Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training

MRI findings in athletic groin pain: correlation of imaging with history and examination in symptomatic and asymptomatic athletes

OBJECTIVE

To determine differences in prevalence and diagnostic accuracy of MRI findings between asymptomatic athletes and athletes with longstanding groin pain.

MATERIALS AND METHODS

One hundred twenty-three adult male athletes were approached with 85 consecutive athletes recruited. Group 1 (symptomatic, n = 34) athletes referred for longstanding groin pain (insidious onset, > 3 weeks duration). Group 2 (control, n = 51) athletes referred for injuries remote from the pelvis and no groin pain in the last 12 weeks. All referrers completed a clinical examination proforma documenting absence or presence of pelvis and hip abnormality. All patients completed the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire and underwent a 3T MRI groin and hip protocol. MRIs were scored independently by two musculoskeletal radiologists blinded to clinical details. Statistical analysis was performed to evaluate associations between MRI findings, inter-reader reliability, clinical examination and HAGOS scores.

RESULTS

Pubic body subchondral bone oedema, capsule/aponeurosis junction tear and soft tissue oedema were more prevalent in the symptomatic group (p = 0.0003, 0.0273 and 0.0005, respectively) and in athletes with clinical abnormality at symphysis pubis, adductor insertion, rectus abdominis, psoas and inguinal canal (p = 0.0002, 0.0459 and 0.00002, respectively). Pubic body and subchondral oedema and capsule/aponeurosis tear and oedema significantly correlated with lower (worse) HAGOS scores (p = 0.004, 0.00009, 0.0004 and 0.002, respectively). Inter-reader reliability was excellent, 0.87 (range 0.58-1). Symphyseal bone spurring, disc protrusion and labral tears were highly prevalent in both groups.

CONCLUSION

Clinical assessment and MRI findings of pubic subchondral bone oedema and capsule/aponeurosis abnormality appear to be the strongest correlators with longstanding groin pain.

Sports Hernias: A Comprehensive Review for Clinicians

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

Imaging Review of Hockey-related Lower Extremity Injuries

Hockey is a fast-paced contact sport with a high incidence of injuries. Although injuries are more frequent among elite players, recreational hockey injuries are a common issue faced by primary care and emergency physicians. Lower extremity injuries in hockey are particularly important because they account for approximately a third of all injuries and > 60% of all overuse injuries. This pictorial review provides the general and specialty trained radiologist with a knowledge of the patterns of lower extremity injury that occur in ice hockey.

Long-standing pubic-related groin pain in professional academy soccer players: a prospective cohort study on possible risk factors, rehabilitation and return to play

Background

Despite being a common overuse entity in youth soccer, scientific data on risk factors, rehabilitation and return to play for long-standing pubic-related groin pain is still rare. The current prospective cohort study aims to evaluate potential risk-factors, propose a criteria-based conservative rehabilitation protocol and assess return-to-play outcomes among professional youth soccer players suffering from long-standing pubic-related groin pain.

Methods

Male soccer players with long-standing (> 6 weeks) pubic-related groin pain from a professional soccer club’s youth academy were analyzed for possible risk factors such as age, team (U12 - U23), younger/older age group within the team, position and preinjury Functional movement score. All injured players received a conservative, standardized, supervised, criteria-based, 6-level rehabilitation program. Outcome measures included time to return to play, recurrent groin pain in the follow-up period and clinical results at final follow-up two years after their return to play.

Results

A total of 14 out of 189 players developed long-standing pubic-related groin pain in the 2017/2018 season (incidence 7.4%). The average age of the players at the time of the injury was 16.1 ± 1.9 years. Risk factor analysis revealed a significant influence of the age group within the team (p = .007). Only players in the younger age group were affected by long-standing pubic-related groin pain, mainly in the first part of the season. Injured players successfully returned to play after an average period of 135.3 ± 83.9 days. Only one player experienced a recurrence of nonspecific symptoms (7.1%) within the follow-up period. The outcome at the 24-month follow-up was excellent for all 14 players.

Conclusions

Long-standing pubic-related groin pain is an overuse entity with a markedly high prevalence in youth soccer players, resulting in a relevant loss of time in training and match play. In particular, the youngest players in each team are at an elevated risk. Applying a criteria-based rehabilitation protocol resulted in an excellent return-to-play rate, with a very low probability of recurrence.

Trial registration

The trial was retrospectively registered under DRKS00016510 in the German Clinical Trials Register on 19.04.2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04837-x.

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

Background:

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

Purpose:

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

Study Design:

Systematic review; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

The cleft sign may be an independent factor of magnetic resonance imaging findings associated with a delayed return-to-play time in athletes with groin pain

PURPOSE

To investigate the prevalence of magnetic resonance imaging (MRI) findings and define prognostic factors of the return-to-play time in young athletes with groin pain.

METHODS

A total of 1091 consecutive athletes were retrospectively screened; 651 athletes, aged 16-40 years, with pain in the groin regions were assessed using MRI. Of these athletes, 356 were included for analysing the time to return-to-play. Univariate and multiple linear regression analyses were used to determine the associations between the time to return-to-play (primary outcome variable) and the following variables: age, sex, body mass index, type of sports, Hip Sports Activity Scale, clear trauma history, and 12 MRI findings.

RESULTS

Four MRI findings, including cleft sign, pubic bone marrow oedema of both the superior and inferior ramus, and central disc protrusion of the pubic symphysis, appeared together in more than 44% of the cases. The median time to return-to-play was 24.7 weeks for athletes with a cleft sign on MRI, which was significantly longer than the 11.9 weeks for athletes without the sign. The median time to return-to-play was 20.8 weeks for athletes with BMI > 24, which was significantly longer than the 13.6 weeks for athletes with BMI ≦ 24. In multiple linear regression analysis of 356 athletes, in whom hip-related groin pain was excluded, and who were followed-up until the return-to-play, the body mass index and cleft sign were the independent factors associated with a delayed return-to-play. In contrast, iliopsoas muscle strain and other muscle injuries were associated with a shorter return-to-play.

CONCLUSIONS

Multiple MRI findings were present in almost half of all cases. Body mass index and the cleft sign were independently associated with a delayed return-to-play time in young athletes suffering from groin pain.

LEVEL OF EVIDENCE

III.

Pubic and adductor related groin pain in an athlete: A case report linking pathology to conservative care

STUDY DESIGN

Case Report.

BACKGROUND

Groin pain in athletes is considered a common condition among males participating in sports that require sprinting, twisting, pivoting and kicking activities. While the condition is considered self-limiting, it often keeps athletes away from sport for a prolonged period of time. Much controversy exists regarding the pathogenesis of groin pain. This conflict translates to disagreement regarding diagnostic criteria, reporting and management strategies.

CASE PRESENTATION

a 28-year old recreational soccer player presented with a five-month history of groin pain that was resistant to passive care. With reference to the current conservative management literature, the athlete was progressed through an individualized multimodal program of care.

OUTCOMES

Following 10-weeks of care, the athlete was able to return to sport participation pain-free.

CONCLUSION

It is suggested that groin pain in athletes is likely multifactorial and therefore the management should reflect its multifactorial nature. Conservative therapy can evidently reduce the time to return to play however the benefits of incorporating plyometrics into the rehabilitation program should be investigated.

Classifying radiographic changes of the pubic symphysis in male athletes: Development and reproducibility of a new scoring protocol

PURPOSE

To develop a specified radiographic scoring system for the pubic symphysis and adjacent bones, and to examine the intra- and inter-rater reproducibility of this system.

METHOD

Development of the scoring protocol was performed in three stages using AP pelvis radiographs of 102 male adult athletes. The final protocol included 5 overall scoring items, which included further specification of locations: 1) bone lucency (erosion-like configuration and cysts), 2) proliferation, 3) fragmentation, 4) sclerosis, and 5) joint space width. Intra- and inter-rater reproducibility were determined using Cohen's kappa statistic (κ) and intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and minimal detectable difference (MDD) were also determined.

RESULTS

We present a radiographic scoring protocol with clear definitions and examples to improve clinical usability. Intra-rater reproducibility was: bone lucency (erosion-like configuration or cysts): κ = 0.67 (95 %CI 0.56-0.78), proliferation: κ = 0.54 (95 %CI 0.38-0.70), fragmentation: κ = 0.80 (95 %CI 0.67-0.93), sclerosis: κ = 0.60 (95 %CI 0.49-0.71), and joint space width: ICC(2.1) 0.85 (95 %CI 0.78-0.89), SEM 0.4 mm, MDD 1.2 mm. Inter-rater reproducibility was: bone lucency: κ = 0.61 (95 %CI 0.50-0.72), proliferation: κ = 0.34 (95 %CI 0.20-0.48), fragmentation: κ = 0.67 (95 %CI 0.50-0.84), sclerosis: κ = 0.30 (95 %CI 0.17-0.43), and joint space width: ICC(2.1) 0.72 (95 %CI 0.59-0.81), SEM 0.5 mm., MDD 1.5 mm.

CONCLUSIONS

The Aspetar pubic symphysis radiographic scoring protocol contains five overall scoring items, with additional specifications. These five items showed moderate to almost perfect intra-rater reproducibility, and fair to substantial inter-rater reproducibility. This protocol provides the basis for use in clinical practice, and will allow future investigations of the clinical significance of radiographic changes at the pubic symphysis in athletes.

The arterial blood supply of the symphysis pubis - Spatial orientated and highly variable

BACKGROUND

Open surgical treatment of the pubic region and adductor related pathologies require an exact knowledge of the arterial blood supply of the symphysis pubis that seems furthermore important to explain the hematogenous occurrence of symphysitis. Pubic bone marrow oedema (PBME) is a frequent occurring magnetic resonance imaging finding in groin pain. However, even asymptomatic athletes present PBME and a correlation to the physical activity or higher blood flow was suggested. Data on the vascular anatomy of the symphysis pubis are rare.

METHODS

Ten formaldehyde-embalmed cadavers were dissected, and the arterial blood supply was investigated and photographically documented.

RESULTS

In the majority of cases the following pattern was determined: superior-inferior epigastric artery (n=12 hemipelves), inferior - dorsal artery of the penis/dorsal artery of the clitoris (n=16), posterior- obturator artery (n=16 hemipelves), anterior- deep external pudendal artery (n=14 hemipelves). Besides variations for the deep external pudendal artery anteriorly, we observed a highly variable arterial supply, especially superior. Superior in 4/10 cadavers, inferior in 0/10 cadavers, posterior in 2/10 cadavers and anterior in 5/10 cadavers side variations were found.

CONCLUSION

The symphysis pubis has a spatial and rich organized arterial blood supply with several variations. Despite the symphysis pubis is recognized as bradytroph, the high number of vessels is presumably required in stress situations for example in heavy training.

Prevalence of asymptomatic radiological findings in the groin region: a systematic review

Objective: The aim of this study is to investigate in current literature the prevalence of asymptomatic adductor and pubic abnormalities on MRI and ultrasound. Methods: A systematic review of the literature was carried out using PubMed to identify all studies reporting asymptomatic pubic- and adductor-related findings on MRI and/or ultrasound. All types of studies were eligible for inclusion, except case reports. Studies with an asymptomatic cohort, or where at least a part of the study population was asymptomatic, were included. Results: Thirteen studies were included. Two articles describe only asymptomatic adductor abnormalities, six articles only asymptomatic pubic abnormalities. Five articles describe both adductor and pubic abnormalities. All studies were conducted with MRI. Only one of the included articles describes asymptomatic groin findings on ultrasound. Conclusions: Asymptomatic adductor and pubic abnormalities on MRI are frequently present but vary greatly between selected studies. No exact conclusions can be drawn about the prevalence of asymptomatic adductor or pubic findings on MRI due to high heterogeneity between studies. Furthermore, the one article about ultrasound was not enough to draw conclusions for ultrasound findings. It is nonetheless clear that clinicians should be careful to make diagnoses purely based on radiologic findings. A thorough clinical examination and individual interpretation conducted by the clinician remains indispensable.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Trial registration number

NCT02560480

MRI in chronic groin pain: sequence diagnostic reliability compared to systematic surgical assessment

OBJECTIVE

To determine the diagnostic reliability of magnetic resonance imaging (MRI) sequences in chronic groin pain (CGP) compared to surgery and try to propose a suitable MRI protocol.

MATERIALS AND METHODS

Forty-three consecutive patients with resistant clinical CGP underwent a pre-surgical pelvis MRI. Eight MRI sequences were acquired: axial fast spin-echo T1-weighted (FSE T1), coronal FSE T1, axial-oblique (in symphysis plane) proton density weighted with fat saturation (PDFS), coronal PDFS, sagittal PDFS, axial FSE T1 with fat saturation and gadolinium enhancement (FSGE), coronal FSE T1 FSGE and axial FSE T1 with Valsalva maneuver (VM). These sequences were reviewed for pubic symphysis assessment, adductor longus (AL) tendon and abdominal wall (AW) injuries. The same surgeon operated on all of these patients (26 AL and 49 AW). Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative prospective value (NPV) and accuracy of each sequence and combinations for AL or AW injuries were calculated in comparison to surgical findings.

RESULTS

One hundred ninety-two sequences were obtained. Coronal T1 FSGE and axial T1 VM proved to be the most reliable sequences (accuracy: 91.67% in AL and 83.33% in AW). The best sequence combination was coronal T1, axial PDFS, sagittal PDFS and axial T1 VM (accuracy: 77.78%; Se: 100.00%, Sp: 69.23%, PPV: 55.56%, NPV: 100.00%).

CONCLUSION

MRI has 77.78% accuracy, 100.00% sensitivity, 69.23% specificity, 55.56% PPV and 100.00% NPV in evaluating CGP, with coronal T1-axial PDFS-sagittal PDFS-axial T1 VM as the optimal protocol in terms of diagnostic performance within a reasonable scan time. Diagnostic performance of MRI was examined in the evaluation of CGP using surgery as reference standard.

Laparoscopic Treatment of Pubic Symphysis Instability With Anchors and Tape Suture

Patients with pubic symphysis instability who had failed nonoperative treatments may benefit from surgical repair. This disease process is rare, most commonly seen in postpartum women and athletes, and its surgical treatment is invasive and nonphysiological. Currently described surgical interventions, although limited, include plating, which provides an overly rigid construct with the risk of failure and possibly poor long-term outcomes particularly in athletes, and treatments such as curettage, more commonly used in the treatment of osteitis pubis. An emerging option is minimally invasive laparoscopic fixation using knotless anchors with a tape suture in a crisscross configuration. This possibly allows more physiological movement of the pubic symphysis in a less invasive manner. A detailed technical description and discussion of the technique are provided.

Nonoperative Management, Rehabilitation, and Functional and Clinical Progression of Osteitis Pubis/Pubic Bone Stress in Professional Soccer Players: A Case Series

Study Design Case series. Background Pubic bone stress (PBS) is a common acute or chronic response of the pelvis in sports where sprinting, kicking, twisting, and cutting are the dominant movements. There are few nonoperative rehabilitation strategies for the condition reported in the literature, and the outcome of conservative treatment has not been documented. Case Description Five professional and academy soccer players complaining of pubic symphysis pain, confirmed as PBS on magnetic resonance imaging and objective assessment, were treated with a nonoperative rehabilitation program that featured functional and clinical objective markers as progression criteria. Interventions in the acute phase included pharmacological and physical therapeutic modalities to reduce pain initially. Rehabilitation management focused on improving range of motion at the hips and thorax, adductor strengthening, trunk and lumbopelvic stability, gym-based strength training, and field-based rehabilitation and conditioning. Clinical follow-up was performed at least 8 months following return to play. Outcomes All players demonstrated reduced or resolved pain, increased adductor squeeze strength, and return to pain-free training and match play. Return-to-training time averaged 40.6 days (range, 30-60 days) and return to play averaged 49.4 days (range, 38-72 days) within the 5 players. At final follow-up (mean, 29.6 months; range, 16-33 months), there had been no recurrences. Discussion This report of 5 cases suggests that a nonoperative protocol, using clinical and functional progression criteria, may be successful in rehabilitating athletes with PBS for return to sport within 11 weeks. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2017;47(9):683-690. Epub 3 Aug 2017. doi:10.2519/jospt.2017.7314.

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

Background:

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

Purpose:

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

Study Design:

Cohort study; Level of evidence, 3.

Methods:

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

Results:

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

Conclusion:

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

Athletic Hip Injuries

Historically, athletic hip injuries have garnered little attention; however, these injuries account for approximately 6% of all sports injuries and their prevalence is increasing. At times, the diagnosis and management of hip injuries can be challenging and elusive for the team physician. Hip injuries are seen in high-level athletes who participate in cutting and pivoting sports that require rapid acceleration and deceleration. Described previously as the "sports hip triad," these injuries consist of adductor strains, osteitis pubis, athletic pubalgia, or core muscle injury, often with underlying range-of-motion limitations secondary to femoroacetabular impingement. These disorders can happen in isolation but frequently occur in combination. To add to the diagnostic challenge, numerous intra-articular disorders and extra-articular soft-tissue restraints about the hip can serve as pain generators, in addition to referred pain from the lumbar spine, bowel, bladder, and reproductive organs. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.

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 Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete

The nomenclature and the lack of consensus of clinical evaluation and imaging assessment in groin pain generate significant confusion in this field. The Groin Pain Syndrome Italian Consensus Conference has been organised in order to prepare a consensus document regarding taxonomy, clinical evaluation and imaging assessment for groin pain. A 1-day Consensus Conference was organised on 5 February 2016, in Milan (Italy). 41 Italian experts with different backgrounds participated in the discussion. A consensus document previously drafted was discussed, eventually modified, and finally approved by all members of the Consensus Conference. Unanimous consensus was reached concerning: (1) taxonomy (2) clinical evaluation and (3) imaging assessment. The synthesis of these 3 points is included in this paper. The Groin Pain Syndrome Italian Consensus Conference reached a consensus on three main points concerning the groin pain syndrome assessment, in an attempt to clarify this challenging medical problem.

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.

Systematic review: laparoscopic treatment of long-standing groin pain in athletes

OBJECTIVES

No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes.

DATA SOURCES

The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations.

RESULTS

Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266).

CONCLUSIONS

Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.

Which factors differentiate athletes with hip/groin pain from those without? A systematic review with meta-analysis

Background

Hip and groin injuries are common in many sports. Understanding the factors differentiating athletes with hip/groin pain from those without these injuries could facilitate management and prevention.

Objective

Conduct a systematic review and meta-analysis of the literature on factors differentiating athletes with and without hip/groin pain.

Methods

The review was registered as PROSPERO CRD42014007416 and a comprehensive, systematic search was conducted in June 2014. Inclusion criteria were: cross-sectional, cohort or case–control study designs of n>10 that examined outcome measures differentiating athletes with and without hip/groin pain. Two authors independently screened search results, assessed study quality, and performed data extraction. Methodological heterogeneity was determined and data pooled for meta-analysis when appropriate. A best evidence synthesis was performed on the remaining outcome measures.

Results

Of 2251 titles identified, 17 articles were included of which 10 were high quality. Sixty two different outcome measures were examined, 8 underwent meta-analysis. Pooled data showed strong evidence that athletes with hip/groin pain demonstrated: pain and lower strength on the adductor squeeze test, reduced range of motion in hip internal rotation and bent knee fall out; however, hip external rotation range was equivalent to controls. Strong evidence was found that lower patient-reported outcome (PRO) scores, altered trunk muscle function, and moderate evidence of bone oedema and secondary cleft sign were associated with hip/groin pain.

Conclusions

PROs, pain and reduced strength on the adductor squeeze test, reduced range of motion in internal rotation and bent knee fall out are the outcome measures that best differentiate athletes with hip/groin pain from those without this pain.

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.

Management of chronic recurrent osteitis pubis/pubic bone stress in a Premier League footballer: Evaluating the evidence base and application of a nine-point management strategy

BACKGROUND/AIM

The aim of this paper was to use a clinical example to describe a treatment strategy for the management of recurrent chronic groin pain and evaluate the evidence of the interventions.

METHODS

A professional footballer presented with chronic recurrent OP/PBS. The injury was managed successfully with a nine-point programme - 1. Acute pharmacological management. 2. Tone reduction of over-active structures. 3. Improved ROM at hips, pelvis and thorax. 4. Adductor strength. 5. Functional movement assessment. 6. Core stability. 7. Lumbo-pelvic control. 8. Gym-based strengthening. 9. Field-based conditioning/rehabilitation. The evidence for these interventions is reviewed.

RESULTS

The player returned to full training and match play within 41 and 50 days, respectively, and experienced no recurrence of his symptoms in follow up at 13 months.

CONCLUSION

This case report displays a nine-point conservative management strategy for OP/PBS, with non-time dependent clinical objective markers as the progression criteria in a Premier League football player.

Magnetic resonance imaging has no role in diagnosing the origin of pain in patients with overwhelmingly painful inguinal hernia

PURPOSE

Clinical tools for predicting postoperative pain should be developed to provide better care for patients. The aims of this study were to evaluate preoperative magnetic resonance imaging (MRI) findings to reveal reasons for overwhelming pain in patients with inguinal hernia and to detect changes in quality-of-life (QoL) and pain scores preoperatively and following laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia.

METHODS

Twenty-two patients aged 18-50 years presenting with extremely painful inguinal hernias (highest pain scores >50, scale 0-100) were examined with MRI prior to operative treatment with TEP repair. Postoperative follow-up lasted 6 months and consisted of questionnaires regarding functional status, pain, QoL and possible complications. Postoperative MRI scans were performed only in cases of preoperative findings on the MRI or prolonged inguinal pain persisting over 6 months.

RESULTS

Prolonged postoperative pain could not be predicted from preoperative MRI scans, because no signs of the pain's origin such as pubic periostal irritation, bone marrow edema, pelvic bone or hip joint abnormalities, or lower abdominal muscle hemorrhage were detected in MRI. TEP repair of inguinal hernia significantly improved the patients' quality of life and relieved pain symptoms. High preoperative pain scores were major predictors of prolonged postoperative pain.

CONCLUSIONS

Carefully evaluated preoperative pelvic MRI was usually normal in patients with high pain scores prior to operation. Preoperative pain scores may serve as indicators of development of prolonged inguinal pain.

Contemporary management of 'Inguinal disruption' in the sportsman's groin

Background

This article helps define the basic principles to diagnosis and manage one of the surgically correctable causes of the ‘painful groin’, which is commonly described as the sportsman’s groin.

Discussion

Often many surgeons will describe a single pathology for the sportsman’s groin such as a ‘hernia’ but often other coexisting etiologies may be present.

Management relies on a multidisciplinary approach with a diagnosis initially made by a history of pain in the groin on exercise. Physiotherapy is the recommended first line treatment and is designed to concentrate on strengthening of the abdominal wall muscle and tendon groups around the groin area.

Surgery does have a role in the sportsman’s groin but only once all conservative measures have been exhausted or if there is a clear identified pathology causing the groin symptoms such as posterior wall defect.

Surgical principles for an inguinal disruption include either open or laparoscopic techniques reinforcing the inguinal canal with a mesh or suture repair followed by an active rehabilitation programme.

Summary

Once an accurate diagnosis has been achieved, contemporary guidance for inguinal disruption requires a multidisciplinary approach including a specially designed physiotherapy regime and possibly surgery.

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.

The recognition and evaluation of patterns of compensatory injury in patients with mechanical hip pain

Context:

In active individuals with femoroacetabular impingement (FAI), the resultant reduction in functional range of motion leads to high impaction loads at terminal ranges. These increased forces result in compensatory effects on bony and soft tissue structures within the hip joint and hemipelvis. An algorithm is useful in evaluating athletes with pre-arthritic, mechanical hip pain and associated compensatory disorders.

Evidence Acquisition:

A literature search was performed by a review of PubMed articles published from 1976 to 2013.

Level of Evidence:

Level 4.

Results:

Increased stresses across the bony hemipelvis result when athletes with FAI attempt to achieve supraphysiologic, terminal ranges of motion (ROM) through the hip joint required for athletic competition. This can manifest as pain within the pubic joint (osteitis pubis), sacroiliac joint, and lumbosacral spine. Subclinical posterior hip instability may result when attempts to increase hip flexion and internal rotation are not compensated for by increased motion through the hemipelvis. Prominence of the anterior inferior iliac spine (AIIS) at the level of the acetabular rim can result in impingement of the anterior hip joint capsule or iliocapsularis muscle origin against the femoral head-neck junction, resulting in a distinct form of mechanical hip impingement (AIIS subspine impingement). Iliopsoas impingement (IPI) has also been described as an etiology for anterior hip pain. IPI results in a typical 3-o’clock labral tear as well as an inflamed capsule in close proximity to the overlying iliopsoas tendon. Injury in athletic pubalgia occurs during high-energy twisting activities in which abnormal hip ROM and resultant pelvic motion lead to shearing across the pubic symphysis.

Conclusion:

Failure to recognize and address concomitant compensatory injury patterns associated with intra-articular hip pathology can result in significant disability and persistent symptoms in athletes with pre-arthritic, mechanical hip pain.

Strength-of-Recommendation Taxonomy (SORT):

B

Effect of pubic bone marrow edema on recovery from endoscopic surgery for athletic pubalgia

Athletic pubalgia (sportsman's hernia) is often repaired by surgery. The presence of pubic bone marrow edema (BME) in magnetic resonance imaging (MRI) may effect on the outcome of surgery. Surgical treatment of 30 patients with athletic pubalgia was performed by placement of totally extraperitoneal endoscopic mesh behind the painful groin area. The presence of pre-operative BME was graded from 0 to 3 using MRI and correlated to post-operative pain scores and recovery to sports activity 2 years after operation. The operated athletes participated in our previous prospective randomized study. The athletes with (n = 21) or without (n = 9) pubic BME had similar patients' characteristics and pain scores before surgery. Periostic and intraosseous edema at symphysis pubis was related to increase of post-operative pain scores only at 3 months after surgery (P = 0.03) but not to long-term recovery. Two years after surgery, three athletes in the BME group and three in the normal MRI group needed occasionally pain medication for chronic groin pain, and 87% were playing at the same level as before surgery. This study indicates that the presence of pubic BME had no remarkable long-term effect on recovery from endoscopic surgical treatment of athletic pubalgia.

A European survey on the aetiology, investigation and management of the "sportsman's groin"

INTRODUCTION

A sportsman's groin has no accepted definition or consensus on treatment. The aim of this study was to assess current opinion among a large body of European surgeons using an online survey.

METHODS

An online questionnaire comprising 16 multiple-choice questions was sent by email to general surgeons in Europe. The survey was live from the 6th to 30th September 2011.

RESULTS

In total 143 responses were received. One hundred and six respondents (74 %) expressed experience in managing this condition. The majority (91 %) managed <26 cases per year. Posterior wall weakness (53 %), pubic tendinitis (43 %), nerve entrapment (37 %) and conjoint tendon injury (36 %) were the commonest aetiological factors described. Preferred diagnostic investigations were ultrasound of the groin (44 %) and MRI of the pelvis (29 %). The most common initial treatment (91 % of respondents) was conservative measures (rest and analgesia) for a maximum of 6-month period. When surgery was undertaken, Lichtenstein repair (29 %), TEP (27 %), TAPP (20 %), and posterior wall repair (21 %) were the commonest procedures. The majority (95 %) of respondents would not offer bilateral surgery for those presenting with unilateral groin pain.

CONCLUSIONS

Most European surgeons see <26 cases of "sportsman's groin" per year, which is in keeping with the low incidence of this condition. There remains wide variation in its investigation and management, which reflects the differences in opinion on its aetiology. The majority of surgeons agree that surgery is not the only treatment option available, but there is little consensus on the optimal management.

An algorithmic approach to mechanical hip pain

BACKGROUND

As our understanding of hip pathology evolves, the focus is shifting toward earlier identification of hip pathology. Therefore, it is vitally important to elucidate intra-articular versus extra-articular pathology of hip pain in every step of the patient encounter: history, physical examination, and imaging.

QUESTIONS/PURPOSES

The objective was to address the following research questions: (1) Can an algorithmic approach to physical examination of a painful non-arthritic hip provide a more accurate diagnosis and improved treatment plan? (2) Does an anatomical layered concept of clinical diagnosis improve diagnostic accuracy? (3) What are the diagnostic tools necessary for the accurate application of a four-layer (osteochondral, inert, contractile, and neuromechanical) diagnosis?

METHODS

An unrestricted computerized search of MEDLINE was conducted. Different terms were used in various combinations.

RESULTS

An algorithmic approach to physical examination of a painful nonarthritic hip, including history, physical examination (specific tests), and advanced imaging allow for better interpretation of debilitating intra- and extra-articular disorders and their effect on core performance. Additionally, it improves our understanding as to how underlying abnormal joint mechanics may predispose the hip joint and the associated hemipelvis to asymmetric loads. These abnormal joint kinematics (layer I) can lead to cartilage and labral injury (layer II), as well as resultant injury to the musculotendinous (layer III) and neural structures (layer IV) about the hip joint and the hemipelvis. The layer concept is a systematic means of determining which structures about the hip are the source of hip pathology and how to best implement treatment.

CONCLUSIONS

A clear understanding of the differential diagnosis of hip pain through a detailed and systematic physical examination, diagnostic imaging assessment, and the interpretation of how mechanical factors can result in such a wide range of compensatory injury patterns about the hip can facilitate the diagnosis and treatment recommendations.

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).

Prevalence and etiological factors of sport-related groin injuries in top-level soccer compared to non-contact sports

PURPOSE

Groin injuries and chronic pain are relatively common in soccer and other contact sports. Our aim was to define the gender-related frequency of both acute and chronic groin injuries in soccer compared to non-contact endurance sports.

METHODS

A 12-month study of 613 professional athletes was conducted in 2006. Premier league soccer players (77 males and 90 females) answered retrospectively 70 multi-choice questions of sport injuries. Factors related to groin injuries were compared with corresponding data of elite-level swimmers (n = 154), long-distance runners (n = 143) and cross-country skiers (n = 149).

RESULTS

In soccer, 125/167 players had 375 injuries (274 acute and 101 overuse injuries) and the number of acute injuries were 146/274 (53%) in males and 128/274 (47%) in females (p = 0.368). Acute groin injury was reported in 15/167 (9.0%) of elite soccer players compared to 3/154 (2.0%) in swimmers (p = 0.006) and 1.4% in both long-distance running (n = 2) and skiing (n = 2, p = 0.003). Male soccer players had acute groin injuries nearly three times more frequently than females. Chronic persistent groin pain was found in only one male and two female soccer players and no athletes in endurance sports.

CONCLUSIONS

Almost every tenth soccer player had an acute groin injury. Long-standing groin pain was not frequent in soccer and it was not found in non-contact endurance sport at the elite-level.

Effect of heavy training in contact sports on MRI findings in the pubic region of asymptomatic competitive athletes compared with non-athlete controls

OBJECTIVE

Bone marrow edema (BME) at the pubic symphysis on magnetic resonance imaging (MRI) is usually associated with groin pain and stress injury of the pubic bone. Little is known of the pubic MR imaging findings of asymptomatic heavy training athletes in contact sports.

MATERIALS AND METHODS

Pelvic MRI of male asymptomatic soccer (n=10), ice hockey (n=10), bandy (n=10) and female floor-ball players (n=10) were compared with non-athlete controls (10 males, 10 females) without groin pain to analyse the presence of BME (on a four-point scale). To study the possible changes of BME directly following heavy physical activity, 10 bandy players underwent MRI before and immediately after a 2-h training session.

RESULTS

Magnetic resonance imaging showed minimal BME (grade 1) at the pubic symphysis in 19 of the 40 athletes (48%). Two soccer and 2 ice hockey players (20%) had moderate grade 2 pubic edema, but severe grade 3 BME findings were not found. Also 10 out of 20 (50%) of controls had grade 1 BME. The extent of increased signal was equally distributed in the asymptomatic athletes of different contact sports and controls. A heavy 2-h training session did not cause any enhanced signal at the pubic symphysis.

CONCLUSIONS

This study indicates that the presence of grade 1 pubic BME was a frequent finding in contact sports and comparable to that in non-athletes. Grade 2 BME was found only in asymptomatic athletes undergoing heavy training.

COMPARATIVE STUDY BETWEEN THE PUBIS OF ASYMPTOMATIC ATHLETES AND NON-ATHLETES WITH MRI

Objective: To compare the magnetic resonance imaging findings from the pubis of professional soccer players without any history or clinical findings of groin pain, and from sedentary individuals, also without symptoms, and to determine the prevalence of changes compatible with pubic overload. Methods: Nineteen professional soccer players without complaints of groin pain and seventeen sedentary individuals, also asymptomatic, underwent magnetic resonance imaging of the pubis. The results from the examinations were analyzed regarding the presence of degenerative changes, boned medullary edema and tendinopathy, and the two study groups were compared. Results: High prevalence of bone edema, tendinopathy and degenerative findings in the pubic symphysis was seen in the athletes, with statistically significant higher odds ratios and relative risk in the population studied. Conclusion: Professional soccer players are at a higher risk of developing changes in the pubic region, shown in magnetic resonance images, compared with sedentary individuals. These findings are not necessarily caused by groin pain, and are probably related to intense exertion.

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.

Differential diagnosis of pain around the hip joint

The differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology, and mimickers, including the joints of the pelvic ring. With the current advancements in hip arthroscopy, more patients are being evaluated for hip pain. In recent years, our understanding of the functional anatomy around the hip has improved. In addition, because of advancements in magnetic resonance imaging, the diagnosis of soft tissue causes of hip pain has improved. All of these advances have broadened the differential diagnosis of pain around the hip joint and improved the treatment of these problems. In this review, we discuss the causes of intra-articular hip pain that can be addressed arthroscopically: labral tears, loose bodies, femoroacetabular impingement, capsular laxity, tears of the ligamentum teres, and chondral damage. Extra-articular diagnoses that can be managed arthroscopically are also discussed, including: iliopsoas tendonitis, "internal" snapping hip, "external" snapping hip, iliotibial band and greater trochanteric bursitis, and gluteal tendon injury. Finally, we discuss extra-articular causes of hip pain that are often managed nonoperatively or in an open fashion: femoral neck stress fracture, adductor strain, piriformis syndrome, sacroiliac joint pain, athletic pubalgia, "sports hernia," "Gilmore's groin," and osteitis pubis.

Treatment of osteitis pubis and osteomyelitis of the pubic symphysis in athletes: a systematic review

OBJECTIVES

The authors examined the most current evidence for treatment options in athletes with osteitis pubis and osteomyelitis pubis, attempting to determine which options provide optimal pain relief with rapid return to sport and prevention of symptom reoccurrence.

METHODS

Three databases-MEDLINE, Cochrane Database of Systematic Reviews and CINAHL-were searched using the OVID interface for all years between 1985 and May 2008. References were analysed from included studies, and additional relevant articles were obtained for inclusion. Inclusion criteria included (1) humans only, (2) subjects had no apparent risk factors for development of osteitis pubis or osteomyelitis of the pubic symphysis other than athletic involvement, (3) both physical exam findings and diagnostic imaging were used to confirm either diagnosis, and (4) a definitive treatment strategy was identifiable for management of osteitis pubis or osteomyelitis of the pubic symphysis. In total, 25 articles were included in the review.

RESULTS

There were no randomised controlled trials identified with this study's search strategy. A total of 195 athletes were diagnosed as having osteitis pubis (186 males, nine females) and treated with either conservative measures/physical therapy, local injection with corticosteroids and/or local anaesthetic, dextrose prolotherapy, surgery or antibiotic therapy. Six case reports/series described conservative treatment measures (physical therapy, rest, non-steroid anti-inflammatory drugs). Four case series explored the use of corticosteroid injections in treatment. One case series described the use of dextrose prolotherapy as a treatment modality. Six case series described various surgical techniques (pubic symphysis curettage, polypropylene mesh placement and pubic bone stabilisation) in treatment. Ten case reports/series (10 subjects) outlined antibiotic treatment of osteomyelitis of the pubic symphysis.

CONCLUSIONS

The current medical literature shows only level 4 evidence of the treatment for osteitis pubis in 24 case reports/series in athletes. Without any direct comparison of treatment modalities, it is difficult to determine which individual treatment option is the most efficacious. Further study comparing the different treatment options is necessary to determine which modality provides the fastest return to sport.