Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia). Surgery. 2011;150:99-107. [PMID: 21549403 DOI: 10.1016/j.surg.2011.02.016]

Nonsurgical Management of Adductor-related groin pain with Ultrasound-Guided Platelet-Rich Plasma Injection and Physical Therapy in a Competitive Soccer Player: A Case Report

Introduction

Adductor-related groin pain involves an injury to the common aponeurosis connecting the rectus abdominus and adductor longus to the pubis. It commonly occurs in sports that require cutting and pivoting and can result in significant loss of playing time. Platelet-Rich Plasma (PRP) is often indicated for treatment of musculoskeletal disorders and may represent an alternative treatment for patients with adductor-related groin pain. The purpose of this case report is to describe the non-surgical management of adductor-related groin pain in a competitive soccer player with a with an ultrasound (US)-guided PRP injection and physical therapy management.

Case Description

A 17-year-old male competitive soccer player with right-sided adductor-related groin pain was treated with an US-guided PRP and a multi-phased physical therapy regimen based on tissue healing and individual patient/criteria progression. The patient completed 12 physical therapy sessions over six weeks post PRP injection.

Outcomes

At the end of treatment, clinically meaningful improvements were observed in pain intensity, passive range of motion, strength (handheld dynamometry, Biodex), functional tests, psychosocial (OSPRO-YF) and patient-reported outcomes (HAGOS, LEFS). The subject returned to sport at six weeks post injection without limitation and at three months follow up, the subject reported that he had returned to 95% of his previous level of play.

Discussion

This case report may offer support for PRP as an alternative treatment in the management of adductor-related groin pain. Incorporation of PRP as an adjunct to physical therapy led to improvements on all outcomes that surpassed the clinical significance change criteria.

Level of evidence

5.

Optimised return to play: high treatment success rate in core muscle injury with surgical release of the anterior tendon of the rectus abdominis muscle and proximal tenotomy of the adductor longus muscle

OBJECTIVES

Core muscle injury is a debilitating condition that causes chronic groin pain in athletes, particularly common in soccer players. The condition is characterised by pain in the inguinal region and can lead to a significant number of absences from high-intensity physical activity. It is caused by repetitive overload without proper counterbalance from the abdominal muscles, hip flexors, and adductors in susceptible athletes. Surgical indications for core muscle injury consider cases where non-surgical treatments have not provided sufficient relief. The aim of this study was to assess the results of surgical intervention for core muscle injury using the technique employed by the Sports Medicine Group of (Institute of Orthopedics and Traumatology of Hospital das Clínicas - Universidade de São Paulo). The procedure involves releasing the anterior portion of the tendon of the rectus abdominis muscle near the pubic symphysis, along with proximal tenotomy of the adductor longus muscle tendon.

METHODS

This study utilised a consecutive historical cohort analysis of the medical records of 45 male athletes, of which, 75.6% were professional soccer players, who underwent surgical treatment between January 1, 2002, and December 31, 2021. The participants included active athletes aged between 18 and 40 years, with a mean age of 23.9 years, and were diagnosed with myotendinous core muscle injury. These athletes experienced pain in the pubic symphysis and adductor tendon region and had previously undergone medical treatment and physical therapy for a duration of three to six months without significant improvement.

RESULTS

The average time for athletes to return to sport after surgery was 135 days, with a majority of participants being soccer and futsal players. The surgical intervention yielded promising results, with a positive correlation between unilateral injuries and the time taken to return to sport. The complication rate was low, at 6.7%. Notably, the rate of symptom resolution was high, at 93.3%. Furthermore, the analysis indicated that the player's position on the field significantly influenced the discharge period, suggesting that the game position plays a role in the recovery process.

CONCLUSION

The combined surgical procedure involving the release of the rectus abdominis tendon and adductor longus muscle tenotomy demonstrates favourable outcomes for athletes with core muscle injury. This study provides strong support for the effectiveness of this surgical approach in managing the condition and offers a potential path to recovery and return to sports activities.

LEVEL OF EVIDENCE: 4

STUDY DESIGN

Cross-sectional study.

Surgical approaches for core abdominal injuries: a review of the Abdominal Core Health Quality Collaborative database

INTRODUCTION

Core abdominal injury (CAI) is a broad term that describes injuries resulting from repetitive loading of the pubis that leads to inflammation, rupture, or destabilization of the core muscles from the pubic bone. There is no clear recommendation on the surgical approach to CAI. We aimed to describe how hernia surgeons within the Abdominal Core Health Quality Collaborative (ACHQC) address this problem surgically and the short-term outcomes.

METHODS

We queried the ACHQC registry for patients undergoing surgery for isolated CAI and concomitant inguinal hernias (IH) and CAI. Operative approach and quality of life (using EuraHS survey scores) was abstracted.

RESULTS

A total of 29,451 patients underwent surgery for IHs, CAIs, or both within the registry. Twenty patients underwent surgery for isolated CAI (median age 29, 90% males). Eleven patients (55%) underwent surgery with mesh (four Lichtenstein, three TAPP, and four TEP). Nine patients (45%) underwent tissue-based repairs (four closure of floor, one Bassini, one McVay, one Shouldice, one femoral exploration, and one laparoscopic-to-open conversion). There were no postoperative complications or reoperations within 30 days. EuraHS scores showed improvement at 30 days from baseline (median 29 [6.75-41.75] from 42 [29.42-57.61]). Sixty patients had both IHs and CAIs (median age 31, 97% males). All patients received mesh. Thirty-one patients (52%) underwent open surgery (23 Lichtenstein, 1 plug, 7 TREPP) and 29 underwent minimally invasive repairs (23 TAPP, 6 TEP). There was one seroma at 30 days. EuraHS scores showed improvement at 30 days from baseline (median 16 [5.17-27.33] from 37.5 [26.44-46.58]).

CONCLUSIONS

Despite technical variability, CAIs with or without concomitant IH generally undergo operations commonly used for IH repairs. Within our series, there was inconsistency with approach and mesh placement. Future work should be focused on standardizing the approach to CAI and capturing long-term data within the ACHQC.

Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair: long-term benefits of a prospective cohort

PURPOSE

Inguinal-related groin pain (IRGP) in athletes is a multifactorial condition, posing a therapeutic challenge. If conservative treatment fails, totally extraperitoneal (TEP) repair is effective in pain relief. Because there are only few long-term follow-up results available, this study was designed to evaluate effectiveness of TEP repair in IRGP-patients years after the initial procedure.

METHODS

Patients enrolled in the original, prospective cohort study (TEP-ID-study) were subjected to two telephone questionnaires. The TEP-ID-study demonstrated favorable outcomes after TEP repair for IRGP-patients after a median follow-up of 19 months. The questionnaires in the current study assessed different aspects, including, but not limited to pain, recurrence, new groin-related symptoms and physical functioning measured by the Copenhagen Hip and Groin Outcome Score (HAGOS). The primary outcome was pain during exercise on the numeric rating scale (NRS) at very long-term follow-up.

RESULTS

Out of 32 male participants in the TEP-ID-study, 28 patients (88%) were available with a median follow-up of 83 months (range: 69-95). Seventy-five percent of athletes were pain free during exercise (p < 0.001). At 83 months follow-up, a median NRS of 0 was observed during exercise (IQR 0-2), which was significantly lower compared to earlier scores (p <0.01). Ten patients (36%) mentioned subjective recurrence of complaints, however, physical functioning improved on all HAGOS subscales (p <0.05).

CONCLUSION

This study demonstrates the safety and effectivity of TEP repair in a prospective cohort of IRGP-athletes, for whom conservative treatment had failed, with a follow-up period of over 80 months.

Sports Hernias: A Comprehensive Review for Clinicians

Sports hernias are a complex cause of chronic groin pain in athletes, posing diagnostic and treatment challenges for clinicians. This review article synthesizes current knowledge on sports hernias, exploring pathogenesis, diagnostic approaches, and management strategies. Despite the growing body of research, sports hernias continue to present a significant challenge, necessitating a multidisciplinary approach and further research to improve clinical outcomes. This comprehensive review aims to equip clinicians with an updated understanding of sports hernias, ensuring optimal patient care and informing future research.

Return To Play Rate and Performance Following Surgical Repair of Athletic Pubalgia in Major League Soccer Players: A Retrospective Case-Control Study

Introduction Athletic pubalgia (AP) injuries requiring surgical repair in elite-level soccer players are significant injuries with the potential of impacting a player's playing time and performance. Currently, no data exists explicitly analyzing Major League Soccer (MLS) players' return to play (RTP) rates and performance following these surgeries. Methods A retrospective review of publicly available data of all MLS players who underwent surgery to repair an isolated AP injury from the league inception year of 1993 through 2021 was performed. Demographic data at the time of injury was collected. Athletes who successfully returned to play for at least two seasons in the MLS were matched to healthy controls in a 1:2 ratio by demographics and position. The index year was defined as the season, including pre- and post-season, that the surgery occurred. RTP date and performance metrics one and two years pre- and post-index year were collected. Statistical analysis was performed. Results Eighty-eight players underwent surgical repair for AP from 1993 through 2021. Eighty-five athletes were able to successfully RTP (96.5%). Twenty-five players met the inclusion criteria and were included in the final analysis. The average RTP time was 1.08±4.92 months. During the combined seasons following surgery, athletes in the AP group displayed a significant reduction in minutes played compared to the two combined seasons prior to surgery (4153±912.77 vs. 3405.36±1342.35 minutes; p=0.03). There was no significant reduction in performance metrics when compared to both prior season statistics and the matched cohort (p>0.05).  Conclusion There is a high RTP rate among MLS players who undergo isolated surgical repair of AP. Although there was a significant reduction in combined minutes played in the two ensuing seasons following surgery, athletes who RTP demonstrated equivalent performance metrics comparable to their pre-injury seasons as well as to a matched cohort.

Core Muscle Injury Producing Groin Pain in the Athlete: Diagnosis and Treatment

Groin pain is a common cause of pain in the athlete and may be the result of a variety of causes. Musculoskeletal groin injuries are often associated with muscle strain, particularly the adductor and abdominal muscles, termed "core muscle injury" (CMI). Since the early 1960s, there have been a growing number of articles intending to identify, define, prevent, and treat this condition; to date, however, the lack of a universal definition and treatment approach has complicated the narrative around CMI. This article intends to review the recent literature surrounding CMI, identifying common defining characteristics, as well as delineating treatment protocols that benefit the injured patient populations. Emphasis is placed on the clinical outcomes of different treatment methodologies and failure rates.

Core Muscle Injury: Evaluation and Treatment in the Athlete

BACKGROUND

Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature.

PURPOSE

To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury.

STUDY DESIGN

Narrative and literature review; Level of evidence, 4.

METHODS

A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms.

RESULTS

The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks.

CONCLUSION

Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.

[Groin pain in sports games: a systematic review]

BACKGROUND

In sports games, epidemiological data show that groin pain is relatively common and can lead to repeated loss of time. Consequently, it is essential to be aware of the evidence-based prevention strategies. The aim of this systematic review was to examine risk factors and prevention strategies for groin pain and to rank them based on their evidence in sports games.

METHODS

The review was conducted according to the PRISMA guidelines, using a PICO-scheme in the PubMed, Web of Science and SPOLIT databases. We included all available intervention and observational studies on the influence of risk factors and prevention strategies on groin pain in sports games. The methodological quality and level of evidence was assessed using the PEDro-Scale and OCEBM model, respectively. Finally, the quantity, quality and level of evidence was used to rank each risk factor for its grade.

RESULTS

Moderate evidence was found for four risk factors that significantly influence the risk of groin pain: male sex, previous groin pain, hip adductor strength and not participating in the FIFA 11+ Kids. Moreover, moderate evidence was found for the following non-significant risk factors: older age, body height and weight, higher BMI, body fat percentage, playing position, leg dominance, training exposure, reduced hip abduction, adduction, extension, flexion, and internal rotation-ROM, hip flexor strength, hip abductor, adductor, flexor and core strengthening with balance exercises, clinical hip mobility tests and physical capacities.

CONCLUSION

The identified risk factors can be considered when developing prevention strategies to reduce the risk of groin pain in sports games. Thereby, not only the significant, but also the non-significant risk factors should be considered for prioritisation.

Diagnostic Accuracy of Imaging Modalities on Occult Groin Hernias According to Hernia type and a Surgeon-centered Individualized Groin Hernia Management Algorithm

BACKGROUND

The purpose of this study is to evaluate the diagnostic performance of imaging techniques for the identification of groin hernias based on the type of hernia and to demonstrate the efficacy of an algorithm based on the surgeon and surgical technique.

MATERIALS AND METHODS

Medical records of 561 patients who were operated on for groin hernia were retrospectively analyzed. A total of 102 patients who had both pelvic computed tomography (CT) and ultrasonography (USG) recordings preoperatively and underwent transabdominal preperitoneal repair were included in the study.

RESULTS

A contralateral asymptomatic occult groin hernia was detected in 25.5% of all patients. The overall sensitivity of USG and CT on contralateral asymptomatic occult hernia was 42.3% and 65.4%, respectively. The sensitivity of USG according to the contralateral occult hernia type was 66.7%, 35.7%, 33.3%, and 50% for direct, indirect, femoral, and pantaloon hernias, respectively. The sensitivity of CT according to the contralateral occult hernia type was 0%, 57.1%, 100%, and 100% for direct, indirect, femoral, and pantaloon hernias, respectively.

CONCLUSIONS

The handicap created by the variability in the diagnostic sensitivity of imaging modalities can be overcome with the choice of transabdominal preperitoneal repair in the surgical technique.

Swinging injuries in competitive baseball players

Injuries are common in competitive baseball players and can occur in all facets of the game. The majority of the existing literature on injuries in baseball players has focused on injuries secondary to the overhead throw with very little attention given to injuries sustained while batting. The baseball swing is a complex, often violent, motion that predisposes batters to a variety of injuries affecting the spine, trunk, pelvis, and extremities. Knowledge of injury patterns that commonly occur during the baseball swing and radiologic findings important to the treating physician can help radiologists provide accurate imaging interpretations that appropriately guide patient management.

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.

Open Surgery for Sportsman’s Hernia a Retrospective Study

Sportsman’s hernia is a painful syndrome in the inguinal area occurring in patients who play sports at an amatorial or professional level. Pain arises during sport, and sometimes persists after activity, representing an obstacle to sport resumption. A laparoscopic/endoscopic approach is proposed by many authors for treatment of the inguinal wall defect. Aim of this study is to assess the open technique in terms of safety and effectiveness, in order to obtain the benefit of an open treatment in an outpatient management. From October 2017 to July 2019, 34 patients underwent surgery for groin pain syndrome. All cases exhibited a bulging of the inguinal posterior wall. 14 patients were treated with Lichtenstein technique with transversalis fascia plication and placement of a polypropylene mesh fixed with fibrin glue. In 20 cases, a polypropylene mesh was placed in the preperitoneal space. The procedure was performed in day surgery facilities. Early or late postoperative complications did not occur in both groups. All patients returned to sport, in 32 cases with complete pain relief, whereas 2 patients experienced mild residual pain. The average value of return to sport was 34.11 ± 8.44 days. The average value of return to play was 53.82 ± 11.69 days. With regard to postoperative pain, no substantial differences between the two techniques were detected, and good results in terms of the resumption of sport were ensured in both groups. Surgical treatment for sportsman’s hernia should be considered only after the failure of conservative treatment. The open technique is safe and allows a rapid postoperative recovery.

Resisted adduction sit-up test (RASUT) as a screening tool for pelvic versus hip pathology

Groin pain is a common symptom in hip and pelvic pathology and differentiating between the two remains a challenge. The purpose of this study was to examine whether a test combining resisted adduction with a sit-up (RASUT) differentiates between pelvic and hip pathology. The RASUT was performed on 160 patients with complaints of hip or groin pain who subsequently had their diagnosis confirmed by magnetic resonance imaging (MRI) or surgery. Patients were categorized as having pelvic pathology (athletic pubalgia or other) or hip pathology (intra-articular or other). Athletic pubalgia was defined as any condition involving the disruption of the pubic aponeurotic plate. Sensitivity, specificity, positive predictive accuracy, negative predictive accuracy and diagnostic odds ratios were computed. Seventy-one patients had pelvic pathology (40 athletic pubalgia), 81 had hip pathology and 8 had both. The RASUT was effective in differentiating pelvic from hip pathology; 50 of 77 patients with a positive RASUT had pelvic pathology versus 29 of 83 patients with a negative test (P < 0.001). RASUT was diagnostic for athletic pubalgia (diagnostic odds ratio 6.08, P < 0.001); 35 of 45 patients with athletic pubalgia had a positive RASUT (78% sensitivity) and 73 of 83 patients with a negative RASUT did not have athletic pubalgia (88% negative predictive accuracy). The RASUT can be used to differentiate pelvic from hip pathology and to identify patients without athletic pubalgia. This is a valuable screening tool in the armamentarium of the sports medicine clinician.

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.

Long-term pain relief after groin hernia repair for sports groin: A nationwide cohort study

BACKGROUND

The groin is a complex anatomical area with multiple structures that can be injured and cause pain. One condition with groin pain is the so-called "sports groin," which can be treated with a groin hernia repair even though no hernia is present. The aim of this study was to assess the prevalence of chronic groin pain several years after a groin hernia repair performed in patients with a sports groin.

METHODS

This nationwide cohort study included adults who had a groin hernia repair for a sports groin through the years 1998-2011. The patients were identified through the Danish Hernia Database and in surgical records. Patients were asked to fill out four questionnaires several years after the repair: a visual analogue scale, the Activity Assessment Scale, the Inguinal Pain Questionnaire, and a questionnaire about treatment satisfaction.

RESULTS

Of 118 contacted patients, 71 gave informed consent and were included in the study (60%), and of these the response rate was 100%. The questionnaires were filled out median 14 years after surgery. Most of the patients were pain-free in the operated groin (87%), and only a few had physical impairment caused by groin pain (20%). Prior to surgery, 79% had groin pain that they could not ignore. Overall, 90% of the patients were satisfied with the treatment.

CONCLUSIONS

Most patients were pain-free and without physical impairment several years after groin hernia repair for a sports groin and with high satisfaction rate.

Surgical Outcomes of Inguinal-, Pubic-, and Adductor-Related Chronic Pain in Athletes: A Systematic Review Based on Surgical Technique

Background:

Controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes.

Purpose:

To investigate the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level 1 to 4 evidence, mean patient age >15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was performed with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed.

Results:

Overall, 47 studies published between 1991 and 2020 were included. There were 2737 patients (94% male) with a mean age at surgery of 27.8 years (range, 12-65 years). The mean duration of symptoms was 13.1 months (range, 0.3-144 months). The most frequent sport involved was soccer (71%), followed by rugby (7%), Australian football (5%), and ice hockey (4%). Of the 47 articles reviewed, 44 were classified as level 4 evidence, 1 study was classified as level 3, and 2 randomized controlled trials were classified as level 1b. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return to play at preinjury or higher level was observed in 92% (95% CI, 88%-95%) of the athletes after surgery to the inguinal area, 75% (95% CI, 57%-89%) after surgery to the adductor origin, 84% (95% CI, 47%-100%) after surgery to the pubic symphysis, and 89% (95% CI, 70%-99%) after combined surgery in the inguinal and adductor origin.

Conclusion:

Return to play at preinjury or higher level was more likely after surgery for inguinal-related CGP (92%) versus adductor-related CGP (75%). However, the majority of studies reviewed were methodologically of low quality owing to the lack of comparison groups.

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.

Totally extra-peritoneal repair versus trans-abdominal pre-peritoneal repair for the laparoscopic surgical management of sportsman's hernia: A systematic review and meta-analysis

BACKGROUND

Open and laparoscopic modalities are employed for treatment of sportsman's hernia with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated a beneficial superiority for sportsman's hernia repair, as concluded in the most recent systematic review comparing the outcomes of each technique. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair.

METHODS

A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively.The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed.

RESULTS

28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was more pronounced for return to sporting activity meaning that meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques.

CONCLUSIONS

There is no observed difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data on this matter.

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy: a 10-year experience in the treatment of athletic pubalgia

BACKGROUND

Athletic pubalgia, commonly referred to as a "sports hernia," is a disease process characterized by groin pain produced by physical exertion often occurring in patients whose athletic activities require them to make rapid changes in direction. The groin pain is due to the traction-countertraction relationship between the adductor muscles and the weaker abdominal muscles. Hence, a few studies have shown inguinal hernia repair with adductor tenotomy to be an effective treatment for this pathology (Brody in Hernia 21:139-147, 2016, https://doi.org/10.1007/s10029-016-1520-8 ; Rossidis et al. in Surg Endosc 29:381-386, 2015, https://doi.org/10.1007/s00464-0143679-3 ). However, these studies are small and few in quantity but have demonstrated promising results. Thus, we sought to further study this combined surgical approach as a treatment for this multifactorial disease to improve our understanding and outcomes.

METHODS

With IRB approval, we retrospectively reviewed the charts of all patients who underwent adductor tenotomy and inguinal hernia repair for the treatment of athletic pubalgia at Mount Sinai Medical Center, Miami Beach FL. Parameters gathered included basic demographics, past medical and surgical history, athletic activity, length of surgery, length of time between surgery and follow-up, intraoperative and postoperative complications, and time to return to athletic activities.

RESULTS

A total of 93 patients underwent inguinal hernia repair with adductor tenotomy. These procedures were all performed by a single surgeon at two academic institutions. The average age of patients was 23.4 years. Athletic activities reported by the patients were as follows: American football (n = 36), soccer (n = 18), triathlon (n  = 11), track and field (n = 8), and baseball (n = 5). Less-represented activities included swimming (n = 3), tennis (n = 2), lacrosse (n = 1), golf (n = 1), and other (n = 8). Mean operative time was 72.4 min. Most patients were found to return to athletic activity in 28 days following a standardized physical therapy regimen (92.5%). Postoperative complications included recurrence of pain/symptoms (7.5%, n = 7), urinary retention (2.2%, n = 2), pain along the adductor magnus/brevis muscle group with more extraneous activity (1.1%,  n = 1), and adductor brevis hematoma 3 months following surgery and rehabilitation (1.1%, n = 1). Of the patients with recurrent pain, 2/7 reported contralateral pain.

CONCLUSIONS

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy appears to be a relatively quick and safe procedure with few postoperative complications. The majority of treated athletes are able to return to full athletic activities within 28 days of operation. While a return of symptoms has been seen in some patients, it is frequently observed on the contralateral side.

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)

Early recovery after endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption: A prospective cohort study

Background

Groin pain is a common problem in athletes which results in loss of playing time. Moreover, it can be for the cause of athletic career termination. A common cause of groin pain in athletes is inguinal disruption; pain in the groin area near the pubic tubercle were no obvious other pathology exists to explain the symptoms. Aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption.

Methods

Thirty-one athletes with chronic groin pain due to inguinal disruption, who had undergone conservative therapy without any effect, were included in this prospective cohort study. Prior to surgery patients were assessed by clinical examination, ultrasound of the inguinal region, x-ray and a radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT). TEP hernia repair was performed and a lightweight polypropylene mesh was placed pre-peritoneally. Additionally the athletes’ perception about their groin disability was assessed preoperatively and 6 weeks postoperatively by means of the Hip and Groin Outcome Score (HAGOS). The HAGOS consists of six subscales: Pain, Symptoms, Physical function in daily living, Physical function in Sport and Recreation, Participation in Physical Activities, and hip and/or groin-related Quality of Life.

Results

No complications occurred during and after surgery. After six weeks patients improved in all the separate subscales of the Hip and Groin Outcome Score (HAGOS). Within 6 weeks of surgery, 26 patients (84%) returned to sports activities with no or less groin pain.

Conclusions

This study showed that endoscopic totally extraperitoneal (TEP) hernia repair is an effective surgical treatment of inguinal disruption in athletes with chronic groin pain.

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.

Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia

Background

Sportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair.

Methods

A randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year.

Results

A total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70–80 to 10–20 in both groups (P &lt; 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408).

Conclusion

Totally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).

Characteristics of groin hernia repair in patients without a groin hernia: a nationwide cohort study

BACKGROUND

Sports hernia is a condition with longstanding groin pain without an obvious pathology. Even though no hernia is present, some of these patients have a groin hernia repair to relieve the pain. The aim of this study was to establish an overview of patient characteristics and surgical techniques in patients that have a groin hernia repair without a hernia present.

METHODS

This cohort study is based on nationwide data on hernia repairs from the Danish Hernia Database. Patients having a primary groin hernia repair without having a hernia between 1998 and 2011 were included and followed for minimum 4 years. We evaluated patient characteristics, type of surgery, and re-operation rates for laparoscopic and open surgeries.

RESULTS

Groin hernia repairs were performed in 1,028 groins where no hernia was present. The median follow-up after primary surgery was 11 years (range 4-17). Men represented 78% of the patients, and the mean age was 50 years (standard deviation 16.4). The most frequent type of surgery was the open Lichtenstein repair. The overall re-operation rate was 7% and this was evenly distributed across the different types of primary surgeries with no difference in neither the crude nor the cumulated re-operation rates. During re-operation, a groin hernia was found in 88% of the repairs.

CONCLUSION

Groin hernia repairs in groins without a hernia are performed at all ages and with the typical patient being a middle-aged man receiving an open mesh repair.

Long-standing groin pain in contact sports: a prospective case-control and MRI study

Objectives

We aimed to prospectively evaluate the prevalence of long-standing groin pain and related MRI findings in contact sports.

Methods

This case–control study followed three male elite-level soccer, ice-hockey and bandy teams (102 players) for 2 years. All athletes with long-standing groin pain lasting >30 days and age-matched controls (1:3) from the same teams were examined clinically, using pelvic MRI and Hip and Groin Outcome Scores (HAGOS). Primary outcome measures were annual prevalence of groin pain and underlying MRI findings.

Results

The annual prevalence of chronic groin pain was 7.5%. Training characteristics and pain scores of athletes were similar in all teams. On MRI, there was no significant difference in the percentage of pubic bone marrow oedema (p = 0.80) between symptomatic players (8/15; 53%) versus controls (20/43; 47%), but adductor tendinopathy and degenerative changes at the pubic symphysis were twice more common among players with pain. Rectus muscle or iliopsoas pathology were seldom observed. Lower HAGOS subscales (p < 0.01) were recorded in players who experienced groin pain compared with the controls.

Conclusion

Long-standing groin pain was observed annually in 1 of 14 athletes in contact sports. Abnormalities in the pubic symphysis were common MRI findings in both symptomatic and asymptomatic players.

Trial registration number

NCT02560480

[Sportsmen's groin : Definition, differential diagnosis and treatment]

Groin pain in athletes is a common problem and can have extensive consequences for professional athletes. The anatomical and functional complexity of the groin as well as radiating pain from remote anatomical regions can make the differential diagnosis a challenge and requires special attention. As there are a wide variety of possible causes for groin pain, a multidisciplinary approach is required. The treating orthopedic surgeon needs to pay special attention to pre-arthritic hip deformities to avoid irreversible damage of the hip joint. By a meticulous patient history and identification of the pain character, followed by clinical, sonographic and radiographic investigations, a differential diagnosis can usually be achieved. Besides typical orthopedic causes, pathological findings particularly in the area of the groin need to be considered, clarified and adequately treated; therefore, a clear terminology of the different diseases is necessary. Sportsmen's groin is not a hernia but should be perceived as a separate entity due to its typical pain character and detection of a measurable protrusion of the posterior wall of the inguinal canal by ultrasound.

Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management

Synopsis Groin pain is common in athletes who participate in multidirectional sports and has traditionally been considered a difficult problem to understand, diagnose, and manage. This may be due to sparse historical focus on this complex region in sports medicine. Until recently, there has been little agreement regarding terminology, definitions, and classification of groin pain in athletes. This has made clear communication between clinicians difficult, and the results of research difficult to interpret and implement into practice. However, during the past decade, the field has evolved rapidly, and an evidence-based understanding is now emerging. This clinical commentary discusses the clinical examination (subjective history, screening, physical examination); imaging; testing of impairments, function, and performance; and management of athletes with groin pain in an evidence-based framework. J Orthop Sports Phys Ther 2018;48(4):239-249. Epub 6 Mar 2018. doi:10.2519/jospt.2018.7850.

The value of laparoscopy in the management of chronic groin pain

BACKGROUND

Chronic groin pain problem represents a diagnostic and management challenge. This study is reporting all patients who underwent laparoscopic exploration of the groin and pelvis for undiagnosed chronic groin pain.

MATERIALS AND METHODS

A retrospective cohort study. Evaluators were not involved in the operations. Laparoscopic exploration and mesh insertion using Trans-Abdominal Pre-Preitoneal (TAPP) approach was performed for all patients. Follow up in the; clinic at 2 weeks and 6 months was arranged. This was a consecutive series of patients who were presented with chronic groin pain and no pre-operative radiological, orthopedic, gynecological or urologic abnormalities. Patients who were diagnosed with clinical hernia or other positive finding were excluded.

RESULTS

Data were collected and analyzed for 92 patients. The operation had successfully managed the groin pain in 81 patients (88.04%), and the pain was improved in another 3 patients (3.26%). Six patients (6.52%) had no change in their symptoms, and worse pain was reported in two patient (2.17%).

CONCLUSION

Laparoscopic groin exploration is an effective method to diagnose the chronic groin pain that under diagnosed by clinical, ultrasound and MRI tests. Laparoscopic management had resulted in resolution of the pain in the majority of the patients. The procedure is effective in athletes' patients who did not have clinical, radiological and laparoscopic evidence of groin hernia.

Diagnosis of inguinal hernia by prone- vs. supine-position computed tomography

PURPOSE

The aim of this study was to investigate the efficacy of prone-position computed tomography (CT) for detecting and classifying inguinal hernia relative to supine-position CT before laparoscopic inguinal hernia repair.

METHODS

Seventy-nine patients who underwent laparoscopic transabdominal preperitoneal repair of inguinal hernia were enrolled in this prospective study. Patients diagnosed with inguinal hernia by physical examination underwent abdominal CT in the supine and prone positions for preoperative assessment. The anatomy of the right and left inguinal regions was confirmed during the surgery and compared with the preoperative CT findings.

RESULTS

The 79 cases included 87 operated lesions and 71 non-operated contralateral inguinal sites. Of the 84 clinical hernias, inguinal hernia was detected significantly more frequently on prone-position CT images (84, 100%) than on supine-position CT images (55, 65.5%). In addition, the inguinal hernia type was determined with significantly greater accuracy on prone-position CT images (96.4%) than on supine-position CT images (58.3%). Twenty-two occult hernias were detected by laparoscopy. The detection rate and accuracy for determining the type of occult hernia were significantly greater when using prone-position CT images [19 of 22 lesions (86.4%) and 77.3%, respectively] than when using supine-position CT images [8 of 22 lesions (36.4%) and 27.3%, respectively].

CONCLUSIONS

Prone-position CT is adequate for detecting and classifying inguinal hernia and for evaluating occult hernia.

Athletic Pubalgia in Females: Predictive Value of MRI in Outcomes of Endoscopic Surgery

Background:

Athletic pubalgia is typically associated with male athletes participating in contact sports and less frequently with females. Endoscopic surgery may fully treat the patient with athletic pubalgia.

Purpose:

To perform an outcomes analysis of magnetic resonance imaging (MRI) and endoscopic surgery in female patients with athletic pubalgia.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Fifteen physically active female patients (mean age, 37 years) with athletic pubalgia were treated surgically via placement of total extraperitoneal endoscopic polypropylene mesh behind the injured groin area. The presence of preoperative bone marrow edema (BME) at the pubic symphysis seen on MRI was graded from 0 to 3 and correlated with pain scores after surgery. The outcome measures were pre- and postoperative pain scores and recovery to daily activity between 1 and 12 months after surgery. Results were compared with previously published scores from male athletes (n = 30).

Results:

With the exception of lower body mass index, the females with (n = 8) and without (n = 7) pubic BME had similar patient characteristics to the corresponding males. Mean inguinal pain scores (0-10) before surgical treatment were greater in females than males (during exercise, 7.8 ± 1.1 vs 6.9 ± 1.1; P = .0131). One month after surgery, mean pain scores for females were still greater compared with males (2.9 ± 1.7 vs 1.3 ± 1.6; P = .0034). Compared with female athletes with normal MRI, pubic BME was related to increased mean preoperative pain scores (8.13 ± 0.99 vs 6.43 ± 1.2; P = .0122). After 1 year, surgical outcomes were excellent or good in 47% of women.

Conclusion:

Endoscopic surgery was helpful in half of the females with athletic pubalgia in this study. The presence of pubic BME may predict slightly prolonged recovery from surgery.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine

PURPOSE

To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine.

METHODS

Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI).

RESULTS

AP repair was identified in 4.2% (n = 55) of athletes. MRI was performed in 35% (n = 19 of 55) with AP repair, of which 53% (n = 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P = .87) or starting (P = .45) fewer regular season games, going undrafted (P = .27), or not being on an active NFL roster (P = .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P = .74), games started (P = .48), draft status (P = .26), or being on an active roster (P = .74). Offensive linemen (P = .005) and athletes with a history of repair within 1 year of the Combine (P = .03) had a significantly higher risk of possessing positive pathology on MRI.

CONCLUSIONS

Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1 year out from surgery have a higher risk for positive MRI findings at the pubic symphysis.

LEVEL OF EVIDENCE

Level IV, prognostic study-case series.

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.

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.

Groin Injuries (Athletic Pubalgia) and Return to Play

Context:

Groin pain is a common entity in athletes involved in sports that require acute cutting, pivoting, or kicking such as soccer and ice hockey. Athletic pubalgia is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of nonoperative measures. A variety of surgical options have been used, and most patients improve and return to high-level competition.

Evidence Acquisition:

PubMed databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results and Conclusion:

Athletic pubalgia is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases.

[Chronic instability of the pubic symphysis : Etiology, diagnostics and treatment management]

The most frequent causes of chronic instability of the pubic symphysis are sports-related continual overload and traumatic symphyseal injuries. Acute injury of the pubic symphysis may be the result of external forces acting on the anterior pelvic ring or the result of internal forces, such as those arising during parturition. The postpartum form of instability following a complication-free birth is reversible and usually returns to normal within a few months through strengthening of the pelvic floor muscles. Residual instability of the pubis symphysis is on the whole a rare complication. Although established therapy options for acute symphyseal separation can be found in the literature, there are only a few case reports on chronic symphyseal instability. There are no guidelines on standardized therapy options. This review article examines the etiology, clinical findings, diagnostic techniques and management options for patients suffering from chronic symphyseal instability.