Groin injuries and groin pain in athletes: part 1

Muscle injury characteristics and incidence rates in men's amateur soccer: A one season prospective study

The objectives of the study were to examine the incident rate (IR), characteristics, and mechanisms of muscle injuries of 121 men amateur soccer players that voluntarily participated in this project. Sixty-five muscle injuries with an overall IR of 3.62/1000 h, 95% CI 2.7-4.5, were reported. The most frequently injured muscle groups were the hamstrings (IR 1.78/1000 h, 95% CI 1.1-2.3), followed by the adductors (IR 1.5/1000 h, 95% CI 0.93-2.06). Most muscle injuries were characterized as mild (IR 2.3/1000 h, 95% CI 1.53-2.92) or minimal (IR 1.28/1000 h, 95% CI 1.16-2.39. Higher incidence of injury sustained during matches (IR 14.09 injuries/1000 h, 95% CI 9.49-18.7), than in training (IR 1.88 injuries/1000 h, 95% CI 1.19-2.56). The most frequent injury mechanisms were high-speed running (84.4%) and change of direction (44.4%), for hamstring and adductors-related groin injuries, respectively. Players aged over 24 years had a 7-fold increased risk to sustain a hamstring injury but a lower risk to sustain an adductor-related groin injury. Injury prevention and rehabilitation management strategies may reduce muscle injury rates in amateur soccer.

Effectiveness of a Preventative Program for Groin Pain Syndrome in Elite Youth Soccer Players: A Prospective, Randomized, Controlled, Single-Blind Study

Groin pain syndrome (GPS) is a prevalent issue in soccer. This study assessed the effectiveness of a new preventive protocol on GPS for youth soccer players. The protocol included targeted stretching and strengthening exercises for the adductor and core muscles from preseason to midseason. A questionnaire and two pain provocation tests were used for the evaluation. Mild GPS required positive results in at least two evaluations, while severe GPS was associated with pain incompatible with engagement in any activity confirmed by diagnostic ultrasound. Forty-two elite male athletes (aged 16.9 ± 0.7 years) participated in the study, with half of them assigned to the usual training (control group) and the remaining athletes undergoing the preventive protocol (treatment group) for 24 weeks. GPS rates were 14.3% (three diagnoses: two mild, one severe) in the treatment group and 28.6% (six diagnoses: three mild, three severe) in the control group. Toward the end of the season, three players, one from the treatment group and two from the control group had to stop playing due to severe GPS problems. In addition, one player in the control group stopped midseason. Even though the reduction in the risk of developing GPS was not significant (relative risk of 0.50 ([95%CI 0.14 to 1.74], p = 0.2759), the halved incidence of severe GPS and the increased muscle strength related to the treatment (p = 0.0277) are encouraging data for future studies.

Measuring direct and indirect tendon parameters to characterize the proximal tendinous complex of the rectus femoris in football and futsal players

Objective: To present unprecedented radiological parameters that characterize the angle between the direct and indirect tendons of the proximal rectus femoris (RF) and its inclinations and to evaluate the population variability according to demographic variables. Materials and methods: From September 2019 to July 2021, using MRI multiplanar reconstructions of the proximal thigh/hip, two blinded radiologists measured the direct and indirect tendon angle and the inclination of each tendon in different planes. The intra- and inter-observer agreements were assessed with Bland-Altman analysis and intraclass correlation coefficient (ICC). The correlations between radiological parameters and demographic variables were evaluated using linear regression, Student's t-test, and analysis of variance. Results: We performed 112 thigh/hip MRI scans on 91 football players of different age, gender, and disciplines (football and futsal). For observer 1 (the reference), the mean direct and indirect tendon angle was 56.74° ± 9.37, the mean indirect tendon slope was -7.90° ± 7.49, and the mean direct tendon slope was 22.16° ± 5.88. The three measurements showed inter- and intra-observer agreement (mean differences ∼0). No correlation was observed between age and the parameters. Likewise, no statistically significant differences were found for gender, dominant limb, examined limb, and sport. Conclusion: There is an inter- and intra-observer agreement in the measurements of the direct and indirect tendon angle and the inclination of each tendon. There is population variability in the proximal tendinous complex unrelated to demographic factors. These results allow further detection of morphological patterns that represent a risk factor for lesions in the RF in professional football and futsal players and other sports.

Are sprint accelerations related to groin injuries? A biomechanical analysis of adolescent soccer players

Groin injuries have one of the highest incidences in soccer and can be career threatening, especially for adolescents, due to their high recurrence rate. Quick accelerations have been connected to groin injuries along with kicking and change of directions. Purpose of this study was to examine the hip joint kinematics, kinetics and the muscle forces of adductor longus and gracilis during first ground contact of a linear sprint acceleration performed by adolescent soccer players. Twenty-two male participants were investigated with 3D motion capture and two force plates. Inverse dynamics were used to calculate the kinematics, kinetics and muscle forces. The kinematics show a constant extension during the stance phase and a quick transition from an abduction to an adduction movement at 90% stance, which coincides with the highest forces in adductor longus and gracilis. This indicates a high load on the adductor muscles due to eccentric contractions combined with high muscle forces in the adductors. Compared to previously investigated inside passing and change of direction movements, adductor muscle forces and angular velocities are higher in this study. Therefore, it is suggested that sprint accelerations are likely to be connected to the development of groin injuries in adolescent soccer players.

A newly discovered membrane at the origin of the proximal tendinous complex of the rectus femoris

PURPOSE

The rectus femoris (RF) forms the anterior portion of the quadriceps muscle group. It has a proximal tendinous complex (PTC) which is constituted by a direct tendon (DT), an indirect tendon (IT), and a variable third head. Direct and indirect tendons finally converge into a common tendon (CT). All the PTC shows a medially sloping in its proximal insertion.We investigated several anatomical specimens and discovered a new component: a membrane connecting the CT with the anterior superior iliac spine. Such membrane constitutes a new origin of the PTC. The aim of this study was to clarify whether this membrane was an anatomical variation of the PTC or a constant structure and to describe its morphology and trajectory.

MATERIAL AND METHODS

We dissected 42 cadaveric lower limbs and examined the architecture of the PTC. We paid special attention to the morphology and interaction patterns between the tendons and the membrane.

RESULTS

We demonstrated that the membrane is a constant component of the PTC. It has a lateral to medial trajectory and is in relation to the common tendon, the DT, and IT, which present a medial slope. This suggests that the membrane has an stabilizer role for the PTC, acting as a corrector of the inclined vector of the complex.

CONCLUSION

The RF injuries are frequent in football. The newly discovered membrane is a constant component of the PTC and its integrity should be included in the algorithm to diagnose injuries.

Anatomical variations of the pyramidalis muscle: a systematic review and meta-analysis

PURPOSE

To provide a comprehensive evidence-based assessment of the anatomical characteristics of the pyramidalis muscle (PM).

MATERIALS AND METHODS

A thorough systematic search of the literature through August 31st 2020 was conducted on major electronic databases PubMed, Scopus and Web of Science (WOS) to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaFor package in R and MetaXL. A random-effects model was applied. The primary outcome of interest was the prevalence of PM. The secondary outcomes were the dimensions (length and width) of the PM.

RESULTS

A total of 11 studies (n = 787 patients; 1548 sides) were included in the meta-analysis. The multinomial pooled prevalence estimate (PPE) for a bilateral absence of the PM was 11.3% (95% CI [7.2%, 16.2%], 82.3% (95% CI [76.2%, 87.6%]) for a bilateral presence, and 6.3% (95% CI [3.3%, 10.2%]) for a unilateral presence. Of four studies (n = 37 patients) that reported the side of a unilateral presence, the PPE of a unilateral right-side presence was 42.2% (95% CI [23.0%, 62.3%]) compared to 57.8% for a unilateral left-side presence (95% CI [37.7%, 77.0%]). The mean length of the PM displayed high levels of heterogeneity, ranging from 3.12 to 12.50 cm.

CONCLUSION

The pyramidalis muscle is a rather constant anatomical structure being present in approximately 90% of individuals.

Surgical or conservative treatment in ARGP syndrome? A systematic review

Background and aim of the work: The rectus-adductor syndrome is a common cause of groin pain. In literature the adductor longus is reported as the most frequent site of injury so that the syndrome can be fitted into the adductor related groin pain (ARGP) group. The aim of this study was to define what is the best treatment between surgical and conservative in athletes affected by ARGP in terms of healing and return to play (RTP) time. Methods: A systematic review was performed searching for articles describing studies on RTP time for surgical or conservative interventions for ARGP. A qualitative synthesis was performed. Only 10 out 7607 articles were included in this systematic review. An exploratory meta-analysis was carried out. Due to high heterogeneity of the included studies, raw means of surgery and conservative treatment groups were pooled separately. A random effects model was used. Results: The results showed quicker RTP time for surgery when pooled raw means were compared to conservative treatments: 11,23 weeks (CI 95%, 8.18,14.28, p<0.0001, I^2=99%) vs 14,9 weeks (CI 95%, 13.05,16.76, p<0.0001, I^2 = 77%). The pooled results showed high statistical heterogeneity (I^2), especially in the surgical group. Conclusions: Surgical interventions are associated with quicker RTP time in athletes affected by ARGP, but due to the high heterogeneity of the available studies and the lack of dedicated RCTs this topic needs to be investigated with dedicated high quality RCT studies. (www.actabiomedica.it)

Neuropathic painful complications due to endopelvic nerve lesions after robot-assisted laparoscopic prostatectomy: Three case reports

RATIONALE

Robot-assisted laparoscopic prostatectomy (RALP) is the most frequent strategy used for the surgical remedy of patients with localized prostate cancer. Although there is awareness about potential patient positioning nerve injuries, iatrogenic nerve lesions are less described in the literature. Here, we report 3 cases of patients who presented with neuropathic painful complications due to RALP-associated nerve lesions.

PATIENT CONCERNS

A 62-year-old patient (case 1), a 72-year-old male (case 2), and a 57-year-old patient (case 3) presented at the clinic with symptoms of neuropathic pain after RALP surgery.

DIAGNOSIS

Patients were diagnosed with a potential injury of different branches of the pudendal nerve (cases 1 and 2), and left obturator nerve (case 3).

INTERVENTIONS

Patients underwent multimodal pharmacologic treatment through pregabalin, weak opioids, strong opioid, paracetamol, and adjuvants. In cases 2 and 3, a multidisciplinary approach was needed. As the patients responded to conservative treatment, invasive approaches were not necessary.

OUTCOMES

After treatment, the patients of case 1 showed pain relief after 4 days, paresthesia resolved in 15 days, whereas the anal crushing sensation lasted for approximately 1 month. In case 2, after 4 weeks of treatment, the patient experienced a considerable decrement in pain intensity with complete response after 4 months. In case 3, pain relief was achieved after 2 days, motor symptoms recovery after 2 weeks, and neuropathic features resolved completely after 5 weeks although the obturator sign resolved within 2 months.

LESSONS

The RALP-associated neurologic injuries may occur even when performed by highly experienced surgeons. A better understanding of the potential iatrogenic nerve lesions can surely allow an improvement in the surgical technique. A multidisciplinary approach and early multimodal pain strategy are mandatory for managing these complications.

Inter- and Intraobserver reproducibility of T2 relaxation times of the discus interpubicus: A feasibility study at 3 Tesla

Objective

To quantify standard values of the discus interpubicus in healthy subjects and to determine reliability and repeatability using T2 relaxation time measurements at 3T.

Methods

20 asymptomatic participants (10 male, 10 female; mean age: 27.3 years ±4.1, BMI: 22.2 ±1.8) underwent a 3T Magnetic Resonance Imaging (MRI) of the pelvic region in a supine position. We included sagittal and para-axial T2w sequences centred over the pubic symphysis in order to identify the complete discus interpubicus. For quantitative analysis, a multi-echo Turbo Spin Echo (TSE) sequence (including 12 echo times between 6.4 and 76.8 ms) was acquired and analysed by using an in-house developed quantification plugin tool (qMapIt) extending ImageJ. Two readers in consensus defined three central slices of the pubic symphysis with the greatest length. For each slice, both readers separately placed three regions-of-interest (ROI) covering the whole discus interpubicus. Both readers repeated the ROI placements in identical fashion after a four-week interval on the original MRI images. Statistical analysis included intraclass correlation coefficient (ICC), nonparametric Wilcoxon test, Fisher exact test and mean relaxation time in ms and 95% confidence intervals.

Results

T2 relaxation time analysis was performed for all 20 participants. In total, a mean relaxation time of all analysed segments for both observers was 48.6 (±6.3 ms), with a mean relaxation time for observer 1 of 48.7 (±6.0 ms) and for observer 2 of 48.5 ms (±6.6ms). The calculated ICC comparing inter- and intrarater reproducibility was excellent in all segments (≥0.75).

Conclusion

T2 mapping of the discus interpubicus demonstrates good inter- and intrarater repeatability as well as reliability. Mean relaxation times were calculated with 48.6ms in healthy volunteers.

Twenty-Year Systematic Review of the Hip Pathology, Risk Factors, Treatment, and Clinical Outcomes in Artistic Athletes-Dancers, Figure Skaters, and Gymnasts

OBJECTIVE

To identify (1) the predominant level of evidence of the clinical studies regarding the hip pathology, risk factors, treatment, and clinical outcomes in artistic athletes (dancers, figure skaters, and gymnasts) (2) the most commonly reported hip pathology, risk factors, treatments, and clinical outcomes in dancers, figure skaters, and gymnasts.

METHODS

To conduct this systematic review PubMed, EMBASE, and Scopus databases were searched for relevant studies and pertinent data were collected from the eligible articles. Included were studies which reported hip injuries in artistic athletes, the risk factors, treatment, and/or the clinical outcomes. We excluded case reports or irrelevant studies. No meta-analysis was performed because of study heterogeneity. The methodical index for nonrandomized studies (MINORS) criteria were used for quality control.

MAIN RESULTS

Thirty-eight studies were included in the analysis. The mean MINORS score was 13.6 ± 4.6 points indicating fair quality of evidence of the included articles. The predominant level of evidence was level IV. Chondrolabral pathology and muscle injuries were the most commonly reported pathologies. We found only 2 risk factor analysis studies; however, many studies reported risk correlation between artistic sports or imaging findings and hip pathology. Treatment strategies were reported in only 7 studies, clinical outcomes are significantly underreported.

CONCLUSION

Chondrolabral pathology was the most commonly reported hip pathology in artistic athletes, however, prospective cohort studies are necessary to really understand these injuries and their associated risk factors. The lack of clinical outcomes is significant and future data collection is required to assess the effectiveness of the various treatments.

Osteitis pubis in professional football players: MRI findings and correlation with clinical outcome

BACKGROUND AND PURPOSE

Osteitis pubis (OP), a common pathology in elite athletes, is an aseptic inflammatory process of the pubic symphysis bone, and may involve surrounding soft tissues, tendons and muscles. OP is typically characterized by (often recurring) groin pain and is an important cause of time-off from sports activity in athletes. Aim of this retrospective study was to analyze magnetic resonance imaging (MRI) findings in professional football players with clinical diagnosis of OP and to correlate MRI findings with clinical outcome.

MATERIAL AND METHODS

All professional football players (23 males, 1 female; mean age: 21±3.7years; range: 16-30 years) with groin pain and clinical diagnosis of OP, who underwent pelvic MRI in our institution were retrospectively analyzed. The MR images were analyzed regarding the presence of bone marrow edema and its extension, whether fluid in the symphysis pubis or periarticular soft tissue edema with a rim-like periosteal distribution or edema in the muscles located around the symphyseal joint were present, whether degenerative changes of the symphysis pubis and of signs of symphyseal instability were encountered. A quantitative measurement of the signal intensity in bone marrow edema on 3T STIR sequences was performed, normalizing these values to the mean signal intensity values in the ipsilateral iliopsoas muscle. All patients were classified according to a 3-point grading scale. For each patient, both the symptoms 18 months after the initial MRI examination, the duration of time off from playing football and the kind of treatment applied were evaluated.

RESULTS

Among all professional athletes, in 20/24 (83.3%) MRI showed signs of OP with bone marrow edema at the pubic bone. 12 of these patients showed complete clinical recovery without any symptoms after 18 months, while in 8 patients partial recovery with persistence of groin pain during higher sports activity was observed. Patients with edema in periarticular soft tissues or in the muscles around the symphyseal joint on MRI at the beginning of symptoms presented significantly more often with a partial recovery after returning to high sports activity (p=0.042 and p=0.036, respectively). A partial recovery was also significantly associated with higher normalized mean signal intensity values in bone marrow edema on STIR sequences at the beginning of symptoms (mean=4.77±1.63 in the group with partial recovery vs. mean=2.86±0.45 in the group with complete recovery; p=0.0019). No significant association was noticed between MRI findings and time of abstinence from high sports activity, as well as between the 3-point grading scale and the time off from high sport activity and recovery at 18 months.

CONCLUSIONS

Edema in periarticular soft tissues, edema with extension to the muscles located around the symphyseal joint, as well as higher normalized signal intensity values in bone marrow edema on STIR sequences in the pubic bones at the beginning of groin pain are the most reliable MRI findings of a poor clinical long-term outcome of OP in professional football players and should be regarded as negative prognostic factors.

Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features

CONTEXT

Evaluation of groin pain in athletes may be challenging as pain is typically poorly localized and the pubic symphyseal region comprises closely approximated tendons and muscles. As such, magnetic resonance imaging (MRI) and ultrasound (US) may help determine the etiology of groin pain.

EVIDENCE ACQUISITION

A PubMed search was performed using the following search terms: ultrasound, magnetic resonance imaging, sports hernia, athletic pubalgia, and groin pain. Date restrictions were not placed on the literature search.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

MRI is sensitive in diagnosing pathology in groin pain. Not only can MRI be used to image rectus abdominis/adductor longus aponeurosis and pubic bone pathology, but it can also evaluate other pathology within the hip and pelvis. MRI is especially helpful when groin pain is poorly localized. Real-time capability makes ultrasound useful in evaluating the pubic symphyseal region, as it can be used for evaluation and treatment.

CONCLUSION

MRI and US are valuable in diagnosing pathology in athletes with groin pain, with the added utility of treatment using US-guided intervention. Strength-of Recommendation Taxonomy: C.

Current concepts of inguinal-related and adductor-related groin pain

Groin pain encompasses a number of conditions from the lower abdomen, inguinal region, proximal adductors, hip joint, upper anterior thigh and perineum. The complexity of the anatomy, the heterogeneous terminology and the overlapping symptoms of different conditions that may co-exist epitomise the challenges in diagnosis and treatment. Inguinal-related and adductor-related pain is the most common cause of groin pain and will be discussed in this article.

Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment

Introduction

Athletic groin pain requiring surgery remains a diagnostic and therapeutic challenge. This systematic review aims to identify the most common causes of groin pain in athletes requiring surgery. Additionally, it aims to further characterise their susceptible athlete profiles, common physical examination and imaging techniques, and surgical procedures performed. This will enable the orthopaedic sports medicine clinician/surgeon to best treat these patients.

Materials and methods

The electronic databases MEDLINE, PubMed and EMBASE were searched from database inception to 13 August 2014 for studies in the English language that addressed athletic groin pain necessitating surgery. The search was updated on 4 August 2015 to find any articles published after the original search. The studies were systematically screened and data were abstracted in duplicate, with descriptive data presented.

Results

A total of 73 articles were included within our study, with data from 4655 patients abstracted. Overall, intra-articular and extra-articular causes of groin pain in athletes requiring surgery were equal. The top five causes for pain were: femoroacetabular impingement (FAI) (32%), athletic pubalgia (24%), adductor-related pathology (12%), inguinal pathology (10%) and labral pathology (5%), with 35% of this labral pathology specifically attributed to FAI.

Conclusions

Given the complex anatomy, equal intra-articular and extra-articular contribution, and potential for overlap of clinical entities causing groin pain leading to surgery in athletes, further studies are required to ascertain the finer details regarding specific exam manoeuvres, imaging views and surgical outcomes to best treat this patient population.

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.

Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes

Background

Sport-related pubalgia is often a diagnostic challenge in elite athletes. While scientific attention has focused on adults, there is little data on adolescents. Cadaveric and imaging studies identify a secondary ossification centre located along the anteromedial corner of pubis beneath the insertions of symphysial joint capsule and adductor longus tendon. Little is known about this apophysis and its response to chronic stress.

Aim

We report pubic apophysitis as a clinically relevant entity in adolescent athletes.

Methods

The clinical and imaging findings in 26 highly trained adolescent football players (15.6 years±1.3) who complained of adductor-related groin pain were reviewed. The imaging features (X-ray 26/26, US 9/26, MRI 11/26, CT 7/26) of the pubic apophyses in this symptomatic group were compared against those of a comparison group of 31 male patients (age range 9–30 years) with no known history of groin pain or pelvic trauma, who underwent pelvic CT scans for unrelated medical reasons.

Results

All symptomatic subjects presented with similar history and physical findings. The CT scans of these patients demonstrated open pubic apophyses with stress-related physeal changes (widening, asymmetry and small rounded cyst-like expansions) that were not observed in the comparison group. No comparison subject demonstrated apophyseal maturity before 21 years of age, and immaturity was seen up to the age of 26 years.

Conclusions

This retrospective case series identifies pubic apophyseal stress (or ‘apophysitis’) as an important differential consideration in the adolescent athlete who presents with groin pain.

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.

Relation between performance in side bridge and injuries in amateur soccer

AbstractIntroduction Central instability is associated with insufficient endurance and strength of the stabilizer muscles, and it can lead to muscle imbalance and injuries.Objective Relate side bridge performance with the presence of injuries in amateur soccer athletes.Materials and methods A cross-sectional study with a sample of 188 male athletes, aged between 11 and 17 years. To identify the injuries, a questionnaire developed by researchers was applied and the players’ clinical records were reviewed. The time of the side bridge test was used to identify muscle imbalance. For statistical analysis, the following tests were used: chi-square test; Pearson’s chi-square test; Fisher’s exact test; Yates’s correction for continuity; two-way ANOVA; one-way ANOVA; and t-test. The significance level (α) of 5% was adopted.Results Injuries were reported by 59.6% of the athletes: sprain (31.3%); muscle strain (28.6%) and fracture; luxation and subluxation (19.6%) were the most frequently reported injuries. Athletes that reported any injury corresponded to 73.2% of the sample. The presence of injuries was not associated with muscle imbalance (p = 0.565), as it prevailed in athletes with both balance (64%) and imbalance (58%). Injury type and prevalence were not significant when compared with the presence of imbalance (p > 0.05).Final considerations No significant relation between muscle imbalance and injury was observed in the studied sample.

Groin pain in athletes: a novel diagnostic approach

Groin pain in a performing athlete can be very challenging to diagnose and treat. The differential diagnosis includes intra-articular causes, extra-articular causes and non-musculoskeletal causes. A detailed clinical and radiological assessment of groin pain in this group is critical and can identify the underlying pathology. Diagnostic hip block is a valuable tool to differentiate intra-articular causes from extra-articular causes. Hip arthroscopy can help in identifying some of the elusive intra-articular conditions, which were once undiagnosed and therefore, left untreated, resulting in premature ending of competitive careers. This article attempts to explore current thinking on evaluation of groin pain, particularly in young individuals, and to establish a simple protocol for a clinical and diagnostic approach to this difficult problem.

Sonography of sports injuries of the hip

CONTEXT

Sports-related injuries of the hip are a common complaint of both competitive and recreational athletes of all ages. The anatomic and biomechanical complexity of the hip region often cause diagnostic uncertainty for the clinicians evaluating these injuries. Therefore, obtaining additional diagnostic information is often crucial for providing injured athletes with a prompt and accurate diagnosis so they can return to activity as soon as possible. Musculoskeletal ultrasound is becoming increasingly important in evaluating and treating sports-related injuries of the hip.

EVIDENCE ACQUISITION

The PubMed database was searched in May of 2013 for English-language articles pertaining to sonography of sports injuries of the hip using the following keywords in various combinations: musculoskeletal, ultrasound, hip, hip sonography, and sports.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Musculoskeletal ultrasound is currently being used for both diagnosis and treatment in a wide range of acute and chronic conditions affecting the hip, including tendinosis, tendon/muscle strains, ligamentous sprains, enthesopathies, growth plate injuries, fractures, bursitis, effusions, synovitis, labral tears, and snapping hip. Therapeutically, it is used to guide injections, aspirations, and biopsies.

CONCLUSION

Musculoskeletal ultrasound use is expanding and will likely continue to do so as more clinicians realize its capabilities. Characteristics, including accessibility, portability, noninvasiveness, dynamic examination, power Doppler examination, and low cost highlight the potential of ultrasound.

Review of sport-induced groin injuries

CONTEXT

Groin injuries are among the most common injuries co-existing with sports. The aim of this review was to outline the epidemiology and identify risk factors, as well as examine preventative and interventional measures for reducing the occurrence of this form of injury among athletes.

EVIDENCE ACQUISITION

An electronic, systematic search for relevant keywords, either separately or in combination was sought in the academic scientific databases.

RESULTS

Groin injuries, acute or chronic, consist of a high percentage of injuries that manifest with pain. Despite the specific tendency for injury among some sports, such injuries make up 2-5% of sport-induced injuries. There are few available reports on lower limb injuries, especially groin injuries, in Iran. Numerous factors predispose to groin injuries. A lengthy list of preventive/ treatment measures, from preliminary to sophisticated, have been proposed.

CONCLUSIONS

Although using a programmed strategy designed to decrease the risk of groin injuries by taking a strategic approach to exercise may alleviate complications, in some cases the chronic nature of the injury may threaten the professional life of the athlete. More research is required to plan suitable programs for reducing the risk of this type of injury in athletes.

Emerging intra-articular causes of groin pain in athletes

Groin pain remains one of the most poorly understood conditions in clinical sports medicine. It may be caused by either extra-articular or intra-articular conditions. While extra-articular causes have been extensively studied and reasonably understood, a number of elusive intra-articular causes are emerging, many of which were previously unknown and therefore undiagnosed, leading to premature ending of many competitive careers. This article makes an attempt to look at various, elusive intra-articular causes of groin pain in athletes. This article also analyses the currently available evidence on trends in diagnosis and treatment for these conditions.

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.

The relationship between pre-season fitness testing and injury in elite junior Australian football players

OBJECTIVES

Australian Football (AF) is a collision sport containing high injury rates in junior competition. Successful performance at the elite junior level not only requires superior specific football knowledge and skills, but also well developed fitness qualities. However, no studies have examined the link between physical fitness qualities and injury in AF.

DESIGN

Prospective cohort.

METHODS

Injury data were collected through the use of a Player Movement Record (PMR) and a standardized Injury Report Form (IRF). Fitness test data was collected during the pre-season of the 2010 and 2011 seasons.

RESULTS

382 players consented to participate in the study. The cohort experienced an injury incidence rate of 24.29/standardized club (40 players/club). A faster 5-m sprint was associated with 'injury status' (p=0.016) and a 'knee' region (p≤0.001) injury. A faster planned agility score was associated with an increased risk of a 'hip/groin/thigh' region (p=0.010) injury, and specifically a 'quadriceps strain' (p=0.005). A lower 20-m shuttle run was associated with an increased risk of a 'shin/ankle/foot' (p=0.045) injury. Increased injury severity was associated with a higher left foot running vertical jump (VJ) (p=0.040), and faster 5-m sprint (p=0.043).

CONCLUSIONS

Lower aerobic endurance, faster 5-m acceleration and greater planned agility were associated with an increased risk of various injury types in elite junior AF players. Furthermore, a higher left foot running VJ and faster 5-m acceleration were associated with injury severity. These results may largely relate to a greater work capacity placing a higher load upon the musculoskeletal system in contact and non-contact situations.

Athletes Hernia—A True, Early Direct Inguinal Hernia: Diagnosis, Pathophysiology, and Surgical Treatment

Athlete's hernia (AH) is an activity limiting condition that presents as chronic inguinal pain in elite athletes. The diagnosis involves a thorough history and physical examination and can be aided by ultrasound interrogation of the groin. Operative treatment with a direct tissue repair of the inguinal floor successfully alleviates symptoms and allows for full return to activity. A retrospective analysis of patients with the diagnosis of AH from January 1998 to May 2010 who underwent operative repair was reviewed. Patients were evaluated based on age, gender, sport, time to presentation, subjective and objective physical findings, imaging findings, operative findings, length of follow-up, and return to activity. Ninety-six patients (6 females) with a median age of 22.6 years were evaluated. In the majority of these patients, operative exploration revealed a wide external ring with separation of the fibers of the external oblique aponeurosis and an unprotected and bulging transverses abdominis aponeurosis, very akin to an early direct inguinal hernia. The mean initial follow-up time was 6 weeks at which point all but two of the patients were able to resume their full level of activity without restrictions. The diagnosis of AH, although somewhat elusive, can be easily established with a high degree of suspicion after doing a thorough history and physical exam augmented with ultrasonography. AH is equivalent to an early direct inguinal hernia found in young athletes and can be surgically corrected allowing return to full activity.

Review of MRI technique and imaging findings in athletic pubalgia and the "sports hernia"

The clinical syndrome of athletic pubalgia has prematurely ended many promising athletic careers, has made many active, fitness conscious adults more sedentary, and has served as a diagnostic and therapeutic conundrum for innumerable trainers and physicians worldwide for decades. This diagnosis actually arises from one or more lesions within a spectrum of musculoskeletal and visceral injuries. In recent years, MRI has helped define many of these syndromes, and has proven to be both sensitive and specific for numerous potential causes of athletic pubalgia. This text will provide a comprehensive, up to date review of expected and sometimes unexpected MRI findings in the setting of athletic pubalgia, and will delineate an imaging algorithm and MRI protocol to help guide radiologists and other clinicians dealing with refractory, activity related groin pain in an otherwise young, healthy patient. There is still more to be learned about prevention and treatment plans for athletic pubalgia lesions, but accurate diagnosis should be much less nebulous and difficult with the use of MRI as a primary imaging modality.

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.

[Imaging features of pubalgia]

Pubalgia is a generic term used to describe groin pain due to a multitude of different etiologies such as skeletal (microtraumatic pubic symphysis arthropathy), muscular (adductor or rectus abdominis disorders), or abdominal wall (inguinal hernia) disorders. Diagnosis relies mainly on MRI for musculoskeletal disorders and ultrasound for abdominal wall disorders.

Intrinsic risk factors for groin injuries among male soccer players: a prospective cohort study

BACKGROUND

This study was conducted to determine if risk factors for groin injuries among male soccer players could be identified.

HYPOTHESIS

Previous groin injuries, reduced function scores, age, findings on clinical examination, and low isometric groin strength are associated with increased risk of new groin injuries.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 508 players representing 31 amateur teams were tested during the 2004 preseason for potential risk factors for groin injury through a questionnaire on previous injury and function score (Groin Outcome Score [GrOS]) and a clinical examination of the groin. Generalized estimating equations were used in univariate analyses to identify candidate risk factors, and factors with a P value <.10 were then examined in a multivariate model.

RESULTS

During the soccer season, 61 groin injuries affecting 55 legs (51 players) were registered. The total incidence of groin injuries was 0.6 injuries per 1000 playing hours (95% confidence interval [CI], 0.4-0.7), 0.3 injuries per 1000 training hours (95% CI, 0.2-0.4), and 1.8 injuries per 1000 match hours (95% CI, 1.2-2.5). In a multivariate analysis, previous acute groin injury (adjusted odds ratio [OR], 2.60; 95% CI, 1.10-6.11) and weak adductor muscles as determined clinically (adjusted OR, 4.28; 95% CI, 1.31-14.0) were significantly associated with increased risk of groin injuries. A multivariate analysis based only on acute time-loss injuries revealed the 40-m sprint test result (adjusted OR, 2.03 for 1 standard deviation change [injured group faster]; 95% CI, 1.06-3.88; P = .03) and functional testing of the rectal abdominal muscles (adjusted OR, 15.5 [painful in 19% of the players in the injured group compared to 16% in the uninjured group]; 95% CI, 1.11-217; P = .04) as significant risk factors.

CONCLUSION

A history of acute groin injury and weak adductor muscles are significant risk factors for new groin injuries.

Ultrasonography of the hip and lower extremity

Musculoskeletal ultrasonographic evaluation of the proximal lower limb includes the evaluation of the soft tissue structures, including tendons, ligaments, or muscles, and the bony structures of this region, include the hip, pubic symphysis, and sacroiliac joints. The evaluation of the hip or proximal lower limb region can be performed in an efficient and systematic manner. Ultrasonography of the lateral hip, intra-articular hip, medial thigh, and posterior thigh are discussed in the article.

Sportsmen hernia: what do we know?

Athletes and other physically active people often suffer prolonged inguinal pain, which can become a serious debilitating condition and may place an athlete's career at risk. A sportsmen hernia is a controversial cause of this chronic groin pain, as it is difficult to be defined. From an anatomical point of view, the definition and the name of this entity should be reviewed. In the majority of athletic manoeuvres, a tremendous amount of torque or twisting occurs in the mid-portion of the body and the front, or anterior portion, of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. These opposing forces cause a disruption of the muscle/tendon at their insertion site on the pubis, so the problem could be related to the fact that the forces are excessive and imbalanced, and a weak area at the groin could be increased due to the forces produced by the muscles. The forces produced by these muscles may be imbalanced and could produce a disruption of the muscle/tendon at their insertion site on the pubis or/and a weak area may be increased due to the forces produced by the muscles, and just this last possibility could be defined as "sportsmen hernia." In conclusion, this global entity could be considered to be an imbalance of the muscles (abductor and abdominal) at the pubis, that leads to an increase of the weakness of the posterior wall of the groin and produces a tendon enthesitis, once a true origin is not detected, that may lead to a degenerative arthropathy of the pubic symphysis in the advanced stages. Based on this, this entity could be re-named as "syndrome of muscle imbalance of the groin" and the sportsmen hernia could be considered as an entity included in this syndrome. It is recommended that a multidisciplinary approach is given to this entity, since the present literature does not supply the proper diagnostic studies and the correct treatment which should be performed in these patients.

Imaging of groin pain

Groin pain is a commonly encountered problem in musculoskeletal radiology. The diagnosis can be difficult to establish, based on the complex interconnected anatomy at the pubic symphysis and surrounding structures. The differential diagnosis is therefore broad, and diagnostic imaging is crucial in reaching the correct diagnosis, thus allowing appropriate therapy to be instituted. This article reviews the relevant anatomy and differential diagnoses encountered in overuse injuries of the groin. The common mechanisms of injury, presenting symptoms, and imaging findings for each diagnosis are addressed.

Athletic pubalgia and "sports hernia": optimal MR imaging technique and findings

Groin injuries are common in athletes who participate in sports that require twisting at the waist, sudden and sharp changes in direction, and side-to-side ambulation. Such injuries frequently lead to debilitating pain and lost playing time, and they may be difficult to diagnose. Diagnostic confusion often arises from the complex anatomy and biomechanics of the pubic symphysis region, the large number of potential sources of groin pain, and the similarity of symptoms in athletes with different types or sites of injury. Many athletes with a diagnosis of "sports hernia" or "athletic pubalgia" have a spectrum of related pathologic conditions resulting from musculotendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of athletic pubalgia are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification. However, a large-field-of-view magnetic resonance (MR) imaging survey of the pelvis, combined with high-resolution MR imaging of the pubic symphysis, is an excellent means of assessing various causes of athletic pubalgia, providing information about the location of injury, and delineating the severity of disease. Familiarity with the pubic anatomy and with MR imaging findings in athletic pubalgia and in other confounding causes of groin pain allows accurate imaging-based diagnoses and helps in planning treatment that targets specific pathologic conditions.

Sports hernias

Sportsman's hernia is an increasingly recognized cause of chronic groin pain in athletes. Although the definition is controversial, it is a condition of chronic inguinal/pubic exertional pain caused by rectus abdominal wall weakness or injury without a palpable hernia, usually affecting high-performance male athletes. Diagnosis is made after careful history and physical examination. Some radiographic studies such as ultrasound or MRI may be helpful in evaluating these patients and ruling out other pathology, although no radiographic study can rule out sportsman's hernias. Because sports hernias are not true hernias but an injury in the rectus insertion, unilateral or bilateral rectus reattachment is the most appropriate surgical treatment. This reattachment may be done in combination with adductor release in the setting of adductor pain or weakness on physical examination. Other surgical repairs (eg, Lichtenstein, Shouldice, Kugel, laparoscopic) do not stabilize the pelvis and tend not to be as successful. In the motivated patient, after surgical repair and physical rehabilitation, 95% are free of pain and able to return to competitive sports.

Analysis of the cross-sectional area of the adductor longus tendon: a descriptive anatomic study

BACKGROUND

Strain injury to the adductor longus muscle is a common cause of groin pain in athletes and generally occurs in the proximal portion of the muscle, near its origin from the anterior aspect of the pubis. The composition and cross-sectional anatomy of this muscle's origin has not been previously described.

HYPOTHESIS

We hypothesize that the adductor longus muscle origin is composed mainly of muscle fibers and that the tendon composes only a small part of the cross section at the origin of the muscle.

STUDY DESIGN

Descriptive laboratory study.

METHODS

We harvested 42 adductor longus muscles from 28 cadavers and measured the cross-sectional dimensions of the tendon with microcalipers. Next, we determined the relative contributions of the tendon and muscle fibers to the cross-sectional anatomy of the muscle using optical scanning. These 2 sets of measurements were obtained at 3 locations: at the muscle origin and 1.0 and 2.0 cm distal to the origin.

RESULTS

The average length and width of the tendon was 11.6 and 3.7 mm, respectively, at the origin. The average cross-sectional areas of the tendon were 49.3, 27.9, and 25.7 mm(2) at points 0.0, 1.0, and 2.0 cm from its origin, respectively. The origin of the adductor longus muscle was composed of 37.9% tendon and 62.1% muscle tissue. At 1.0 cm from the origin, the percentage of tendon decreased to 34%. At 2.0 cm from the origin, the tendon composed 26.7% of the cross section.

CONCLUSION

The cross-sectional area of the tendon of the adductor longus muscle is relatively small. The muscle origin is composed predominantly of direct attachment of muscle fibers.

CLINICAL RELEVANCE

Knowledge of the cross-sectional anatomy of the adductor longus muscle at its origin may help clinicians better understand the complex nature of injuries in this area.

Patterns of Bone and Soft-Tissue Injury at the Symphysis Pubis in Soccer Players: Observations at MRI

OBJECTIVE

The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other.

MATERIALS AND METHODS

One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test.

RESULTS

Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p < 0.001); it correlated with the side of symptoms in all cases. Bone edema was identified in 91 of 100 patients: 49 had focal edema at the attachment site of the adductor tendons accompanying an adductor microtear, two patients had focal edema without an adductor tear, and 40 patients had diffuse edema in the pubic bones secondary to osteitis pubis. There was no evidence of either adductor dysfunction or symphyseal inflammation in the control subjects (p < 0.001).

CONCLUSION

In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.

Groin pain in athletes

Groin pain is a common and often frustrating problem in athletes who engage in sports involving kicking, rapid accelerations and decelerations, and sudden direction changes. The most common problems are adductor strain, osteitis pubis, and sports hernia. Other causes must be considered, including nerve pain, stress fractures, and intrinsic hip pathology. There is significant overlap and multiple problems frequently coexist. Accurate diagnosis leads to directed treatment, with rehabilitation focused on functional closed-chain strengthening and core stability.