Groin pain in athletes

Nonsurgical Interventions for the Management of Long-Standing Groin Pain in Athletes: A Systematic Review of Randomized Controlled Trials

Groin pain is a common problem in athletes, leading to significant distress and long periods of absence from sports. Nonsurgical interventions are usually the first line of treatment. However, the most effective intervention for groin pain is unknown and recommendations are scarce. The primary objective of this systematic review was to assess the effectiveness of nonsurgical interventions in the treatment of long-standing groin pain in athletes and to provide some guidance for clinical practice and further research. A search strategy was performed in March 2020 in Pubmed, Google Scholar, PEDro, and Cochrane Central Register of Controlled Trials databases, without any time restrictions. Only randomized controlled trials (RCT) were included for full-text analysis. Data on the patient's characteristics, duration of pain, study groups, outcome measures results, follow-up time, and return to play time were extracted. The risk of bias in each study was assessed using the Cochrane risk-of-bias assessment tool. Data for analysis could not be pooled for meta-analysis and, as such, a narrative summary of the outcomes was instead performed. The certainty of the evidence was assessed using a variation of the GRADE approach for when a meta-analysis is not possible to perform. Seven RCTs were included for analysis. Most studies were classified as uncertain risk of bias. All studies provided evidence that nonsurgical interventions have significant positive effects and may lead to good outcomes concerning pain, function, and return to sports at previous levels. The certainty of the evidence was assessed to be low using the modified GRADE approach. Despite the low quality of the available evidence, nonsurgical treatments demonstrated efficacy in the management of groin pain and should probably be the initial approach to treatment. More RCTs of high quality are necessary to provide clear recommendations on the most efficient nonsurgical treatment strategy for groin pain.

Acute Groin Pain Syndrome Due to Internal Obturator Muscle Injury in a Professional Football Player

Traumatic groin pain syndrome is the result of an acute trauma, usually an indirect muscle injury (i.e., an overstretching of the muscle fibers). The most affected muscles in traumatic groin pain syndrome are rectus abdominis, adductors, and iliopsoas. The internal obturator muscle lesion is very rare. The internal obturator muscle externally rotates the thigh and contributes to the stabilization of the hip joint and its indirect injury may cause the onset of traumatic groin pain syndrome. This case report describes a rare indirect injury of internal obturator in a 29-year-old professional male soccer player.

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.

Non-surgical treatment of pubic overload and groin pain in amateur football players: a prospective double-blinded randomised controlled study

PURPOSE

The incidence of groin pain in athletes is steadily increasing. Symptomatic pubic overload with groin pain and aseptic osteitis pubis represent well-known and frequently misdiagnosed overuse injuries in athletes. This study investigated the benefits of standardised non-surgical treatment for swift return-to-football.

METHODS

In a prospective double-blinded controlled study, 143 amateur football players with groin pain as well as radiological signs and clinical symptoms of pubic overload were analysed for 1 year. Two randomised study groups participated in an intensive physical rehabilitation programme, either with or without shock wave therapy. The control group did not participate in any standardised rehabilitation programme but only stopped participating in sports activity. Follow-up examinations took place 1, 3 months and 1 year after the beginning of therapy. Endpoints were visual analogue scale (VAS), functional tests, the time of return-to-football, recurrent complaints and changes in the MR image.

RESULTS

Forty-four football players with groin pain and aseptic osteitis pubis were randomised into two study groups; 26 received shock wave therapy, 18 did not. Clinical examination showed pubic overload as a multi-located disease. Players receiving shock wave therapy showed earlier pain relief in the VAS (p < 0.001) and returned to football significantly earlier (p = 0.048) than players without this therapy. Forty-two of 44 players of both study groups returned to football within 4 months after the beginning of therapy and had no recurrent groin pain within 1 year after trauma. Fifty-one players of the control group returned to football after 240 days (p < 0.001), of whom 26 (51%) experienced recurrent groin pain. Follow-up MRI scans did not show any effect of shock wave therapy.

CONCLUSION

Non-surgical therapy is successful in treating pubic overload and osteitis pubis in athletes. Shock wave therapy as a local treatment significantly reduced pain, thus enabling return-to-football within 3 months after trauma. Early and correct diagnosis is essential for successful intensive physiotherapy.

LEVEL OF EVIDENCE

I.

Evaluation and Management of Hip and Pelvis Injuries

Injuries to the hip and pelvis among runners can be among the most challenging to treat. Advances in the understanding of running biomechanics as it pertains to the lumbopelvic and hip regions have improved the management of these conditions. Conservative management with an emphasis on activity modification and neuromuscular exercises should comprise the initial plan of care, with injection therapies used in a supportive manner.

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

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

Sportsman's hernia? An ambiguous term

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

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

Review of sport-induced groin injuries

CONTEXT

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

EVIDENCE ACQUISITION

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

RESULTS

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

CONCLUSIONS

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

Emerging intra-articular causes of groin pain in athletes

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

Lateral hip pain in an athletic population: differential diagnosis and treatment options

CONTEXT

Historically, the term greater trochanteric pain syndrome has been used to describe a spectrum of conditions that cause lateral-sided hip pain, including greater trochanteric bursitis, snapping iliotibial band, and/or strains or tendinopathy of the abductor mechanism. Diagnosis of these conditions may be difficult because clinical presentations are variable and sometimes inconclusive. Especially difficult is differentiating intrinsic pain from pain referred to the greater trochanteric region. The purposes of this article are to review the relevant anatomy and pathophysiology of the lateral hip.

EVIDENCE ACQUISITION

Data were collected through a thorough review of the literature conducted through a MEDLINE search of all relevant papers between 1980 and January 2010.

RESULTS

Recent advances in imaging and an improved understanding of pathomechanics have helped to guide the evaluation, diagnosis, and appropriate treatment for patients presenting with lateral hip pain.

CONCLUSION

Various diagnostic tools and treatment modalities can be used to effectively manage the athletic patient presenting with lateral hip pain.

Bilateral mini-invasive adductor tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes

BACKGROUND

To date, the best management of chronic groin pain related to adductor longus tendinopathy has not been defined. Although there have been some studies investigating the effectiveness of adductor longus tenotomy, none have investigated bilateral adductor tenotomy for unilateral tendinopathy.

HYPOTHESIS

The use of bilateral percutaneous adductor tenotomy for the management of chronic unilateral groin pain as a result of adductor longus tendinopathy will result in improvement of overall function and facilitate a return to athletic activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

During the period from 2004 to 2007, we prospectively enrolled 29 consecutive athletes (26 male and 3 female; median age, 28 years) with chronic groin pain from unilateral adductor longus tendinopathy who underwent bilateral adductor tenotomy. Functional outcome and health status were assessed with the Hip Disability and Osteoarthritis Outcome Score (HOOS), Short Form Health Survey (SF-36), and European Quality of Life-5 Dimensions scale (EQ-5D). The ability to participate in sport before and after surgery and the time to return to training and return to sport were also recorded. The median follow-up after surgery was 36 months.

RESULTS

All questionnaires showed a statistically significant improvement (P < .0001) after surgery. At the time of latest follow-up, 20 of 29 patients (69%) returned to their preinjury level of sport and 2 of 29 patients (7%) to higher levels compared with preinjury status. However, 4 of 29 patients (14%) returned to sport at lower levels than those of preinjury status, and 3 of 29 patients (10%) ceased to participate in sport. The median time to return to training was 11 weeks and to return to sport was 18 weeks.

CONCLUSION

Bilateral mini-invasive adductor tenotomy can be an effective treatment for athletes suffering from unilateral chronic groin pain associated with adductor longus tendinopathy refractory to nonoperative management.

Adductor tenotomy: its role in the management of sports-related chronic groin pain

PATIENTS AND METHODS

Chronic adductor-related groin pain in athletes is debilitating and is often challenging to treat. Little is published on the surgical treatment when conservative measures fail. This single center study reviews the outcomes of 48 patients (68 groins) who underwent percutaneous adductor tenotomy for sports-related chronic groin pain. Questionnaire assessments were made preoperatively and at a minimum follow-up of 25 months.

RESULTS

Mean pre-injury Tegner activity scores of 8.8 reduced to 6.1 post-injury and these improved to 7.7 following surgery (p < 0.001). Sixty percent of patients regained or bettered their pre-injury Tegner activity scores after the adductor surgery; however, mean post-surgical Tegner scores still remained lower than pre-injury scores (p < 0.001). No patient had been able to engage in their chosen sport at their full ability pre-operatively, and 40% had been unable to participate in any sporting activity. The mean return to sports was at 18.5 weeks postoperatively, with 54% returning to their pre-injury activity levels, and only 8% still unable to perform athletic activities at latest follow-up. Seventy-three percent patients rated the outcome of their surgery as excellent or very satisfactory, and only three patients would not have wished to undergo the procedure again if symptoms recurred or developed on the opposite side. No patients reported their outcome as worse. A 78.1% mean improvement in function and an 86.5% mean improvement in pain were reported, and these two measures showed statistically significant correlation (p = 0.01). Groin disability scores improved from a mean of 11.8 to 3.9, post-operatively (p < 0.001). Bruising was seen in 37% of procedures, 3 patients developed a scrotal hematoma and 1 patient had a superficial wound infection. One patient developed recurrent symptoms following re-injury 26 months post-surgery, and fully recovered following a further adductor tenotomy.

CONCLUSIONS

Adductor tenotomy provides good symptomatic and functional improvement in chronic adductor-related groin pain refractory to conservative treatment.

A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes

Background

Athletes competing in sports that require running, changes in direction, repetitive kicking and physical contact are at a relatively higher risk of experiencing episodes of athletic groin pain. To date, there has been no systematic review that aims to inform clinicians about the best available evidence on features of exercise interventions for groin pain in athletes. The primary aim of this systematic review was to evaluate the available evidence on the effectiveness of exercise therapy for groin pain in athletes. The secondary aim of this review was to identify the key features of exercise interventions used in the management of groin pain in an athletic population.

Methods

MEDLINE, CINAHL, PubMed, SPORTSDiscus, Embase, AMED, Ovid, PEDro, Cochrane Controlled Trials Register and Google Scholar databases were electronically searched. Data relating to research design, sample population, type of sport and exercise intervention was extracted. The methodological evaluation of included studies was conducted by using a modified quantitative critical appraisal tool.

Results

The search strategy identified 468 studies, 12 of which were potentially relevant. Ultimately five studies were included in this review. Overall the quality of primary research literature was moderate, with only one randomised controlled trial identified. All included studies provided evidence that an exercise intervention may lead to favourable outcomes in terms of return to sport. Four of the five studies reviewed included a strengthening component and most utilised functional, standing positions similar to those required by their sport. No study appropriately reported the intensity of their exercise interventions. Duration of intervention ranged from 3.8 weeks to 16 weeks. All five studies reported the use of one or more co-intervention.

Conclusion

Best available evidence to date, with its limitations, continues to support common clinical practice of exercise therapy as a key component of rehabilitation for groin pain in athletes. Overall, the available evidence suggests that exercise, particularly strengthening exercise of the hip and abdominal musculature could be an effective intervention for athletes with groin pain. Literature provides foundational evidence that this may need to be in the form of progressive exercises (static to functional) and performed through range. There is currently no clear evidence regarding the most effective intensity and frequency of exercise, because of a lack of reporting in the primary literature.

Persistent anterior hip pain in young adults: current aspects of diagnosis

Persistent anterior hip pain, in young adults, presents a diagnostic and treatment challenge to hip surgeons. Diagnosis, in some cases, is difficult because available diagnostic tools are not very reliable, resulting in a difficult decision making process. This article discusses the possible causes, current knowledge of the condition and outlines a method to approach this difficult problem.

Self-reported injury history and lower limb function as risk factors for injuries in female youth soccer

BACKGROUND

Identifying and understanding injury risk factors are necessary to develop and target measures to prevent injuries. Because youth teams rarely have health care professionals working directly with the team, identifying players at increased risk through elaborate clinical tests is not feasible. Questionnaires may be a possible alternative as screening instruments.

PURPOSE

To examine whether injury history and lower limb function assessed by a self-administered questionnaire represent risk factors for injury.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

At baseline, female soccer players (aged 14-16 years) were asked to complete a detailed questionnaire covering sports participation; history of previous injuries to the ankle, knee, hamstring, or groin; as well as present function of these 4 specific regions. A total of 1430 (71% of the entire cohort) were followed up to record injuries during the subsequent 8 months.

RESULTS

A history of a previous injury to the ankle (rate ratio, 1.2 [1.1-1.3]; P < .001), knee (rate ratio, 1.4 [1.2-1.6]; P <.001), or groin (rate ratio, 1.6 [1.2-2.1]; P = .004) increased the risk of new injuries to the same region. Reporting a reduced function (defined as <80% of the maximum score) for the ankle (rate ratio, 1.7 [1.1-2.7]; P =.021) or knee (rate ratio, 3.2 [1.8-5.7]; P <.001) was also a significant risk factor. However, the sensitivity of previous injuries and lower limb function in predicting new injuries was low.

CONCLUSION

A history of previous injury and reduced function at baseline were significant risk factors for new injuries to the same region during the following season.