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

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).

Adductor longus and brevis lesion in an amateur soccer player: platelet rich plasma and multifractioned hyaluronic acid injections to enhance clinical recovery

Groin pain is a common issue in athletes, with a particularly high incidence in male soccer players. Adductor muscles are the most involved site of the groin, accounting for up to one-fourth of muscle injuries of that region. Physical therapy and rehabilitation programs for adductor-related groin pain using active exercises are effective in getting athletes back to sport. However, the return-to-play time varies according to the injury severity. Minor lesions can recover in 1-2 weeks, while severer injuries require 8-12 weeks. To enhance tendon healing and shorten the return to play time, intrandentinous injections of Platelet Rich Plasma (PRP) have been proposed. An increasing body of evidence in literature have shown efficacy of platelet rich plasma in aiding the healing process in tendinopathies. Similarly, more recent evidences have proven hyaluronic (HA) acid to have anti-inflammatory, proliferative, repairing, and analgesic effects. This case report presents the clinical application of combined PRP and a multifractioned (a mixture of different molecular weights) HA in a 24-year-old athlete suffering from a hip adductor rupture.

Anatomy and terminology of groin pain: Current concepts

Groin pain is a common symptom in athletes. The complex anatomy of the area and the various terms used to describe the etiology behind groin pain have led to a confusing nomenclature. To solve this problem, three consensus statements have been already published in the literature: the Manchester Position Statement in 2014, the Doha agreement in 2015, and the Italian Consensus in 2016. However, when revisiting recent literature, it is evident that the use of non-anatomic terms remains common, and the diagnoses sports hernia, sportsman's hernia, sportsman's groin, Gilmore's groin, athletic pubalgia, and core muscle injury are still used by many authors. Why are they still in use although rejected? Are they considered synonyms, or they are used to describe different pathology? This current concepts review article aims to clarify the confusing terminology by examining to which anatomical structures authors refer when using each term, revisit the complex anatomy of the area, including the adductors, the flat and vertical abdominal muscles, the inguinal canal, and the adjacent nerve branches, and propose an anatomical approach, which will provide the basis for improved communication between healthcare professionals and evidence-based treatment decisions.

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.

Sex-related differences in hip and groin injuries in adult runners: a systematic review

OBJECTIVES

Hip/groin running-related injuries (RRIs) are relatively uncommon. It is unclear if runners of either sex are disproportionately affected. Our objective was to systematically review differences in hip/groin RRIs between males and females.

DATA SOURCES

A structured and comprehensive search of four medical literature databases was performed (PubMed, Embase, Ovid Medline, and CINAHL). Terms searched were as follows: risk, epidemiology, hip injury, groin injury, overuse injury, running, sprinting, and track and field.

STUDY SELECTION

Studies reporting sex-specific data on hip/groin RRIs in adult runners were included. Data was extracted and reviewed independently by two authors.

STUDY APPRAISAL AND DATA SYNTHESIS

Sex-specific injury rates, risk factors, and return to sport (RTS) following hip/groin RRI were extracted. Risk of bias was assessed using the Joanna-Briggs Institute Critical Appraisal Tool.

RESULTS

Ten studies with 7,353 total runners were included: 2,315 (47%) males and 2,559 (53%) females. The mean age of the included runners was 37.3 ± 8.9 years and the mean weekly running distance was 10.4 ± 8.4 km. Hip/groin injuries comprised 10.1% (491/4,874) of total RRIs, including 6.3% of RRIs sustained by males and 11.0% by females. Three studies reported significantly higher rates of hip/groin RRIs in female runners. One study reported significantly higher rates of gluteus medius and adductor RRIs for females and males, respectively. One study identified female sex as an independent risk factor for hip/groin RRIs. Three studies reported on RTS after hip/groin RRIs: the pooled RTS rate was 81.4% (57/70) at 1 to 368 days after injury.

LIMITATIONS

Data was pooled when possible; however, there was considerable clinical, methodological, and statistical heterogeneity across studies.

CONCLUSIONS

Hip/groin RRIs comprise a greater percentage of total injuries among injured female runners relative to males. Females may be at a higher risk for sustaining hip/groin RRIs though more research on risk factors and RTS is needed.

Adductor Muscle Injuries in UEFA Soccer Athletes: A Matched-Cohort Analysis of Injury Rate, Return to Play, and Player Performance From 2000 to 2015

Background:

The effects of adductor muscle injury on performance in soccer athletes are unknown.

Purpose:

To (1) determine the rate and time to return to play (RTP) after adductor muscle injury, (2) investigate the rate of reinjury after RTP, and (3) investigate any long-term effects of injury on elite soccer player performance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Using publicly available records, athletes sustaining adductor muscle injury were identified across the 5 major European soccer leagues (English Premier League, Bundesliga, La Liga, Ligue 1, and Serie A) between 2000 and 2015. Injured athletes were matched to controls by demographic characteristics and performance metrics from 1 season before the index timepoint. Investigations included the rate of RTP, reinjuries, player characteristics associated with RTP within 2 seasons, player availability, field time, and performance metrics during the 4 seasons after injury.

Results:

A total of 671 players with adductor muscle injury were included. Based on time to RTP, 86% of injuries were mild to moderate (4-28 days missed), and 4% required surgical intervention. Players with adductor muscle injury were absent for a median of 22 days (range, 1-700 days) and 4 games (range, 1-76 games). A total of 521 (78%) players returned at the same level, with no demographic or clinical characteristics associated with RTP on the multivariable regression. Of those returning to play, 143 (21%) experienced adductor reinjury. After RTP, defenders demonstrated decreased field time compared with controls (P < .05). As compared with controls, defenders and midfielders scored more points and goals per game during the season of the injury (P < .01), while attackers recorded more goals and assists per game the season after injury (P < .05).

Conclusion:

Only 3 in 4 players (78%) returned to participate in an official match, and the reinjury rate was high (21%). After RTP, defenders demonstrated decreased field time versus controls. On the other hand, defenders and midfielders recorded more points and goals per game, while attackers recorded more goals and assists per game versus controls. Although the multivariable analysis results did not identify player characteristics associated with RTP, there was a position-dependent association on player performance after RTP.

High Return to Play Rate and Reduced Career Longevity Following Surgical Management of Athletic Pubalgia in National Basketball Association Players

Purpose

To assess the effects of surgical treatment of athletic pubalgia (AP) on game use and performance metrics in National Basketball Association (NBA) players.

Methods

A retrospective review of all NBA players who underwent surgical management for AP from 1996 to 2018 was performed. A matched control group was created for comparison. The index period was defined as the entire NBA season in which surgery occurred, including the corresponding offseason. Player demographics, use (games played, games started, and minutes per game) and performance (player efficiency rating) metrics were collected for all players. Statistical analysis was performed to compare data before and after return to play.

Results

Thirty players with a history of surgical management for AP were included in the final analysis. Following surgery for AP, NBA players were found to have a return to play (RTP) rate of 90.91% (30/33). The average RTP following surgery was 4.73 ± 2.62 months. Compared with control athletes, athletes in the AP group played significantly fewer seasons postinjury (4.17 ± 2.70 vs 5.49 ± 3.04 seasons, respectively; P = .02). During the first year following RTP, NBA players experienced significant reductions in game use and performance, both when compared with the year prior and matched control athletes (P < .05). At 3-year follow-up, players continued to demonstrate significant reductions in game use (minutes per game, P < .05) but not performance.

Conclusions

Following surgical treatment of AP, NBA players demonstrated a high RTP rate, but shortened career. A short-term reduction in game use and performance metrics was found the year of return following surgery. However, 3-year follow-up performance metrics normalized when compared with healthy controls.

Study Design

Level III; retrospective case-control study.

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.

Endoscopic Repair of Proximal Adductor Avulsion

Optimal treatment of complete grade 3 tears of the adductor longus tendon from the pubic body has support for both nonsurgical management and surgical reattachment. We demonstrate the feasibility of endoscopic reattachment of an adductor avulsion with >3 cm of retraction. Using our previously described anterior pubic symphyseal portal and an anteromedial adductor portal, initial diagnostic endoscopy is followed by debridement of adhesions, preparation of the pubic body bony footprint, secure passage of suture tape through the avulsed tendon, reduction of the avulsed tendon, and knotless suture anchor reattachment. Endoscopic primary repair is a technically feasible, minimally invasive option in the treatment of retracted grade 3 adductor tears.

Core Muscle and Adductor Injury

Core muscle injury is a common but difficult problem to treat. Although it can affect all individuals, it is most commonly seen in male athletes in cutting, twisting, pivoting, and explosive sports. Owing to the high association of femoroacetabular impingement, we believe these individuals are best treated with a multidisciplinary approach involving both orthopedic and general surgeons. Conservative treatment should be the first step in management. When conservative means are unsuccessful, operative intervention to correct all the pathologic issues around the pubis can have extremely high success rates.