Sports Hernia Research Articles

The Adductor–Rectus Angle: A Novel Magnetic Resonance Imaging Measurement in Healthy Adult Individuals

Abstract Background: Groin pain is a complex musculoskeletal condition, causing significant difficulty in its diagnosis and management. The stability of the anterior pelvis is maintained by the formation of a complex fibrous aponeurotic plate by the rectus abdominis and adductor longus tendons. It is, therefore, vital to have a comprehensive understanding of this condition to guide appropriate management. We aimed to measure the adductor–rectus angle (ARA), which is the angle between the rectus abdominis and adductor longus tendon to establish a normal range in a diverse group of healthy individuals on magnetic resonance imaging (MRI) with the aim of investigating its possible association with the occurrence of athletic pubalgia. Materials and Methods: A retrospective cross-sectional study assessed the ARA in 100 asymptomatic normal healthy individuals who had undergone an MRI of the pelvis. The participants were categorized based on gender and divided into three age groups: under 40, between 40 and 60, and above 60 years. Descriptive statistics were calculated for each group and were followed by a one-way analysis of variance to identify any significant differences between these groups. Results: The mean ARA in the entire study cohort was 135.543° +6.4814°. The ARA did not differ significantly among different age groups or genders. Conclusion: The ARA helps to evaluate pelvic muscles’ alignment and offers valuable insights into the force applied to the fibrous aponeurotic plate. This information could potentially aid in identifying athletes at risk of sports hernias and inform the development of personalized treatment strategies.

Outcomes and Proportions of Subsequent Contralateral Sports Hernia Repair Following Primary Unilateral Repair.

In the event that nonoperative treatment for sports hernia fails, surgical repair may be warranted. Bilateral repair can occur in up to 45% of surgically treated patients. To investigate the clinical outcomes of athletes who underwent unilateral sports hernia repair and determine the proportion of patients who required contralateral sports hernia repair. Case series; Level of evidence, 4. We identified patients at our institution who underwent primary unilateral sports hernia repair (rectus abdominis-adductor longus aponeurotic plate repair and adductor lengthening) with a single surgeon between 2015 and 2020. We assessed patient-reported outcomes using the Hip Outcome Score-Sport (HOS-Sport), the Numeric Pain Rating Scale, and an internally developed return-to-play questionnaire. We further collected data regarding subsequent sports hernia procedures on the ipsilateral or contralateral side. We calculated summary statistics for outcomes and examined the association between preinjury patient characteristics and the HOS-Sport score at follow-up or successful return to preinjury sport using linear and logistic regression, respectively. A total of 104 of 128 (81.3%) eligible patients (mean age at surgery, 23.0 ± 6.2 years; 94.2% male; 51.9% American football athletes) completed follow-up at a mean time of 4.4 ± 1.5 years. Overall, 79.8% of athletes (n = 83) were able to return to their preinjury sport/activity, but 90.2% (83/92) who attempted to return were able to do so. When examining reasons for not returning to preinjury sport, only 9 patients reported not returning to preinjury sport because of limitations or persistent symptoms from their original injury. Only 4 patients underwent subsequent sports hernia procedures (3 contralateral, 1 ipsilateral revision) after their index unilateral sports hernia repair. At follow-up, the mean HOS-Sport score was high (94.0 ± 10.8), and the mean Numeric Pain Rating Scale score was low (0.31 ± 1.26). There were no preinjury patient characteristics associated with either the HOS-Sport score at follow-up or the successful return to preinjury sport. Patients with unilateral sports hernia symptoms can undergo repair and return to sport at the preinjury level with little concern for injuries to the contralateral groin. In our cohort, patient-reported hip function and pain outcomes at follow-up were excellent.

Diagnosis and Treatment of Athletic Pubalgia

Athletic palagia, frequently termed as sports hernia or core muscle injury, is a prevailing cause of groin discomfort in athletes. Originating from potentially multifaceted interactions in the anterior pelvic region, its diagnosis is convoluted, owing to overlapping symptoms with other conditions and the absence of definitive diagnostic tools. Treatment approaches oscillate between conservative and operative modalities. Conservative treatment typically constitutes rest, physical therapy, and medication, while operative treatment comprises techniques like open, laparoscopic, and endoscopic repairs. Efficacy of treatments can significantly be modulated by personalized rehabilitation protocols. Recent studies indicate that while both treatments can be effective, surgery might facilitate a marginally quicker return to sports. Continued research aims at refining the understanding of athletic palagia, its treatment, and rehabilitation, underscoring the need for standardized measures, randomized trials, exploration of etiological factors, and enhanced preventative strategies. This paper provides an exhaustive overview of current methods, challenges, and prospective avenues in athletic palagia management.

Groin Pain Syndrome Italian Consensus Conference update 2023.

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

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.

Relationship Between Sensory Organization Testing Scores With Lower Extremity Injuries and Prior Concussion in Professional Soccer Players.

To evaluate for associations between concussion history or lower extremity (LE) injury and computerized sensory organization testing (SOT) performance in professional soccer players. Cross-sectional study. Tertiary care center. Thirty-three, professional, male soccer players on an American club, between the years 2019 and 2021. Player age, history of reported LE injury (gluteal, hamstring, ankle, knee, hip, groin, and sports hernia), history of diagnosed concussion, and the number of prior concussions were documented for each player. Baseline SOT of postural sway was conducted in 6 sensory conditions for all players. Eleven athletes (33%) reported a previous concussion, and 15 (45%) reported a previous LE injury. There were no significant differences in SOT scores between those with and without a previous diagnosis of concussion ( P > 0.05). Those reporting a previous LE injury performed better on condition 3 (eyes open, unstable visual surround) than those who did not ( P = 0.03). Athletes aged 25 years or younger performed worse on condition 3 ( P = 0.01) and had worse, although not statistically significant, median performance on all other balance measures than those older than 25 years. Intraclass correlation coefficient for repeat SOT assessment was 0.58, indicating moderate reliability, without an evident practice effect. Professional soccer players with a previous concussion or history of LE injury did not demonstrate long-term deficits in postural control, as assessed by multiyear computerized SOT baseline testing. The SOT was reliable over time with younger athletes exhibiting greater postural sway than older athletes.

Successful treatment for sports hernia by total extraperitoneal repair with intraperitoneal examination: Report a case

and importance: TEP might be one of options for treating such a sports hernia. An 18-year-old Japanese male presented with right groin pain for approximately two years. The pain was initially felt on the right side only, especially on kicking. We assessed the patient using laparoscopic examination with an intra-abdominal scope and subsequently diagnosed a sports hernia with a bilateral internal inguinal hernia. We then performed total extraperitoneal repair (TEP) for its treatment. The patient had a good postoperative course and was discharged from our hospital in remission after 3 days. Finally, the patient was able to play soccer without groin pain. Chronic groin pain in athletes can be caused by a bulge in the posterior inguinal wall, consistent with an incipient direct inguinal hernia. We show that intraperitoneal examination with TEP might be one of options for treating such a sports hernia. Endoscopic placement of the retropubic mesh must be considered an important option for this type of hernia.

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.

Prolene Hernia System Maximum Repair: A New Concept in Sports Hernia Surgery.

To describe and present the clinical results of a new surgical treatment for sports hernia. Retrospective cohort study. Tertiary hospital. Athletes who underwent sports hernia repair using the proposed technique between July 2006 and June 2020. The surgery consists of a combination of a mini-open incision and preperitoneal placement of a three-dimensional bilayer permanent mesh (PHS). The main clinical outcomes of the procedure were reviewed, including incidence of complications, long-term results, and recurrence rate. Ninety-two sports hernia repairs were performed on 87 patients (79 male and 8 female patients, median age 30.2 ± 7.8 years). No intraoperative complications were observed. The mean follow-up was 15 months. Seventy-seven patients (88.5%) successfully resumed preinjury physical activities within 8 weeks; 80 patients (91.9%) within 12 weeks; and 83 (95.4%) within 6 months (median time of 10 weeks). Only one patient reported recurrence of symptoms. Mini-open incision PHS repair seems to be a safe and effective method for treatment of sports hernia, resulting in early return to physical activities, with few complications, and low recurrence rate.

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.

A proposed algorithm for the treatment of core muscle injuries.

ABSTRACTIn 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.

Use of Preoperative Magnetic Resonance Imaging to Predict Clinical Outcomes After Core Muscle Injury Repair.

Background:Core muscle injury (CMI), often referred to as a sports hernia or athletic pubalgia, is a common cause of groin pain in athletes. Imaging modalities used to assist in the diagnosis of CMI include ultrasound (US) and magnetic resonance imaging (MRI).Purpose:To determine if preoperative MRI findings predict clinical outcomes after surgery for CMI.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective cohort study was performed on a consecutive series of patients who were operatively treated for CMI by a single surgeon. CMI was diagnosed based on history, physical examination, and a positive US. In addition, all patients underwent a preoperative MRI. Patients were divided into 2 groups based on whether the MRI was interpreted as positive or negative for CMI. All patients underwent mini-open CMI repair. Patient-reported outcomes (PROs) were collected both pre- and postoperatively and included a visual analog scale (VAS) for pain, the University of California, Los Angeles (UCLA) activity score, and the modified Harris Hip Score.Results:A total of 39 hips were included in this study, of which 17 had a positive MRI interpretation for CMI (44%) and 22 had a negative MRI interpretation (56%). Mean age at the time of surgery was 35 years (range, 17-56 years), and mean follow-up was 21 months (range, 12-35 months). No significant difference was found between groups in mean age or time to follow-up. Patients in both groups demonstrated significant improvement from preoperative to most recent follow-up in terms of the UCLA activity score (P < .05). VAS scores significantly improved for patients with a positive MRI interpretation (P = .001) but not for those with a negative MRI interpretation (P = .094). No significant difference on any PROs was found between groups at the most recent follow-up.Conclusion:Successful clinical outcomes can be expected in patients undergoing surgery for CMI diagnosed based on history, physical examination, and US. Patients with a preoperative MRI consistent with CMI may experience greater improvement in pain postoperatively, although MRI does not predict postoperative activity level in these patients.

THE FEATURES OF THE BIOMECHANICS IN FOOTBALL PLAYERS ON THE ANATOMICAL STRUCTURES OF THE GROIN

&#x0D; &#x0D; &#x0D; Pain in the lower abdomen and groin can oc- cur in athletes who perform sharp lower extrem- ity movement during training or sports, make sharp turns and change direction of the trunk movement as well as lower extremity accelera- tion/deceleration. An excessive load during the sports game can disturb the biomechanics of the player’s movements. A precise localization of damaged tissues can improve for the diagnosis, determining treatment and forecasting the time ofreturn to sports.&#x0D; The aim was to estimate the importance of the football biomechanics movement for the anato- my of the groin and to determine the anatomi- cal features of the groin in football players with sports hernia.&#x0D; We analysed the thickness and length measure- ments on MRI of the rectus abdominis muscle in 51 football players of professional and amateur clubs aged 17 to 33 years with groin pain who were treated at the Kyiv Clinical City Hospital No3 for the period 2014-2020. In the second stage of the study, we investigated the peak force of the abdominal muscles (rectus abdominis, exter- nal oblique abdominal muscles) and the adductor muscles of both lower extremities using the mi- croFET2 dynamometer for 4 groups of football players. The first group of the study includes 15 football players of professional clubs with sports hernia who had received conservative treatment, the partipants of the second group are 36 football players after laparoscopic hernioplasty, the third group consisted of 54 healthy young football players and 11 teenage footballers. In the third stage of the study, a formula was substantiated, according to which we calculated the accelera- tion of the lower extremity when kicking the ball.&#x0D; &#x0D; &#x0D; &#x0D; The results of the study demostrate that the disruption of the lower extremity biomechanics during kicking the ball cause the appearance of sports hernia in football players. An axial MRI scan of groin areas of football players with sports hernia represented changes in the lateral edge of the rectus abdominis. The groin pain syndrome of football players with sports hernia includes three pathogenetic mechanisms of development: dis- ruption of the biomechanics, muscle imbalance and microtrauma and inflammation.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

Athletic Pubalgia (Sports Hernia): Presentation and Treatment

AbstractOften 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.

Assoсiation analysis of gene polymorphisms col1a, mct1, col12a1 with sports hernia in football players

Sports hernias are diagnosed in over 80% of athletes presenting with chronic groin pain. The genotype distributions of the examined polymorphisms were studied in 95 football players, all males, using the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire. DNA extracted from buccal epithelium. Statistical calculations were performed in the R statistical environment (r-project.org) and Odds ratios (OR) were used to estimate genotype associations. Multifactor dimensionality reduction was used to identify multiple sports hernia susceptibility loci.Two single nucleotide polymorphisms MCT1 rs1049434 and COL1A1 rs1800012 are associated with sports hernias (63% testing accuracy shown by random forest). According to the HAGOS questionnaire outcomes, exercise-related pain, reduced mobility, and range of motion in the groin and thigh are typically associated with sports hernia diagnosis (75% testing accuracy shown by random forest).The combination of genetic research and HAGOS questionnaire helped obtain a sensitivity of 93% for the detection of sports hernia. Active engagement in sport is the most important risk factor for sports hernia, so the identification genes SNP in footballers may contribute to taking timely preventive actions. This study is the first demonstration of an association between sports hernia and COL1A1 rs1800012 genotype. The study discovered a synergistic interaction between the indicated polymorphism and the gene polymorphism MCT1 rs1049434. Further investigations are required to study the association between COL12A1 rs240736 gene SNP and sports hernia.

Use of Acupuncture for the Treatment of Sports-Related Injuries in Athletes: A Systematic Review of Case Reports.

Acupuncture is one of the representative complementary and alternative medicine treatments used for various types of pain. This systematic review summarized and analyzed clinical case reports/series utilizing acupuncture for treating sports injuries in athletes, thereby providing the basis for further research to establish clinical evidence on acupuncture treatment in sports medicine. A comprehensive literature search was conducted in Embase including MEDLINE up to 21 August 2019 without language and publication date restrictions. Due to the heterogeneity of each study, explanatory and descriptive analyses were performed. As a result, in each case report/series, it was confirmed that acupuncture was applied for treating various types of sports injuries experienced by athletes. Acupuncture can help relieve short-term pain and recover from dysfunction and has been used as a useful, noninvasive, and conservative modality for managing sports injuries such as lateral meniscus rupture, femoral acetabular impingement, ganglion cysts, and sports hernia. In addition, acupuncture has been suggested as a treatment worth trying for diseases such as yips and delayed onset muscle soreness. The included cases showed some potential of acupuncture in the treatment of various types of sports injuries, beyond pain control in musculoskeletal disorders. However, considering that this review was based on case reports/series, a limited understanding of the clinical value of acupuncture in athletes is required. In the future, more specific research questions and hypotheses should be addressed to generate evidence based on experimental research.

ОСОБЛИВОСТІ ДІАГНОСТИКИ ТА ЛІКУВАННЯ СПОРТИВНОЇ ГРИЖІ: ОГЛЯД ЛІТЕРАТУРИ

Спортивна грижа є надзвичайно актуальною проблемою в професійному та аматорському спорті. Актуальність дослідження даної патології обумовлена тим, що на даний момент не існує єдиної класифікації, немає чіткого алгоритму діагностики та ефективного загальноприйнятого хірургічного лікування. В статті проведена систематизація літературних джерел та підходів до вирішення проблеми болю в пахвинній ділянці при фізичних навантаженнях, що є основним проявом спортивної грижі у футболістів. Представлені результати досліджень свідчать, що характерною ознакою спортивної грижі є наявність слабкості задньої стінки пахвинного каналу без наявності анатомічних ознак типової грижі, а для верифікації діагнозу важливе значення має ультразвукове дослідження та магнітно- резонансна томографія пахвинної ділянки. В дослідженні проведено порівняльний аналіз результатів хірургічного лікування спортивної грижі. Результати проведеного дослідження можуть бути корисними для загальних хірургів, спортивних лікарів, сімейних лікарів, ортопедів-травматологів

Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy: a 10-year experience in the treatment of athletic pubalgia.

Athletic pubalgia, commonly referred to as a "sports hernia," is a disease process characterized by groin pain produced by physical exertion often occurring in patients whose athletic activities require them to make rapid changes in direction. The groin pain is due to the traction-countertraction relationship between the adductor muscles and the weaker abdominal muscles. Hence, a few studies have shown inguinal hernia repair with adductor tenotomy to be an effective treatment for this pathology (Brody in Hernia 21:139-147, 2016, https://doi.org/10.1007/s10029-016-1520-8 ; Rossidis et al. in Surg Endosc 29:381-386, 2015, https://doi.org/10.1007/s00464-0143679-3 ). However, these studies are small and few in quantity but have demonstrated promising results. Thus, we sought to further study this combined surgical approach as a treatment for this multifactorial disease to improve our understanding and outcomes. With IRB approval, we retrospectively reviewed the charts of all patients who underwent adductor tenotomy and inguinal hernia repair for the treatment of athletic pubalgia at Mount Sinai Medical Center, Miami Beach FL. Parameters gathered included basic demographics, past medical and surgical history, athletic activity, length of surgery, length of time between surgery and follow-up, intraoperative and postoperative complications, and time to return to athletic activities. A total of 93 patients underwent inguinal hernia repair with adductor tenotomy. These procedures were all performed by a single surgeon at two academic institutions. The average age of patients was 23.4years. Athletic activities reported by the patients were as follows: American football (n = 36), soccer (n= 18), triathlon (n = 11), track and field (n = 8), and baseball (n = 5). Less-represented activities included swimming (n = 3), tennis (n = 2), lacrosse (n = 1), golf (n = 1), and other (n = 8). Mean operative time was 72.4min. Most patients were found to return to athletic activity in 28days following a standardized physical therapy regimen (92.5%). Postoperative complications included recurrence of pain/symptoms (7.5%, n = 7), urinary retention (2.2%, n = 2), pain along the adductor magnus/brevis muscle group with more extraneous activity (1.1%, n = 1), and adductor brevis hematoma 3months following surgery and rehabilitation (1.1%, n = 1). Of the patients with recurrent pain, 2/7 reported contralateral pain. Total extraperitoneal laparoscopic inguinalhernia repair with adductor tenotomy appears to be a relatively quick and safe procedure with few postoperative complications. The majority of treated athletes are able to return to full athletic activities within 28days of operation. While a return of symptoms has been seen in some patients, it is frequently observed on the contralateral side.

Diagnostic Accuracy of Physical Examination Tests in Core Muscle Injury

Background: Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury. Purpose: To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient’s chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard. Results: A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%). Conclusion: Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.

Evaluation and treatment of groin pain syndromes in athletes

Groin pain syndromes, commonly referred to as sports hernias, are pathologic conditions which are not commonly well understood by those treating athletes despite making up approximately 6% of athletic injuries. The purpose of this article is to provide a comprehensive understanding and consistent nomenclature for appropriate identification and treatment of this relatively common condition. A computerized database search was conducted up to June 2019 and pertinent articles were cited using the terms sports hernia, athletic pubalgia, and groin pain. The quality and validity of the evidence was assessed based on journal prestige and impact factor as well as consistency with the other reviewed literature. The reviewed literature was inconsistent in terms of terminology. Few comprehensive reviews exist combining intra- and extra-articular causes of groin pain syndromes in athletes. Further, little orthopedic literature exists regarding pathologic inguinal and abdominal wall conditions. Groin pain syndromes refers to inguinal pain where the pathology is not caused by disturbances in the intra-articular hip joint, however, concomitant pathology in both locations are common. It is thought to be associated with a number of factors, including imbalances in abdominal and hip adductor strength, deficits in hip range of motion, poor tissue extensibility, and high intensity or high repetition hip adductor muscle shearing. The history and physical exam remain central to the appropriate diagnosis. Diagnostic imaging modalities such as MRI, CT, and diagnostic ultrasound are recommended due to difficulty of diagnosis based on physical exam alone. Non-operative treatment should first be attempted with surgical intervention yielding good outcomes in those that require it.