Groin Pain in the Athlete GUY VOELLER, MD,FACS Professor of Surgery University of Tennessee Past President, The AHS

GPA Misunderstood by many surgeons Difficult diagnostic issues Difficult treatment issues Many treatment options No RPCT to show surgery is helpful

GPA Sports hernia is bad name Pelvis has 2 joints The ball and socket hip joint The pubic bone joint Right and left pubic symphyses act together as the center for a lot of symmetrical soft tissue structures Meyers uses athletic pubalgia interchangeably with SH

GPA Unclear etiology Possible causes of groin pain are vast Dull, diffuse pain In groin, pubic, adductor area Can radiate to inner thigh, perineum or across the midline Can be acute but 90% give insidious onset Athletes must stop their activity due to the pain

GPA Cabot in 1966 42,000 Spanish soccer players Found 202 cases of groin pain (0.5%) Over a 30 year period

GILMORE’S GROIN Described dilated superficial inguinal ring Rarely was a hernia present Described other pathology Torn EOA, conjoined tendon, muscle torn from pubic bone Mainly in soccer players Common term in Europe and Australia

SPORTS HERNIA 1992 Malycha and Lovell Coined the term sports hernia Sportsman’s hernia was a bulge in posterior inguinal floor Some felt there was a tear in the TF Many feel is primary pathology in true SH Many definitions now and much confusion Term “SPORTS HERNIA” should only be used for this entity

Malycha and Lovell 50 athletes with groin pain; prospective; 1992 Examined adductors, hips, low back, spine, groin, pubic bone Plain xrays and herniography Local tenderness above inguinal ligament, lateral and superior to pubic tubercle Had stopped or curtailed sport and failed conservative therapy Repaired posterior inguinal wall in 2 layers

Malycha and Lovell (cont.) Light activity at 3-4 weeks Return to sport at 6-8 weeks Questionnaire at 6 months Asked to complete pain scale and success All males, duration of symptoms 9 months 40 patients with significant bulge in posterior wall 7 patients had no abnormality, 2 indirect hernias and one scar of nerve from repair as youth 44 filled out questionnaire

Malycha and Lovell 41 patients returned to normal activity 33 said result was “good” and 10 “improved No one was made worse and one not helped Last sentence of paper is key Athletes who are unable to compete in active sport due to chronic groin pain should be considered for routine inguinal hernia repair if no other pathology is evident after clinical examination and radiologic evaluation

DIFFERENTIAL DIAGNOSIS Must rule out intraabdominal pathology Urologic problems Hip joint is common cause of groin pain Can see with spinal pathology Muscle strains, nerve entrapment Osteitis pubis, stress fractures Ligament problems

MRI Entire spectrum of related pathology Results from musculotendinous injuries Leads to instability of the pubic symphysis Causal mechanisms of AP poorly understood Imaging studies in past not helpful MRI now seen as the study of choice Must know what to order however

MRI Empty the bladder Survey imaging of entire pelvis Do small field of view, high resolution studies based on survey Do both non-fat suppressed and fat suppressed fluid sensitive T1 weighted images Do axial obliques, sagittal and coronal

LIGAMENT and MUSCLE STRAIN Most common is adductor muscle or tendon Pain in the upper thigh Tender along the adductor No loss of strength MRI is diagnostic Avoid lateral movements and PT Akermark described tenotomy and adductor release Good if injury is isolated to adductor

Akermark First to describe tenotomy of adductor longus for chronic groin pain in athletes 16 patients, all competitive athletes ; had to stop athletic activity ; mean duration of pain 18 months Pain at adductor refractory to conservative therapy Soccer, hockey and runners Tenotomy one cm. from muscle origin at pubic bone At 35 month mean f/u all but one returned to sport within a mean of 6 weeks

Meyers – AOS 2008 Describes patients with groin pain and adductor strain; pain with hip adduction against resistance Treatment of groin, adductors or both combined Attaches rectus abd. to pubis; similar but not identical to the NA Bassini repair Adductor longus tendon tenotomy He calls it athletic pubalgia; problem is pubic joint 8490 patients; 5460 operations Uncontrolled series with 95% success

ACETABULAR LABRAL TEARS 22% of athletes with groin pain have labral tear The lip of tissue that surrounds acetabulum Thought to add stability to hip jt. Explosive lateral moves like in soccer or hockey known to damage labrum suddenly Can be insidious over months to years thought due to repetitive microtrauma MRI arthrography is 91% accurate in dx.

OSTEITIS PUBIS Tender over symphysis MRI to diagnose Steroid and local injection Physical rehab May take 6-9 months to resolve without injection

NERVE ENTRAPMENT Irshad 30 NHL players found tears in external oblique with nerves coming through the tears Smedberg found same thing in 7 players Pain relief with ilioinguinal nerve block Operate and cut the nerve Irshad reinforced the EOA

RANDOMIZED TRIAL Only one RPCT 66 soccer players with failed conservative tx. Four groups One had repair and neurolysis Others had conserv tx like PT and meds None lost to f/u Only surgical grp. had SS improvement and resumed soccer play by 6 weeks Pathology at surgery not defined however

SURGERY? CHRONIC PAIN REFRACTORY TO LOCAL INJECTION, NSAIDs, PHYSICAL THERAPY AND/OR REST

OPEN REPAIRS “Bassini” “Modified Shouldice” TF to IL Lichtenstein Meyer’s repair Irshad’s technique Muschaweck All report 90-95% return to full activity quickly

LAPAROSCOPIC REPAIRS TAPP and TEP 5-10 reports with 30-130 patients Describe tear in posterior wall, a weakness or bulge, true hernia or lipoma All used mesh 95-100% return to full activity quickly

AP Both conservative and various operations applied Herniorraphy, adductor release, pelvic floor reconstruction, reinforcement of inguinal floor etc Variable success with all

SUMMARY Diagnosis of SH must exclude many other pathologies Patient population is most likely heterogeneous Once true SH diagnosed there are many surgical options Many of the open repair techniques are not well described in the papers Many things described at surgery but not many pictures Majority of repairs seem to work