Sportsmen hernia: what do we know?

Return to sport after conservative versus surgical treatment for pubalgia in athletes: a systematic review

Background

To assess the time required to return to sport (RTS) after conservative versus surgical treatment in athletes for pubalgia.

Methods

The PRISMA guidelines were followed. Pubmed, SportDiscus and Web of Science were last accessed on September 2022. All the studies investigating the time to RTS after conservative versus surgical treatment in athletes for pubalgia.

Results

In total, 33 studies were selected for full text assessment, and 10 studies were included in the qualitative analysis. Seven studies reported data on conservative management, two on surgical management and one compared both. A total of 468 subjects were included for analysis. 58.7% (275 of 468) were soccer players, 5.9% (28 of 468) runners, and 3.8% (18 of 468) hockey players. Two studies did not specify the type of sport. The quality of the studies detailing the results of conservative management was higher than surgical procedures.

Conclusion

This review highlights that individuals undergoing surgery for pubalgia may return to sport earlier than those receiving conservative treatment. However, conservative management should be considered before surgical treatment is indicated.

High Return to Play Rate and Reduced Career Longevity Following Surgical Management of Athletic Pubalgia in National Basketball Association Players

Purpose

To assess the effects of surgical treatment of athletic pubalgia (AP) on game use and performance metrics in National Basketball Association (NBA) players.

Methods

A retrospective review of all NBA players who underwent surgical management for AP from 1996 to 2018 was performed. A matched control group was created for comparison. The index period was defined as the entire NBA season in which surgery occurred, including the corresponding offseason. Player demographics, use (games played, games started, and minutes per game) and performance (player efficiency rating) metrics were collected for all players. Statistical analysis was performed to compare data before and after return to play.

Results

Thirty players with a history of surgical management for AP were included in the final analysis. Following surgery for AP, NBA players were found to have a return to play (RTP) rate of 90.91% (30/33). The average RTP following surgery was 4.73 ± 2.62 months. Compared with control athletes, athletes in the AP group played significantly fewer seasons postinjury (4.17 ± 2.70 vs 5.49 ± 3.04 seasons, respectively; P = .02). During the first year following RTP, NBA players experienced significant reductions in game use and performance, both when compared with the year prior and matched control athletes (P < .05). At 3-year follow-up, players continued to demonstrate significant reductions in game use (minutes per game, P < .05) but not performance.

Conclusions

Following surgical treatment of AP, NBA players demonstrated a high RTP rate, but shortened career. A short-term reduction in game use and performance metrics was found the year of return following surgery. However, 3-year follow-up performance metrics normalized when compared with healthy controls.

Study Design

Level III; retrospective case-control study.

Totally extraperitoneal repair for the 'sportsman's groin' via 'the Manchester Groin Repair': a comparison of elite versus amateur athletes

BACKGROUND

Surgery has a recognised role in the treatment of 'sportsman's groin'. This study hypothesises that elite athletes have a superior advantage in both pre- and post-op rehabilitation and therefore will present and resume sporting activities quicker.

METHODS

A retrospective analysis on a secure database of athletes presenting with groin pain that underwent surgery for 'inguinal disruption'. All data were explored via appropriate descriptive statistics and comparisons made between elite and amateur athletes.

RESULTS

All patients were male (n = 144). The median age 33 years (range 14-72). The median return to sporting activity was 4.5 weeks (range 2.0-16.0) with one amateur athlete being unable to return to sporting activity. Using the mean of both sides, a comparison of VAS pain scores at pre-operative and 1 month post-operative time points showed a significant reduction (p < 0.001). Comparing 'elite' versus 'amateur' athletes, significant differences were seen in patient age (median 26 vs 40 years; p < 0.001), lead time to clinic presentation (median 62.0 vs 111.5 days; p = 0.004), and time to return to sporting activity (4 vs 5 weeks; p = 0.019). Additional MRI findings within the groin girdle were found in 89 patients (66.4%) and 34 patients (23.6%) had an MRI finding within the adductor tendon.

CONCLUSION

The Manchester Groin Rrepair is an effective surgical management for 'inguinal disruption'. Elite athletes present quicker and return to sport sooner. Given the prevalence of other findings, a multidisciplinary approach to the 'sportsman's groin' is required.

Groin pain in athletes and non-interventional rehabilitative treatment: a systematic review

INTRODUCTION

Groin pain is a common complaint both in high-performance and recreational athletes. Diagnosis is based on the patient's history and physical examination. Imaging assessments are often considered to exclude other pathologies. To date there is no strong evidence to support conservative or surgical treatment options. The purpose of this study is to shed light on the more effective non-interventional rehabilitative treatments for the management of groin pain in athletes and, if possible, provide guidelines useful for clinical practice.

EVIDENCE ACQUISITION

The following electronic databases were searched: PubMed, Physiotherapy Evidence Database (PEDro), Scopus, Web of Science, Google and Google Scholar. Databases were investigated from January 1997 until March 2017.

EVIDENCE SYNTHESIS

The results reported in the randomized clinical trial studies highlight that active treatment is better than passive treatment to improve clinical signs of groin pain. Comparing the active strategy with multi-modal treatment the latter allows a faster return to sport activity. Although the evidence remains poor, all the included literature highlights that an integrated strategy which combines active and passive treatment, the assessment of perceived pain, a return to running program and specific-sport exercises is an effective strategy for management of groin pain in athletes.

CONCLUSIONS

Although we shed some light on common key aspects able to improve the typical signs of groin pain, on the basis of available data we were unable to provide practice guidelines. Further studies are necessary to set the best treatment algorithm for the management of groin pain in athletes.

Fast Early Recovery After Transabdominal Preperitoneal Repair in Athletes with Sportsman's Groin: A Prospective Clinical Cohort Study

BACKGROUND

Current literature on chronic groin pain suggests that laparoscopic mesh repair on athletes enables a faster recovery and subsequent return to unrestricted athletic activities. The aim of this study was to evaluate the role of transabdominal preperitoneal (TAPP) mesh repair in athletes resistant to conservative therapy.

METHODS

A multidisciplinary approach with tailored physiotherapy. Thirty-nine professional athletes with chronic groin pain were referred to surgery at a single clinic. A full assessment was carried out on each, including medical history, physical examination, dynamic ultrasound, and pelvic magnetic resonance imaging. TAPP repair was performed using a polypropylene mesh and fibrin glue fixation on 30 athletes who had exhibited typical symptoms, shown resistance to conservative therapy, not benefited from accompanying physiotherapy, and had ceased training in the 3 to 6 months prior. The outcome measures were early postoperative recovery of 6 weeks and full resumption of athletic activities.

RESULTS

Mean duration of symptoms from onset to surgical repair was 7 months. Conservative treatment had improved symptoms temporarily or to some extent in 7 athletes, while 2 ceased competing altogether. Twenty-three athletes exhibited unilateral and 16 bilateral groin pain. Laparoscopy confirmed posterior wall deficiency in 24 and true inguinal hernia in 6 athletes. Mild scrotal hematoma occurred in 2 athletes postoperatively; all were discharged within 24 hours of surgery. Twenty-one (70%) returned to sports activities after 6 weeks of convalescence. Persistent mild pain was experienced by 5 athletes postoperatively for up to 1 year, yet did not interfere with normal daily activity. Twenty-five participants (85%) reported full satisfaction with the procedure 1 year after treatment; all returned to the same or even higher level of athletic performance.

CONCLUSION

The study confirms that the endoscopic placement of retropubic mesh is an efficient, safe, and minimally invasive treatment that enables fast early recovery.

Intermuscular force transmission along myofascial chains: a systematic review

The present review aims to provide a systematic overview on tensile transmission along myofascial chains based on anatomical dissection studies and in vivo experiments. Evidence for the existence of myofascial chains is growing, and the capability of force transmission via myofascial chains has been hypothesized. However, there is still a lack of evidence concerning the functional significance and capability for force transfer. A systematic literature research was conducted using MEDLINE (Pubmed), ScienceDirect and Google Scholar. Studied myofascial chains encompassed the superficial backline (SBL), the back functional line (BFL) and the front functional line (FFL). Peer-reviewed human dissection studies as well as in vivo experiments reporting intermuscular tension transfer between the constituents of a myofascial chain were included. To assess methodic quality, two independent investigators rated studies by means of validated assessment tools (QUACS and PEDro Scale). The literature research identified 1022 articles. Nine studies (moderate to excellent methodological quality) were included. Concerning the SBL and the BFL, there is moderate evidence for force transfer at all three transitions (based on six studies), and one of two transitions (three studies). One study yields moderate evidence for a slight, but not significant force transfer at one transition in the FFL. The findings of the present study indicate that tension can be transferred between some of the examined adjacent structures. Force transfer might have an impact in overuse conditions as well as on sports performance. However, different methods of force application and measurement hinder the comparability of results. Considering anatomical variations in the degree of continuity and histological differences of the linking structures is crucial for interpretation. Future studies should focus on the in vivo function of myofascial continuity during isolated active or passive tissue tensioning.

Sports hernia and femoroacetabular impingement in athletes: A systematic review

AIM: To investigate the association between sports hernias and femoroacetabular impingement (FAI) in athletes.

METHODS: PubMed, MEDLINE, CINAHL, Embase, Cochrane Controlled Trials Register, and Google Scholar databases were electronically searched for articles relating to sports hernia, athletic pubalgia, groin pain, long-standing adductor-related groin pain, Gilmore groin, adductor pain syndrome, and FAI. The initial search identified 196 studies, of which only articles reporting on the association of sports hernia and FAI or laparoscopic treatment of sports hernia were selected for systematic review. Finally, 24 studies were reviewed to evaluate the prevalence of FAI in cases of sports hernia and examine treatment outcomes and evidence for a common underlying pathogenic mechanism.

RESULTS: FAI has been reported in as few as 12% to as high as 94% of patients with sports hernias, athletic pubalgia or adductor-related groin pain. Cam-type impingement is proposed to lead to increased symphyseal motion with overload on the surrounding extra-articular structures and muscle, which can result in the development of sports hernia and athletic pubalgia. Laparoscopic repair of sports hernias, via either the transabdominal preperitoneal or extraperitoneal approach, has a high success rate and earlier recovery of full sports activity compared to open surgery or conservative treatment. For patients with FAI and sports hernia, the surgical management of both pathologies is more effective than sports pubalgia treatment or hip arthroscopy alone (89% vs 33% of cases). As sports hernias and FAI are typically treated by general and orthopedic surgeons, respectively, a multidisciplinary approach for diagnosis and treatment is recommended for optimal treatment of patients with these injuries.

CONCLUSION: The restriction in range of motion due to FAI likely contributes to sports hernias; therefore, surgical treatment of both pathologies represents an optimal therapy.

Sports hernias: experience in a sports medicine center

PURPOSE

Chronic pain of the inguino-crural region or "pubalgia" explains the 0.5-6.2% of the consultations by athletes. Recently, areas of weakness in the posterior wall called "sports hernias," have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by "pubalgia".

METHODS

1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic "TAPP" repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U Mann-Whitney test for continuous scale variables and the chi-square test for dichotomous variables with p < 0.05 as a level of significance.

RESULTS

In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 "sport hernias" in 769 patients with previous diagnosis of adductor muscle strain (10.92%); on the other hand, in 127 (21.52%) of our patients with "sport hernias" US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42% and a specificity of 100%; the positive and negative predictive values were 100 and 99.4% respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81%); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle.

CONCLUSIONS

Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of "pubalgia". "Sports hernias" are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care.

Radiographic evidence of femoroacetabular impingement in athletes with athletic pubalgia

Background:

Two of the most common causes of groin pain in athletes are femoroacetabular impingement (FAI) and athletic pubalgia. An association between the 2 is apparent, but the prevalence of radiographic signs of FAI in patients undergoing athletic pubalgia surgery remains unknown. The purpose of this study was to determine the prevalence of radiologic signs of FAI in patients with athletic pubalgia.

Hypothesis:

We hypothesized that patients with athletic pubalgia would have a high prevalence of underlying FAI.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

A retrospective review of all patients evaluated at our institution with athletic pubalgia who underwent surgical treatment (ie, for sports hernia) from 1999 to 2011 was performed. The radiographs of patients with athletic pubalgia were reviewed for radiographic signs of FAI. Alpha angles were measured using frog-leg lateral radiographs. Pincer lesions were identified by measuring the lateral center-edge angle and identifying the presence of a “crossover” sign on anteroposterior radiographs. Phone follow-up was performed 2 years or more after the initial sports hernia surgery to evaluate recurrent symptoms.

Results:

Forty-three patients underwent 56 athletic pubalgia surgeries. Radiographic evidence of FAI was identified in at least 1 hip in 37 of 43 patients (86%). Cam lesions were identified in 83.7% of the population; the alpha angle averaged 66.7° ± 17.9° for all hips. Pincer lesions were present in 28% of the hips. Eight patients had recurrent groin pain, 3 patients had revision athletic pubalgia surgery, and 1 had hip arthroscopy.

Conclusion:

The study demonstrates a high prevalence of radiographic FAI in patients with athletic pubalgia.

Clinical Relevance:

Underlying FAI may be a cause of continued groin pain after athletic pubalgia surgery. Patients with athletic pubalgia should be evaluated closely for FAI.

Surgical treatment of chronic groin pain in athletes

PURPOSE

Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities.

METHODS

We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure.

RESULTS

Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three-16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten-15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12-16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity.

CONCLUSION

Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.

Conservative care of sports hernias within soccer players: a case series

OBJECTIVE

To detail the progress of 2 high-level soccer players and 1 recreational soccer player with chronic groin pain that was exacerbated by participation in sports and relieved by rest. The patients under went a conservative treatment plan featuring manual therapy, therapeutic modalities, and plyometric training.

CLINICAL FEATURES

The most important examination findings were palpable tenderness over the internal oblique fascia and anterior pubic tubercle, pain with resisted hip adduction, and pain with a resisted abdominal curl-up. Conventional treatment aimed at decreasing healing time of the injury through manual therapy, including soft tissue and modality techniques; rehabilitative exercises, focusing on the pelvic muscles; and plyometric training, aiming at sport specific functional improvement.

INTERVENTION

The conservative treatment approach utilized in this case series involved manual therapy, 1-2 times a week for 6-8 weeks, consisting of soft tissue, laser, microcurrent, and acupuncture; rehabilitative exercise and plyometric training, 3 times a week for 8 weeks, to help improve strength, coordination, and correct pelvic muscle imbalances. Outcome measures included visual analog scale scores and resisted muscle testing.

SUMMARY

Three soccer players, of varying levels of ability, presenting with a suspected sports hernia (chronic groin pain exacerbated by sports and relieved by rest) were relieved of their pain after 8 weeks of conservative care featuring manual therapy, rehabilitative exercises, and plyometric training.

Toxoplasma gondii infection and abdominal hernia: evidence of a new association

BACKGROUND

We performed a retrospective, observational study in 1156 adult subjects from the general population of Durango City, Mexico, Fifty five subjects with a history of abdominal hernia repair and 1101 subjects without hernia were examined with enzyme-linked immunoassays for the presence of anti-Toxoplasma IgG and IgM antibodies.

RESULTS

The seroprevalence of anti-Toxoplasma IgG antibodies and IgG titers was significantly higher in subjects with abdominal hernia repair than those without hernia. There was a tendency for subjects with hernia repair to have a higher seroprevalence of anti-Toxoplasma IgM antibodies than subjects without hernia. The seroprevalence of anti-Toxoplasma IgG antibodies in subjects with hernia repair was significantly higher in subjects ≥ 50 years old than those < 50 years old. Further analysis in subjects aged ≥ 50 years showed that the seroprevalence of anti-Toxoplasma IgG antibodies was also significantly higher in individuals with hernia repair than those without hernia (OR = 2.72; 95% CI: 1.10-6.57). Matching by age and sex further showed that the seroprevalence of Toxoplasma infection was significantly higher in patients with hernia repair than those without hernia (OR: 4.50; 95% CI: 1.22-17.33).

CONCLUSIONS

Results indicate that infection with Toxoplasma is associated with abdominal hernia. The contributing role of infection with Toxoplasma in abdominal hernia was observed mainly in subjects aged ≥ 50 years old. Our results might have clinical, prevention and treatment implications and warrant for further investigation.

Sports hernia: diagnosis and treatment highlighting a minimal repair surgical technique

Groin injuries are a common occurrence in elite-level athletes. These injuries can cause significant pain and disability, leading to prolonged periods of inactivity and consternation among athletes, coaches, athletic trainers, and physicians alike. The differential diagnosis for groin pain is vast and spans multiple disciplines, including orthopaedics, general surgery, urology, gynecology, and neurology. Sports hernias are one cause of chronic groin pain in athletes and are distinct entities from classic hernias. They are often caused by a deficient posterior wall of the inguinal canal, but may also involve concurrent injuries, such as conjoint and adductor tendinopathies and nerve entrapment. Understanding the complex lower abdominal, pelvic, and hip anatomy and pathophysiology of sports hernias is crucial to making an accurate diagnosis and providing appropriate treatment options. Newer, less invasive surgical repair techniques show promising early results in improving pain and decreasing recovery time.

Re-recognizing the pathogenesis of inguinal hernias

Over the past century, there has been a significant increase in the understanding of groin anatomy as it is related to inguinal hernia. But no one really knows the function of iliopsoas in sealing the inguinal canal and promoting defecation in squatting position. This paper presents the hypothesis that iliopsoas plays an important role in iliopsoas-abdominal reflex by strengthening the groin region, and thus offers a new insight into the study of the pathogenesis of groin hernia and defecation in the aged. This discovery may explain why squatting instead of sitting is better for defecation and urination and why the elderly males are more susceptible to groin hernia. Moreover, the colorectal disease might also benefit from this discovery.