Sports hernia: diagnosis and therapeutic approach

Athletes treated for inguinal-related groin pain by endoscopic totally extraperitoneal (TEP) repair: long-term benefits of a prospective cohort

PURPOSE

Inguinal-related groin pain (IRGP) in athletes is a multifactorial condition, posing a therapeutic challenge. If conservative treatment fails, totally extraperitoneal (TEP) repair is effective in pain relief. Because there are only few long-term follow-up results available, this study was designed to evaluate effectiveness of TEP repair in IRGP-patients years after the initial procedure.

METHODS

Patients enrolled in the original, prospective cohort study (TEP-ID-study) were subjected to two telephone questionnaires. The TEP-ID-study demonstrated favorable outcomes after TEP repair for IRGP-patients after a median follow-up of 19 months. The questionnaires in the current study assessed different aspects, including, but not limited to pain, recurrence, new groin-related symptoms and physical functioning measured by the Copenhagen Hip and Groin Outcome Score (HAGOS). The primary outcome was pain during exercise on the numeric rating scale (NRS) at very long-term follow-up.

RESULTS

Out of 32 male participants in the TEP-ID-study, 28 patients (88%) were available with a median follow-up of 83 months (range: 69-95). Seventy-five percent of athletes were pain free during exercise (p < 0.001). At 83 months follow-up, a median NRS of 0 was observed during exercise (IQR 0-2), which was significantly lower compared to earlier scores (p <0.01). Ten patients (36%) mentioned subjective recurrence of complaints, however, physical functioning improved on all HAGOS subscales (p <0.05).

CONCLUSION

This study demonstrates the safety and effectivity of TEP repair in a prospective cohort of IRGP-athletes, for whom conservative treatment had failed, with a follow-up period of over 80 months.

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Retrospective cohort design.

LEVEL OF EVIDENCE

Level 3.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Epidemiological Analysis of 245 Patients with Athletic Pubalgia

Objective To analyze the clinicoepidemiological characteristics of pubalgia in athletes and to define the epidemiological profile of patients complaining of lower abdomen and groin pain at a specialized center. Methodology  We conducted a retrospective study based on a case series to evaluate the epidemiological profile of 245 athletes with pubalgia reported in their medical records from October 2015 to February 2018. The selected sample underwent a clinical evaluation, and the results were recorded through the application of a questionnaire. Results  The sample consisted of 245 patients aged between 14 and 75 years. Soccer and running were the most prevalent sports. Most subjects (58%) trained or played sports 3 or more days a week. After evaluating specific sports movements, symptoms worsened in 24% of the patients when changing direction; in 23%, when kicking; in 22%, during sprints and speed training; in 17%, during long runs; and in 14%, when jumping. Pain during intercourse was reported by 13% of the patients. For most subjects (80%), the inguinal region, the adductor muscles, and the pubis (midline) were the main pain sites. The tests involving adductor contraction against resistance with an extended knee was positive in 77.6% of the patients, and the one involving simultaneous hip and abdomen flexion against resistance was positive in 76.7% of the sample. Conclusion  The present study has demonstrated the predominance of pubalgia in male patients who play soccer and practice running. In most cases (80%), pain occurred in the inguinal region, the adductor muscles, and the pubis. Confirmation of the clinical diagnosis took more than six months for most patients.

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.

Recovery of two elite footballers from adductor strain with dry needling and eccentric strengthening: Two case studies

INTRODUCTION

Groin injuries are common in sports, almost 68% adductor strain among them, which generally more prone in football, soccer, hockey, and other games. The available literature well describes the rehabilitation phase of adductor strain but an application of dry needling on adductor injuries are not yet established.

CASE DESCRIPTION

Two national-level younger football players were clinically diagnosed with the adductor strain. They had severe pain on medial aspect of the thigh, aggravated with kicking and functional activity (VAS- 8/10, LEFS 58/80, 69/80). The therapist assessed the patients and designed their rehabilitation protocol as per their findings of the examination.

OUTCOME

The lower extremity functional scale (LEFS), global rating scale, and VAS were used as outcome variables. The total intervention was given for 10-12 weeks, follow up had been taken for 4 months.

DISCUSSION

The application of dry needling reduced the pain, improved and relieved the symptoms. The eccentric strengthening of the adductors and core stability improved the strength as well as functional activity of the lower limb. The case study is not generalized the effect of treatment. Thus, a randomized control trial is suggested for further study.

Core Muscle Injury: Evaluation and Treatment in the Athlete

BACKGROUND

Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature.

PURPOSE

To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury.

STUDY DESIGN

Narrative and literature review; Level of evidence, 4.

METHODS

A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms.

RESULTS

The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks.

CONCLUSION

Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.

Robotic Abdominal Wall Repair with Endoscopic Adductor Lengthening: A Minimally Invasive Approach for Core Muscle Injuries

Groin pain is a common complaint in sports medicine practices but can be a challenge to accurately diagnose given the expanse of differentials. In the athlete, groin pain may be caused by a core muscle injury, also known as sports hernia or athletic pubalgia. These injuries most frequently occur in young males who participate in explosive and rotationally demanding activities such as soccer, football, and ice hockey, which generate large forces across the trunk and hip joint. These injuries are becoming more frequently diagnosed, in part, due to the utilization of diagnostic modalities, such as dynamic ultrasound and magnetic resonance imaging (MRI) and sensitive physical examination tests, such as the cross-body sit-up and squeeze test. When conservative management fails, surgical intervention is a good option for the athletes who desire to return to play. Surgical options include both open and laparoscopic techniques to repair abdominopelvic defects with or without attention to adductor pathology. The purpose of this article is to present a technique for minimally invasive robotic abdominal wall repair with endoscopic adductor lengthening for core muscle injuries.

Resisted adduction sit-up test (RASUT) as a screening tool for pelvic versus hip pathology

Groin pain is a common symptom in hip and pelvic pathology and differentiating between the two remains a challenge. The purpose of this study was to examine whether a test combining resisted adduction with a sit-up (RASUT) differentiates between pelvic and hip pathology. The RASUT was performed on 160 patients with complaints of hip or groin pain who subsequently had their diagnosis confirmed by magnetic resonance imaging (MRI) or surgery. Patients were categorized as having pelvic pathology (athletic pubalgia or other) or hip pathology (intra-articular or other). Athletic pubalgia was defined as any condition involving the disruption of the pubic aponeurotic plate. Sensitivity, specificity, positive predictive accuracy, negative predictive accuracy and diagnostic odds ratios were computed. Seventy-one patients had pelvic pathology (40 athletic pubalgia), 81 had hip pathology and 8 had both. The RASUT was effective in differentiating pelvic from hip pathology; 50 of 77 patients with a positive RASUT had pelvic pathology versus 29 of 83 patients with a negative test (P < 0.001). RASUT was diagnostic for athletic pubalgia (diagnostic odds ratio 6.08, P < 0.001); 35 of 45 patients with athletic pubalgia had a positive RASUT (78% sensitivity) and 73 of 83 patients with a negative RASUT did not have athletic pubalgia (88% negative predictive accuracy). The RASUT can be used to differentiate pelvic from hip pathology and to identify patients without athletic pubalgia. This is a valuable screening tool in the armamentarium of the sports medicine clinician.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success

Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

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.

Outcomes following surgical management of inguinal-related groin pain in athletes: a case series

To determine the outcomes of a limited surgical intervention, consisting of neurolysis, inguinal wall repair and/or adductor debridement of adhesions based on intraoperative findings. Retrospective case series. Outpatient orthopedic/general surgery clinic. Fifty-one athletes treated surgically for inguinal-related groin pain from 2009 to 2015. Limited surgical intervention, consisting of neurolysis, inguinal wall repair and/or adductor debridement based on intra-operative findings. Ability to return to sport at the same level, time to return to play. Fifty-one athletes were included in the study with an average follow-up of 4.42 years (range 2.02–7.01). The average age was 24.2 years (range 16–49) and consisted of 94.0% males and 6.0% females. Nerve entrapment was demonstrated in 96.2% of cases with involvement of the ilioinguinal in 92.5%, the iliohypogastric in 30.8% and the genitofemoral in 13.2%. Attenuation of the posterior inguinal wall was present and repaired in 79.3% of cases. Scar tissue was present around the adductor origin and required debridement in 56.7% of cases. Forty-nine (96.1%) athletes returned to sport at the same level of play at an average of 5.9 weeks. Two athletes required a revision surgery. High rates of return to sport were achieved after surgery for inguinal-related groin pain that addresses the varying pathology and associated nerve entrapment.

Early recovery after endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption: A prospective cohort study

Background

Groin pain is a common problem in athletes which results in loss of playing time. Moreover, it can be for the cause of athletic career termination. A common cause of groin pain in athletes is inguinal disruption; pain in the groin area near the pubic tubercle were no obvious other pathology exists to explain the symptoms. Aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption.

Methods

Thirty-one athletes with chronic groin pain due to inguinal disruption, who had undergone conservative therapy without any effect, were included in this prospective cohort study. Prior to surgery patients were assessed by clinical examination, ultrasound of the inguinal region, x-ray and a radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT). TEP hernia repair was performed and a lightweight polypropylene mesh was placed pre-peritoneally. Additionally the athletes’ perception about their groin disability was assessed preoperatively and 6 weeks postoperatively by means of the Hip and Groin Outcome Score (HAGOS). The HAGOS consists of six subscales: Pain, Symptoms, Physical function in daily living, Physical function in Sport and Recreation, Participation in Physical Activities, and hip and/or groin-related Quality of Life.

Results

No complications occurred during and after surgery. After six weeks patients improved in all the separate subscales of the Hip and Groin Outcome Score (HAGOS). Within 6 weeks of surgery, 26 patients (84%) returned to sports activities with no or less groin pain.

Conclusions

This study showed that endoscopic totally extraperitoneal (TEP) hernia repair is an effective surgical treatment of inguinal disruption in athletes with chronic groin pain.

[Sportsmen's groin : Definition, differential diagnosis and treatment]

Groin pain in athletes is a common problem and can have extensive consequences for professional athletes. The anatomical and functional complexity of the groin as well as radiating pain from remote anatomical regions can make the differential diagnosis a challenge and requires special attention. As there are a wide variety of possible causes for groin pain, a multidisciplinary approach is required. The treating orthopedic surgeon needs to pay special attention to pre-arthritic hip deformities to avoid irreversible damage of the hip joint. By a meticulous patient history and identification of the pain character, followed by clinical, sonographic and radiographic investigations, a differential diagnosis can usually be achieved. Besides typical orthopedic causes, pathological findings particularly in the area of the groin need to be considered, clarified and adequately treated; therefore, a clear terminology of the different diseases is necessary. Sportsmen's groin is not a hernia but should be perceived as a separate entity due to its typical pain character and detection of a measurable protrusion of the posterior wall of the inguinal canal by ultrasound.

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

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

Athletic Pubalgia Secondary to Rectus Abdominis-Adductor Longus Aponeurotic Plate Injury: Diagnosis, Management, and Operative Treatment of 100 Competitive Athletes

Background

A rectus abdominis-adductor longus (RA-AL) aponeurotic plate injury, commonly associated with athletic pubalgia, sports hernia, or a core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia abnormalities has led to better management of this debilitating condition.

Hypothesis

Surgical repair of RA-AL aponeurotic plate injuries will result in decreased symptoms and high rates of return to play.

Study Design

Case series; Level of evidence, 4.

Methods

Using our billing and clinical database, patients who underwent RA-AL aponeurotic plate repair by a single surgeon at a single institution were contacted for Hip Outcome Score (HOS) and return-to-play data. Patients with a confirmed diagnosis by history, physical examination, and magnetic resonance imaging who failed 6 to 12 weeks of appropriate conservative treatment were indicated for surgery. Surgical repair involved adductor longus fractional lengthening, limited adductor longus tenotomy, and a turn-up flap of the released adductor tendon and aponeurosis onto the rectus abdominis for imbrication reinforcement.

Results

Of 100 patients who met the inclusion criteria, 85 (85%) were contacted. A total of 82 (96%) patients were able to return to play at a mean of 4.1 months after repair. Hip function was rated as 98% of normal and sports function as 92% of normal. Factors associated with negative outcomes were multiple procedures, prior inguinal hernia repair, and female sex. Negative outcomes were demonstrated by decreased HOS scores and decreased sports function. The overall complication rate was 7%.

Conclusion

RA-AL aponeurotic plate repair by the method of an adductor-to-rectus abdominis turn-up flap is a safe procedure with high return-to-play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic-related surgery and female patients had worse outcomes.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Outcomes of surgery on patients with a clinically inapparent inguinal hernia as diagnosed by ultrasonography

BACKGROUND

Chronic post-operative inguinal pain (CPIP) is the most significant complication following inguinal hernia repair. Patients without a palpable hernia prior to surgery seemed to report more CPIP. Our aim was to evaluate the effects of surgery on patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography.

METHODS

A total of 179 hernia repairs in patients with a positive ultrasonography but negative physical examination were analysed retrospectively. Patients with recurrent hernias, femoral hernias or previous surgery to the inguinal canal were excluded. The primary outcome was the presence of chronic postoperative inguinal pain (pain > 3 months postoperatively). Data on preoperative complaints, surgical technique and findings during ultrasonography and surgery were also studied in relation to the development of CPIP.

RESULTS

A quarter (25.1%) of the patients reported chronic postoperative pain. Female gender (p = 0.03), high BMI (p = 0.04) and atypical symptoms prior to surgery (p < 0.001) were significant univariate risk factors for developing CPIP. Logistic regression showed a significant association between atypical symptoms and CPIP [OR = 6.31, p < 0.001, 95% CI (2.32, 17.16)], which was still present after correction for the significant univariate variables [OR = 4.23, p = 0.02, 95% CI (1.26, 14.21)].

CONCLUSION

Patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography report a high incidence of CPIP after elective hernia repair. Patients with atypical groin pain prior to surgery are especially prone to CPIP. It is questionable whether these hernias should be classified and treated as symptomatic inguinal hernias. The results advocate taking other causes of groin pain into consideration before choosing surgical treatment.

Cam morphology and inguinal pathologies: is there a possible connection?

Background

To analyse the prevalences of the cam and pincer morphologies in a cohort of patients with groin pain syndrome caused by inguinal pathologies.

Materials and methods

Forty-four patients (40 men and 4 women) who suffered from groin pain syndrome were enrolled in the study. All the patients were radiographically and clinically evaluated following a standardised protocol established by the First Groin Pain Syndrome Italian Consensus Conference on Terminology, Clinical Evaluation and Imaging Assessment in Groin Pain in Athlete. Subsequently, all of the subjects underwent a laparoscopic repair of the posterior inguinal wall.

Results

The study demonstrated an association between the cam morphology and inguinal pathologies in 88.6% of the cases (39 subjects). This relationship may be explained by noting that the cam morphology leads to biomechanical stress at the posterior inguinal wall level.

Conclusions

Athletic subjects who present the cam morphology may be considered a population at risk of developing inguinal pathologies.

Level of evidence

Level IV, Observational cross-sectional study.

The value of laparoscopy in the management of chronic groin pain

BACKGROUND

Chronic groin pain problem represents a diagnostic and management challenge. This study is reporting all patients who underwent laparoscopic exploration of the groin and pelvis for undiagnosed chronic groin pain.

MATERIALS AND METHODS

A retrospective cohort study. Evaluators were not involved in the operations. Laparoscopic exploration and mesh insertion using Trans-Abdominal Pre-Preitoneal (TAPP) approach was performed for all patients. Follow up in the; clinic at 2 weeks and 6 months was arranged. This was a consecutive series of patients who were presented with chronic groin pain and no pre-operative radiological, orthopedic, gynecological or urologic abnormalities. Patients who were diagnosed with clinical hernia or other positive finding were excluded.

RESULTS

Data were collected and analyzed for 92 patients. The operation had successfully managed the groin pain in 81 patients (88.04%), and the pain was improved in another 3 patients (3.26%). Six patients (6.52%) had no change in their symptoms, and worse pain was reported in two patient (2.17%).

CONCLUSION

Laparoscopic groin exploration is an effective method to diagnose the chronic groin pain that under diagnosed by clinical, ultrasound and MRI tests. Laparoscopic management had resulted in resolution of the pain in the majority of the patients. The procedure is effective in athletes' patients who did not have clinical, radiological and laparoscopic evidence of groin hernia.

Inguinal Hernia in Athletes: Role of Dynamic Ultrasound

Background:

Inguinal hernia is a commonly encountered cause of pain in athletes. Because of the anatomic complexity, lack of standard imaging, and the dynamic condition, there is no unified opinion explaining its underlying pathology.

Hypothesis:

Athletes with persistent groin pain would have a high prevalence of inguinal hernia with dynamic ultrasound, and herniorrhaphy would successfully return athletes to activity.

Study Design:

Case-control study.

Level of Evidence:

Level 3.

Methods:

Forty-seven amateur and professional athletes with sports-related groin pain who underwent ultrasound were selected based on history and examination. Patients with prior groin surgery or hip pathology were excluded. Clinical and surgical documentation were correlated with imaging. The study group was compared with 41 age-matched asymptomatic athletes.

Results:

Ultrasound was positive for hernia with movement of bowel, bladder, or omental tissue anterior to the inferior epigastric vessels during Valsalva maneuver. The 47-patient symptomatic study group included 41 patients with direct inguinal hernias, 1 with indirect inguinal hernia, and 5 with negative ultrasound. Of 42 patients with hernia, 39 significantly improved with herniorrhaphy, 2 failed to improve after surgery and were diagnosed with adductor longus tears, and 1 improved with physical therapy. Five patients with negative ultrasound underwent magnetic resonance imaging and were diagnosed with hip labral tear or osteitis pubis. The 41-patient asymptomatic control group included 3 patients with direct inguinal hernias, 2 with indirect inguinal hernias, and 3 with femoral hernias.

Conclusion:

Inguinal hernias are a major component of groin pain in athletes. Prevalence of direct inguinal hernia in symptomatic athletes was greater than that for controls (P < 0.001). Surgery was successful in returning these athletes to sport: 39 of 42 (93%) athletes with groin pain and inguinal hernia became asymptomatic.

Clinical Relevance:

Persistent groin pain in the athlete may relate to inguinal hernia, which can be diagnosed with dynamic ultrasound imaging. Herniorrhaphy is successful at returning athletes to sports activity.

Prevalence of Surgical Repair for Athletic Pubalgia and Impact on Performance in Football Athletes Participating in the National Football League Combine

PURPOSE

To examine the prevalence and impact of athletic pubalgia (AP) surgery in elite American football athletes participating in the National Football League (NFL) Combine.

METHODS

Results from 1,311 athletes participating in the Combine from 2012 to 2015 were evaluated. Athletes with a history of AP repair were identified using the NFL Combine Database. Athlete history and available imaging was reviewed. NFL performance based on draft status, games played, games started, and current status in the NFL was gathered using publicly available databases. Statistical analysis was performed to detect for significant associations between athlete history and NFL performance in the presence of AP repair and pelvic pathology on postsurgical magnetic resonance imaging (MRI).

RESULTS

AP repair was identified in 4.2% (n = 55) of athletes. MRI was performed in 35% (n = 19 of 55) with AP repair, of which 53% (n = 10 of 19) had positive pathology. Athletes with repair were not at risk of playing (P = .87) or starting (P = .45) fewer regular season games, going undrafted (P = .27), or not being on an active NFL roster (P = .51). Compared with athletes with negative imaging findings, positive pathology on MRI did not have a significant impact on games played (P = .74), games started (P = .48), draft status (P = .26), or being on an active roster (P = .74). Offensive linemen (P = .005) and athletes with a history of repair within 1 year of the Combine (P = .03) had a significantly higher risk of possessing positive pathology on MRI.

CONCLUSIONS

Athletes with a history of successful AP surgery invited to the NFL Combine and those with persistent pathology on MRI are not at increased risk for diminished performance in the NFL. Offensive linemen and athletes less than 1 year out from surgery have a higher risk for positive MRI findings at the pubic symphysis.

LEVEL OF EVIDENCE

Level IV, prognostic study-case series.

Performance and Return to Sport After Sports Hernia Surgery in NFL Players

Background:

Recognition, diagnosis, and treatment of athletic pubalgia (AP), also known as sports hernia, once underrecognized and undertreated in professional football, are becoming more common. Surgery as the final treatment for sports hernia when nonsurgical treatment fails remains controversial. Given the money involved and popularity of the National Football League (NFL), it is important to understand surgical outcomes in this patient population.

Hypothesis:

After AP surgery, players would: (1) return to sport (RTS) at a greater than 90% rate, (2) play fewer games for fewer years than matched controls, (3) have no difference in performance compared with before AP surgery, and (4) have no difference in performance versus matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Internet-based injury reports identified players who underwent AP surgery from January 1996 to August 2015. Demographic and performance data were collected for each player. A 1:1 matched control group and an index year analog were identified. Control and case performance scores were calculated using a standardized scoring system. Groups were compared using paired Student t tests.

Results:

Fifty-six NFL players (57 AP surgeries) were analyzed (mean age, 28.2 ± 3.1 years; mean years in NFL at surgery, 5.4 ± 3.2). Fifty-three players were able to RTS. Controls were in the NFL longer (P < .05) than players who underwent AP surgery (3.8 ± 2.4 vs 3.2 ± 2.1 years). Controls played more games per season (P < .05) than post-AP players (14.0 ± 2.3 vs 12.0 ± 3.4 games per season). There was no significant (P > .05) difference in pre- versus post-AP surgery performance scores and no significant (P > .05) difference in postoperative performance scores versus controls post-index.

Conclusion:

There was a high RTS rate after AP surgery without a significant difference in postoperative performance, though career length and games per season after AP surgery were significantly less than that of matched controls.

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.

Core Muscle Injury/Sports Hernia/Athletic Pubalgia, and Femoroacetabular Impingement

Core muscle injury/sports hernia/athletic pubalgia is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of nonoperative management have not been well delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates. In this review, we outline the clinical entity and treatment of core muscle injury and athletic pubalgia. In addition, we describe the relationship between athletic pubalgia and femoroacetabular impingement along with recent studies that have investigated the treatment of these related disorders.

Groin Injuries (Athletic Pubalgia) and Return to Play

Context:

Groin pain is a common entity in athletes involved in sports that require acute cutting, pivoting, or kicking such as soccer and ice hockey. Athletic pubalgia is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of nonoperative measures. A variety of surgical options have been used, and most patients improve and return to high-level competition.

Evidence Acquisition:

PubMed databases were searched to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears.

Study Design:

Clinical review.

Level of Evidence:

Level 4.

Results and Conclusion:

Athletic pubalgia is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases.

Restriction in hip internal rotation is associated with an increased risk of ACL injury

PURPOSE

Evidence suggests that femoroacetabular impingement (FAI) in athletes may increase the risk of anterior cruciate ligament (ACL) injury. This study correlates ACL injury with hip range of motion in a consecutive series of elite, contact athletes and tests the hypothesis that a restriction in the available hip axial rotation in a dynamic in silico model of a simulated pivot landing would increase ACL strain and the risk of ACL rupture.

METHODS

Three hundred and twenty-four football athletes attending the 2012 NFL National Invitational Camp were examined. Hip range of internal rotation was measured and correlated with a history of ACL injury and surgical repair. An in silico biomechanical model was used to study the effect of FAI on the peak relative ACL strain developed during a simulated pivot landing.

RESULTS

The in vivo results demonstrated that a reduction in internal rotation of the left hip was associated with a statistically significant increased odds of ACL injury in the ipsilateral or contralateral knee (OR 0.95, p = 0.0001 and p < 0.0001, respectively). A post-estimation calculation of odds ratio for ACL injury based on deficiency in hip internal rotation demonstrated that a 30-degree reduction in left hip internal rotation was associated with 4.06 and 5.29 times greater odds of ACL injury in the ipsilateral and contralateral limbs, respectively. The in silico model demonstrated that FAI systematically increased the peak ACL strain predicted during the pivot landing.

CONCLUSION

FAI may be associated with ACL injury because of the increased resistance to femoral internal axial rotation during a dynamic maneuver such as a pivot landing. This insight may lead to better interventions to prevent ACL injury and improved understanding of ACL reconstruction failure.

LEVEL OF EVIDENCE

Cohort study, Level IV.

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

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

Sportsman's hernia? An ambiguous term

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

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

[Sportsmen's groin. Definition, differential diagnostics and therapy]

Groin pain in athletes is a common problem and can have extensive consequences for professional athletes. The anatomical and functional complexity of the groin as well as radiating pain from remote anatomical regions can make the differential diagnostic a challenge and requires special attention. As there are a wide variety of possible causes for groin pain, a multidisciplinary approach is required. The treating orthopedic surgeon needs to pay special attention to prearthritic hip deformities to avoid irreversible damage of the hip joint. By a meticulous patient history and identification of the pain character, followed by clinical, sonographic and radiographic investigations, a differential diagnosis can usually be achieved. Besides typical orthopedic causes pathological findings particularly in the area of the groin need to be considered, clarified and adequately treated; therefore, a clear terminology of the different diseases is necessary. Sportsmen's groin is not a hernia but should be perceived as a separate entity due to its typical pain character and detection of a measurable protrusion of the posterior wall of the inguinal canal by ultrasound.

Sportsman hernia; the review of current diagnosis and treatment modalities

Groin pain is an important clinical entity that may affect a sportsman's active sports life. Sportsman's hernia is a chronic low abdominal and groin pain syndrome. Open and laparoscopic surgical treatment may be chosen in case of conservative treatment failure. Studies on sportsman's hernia, which is a challenging situation in both diagnosis and treatment, are ongoing in many centers. We reviewed the treatment results of 37 patients diagnosed and treated as sportsman's hernia at our hospital between 2011-2014, in light of current literature.

Sports hernias: experience in a sports medicine center

PURPOSE

Chronic pain of the inguino-crural region or "pubalgia" explains the 0.5-6.2% of the consultations by athletes. Recently, areas of weakness in the posterior wall called "sports hernias," have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by "pubalgia".

METHODS

1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic "TAPP" repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U Mann-Whitney test for continuous scale variables and the chi-square test for dichotomous variables with p < 0.05 as a level of significance.

RESULTS

In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 "sport hernias" in 769 patients with previous diagnosis of adductor muscle strain (10.92%); on the other hand, in 127 (21.52%) of our patients with "sport hernias" US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42% and a specificity of 100%; the positive and negative predictive values were 100 and 99.4% respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81%); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle.

CONCLUSIONS

Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of "pubalgia". "Sports hernias" are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care.

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.

Practical approach to hip pain

Hip pain is a common complaint among patients presenting to outpatient clinics. Stratifying patients based on age, acuity, and location of pain (extra-articular vs intra-articular) can help to aid in appropriate imaging and timely referral to an orthopedic surgeon. A thorough history and an organized physical examination combined with radiographs are usually sufficient to diagnose most hip complaints. If the diagnosis remains uncertain, magnetic resonance imaging, usually with intra-articular gadolinium, is the imaging modality of choice in diagnosing both intra-articular and extra-articular pathologies.

Sports hernia/athletic pubalgia: evaluation and management

Context:

Sports hernia/athletic pubalgia has received increasing attention as a source of disability and time lost from athletics. Studies are limited, however, lacking consistent objective criteria for making the diagnosis and assessing outcomes.

Evidence Acquisition:

PubMed database through January 2013 and hand searches of the reference lists of pertinent articles.

Study Design:

Review article.

Level of Evidence:

Level 5.

Results:

Nonsurgical outcomes have not been well reported. Various surgical approaches have return-to–athletic activity rates of >80% regardless of the approach. The variety of procedures and lack of outcomes measures in these studies make it difficult to compare one surgical approach to another. There is increasing evidence that there is an association between range of motion–limiting hip disorders (femoroacetabular impingement) and sports hernia/athletic pubalgia in a subset of athletes. This has added increased complexity to the decision-making process regarding treatment.

Conclusion:

An association between femoroacetabular impingement and athletic pubalgia has been recognized, with better outcomes reported when both are managed concurrently or in a staged manner.

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

Sports hernia treatment: modified bassini versus minimal repair

Background:

The minimal repair technique for sports hernias repairs only the weak area of the posterior abdominal wall along with decompressing the genitofemoral nerve. This technique has been shown to return athletes to competition rapidly. This study compares the clinical outcomes of the minimal repair technique with the traditional modified Bassini repair.

Hypothesis:

Athletes undergoing the minimal repair technique for a sports hernia would return to play more rapidly compared with athletes undergoing the traditional modified Bassini repair.

Methods:

A retrospective study of 28 patients who underwent sports hernia repair at the authors’ institution was performed. Fourteen patients underwent the modified Bassini repair, and a second group of 14 patients underwent the minimal repair technique. The 2 groups were compared with respect to time to return to sport, return to original level of competition, and clinical outcomes.

Results:

Patients in the minimal repair group returned to sports at a median of 5.6 weeks (range, 4-8 weeks), which was significantly faster compared with the modified Bassini repair group, with a median return of 25.8 weeks (range, 4-112 weeks; P = 0.002). Thirteen of 14 patients in the minimal repair group returned to sports at their previous level, while 9 of 14 patients in the Bassini group were able to return to their previous level of sport (P = 0.01). Two patients in each group had recurrent groin pain. One patient in the minimal repair group underwent revision hernia surgery for recurrent pain, while 1 patient in the Bassini group underwent hip arthroscopy for symptomatic hip pain.

Conclusion:

The minimal repair technique allows athletes with sports hernias to return to play faster than patients treated with the modified Bassini.

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.

Hip pathology in the adolescent athlete

Hip injuries in young athletes are being diagnosed with increasing frequency. Improvements in diagnostic imaging and surgical technologies have helped facilitate the diagnosis of intra- and extra-articular derangements that were previously untreated in this age group. Athletic injuries of the hip in the young athlete encompass both osseous and soft-tissue etiologies, which can be the result of a single traumatic event or repetitive microtrauma or may be associated with an underlying pediatric hip disorder. Without accurate diagnosis and management, these injuries may result in debilitating consequences. This article will review the more common causes of hip and groin pain in the adolescent athlete, as well as advances in diagnostic and therapeutic interventions.