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Athletic Pubalgia (Sports Hernia): Presentation and Treatment

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Abstract

Often referred to as a “sports hernia” or “core muscle injury,” athletic pubalgia is a common yet poorly defined athletic injury. It is characterized by abdominal and groin pain likely from weakening or tearing of the abdominal wall without evidence of a true hernia. Symptoms can appear acutely or insidiously, primarily as groin and lower abdominal pain that can radiate toward the perineum and proximal adductors. Pain is exacerbated by athletic activity such as kicking, cutting, and sprinting. The pubis acts as a pivot point between the abdominal musculature and lower-extremity adductors, and therefore, pain with palpation over the symphysis or its surrounding structures is typical in athletic pubalgia. Symptoms can be reproduced during a resisted sit-up or with a forced cough or sneeze. Clinical examination should include an evaluation of articular hip pathology to identify underlying femoroacetabular impingement syndrome. Magnetic resonance imaging can aid in ruling out other pathologies and identify specific findings including tears or strains of the ipsilateral rectus abdominis or adductor tendons. Lidocaine injections can be used to localize the source of the pain. First-line treatment consists of a period of rest and anti-inflammatories, followed by a course of focused physical therapy. If conservative therapy fails to allow an athlete to return to activity, a variety of open or laparoscopic surgical techniques can be used. The surgical principles include reattachment of the rectus abdominis and repair or reinforcement of the abdominal musculature in layers to re-create the inguinal ligament anatomy. At times, variations of pelvic floor repair are performed or the addition of an adductor tenotomy or repair is used concomitantly. Numerous studies report a high rate of return to play after surgical management. Diagnosis and appropriate treatment of coexisting femoroacetabular impingement syndrome are crucial to a successful return to athletic activity.

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... [1][2][3] Athletic pubalgia (AP), or sports hernia, has become increasingly recognized in athletes over time, often presenting as chronic groin or lower abdominal pain without evidence of a true hernia. [4][5][6] Basketball players are particularly at high risk of AP due to the physical demand of the sport requiring rapid cutting, sprinting, sudden acceleration, and deceleration. [6][7][8] These physical activities may create imbalanced strain and tension on the muscles and tendons surrounding the pubis and may lead to injury. ...
... 16,[29][30][31][32][33] This significant variability may be attributed to the inherent ambiguity of the term "sports hernia" or "athletic pubalgia," 34 which encompasses multiple sites of pathology such as the rectus abdominis, inguinal wall, adductor longus tendon, and pubis symphysis. 5,10,35 In a systematic review and meta-analysis of inguinal groin pain in athletes of various skill levels from 1980 to 2013 stratified by anatomic sites, King et al. 36 reported the lowest RTP rates for adductor tendon related pain (81%) and highest RTP rates for abdominal pain (96%). Time to RTP after surgery also varied by location, with pubic and abdominal þ adductor pain requiring the longest RTP times (23.1 and 21.9 weeks, respectively) whereas abdominal alone had the shortest (7.9 weeks). ...
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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.
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In recent years, there has been increased awareness and treatment of groin injuries in athletes. These injuries have been associated with various terminologies including sports hernia, core muscle injury (CMI), athletic pubalgia and inguinal disruption, among others. Treatment of these injuries has been performed by both orthopaedic and general surgeons and may include a variety of procedures such as rectus abdominis repair, adductor lengthening, abdominal wall repair with or without mesh, and hip arthroscopy for the treatment of concomitant femoroacetabular impingement. Despite our increased knowledge of these injuries, there is still no universal terminology, diagnostic methodology or treatment for a CMI. The purpose of this review is to present a detailed treatment algorithm for physicians treating patients with signs and symptoms of a CMI. In doing so, we aim to clarify the various pathologies involved in CMI, eliminate vague terminology, and present a clear, stepwise approach for both diagnosis and treatment of these injuries.
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Purpose: The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included. Methods: This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs. Results: The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%). Conclusion: There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.
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Historically, athletic hip injuries have garnered little attention; however, these injuries account for approximately 6% of all sports injuries and their prevalence is increasing. At times, the diagnosis and management of hip injuries can be challenging and elusive for the team physician. Hip injuries are seen in high-level athletes who participate in cutting and pivoting sports that require rapid acceleration and deceleration. Described previously as the "sports hip triad," these injuries consist of adductor strains, osteitis pubis, athletic pubalgia, or core muscle injury, often with underlying range-of-motion limitations secondary to femoroacetabular impingement. These disorders can happen in isolation but frequently occur in combination. To add to the diagnostic challenge, numerous intra-articular disorders and extra-articular soft-tissue restraints about the hip can serve as pain generators, in addition to referred pain from the lumbar spine, bowel, bladder, and reproductive organs. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.
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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.
Article
Purpose: To characterize the 3-dimensional muscular, musculotendinous, and neurovascular anatomy about the pubic symphysis relevant to core muscle injury (CMI). Methods: Ten cadaveric hips were dissected to characterize the musculotendinous insertion of the rectus abdominis and inguinal ligament, origins of the adductor longus and adductor brevis, and the pubic cartilage plate. A 3-dimensional coordinate measuring system and data acquisition software were used to calculate structure cross-sectional area, and the landmark anatomical relationships to 1 another and relevant neurovascular structures. Results: All specimens were male with an average age of 62 ± 2 years. The mean footprints of the rectus abdominis, inguinal ligament, adductor longus, and adductor brevis were 8.4 ± 3.1, 1.2 ± 0.5, 3.8 ± 1.6, and 2.9 ± 1.3 cm2, respectively. The mean pectineus and gracilis footprints were 6.3 ± 2.4 and 3.4 ± 0.9 cm2, respectively. The mean cross-sectional area of the cartilage plate was 24.8 ± 5.6 cm2. The adductor longus was an average 1.5 ± 0.25 cm from the adductor brevis and 0.69 ± 0.52 cm from the rectus abdominis. The genital branch of the genitofemoral nerve was an average of 4.3 cm (range, 2.8-6.4) lateral to the insertion of the inguinal ligament. The femoral vein and artery were 3.0 cm (range, 2.5-3.6) and 3.7 cm (range, 2.5-5.9) lateral to the inguinal ligament footprint. The obturator nerve was 2.5 cm (range, 1.6-3.4) lateral to the adductor longus. Conclusions: Familiarity with the anatomy of the pubic symphysis is essential for surgeons treating patients with CMI. We have shown that this relatively small area is the site of many muscular, musculotendinous, and neurovascular structures with various sized footprints and described the 3-dimensional anatomy of the anterior pubic symphysis. The origin of the adductor longus lies in close proximity to other structures, such as the adductor brevis, the insertion of the rectus abdominis, and the obturator nerve. These findings should be considered when operating in this region and treating patients with chronic groin pain. Clinical relevance: The anatomy of the pelvic region and pubic symphysis has not been well characterized. Intimate knowledge of relevant anatomy is essential to treating CMI, also known as athletic pubalgia or sports hernia.
Article
Sports hernia is a non-anatomic, non-diagnostic term that has been attributed to many different causes of groin pain.» Sports hernia is better described as pain localized anatomically to the inguinal region of an athlete without an actual hernia.» Nonoperative management including core stability while avoiding extreme hip range of motion should be attempted for at least 2 months prior to any operative intervention.» Associated pathology such as femoroacetabular impingement or adductor tear should be addressed.» If a sports hernia is not responsive to rehabilitation, referral to a general surgeon is appropriate. Copyright
Article
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. PubMed database through January 2013 and hand searches of the reference lists of pertinent articles. Review article. Level 5. 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. 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.