Sportsman's Hernia Research Articles

Anatomy and terminology of groin pain: Current concepts

Groin pain is a common symptom in athletes. The complex anatomy of the area and the various terms used to describe the etiology behind groin pain have led to a confusing nomenclature. To solve this problem, three consensus statements have been already published in the literature: the Manchester Position Statement in 2014, the Doha agreement in 2015, and the Italian Consensus in 2016. However, when revisiting recent literature, it is evident that the use of non-anatomic terms remains common, and the diagnoses sports hernia, sportsman's hernia, sportsman's groin, Gilmore's groin, athletic pubalgia, and core muscle injury are still used by many authors. Why are they still in use although rejected? Are they considered synonyms, or they are used to describe different pathology? This current concepts review article aims to clarify the confusing terminology by examining to which anatomical structures authors refer when using each term, revisit the complex anatomy of the area, including the adductors, the flat and vertical abdominal muscles, the inguinal canal, and the adjacent nerve branches, and propose an anatomical approach, which will provide the basis for improved communication between healthcare professionals and evidence-based treatment decisions.

OC-041 TOTALLY EXTRA-PERITONEAL REPAIR VERSUS TRANS-ABDOMINAL PRE-PERITONEAL REPAIR FOR THE LAPAROSCOPIC SURGICAL MANAGEMENT OF SPORTSMAN'S HERNIA: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Aim Open and laparoscopic modalities are employed for treatment of sportsman's hernia, with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated superiority for sportsman's hernia repair. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair. Material & Methods A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies. Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively. The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed. Results 28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was signficant for return to sporting activity; thus meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques. Conclusions There is no difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data.

Open Surgery for Sportsman's Hernia a Retrospective Study.

Sportsman’s hernia is a painful syndrome in the inguinal area occurring in patients who play sports at an amatorial or professional level. Pain arises during sport, and sometimes persists after activity, representing an obstacle to sport resumption. A laparoscopic/endoscopic approach is proposed by many authors for treatment of the inguinal wall defect. Aim of this study is to assess the open technique in terms of safety and effectiveness, in order to obtain the benefit of an open treatment in an outpatient management. From October 2017 to July 2019, 34 patients underwent surgery for groin pain syndrome. All cases exhibited a bulging of the inguinal posterior wall. 14 patients were treated with Lichtenstein technique with transversalis fascia plication and placement of a polypropylene mesh fixed with fibrin glue. In 20 cases, a polypropylene mesh was placed in the preperitoneal space. The procedure was performed in day surgery facilities. Early or late postoperative complications did not occur in both groups. All patients returned to sport, in 32 cases with complete pain relief, whereas 2 patients experienced mild residual pain. The average value of return to sport was 34.11 ± 8.44 days. The average value of return to play was 53.82 ± 11.69 days. With regard to postoperative pain, no substantial differences between the two techniques were detected, and good results in terms of the resumption of sport were ensured in both groups. Surgical treatment for sportsman’s hernia should be considered only after the failure of conservative treatment. The open technique is safe and allows a rapid postoperative recovery.

P081 CHRONIC GROIN PAIN IN SPORTSMEN. EVIDENCE-BASED IN EXPERIENCE

Abstract Aim The main objective of this study is to describe and analyze the assessment and treatment of chronic groin pain (CGP) based on the experience collected in 20 years. Material and Methods Descriptive, observational, and retrospective study. It is a multidisciplinary team formed by surgeons, physiotherapists, orthopedists, and imaging specialists. That had developed an assessment, diagnosis, and treatment algorithm for (CGP), which have been implemented for more than 20 years. Follow-up included a record of clinical examination findings, clinical entities diagnosed, ultrasound findings, physiotherapy treatment, operation notes, and postoperative recovery, time to return to sporting activity, and complications. Results In the period between August 2000 and August 2020, we assessed 9996 patients with CGP. (91%) men and (9%) women with a mean age of 30 (SD: 11.21). The most frequently practiced sports were: football (43%), rugby (25%), tennis (12%). The most frequent clinical entities registered were tendinopathies (69%): iliopsoas-pectineus- related (36%) and adductor-related (33%). Tendinopathy sports rehabilitation treatment: (95.7%) presented total recovery in 45 days; 260 patients (4.3%)intra-tissue percutaneous electrolysis was used with favorable recovery. Only 16 patients required tenotomies The ultrasound has been used to detect signs of adductor tendinopathy (92%) and sportsman hernia, but has low sensitivity in iliopsoas-pectineus tendinopathy (21%). Conclusions The algorithm used has proven to be safe and successful. Tendinopathies and Sportsman's hernia are the most common causes of chronic groin pain in sportsmen, presenting together in 82% of the cases. TAPP hernioplasty repair, followed by physical rehabilitation offered excellent results to treat sportsman hernia.

Totally extra-peritoneal repair versus trans-abdominal pre-peritoneal repair for the laparoscopic surgical management of sportsman's hernia: A systematic review and meta-analysis.

Open and laparoscopic modalities are employed for treatment of sportsman's hernia with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated a beneficial superiority for sportsman's hernia repair, as concluded in the most recent systematic review comparing the outcomes of each technique. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair. A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively.The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed. 28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was more pronounced for return to sporting activity meaning that meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28days for both techniques. There is no observed difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data on this matter.

Randomized clinical trial of open suture repairversustotally extraperitoneal repair for treatment of sportsman's hernia

Sportsman's hernia/athletic pubalgia is a recognized cause of chronic groin pain in athletes. Both open and laparoscopic surgical repairs have been described for treatment, but there are no comparative studies. The hypothesis here was that relief of pain would be achieved earlier in patients treated with open minimal suture repair than totally extraperitoneal repair. A randomized multicentre trial in four European countries was conducted to compare open minimal suture repair with totally extraperitoneal repair. The primary endpoint was complete relief of pain (visual analogue scale (VAS) score 20 or less on a scale from 0 to 100 mm) at 1 month. Secondary endpoints included complications, time to return to sporting activity, and number of patients returning to sport within 1 year. A total of 65 athletes (92 per cent men) with a median age of 29 years were enrolled (31 open repair, 34 totally extraperitoneal repair). By 4 weeks after surgery, median preoperative VAS scores had dropped from 70-80 to 10-20 in both groups (P < 0·001). Relief of pain (VAS score 20 or less) during sports activity 4 weeks after surgery was achieved in 14 of 31 patients after open repair and 24 of 34 after totally extraperitoneal repair (P = 0·047). Return to full sporting activity was achieved by 16 and 18 patients respectively after 1 month (P = 0·992), and by 25 versus 31 after 3 months (P = 0·408). Totally extraperitoneal repair was less painful than open repair in the first month, but otherwise both procedures were similarly effective in treating chronic pain due to sportsman's hernia. Registration number: NCT02297711 ( http://www.clinical.trials.gov).

Sportsman's hernia? An ambiguous term.

Groin pain is common in athletes. Yet, there is disagreement on aetiology, pathomechanics and terminology. A plethora of terms have been employed to explain inguinal-related groin pain in athletes. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term inguinal disruption based on the pathophysiology while lately the Doha agreement in 2014 defined it as inguinal-related groin pain, a clinically based taxonomy.This review article emphasizes the anatomy, pathogenesis, standard clinical assessment and imaging, and highlights the treatment options for inguinal disruption.

Endoscopic totally extraperitoneal (TEP) hernia repair for inguinal disruption (Sportsman's hernia): rationale and design of a prospective observational cohort study (TEP-ID-study)

IntroductionChronic inguinal pain is a frequently occurring problem in athletes. A diagnosis of inguinal disruption is performed by exclusion of other conditions causing groin pain. Up to now, conservative medical...

Sportsman hernia; the review of current diagnosis and treatment modalities.

Groin pain is an important clinical entity that may affect a sportsman's active sports life. Sportsman's hernia is a chronic low abdominal and groin pain syndrome. Open and laparoscopic surgical treatment may be chosen in case of conservative treatment failure. Studies on sportsman's hernia, which is a challenging situation in both diagnosis and treatment, are ongoing in many centers. We reviewed the treatment results of 37 patients diagnosed and treated as sportsman's hernia at our hospital between 2011-2014, in light of current literature.

Efficacy of physiotherapy compared to steroid injection for adductor muscle strain

Introduction: Adductor muscle strain or sportsman hernia (SH) is one of the most common disorders in cases who underwent heavy physical activity. An injection of corticosteroids is used to treat inflammation on the last step. Recently, physiotherapy (PT) considered as one of the most effective treatment for muscle strain. The aim of this study was the evaluation of the efficacy of steroid injection compared physiotherapy in adductor muscle strain. Materials and Methods: This cohort study was conducted on the patients who have presented to the physical medicine clinic of Baqiyatallah hospital with chronic groin pain definitely diagnosed SH. Other cause of unilateral groin pain was overruled, and the patients were divided into the two groups accidentally. Patients at the first group underwent 40 mg prednisolone injection and follow-up of 4 weeks later, and at the second group, the patients underwent PT containing stretching adductor muscle lasting 30 seconds 3 times per week for 2 weeks. Results: Seventy-six male patients with the mean age of 24.62 ± 3.49 including 24 athletes, 26 soldiers, and 26 martials were enrolled whom 37 of them divided into the first group and 39 into the second one. The mean ± SD of Visual Analogue Scale (VAS) before and after treatment in first group was 7.784 ± 0.492 and 3.340 ± 0.836, respectively and in second group equals to 8.008 ± 0.457 and 3.370 ± 0.297, respectively. These differences between and within groups were statistically significant. (P < 0.05). Conclusion: Both therapeutic protocols were effectively repressed the pain scores (VAS) although PT protocol was more effective than prednisolone injection. We suggest PT protocol as the first choice of SH treatment.

New approaches to sportsman hernia; logical integration between surgery and muscles sport rehabilitation

Sport Groin injuries are very common among professional Athletes, 40% of Sucker and Hokey players and 10% of all the Athletes, but lastly become common also amongst sport active people. In part is treated by conservative treatment and in part by Endoscopic surgery. Making the diagnosis for selecting the right treatment it is a challenge but lastly become more feasible after publishing the new guidelines for diagnosis and treatment of Sportsman Hernia. In some of the cases there is more complexes injury that will need combined Endoscopic surgery with conservative treatments.

New Approaches to Sportsman Hernia; Logical Integration between Surgery and Muscles Sport Rehabilitation

New Approaches to Sportsman Hernia; Logical Integration between Surgery and Muscles Sport Rehabilitation

The management of sportsman's groin hernia in professional and amateur soccer players: a revised concept.

Chronic groin pain appears in athletes with a diverse etiology. In a select few, it can be defined as a sportsman's hernia, that may be related, among other pathologies, to weakness of the posterior inguinal wall and may successfully respond to surgery. Surgical repair of the sportsman's hernia is associated with good functional outcomes, if the diagnosis is based on meticulous examination and follows a simple selection flowchart. Prospective case cohort study. The study assessed patients recruited from 2006 until the present assessed by a dedicated team with clinical and radiographic features of a sportsman's hernia who had failed a specified period of conservative therapies. Surgery was performed using a tension-free mesh open inguinal hernia repair. Of 246 male patients with chronic groin pain, 51 underwent surgery (mean age 20.7 years, range 14-36 years) with 58 inguinal procedures performed. Of the operated group, seven underwent bilateral surgery with a direct hernia found in 9/58 operated sides (15.5%), an indirect hernial sac in 8/58 (14%) and a direct and indirect hernia being found in 3/58 (5%) of operated sides. There was no post-operative morbidity (median follow-up 36.1 months; range 1-74 months), with two failures (3.45 % of operated sides). All other patients were asymptomatic, returned to full sports activity within 4.3 weeks (range 3-8 weeks) after surgery, and required no analgesics or further treatment. Selective surgical hernia repair, based on meticulous anamnesis and physical examination is effective in the management of chronic groin pain in athletes.

Effect of pubic bone marrow edema on recovery from endoscopic surgery for athletic pubalgia

Athletic pubalgia (sportsman's hernia) is often repaired by surgery. The presence of pubic bone marrow edema (BME) in magnetic resonance imaging (MRI) may effect on the outcome of surgery. Surgical treatment of 30 patients with athletic pubalgia was performed by placement of totally extraperitoneal endoscopic mesh behind the painful groin area. The presence of pre-operative BME was graded from 0 to 3 using MRI and correlated to post-operative pain scores and recovery to sports activity 2 years after operation. The operated athletes participated in our previous prospective randomized study. The athletes with (n = 21) or without (n = 9) pubic BME had similar patients' characteristics and pain scores before surgery. Periostic and intraosseous edema at symphysis pubis was related to increase of post-operative pain scores only at 3 months after surgery (P = 0.03) but not to long-term recovery. Two years after surgery, three athletes in the BME group and three in the normal MRI group needed occasionally pain medication for chronic groin pain, and 87% were playing at the same level as before surgery. This study indicates that the presence of pubic BME had no remarkable long-term effect on recovery from endoscopic surgical treatment of athletic pubalgia.

‘Treatment of the Sportsman's groin’: British Hernia Society's 2014 position statement based on the Manchester Consensus Conference

IntroductionThe aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG).MethodsExperts in the diagnosis and...

“Superior cleft sign” as a marker of rectus abdominus/adductor longus tear in patients with suspected sportsman’s hernia

We describe a new imaging sign, the "superior cleft sign", identified at both symphysography and MRI, which should be used as a marker of rectus abdominis/adductor longus attachment tearing. A study population of 25 patients presenting with clinically suspected sportsman's hernia, who had undergone both symphysography and MRI of the groin were included for study. In each case, images were reviewed to determine the presence of a superior cleft, secondary cleft, and or both abnormalities. Images of all patients complaining of groin crease discomfort similar to sportsman's hernia revealed the presence of a superior cleft at the rectus abdominis/adductor longus attachment. This "superior cleft sign" correlated with the side of symptoms in each case, and, in contrast to the previously described secondary cleft along the inferior margin of the inferior pubic ramus, occurred parallel to the inferior margin of the superior pubic ramus. The presence of the "superior cleft sign" should be sought in addition to the previously described secondary cleft sign in sportspeople presenting with exercise-related groin pain or pubalgia. It should specifically be sought in patients referred with suspected sportsman's hernia.

Radiofrequency denervation of the inguinal ligament for the treatment of ‘Sportsman's Hernia’: a pilot study

BackgroundChronic groin pain is a common and debilitating condition in highly active athletes. Symptoms are often ascribed to the so-called Sportsman's Hernia, and these patients frequently undergo prolonged and often...

"Sportsman's Hernia". Part Two: Multispecialist Differentia Diagnosis of Most Common Disorders

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Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia)

Chronic groin pain in athletes presents often a diagnostic and therapeutic challenge. Sportsman's hernia (also called "athletic pubalgia") is a deficiency of the posterior wall of the inguinal canal, which is often repaired by laparoscopic mesh placement. Endoscopic mesh repair may offer a faster recovery for athletes with sportsman's hernia than nonoperative therapy. A randomized, prospective study was conducted on 60 patients with a diagnosis of chronic groin pain and suspected sportsman's hernia. Clinical data and MRI were collected on all patients. After 3 to 6 months of groin symptoms, the patients were randomized into an operative or a physiotherapy group (n = 30 patients in each group). Operation was performed using a totally extraperitoneal repair in which mesh was placed behind the symphysis and painful groin area. Conservative treatment included at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. The outcome measures were pre- and postoperative pain using a visual analogue scale and partial or full recovery to sports activity at 1, 3, 6, and 12 months after randomization. The athletes in both treatment groups had similar characteristics and pain scores. Operative repair was more effective than nonoperative treatment to decrease chronic groin pain after 1 month and up to 12 months of follow-up (P < .001). Of the 30 athletes who underwent operation, 27 (90%) returned to sports activities after 3 months of convalescence compared to 8 (27%) of the 30 athletes in the nonoperative group (P < .0001). Of the 30 athletes in the conservatively treated group, 7 (23 %) underwent operation later because of persistent groin pain. This randomized controlled study indicated that the endoscopic placement of retropubic mesh was more efficient than conservative therapy for the treatment of sportsman's hernia (athletic pubalgia).

Sportsman hernia: what can we do?

Sportsman (sports) hernia is a medially located bulge in the posterior wall of the inguinal canal that is common in football players. About 90% of cases occur in males. The injury is also found in the general population. The presenting symptom is chronic groin pain which develops during exercise, aggravated by sudden movements, accompanied by subtle physical examination findings and a medial inguinal bulge on ultrasound. Pain persists after a game, abates during a period of lay-off, but returns on the resumption of sport. Frequently, sports hernia is one component of a more extensive pattern of injury known as 'groin disruption injury' consisting of osteitis pubis, conjoint tendinopathy, adductor tendinopathy and obturator nerve entrapment. Certain risk factors have been identified, including reduced hip range of motion and poor muscle balance around the pelvis, limb length discrepancy and pelvic instability. The suggested aetiology of the injury is repetitive athletic loading of the symphysis pubis disc, leading to accelerated disc degeneration with consequent pelvic instability and vulnerability to micro-fracturing along the pubic osteochondral junction, periosteal stripping of the pubic ligaments and para-symphyseal tendon tears, causing tendon dysfunction. RADIOLOGY: Diagnostic imaging includes an erect pelvic radiograph (X-ray) with flamingo stress views of the symphysis pubis, real-time ultrasound and, occasionally, computed tomography (CT) scanning and magnetic resonance imaging (MRI), but seldom contrast herniography. Other imaging tests occasionally performed can include nuclear bone scan, limb leg measurement and test injections of local anaesthetic/corticosteroid. PREVENTION AND TREATMENT: The injury may be prevented by the detection and monitoring of players at risk and by correcting significant limb length inequality. Groin reconstruction operation consists of a Maloney darn hernia repair technique, repair of the conjoint tendon, transverse adductor tenotomy and obturator nerve release. Rehabilitation involves core stabilisation exercises and the maintenance of muscle control and strength around the pelvis. Using this regimen of groin reconstruction and post-operative rehabilitation, a player would be anticipated to return to their pre-injury level of activity approximately 3 months after surgery.