Sportsman's hernia

Ultrasound of Groin Pain in the Athlete

Groin pain is a common cause of disability in athletes. Imaging is crucial in a clinical diagnosis, given the multiple associated etiologies. The main sites of groin pain are the adductors, iliopsoas muscles, inguinal ring, hip joint, and pubic symphysis. Although magnetic resonance imaging is the gold standard to image groin pain, ultrasound (US) offers excellent accuracy in pinpointing muscle injuries, inguinal disruption, and hernias. US requires a detailed knowledge of anatomical landmarks; imaging pitfalls, and pathologic patterns. We review the complex anatomy of the groin region, the sonographic appearance of the involved structures, and the strengths and weaknesses of US.

The conservative treatment of longstanding adductor-related groin pain syndrome: a critical and systematic review

Longstanding (chronic) adductor-related groin pain syndrome is a widely common problem for athletes in many sports activities which often drastically reduces player activity and performance. The first choice in therapeutic treatment is conservative therapy. The objective of this study is to provide a systematic review regarding conservative treatment for longstanding adductor-related groin pain syndrome present in literature today. Furthermore, this study aims to give a critical vision of the current state of the art of the considered topic. After screening 234 articles, 19 studies following the inclusion criteria were included and summarized in this current systematic review and seven different types of therapeutic interventions were described. Compression clothing therapy, manual therapy together with strengthening exercise and prolotherapy were the therapeutic interventions which showed both the greatest level of strength of evidence (Moderate) and grade of recommendation (D). The remaining four types of therapeutic interventions i.e.: corticoid injection, platelet rich plasma therapy, intra-tissue percutaneous electrolysis and pulse-dose radiofrequency, showed both lower levels of strength of evidence (Conflicting) and grade of recommendation (C). In conclusion the literature available on the conservative treatment for longstanding adductor-related groin pain syndrome is limited and characterized by a low level of evidence. Therefore, our recommendation is to refer only to the few studies with higher level of evidence and at the same time to encourage further research in this area. The intervention showing the greater level of strength of evidence, and the greater grade of recommendation are compression clothing therapy, manual therapy and strengthening exercise, and prolotherapy. Other therapeutic interventions such as intra-tissue percutaneous electrolysis and pulse-dose radiofrequency seem promising but require further studies to confirm their efficacy.

Incidence of chronic groin pain following open mesh inguinal hernia repair, and effect of elective division of the ilioinguinal nerve: meta-analysis of randomized controlled trials

PURPOSE

Chronic post-operative groin pain is a substantial complication following open mesh inguinal hernia repair. The exact cause of this pain is still unclear, but entrapment or trauma of the ilioinguinal nerve may have a role to play. Elective division of this nerve during hernia repair has been proposed in an attempt to reduce the incidence of chronic groin pain.

METHODS

We performed a meta-analysis of nine randomized controlled trials comparing preservation versus elective division of the ilioinguinal nerve during this operation.

RESULTS

A substantial proportion of patients having open mesh inguinal hernia repair experience chronic groin pain when the ilioinguinal nerve is preserved (estimated rate of 9.4% at 6 months and 4.8% at 1 year). Elective division of the nerve resulted in a significant reduction of groin pain at 6-months post-surgery (RR 0.47, p = 0.02), including moderate/severe pain (RR 0.57, p = 0.01). However, division of the nerve also resulted in an increase of subjective groin numbness at this time point (RR 1.55, p = 0.06). At 12-month post-surgery, the beneficial effect of nerve division on chronic pain was reduced, with no significant difference in the rates of overall groin pain (RR 0.69, p = 0.38), or of moderate-to-severe groin pain (RR 0.99, p = 0.98) between the two groups. The prevalence of groin numbness was also similar between the two groups at 12-month post-surgery (RR 0.79, p = 0.48).

CONCLUSIONS

Routine elective division of the ilioinguinal nerve during open mesh inguinal hernia repair does not significantly reduce chronic groin pain beyond 6 months, and may result in increased rates of groin numbness, especially in the first 6-months post-surgery.

Sportsmans Groin: The Inguinal Ligament and the Lloyd Technique

Groin pain is a catch all phrase used to define a common set of symptoms that affect many individuals. It is a common condition affecting sportsmen and women (1, 2) and is often referred to as the sportsman groin (SG). Multiple surgical operations have been developed to treat these symptoms yet no definitive imaging modalities exist to diagnose or predict prognosis. This article aims to discuss the anatomy of the groin, suggest a biomechanical pathophysiology and outline a logical surgical solution to treat the underlying pathology. A systematic clinical and imaging approach with inguinal ligament and pubic specific MRI assessment, can result in accurate selection for intervention. Close correlation with clinical examination and imaging in series is recommended to avoid misinterpretation of chronic changes in athletes.

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.

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.

Sonographic evaluation of athletic pubalgia

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

Sports hernia and femoroacetabular impingement in athletes: A systematic review

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

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

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

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

Sportsman hernia; the review of current diagnosis and treatment modalities

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

A literature review on the role of totally extraperitoneal repairs for groin pain in athletes

A literature review was made on the role of totally extraperitoneal (TEP) hernia repairs for groin pain in athletes. Electronic databases were searched for literature published from January 1993 to November 2011. There were 10 articles incorporating 196 patients included in this review. Thirty percent of patients were reported to have direct inguinal hernias, 22% had indirect inguinal hernias, and 41% had dilated internal rings. Of note, 30% of cases had no macroscopic abnormality. Four studies reported on an early follow-up ranging between 3 and 6 weeks. Only minimal or mild symptoms were reported. Up to 33% of patients had impaired ability to perform at peak levels. Up to 53% of patients had persistence of symptoms at the early follow-up. Total follow-up time ranged from 3 to 80 months, and most patients were active (90%-100%). At long-term follow-up, 3% to 10% were unable to play, and 5% were reported as being unable to train. Two studies from the same center reported on TEP surgery for osteitis pubis, and most patients returned to sporting activity after 4 to 8 weeks. TEP repair is a good operative intervention in athletes with chronic groin pain not relieved by conservative measures. Athletes recover quickly and return to sport early.

Radiographic evidence of femoroacetabular impingement in athletes with athletic pubalgia

Background:

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

Hypothesis:

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

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

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

Results:

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

Conclusion:

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

Clinical Relevance:

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

Laparoscopic Repair of Sportman's Hernia - The Trinidad Experience

Sportman's hernia: (Athletic pubalgia) is an uncommon and poorly understood condition afflicting athletic individuals. Sufferers complain of chronic groin pain and often present diagnostic dilemmas to physicians and physiotherapists. We present a series of cases illustrating the varying presentations of sportman's hernia and diagnostic approaches that can be utilized to exclude common differentials. We also describe laparoscopic mesh repair as an effective treatment option for this condition.

Health-related quality of life after TAPP repair for the sportsmen's groin

BACKGROUND

Sportsmen's groin (SG) is a clinical diagnosis of chronic, painful musculotendinous injury to the medial inguinal floor in the absence of a groin hernia. Long-term results for laparoscopic inguinal hernia repair, especially data on health-related quality of life (HRQOL), are scant and there are no available data whatsoever on HRQOL after SG. The main goal of this study was to compare postoperative QOL data in the long term after transabdominal preperitoneal hernioplasty (TAPP) in groin hernia and SG patients with QOL data of a normal population.

METHODS

This study included all patients (n = 559) who underwent TAPP repair between 2000 and 2005. Forty seven patients (8.4 %) were operated on for SG. We sent out the Short Form 36 Health Survey (SF-36) questionnaire for QOL evaluation. QOL data were compared with data from an age- and sex-matched normal population.

RESULTS

Ultimately, 383 completed questionnaires were available for evaluation (69 % response rate). The mean follow-up time was 94 ± 20 months. In the SG group there were statistically significant differences in three subscales of the SF-36 and the mental component summary measure, showing better results for the SG group compared to the sex- and age-matched normal group data. There were no statistically significant differences between groin hernia patients and the sex- and age-matched normal population.

CONCLUSION

TAPP repair for SG as well as groin hernia results in good HRQOL in the long term. Results for SG patients are comparable with QOL data of a normal population or even better.

Imaging assessment of groin pain

Groin pain is a common condition in athletes, especially those who play certain sports, for instance soccer, ice hockey, fencing which request rapid acceleration and frequent changes of movement. This condition represents a diagnostic difficulty for the radiologist due to either the anatomical pubic region complexity than the many causes that can be a source of pain, because the groin pain can be determined by conditions affecting the bony structures, cartilage and muscle tendons that are part of the proper pubis but also from those involving the hip. The approach to the groin through diagnostic imaging is multidisciplinary: The study of the patient is performed by traditional radiographs, ultrasound examination, magnetic resonance imaging or computed tomography, based on clinical suspicion, and each of these methods provides different results depending on the disease in question. The purpose of this article is to examine what are the optimal imaging techniques to investigate the various diseases affecting the patient with groin pain.

"Superior cleft sign" as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman's hernia

OBJECTIVE

We describe a new imaging sign, the "superior cleft sign", identified at both symphysography and MRI, which should be used as a marker of rectus abdominis/adductor longus attachment tearing.

MATERIALS AND METHODS

A study population of 25 patients presenting with clinically suspected sportsman's hernia, who had undergone both symphysography and MRI of the groin were included for study. In each case, images were reviewed to determine the presence of a superior cleft, secondary cleft, and or both abnormalities.

RESULTS

Images of all patients complaining of groin crease discomfort similar to sportsman's hernia revealed the presence of a superior cleft at the rectus abdominis/adductor longus attachment. This "superior cleft sign" correlated with the side of symptoms in each case, and, in contrast to the previously described secondary cleft along the inferior margin of the inferior pubic ramus, occurred parallel to the inferior margin of the superior pubic ramus.

CONCLUSIONS

The presence of the "superior cleft sign" should be sought in addition to the previously described secondary cleft sign in sportspeople presenting with exercise-related groin pain or pubalgia. It should specifically be sought in patients referred with suspected sportsman's hernia.

Sports hernia in National Hockey League players: does surgery affect performance?

BACKGROUND

Athletic pubalgia is a complex injury that results in loss of play in competitive athletes, especially hockey players. The number of reported sports hernias has been increasing, and the importance of their management is vital. There are no studies reporting whether athletes can return to play at preinjury levels.

PURPOSE

The focus of this study was to evaluate the productivity of professional hockey players before an established athletic pubalgia diagnosis contrasted with the productivity after sports hernia repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Professional National Hockey League (NHL) players who were reported to have a sports hernia and who underwent surgery from 2001 to 2008 were identified. Statistics were gathered on the players' previous 2 full seasons and compared with the statistics 2 full seasons after surgery. Data concerning games played, goals, average time on ice, time of productivity, and assists were gathered. Players were divided into 3 groups: group A incorporated all players, group B were players with 6 or fewer seasons of play, and group C consisted of players with 7 or more seasons of play. A control group was chosen to compare player deterioration or improvement over a career; each player selected for the study had a corresponding control player with the same tenure in his career and position during the same years.

RESULTS

Forty-three hockey players were identified to have had sports hernia repairs from 2001 to 2008; ultimately, 80% would return to play 2 or more full seasons. Group A had statistically significant decreases in games played, goals scored, and assists. Versus the control group, the decreases in games played and assists were supported. Statistical analysis showed significant decreases in games played, goals scored, assists, and average time on ice the following 2 seasons in group C, which was also seen in comparison with the control group. Group B (16 players) showed only statistical significance in games played versus the control group.

CONCLUSION

Players who undergo sports hernia surgeries return to play and often perform similar to their presurgery level. Players with over 7 full seasons return but with significant decreases in their overall performance levels. Less veteran players were able to return to play without any statistical decrease in performance and are likely the best candidates for repair once incurring injury.

Groin injuries in sports medicine

Context:

An in-season groin injury may be debilitating for the athlete. Proper diagnosis and identification of the pathology are paramount in providing appropriate intervention. Furthermore, an adductor strain that is treated improperly can become chronic and career threatening. Any one of the 6 muscles of the adductor muscle group can be involved. The degree of injury can range from a minor strain (grade 1), where minimal playing time is lost, to a severe strain (grade 3), in which there is complete loss of muscle function. Persistent groin pain and muscle imbalance may lead to athletic pubalgia.

Evidence Acquisition:

Relevant studies were identified through a literature search of MEDLINE and the Cochrane database from 1990 to 2009, as well as a manual review of reference lists of identified sources.

Results:

Ice hockey and soccer players seem particularly susceptible to adductor muscle strains. In professional ice hockey and soccer players throughout the world, approximately 10% to 11% of all injuries are groin strains. These injuries have been linked to hip muscle weakness, a previous injury to that area, preseason practice sessions, and level of experience. This injury may be prevented if these risk factors are addressed before each season.

Conclusion:

Despite the identification of risk factors and strengthening intervention for athletes, adductor strains continue to occur throughout sport. If groin pain persists, the possibility of athletic pubalgia needs to be explored, because of weakening or tears in the abdominal wall muscles. A diagnosis is confirmed by exclusion of other pathology.

Imaging of sports-related hip and groin injuries

A normally functioning hip joint is imperative for athletes who use their lower extremities with running, jumping, or kicking activities. Sports-related injuries of the hip and groin are far less frequent than injuries to the more distal aspect of the extremity, accounting for less than 10% of lower extremity injuries. Despite the lower incidence, hip and groin injuries can lead to significant clinical and diagnostic challenges related to the complex anatomy and biomechanical considerations of this region. Loads up to 8 times normal body weight have been documented in the joint in common daily activities, such as jogging, with significantly greater force expected during competitive athletics. Additionally, treatment for hip and groin injuries can obviate the participation of medical and surgical specialties, with a multidisciplinary approach frequently required. Delay in diagnosis and triage of these injuries may cause loss of time from competition and, potentially, early onset of degenerative changes. Magnetic resonance imaging (MRI) of the hip has proven to be the gold standard for the diagnosis of sports-related hip and groin injuries in the setting of negative radiographs. With its exquisite soft tissue contrast, multiplanar capabilities, and lack of ionizing radiation, MRI is unmatched in the noninvasive diagnosis of intra-articular and extra-articular pathology, as well as intraosseous processes. This review focuses on MRI of common athletic injuries of the hip and groin, including acetabular labral tears, femoral acetabular impingement syndrome, muscle injuries around the hip and groin (including athletic pubalgia), and athletic osseous injuries.

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.

Hip pain from the orthopeadic point of view

The hip and its disorders represent a clinical, diagnostic and therapeutic challenge greater than any other joints. Clinical symptoms are usually non specific and provocative maneuvers are sometimes unreliable, pain might be referred even from other joints and many times accurate assessment need imaging techniques. New surgical options, especially the latest development of hip arthroscopy has open horizons for treating intraarticular disorders. In this review article we will review basic clinical assessment and what we need as orthopeadic surgeons from radiology.

US in pubalgia

There is considerable confusion over the word "pubalgia" with regard to the definition and the etiological causes of this condition. The term pubalgia should be used to indicate disabling pain affecting the pubic region in people who practise sports. Pubalgia affects 10% of those who practise sports and it is particularly prevalent in football players. According to the literature, about 40% of cases of pubalgia are caused by overuse of the symphysis pubis with progressive lesions affecting the rectus abdominal muscles, adductors (rectal-adductor syndrome) and the symphysis itself (osteitis pubis and joint injury). An initial study of the tendons is carried out by ultrasound (US) whereas magnetic resonance imaging (MRI) should be performed to study the bones and joints.Another 40% of cases of pubalgia are caused by "sports hernia" defined as anteroinferior abdominal wall insufficiency. These alterations can only be identified at dynamic US examination.About 20% of cases of pubalgia are caused by diseases of the neighboring structures or joints such as diseases of the hip, iliopsoas, hamstring, sacred iliac or nerves, or by urogenital diseases.

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.

Herniography influences the management of patients with suspected occult herniae and patient factors can predict outcome

PURPOSE

Patients with groin pain and no palpable hernia are a diagnostic challenge for the surgeon. It is recognised that some patients will have an occult hernia and benefit from surgical repair. Herniography remains popular in some units, as it has a high diagnostic sensitivity.

METHODS

Presenting symptoms and signs were recorded, along with herniogram findings, management plan and outcome for all patients undergoing herniography between July 2004 and December 2009. Demographic factors and individual symptoms and signs were analysed for their ability to predict a positive herniogram.

RESULTS

There were a total of 72 positive and 132 negative herniograms. For positive herniograms, only 41 (59%) patients underwent surgery and six (16%) patients were found not to have a hernia. The most common reasons for not proceeding to surgery were herniogram findings thought to be insignificant and the herniogram being positive on the contralateral side. For negative herniograms, despite a negative herniogram, four (3%) patients underwent surgery and a hernia was confirmed in two patients. Regarding predictive symptoms and signs, history of a groin lump and greater patient age were significantly associated with a positive herniogram and a confirmed hernia at surgery.

CONCLUSIONS

After a positive herniogram, less than two-thirds of patients undergo surgery. The majority have improved symptoms on review and we, therefore, suggest a period of watchful waiting prior to herniography. Older patients and a history of a groin lump are associated with a positive herniogram and confirmed hernia at surgery, and could be used to select patients for laparoscopic exploration.

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)

BACKGROUND

Chronic groin pain in athletes presents often a diagnostic and therapeutic challenge. Sportsman's hernia (also called "athletic pubalgia") is a deficiency of the posterior wall of the inguinal canal, which is often repaired by laparoscopic mesh placement. Endoscopic mesh repair may offer a faster recovery for athletes with sportsman's hernia than nonoperative therapy.

METHODS

A randomized, prospective study was conducted on 60 patients with a diagnosis of chronic groin pain and suspected sportsman's hernia. Clinical data and MRI were collected on all patients. After 3 to 6 months of groin symptoms, the patients were randomized into an operative or a physiotherapy group (n = 30 patients in each group). Operation was performed using a totally extraperitoneal repair in which mesh was placed behind the symphysis and painful groin area. Conservative treatment included at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. The outcome measures were pre- and postoperative pain using a visual analogue scale and partial or full recovery to sports activity at 1, 3, 6, and 12 months after randomization.

RESULTS

The athletes in both treatment groups had similar characteristics and pain scores. Operative repair was more effective than nonoperative treatment to decrease chronic groin pain after 1 month and up to 12 months of follow-up (P < .001). Of the 30 athletes who underwent operation, 27 (90%) returned to sports activities after 3 months of convalescence compared to 8 (27%) of the 30 athletes in the nonoperative group (P < .0001). Of the 30 athletes in the conservatively treated group, 7 (23 %) underwent operation later because of persistent groin pain.

CONCLUSION

This randomized controlled study indicated that the endoscopic placement of retropubic mesh was more efficient than conservative therapy for the treatment of sportsman's hernia (athletic pubalgia).

Review: imaging of groin pain in the athlete

Chronic groin pain is a common entity in the sporting population and causes considerable morbidity. The differential diagnosis is wide, and this article presents a review of the common causes with particular reference to anatomy, ultrasound and magnetic resonance imaging (MRI) findings.

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.

Laparoscopic surgery for chronic groin pain in the general population: a prospective study

BACKGROUND

Chronic groin pain is a challenging problem among not only athletes but also the general population. The aim of this study was to evaluate the role of laparoscopic surgery in the management of these patients.

PATIENTS AND METHODS

Prospective data including the outcomes were collected and analyzed for 43 patients who had groin pain without clinical or radiologic evidence of hernia. All patients had magnetic resonance imaging scan and had consulted an orthopedic surgeon when appropriate. All patients were followed in clinic 2 weeks after operation and 6 months after the operation by phone call, and all were asked to call our unit in case of partial or no improvement.

RESULTS

From September 1999 to August 2006, we performed 1617 laparoscopic groin hernia repairs in 1209 patients using the transabdominal preperitoneal approach. Forty-three patients (3 women and 40 men) with variable life activities and employment were included in this study. Only five patients played football at a professional level. The mean age of these patients was 38 years (range, 17-74 years), and the mean follow-up was 43 months (range, 14-72 months).The clinical invagination test showed wide external inguinal ring in 27 (62.7%) patients and tender inguinal canal in another 6 (13.95%) patients. Negative laparoscopy was reported in 7 (16.27%) patients. All patients had mesh insertion. The operation cured groin pain in 30 (69.76%) patients, and the pain improved in another 9 (20.93%) patients. Three (6.97%) patients had no change in their symptoms, and the pain became worse in 1 (2.32%) patient.

CONCLUSION

We suggest offering laparoscopic groin exploration and mesh insertion for any adult patient presenting with chronic groin pain without clinical evidence of groin hernia or radiologic abnormality regardless of age, life activities, and employment.

Transabdominal preperitoneal laparoscopic approach for the treatment of sportsman's hernia

BACKGROUND

Groin pain in athletes presents a diagnostic and therapeutic challenge, particularly in distinguishing between those that will respond to nonoperative management and those that require surgery. Repair of sportsman's hernia, using the Modified Bassini darn or tension-free Lictenstein mesh technique, have been well described. The aim of this study was to assess the role of laparoscopy in the management of these hernias.

PATIENTS AND METHODS

Seventeen consecutive male patients (median age, 27 years), presenting with symptoms and signs of sportsman's hernia to a district general hospital were reviewed. Five patients presented with unilateral groin pain, whereas 12 had bilateral symptoms. All patients underwent a diagnostic laparoscopy, followed by transabdominal preperitoneal polypropelene mesh (15 x 10 cm) repair. All patients except 1 were discharged within 24 hours of surgery, and their rehabilitation was supervised by a single physiotherapist. All patients were assessed postoperatively by the authors and at a median follow-up of 23 weeks.

RESULTS

The laparoscopy confirmed posterior wall weakness in all patients with bilateral symptoms and in 4 of 5 patients with unilateral groin pain. Following repair, no surgical morbidity occurred and the median return to sporting activities was 42 days. All but 1 patient returned to the level of sport reached prior to injury, and mild pain was experienced in 5 groins, which did not interfere with either normal daily or sports activity.

CONCLUSION

The transabdominal preperitoneal laparoscopic approach is safe and feasible in the diagnosis and treatment of Sportsman's hernia, enabling a full return to sports activities.

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.

An 18-year review of sports groin injuries in the elite hockey player: clinical presentation, new diagnostic imaging, treatment, and results

OBJECTIVE

This is a retrospective study of 98 hockey players who underwent 107 surgical explorations for refractory lower abdominal and groin pain that prevented them from playing hockey at an elite level.

DESIGN

Retrospective chart review combined with a complete follow-up examination and questionnaire.

SETTING

The players were treated in an ambulatory care university tertiary care centre.

PATIENTS

A total of 98 elite hockey players underwent 107 surgical groin explorations for intractable groin pain preventing their play. Follow-up was 100%.

INTERVENTION

Each player had repair of a tear of the external oblique muscle and fascia reinforced by a Goretex mesh. The ilioinguinal nerve was resected in each patient.

OUTCOME MEASURES

There was absence of groin pain on the return to play hockey at an elite level.

RESULTS

In all, 97 of 98 players returned to play after the surgical procedures. No morbidity was attributed to division of the ilioinguinal nerve.

CONCLUSIONS

Surgical exploration of the involved groin with repair of the torn external oblique muscle and division of the ilioinguinal nerve has resulted in resolution of refractory groin pain and return to play in the elite hockey player. The surgical procedure is associated with a low morbidity. Recent observations on dynamic ultrasound show promise in accurately diagnosing this injury.

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.

Risk factors for chronic pain after inguinal hernia repair

INTRODUCTION

Chronic postoperative pain after inguinal hernia repair has an incidence of 0.7-36.7%. This study aimed to look for any relationship between patients presenting with severe pain at initial presentation or a past history of chronic pain conditions and the development of severe chronic pain following inguinal hernia repair.

PATIENTS AND METHODS

This was a retrospective study in which 24 patients referred to a chronic pain clinic following inguinal hernia repair were compared with 24 age- and sex-matched controls. Hospital notes were reviewed for the severity of presenting pain and a past history of chronic pain.

RESULTS

Average age was 55.4 years. In the chronic postoperative pain group, 14 (58%) presented with severe pain versus 3 (13%) in the pain-free group. Twelve (50%) of the chronic postoperative pain group had a past history of chronic pain conditions versus none of the pain-free group. Both of these factors showed a significant (P < 0.005) association with severe chronic pain postoperatively.

CONCLUSIONS

Patients with severe pain at presentation or with a past history of chronic pain conditions are at increased risk of severe chronic pain after inguinal hernia repair. A prospective study is needed to quantify any increased risk, although this would need to be of significant size.

Successful endoscopic treatment of chronic groin pain in athletes

BACKGROUND

Chronic groin pain, especially in professional sportsmen, is a difficult clinical problem.

METHODS

From January 1999 to August 2005, 55 professional and semiprofessional sportsmen (53 males; mean age, 25 +/- 4.5 years; range, 17-36 years) with undiagnosed chronic groin pain were followed prospectively. All the patients underwent an endoscopic total extraperitoneal (TEP) mesh placement.

RESULTS

Incipient hernia was diagnosed in the study athletes: 15 on the right side (27%), 12 on the left side (22%), and 9 bilaterally (16%). In 20 patients (36%), an inguinal hernia was found: 3 direct inguinal hernias (5%) and 17 indirect hernias (31%). All the athletes returned to their normal sports level within 3 months after the operation.

CONCLUSIONS

A TEP repair must be proposed to patients with prolonged groin pain unresponsive to conservative treatment. If no clear pathology is identified, reinforcement of the wall using a mesh offers good clinical results for athletes with idiopathic groin pain.

Abnormalities in and Around the Hip: MR Imaging Versus Sonography

Sonography and MR imaging should be considered complementary rather than competing modalities. They demonstrate similar abnormalities of the soft tissues, but MR imaging is able to demonstrate intraosseous and articular abnormalities and offers a better anatomic overview because of its larger field of view, whereas sonography offers dynamic evaluation and can provide real-time guidance for percutaneous procedures. Both of these modalities have roles in the imaging evaluation of injuries in and around the hip.