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

Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play

For nonsurgical musculoskeletal (MSK) injuries in athletes, image-guided percutaneous intervention may aid in recovery and decrease return to play (RTP) time. These interventions fall into two major categories: to reduce inflammation (and therefore alleviate pain) or to promote healing. This review describes the risks and benefits of the various percutaneous interventions in MSK athletic injury and surveys the literature regarding the implication of these interventions on RTP.

Groin Pain Syndrome Italian Consensus Conference update 2023

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Cadaveric Analysis of Key Anatomic Structures of Athletic Pubalgia

PURPOSE

This study proposes to establish in-depth inspection of the anatomic structures involved with the pathology of athletic pubalgia in a cadaver model.

METHODS

Eight male fresh frozen cadavers were dissected in a layered fashion. The rectus abdominis (RA) and adductor longus (AL) tendon insertions were isolated to quantify the size of the anatomic footprint and distance from the surrounding anatomy.

RESULTS

The RA insertional footprint was 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, and the AL insertional footprint on the underside of the pubis was 1.95 cm (SD, 0.28) in length by 1.23 cm (SD, 0.33) in width. The ilioinguinal nerve was 2.49 cm (SD, 0.36) lateral to the center of the RA footprint and 2.01 cm (SD, 0.37) lateral to the center of the AL footprint. The spermatic cord and the genitofemoral nerve were just lateral to the ilioinguinal nerve and were 2.76 cm (SD, 0.44) and 2.66 cm (SD, 0.46) from the rectus and AL footprints, respectively.

CONCLUSION

Surgeons should be cognizant of these anatomic relations during both initial dissection and tendon repair to optimize repair and avoid iatrogenic injury to critical structures in the anterior pelvis.

[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).

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.

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.

Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete

Background

Chronic strain and/or tendinopathy of the adductor longus tendon can be a cause of long-standing groin pain in the elite athlete, resulting in significant time lost from competition. Accurate diagnosis and treatment can expedite return to play.

Purpose/Hypothesis

To evaluate return to sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. We hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes.

Study Design

Case series; Level of evidence, 4.

Methods

A cohort study was performed of all NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopaedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to assess long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which "performance scores" were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or femoral acetabular impingement, prostatic or urinary tract disease, or nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves were excluded from the study.

Results

A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range, 12-178 months). Of the 32 patients, 20 had a concomitant sports hernia repair in addition to an adductor longus tenotomy. Thirty-one patients (97%) were able to return to their previous sport, and 30 (94%) were able to return at their previous level of play. Thirty patients (94%) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return to play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus postoperative comparisons of the athlete performance scores (P = .74) and the percentage of the games started versus played (P = .46). After separation of players who had a concomitant hernia repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started.

Conclusion

In this study of elite athletes, adductor longus tenotomy with or without a concomitant sports hernia repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain. Return to play in an NFL game averaged 12 weeks following surgery.

Ultrasound-Guided Cutting Wire Release of the Proximal Adductor Longus Tendon: A Feasibility Study

Background:

Adductor longus tendinopathy is a well-known etiology of chronic groin pain in elite athletes. Surgery is indicated for those who fail conservative treatment. No studies to date have evaluated the feasibility of an ultrasound-guided release of the proximal adductor longus tendon.

Purpose/Hypothesis:

The primary aim of this study was to determine the feasibility of an ultrasound-guided selective adductor longus release with a cutting wire. A secondary aim was to determine safety by avoiding injury to adjacent structures. We hypothesized that the proximal adductor longus tendon can be released under ultrasound guidance with a cutting wire without injury to adjacent neurovascular or genitourinary structures.

Study Design:

Descriptive laboratory study.

Methods:

Ten adductor longus tendons (5 cadaveric specimens) from 4 males and 1 female between 76 and 89 years of age with a mean body mass index of 21.9 kg/m² (range, 16.8-29.6 kg/m²) were used during this study. A single experienced physician sonographer performed ultrasound-guided proximal adductor longus tendon releases on all cadaveric specimens using a cutting wire. Dissection was performed by a second physician to determine the completeness of the tendon transections and to detect injury to adjacent neurovascular or genitourinary structures.

Results:

All 10 adductor longus tendons were transected. Eight of 10 transections were complete, whereas in 2 transections, >99% of the tendon was transected. There were no injuries to adjacent genitourinary or neurovascular structures.

Conclusion:

Ultrasound-guided adductor tendon release is feasible and safe in a cadaveric model. Further translational research should be performed to determine whether these results can be replicated in the clinical setting.

Clinical Relevance:

Adductor longus tendinopathy frequently requires surgical intervention and prolonged time away from sport. The present study suggests that a selective adductor longus tendon release can be performed with ultrasound guidance. This procedure warrants further translational research to explore its use in clinical practice.

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.

Clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain: prospective cohort of 205 patients

Background

Clinical assessments and rehabilitation in athletic groin pain (AGP) have focused on specific anatomical structures and uniplanar impairments rather than whole body movement.

Objective

To examine the effectiveness of rehabilitation that targeted intersegmental control in patients with AGP and to investigate post rehabilitation changes in cutting biomechanics.

Methods

Two hundred and five patients with AGP were rehabilitated focusing on clinical assessment of intersegmental control, linear running and change of direction mechanics in this prospective case series. Hip and Groin Outcome Score (HAGOS) was the primary outcome measure. Secondary measures included pain-free return to play rates and times, pain provocation on squeeze tests and three-dimensional (3D) biomechanical analysis during a 110° cutting manoeuvre.

Results

Following rehabilitation, patients demonstrated clinically relevant improvements in HAGOS scores (effect size (ES): 0.6–1.7). 73% of patients returned to play pain-free at a mean of 9.9 weeks (±3.5). Squeeze test values also improved (ES: 0.49–0.68). Repeat 3D analysis of the cutting movement demonstrated reductions in ipsilateral trunk side flexion (ES: 0.79) and increased pelvic rotation in the direction of travel (ES: 0.76). Changes to variables associated with improved cutting performance: greater centre of mass translation in the direction of travel relative to centre of pressure (ES: 0.4), reduced knee flexion angle (ES: 0.3) and increased ankle plantar flexor moment (ES: 0.48) were also noted.

Conclusions

Rehabilitation focused on intersegmental control was associated with improved HAGOS scores, high rates of pain-free return to sporting participation and biomechanical changes associated with improved cutting performance across a range of anatomical diagnoses seen in AGP.

Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment

Introduction

Athletic groin pain requiring surgery remains a diagnostic and therapeutic challenge. This systematic review aims to identify the most common causes of groin pain in athletes requiring surgery. Additionally, it aims to further characterise their susceptible athlete profiles, common physical examination and imaging techniques, and surgical procedures performed. This will enable the orthopaedic sports medicine clinician/surgeon to best treat these patients.

Materials and methods

The electronic databases MEDLINE, PubMed and EMBASE were searched from database inception to 13 August 2014 for studies in the English language that addressed athletic groin pain necessitating surgery. The search was updated on 4 August 2015 to find any articles published after the original search. The studies were systematically screened and data were abstracted in duplicate, with descriptive data presented.

Results

A total of 73 articles were included within our study, with data from 4655 patients abstracted. Overall, intra-articular and extra-articular causes of groin pain in athletes requiring surgery were equal. The top five causes for pain were: femoroacetabular impingement (FAI) (32%), athletic pubalgia (24%), adductor-related pathology (12%), inguinal pathology (10%) and labral pathology (5%), with 35% of this labral pathology specifically attributed to FAI.

Conclusions

Given the complex anatomy, equal intra-articular and extra-articular contribution, and potential for overlap of clinical entities causing groin pain leading to surgery in athletes, further studies are required to ascertain the finer details regarding specific exam manoeuvres, imaging views and surgical outcomes to best treat this patient population.

Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients--clinical findings, MRI findings and patient-reported outcome measures at baseline

Background

Athletic groin pain remains a common field-based team sports time-loss injury. There are few reports of non-surgically managed cohorts with athletic groin pain.

Aim

To describe clinical presentation/examination, MRI findings and patient-reported outcome (PRO) scores for an athletic groin pain cohort.

Methods

All patients had a history including demographics, injury duration, sport played and standardised clinical examination. All patients underwent MRI and PRO score to assess recovery. A clinical diagnosis of the injured anatomical structure was made based on these findings. Statistical assessment of the reliability of accepted standard investigations undertaken in making an anatomical diagnosis was performed.

Result

382 consecutive athletic groin pain patients, all male, enrolled. Median time in pain at presentation was (IQR) 36 (16–75) weeks. Most (91%) played field-based ball-sports. Injury to the pubic aponeurosis (PA) 240 (62.8%) was the most common diagnosis. This was followed by injuries to the hip in 81 (21.2%) and adductors in 56 (14.7%) cases. The adductor squeeze test (90° hip flexion) was sensitive (85.4%) but not specific for the pubic aponeurosis and adductor pathology (negative likelihood ratio 1.95). Analysed in series, positive MRI findings and tenderness of the pubic aponeurosis had a 92.8% post-test probability.

Conclusions

In this largest cohort of patients with athletic groin pain combining clinical and MRI diagnostics there was a 63% prevalence of PA injury. The adductor squeeze test was sensitive for athletic groin pain, but not specific individual pathologies. MRI improved diagnostic post-test probability. No hernia or incipient hernia was diagnosed.

Clinical trial registration number

NCT02437942.

Imaging of adductor-related groin pain

Groin pain is a common condition in athletes and results from various causes. Osteitis pubis, adductor dysfunction, inguinal hernia, or a combination of all three entities, generally explains the onset of symptoms. Adductor longus tendinopathy is the main cause of adductor-related groin pain. It leads to a significant reduction of sports participation and can require surgical management. Diagnosis is based on ultrasonography and magnetic resonance imaging. Asymptomatic findings (tendinosis, calcifications, cortical erosions) are common in athletes and care should be taken when assessing groin pain. The most specific sign of tendinopathy is an intratendinous tear of the adductor longus.

Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes

Background

Groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the efficacy of these treatments is unknown.

Objective

Systematically review the literature on the efficacy of treatments for groin pain in athletes.

Methods

Nine medical databases were searched in May 2014. Inclusion criteria: treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n>10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and two authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Review registration number CRD42014010262.

Results

72 studies were included for quality analysis. Four studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman's hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p<0.001, r=−0.41), but not between study quality and publication year (p=0.09, r=0.20).

Conclusions

Only 6% of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. There is moderate evidence for the efficacy of conservative treatment (active exercises and multimodal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for efficacy of surgical treatment in sportsman's hernia.

The role of eccentric exercise in sport injuries rehabilitation

INTRODUCTION

Sports injuries frequently involve tendons, muscles and ligaments. The variable outcome of surgery and medical treatment support early functional treatments. Eccentric exercise (EE) showed effectiveness in the management of Achilles tendinopathy (AT), patellar tendinopathy (PT) and lateral epicondyle tendinopathy (LET). Preliminary results of EE in other tendinopathies and sports injuries suggest its wide prescription in the sport rehabilitation field.

SOURCES OF DATA

A comprehensive search of PubMed, Web of Science, the Cochrane Collaboration Database, Physiotherapy Evidence Database (PEDro), Evidence Based Medicine (EBM) Search review, National Guidelines, Scopus and Google Scholar was performed using keywords such as 'eccentric exercise', 'sports injuries rehabilitation', 'tendinopathy', 'hamstrings strain' 'adductor injuries' and 'ACL reconstruction rehabilitation'.

AREAS OF AGREEMENT

EE, alone or associated with other therapies, represents a feasible, cost-effective and successful tool in the treatment of well-known targets and might be promising in shoulder tendinopathy, adductor-related groin pain, hamstring strains, and ACL rehabilitation.

AREA OF CONTROVERSY

The lack of standardization of protocols, the variable amount, quality and follow-up of studies, the different anatomy and pathophysiology of the therapeutic targets limit the evidence of applicability of EE to sports injuries.

GROWING POINTS

The role of pathology and biomechanics in the response to EE should be further investigated.

AREAS TIMELY FOR DEVELOPING RESEARCH

New randomized controlled trials should test the effectiveness of standardized EE regimens to various sites of sports injuries.

Surgical technique for treatment of recalcitrant adductor longus tendinopathy

Chronic groin pain in the athlete can be a difficult problem to manage. Adductor dysfunction is the most common cause of groin pain in athletes, with the adductor longus being the tendon most commonly involved. The most reproducible finding for adductor longus tendinopathy is tenderness along the tendon with passive abduction and resisted hip adduction in extension. Magnetic resonance imaging and injection of a corticosteroid and anesthetic into the proximal muscle-tendon junction are both helpful in confirming the diagnosis. Nonoperative treatment may consist of protected weight bearing, ice application, ultrasonography, electrical stimulation, and gentle stretching with progressive strengthening. However, nonoperative management is not always successful. In these instances, surgical treatment can be quite effective. We present the indications, surgical technique, and rehabilitation protocol of adductor tenotomy for chronic tendinopathy. This can prove a useful tool for the treatment of recalcitrant groin pain attributable to the adductor longus.

Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes

PURPOSE

There are several reports on the association between pubalgia and intra-articular hip disorders. The purpose of this study was to evaluate the long-term outcome in athletes who underwent tenotomy due to long-standing groin pain. A secondary purpose was evaluating the frequency of femoro-acetabular impingement (FAI) and its impact on the long-term outcome.

METHODS

Thirty-two high-level male athletes treated with adductor tenotomy, rectus abdominis tenotomy or both were included. At a median follow-up time of 6 years after the tenotomy, the subjects underwent standardised clinical examination, plain radiographs, completed web-based health-related patient-reported outcomes, including iHOT12, HAGOS (six subscales), EQ-5D (two subscales), HSAS for physical activity level and a VAS for overall hip function. Furthermore, patient satisfaction and return to sports were documented.

RESULTS

Twenty-four of the 32 (75 %) athletes were satisfied with the outcome of the tenotomy, and 22 of the athletes (69 %) were able to return to their pre-injury sport. Before the long-term follow-up, two of these satisfied athletes had undergone repeat surgery (one hip arthroscopy due to FAI and one repeat tenotomy). Of the 24 satisfied athletes, eight (33 %) had a positive hip impingement test at the follow-up. Of the remaining eight athletes not satisfied with the outcome, only one returned to their pre-injury sport and three had undergone hip arthroscopy prior to follow-up. Five had positive hip impingement tests which was significantly more frequently than in the satisfied group (p = 0.008). The group with a positive hip impingement test reported significantly more pain and symptoms, more hip problems during sports and physical activity, as well as lower hip-related quality of life according to the HAGOS scores (p < 0.05), at follow-up.

CONCLUSION

Tenotomy for pubalgia yielded a satisfactory long-term outcome, with three of four athletes being able to return to their pre-injury sport. The athletes that did not return to their pre-injury sport had higher frequency of positive hip impingement test and inferior functional outcome compared with the athletes that did return to their pre-injury sport. It is therefore recommended that the hip should be carefully evaluated for hip impingement before tenotomy is considered as treatment for athletes with pubalgia.