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Surgery for posterior inguinal wall deficiency in athletes
Abstract
This study retrospectively evaluated the outcome for patients undergoing herniorraphy for chronic groin pain due to posterior inguinal wall deficiency, and correlated the outcome with preoperative investigation findings. There were 47 patients (with a total of 52 herniorraphies) who were contacted by phone between six and 50 months post surgery. Subjects had a diagnosis of posterior inguinal wall deficiency made on history and clinical examination. Thirty seven patients had an ultrasound scan prior to the surgery (three bilateral) with a total of 40 symptomatic groins scanned. There were 26 abnormal scans (22 posterior inguinal wall deficiency and four hernias) and 14 normal scans. Twenty nine patients had a technetium-99m bone scan with 22 having increased uptake at the symptomatic pubic tubercle, while 13 had increased uptake at other sites in the groin. Seventy seven percent of patients had a full return to sport after surgery and the average time to return to sport was four months. There was no significant difference in outcome between subjects who had an abnormal ultrasound scan on the symptomatic side and those who had a normal scan. There was a significant difference in outcome between patients who had a bone scan with increased uptake at the symptomatic pubic tubercle and those who did not (p < 0.04). Our study supports previous research that good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. Ultrasound scan does not appear to aid in predicting surgical outcome, while the role of isotope bone scanning requires further study.
... There is a lack of studies assessing accuracy or reproducibility of ultrasound in long-standing athletic groin pain, and it is relatively insensitive to edema that is best detected by MRI. 33,34 Ultrasound is frequently used for image-guided diagnostic injections of anesthetic to help distinguish between possible causative sites of pain and assist treatment decisions. 31,35 By far the most useful imaging modality is MRI, now the gold standard in the context of imaging groin injury. ...
... 5c) is then viewed with Valsalva maneuvers looking for a hernia or bulging related to wall deficiency, although the significance of this latter finding is controversial (see Tips 4 and 6). 33,39 Evaluation can then continue to the iliopsoas and hip region if clinically appropriate, to assess for any snapping, bursitis, or joint effusion. 35,40 Tip 5 Summary: Imaging Technique ...
... 27,36 Ultrasound On ultrasound, the tendinopathic adductor longus tendon can be thickened and hypoechoic with a possible convex contour, but differentiating between this and normal variation or a partial tear can be difficult, and, in practice, MRI will be needed to assess the presence of edema in the adductor/rectus aponeurosis capsular attachment site as described earlier. 1,33 Chronic complete tears are relatively rare and much easier to diagnose on MRI. If retracted, they often present as an underlying fibrous mass with possible sheets of myositis ossificans-related calcification with peripheral low T1/T2 signal foci on MRI or echogenic foci with posterior acoustic shadowing on ultrasound. ...
Athletic groin injury remains a challenging prospect for sports clinicians and radiologists because of the closely related anatomical structures and overlapping clinical presentations. Recent consensus work designated four causative clinical entities, with the adductor/rectus aponeurosis and pubic symphysis capsule emphasized as key areas. This article highlights these key aspects of athletic groin injury with tips on anatomy, potential abnormalities, acronyms, and imaging appearances in this complex but common and potentially incapacitating entity. Many clinical and radiologic terms are in use such as cleft, enthesitis, plate injury, or defect that can cause confusion, and thus anatomical descriptions are preferable.
Detailed clinical assessment is necessary but remains challenging because of the nonspecific presentations. Imaging, and in particular magnetic resonance imaging, plays an essential role in the evaluation process. But only when the two are used in combination can an accurate diagnosis be reached because several studies in asymptomatic athletes show that reactive changes are common.
... Herniorrhaphy is the definitive treatment for sports hernias. Although surgical techniques vary, the general principles are to release abnormal tension on the inguinal canal and reinforce the posterior wall of the inguinal canal [32]. There are two main types of surgery for sports hernias, namely, open and laparoscopic techniques. ...
... Returning to sport following treatment for athletic pubalgia, whether pursued through conservative or surgical avenues, is shaped by the treatment's modality, individualized factors, and injury severity. The time to fully return to sports ranges from four to 12 weeks depending on the type of surgery and individual recovery factors [32]. Post-surgery, the rate of return to the prior level of activity is reported to be between 80% and 95% [35,36]. ...
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.
... 13 Duas outras séries descreveram a protrusão do canal inguinal (expansão do conteúdo com uma parede posterior convexa) na avaliação com manobra dinâmica, com conclusões contraditórias quanto à sua utilidade clínica. 14, 15 A interpretação das alterações patológicas radiológicas beneficiaria de estudos de imagem com uma abordagem sistemática. A qualidade metodológica beneficiaria da inclusão de grupos de estudo homogéneos (em termos de idade, sexo e modalidade desportiva), grupos de controle bem combinados, exames clínicos reprodutíveis e protocolos radiológicos idênticos e bem elaborados. 2 Para responder a muitas perguntas fundamentais, um consenso sobre terminologia e definições na avaliação por imagem da dor púbica de longa evolução em atletas, embora desafiante, seria uma ótima conquista. ...
The diagnosis of groin pain centered on the early detection of injuries is essential to allow an early implementation of therapeutic and prophylactic strategies. In this second part (part 2), we address the basic concepts of imaging evaluation of groin pain, the main imaging findings and the current challenges in imaging diagnosis of this pathology.
... In the current study, 96% of patients were able to return to sport at a mean 4.1 months (17.8 weeks) after surgical repair, compared with previous studies, in which 79% to 100% of athletes returned at a mean 2 to 30 weeks after a wide variety of surgical treatments for varying anatomic entities. 3,12,14,15,17,20,[24][25][26][27] Nonetheless, our results raise several questions, and there does appear to be an association with poorer outcomes after RA-AL aponeurotic plate repair. Our indications are based on very specific clinical and imaging findings, yielding a reliable return to high-level athletics. ...
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.
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.
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.
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.
In the second part we addressed the basic concepts of imaging evaluation of groin pain, the main imaging findings and the current challenges in imaging diagnosis of this pathology. In this third part we describe the many imaging modalities that can be used to support the diagnosis of groin pain. Na segunda parte abordámos os conceitos básicos de avaliação imagiológica da síndrome pubálgica, os principais achados radiológicos e os desafios atuais no diagnóstico imagiológico desta patologia. Nesta terceira parte descrevemos as várias modalidades imagiológicas que poderão suportar o diagnóstico da síndrome pubálgica.
Groin injuries are common in sports, most of which are muscular/tendon strain-type injuries that resolve with conservative treatment. The term sports hernia or athletic pubalgia refers to a subset of athletic groin injuries that present with exertional inguinal/rectus abdominal insertional pain that limits athletic performance. These injuries not infrequently may have an associated adductor component. The diagnosis can be made based on the history and physical examination and supportive imaging, most commonly with a pelvic MRI. Surgery is indicated for athletes who fail 6–8 weeks of conservative management or who have evidence of a rectus abdominal tear on imaging. A variety of surgical approaches have been used to address this problem that comprises the spectrum from primary tissue repairs to both open and laparoscopic tension-free mesh repairs. In this chapter, the pathophysiology of athletic pubalgia injuries is reviewed along with diagnostic considerations and the different treatment options. The importance of a multidisciplinary approach to the diagnostic evaluation and treatment of these athletes along with structured rehabilitation program cannot be overemphasized and is essential to a successful outcome.
Abstract
Diagnosis and treatment of inguinal pain in athletes is an important chapter of modern surgery, sometimes having a high degree of difficulty in terms of positive diagnosis. Many athletes can be affected by groin pain, which is also prevalent in non-athletes. The aim of this study was to update the current position on the nomenclature, definition, diagnosis and management of inguinal pain in athletes, by reviewing the literature, thus defining and overviewing treatment in “inguinal disruption”, the agreed term to be used in this condition, based on the Manchester Consensus Conference, held in Manchester, in october 2012. The treatment algorithm in these cases must be chosen correctly, the differential diagnosis thus gaining special importance. If it is wrongly diagnosed and treated, this pathology can lead to a premature termination of the athlete’s career, or the late return of the athletes to the characteristic activity of the chosen sport, having an important negative economical impact on the club or organization where the athlete is active.
Key words: inguinal disruption, laparoscopic treatment, athletes
Groin pain is common in modern soccer players, particularly professionals, because of the extremely forceful movements of the leg that affect the adductor muscles and pelvic ring. The injury may be acute, due to a specific stress, or chronic, due to multiple microtraumas that accumulate over a long time. Treatment consists of immediate rest and application of cold followed by heat. When the pain subsides, range-of-motion exercises are added to develop maximal flexibility and strength in the groin area. Prevention is most important. It consists of exercises to increase the maximal range of motion of the hip and strength in all structures.
In 21 male athletes (age 20 to 40 years) with longstanding unexplained groin pain, a multidisciplinary investigation was performed in order to reveal the underlying cause. These examinations included general surgery for detection of inguinal hernia and neuralgia, orthopaedic surgery for detection of adductor tenoperiostitis and symphysitis, urology for detection of prostatitis, radiology for performing herniography and plain film of the pelvic bones, nuclear medicine for isotope studies of the pubic bone and symphysis. In 19 patients there was a positive diagnosis for 2 or more of the diseases (10 patients had 2 diseases, 6 patients had 3 diseases, 3 patients had 4 diseases). Two patients had only signs of symphysitis.
Our results show the complexity of longstanding groin pain in athletes. It also explains why therapy for one specific disease entity may fail. We conclude that this clinical setting demands the recruitment of a team with experience of different aspects of groin pain.
Background:
Musculotendinous groin disruption is common in professional sportsmen. Diagnosis is difficult and management complicated by strong desires for early return to sporting activity. The possible role of laparoscopic repair in promoting early recovery was examined.
Methods:
A series of patients with persistent pain that prevented sport for more than 3 months were treated surgically. Thirty repairs were performed on 28 players, 18 professional and nine amateur. Seventeen injuries were sustained playing rugby league, seven association football and four other sports. There were 14 conventional repairs (11 Lichtenstein) and 14 laparoscopic (two bilateral). All patients were discharged within 24 h.
Results:
No player complained of severe postoperative pain. Seven of 14 patients who had laparoscopic repair denied experiencing any pain at all. Training was resumed within 4 weeks for nine of 14 patients who had a conventional repair and 13 of 14 who underwent laparoscopic repair. Full contact training restarted at a median 5 (range 1-6) weeks for conventional and 3 (range 1-9) weeks for laparoscopic repair (P < 0.05). Two players had persistent neuralgia after laparoscopic repair which settled by 2 months. One player had recurrent pain 5 months after laparoscopic repair, and one had a recurrent hernia 22 months after conventional repair. There were no wound problems.
Conclusion:
Laparoscopic repair appears as effective as conventional repair for sporting injuries, and merits further evaluation as a technique to permit early return to activity.
Musculotendinous groin disruption is common in professional sportsmen. Diagnosis is difficult and management complicated by strong desires for early return to sporting activity. The possible role of laparoscopic repair in promoting early recovery was examined.
A series of patients with persistent pain that prevented sport for more than 3 months were treated surgically. Thirty repairs were performed on 28 players, 18 professional and nine amateur. Seventeen injuries were sustained playing rugby league, seven association football and four other sports. There were 14 conventional repairs (11 Lichtenstein) and 14 laparoscopic (two bilateral). All patients were discharged within 24 h.
No player complained of severe postoperative pain. Seven of 14 patients who had laparoscopic repair denied experiencing any pain at all. Training was resumed within 4 weeks for nine of 14 patients who had a conventional repair and 13 of 14 who underwent laparoscopic repair. Full contact training restarted at a median 5 (range 1-6) weeks for conventional and 3 (range 1-9) weeks for laparoscopic repair (P < 0.05). Two players had persistent neuralgia after laparoscopic repair which settled by 2 months. One player had recurrent pain 5 months after laparoscopic repair, and one had a recurrent hernia 22 months after conventional repair. There were no wound problems.
Laparoscopic repair appears as effective as conventional repair for sporting injuries, and merits further evaluation as a technique to permit early return to activity.
Groin injuries in athletes are being recognized as one of the most difficult problems in sport. The symptoms associated with chronic groin injuries are often diffuse and uncharacteristic. These injuries usually constitute a major diagnostic and therapeutic challenge, the success of which depends on a correct diagnosis. It is necessary to establish a broad, differential background, and therefore, this article includes a broad description of groin injuries.
Book reviews in this article:
Fifty athletes with chronic undiagnosed groin pain underwent surgical exploration and inguinal hernia repair. Six months later, all athletes were sent questionnaires to assess their return to sport, level of pain (using analogue pain scores) and the overall result of their surgery. Operative findings revealed a significant bulge in the posterior inguinal wall in 40 athletes. Forty-four athletes (88%) replied to the questionnaire. Forty-one athletes (93% of respondents) had returned to normal activities. Pain scores indicated a marked improvement in their level of pain (P < 0.001). Thirty-three athletes (75%) rated the result as good and 10 (23%) as improved.
It is concluded that athletes with chronic groin pain who are unable to compete in active sport should be considered for routine inguinal hernia repair if no other pathology is evident after clinical examination and investigation.
To identify and surgically treat correctable inguinal injuries in athletes with chronic groin pain and to assess the results of surgical treatment.
Sixty-four athletes presented between March 1987 and January 1990 for treatment of chronic groin pain in which surgical exploration of the inguinal canal was considered necessary. Follow-up was performed by questionnaire.
Patient self-assessment of the success of the operation, including postoperative pain, ability to return to active sport and any further treatment required.
Sixty-four athletes were treated, Australian Rules footballers predominated (46/64, 72%). Eight athletes had bilateral groin pain. Fifty-nine (92%) reported an incipient onset of pain. The most common operative finding was of a substantially deranged posterior wall of the inguinal canal which was evident in 61/72 instances (85%). Apparent splitting of the conjoint tendon was found in 19 instances (26%) and previously occult indirect inguinal hernias were discovered in six (8%). Repair of the posterior wall of the inguinal canal was by the standard Bassini repair and Tanner slide or by plication of the transversalis fascia followed by a nylon darn. Follow-up by questionnaire of the 64 athletes revealed that 40 athletes (62.5%) considered themselves cured and had returned to competitive sport. Twenty athletes (31.3%) were partially satisfied with the results of their operation, and also able to return to active sport. Three athletes (4.7%) were dissatisfied with the operative result. One patient was lost to follow-up.
The most common finding in athletes with chronic groin pain was a deficiency of the posterior wall of the inguinal canal. Surgical exploration and repair of the posterior wall of the inguinal canal in athletes with chronic debilitating groin pain achieved excellent or good relief of pain in 93.8% of athletes and improved physical performance.
In 21 male athletes (age 20 to 40 years) with longstanding unexplained groin pain, a multidisciplinary investigation was performed in order to reveal the underlying cause. These examinations included general surgery for detection of inguinal hernia and neuralgia, orthopaedic surgery for detection of adductor tenoperiostitis and symphysitis, urology for detection of prostatitis, radiology for performing herniography and plain film of the pelvic bones, nuclear medicine for isotope studies of the pubic bone and symphysis. In 19 patients there was a positive diagnosis for 2 or more of the diseases (10 patients had 2 diseases, 6 patients had 3 diseases, 3 patients had 4 diseases). Two patients had only signs of symphysitis. Our results show the complexity of longstanding groin pain in athletes. It also explains why therapy for one specific disease entity may fail. We conclude that this clinical setting demands the recruitment of a team with experience of different aspects of groin pain.
In the years 1974 to 1981, herniography was performed in 78 athletes with groin pain. The investigation comprised 101 painful groin sides in 23 athletes with bilateral symptoms. Before herniography, a hernia was palpated in only eight (7.9 percent) groins with pain. Hernias were found at herniography in 84.2 percent of the symptomatic groin sides and in 49.1 percent of the asymptomatic groin sides.
Sixty-three hernia operations were performed. The herniographic and operative diagnoses corresponded well. Direct hernias dominated among the operated athletes, and were found in 55.6 percent of those below 30 years of age. Altogether 69.8 percent of the operated patients were cured by hernia repair and another 20.6 percent were improved. Tenoperiostitis of the adductor muscles was the most frequent diagnosis in those not cured by operation and among the nonoperated patients.
Herniography was of great value in selecting those patients who needed a repair. A broad differential diagnostic approach when examining these patients is of the utmost importance.