacy language. Replace strong statements implying intervention effectiveness with more precise wording such as “the patient improved during a structured rehabilitation program” rather than “the programme achieved clinically meaningful recovery,” unless explicitly framed as a single-case observation.

4. Improve outcome interpretation. Discuss HAGOS change in relation to measurement properties from the cited validation literature rather than inferring sensitivity from one patient alone.

5. Expand the clinical reasoning narrative. Explain why MRI was not obtained, how differential diagnoses were prioritized, and which findings most strongly supported the pubic/adductor classification under the Doha framework.

6. Clarify the setback episode. Provide more precise detail regarding the “premature competitive participation” event, including the type and intensity of activity, symptom response timeline, and rationale for regression to Phase 2.

7. Tighten scholarly structure. Separate the manuscript into conventional case report components and ensure figures, tables, and pagination do not disrupt reading flow.

8. Maintain the balanced limitations section, but extend it. The acknowledgment that “Specific clinical tests with demonstrated high diagnostic accuracy were not systematically applied, and home exercise adherence was self-reported” is important and should be expanded into a clearer discussion of internal validity and risk of measurement or adherence bias.

Overall, I judge the manuscript to be clinically relevant and coherent, with low overt fraud concern, but in need of substantive revision before it can function as a rigorous and reproducible scholarly case report.

Reviewer3 (AI review)

September 21, 2026

AI Review (reviewer3.com)

Comments (6)

1. Inconsistent rehabilitation phase timeline and assessment dates — Minor

free completion of Phase 2. Phase 4 (Weeks 4 - 5) introduced treadmill running and backward walking following an 80% symptom reduction. After two days of unstructured competitive participation, the patient experie nced a transient symptom flare and was regressed to Phase 2, progressing back through Phase 4 over four weeks before Phase 5 (Weeks 7 - 10) introduced ground - based running with incrementally increased pace, distance, and step length, culminating in full spor t - readiness and discharge.

The text states that 'Phase 4 (Weeks 4-5) introduced treadmill running...' and that the patient experienced a symptom flare-up 'After two days of unstructured competitive participation,' leading to regression. However, Table I and Figure 3 show that the 'Pre-Event' assessment occurred on March 20, 2026, which is exactly 3 weeks (21 days) after the Baseline assessment on February 27, 2026, and the 'Post-Event' assessment occurred on March 23, 2026. This means the premature competition and subsequent flare-up occurred at the very beginning of Week 4, making it chronologically impossible for the patient to have completed or even participated in 'Phase 4 (Weeks 4-5)' prior to the event. Additionally, if the patient regressed to Phase 2 on March 23 and spent 'four weeks' progressing back through Phase 4, they would not have completed Phase 4 until approximately April 20 (Week 8 of the overall timeline), which contradicts the definition of 'Phase 5 (Weeks 7-10)' starting at Week 7.

2. Sensitivity claim unsupported by n=1 — Critical

Conclusion A five - phase, criterion - based physiotherapy programme produced clinically meaningful impr ovement in GPS in a recreational cricket player, with full return to sport. Serial HAGOS 5 assessment provided a sensitive framework for monitoring recovery and identifying event

The authors infer that serial HAGOS assessment is a sensitive tool for monitoring progress and detecting decline. However, establishing the sensitivity to change (responsiveness) of an outcome measure requires cohort-level clinimetric analysis, such as calculating standard error of measurement, minimal detectable change, or standardized response means. A single-subject case report cannot validate the sensitivity or responsiveness of an instrument, as the observed score changes may be unique to this patient's specific presentation and recall. The authors should temper this claim, stating that the HAGOS scores reflected the clinical course in this patient, rather than asserting the tool's general sensitivity.

3. Contradiction regarding pain-free status — Minor

recovery. The patient achieved complete, pain - free return to recreational cricket.

The authors assert that the patient achieved a complete, pain-free return to recreational cricket. However, Table I shows that at the final assessment, the patient's HAGOS Pain score was 93 and Symptoms score was 86. On the HAGOS scale, a score of 100 represents a completely pain-free and asymptomatic state; a score of 93 indicates that mild pain or discomfort persists. The authors should reconcile this discrepancy by tempering the claim of a pain-free return or clarifying that mild residual symptoms remained.

4. Unvalidated composite HAGOS score — Critical

Results: Overall mean HAGOS improved from 26.5 at baseline to 76.2 at final assessment, with a transient decline to 36.5 following premature competitive participation before full recovery. The patient achieved complete, pain

The authors use an "overall mean HAGOS score" (calculated as the unweighted average of the six subscales) to operationalize and track functional recovery. However, the HAGOS is not validated as a composite measure; its design and validation literature specify that the six subscales must be reported and interpreted independently. Averaging these distinct domains assumes they are unidimensional and equally weighted, which can mask specific functional deficits and lacks clinical validation. The authors should present and analyze the six subscales individually rather than relying on an unvalidated composite mean score.

5. Lack of control in n=1 design — Major

A five-phase, criterion-based physiotherapy programme produced clinically meaningful improvement in GPS in a recreational cricket player, with full return to sport.

The study employs a simple longitudinal single-subject design without a control group or an experimental single-case design (such as an ABAB withdrawal design). Because the patient had a short history of symptoms (one month) prior to the intervention, it is impossible to rule out spontaneous recovery, regression to the mean, or the effects of simple rest (which was prescribed in Phase 1) as the primary drivers of recovery. To support the claim that the specific five-phase programme produced the improvement, the authors should temper their causal language to describe the recovery as associated with the programme.

6. Overlapping recall periods in serial administration — Minor

points (Table I). Overall mean HAGOS improved from 26.5 at baseline to 66.3 pre - event, declined transiently to 36.5 following premature competitive participation, recovered to 62.0 at follow - up, and reached 76.2 at final assessment (Figures 1

The HAGOS questionnaire is validated with a recall period of 'the last week' (7 days) for all items. The authors administered the 'Pre-Event' HAGOS on 20-03-2026 and the 'Post-Event' HAGOS on 23-03-2026, which is an interval of only 3 days. Consequently, the 7-day recall windows for these two assessments heavily overlap (both covering the period from March 17 to March 20). This overlap violates the instrument's design and means the 'Post-Event' scores do not purely reflect the post-event state, but rather conflate pre- and post-event symptoms. The authors should acknowledge this overlap as a limitation in their serial monitoring design.

XSci (AI review)

September 21, 2026

Summary and Recommendation

This manuscript reports the clinical course of a 43-year-old male recreational cricket player who presented with a one-month history of right-sided lower abdominal and adductor pain and was diagnosed, following clinical examination and dynamic ultrasonography excluding inguinal hernia, with combined pubic- and adductor-related groin pain syndrome (GPS). The authors implemented a five-phase, criterion-based physiotherapy programme progressing from relative rest through isometric adductor loading, dynamic neuromuscular control, treadmill loading, and ground-based sport-specific training over approximately ten weeks, with an interruption and regression after the patient returned prematurely to unstructured competitive play. Recovery was tracked using the Copenhagen Hip and Groin Outcome Score (HAGOS) at five time points, with overall mean HAGOS rising from 26.5 at baseline to 76.2 at final assessment, including a transient decline to 36.5 following the premature return to competition. The patient achieved a pain-free return to recreational cricket.

The manuscript makes a genuine contribution to an underrepresented area of the sports physiotherapy literature: structured, phase-based management of groin pain syndrome in a recreational, non-elite athlete, tracked with granular, validated outcome measurement across a full episode of care that includes a clinically instructive setback. These are real strengths that a revision can preserve and build upon. At the same time, the manuscript's conclusions currently outrun what a single, uncontrolled case can support in several specific respects: the diagnostic label and the causal narrative linking the programme to recovery are each asserted with more certainty than the reported work-up and study design allow, the primary outcome metric is a non-standard composite whose properties are undiscussed, and several reporting gaps limit the paper's reproducibility and the durability of its central recovery claim. None of these issues require new data collection from the patient; they are addressable through more calibrated interpretation and more complete reporting of information the authors likely already hold. Major revision is recommended.

Major Concern Category 1: Diagnostic Certainty and Causal Interpretation

1.1 The diagnostic label is asserted with more confidence than the reported work-up supports

The manuscript labels the presentation as "combined pubic- and adductor-related GPS" and maintains this label through the Discussion and Conclusion, yet the diagnostic work-up consisted of clinical examination and dynamic ultrasonography performed specifically to exclude inguinal hernia. The authors themselves acknowledge that intra-articular hip pathology was not excluded in the absence of MRI and that specific clinical tests with demonstrated high diagnostic accuracy were not systematically applied. Compounding this, the manuscript's diagnostic sentence attributes the classification approach to the Doha Agreement framework, yet does not walk through which specific Doha-defined criteria were met for each subtype component; the "combined" terminology used throughout appears to derive more directly from a separately cited cohort classification than from the Doha framework itself. A 43-year-old presenting with insidious groin pain sits within an age range where degenerative or structural intra-articular pathology is a recognised contributor to symptoms and could coexist with or mimic adductor-related pain. The diagnostic label should be presented consistently as a working clinical impression, with the specific examination findings mapped explicitly onto the cited classification criteria, rather than treated as a settled diagnosis in the Discussion and Conclusion.

1.2 Recovery is attributed to the programme without adequately engaging alternative explanations

The Discussion frames the ten-week improvement as demonstrating that the phase-based programme "effectively managed" the condition, a causal claim that a single-subject, unblinded, uncontrolled observation cannot, on its own, establish. Adductor-related and pubic-related groin strains frequently show substantial improvement from rest and activity modification alone over similar timeframes, and the Discussion does not address regression to the mean, natural history, or the contribution of the multiple co-interventions, including cryotherapy and activity cessation, bundled into the earliest phase. Because HAGOS was not recorded at the end of every individual phase, the manuscript cannot fully separate the contribution of early load management from that of the later structured loading phases, but this open question could at least be acknowledged rather than left implicit in causal language such as "produced" and "effectively managed." Softening this language and adding a short discussion of competing explanations would better calibrate the strength of the paper's central claim to what the design can actually support.

1.3 The reasoning for excluding the incidental gallbladder finding is not stated

Dynamic ultrasonography incidentally identified grade-I cholelithiasis, described only as "managed pharmacologically, deemed unrelated." The presenting complaint explicitly included lower abdominal pain, and the examination findings included pain on lumbar movements producing abdominal contraction and mild pain at end-range abdominal stretch, indicating that an abdominal component was a meaningful part of the presentation rather than an incidental descriptor. While the anatomical distribution described differs from that classically associated with biliary pathology, no clinical reasoning, such as the character, timing, or distribution of the abdominal pain relative to the musculoskeletal findings, is offered to support the exclusion. A brief statement of that reasoning would strengthen the credibility of this determination without requiring any new investigation.

Major Concern Category 2: Outcome Measurement, Composite Scoring, and Clinical Significance

2.1 The validity of the "overall mean HAGOS" composite is not established

Throughout the Results, Discussion, and Table I, the authors report an "overall mean HAGOS," defined in the table footnote as an unweighted mean across all six HAGOS domains. This composite is not part of the instrument as developed and validated, which was designed to report six independent subscale scores precisely because the domains capture distinct constructs that need not move together or carry equal clinical weight. No citation or rationale is offered for averaging the six subscales, and no discussion addresses the measurement properties of the derived metric. The authors should either report and interpret the six subscales individually as the primary outcome, consistent with the instrument's validated use, or provide an explicit rationale and caveat for the composite if it is retained.

2.2 Floor-effect considerations in the lowest-scoring domains are not addressed

The Physical Activity domain begins at a score of 0 at baseline, and Quality of Life begins at 25, both markedly lower than the other four domains, and both remain the lowest-scoring domains at every subsequent time point. A baseline of 0 indicates the most severe possible response on every contributing item, a floor observation with no room to register further decline, yet the manuscript does not discuss how this may shape the overall mean's trajectory or the interpretation of the "event-related decline" the paper emphasises. Because the composite is substantially influenced by domains that started at or near the scale's floor, the apparent magnitude of overall improvement may partly reflect this boundary effect rather than a uniform pattern of recovery across domains. Presenting domain-level change alongside the composite, with explicit acknowledgment of the floor-level baseline, would allow readers to judge this more accurately.

2.3 "Clinically meaningful improvement" is asserted without an applied benchmark

The Conclusion states that the programme "produced clinically meaningful improvement," a specific claim that is never benchmarked against a published minimal clinically important difference or minimal important change threshold for HAGOS or its subscales. Domain-level movements vary considerably in size across the five time points, and without a stated threshold, readers cannot judge which changes plausibly exceed measurement variability and which do not. Citing an appropriate benchmark, even an approximate, appropriately caveated one, and applying it domain by domain, or otherwise softening the "clinically meaningful" language to a more descriptive characterisation, would make this claim considerably more defensible.

Major Concern Category 3: Reporting Completeness, Assessment Timing, and Outcome Durability

3.1 Intervention detail is insufficient for reproducibility

The five-phase programme is described through named exercises and general progression criteria such as "pain-free completion" and "80% symptom reduction," but omits dosage parameters, sets, repetitions, hold times, loading progression, and session frequency, that a treating clinician would need to reproduce or adapt the approach. Given that the authors themselves describe evidence-based protocols for this population as "sparse," reproducibility is central to the paper's intended contribution, and reconstructing and reporting approximate dosage and session-frequency information, ideally organised by phase, would substantially increase the manuscript's practical value.

3.2 The assessment schedule appears reactive, and the post-event decline rests on a single, sparsely detailed observation

The intervals between the five HAGOS assessments are markedly uneven, with only three days separating the pre-event and post-event time points and considerably longer gaps elsewhere, and the labelling itself indicates that at least two assessments were added around the patient's unplanned return to competition rather than following a schedule fixed at the outset. This matters because the sharpest decline in the entire dataset is documented on the most compressed timescale, and the Discussion draws a fairly firm causal conclusion, that unstructured competition caused a functional decline preceding symptom recurrence, from this single assessment without accompanying clinical examination findings or a description of what specifically triggered the flare. Clarifying which assessments were planned versus reactively added, and reporting any clinical findings that accompanied the post-event assessment, would allow this genuinely instructive episode to be interpreted with appropriate confidence.

3.3 Treatment burden is not reported

The manuscript does not state how many physiotherapy sessions or how much supervised contact time were required across the ten-week programme, nor how much of the programme relied on independent home practice. This is a meaningful gap given the paper's stated aim of informing care for recreational athletes, a population for whom access to frequent supervised physiotherapy is often more constrained than for elite athletes with dedicated medical support. Reporting approximate session counts and home-programme frequency would help readers judge the feasibility of adopting a similar approach in comparable settings.

3.4 No follow-up beyond discharge is reported to confirm durability of recovery

The paper's evidence for a "complete" recovery rests entirely on the final assessment made at the point of discharge, with no subsequent contact reported. This is notable because the case itself demonstrates, within its own ten-week course, that this patient's symptoms recurred after only two days of unstructured competitive participation, which the authors reasonably interpret as evidence of ongoing vulnerability when functional readiness is exceeded. Having established this vulnerability once, the manuscript does not report whether a similar pattern did or did not recur once the patient returned to sustained regular play following formal discharge. Reporting any available follow-up information, even an informal check-in at one or three months, or explicitly noting its absence as a specific limitation, would considerably strengthen confidence in the durability of the reported outcome.

Minor Issues

1. The manuscript contains a heading, "Case Report and Discussion," immediately followed by further subheadings with no direct content beneath it, appearing to be a structural or formatting artifact that should be resolved before typesetting.

2. The Abstract reports only baseline, the transient decline, and the final assessment, omitting the pre-event (66.3) and follow-up (62.0) values present in the full Results and Table I; given that the relapse-and-recovery pattern is one of the paper's more instructive features, briefly reflecting the fuller trajectory in the Abstract would better orient readers.

3. Figures 1 through 3 are referenced by caption only, and their content could not be verified against the tabulated data in the version made available for review; this should be confirmed at the editorial stage.

4. The patient's pre-injury sporting exposure, including training and match frequency and playing role (batting, bowling, or fielding), is not described, information that would help readers interpret the very low baseline Sport/Recreation and Physical Activity scores and judge the specificity of the sport-specific training phase.

5. Cryotherapy and structured bed-transfer education are included in the initial phase without a supporting citation for their specific evidence base in groin pain syndrome management; a brief rationale or reference would strengthen this portion of the intervention description.

6. Prior groin, hip, or lumbar injury history, relevant comorbidities, and pain-intensity scores alongside the HAGOS assessments are not reported; each would add useful clinical context and a complementary, more granular signal to the outcome tracking.

7. Neither an ethical approval or exemption statement beyond consent for publication, nor funding and conflict-of-interest disclosures, are visible in the reviewed manuscript; these are standard requirements for most sports medicine and physiotherapy journals and should be confirmed as present in the submission.

8. The internal progression and ordering of exercises within the dynamic neuromuscular control phase is not detailed, and the objective criteria used to determine discharge and full return-to-sport readiness, such as strength symmetry or functional testing, are not described beyond general narrative.

9. Psychosocial and pain-education components, which contemporary groin pain frameworks increasingly regard as relevant to recovery and re-injury risk, are not mentioned; nor is the mode of HAGOS administration (paper, electronic, or interview) specified, nor whether home-exercise technique fidelity, as distinct from adherence frequency, was checked at follow-up.

10. The patient's occupation and daily physical demands are not described, which would help contextualise the Activities of Daily Living trajectory; the "Pre-Event" and "Post-Event" table labels assume familiarity with the narrative described elsewhere in the text; the keyword list could better reflect the study's recreational and sport-specific focus; the incidental cholelithiasis finding would be clearer in a dedicated subsection; and no statement of adherence to a recognised case report reporting framework, such as CARE, is included.

Missing and Inadequately Integrated Literature

Cited but Inadequately Integrated

The manuscript cites Weir et al.'s Doha Agreement to justify its four-category subtype classification but does not engage with the specific clinical entity criteria the Doha group proposed for assigning each subtype, nor with the agreement's broader recommendations regarding standardised examination procedures, engagement that would have allowed the authors to document more precisely which standardised tests were, and were not, performed in this case. Ayhan et al.'s cohort study is cited for its finding that the "combined type" was the most prevalent subtype and for its high nonsurgical resolution rate, but the specific content of that nonsurgical algorithm is not described, limiting readers' ability to judge how conceptually similar it is to the present five-phase programme. Bastia et al.'s systematic review is cited only for a single return-to-play statistic, though it likely also reports information on recurrence and treatment-failure rates relevant to framing prognosis, and on the resource intensity of the conservative protocols it reviewed, both directly relevant to the durability and feasibility concerns raised above. Thorborg et al.'s HAGOS validation paper is cited to establish that the instrument is validated but is not engaged with regarding its intended subscale-level reporting or its responsiveness properties, engagement that would directly support a more defensible treatment of the composite-scoring and clinical-significance concerns raised in this review.

Truly Missing Papers

Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, Krogsgaard K. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999;353(9151):439-443. This trial established the evidence base for active, progressive exercise-based rehabilitation of adductor-related groin pain over passive physiotherapy and is a natural conceptual and dosage-level point of comparison for the present programme.

Whittaker JL, Small C, Maffey L, Emery CA. Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med. 2015;49(12):803-809. This review identifies reduced hip adductor strength and lower sport-specific training levels as evidence-supported risk factors, relevant to situating the injury mechanism and the sport-specific training rationale within the broader risk-factor literature.

Thorborg K, Kraemer O, Madsen AD, Hölmich P. Patient-Reported Outcomes Within the First Year After Hip Arthroscopy and Rehabilitation for Femoroacetabular Impingement and/or Labral Injury: The Difference Between Getting Better and Getting Back to Normal. Am J Sports Med. 2018;46(11):2607-2614. This paper, from the HAGOS development group, addresses minimal important change and normalisation benchmarks directly relevant to substantiating the manuscript's claims of clinically meaningful and complete recovery.

Conclusion and Path Forward

This case report documents a clinically informative recovery trajectory in a population, recreational athletes with groin pain syndrome, that remains underrepresented in the literature, and its use of repeated validated outcome measurement across a full episode of care, including a genuine functional relapse and second recovery phase, gives it real value beyond a simple before-and-after account. The concerns raised across this review are, without exception, addressable without new data collection from the patient: they call for more calibrated diagnostic and causal language, more complete reporting of the intervention's dosage and the outcome assessment schedule, an explicit rationale for the composite outcome metric and its interpretation in light of floor effects and clinically meaningful change benchmarks, and some indication, even informal, of whether the reported recovery held beyond the point of discharge.

Addressed together, these revisions would align the strength of the manuscript's conclusions with what its design can support, while preserving the genuine clinical narrative that makes the case worth reporting. The authors are encouraged to revise the diagnostic and causal framing throughout, to supplement the intervention and assessment descriptions with the operational detail proposed above, and to engage more fully with the cited and missing literature identified in this review, particularly the foundational active-training evidence base and the HAGOS group's own work on clinically meaningful change. With these revisions, this manuscript would represent a valuable and well-supported contribution to the sports physiotherapy literature on recreational-athlete groin pain management.