Surgical options in the treatmentof sports hernia

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.

Sports hernia and femoroacetabular impingement in athletes: A systematic review

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

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

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

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

Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings

OBJECTIVE

Groin pain in elite athletes is a common yet challenging diagnostic and management dilemma for the sports clinician, accounting for a significant proportion of athletic injuries. It is often debilitating and, if severe enough, may compromise an athlete's career. Traditionally, groin pain has been poorly understood by radiologists.

CONCLUSION

A major reason groin pain has been misunderstood is the complexity of the anatomy of this region, which this article discusses in detail in an effort to inform the reader.

Sports hernia: diagnosis and therapeutic approach

Groin pain is a common entity in athletes involved in soccer, ice hockey, Australian Rules football, skiing, running, and hurdling. An increasingly recognized cause of groin pain in these athletes is a sports hernia, an occult hernia caused by weakness or tear of the posterior inguinal wall, without a clinically recognizable hernia, that leads to a condition of chronic groin pain. The patient typically presents with an insidious onset of activity-related, unilateral, deep groin pain that abates with rest. Although the physical examination reveals no detectable inguinal hernia, a tender, dilated superficial inguinal ring and tenderness of the posterior wall of the inguinal canal are found. The role of imaging studies in this condition is unclear; most imaging studies will be normal. Unlike most other types of groin pain, sports hernias rarely improve with nonsurgical measures; thus, open or laparoscopic herniorrhaphy should be considered.

The athletic hernia: a systematic review

The athletic hernia is an obscure condition of uncertain etiology commonly seen in soccer and rugby players. The pain is often debilitating and may place an athletic career at risk. Treatment failures are frustrating to the athlete and the physician. The anatomy involved, diagnostic criteria, and treatment modalities are inconsistently described in the medical, surgical and orthopaedic literature. There is no evidence-based consensus available to guide decision-making. We performed an overview of the anatomy and pathoanatomy and a systematic review of the literature to gain insight into the disease and its treatment. Most studies are Level IV. The most common operative finding is a deficient posterior wall of the inguinal canal, although other abdominal wall abnormalities are frequently found. Open and laparoscopic repairs produce excellent results, but the latter allows earlier return to play. Magnetic resonance imaging appears to have excellent diagnostic potential for athletic hernia. A multidisciplinary approach to groin pain in the athlete is recommended.