The incidence and differential diagnosis of acute groin injuries in male soccer players

Hip Sideline Emergencies and Hip Injuries in Elite Athletes

PURPOSE OF REVIEW

Hip injuries in elite athletes are an increasingly recognized problem and range from chronic overuse injuries, such as adductor strains and labral tears, to acute traumatic injuries such as hip dislocations. In this article, we review common hip pathology experienced by elite athletes and sideline management of emergent hip injuries.

RECENT FINDINGS

Elite athletes are subject to unique physical and mental stresses and therefore must be evaluated and treated in a unique manner. Hip and groin injuries account for approximately 6% of sport injuries overall and 3-15% of all injuries in professional sports. Hip sideline emergencies were rare but can include hip dislocations, subluxations, and avulsion fractures. Hip and groin injuries represent an important subset of injuries which can greatly impact an athlete's ability to perform. Understanding the physiology and types of hip/groin injuries, which athletes are prone to injuries, the impact on recovery time, recurrence risk, and the potential need for surgery aid sports medicine physicians in decision-making.

Risk Factors for Athletic Pubalgia in Collegiate Football Student-Athletes: A Retrospective Cohort Study

BACKGROUND

Athletic pubalgia (AP) is an increasingly recognized injury among young athletes. This study aimed to evaluate the characteristics associated with AP in college football players.

HYPOTHESIS

Repetitive explosive movements that require aggressive core muscle activation results in AP in collegiate football players.

STUDY DESIGN

Retrospective cohort design.

LEVEL OF EVIDENCE

Level 3.

METHODS

Football student-athletes at a single Division I collegiate institution from January 2010 to December 2019 were included in the study. The primary outcome measure was surgery for AP. The odds of AP were determined using logistic regression, with the dependent variable being whether or not the student-athlete received AP surgery. Independent variables included Olympic weightlifting (OWL) exposure, primary playing position (skill position vs nonskill position), and body mass index (BMI).

RESULTS

A total of 1154 total student-athlete exposures met the inclusion criteria. Of the 576 student-athletes exposed to OWL (OWL occurred throughout entire calendar year), 20 developed AP, whereas 7 student-athletes not exposed to OWL (OWL was not performed at any point during calendar year) developed AP. Student-athletes exposed to OWL had a 2.86 (95% CI, 1.25-7.35; P = 0.02) times higher odds of AP than players not exposed after controlling for primary playing position and BMI. Skill position players had a 9.32 (95% CI, 1.71-63.96; P = 0.01) times higher odds of AP than nonskill position players when controlling for BMI and OWL training.

CONCLUSION

Modifiable factors that increase exposure to repetitive explosive activities, such as OWL and playing a skill position, may be important considerations in developing AP.

CLINICAL RELEVANCE

The cause of AP is multifactorial and poorly understood. Identifying factors associated with AP informs athletes, athletic trainers, physicians, and coaches.

The great pretender: Multi-system tuberculosis and pathological fracture masquerading as a severe acute football groin injury - Case study with a 5-year follow-up

In this clinical case, a man presented with a groin injury on his dominant side, which he apparently sustained in football (soccer) practice on the previous day. The man was unable to walk unassisted and had to be transported in a wheelchair. The consulting practitioner grew suspicious upon finding minimal clinical evidence and nothing notable on the X-ray to suggest a severe acute injury. A subsequent detailed workup revealed extrapulmonary tuberculosis (EPTB) of the musculoskeletal (MSK) and genitourinary tract (GUT) systems, complicated by a pathological fracture of the acetabulum, as the cause of the groin injury. Management of the EPTB resolved the condition with no relapse nor long-term sequelae beyond five years, despite being immunocompromised. We present the clinical case and a five year follow-up. The case serves as a reminder of the possibility that other conditions may mimic sports injuries and further illustrates a rare presentation of such a condition.

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

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

The challenges in diagnosis and management of osteitis pubis: An algorithm based on current evidence

Objective

The objective of this study is to summarise the contemporary evidence regarding the prevalence, diagnosis, and management of osteitis pubis (OP) specially from urological point of view, while proposing an algorithm for the best management based on the current evidence.

Methods

We performed a literature search using the PubMed database for the term 'osteitis pubis' until December 2020. We assessed pre-clinical and clinical studies regarding the aetiology, pathophysiology, and management of OP. Case reports and case series were evaluated by study quality and patient outcomes to determine a potential clinical management algorithm.

Results

Osteitis pubis is a chronic painful condition of the symphysis pubis joint and its surrounding structures. Still, there is a paucity of data outlining the management plan and the possible triggers. The aetiology seems to be multifactorial with different proposals trying to explain the pathophysiology and correlate the findings to the outcome. The diagnosis is usually based on high suspicion index and clinical experience. The infective variant of the disease is aggressive and requires strict and active management. Universal consensus is still lacking regarding a formal algorithm of management of the condition, especially due to multiple specialities involved in the decision-making process. Conservative management remains the cornerstone; nevertheless, surgical interventions may be needed in special settings. Hence, a multi-disciplinary approach is of pivotal value in fashioning the plan for each case. The prognosis is usually satisfactory; however, a longstanding debilitating disease form is not uncommon.

Conclusion

OP remains a rare condition with real challenges in its diagnosis. The current management is focused on conservative management; however, surgical intervention is still needed in some difficult scenarios. Continued research into the triggers of OP, multidisciplinary approach, and standardised clinical pathways can improve the quality of care for patients suffering from this condition.

[Arthroscopically assisted minimally invasive symphysioplasty for the treatment of pubic related groin pain]

OBJECTIVE

Therapy of pubic related groin pain via minimally invasive symphysioplasty.

INDICATIONS

Therapy of refractory pubic related groin pain based on osteitis pubis.

CONTRAINDICATIONS

Groin pain from causes other than pubic related groin pain.

SURGICAL TECHNIQUE

After a minimally invasive approach, an incision in the anterior capsule is made while protecting the dorsal capsule parts and the arcuate pubic ligament. The symphysis end plates are remodeled arthroscopically assisted using a surgical burr. The newly created pubic symphysis joint is filled with autogenous fibrin to support the formation of a new discus interpubicus.

POSTOPERATIVE MANAGEMENT

Partial weight-bearing for 4 weeks with 20 kg using crutches is recommended. During the first 4 weeks the range of motion should be restricted.

RESULTS

Since 2010, 10 athletes (7 men, 3 women; average age 34.1 ± 7.8 (23-47) years) have undergone arthroscopically assisted minimally invasive symphysioplasty and treatment of femoroacetabular impingement syndrome. The average follow-up time was 5.1 (2-9) years. All patients returned to their sport level. The mean preoperative Nonarthritic Hip Score (NAHS) of 64.4 ± 15.1 (32.1-86.5) points improved to a mean postoperative NAHS of 91.4 ± 9.8 (62.4-98.75) points (p < 0.0001). The average patient satisfaction (scale 0 to 10; 10 highest satisfaction) was 9.8 ± 0.4 (9-10).

Sex-Related Hip Strength Measures Among Professional Soccer Players

ABSTRACT

Hedt, CA, Pearson, JM, Lambert, BS, McCulloch, PC, and Harris, JD. Sex-related hip strength measures among professional soccer players. J Strength Cond Res 35(7): 1992-1999, 2021-Lower-extremity musculoskeletal injuries in soccer are common among sexes. However, it remains unknown whether differences between sexes exist with regard to absolute or relative hip strength and how these differences may relate to injury. In the current study, we performed a retrospective cross-sectional analysis of pre-season data from male (♂n = 21) and female (♀n = 19) professional United States soccer organizations. Two years of pre-season data were collected for peak strength of lower extremity and hip musculature (no duplicates used). A 2 × 2 multivariate analysis of variance was used to detect differences in hip strength between sexes and dominant compared with nondominant legs. For all significant multivariate effects indicated by Wilks lambda and follow-up univariate analysis, a Tukey's post hoc test was used for pairwise univariate comparisons. A 2-tailed independent-samples T-test was used for comparison of height, body mass, body mass index (BMI), mean leg length, and strength ratios between dominant and nondominant limbs between sexes. Type I error was set at α = 0.05 for all analyses. Height (♂183.1 ± 6.8 cm, ♀170.0 ± 5.5 cm), body mass (♂79.0 ± 8.7 kg, ♀65.1 ± 5.6 kg), BMI (♂23.5 ± 1.3 kg·m-2, ♀22.5 ± 1.4 kg·m-2), and mean leg length (♂95.5 ± 4.34 cm, ♀ 88.3 ± 3.24 cm) differed between groups (p < 0.05). Sex differences (p < 0.05) were also found for hip abduction (dominant ♂19.5 ± 3.6 kg, ♀17.3 ± 2.2 kg; nondominant ♂18.5 ± 3.7 kg, ♀16.0 ± 2.3 kg), adduction (dominant ♂19.8 ± 3.0 kg, ♀16.7 ± 2.3 kg; nondominant ♂20.1 ± 2.9 kg, ♀17.6 ± 2.9 kg), external rotation (dominant ♂21.7 ± 3.4 kg, ♀17.7 ± 2.4 kg; nondominant ♂21.6 ± 3.9 kg, ♀16.8 ± 2.1 kg), and dominant hamstring strength (♂27.9 ± 6.5 kg, ♀23.0 ± 4.9 kg). The ratio of hip internal to external rotation strength differed in the nondominant leg (♂1.1 ± 0.2, ♀0.9 ± 0.2, p < 0.05). No significant differences were found between males and females when measures were normalized to body mass. These findings provide baseline pre-season normative data for professional soccer athletes and indicate that strength differences can be expected among different sexes, but are attenuated with attention to body mass. Further research should indicate how pre-season strength measures relate to injury.

Hip and Groin Pain in Soccer Players

Purpose  The aim of this article is to illustrate the recent framework necessary to standardize studies on groin pain and review the existing literature on groin pain in football. Methods  The common pathological processes underlying groin pain such as muscle, tendon or ligament strain, bone injury or fracture, sport hernia, bursitis, osteitis pubis, and hip-related diseases have been reviewed and current management options have been considered. Results  Groin pain is considered a pain in pubic or lower abdominal or adductors region which can be monolateral or bilateral. It is common in high-intensity team sports and can negatively affect an athlete's professional carrier, causing serious disruption in the performance. Despite a high prevalence of groin pain in athletes, diagnosis and management of the underlying pathological processes remain a challenge for surgeons, radiologists, and physiotherapists alike. Conclusion  A multidisciplinary approach is essential for patients with groin pain allowing prompt diagnosis and initiation of treatment thus facilitating more rapid return to play and preventing potential long-term sequelae of chronic groin pathology.

Strength Conditioning Program to Prevent Adductor Muscle Strains in Football: Does it Really Help Professional Football Players?

Coaches at the professional level are often concerned about negative side effects from testing and intensive resistance training periods, and they are not willing to base their training prescriptions on data obtained from semiprofessional or amateur football players. Consequently, the purpose of this study was to analyze the reliability and effectiveness of two adductor injury active prevention programs using the adductor/abductor ratio and deficit between legs, on the basis of adduction-abduction power output during the exercises proposed, in professional football players. Forty-eight professional football players undertook complementary strength training for the adductor and abductor muscles in their dominant and non-dominant legs, once or twice a week throughout the playing season. The volume of the session was determined by the adductor/abductor ratio and the deficit between legs in the last session training measured. The number and severity of muscle injuries per 1000 h of exposure were recorded. Both prevention programs showed a very low rate of adductor injury (0.27 and 0.07 injuries/1000 h) with mild-to-moderate severity, maintaining a balance in percentage asymmetry between dominant and non-dominant legs for adductor (10.37%) and in the adductor/abductor ratio (0.92) in top professional football players throughout the season. The strength conditioning program proposed can help to prevent adductor muscle injuries in top professional football players.

Short-term Effect of Ultrasound-Guided Iliopsoas Peritendinous Corticosteroid Injection

OBJECTIVES

Treatment for iliopsoas tendinopathy includes ultrasound (US)-guided iliopsoas peritendinous corticosteroid injection. Evidence is lacking regarding US-guided iliopsoas injection efficacy in patients with iliopsoas tendinopathy and intra-articular (IA) hip abnormalities. The purpose of this study was to examine the efficacy of US-guided iliopsoas corticosteroid injection for iliopsoas tendinopathy in patients with and without IA hip abnormalities.

METHODS

This work was a prospective study evaluating patients aged 12 to 50 years with iliopsoas tendinopathy. Participants completed a Hip Disability and Osteoarthritis Outcome Score (HOOS) questionnaire before and 6 weeks after injection. The main outcome measure was the change in HOOS subcategory scores. Independent variables included time and hip status. Normal hips were compared to abnormal hips with IA abnormalities. A 2-way repeated measures analysis of covariance with effect size (η² ) was used to determine injection effects on HOOS scores before and 6 weeks after injection.

RESULTS

A total of 178 patients (154 female and 24 male) were analyzed. Time effects were found for both normal and abnormal hips in all HOOS subcategories: symptoms (P = .041; η²  = 0.050), pain (P = .001; η²  = 0.184), activities of daily living (P = .011; η²  = 0.076), function in sports and recreation (P = .001; η²  = 0.151), and quality of life (QOL; P = .001; η²  = 0.193). Significant differences between normal versus abnormal hips were found in the sports and recreation (P = .032; η²  = 0.056) and QOL scores (P = .001; η²  = 0.135).

CONCLUSIONS

In patients with iliopsoas tendinopathy, US-guided iliopsoas corticosteroid injection improved outcomes regardless of coexisting IA hip abnormalities. Patients without IA hip abnormalities showed greater improvement in sports and recreation and QOL scores compared to patients with IA hip abnormalities. Ultrasound-guided iliopsoas injection for iliopsoas tendinopathy may advance short-term care and help continue with nonsurgical treatment regimens.

Management of osteitis pubis in athletes: rehabilitation and return to training - a review of the most recent literature

Osteitis pubis is a common cause of chronic groin pain, especially in athletes. Although a precise etiology is not defined, it seems to be related to muscular imbalance and pelvic instability. Diagnosis is based on detailed history, clinical evaluation, and imaging, which are crucial for a correct diagnosis and proper management. Many different therapeutic approaches have been proposed for osteitis pubis; conservative treatment represents the first-line approach and provides good results in most patients, especially if based on an individualized multimodal rehabilitative management. Different surgical options have been also described, but they should be reserved to recalcitrant cases. In this review, a critical analysis of the literature about athletic osteitis pubis is performed, especially focusing on its diagnostic and therapeutic management.

Imaging of the Pelvis and Lower Extremity: Demystifying Uncommon Sources of Pelvic Pain

Pelvic pain can result from gastrointestinal, gynecologic, urologic, neurologic, and musculoskeletal sources. This article focuses on the musculoskeletal lesions that contribute to acute and chronic pain throughout the musculoskeletal core. Armed with an understanding of musculoskeletal core anatomy and biomechanics, imagers play an integral role in the accurate diagnosis and treatment planning for patients with pain and dysfunction from pelvic sources. MR imaging is the primary imaging modality used, but focused sonographic and radiographic techniques have a role. Ultimately, radiologists can help guide patients to the most appropriate subspecialty clinicians based on the underlying source of symptoms.

Groin pain in athletes and non-interventional rehabilitative treatment: a systematic review

INTRODUCTION

Groin pain is a common complaint both in high-performance and recreational athletes. Diagnosis is based on the patient's history and physical examination. Imaging assessments are often considered to exclude other pathologies. To date there is no strong evidence to support conservative or surgical treatment options. The purpose of this study is to shed light on the more effective non-interventional rehabilitative treatments for the management of groin pain in athletes and, if possible, provide guidelines useful for clinical practice.

EVIDENCE ACQUISITION

The following electronic databases were searched: PubMed, Physiotherapy Evidence Database (PEDro), Scopus, Web of Science, Google and Google Scholar. Databases were investigated from January 1997 until March 2017.

EVIDENCE SYNTHESIS

The results reported in the randomized clinical trial studies highlight that active treatment is better than passive treatment to improve clinical signs of groin pain. Comparing the active strategy with multi-modal treatment the latter allows a faster return to sport activity. Although the evidence remains poor, all the included literature highlights that an integrated strategy which combines active and passive treatment, the assessment of perceived pain, a return to running program and specific-sport exercises is an effective strategy for management of groin pain in athletes.

CONCLUSIONS

Although we shed some light on common key aspects able to improve the typical signs of groin pain, on the basis of available data we were unable to provide practice guidelines. Further studies are necessary to set the best treatment algorithm for the management of groin pain in athletes.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

INTRODUCTION

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

Movement Patterns and Muscular Function Before and After Onset of Sports-Related Groin Pain: A Systematic Review with Meta-analysis

Background

Sports-related groin pain (SRGP) is a common entity in rotational sports such as football, rugby and hockey, accounting for 12–18 % of injuries each year, with high recurrence rates and often prolonged time away from sport.

Objective

This systematic review synthesises movement and muscle function findings to better understand deficits and guide rehabilitation.

Study Selection

Prospective and retrospective cross-sectional studies investigating muscle strength, flexibility, cross-sectional area, electromyographic activation onset and magnitude in patients with SRGP were included.

Search Methods

Four databases (MEDLINE, Web of Knowledge, EBSCOhost and EMBASE) were searched in June 2014. Studies were critiqued using a modified version of the Downs and Black Quality Index, and a meta-analysis was performed.

Results

Seventeen studies (14 high quality, 3 low quality; 8 prospective and 9 retrospective) were identified. Prospective findings: moderate evidence indicated decreased hip abduction flexibility as a risk factor for SRGP. Limited or very limited evidence suggested that decreased hip adduction strength during isokinetic testing at ~119°/s was a risk factor for SRGP, but no associations were found at ~30°/s or ~210°/s, or with peak torque angle. Decreased hip abductor strength in angular velocity in ~30°/s but not in ~119°/s and ~210°/s was found as a risk factor for SRGP. No relationships were found with hip internal or external rotation range of movement, nor isokinetic knee extension strength. Decreased isokinetic knee flexion strength also was a potential risk factor for SRGP, at a speed ~60°/s. Retrospective findings: there was strong evidence of decreased hip adductor muscle strength during a squeeze test at 45°, and decreased total hip external rotation range of movement (sum of both legs) being associated with SRGP. There was strong evidence of no relationship to abductor muscle strength nor unilateral hip internal and external rotation range of movement. Moderate evidence suggested that increased abduction flexibility and no change in total hip internal rotation range of movement (sum of both legs) were retrospectively associated with SRGP. Limited or very limited evidence (significant findings only) indicated decreased hip adductor muscle strength during 0° and 30° squeeze tests and during an eccentric hip adduction test, but a decrease in the isometric adductors-to-abductors strength ratio at speed 120°/s; decreased abductors-to-adductors activation ratio in the early phase in the moving leg as well as in all three phases in the weight-bearing leg during standing hip flexion; and increased hip flexors strength during isokinetic and decrease in transversus abdominis muscle resting thickness associated with SRGP.

Conclusions

There were a number of significant movement and muscle function associations observed in athletes both prior to and following the onset of SRGP. The strength of findings was hampered by the lack of consistent terminology and diagnostic criteria, with there being clear guides for future research. Nonetheless, these findings should be considered in rehabilitation and prevention planning.

Epidemiology of time loss groin injuries in a men's professional football league: a 2-year prospective study of 17 clubs and 606 players

BACKGROUND/AIM

Groin injury epidemiology has not previously been examined in an entire professional football league. We recorded and characterised time loss groin injuries sustained in the Qatar Stars League.

METHODS

Male players were observed prospectively from July 2013 to June 2015. Time loss injuries, individual training and match play exposure were recorded by club doctors using standardised surveillance methods. Groin injury incidence per 1000 playing hours was calculated, and descriptive statistics used to determine the prevalence and characteristics of groin injuries. The Doha agreement classification system was used to categorise all groin injuries.

RESULTS

606 footballers from 17 clubs were included, with 206/1145 (18%) time loss groin injuries sustained by 150 players, at an incidence of 1.0/1000 hours (95% CI 0.9 to 1.1). At a club level, 21% (IQR 10%-28%) of players experienced groin injuries each season and 6.6 (IQR 2.9-9.1) injuries were sustained per club per season. Of the 206 injuries, 16% were minimal (1-3 days), 25% mild (4-7 days), 41% moderate (8-28 days) and 18% severe (>28 days), with a median absence of 10 days/injury (IQR 5-22 days). The median days lost due to groin injury per club was 85 days per season (IQR 35-215 days). Adductor-related groin pain was the most common entity (68%) followed by iliopsoas (12%) and pubic-related (9%) groin pain.

CONCLUSION

Groin pain caused time loss for one in five players each season. Adductor-related groin pain comprised 2/3 of all groin injuries. Improving treatment outcomes and preventing adductor-related groin pain has the potential to improve player availability in professional football.

Imaging of Groin Pain: Magnetic Resonance and Ultrasound Imaging Features

CONTEXT

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

EVIDENCE ACQUISITION

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

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

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

CONCLUSION

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

Nonoperative treatment and return to play after complete proximal adductor avulsion in high-performance athletes

PURPOSE

To assess the outcome of nonoperative treatment after complete avulsion of the proximal adductor longus tendon in high-performance athletes.

METHODS

Six consecutive athletes were included. Treatment was conservative following a strict rehabilitation plan. Following parameters were analysed: basic data, mechanism of injury, classification, tendon retraction, size of defect in MRI and return to play (RTP).

RESULTS

Mean age at injury was 28 ± 5 (range 20-32) years. Overstretch (83 %) and kicking (50 %) were the most frequent injury mechanisms, and the dominant leg was involved in 83 %. Average retraction of the avulsed tendon amounted 21 ± 5 mm. Follow-up MRIs demonstrated a gradual reattachment of the tendon in all cases. All athletes returned to full sportive activity on preinjury level within 88.7 ± 12.8 (range 75-110) days with no functional deficiencies. Manual muscle strength was equal to the contralateral side.

CONCLUSION

Nonoperative treatment with a healing phase and a strict rehabilitation plan results in a functional, efficient reattachment of the tendon and allows unrestricted RTP. Since these injuries are rare, present study may help sports physicians when dealing with this type of injuries in professional athletes. Return to sports can be expected at approximately 13 weeks after injury, but can take even longer.

LEVEL OF EVIDENCE

Case series, Level IV.

The reliability of a maximal isometric hip strength and simultaneous surface EMG screening protocol in elite, junior rugby league athletes

OBJECTIVES

Firstly to describe the reliability of assessing maximal isometric strength of the hip abductor and adductor musculature using a hand held dynamometry (HHD) protocol with simultaneous wireless surface electromyographic (sEMG) evaluation of the gluteus medius (GM) and adductor longus (AL). Secondly, to describe the correlation between isometric strength recorded with the HHD protocol and a laboratory standard isokinetic device.

DESIGN

Reliability and correlational study.

METHODS

A sample of 24 elite, male, junior, rugby league athletes, age 16-20 years participated in repeated HHD and isometric Kin-Com (KC) strength testing with simultaneous sEMG assessment, on average (range) 6 (5-7) days apart by a single assessor. Strength tests included; unilateral hip abduction (ABD) and adduction (ADD) and bilateral ADD assessed with squeeze (SQ) tests in 0 and 45° of hip flexion.

RESULTS

HHD demonstrated good to excellent inter-session reliability for all outcome measures (ICC_(2,1)=0.76-0.91) and good to excellent association with the laboratory reference KC (ICC_(2,1)=0.80-0.88). Whilst intra-session, inter-trial reliability of EMG activation and co-activation outcome measures ranged from moderate to excellent (ICC_(2,1)=0.70-0.94), inter-session reliability was poor (all ICC_(2,1)<0.50).

CONCLUSIONS

Isometric strength testing of the hip ABD and ADD musculature using HHD may be measured reliably in elite, junior rugby league athletes. Due to the poor inter-session reliability of sEMG measures, it is not recommended for athlete screening purposes if using the techniques implemented in this study.

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.

Osteitis pubis in elite athletes: Diagnostic and therapeutic approach

Osteitis pubis (OP) is a debilitating overuse syndrome characterizing by pelvic pain and local tenderness over the pubic symphysis commonly encountered in athletes often involved in kicking, twisting and cutting activities in sports such as soccer and rugby and to a lesser degree distance running. It is a common source of groin pain in elite athletes attributable to pubis sympysis instability as the result of microtrauma caused by repetitive muscle strains on pubic bones. Diagnosis is based mainly on detailed sports history and a meticulous clinical examination, although occasionally is difficult to distinguish this nosological entity from other pathologies affecting the involved area which may occur concomitantly in the same patient. Radiologic examinations such as plain radiographs, magnetic resonance imaging and 3 phase bone isotope scanning may be helpful to differentiate from other clinical entities with similar clinical presentation. Most cases respond well to conservative treatment which includes several physical modalities and especially a progressive rehabilitation programmed individualized to each one of patients diagnosed with OP. Local injection therapies have been also been proposed as a non-operative therapeutic option for the efficient management of these patients. In refractory cases, surgical therapeutic strategies are warranted. These include several open or minimally invasive surgical interventions such as arthroscopic or open symphysis curettage, wedge or total resection of pubic sympysis, polypropylene mesh placement and pubic fusion. In this review a critical analysis of OP in elite athletes is performed with special focus on current concepts of diagnosis and management of this source of athletic groin pain.

Sports hernia and femoroacetabular impingement in athletes: A systematic review

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

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

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

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

Diagnosis of Acute Groin Injuries: A Prospective Study of 110 Athletes

BACKGROUND

Acute groin injuries are common in high-intensity sports, but there are insufficient data on injury characteristics such as injury mechanisms and clinical and radiological findings.

PURPOSE

To describe these characteristics in a cohort of athletes.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 110 male athletes (mean age, 25.6 ± 4.7 years) with sports-related acute groin pain were prospectively included within 7 days of injury from August 2012 to April 2014. Standardized history taking, a clinical examination, magnetic resonance imaging (MRI), and/or ultrasound (US) were performed.

RESULTS

The most frequent injury mechanism in soccer was kicking (40%), and change of direction was most frequent in other sports (31%). Clinically, adductor injuries accounted for 66% of all injuries and primarily involved the adductor longus on imaging (91% US, 93% MRI). The iliopsoas and proximal rectus femoris were also frequently injured according to all examination modalities (15%-25%). Acute injury findings were negative in 22% of the MRI and 25% of the US examinations. Of the clinically diagnosed adductor injuries, 3% (US) and 6% (MRI) showed a radiological injury in a different location compared with 35% to 46% for clinically diagnosed iliopsoas and proximal rectus femoris injuries.

CONCLUSION

Adductor injuries account for the majority of acute groin injuries. Iliopsoas and proximal rectus femoris injuries are also common. More than 1 in 5 injuries showed no imaging signs of an acute injury. Clinically diagnosed adductor injuries were often confirmed on imaging, whereas iliopsoas and rectus femoris injuries showed a different radiological injury location in more than one-third of the cases. The discrepancy between clinical and radiological findings should be considered when diagnosing acute groin injuries.

Endoscopic Pubic Symphysectomy for Recalcitrant Osteitis Pubis

Recalcitrant osteitis pubis presents a challenging problem for orthopaedic surgeons. Various surgical interventions have been described for treatment, including opening-wedge resection, symphysiodesis, and curettage. We propose that endoscopic pubic symphysectomy offers an effective method of treating such a challenging problem. This article describes in detail the technique used to perform endoscopic pubic symphysectomy, and a companion video demonstrating the procedure is included. Our experience suggests that removal of the interpubic fibrocartilaginous lamina and resection of approximately 1 cm of bone can successfully eliminate all sources of pain and dysfunction caused by the recalcitrant osteitis pubis.

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.

Hip adductor activations during run-to-cut manoeuvres in compression shorts: implications for return to sport after groin injury

Athletes at high risk of groin strains in sports such as hockey and soccer often choose to wear shorts with directional compression to aid in prevention of or recovery from hip adductor strains. Large, eccentric contractions are known to result in or exacerbate strain injuries, but it is unknown if these shorts have a beneficial effect on hip adductor muscle activity. In this study, surface electromyography (EMG) of the adductor longus and ground reaction force (GRF) data were obtained simultaneously on 29 healthy individuals without previous history of serious injury while performing unanticipated 45° run-to-cut manoeuvres in a laboratory setting wearing shorts with non-directional compression (control, HeatGear, Under Armour, USA) or shorts with directional compression (directional, CoreShort PRO, Under Armour, USA), in random order. Average adductor activity in the stance leg was significantly lower in the directional condition than in the control condition during all parts of stance phase (all P < 0.042). From this preliminary analysis, wearing directional compression shorts appears to be associated with reduced stance limb hip adductor activity. Athletes seeking to reduce demand on the hip adductors as they approach full return to activities may benefit from the use of directional compression shorts.

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.

Incidence and clinical presentation of groin injuries in sub-elite male soccer

BACKGROUND

Groin injuries cause major problems in the football codes, as they are prevalent and lead to prolonged symptoms and high recurrence. The aim of the present study was to describe the occurrence and clinical presentation of groin injuries in a large cohort of sub-elite soccer players during a season.

METHODS

Physiotherapists allocated to each of the participating 44 soccer clubs recorded baseline characteristics and groin injuries sustained by a cohort of 998 sub-elite male soccer players during a full 10-month season. All players with groin injuries were examined using the clinical entity approach, which utilises standardised reproducible examination techniques to identify the injured anatomical structures. The exposure time and the injury time were also recorded. Injury time was analysed using multiple regression on the log of the injury times as the data were highly skewed. Effects are thus reported at relative injury time (RIT).

RESULTS

Adductor-related groin injury was the most common entity found followed by iliopsoas-related and abdominal-related injuries. The dominant leg was significantly more often injured. Age and previous groin injury were significant risk factors for sustaining a groin injury. Groin injuries were generally located on the same side as previously reported groin injuries. Adductor-related injuries with no abdominal pain had significantly longer injury times compared to injuries with no adductor and no abdominal pain (RIT 2.28, 95% CI 1.22 to 4.25, p=0.0096). Having both adductor and abdominal pain also increased the injury time significantly when compared to injuries with no adductor and no abdominal pain (RIT=4.56, 95% CI 1.91 to 10.91, p=0.001).

CONCLUSION

Adductor-related groin injury was the most common clinical presentation of groin injuries in male soccer players and the cause of long injury time, especially when combined with abdominal-related injury.

Does bony hip morphology affect the outcome of treatment for patients with adductor-related groin pain? Outcome 10 years after baseline assessment

BACKGROUND

Adductor-related groin pain and bony morphology such as femoroacetabular impingement (FAI) or hip dysplasia can coexist clinically. A previous randomised controlled trial in which athletes with adductor-related groin pain underwent either passive treatment (PT) or active treatment (AT) showed good results in the AT group. The primary purpose of the present study was to evaluate if radiological signs of FAI or hip dysplasia seem to affect the clinical outcome, initially and at 8-12 years of follow-up.

METHODS

47 patients (80%) were available for follow-up. The clinical result was assessed by a standardised clinical outcome combining patient-reported activity, symptoms and physical examination. Anterioposterior pelvic radiographs were obtained and the centre-edge angle of Wiberg, α angle, presence of a crossover sign and Tönnis grade of osteoarthritis were assessed by a blinded observer using a reliable protocol.

RESULTS

No significant between-group differences regarding the distribution of radiological morphologies were found. There was a decrease over time in clinical outcome in the AT group with α angles >55° compared to those with α angles <55° (p=0.047). In the AT group, there was no significant difference in the distribution of Tönnis grades between hips that had an unchanged or improved outcome compared with hips that had a worse outcome over time (p=0.145).

CONCLUSIONS

No evidence was found that bony hip morphology related to FAI or dysplasia prevents successful outcome of the exercise treatment programme with results lasting 8-12 years. The entity of adductor-related groin pain in physically active adults can be treated with AT even in the presence of morphological changes to the hip joint.

Conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain

BACKGROUND

Musculoskeletal, ligamentous and osseous groin injuries are common in athletes and may result in a delay of several months to resume sports. Even then, this may not be at the former level of sport activity. The treatment of exercise-related groin pain is mainly conservative (non-surgical), using interventions such as exercises, electrotherapy, manual therapy and steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); MEDLINE (1948 to November week 3 2011); EMBASE (1980 to Week 49 2011); CINAHL (1982 to December 2011); LILACS (1982 to December 2011); PEDro (1929 to December 2011), SPORTDiscus (1985 to December 2011), OTseeker (to December 2011), reference lists of papers and conference proceedings (2000 to 2011).

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized controlled trials evaluating conservative interventions for treating exercise-related musculotendinous, ligamentous and osseous groin pain were included. Studies comparing conservative with surgical treatments were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and conducted risk of bias assessments. There was no pooling of data.

MAIN RESULTS

Two studies, involving a total of 122 participants who had experienced adductor-related groin pain for at least two months, were included in this review. All but one of the participants were male athletes aged between 18 and 50 years old. Both studies were assessed as 'high risk of bias' for at least one source of bias domain. The 'successful treatment' outcome reported in both studies was based primarily on pain measures.One study, based on an intention-to-treat analysis, found a significant difference favouring exercise therapy (strengthening with an emphasis on the adductor and abdominal muscles and training muscular co-ordination) compared with 'conventional' physiotherapy (stretching exercises, electrotherapy and transverse friction massage) in successful treatment at 16-week follow-up (25/34 (74%) versus 10/34 (29%); risk ratio (RR) 2.50, 95% CI 1.43 to 4.37, P = 0.001). Similarly, of those followed-up significantly more athletes treated by exercise therapy returned to sport at the same level (23/29 (79%) versus 4/30 (13%); RR 5.95, 95% CI 2.34 to 15.09, P = 0.0002). Although still favouring the exercise group, the differences between the two groups in patients' subjective global assessment at 16 weeks and successful treatment at 8 to 12 years follow-up were not statistically significant.The second study (54 participants) found no significant differences at 16-week follow-up between a multi-modal treatment (heat, manual therapy and stretching) and exercise therapy (the same intervention as in the above study) for the outcomes of successful treatment (14/26 (54%) versus 12/22 (55%); RR 0.99, 95% CI 0.59 to 1.66, P = 0.96) and return to full sports participation (13/26 (50%) versus 12/22 (55%); RR 0.92, 95% CI 0.53 to 1.58, P = 0.75). Those returning to full sports participation returned on average 4.5 weeks earlier after receiving multi-modal therapy (mean difference -4.50 weeks, 95% CI -8.60 to -0.40, P = 0.03) than those in the exercise therapy group. This study reported that there were no complications or side effects found in either intervention group.

AUTHORS' CONCLUSIONS

The available evidence from the randomized trials is insufficient to advise on any specific conservative modality for treating exercise-related groin pain. While still low quality, the best evidence is from one trial which found that exercise therapy (strengthening of hip and abdominal muscles) in athletes improves short-term outcomes (based primarily on pain measures) and return to sports compared with physiotherapy consisting of passive modalities. Given the low quality of the available evidence from both included trials, further randomized trials are necessary to reinforce their findings.

"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.

Femoroacetabular impingement in a professional soccer player

Presented is the case of a 25-year-old professional soccer player with a long-standing history of hip injuries, including a hamstring injury, adductor partial tearing with surgical release and labral tearing in the hip joint. The patient was eventually found to have a mixed type femoracetabular impingement and adaptive bony changes of the hip. The patient was treated with an arthroscopic acetabuloplasty of the pincer lesion, femoroplasty for the treatment of the cam lesion and labral repair along with open proximal adductor repair to restore the native biomechanics of the hip.

LEVEL OF EVIDENCE

V.

EMG evaluation of hip adduction exercises for soccer players: implications for exercise selection in prevention and treatment of groin injuries

INTRODUCTION

Exercise programmes are used in the prevention and treatment of adductor-related groin injuries in soccer; however, there is a lack of knowledge concerning the intensity of frequently used exercises.

OBJECTIVE

Primarily to investigate muscle activity of adductor longus during six traditional and two new hip adduction exercises. Additionally, to analyse muscle activation of gluteals and abdominals.

MATERIALS AND METHODS

40 healthy male elite soccer players, training >5 h a week, participated in the study. Muscle activity using surface electromyography (sEMG) was measured bilaterally for the adductor longus during eight hip adduction strengthening exercises and peak EMG was normalised (nEMG) using an isometric maximal voluntary contraction (MVC) as reference. Furthermore, muscle activation of the gluteus medius, rectus abdominis and the external abdominal obliques was analysed during the exercises.

RESULTS

There were large differences in peak nEMG of the adductor longus between the exercises, with values ranging from 14% to 108% nEMG (p<0.0001). There was a significant difference between legs in three of the eight exercises (35-48%, p<0.0001). The peak nEMG results for the gluteals and the abdominals showed relatively low values (5-48% nEMG, p<0.001).

CONCLUSIONS

Specific hip adduction exercises can be graded by exercise intensity providing athletes and therapists with the knowledge to select appropriate exercises during different phases of prevention and treatment of groin injuries. The Copenhagen Adduction and the hip adduction with an elastic band are dynamic high-intensity exercises, which can easily be performed at any training facility and could therefore be relevant to include in future prevention and treatment programmes.

Surgical treatment of chronic groin pain in athletes

PURPOSE

Conservative treatment of chronic groin pain is prolonged and recurrence is quite common. Coexistence of sports hernia and adductor tendinitis/tendinosis in a single patient is noted in the literature. In our study we evaluated our operative treatment that should enable pain elimination and fast return to sports activities.

METHODS

We performed a prospective study over a six-year period. Ninety-nine (99) patients, all male, with chronic groin pain, resistant to conservative treatment, underwent a surgical procedure.

RESULTS

Seventy athletes with sports hernia returned to sports in an average 4.23 weeks (range three-16). Adductor tendinosis symptoms were present in 24 patients (2 %) with sports hernia. Twenty-four patients that had an additional adductor tenotomy performed returned to sports in an average 11.6 weeks (range ten-15). Five patients with isolated adductor tendinosis (7 %) returned to sports in an average 13.4 weeks (range 12-16). All athletes except two (2.8 %) treated for sports hernia were satisfied with the results of treatment and could continue their previous level of activity.

CONCLUSION

Any surgical procedure used for treating chronic groin pain should address the common causes of pain in this region. Adductor tendinosis can be present in up to 24.2 % of cases with sports hernia or may be isolated in 7 % of cases with chronic groin pain and must be treated by tenotomy. Resection of the genital branch of genitofemoral nerve and ilioinguinal nerve neurolysis should also be performed in patients with sports hernia.