Groin pain in athletes

Abstract

Per Hölmich and colleagues'1Hölmich P Uhrskou P Ulnits L et al.Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial.Lancet. 1999; 353: 439-443Summary Full Text Full Text PDF PubMed Scopus (335) Google Scholar report active physical training as treatment of groin pain in athletes. My own observations of magnetic resonance imaging (MRI) in professional soccer players with groin pain lends support to the notion of a common adductor-rectus abdominis (CA-RA) anatomical and functional unit. Embalming produces tissue contraction and adhesion that distort our perception of so-called normal anatomy. A French anatomical text first published in 19022Latarjet A Arthrologie-articulations du bassin.in: Latarjet A Taite d'anatomie humaine. Doin and Cie Publishers, Paris1948–52Google Scholar based on non-embalmed cadavers showed how a vertical ligamentous continuation of the distal rectus sheath attaches to the anterolateral public margin with this insertion being inseparable from the fused adductors longus and brevis origins. However, such an arrangement does not seem to be recognised in classical English-language texts. In my experience of over 120 professional soccer players with groin pain, MRI seems to confirm that this distal rectus sheath extension interdigitates with the common adductor origin to form such a CA-RA unit.3Gibbon WW Jenkins CN Crowe MTI Freeman SJ Groin pain in soccer players: MRI appearances.Br J Sports Med. 1999; 33: 57Crossref Scopus (85) Google Scholar Condon,4Codon RE Reassessment of groin anatomy during the evolution of preperitoneal hernia repair.Am J Surg. 1996; 172: 5-8Summary Full Text PDF PubMed Scopus (17) Google Scholar in his anatomical study of fresh non-embalmed cadavers reported that, contrary to common belief, only in 3% of specimens did a conjoint tendon representing the fused inferomedial aponeuroses of internal oblique and transversus abdominis actually insert into the pubic tubercle and adjacent pubic crest. In 97% of specimens, these tendinous aponeuroses were separate structures, with 74% inserted into the rectus sheath at least 5 mm above the pubic tubercle. Therefore a shear injury to the common adductor origin could result in decomposition of the external inguinal ring and potential hernia formation (and vice versa). I compared 47 consecutive professional soccer players referred over 12 months for MRI of groin pain (66 symptomatic groins) with 13 age-matched, symptom-free non-athletic male volunteers. The soccer players had significantly more features suggestive of a CA-RA unit shear injury when compared with the volunteers (p< 0·01). These results support the concept that the potential outcomes of a CA-RA unit injury include a tendinitis or avulsion fracture of the common adductor origin. Alternatively, an injury to the rectus abdominis insertion shear injury may result in a concomitant inguinal ligament injury with decompensation of the external inguinal ring and potential direct inguinal hernia. MRI also showed that in the symptomatic groins of the professional soccer players, 29 (44%) exhibited a common-adductor origin injury, 18 (27%) a rectus abdominis-insertion injury, and ten (15%) a combined CA-RA shear injury. A prehernia complex was seen in only ten (15%) of the symptomatic groins of which 10 (80%) had a confirmed CA shear injury. Martens and colleagues5Martens MA Hansen L Mulier JC Adductor tendinitis and musculus rectus abdominis tendopathy.Am J Sports Med. 1987; 15: 353-356Crossref PubMed Scopus (73) Google Scholar have also shown surgically that about a third of athletes with groin pain have both an adductor and a rectus abdominus origin for their symptoms, supporting the possibility that these structures are inter-related in the production of groin pain. Considering the apparent relation between the adductor origin and abdominal wall structures, it would be interesting to know the figures observed by Hölmich and colleagues for inguinal/lower abdominal symptoms before and after their active training therapeutic regime for adductor injury.