Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia. 2014;18:815-823. [PMID: 24121840 DOI: 10.1007/s10029-013-1161-0]

Asymmetry of the pelvis in Polish young adults

Introduction

Symmetry is one of the criteria of correct body posture in upright position. The spatial positioning of the pelvic girdle is crucial to it. Functional and structural asymmetries within the lumbo-pelvic-hip complex can have a significant influence on the structure and functions of many human body organs and systems. The aim of the study was to present the results of inclinometer measurements of selected landmarks of the pelvic girdle in young adults aged 19-29.

Methods

The analysis of occurrence of spatial pelvic asymmetry was based on the authors' original, clinical classification and the significance of the body mass and height for the analyzed asymmetries. The inclinometer measurements of the selected landmarks of the pelvic girdle were performed in a sample consisting of 300 young individuals. Then, the occurrences of the spatial asymmetry of the pelvis were analyzed based on the authors' own clinical classification using alignment symmetry of the iliac crests, the anterior superior iliac spines and the trochanters major as a criterion. All study subjects with asymmetry <1 degree were treated as those with a symmetrical pelvis.

Results

The significance of gender, body mass and height for the analyzed asymmetries was assessed. Symmetric positioning of the iliac crests was observed in only 32% of the respondents. The iliac crest depression on the left side was more frequently observed - in 41% of the respondents. This occurred more often in women (44%) than in men (38%). In the group of women, the rotated pelvis was the most often observed (39.4%) asymmetry, while for men, it was the oblique pelvis (40%). More detailed analysis by pelvic asymmetry subtypes showed their statistical differentiation between women and men (p    <     0.0001). Analysis of moderate rotation of the pelvis for men, were reported slightly higher values but these differences were not statistically significant (p = 0.253). Women, in turn, showed slightly higher mean values but here too, the differences were not statistically significant (p = 0.245).

Discussion

Asymmetries in the pelvis area are common; they were observed in less than three-quarters of the examined population. Oblique pelvis was found in less than a quarter of women and in more than one-third men with the predominant structural asymmetries. Rotated pelvis was observed in more than one-third of women and men with dominating functional asymmetries. There were no linear correlations between the body mass and height, and the angle of asymmetries.

A proposed algorithm for the treatment of core muscle injuries

In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption

PURPOSE

To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported.

RESULTS

Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication.

CONCLUSIONS

A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location.

LEVEL OF EVIDENCE

Level V, systematic review of Level I to V studies.

Arthroscopic Correction of Femoroacetabular Impingement for Concomitant Inguinal Disruption in Athletes With Dual Pathology

BACKGROUND

Inguinal disruption and femoroacetabular impingement (FAI) are well-recognized sources of groin pain in athletes; however, the relationship between inguinal disruption and FAI remains unclear. In cases of dual pathology, where both entities coexist, there is no definitive consensus regarding which pathology should be prioritized for treatment in the first instance.

PURPOSE

(1) To examine the 2-year effectiveness and clinical outcome in athletes presenting with dual pathology in which the FAI component alone was treated with arthroscopic deformity correction. (2) To compare 2-year patient-reported outcome measures between athletes undergoing only hip arthroscopy (HA) and athletes undergoing groin repair and HA.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients undergoing HA for the treatment of FAI with concomitant clinical signs of inguinal disruption at initial consultation were between 2010 and 2016 were included in this study. Inclusion criteria were male sex, age <40 years, and involvement in competitive sporting activity. Athletes with previous HA on the symptomatic side, Tönnis grade >1, or lateral center-edge angle <25° were excluded. Revision HA or subsequent groin surgery was documented. Outcome evaluation consisted of validated patient-reported outcome measures (modified Harris Hip Score; University of California, Los Angeles Activity Scale; 36-Item Short Form Health Survey; Western Ontario and McMaster Universities Osteoarthritis Index) completed preoperatively and a minimum 2 years postoperatively. The minimal clinically important difference was assessed by using a distribution-based technique (SD, 0.5) and an anchor-based technique (percentage of possible improvement). Level of satisfaction and return to play were assessed.

RESULTS

A total of 113 cases of dual pathology were included in 91 patients with a mean ± SD age of 26.3 ± 5.1 years. The index surgical procedure was HA for 104 cases (92%) and groin repair for 9 (8%). For patients undergoing HA as the index procedure, 98.1% (102/104 cases) were successfully followed up to establish survivorship. In 89.2% (91/102 cases), no additional groin surgery was required. In 11 cases (10.8%), additional groin surgery was required for persisting inguinal-related groin pain. At 2 years after the operation, there was no difference for any patient-reported outcome measure (P > .099), improvement from baseline (P > .070), or proportion of cases achieving the minimal clinically important difference (P > .120) between the HA-only group and the group undergoing HA and groin repair at any stage. There was also no difference between groups in terms of return-to-play rate (P = .509) or levels of satisfaction (pain, P = .204; performance, P = .345).

CONCLUSION

In patients with dual pathology, treatment of the FAI component alone using arthroscopic hip surgery results in a successful outcome without need for groin repair in 89.2% of cases. No statistical difference in clinical outcome 2 years after surgery was observed between athletes undergoing 1 procedure (HA alone) and those undergoing 2 procedures (HA and groin repair at any stage).

Asymmetry of the pelvic ring evaluated by CT-based 3D statistical modeling

The human pelvis is a complex anatomical structure that consists of the innominate bones, sacrum and coccyx to form the pelvic ring. Even though considered to be a symmetric entity, asymmetry of the pelvic ring (APR) might occur to alter its anatomy, function, or biomechanics or to impact assessment and treatment of clinical cases. APR and its assessment is complicated by the intricate anatomy of the pelvic ring. There is only limited information and understanding about APR with no established evaluation methods existing. The objective of the present study was to adopt CT-based 3D statistical modeling and analysis to assess APR within the complex anatomy of the pelvic ring. We were interested to establish a better understanding of APR with knowledge and applications transferred to human anatomy, related research, and development subjects and to clinical settings. A series of 150 routine, clinical, pelvic CT protocols of European and Asian males and females (64 ± 15 (20-90) years old) were post-processed to compute gender- and ancestry-specific 3D statistical models of the pelvic ring. Evaluations comprised principal component analysis (PCA) that included size, shape, and asymmetry patterns and their variations to be assessed. Four different CT-based 3D statistical models of the entire pelvic ring were computed according to the gender and ancestry specific groups. PCA mainly displayed size and shape variations. Examination of additional PCA modes permitted six distinct asymmetry patterns to be identified. They were located at the sacrum, iliac crest, pelvic brim, pubic symphysis, inferior pubic ramus, and near to the acetabulum. Accordingly, the pelvic ring demonstrated not to be entirely symmetric. Assessment of its asymmetry proved to be a challenging task. Using CT-based 3D statistical modeling and PCA, we identified six distinct APRs that were located at different anatomical regions. These regions are more prone to APRs than other sites. Minor asymmetry patterns have to be distinguished from the distinct APRs. Side differences with regard to size, shape, and/or position require to be taken into account. APRs may be due different load mechanisms applied via spine or lower extremity or locally. There is a need for simpler and efficient, yet reliable methods to be routinely transferred to human anatomy, related research, and development subjects and to clinical settings.

Laparoscopic resection of an exostosis of the os pubis in a horse

OBJECTIVE

To report the diagnostic findings and laparoscopic removal of an exostosis of the os pubis in a horse.

STUDY DESIGN

Case report.

ANIMAL

One 12-year-old Black Forest draught gelding.

METHODS

History included recurrent colic before and during urination and poor performance. Findings at rectal examination included a pointed osseous prominence adjacent to the symphysis of the pecten ossis pubis. Cystoscopy revealed that this prominence caused a protrusion of the bladder wall into the lumen. Standing laparoscopy and laparoscopy under general anesthesia were performed.

RESULTS

After a failed attempt at standing laparoscopy, the horse was anesthetized, and the exostosis of the os pubis was removed laparoscopically without complications. No recurrence of clinical signs associated with the exostosis was detected 12 months postoperatively.

CONCLUSION

Minimally invasive surgical resection of an exostosis of the os pubis was achieved under general anesthesia with appropriately designed instruments. This treatment alleviated symptoms associated with the exostosis, including potential injury of the urinary bladder wall.

Ultrasound-Guided Cutting Wire Release of the Proximal Adductor Longus Tendon: A Feasibility Study

Background:

Adductor longus tendinopathy is a well-known etiology of chronic groin pain in elite athletes. Surgery is indicated for those who fail conservative treatment. No studies to date have evaluated the feasibility of an ultrasound-guided release of the proximal adductor longus tendon.

Purpose/Hypothesis:

The primary aim of this study was to determine the feasibility of an ultrasound-guided selective adductor longus release with a cutting wire. A secondary aim was to determine safety by avoiding injury to adjacent structures. We hypothesized that the proximal adductor longus tendon can be released under ultrasound guidance with a cutting wire without injury to adjacent neurovascular or genitourinary structures.

Study Design:

Descriptive laboratory study.

Methods:

Ten adductor longus tendons (5 cadaveric specimens) from 4 males and 1 female between 76 and 89 years of age with a mean body mass index of 21.9 kg/m² (range, 16.8-29.6 kg/m²) were used during this study. A single experienced physician sonographer performed ultrasound-guided proximal adductor longus tendon releases on all cadaveric specimens using a cutting wire. Dissection was performed by a second physician to determine the completeness of the tendon transections and to detect injury to adjacent neurovascular or genitourinary structures.

Results:

All 10 adductor longus tendons were transected. Eight of 10 transections were complete, whereas in 2 transections, >99% of the tendon was transected. There were no injuries to adjacent genitourinary or neurovascular structures.

Conclusion:

Ultrasound-guided adductor tendon release is feasible and safe in a cadaveric model. Further translational research should be performed to determine whether these results can be replicated in the clinical setting.

Clinical Relevance:

Adductor longus tendinopathy frequently requires surgical intervention and prolonged time away from sport. The present study suggests that a selective adductor longus tendon release can be performed with ultrasound guidance. This procedure warrants further translational research to explore its use in clinical practice.

Effectiveness of Active Rehabilitation Program on Sports Hernia: Randomized Control Trial

Objective

To determine whether an active rehabilitation program that involves repetitive effortful muscle contractions, including core stability, balancing exercises, progressive resistance exercises, and running activities, after a sports hernia, is effective.

Methods

Forty soccer players with sports hernias were randomly divided into two equal groups: group A (active rehabilitation program) and group B (conventional treatment). The methods of assessment included a visual analog scale (VAS) and hip internal and external range of motion assessments. Group A received conventional treatment (heat, massage, transcutaneous electrical nerve stimulation, and mobilization) plus an active rehabilitation program, while group B received only conventional treatment. Three treatment sessions were given each week for 2 months. Evaluations were performed pre- and post-treatment.

Results

A decrease in VAS was seen in both groups at the end of treatment, 80.25% in group A and 41.93% in group B. The difference between the two groups was statistically significant (p=0.0001), whereas there were no statistical differences in internal and external rotation between the groups at the end of treatment (p>0.05). After treatment, an improvement in outcome measures of group A compared to group B (p=0.01) was seen. Thirteen patients in group A and only three patients in group B returned to sports activities without groin pain.

Conclusion

Active rehabilitation was effective for sports hernia management measured by a decrease in pain and the return to sports.

Laparoscopic Approach to Inguinal Disruption in Athletes: a Retrospective 13-Year Analysis of 198 Patients in a Single-Surgeon Setting

Background

Inguinal disruption (ID) is a condition of chronic groin pain affecting mainly athletes. ID cannot be defined as a true hernia. Pathogenesis is multifactorial due to repetitive and excessive forces applied to the inguino-pelvic region. Examination reveals tenderness to palpation of the inguinal region. Differential diagnosis is challenging; imaging is helpful for excluding other pathologies. Surgery is the treatment of choice when conservative treatment fails. Primary aim of the study was to evaluate the time to return to full sport activity after transabdominal preperitoneal patch plasty (TAPP) technique in ID. Secondary aim was to evaluate the postoperative complication rate both in the immediate post-operative time and in 1 year follow-up and to verify the relapse rate after surgery. In this study, we consider time to return to full sport activity as the time needed to return to pre-injury sport activity.

Results

A retrospective study is reported by evaluating 198 cases of ID from a single surgeon experience. All patients failed a previous conservative treatment. All cases were treated with the TAPP approach. Time to return to full sport activity was 4 weeks for 94.4% of patients, with a total of 98.5% of active patients at 9 months. Post-operative inguinal pain was the main complication (9.1%). On 13 years follow-up, we report a recurrence rate of 2.5%.

Conclusions

Current management algorithm for ID, in professional athletes, supports the role of surgery after at least 2 months of conservative treatment. Recently, the role of surgery has been highlighted for a definitive treatment and a faster full recovery to sport activity, especially for elite professional athletes. In our opinion, laparoscopic surgery is the mainstay for non-responsive ID treatment. We present a long-term retrospective evaluation of a wide cohort of professional athletes diagnosed and treated in a systematic way.

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.

Management of a nonathlete with a traumatic groin strain and osteitis pubis using manual therapy and therapeutic exercise: A case report

INTRODUCTION

Without a definitive single pathoanatomical origin for groin pain, management is difficult. The purpose of this case report is to describe the differential diagnosis and management of an individual with a traumatic groin strain. Case Description: A 47-year-old sedentary male truck driver presented to physical therapy with a 2-month history of right medial groin pain. Pushing the gas pedal and sitting were painful activities. Pain was 3-8/10 on the Numeric Pain Rating Scale (NPRS). The patient reported 46/80 on the Lower Extremity Functional Scale. Examination: Tenderness was noted along the adductor longus muscle belly, right pubic ramus and hip range of motion was limited. Special tests directed at the hip and pelvic region indicated intraarticular and pelvic dysfunction. Treatment included hip and pubic symphysis joint mobilizations, lumbopelvic manipulation, adductor longus soft-tissue mobilization, and core strengthening. Outcome: 12 sessions of physical therapy resulted in LEFS to 80/80, Global Rating of Change (GROC) + 7, and NPRS 0/10 at worst. The patient returned to full work without restriction. Discussion: Groin pain has many pathoanatomical drivers. Management of a traumatic groin injury requires a thorough evaluation and a global treatment approach, in order to improve outcomes and reduce the risk of the pathology becoming chronic.

Evaluation of hernia of the male inguinal canal: sonographic method

Sonography of the male inguinal canal for hernia is a common request. There is debate about the accuracy and even need for sonographic assessment of inguinal hernia. A clear, concise method is presented, with correlated diagrams and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.

Athletic pubalgia: Return to play after targeted surgery

BACKGROUND

Surgery for athletic pubalgia usually consists in abdominal wall repair combined with routine bilateral adductor tenotomy. We currently confine the surgical procedure to the injured structure(s) (abdominal wall only, adductor tendon only, or both) to limit morbidity and expedite recovery. Outcomes of this à la carte approach are unclear. The objectives of this retrospective study were to determine the return to play (RTP) time, evaluate the potential influence of injury location, and assess the frequency of recurrence or contralateral involvement.

HYPOTHESIS

À la carte surgery for athletic pubalgia is associated with similar RTP times as the conventional procedure and is not followed by recurrence.

MATERIAL AND METHODS

Consecutive adults younger than 40 years of age who underwent surgery for athletic pubalgia with injury to the abdominal wall and/or adductor attachment sites between 2009 and 2015 were included. Patients with intra-articular hip disorders, isolated pubic symphysis involvement, or herniation were not eligible. The diagnosis was established clinically then confirmed by at least one imaging technique (ultrasonography plus either a radiograph of the pelvis or magnetic resonance imaging of the pelvis). The criterion for performing surgery was failure of appropriate conservative therapy followed for at least 3 months.

RESULTS

Of the 27 included patients, eight had abdominal wall involvement only, seven adductor tendon involvement only, and 12 both. Overall, 25 (92.6%) patients returned to play at their previous level, after a mean of 112±38 days (range, 53-223 days), and experienced no recurrence during the 1-year follow-up. Mean RTP time was significantly shorter in the group with abdominal wall injury only (91.1±21.0 days) compared to the groups with adductor tendon injury only (101.7±42.0 days) or combined injuries (132.5±39.0) (p=0.02).

DISCUSSION

In patients with athletic pubalgia, à la carte surgery confined to the injured structure(s) produces excellent RTP outcomes. RTP time is shortest in patients with isolated lower abdominal wall injuries.

LEVEL OF EVIDENCE

IV, retrospective study with no control group.

Outcomes of surgery on patients with a clinically inapparent inguinal hernia as diagnosed by ultrasonography

BACKGROUND

Chronic post-operative inguinal pain (CPIP) is the most significant complication following inguinal hernia repair. Patients without a palpable hernia prior to surgery seemed to report more CPIP. Our aim was to evaluate the effects of surgery on patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography.

METHODS

A total of 179 hernia repairs in patients with a positive ultrasonography but negative physical examination were analysed retrospectively. Patients with recurrent hernias, femoral hernias or previous surgery to the inguinal canal were excluded. The primary outcome was the presence of chronic postoperative inguinal pain (pain > 3 months postoperatively). Data on preoperative complaints, surgical technique and findings during ultrasonography and surgery were also studied in relation to the development of CPIP.

RESULTS

A quarter (25.1%) of the patients reported chronic postoperative pain. Female gender (p = 0.03), high BMI (p = 0.04) and atypical symptoms prior to surgery (p < 0.001) were significant univariate risk factors for developing CPIP. Logistic regression showed a significant association between atypical symptoms and CPIP [OR = 6.31, p < 0.001, 95% CI (2.32, 17.16)], which was still present after correction for the significant univariate variables [OR = 4.23, p = 0.02, 95% CI (1.26, 14.21)].

CONCLUSION

Patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography report a high incidence of CPIP after elective hernia repair. Patients with atypical groin pain prior to surgery are especially prone to CPIP. It is questionable whether these hernias should be classified and treated as symptomatic inguinal hernias. The results advocate taking other causes of groin pain into consideration before choosing surgical treatment.

Sonographic evaluation of athletic pubalgia

Athletic pubalgia, or "sports hernia", represents a constellation of pathologic conditions occurring at and around the pubic symphysis. These injuries are primarily seen in athletes or those involved in athletic activity. In this article, we review the sonographic appearance of the relevant complex anatomy, scanning technique for ultrasound evaluation of athletic pubalgia, and the sonographic appearances of associated pathologic conditions.

Sportsman's hernia? An ambiguous term

Groin pain is common in athletes. Yet, there is disagreement on aetiology, pathomechanics and terminology. A plethora of terms have been employed to explain inguinal-related groin pain in athletes. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term inguinal disruption based on the pathophysiology while lately the Doha agreement in 2014 defined it as inguinal-related groin pain, a clinically based taxonomy.

This review article emphasizes the anatomy, pathogenesis, standard clinical assessment and imaging, and highlights the treatment options for inguinal disruption.

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.

Sportsman hernia; the review of current diagnosis and treatment modalities

Groin pain is an important clinical entity that may affect a sportsman's active sports life. Sportsman's hernia is a chronic low abdominal and groin pain syndrome. Open and laparoscopic surgical treatment may be chosen in case of conservative treatment failure. Studies on sportsman's hernia, which is a challenging situation in both diagnosis and treatment, are ongoing in many centers. We reviewed the treatment results of 37 patients diagnosed and treated as sportsman's hernia at our hospital between 2011-2014, in light of current literature.

Posterior symphyseal spurs--an unusual differential diagnosis in athletes with groin pain

We set out to highlight the significance of posterior symphyseal spurs as an unusual diagnostic possibility in athletes with chronic groin pain and to demonstrate that operative resection was successful in quickly and safely returning the patients to sporting activities. Five competitive nonprofessional male athletes, three soccer players, and two marathon runners (median age: 30 [26/33] years), who presented to us with significant groin and central pubic pain with duration of at least 12 months, and who had failed conservative or surgical interventions (symphyseal plating), were evaluated. Physical examination as well as pelvic radiographs confirmed the diagnosis of posterior symphyseal spurs. Four out of five athletes underwent complete resection of the spur. Size of spurs was 2.2 (1.3/2.9) cm (median) with four of them posterosuperiorly and one posterocentrally located. All of them had uneventful postoperative recovery period and were still pain-free at the latest follow up after 26.6 months (24/30). Median time-to-return to competitive sports level was 10 weeks (8/13). None of the patients developed pubic instability due to symphyseal spur resection. The results of considerable postoperative improvement in our patients highlight the significance of posterior symphyseal spurs as a diagnostic possibility in athletes with chronic groin pain.

Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes

Background

Groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the efficacy of these treatments is unknown.

Objective

Systematically review the literature on the efficacy of treatments for groin pain in athletes.

Methods

Nine medical databases were searched in May 2014. Inclusion criteria: treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n>10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and two authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Review registration number CRD42014010262.

Results

72 studies were included for quality analysis. Four studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman's hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p<0.001, r=−0.41), but not between study quality and publication year (p=0.09, r=0.20).

Conclusions

Only 6% of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. There is moderate evidence for the efficacy of conservative treatment (active exercises and multimodal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for efficacy of surgical treatment in sportsman's hernia.