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

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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

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

19. 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

20. 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

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

22. 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

23. 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

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

25. 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