Sports hernia and extra-articular causes of groin pain in the athlete.
The complex local anatomy, including the musculoskeletal system, abdominal and pelvic viscera, and genitourinary systems can make the specific etiology of groin pain difficult to elucidate. As a result, the sports medicine physician encountering an athlete with groin pain must consider the wide differential diagnosis, before focusing on solely orthopaedic etiologies (Table 1). (3) Musculoskeletal causes of groin pain can be broken down into four broad categories: 1. sports hernia, 2. osteitis pubis, 3. adductor dysfunction, and 4. pathologic conditions of the hip joint (i.e., labral tear, cartilage lesion). (4)
To differentiate between these four broad categories, Falvey and coworkers described the "pubic clock" to aid in the examination and diagnosis of athletes with groin pain (Fig. 1). (5) The clock-face is centered on the pubic tubercle and serves as a guide to what may be palpable on exam, including the superficial inguinal ring, rectus abdominis insertion, pubic symphysis, and adductor longus insertion. With a thorough history and physical examination, as well as judicious use of imaging and specialized tests, the treating physician should be able to appropriately diagnose and treat this spectrum of disorders causing groin pain. This review will focus on the extra-articular causes of musculoskeletal groin pain, focusing on the diagnostic and treatment algorithms of sports hernia, osteitis pubis, and adductor dysfunction.
Sports hernia is an occult hernia caused by weakness or tear of the posterior inguinal wall, without clinically recognizable herniation of intra-abdominal contents. (2) It can lead to chronic groin pain and an associated decrease in athletic performance. Due to its insidious onset, nonspecific symptoms, and lack of clinical findings, there is often a delay between presentation and diagnosis. Some investigators consider sports hernia to be a common diagnosis, whereas others consider it to be quite rare. (4) In a review of 189 athletes with chronic groin pain, Lovell found that sports hernia was the primary diagnosis in 50%.6 However, Morelli and Smith noted that groin injuries comprise only 2% to 5% of all sports injuries. (7) To complicate matters, the literature contains many different terms for sports hernia and related diagnoses (Table 2). (2,4-6,8,9) According to Nam and Brody, the colloquial term "sports hernia" is a misnomer and does not embody the true qualities of a hernia. (10) However, the media has popularized this term leading to propagation of its use.
Gilmore first described a "groin disruption" in 1980, with pathologic features including a torn external oblique aponeurosis, torn conjoined tendon, a dehiscence between the conjoined tendon and the inguinal ligament, a dilated superficial inguinal ring, and a lack of clinically detectable hernia. (10,11) Other sports hernia descriptions have included abnormalities of the rectus abdominis muscle, avulsion of part of the internal oblique muscle fibers from the pubic tubercle, tearing within the internal oblique muscle, or abnormality within the external oblique muscle and aponeurosis. (4,12-14) Due to the lack of consistent definition and clinical findings, Caudill and colleagues have referred to the sports hernia as "one of the least understood, poorly defined and under-researched maladies to affect the human body." (4)
The pathogenesis of sports hernia is believed to be an overuse injury. Hip range of motion and resultant pelvic motion from trunk hyperextension and thigh abduction lead to shear across the pubic symphysis. (2,15) This combination of trunk extension and thigh abduction can occur in football with lateral cutting by a running back or in soccer with an aggressive kick. (8) These shear forces are more prominent in athletes with an imbalance between the strong adductor muscles of the thigh and relatively weak lower abdominal muscles. (2,16,17) These shear forces place stress on the inguinal wall musculature and can lead to attenuation of local soft tissues, including the following: tearing of the transversalis fascia or conjoined tendon, abnormalities at the insertion of the rectus abdominis muscle, avulsion of the internal oblique muscle fibers at the pubic tubercle, intrasubstance tear of the internal oblique muscle, and attenuation of the external oblique muscle and aponeurosis.
History and Physical Examination
Athletes with sports hernia often complain of insidious onset of pain in the groin region. Symptoms often dissipate with rest and worsen with activity or while straining. Pain may radiate to the proximal thigh, perineum, lower abdomen, inguinal ligament, or testicles as a result of irritation of the ilioinguinal, genitofemoral, or obturator nerves. (4) Nam and Brody describe four elements consistently found on examination of patients with sports hernia, including 1. inguinal canal tenderness, 2. a dilated superficial inguinal ring, 3. pubic tubercle tenderness, and 4. hip adductor origin tenderness. However, there is usually no detectable inguinal hernia, and these physical examination findings are not specific for sports hernia. (10) Verrall and associates described three provocative tests for chronic sports related groin pain, including 1. having the patient squeeze their knees together while supine with the hip in 45[degrees] of flexion and the knees flexed to 90[degrees], 2. having the patient squeeze their feet together while supine with the hip in 30[degrees] of flexion and slight abduction-internal rotation, and 3. hip flexion-abduction-external rotation. (18) However, these provocative maneuvers are not specific for sports hernia and are found to indicate a high likelihood of parasymphyseal bone marrow edema on MRI. (18)
Plain radiographs of the hips, pelvis, and lumbar spine should be included in the evaluation of athletes with groin pain but are usually unremarkable in patients with sports hernia. However, they are useful for ruling out alternative diagnoses. (2,19) Magnetic resonance imaging may also reveal non-specific findings but can similarly be useful for ruling out alternative pathology. Albers and coworkers reviewed MRI scans from 30 patients with sports hernia confirmed at surgery. Non-specific MRI findings in these patients included increased signal within the pubic bone, increased signal in one or more groin muscles, and attenuation or bulging of the musculofascial layers of the abdominal wall. (20) Recent literature suggests that a noncontrast athletic pubalgia MRI protocol may have improved sensitivity and specificity for diagnosing sports hernia. (21) However, many patients with sports hernia confirmed at surgery have no pathologic findings on MRI. (2)
Dynamic high-resolution ultrasound is a useful noninvasive modality for diagnosing sports hernia. The patient is asked to strain, and a convex anterior bulge or ballooning can be seen at the superficial inguinal ring (Fig. 2). (22,23) However, ultrasound findings can be subtle and are operator dependent.
Initial treatment of sports hernia begins with a trial of 6 to 8 weeks of rest, accompanied by use of non-steroidal anti-inflammatory medications, heat or ice, and massage (Fig. 3). (4,24) Rehabilitation should focus on improving core strength, endurance, coordination, and deficiencies and imbalances at the hip and abdominal muscles. (4,25) A four-phase rehabilitation program consists of 1. massage and stretching, 2. abdominal muscle strengthening, 3. functional activities, and 4. return to sport-specific activities. (2) However, the success rate for long-term pain relief and return to sport with non-operative measures can be less than 20%. (4-26)
Surgical Techniques and Outcomes
Numerous surgical techniques have been described for sports hernia repair, including both open and laparoscopic methods, as well as augmentation with mesh constructs. (10) For example, the modified Shouldice repair involves plication of the transversalis fascia followed by approximation of the internal oblique and transversus abdominis muscles to the iliopubic tract. (10,26) However, Nam and Brody caution that a single technique is not appropriate for all patients, and the operation chosen must reflect each patient's specific symptoms and pathology. (10)
Success rates of greater than 90% have been reported by several investigators. (15,27-29) Meyers and colleagues reported on the results of 157 athletes with chronic groin pain. Surgery consisted of a broad reattachment of the inferolateral edge of the rectus abdominis with fascial investments to the pubis. Twenty-three percent of patients underwent a concomitant adductor release. One hundred fifty-two of the 157 patients (97%) returned to their pre-injury activity levels. (15) Van Der Donckt and associates reviewed 41 high level male athletes with chronic groin pain. The surgical technique consisted of an open hernia repair with percutaneous adductor tenotomy in all treated patients. All patients in this study resumed sporting activity at a mean of 7 months, with 90% performing at equal or improved levels. (27) Ingoldby retrospectively reviewed 28 patients with sports hernia, 14 with open repairs, and 14 repaired laparoscopically. All patients returned to preinjury activity levels, with a statistically significant increase in return by 4 weeks in the laparoscopic group. (28)
Following sports hernia repair, there is no guarantee that high level athletes will be able to obtain their prior performance level. Jakoi and colleagues (29) reviewed 43 National Hockey League players who underwent sports hernia repair from 2001 to 2008. Statistics were compared in the two seasons prior to surgery with the two seasons following recovery. Ninety-three percent of players were able to resume their professional careers. While younger players had no difference in goals, assists, or time on the ice, older players experienced a decrease in goals, assists, and games played. (29) Successful return to high level of sports has been reported in professional soccer, American football, and rugby, as well. (30,31)
Based on a systematic review of 104 studies on sports hernia, Caudill and associates made several broad conclusions. Success rates of laparoscopic repair (96%) are no different than open repair (93%). Laparoscopic repair offers the advantage of faster rehabilitation and earlier return to unrestricted activity. However, the recurrence rate with a laparoscopic approach may be higher, due to the inability to visualize the entire lesion during surgery. Lastly, while surgical release of hip adductors may help restore the balance between abdominal and hip adductor muscles, no recommendation can be made based on the current literature whether or not to perform adductor release concurrently with all sports hernia repairs. (4)
Osteitis pubis is a stress injury to the pubic symphysis and parasymphyseal bone. It was first described by Beer in 1924 as a complication of suprapubic surgery and has been associated with a wide range of clinical scenarios, including vaginal birth, infection, rheumatoid arthritis, and pelvic and perineal surgery. (32) In athletic populations, osteitis pubis is usually the result of repetitive mictotrauma resulting in functional anterior instability of the pelvis. (33) Sports commonly implicated include soccer, ice hockey, American football, rugby, and distance running, with an incidence ranging from 0.5% to 7%. (33-36)
The pubic symphysis is a non-synovial amphiarthroidal joint located at the confluence of the two pubic bones. (37) With weightbearing, the superior pubic rami and the pubic symphysis act as a compression strut, linking the femur to the posterior pelvic structures and spine, with the centers of rotation being near the pubic symphysis. (38,39) As a result, the parasymphyseal bony area is vulnerable to repetitive stressors with athletic activity. Specifically, the biomechanical forces transferred through the pelvis during kicking, rapid acceleration, deceleration, and cutting movements can lead to the development of chronic overloading of the pubic symphysis and subsequent bony stress reaction.
History and Physical Examination
Athletes with osteitis pubis usually complain of gradually increasing pain in the groin and pubic symphysis. Pain may also be present in the lower abdomen, perineal region, or scrotum and may be exaggerated with running or cutting activities. (40) Physical examination findings may include tenderness at the pubic symphysis and adjacent pubic bones, pain with adductor stretch, decreased internal and external hip rotation, and pain with single leg hop. (32,40) However, the specificity of these tests for osteitis pubis is unknown. Pubic osteomyelitis has also been reported in athletes, and the clinician must differentiate the overuse injury of osteitis pubis from infectious pathology in the symphyseal region. (41)
Standard anteroposterior radiographs of the pelvis have traditionally been used in the evaluation of osteitis pubis. Findings include bony sclerosis of the symphysis, widening of the joint, and cystic changes or marginal erosions in the subchondral bone. (32,40) Radiographs can also be used to ruleout associated intra-articular hip pathology. Pubic instability can be investigated with "flamingo views," consisting of anteroposterior pelvis radiographs during single leg stance. (42) Instability is defined as greater than 2 mm of vertical shift or 7 mm of widening across the symphysis.
MRI has become the imaging modality of choice for osteitis pubis, due to its ability to visualize soft tissues and changes within the bone marrow (Fig. 4). MRI findings in patients with osteitis pubis include articular surface irregularity, marrow edema on each side of the symphysis, subchondral cysts, increased fluid intensity in the joint, and edema throughout the periaticular soft tissues. (43)
Osteitis pubis has traditionally been considered self-limiting, but recovery can be lengthy, averaging 3 to 12 months (Fig. 5). (33) Many conservative treatment regimens have been presented in the literature, usually consisting of rest, protected weightbearing, non-steroidal anti-inflammatory medications, and physical therapy modalities. (40,44) Treatment should include reducing loaded weightbearing activities during initial therapy, improving hip range of motion, addressing biomechanical faults, such as limitations in sacroiliac and lumbosacral movement, and improving stability of the pelvic and core muscles. (40)
Corticosteroid injections to the pubic symphysis have been reported in the literature. (34,45) Holt and colleagues reported successful return to sports in 11 of 12 cases after one to two injections. (45) O'Connell and coworkers reported successful early results in 14 of 16 athletes after pubic cleft injections; however, only 5 of 16 patients were pain-free at 6-month follow-up. (46) There are no controlled, prospective studies in the literature evaluating injection therapy in the treatment of osteitis pubis. Overall, up to 90% of cases of osteitis pubis will respond to non-operative management, with surgery reserved for refractory cases and recurrent injuries. (8)
Surgical Techniques and Outcomes
Many operative techniques have been described for osteitis pubis, including open symphysis curettage, arthroscopically-assisted curettage, wedge symphysis resection, placement of extraperitoneal retropubic mesh, and pubic symphysis athrodesis. (32,36,40,42) Radic and associates reviewed open symphysis curettage in 23 athletes with refractory osteitis pubis, with preoperative symptoms averaging 13 months. (33) The surgical technique consisted of open curettage of the fibrocartilaginous disc and hyaline endplates with drilling of the subchondral bony bed until bleeding bone was visible. Twenty-one of 23 athletes returned to pain free running at a mean of 3 months, and 16 of 23 athletes returned to full activity at an average of 5.6 months.
Hechtman and coworkers reviewed four athletes with osteitis pubis resistant to conservative treatment for an average of 6 months. (36) Arthroscopically-assisted curettage was performed through a small incision in the anterior capsule. All four athletes were symptom free at final follow-up. Paajanen and colleagues describe a technique for endoscopic placement of polypropylene mesh posterior to the pubic tubercle to evenly distribute muscle pressure in the symphysis region. (47) All five patients in their series were symptom-free at 1-year follow-up.
Osteitis pubis with pubic instability demonstrated on flamingo view radiographs was reviewed by Williams and associates. (42) Seven rugby players had preoperative symptoms lasting a minimum of 13 months. The surgical technique consisted of pubic symphysis arthrodesis with compression plating and bone graft. At a mean follow-up of 54 months, all seven athletes were pain-free without evidence of postoperative pubic instability. There are currently no defined criteria in the literature to aid in the decision to proceed to surgical management of osteitis pubis.
Adductor dysfunction is the single most common cause of groin pain in athletes, with the adductor longus the most common muscle involved. (48,49) Pathology can range from enthesopathy of the adductor tendon to frank avulsion of the tendon origin, although acute avulsion of the adductor longus enthesis is rare. (50) Adductor strains are common in sports with quick acceleration or deceleration, direction changes, or kicking, such as soccer, hockey, rugby, skiing, and hurdling. (5,48)
The adductor muscle group consists of six different muscles: pectineus, gracilis, obturator externus, adductor brevis, adductor longus, and adductor magnus. Despite being a single-joint muscle, the adductor longus is the most commonly injured adductor muscle. This is because the adductor longus has the least mechanical advantage on adduction of the hip and therefore undergoes the most strain. (51) The adductor longus enthesis is a fibrocartilaginous structure at the site of stress concentration and is thus prone to injury, damage, and inflammation. (52,53) Additionally, decreased adductor strength and conditioning may be a risk factor for adductor strains. (54)
History and Physical Examination
Athletes with adductor strains may present with groin pain that is decreased with rest and worsened with activity. Symptoms may be acute or chronic, often with a history of forced external rotation of the abducted hip. Patients are usually tender along the proximal medial border of the thigh, and a defect may be palpable in the rare cases of a tendon avulsion. Patients with adductor dysfunction will have pain on passive abduction of the thigh and with resisted adduction. (55)
Plain radiographs of the pelvis may reveal enthesophyte formation in cases of chronic tendinopathy or bony avulsion in cases of acute injury. (56) They are also helpful to rule-out concomitant pathology in the hip and groin. MRI is the imaging modality of choice for adductor dysfunction (Fig. 6). With adductor strains, increased signal can be found within the adductor longus enthesis. (48,57) Complete tears of the tendinous insertion can also be seen.
Treatment of adductor dysfunction begins with a period of rest and protected weightbearing along with ice and nonsteroidal anti-inflammatory medications (Fig. 7). (53) Physical therapy programs consist of progressive adductor stretching, closed-chain adductor strengthening, open-chain adductor strengthening, and a sports-specific exercise program.
Schilders and coworkers reviewed entheseal cleft injections, consisting of an anesthetic and corticosteroid injected into the adductor longus insertion. Twenty-one of 28 recreational athletes had continued pain relief at 1 year following 1 to 2 injections. All 24 high level athletes had short-term pain relief, while pain often recurred in those high level athletes with MRI findings of enthesopathy. (53,58)
Acute tears of the adductor tendons are rare injuries, and there are no controlled studies in the literature to compare outcomes of conservative and operative treatment. Schlegel and colleagues (57) reviewed 19 National Football League players with acute avulsion of the adductor longus tendon. Fourteen players were treated non-operatively, with physical therapy programs consisting of early nonresistance exercise bicycle and light stretching, core strengthening, and gradual participation in practice and drills. All 14 athletes returned to professional football at an average of 6.1 weeks post-injury.
Surgical Techniques and Outcomes
Chronic adductor longus tendinopathy resistant to conservative measures can be treated with tenotomy. Maffulli and associates reviewed 29 athletes with long-standing adductor longus tendinopathy. (48) Surgical technique consisted of a 2 cm transverse incision distal to the adductor longus origin. A complete tenotomy was performed in all patients. Twenty-two of 29 patients returned to pre-injury level of sport at a mean of 18 weeks. Complications included three superficial infections that resolved with oral antibiotics and adductor weakness in two patients that improved with continued physical therapy. Akermark and coworkers reviewed 18 adductor tenotomies in 16 patients with chronic adductor longus tendinopathy. (59) All 16 patients were symptom free at 36-month follow-up. However, only 10 of 16 were able to return to full athletic activity, and decreased adductor strength was noted at final follow-up.
Surgical repair of adductor longus ruptures are seldom reported in the literature. Rizio and colleagues describe a surgical technique using bioabsorbable suture anchors. (60) Through a 5 cm bikini incision, the torn tendon is identified and debrided to healthy tissue. The insertion site on the pubic symphysis is burred until bleeding bone is visible. Two 3.5 mm bioabsorbable suture anchors are placed into the pubis with sutures passed through the tendon edge and secured to bone. This technique was used in two National Football League players, both of whom returned to professional football 3 months after surgery. Similar techniques have been reported to be successful in professional soccer players and other athletes. (56,61) There is no consensus in the literature on whether adductor longus avulsions should be repaired, as successful return to sport has been reported with both conservative and surgical treatment.
While sports hernia, osteitis pubis, and adductor dysfunction are common causes of groin pain in athletes, these injuries frequently do not occur in isolation. As the differential diagnosis of groin pain is large, one cannot focus on a narrow musculoskeletal treatment algorithm. Ekberg and as sociates reviewed 21 male athletes with chronic groin pain of unknown etiology. (62) Patients were evaluated for a host of possible diagnoses, including neuralgia, inguinal hernia, prostatitis, osteitis pubis, and adductor tendinopathy by a variety of physicians. Only two patients received an isolated diagnosis of osteitis pubis, while the 19 other patients received two or more diagnoses based on the clinical and radiologic examination. This underscores the importance of evaluating athletes with groin pain for all possible etiologies, and not just the musculoskeletal causes discussed here.
Moreover, many athletes with extra-articular groin pathology also suffer from intra-articular hip pathology. Conditions such as labral tears, femoroacetabular impingement, and hip instability are common in the same athletic populations that experience sports hernia, osteitis pubis, and adductor dysfunction. (63,64) Focusing solely on the extra-articular pathology can lead to suboptimal outcomes. Larson and coworkers reviewed 37 athletes diagnosed with both sports hernia and intra-articular hip pathology. (63) Sixteen patients underwent sports hernia repair as the index procedure. Only 4 of 16 were able to return to sports before subsequently undergoing hip arthroscopy. Eight additional patients had hip arthroscopy as the index procedure, and only 4 patients were able to return to full activity without subsequent sports hernia surgery. The investigators concluded that surgery must address both components of combined intra and extra articular pathology for optimal outcomes.
Groin injuries are common in athletic populations that engage in sports with frequent acceleration and deceleration, kicking, and twisting movements. Due to the wide differential diagnosis of groin pain and the complex anatomy of the region, diagnosis and treatment can be a challenge. Sports hernia, osteitis pubis, and adductor dysfunction are three common diagnoses in athletes with groin pain. Appropriate initial treatment with a trial of physical therapy and anti-inflammatory medications is successful in the majority of cases of osteitis pubis and adductor dysfunction and occasionally for sports hernia. When non-operative treatment fails, surgical options can be successful for athletes with sports hernia, osteitis pubis, adductor enthesopathy, and adductor tendon ruptures.
None of the authors has a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
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Caption: Figure 1 The pubic clock. In reference to a right hip, sports hernias are located in approximately the 12 o'clock position, osteitis pubis in the 3 o'clock position, and adductor dysfunction in the 7 o'clock position. (Reproduced from: Falvey EC, Franklyn-Miller A, McCrory PR. The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes. Br J Sports Med. 2009 Mar;43(3):213-20. With permission from BMJ Publishing Group Ltd.)
Caption: Figure 2 Ultrasound of a right-sided sports hernia. The assessment is performed in real-time as the patient strains. The contour of each posterior inguinal wall is indicated by a superimposed white line. The sports hernia is appreciated as a mild anterior bulge of the posterior inguinal wall on the right side of the patient (arrow). The normal left posterior inguinal wall is straight (arrowhead). (Reproduced with kind permission from Springer Science+Business Media: Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do? Hernia. 2010 Feb;14(1):17-25.)
Caption: Figure 3 Treatment algorithm for sports hernia.
Caption: Figure 4 Twenty-five year-old soccer player with chronic bilateral groin pain. T2 weighted axial MRI demonstrates symmetric parasymphyseal bone marrow edema, consistent with osteitis pubis. (Image courtesy of Jenny T. Bencardino.)
Caption: Figure 5 Treatment algorithm for osteitis pubis.
Caption: Figure 6 Professional baseball player with acute left-sided groin pain. T2 weighted coronal MRI demonstrating edema within the adductor longus enthesis, consistent with an adductor longus strain. (Image courtesy of Jenny T. Bencardino.)
Caption: Figure 7 Treatment algorithm for adductor dysfunction.
Randy M. Cohn, M.D., Assistant Professor of Orthopaedic Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, New York. Frantz Lerebours, M.D., Resident, Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Eric J. Strauss, M.D., Assistant Professor of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.
Correspondence: Eric J. Strauss, M.D., 333 East 38th Street, 4th Floor, New York, New York 10016; firstname.lastname@example.org.
Table 1 Common Differential Diagnosis of Groin Pain Musculoskeletal, Extra-Articular Sports hernia Adductor tendinopathy Osteitis Pubis Rectus abdominis injuries Rectus femoris tendinopathy Psoas tendinopathy Musculoskeletal, Intra-Articular Labral tears Loose bodies Femoroacetabular impingement Instability/capsular laxity Ligamentum teres tears Chondral injury Avascular necrosis Osteoarthritis Gastrointestinal Diverticulitis Appendicitis Inflammatory bowel disease Crohn's disease Gynecologic Endometriosis Pelvic inflammatory disease Ovarian cyst Post-partum symphysis separation Genitourinary Urinary tract infection Prostatitis Epididymitis Hydrocele/varicocele Testicular torsion Testicular cancer Infectious Pubic osteomyelitis Lymphadenopathy Pubic symphysis septic arthritis Psoas abscess Neurologic Nerve entrapment (i.e., ilioinguinal) Lumbar radiculopathy Table 2 Terms in the Literature Used to Describe Sports Hernia and Related Conditions (2,4,8,9,29) Athletic hernia Athletic pubalgia Gilmore's groin Groin disruption Groin pain syndrome Hockey groin syndrome Hockey player's syndrome Incipient hernia Slap-shot gut Sports hernia Sportsman's hernia
Please note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Cohn, Randy M.; Lerebours, Frantz; Strauss, Eric J.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Article Type:||Disease/Disorder overview|
|Date:||Apr 1, 2015|
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