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Sports hernia and extra-articular causes of groin pain in the athlete.

Groin pain is common in athletes that use the musculature of the proximal thigh and lower abdomen in their athletic activities, including kicking and twisting movements. Participants in soccer, ice hockey, skiing, rugby, hurdling, and many other sports can suffer from acute and chronic injuries that present with groin pain. It has been estimated that groin injuries account for 5% to 8% of all injuries in soccer players and 10% to 43% of all injuries in elite ice hockey players. (1,2)

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

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)

Pathogenesis

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)

Imaging

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.

Non-Operative Treatment

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

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)

Pathogenesis

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)

Imaging

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)

Non-Operative Treatment

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

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)

Pathogenesis

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)

Imaging

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.

Non-Operative Treatment

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.

Combined Injuries

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.

Conclusion

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.

Disclosure Statement

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.

References

(1.) Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scand J Med Sci Sports. 1999 Apr;9(2):98-103.

(2.) Farber AJ, Wilckens JH. Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007 Aug;15(8):507-514.

(3.) Leibold MR, Huijbregts PA, Jensen R. Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review. J Man Manip Ther. 2008;16(2):E24-41.

(4.) Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med. 2008 Dec;42(12):954-64.

(5.) 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):21320.

(6.) Lovell G. The diagnosis of chronic groin pain in athletes: a review of189 cases. Aust J Sci Med Sport. 1995 Sep;27(3):769.

(7.) Morelli V, Smith V. Groin injuries in athletes. Am Fam Physician. 2001 Oct 15;64(8):1405-14.

(8.) Gerhart MB, Brown JA, Giza E. occult groin injuries: athletic pubalgia, sports hernia, and osteitis pubis. In: Johnson DH, Pedowitz RA, (eds): Practical Orthopaedic Sports Medicine & Arthroscopy. Lippincott Williams & Wilkins, 2007.

(9.) Paajanen H, Hermunen H, Karonen J. Pubic magnetic resonance imaging findings in surgically and conservatively treated athletes with osteitis pubis compared to asymptomatic athletes during heavy training. Am J Sports Med. 2008 Jan;36(1):117-21.

(10.) Nam A, Brody F. Management and therapy for sports hernia. J Am Coll Surg. 2008 Jan;206(1):154-64.

(11.) Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. 1998 Oct;17(4):787-93, vii.

(12.) Biedert RM, Warnke K, Meyer S. Symphysis syndrome in athletes: surgical treatment for chronic lower abdominal, groin, and adductor pain in athletes. Clin J Sport Med. 2003 Sep;13(5):278-84.

(13.) Irshad K, Feldman LS, Lavoie C, et al. Operative management of "hockey groin syndrome": 12 years of experience in National Hockey League players. Surgery. 2001 Oct;130(4):75964; discussion 764-6.

(14.) Paluska SA. An overview of hip injuries in running. Sports Med. 2005;35(11):991-1014.

(15.) Meyers WC, Foley DP, Garrett WE, et al. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med. 2000 Jan-Feb;28(1):2-8.

(16.) LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia. 2003 Jun;7(2):68-71.

(17.) Zoga AC, Mullens FE, Meyers WC. The spectrum of MR imaging in athletic pubalgia. Radiol Clin North Am. 2010 Nov;48(6):1179-97.

(18.) Verrall GM, Slavotinek JP, Barnes PG, Fon GT. Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria. Scand J Med Sci Sports. 2005 Feb;15(1):36-42.

(19.) Joesting DR. Diagnosis and treatment of sportsman's hernia. Curr Sports Med Rep. 2002 Apr;1(2):121-4.

(20.) Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC. MR findings in athletes with pubalgia. Skeletal Radiol. 2001 May;30(5):270-7.

(21.) Khan W, Zoga AC, Meyers WC. Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice. Magn Reson Imaging Clin N Am. 2013 Feb;21(1):97-110.

(22.) Orchard JW, Read JW, Neophyton J, Garlick D. Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med. 1998 Jun;32(2):134-9.

(23.) Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do? Hernia. 2010 Feb;14(1):17-25.

(24.) Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001 Jul-Aug;29(4):521-33.

(25.) Taylor DC, Meyers WC, Moylan JA, et al. Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia. Am J Sports Med. 1991 May-Jun;19(3):239-42.

(26.) Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med. 1993 Mar;27(1):58-62.

(27.) Van Der Donckt K, Steenbrugge F, Van Den Abbeele K, et al. Bassini's hernial repair and adductor longus tenotomy in the treatment of chronic groin pain in athletes. Acta Orthop Belg. 2003;69(1):35-41.

(28.) Ingoldby CJ. Laparoscopic and conventional repair of groin disruption in sportsmen. Br J Surg. 1997 Feb;84(2):213-5.

(29.) Jakoi A, O'Neill C, Damsgaard C, et al. Sports Hernia in National Hockey League Players: Does Surgery Affect Performance? Am J Sports Med. 2013 Jan;41(1):107-10.

(30.) Susmallian S, Ezri T, Elis M, et al. Laparoscopic repair of "sportsman's hernia" in soccer players as treatment of chronic

inguinal pain. Med Sci Monit. 2004 Feb;10(2):CR52-4.

(31.) Srinivasan A, Schuricht A. Long-term follow-up of laparoscopic preperitoneal hernia repair in professional athletes. J Laparoendosc Adv Surg Tech A. 2002 Apr;12(2):101-6.

(32.) Beatty T. Osteitis pubis in athletes. Curr Sports Med Rep. 2012 Mar-Apr;11(2):96-8.

(33.) Radic R, Annear P Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes. Am J Sports Med. 2008 Jan;36(1):122-8.

(34.) Batt ME, McShane JM, Dillingham MF. Osteitis pubis in collegiate football players. Med Sci Sports Exerc. 1995 May;27(5):629-33.

(35.) Briggs RC, Kolbjornsen PH, Southall RC. Osteitis pubis, Tc99m MDP, and professional hockey players. Clin Nucl Med. 1992 Nov;17(11):861-3.

(36.) Hechtman KS, Zvijac JE, Popkin CA, et al. A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes. Sports Health. 2010 May;2(3):211-5.

(37.) Gamble JG, Simmons SC, Freedman M. The symphysis pubis. Anatomic and pathologic considerations. Clin Orthop Relat Res. 1986 Feb;(203):261-72.

(38.) Alderink GJ. The sacroiliac joint: review of anatomy, mechanics, and function. J Orthop Sports Phys Ther. 1991;13(2):7184.

(39.) Verrall GM, Henry L, Fazzalari NL, et al. Bone biopsy of the parasymphyseal pubic bone region in athletes with chronic groin injury demonstrates new woven bone formation consistent with a diagnosis of pubic bone stress injury. Am J Sports Med. 2008 Dec;36(12):2425-31.

(40.) Hiti CJ, Stevens KJ, Jamati MK, et al. Athletic osteitis pubis. Sports Med. 2011 May 1;41(5):361-76.

(41.) Pauli S, Willemsen P, Declerck K, et al. Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature. Br J Sports Med. 2002 Feb;36(1):71-3.

(42.) Williams PR, Thomas DP, Downes EM. Osteitis pubis and instability of the pubic symphysis. When nonoperative measures fail. Am J Sports Med. 2000 May-Jun;28(3):350-5.

(43.) Nelson EN, Kassarjian A, Palmer WE. MR imaging of sports-related groin pain. Magn Reson Imaging Clin N Am. 2005 Nov;13(4):727-42.

(44.) Verrall GM, Slavotinek JP, Fon GT, Barnes PG. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007 Mar;35(3):467-74.

(45.) Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis in athletes. Results of corticosteroid injections. Am J Sports Med. 1995 Sep-Oct;23(5):601-6.

(46.) O'Connell MJ, Powell T, McCaffrey NM, et al. Symphyseal cleft injection in the diagnosis and treatment of osteitis pubis in athletes. Am J Roentgenol. 2002 Oct;179(4):955-9.

(47.) Paajanen H, Heikkinen J, Hermunen H, Airo I. Successful treatment of osteitis pubis by using totally extraperitoneal endoscopic technique. Int J Sports Med. 2005 May;26(4):3036.

(48.) Maffulli N, Loppini M, Longo UG, Denaro V. Bilateral mini-invasive adductor tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes. Am J Sports Med. 2012 Aug;40(8):1880-6.

(49.) Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999 Feb 6;353(9151):439-43.

(50.) Dimitrakopoulou A, Schilders EM, Talbot JC, Bismil Q. Acute avulsion of the fibrocartilage origin of the adductor longus in professional soccer players: a report of two cases. Clin J Sport Med. 2008 Mar;18(2):167-9.

(51.) Shah A, Busconi B. Hip, pelvis, and thigh. In: DeLee JC, David Drez J, Miller MD, (eds): Orthopaedic Sports Medicine Principles and Practice (3rd ed). Philadelphia: Saunders Elsevier, 2010.

(52.) Benjamin M, Toumi H, Ralphs JR, et al. Where tendons and ligaments meet bone: attachment sites ('entheses') in relation to exercise and/or mechanical load. J Anat. 2006 Apr;208(4):471-90.

(53.) Schilders E, Talbot JC, Robinson P, et al. Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am. 2009 Oct;91(10):2455-60.

(54.) Tyler TF, Nicholas SJ, Campbell RJ, McHugh MP. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. Am J Sports Med. 2001 Mar-Apr;29(2):124-8.

(55.) Holmich P, Holmich LR, Bjerg AM. Clinical examination of athletes with groin pain: an intraobserver and interobserver reliability study. Br J Sports Med. 2004 Aug;38(4):446-51.

(56.) Dimitrakopoulou A, Schilders E, Bismil Q, et al. An unusual case of enthesophyte formation following an adductor longus rupture in a high-level athlete. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):691-3.

(57.) Schlegel TF, Bushnell BD, Godfrey J, Boublik M. Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med. 2009 Jul;37(7):1394-9.

(58.) Schilders E, Bismil Q, Robinson P, et al. Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am. 2007 Oct;89(10):2173-8.

(59.) Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med. 1992 Nov-Dec;20(6):640-3.

(60.) Rizio L 3rd, Salvo JP, Schurhoff MR, Uribe JW. Adductor longus rupture in professional football players: acute repair with suture anchors: a report of two cases. Am J Sports Med. 2004 Jan-Feb;32(1):243-5.

(61.) Vogt S, Ansah P, ImhoffAB. Complete osseous avulsion of the adductor longus muscle: acute repair with three fiberwire suture anchors. Arch Orthop Trauma Surg. 2007 Oct;127(8):6135.

(62.) Ekberg O, Persson NH, Abrahamsson PA, et al. Longstanding groin pain in athletes. A multidisciplinary approach. Sports Med. 1988 Jul;6(1):56-61.

(63.) Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: a case series. Arthroscopy. 2011 Jun;27(6):768-75.

(64.) Bharam S. Labral tears, extra-articular injuries, and hip arthroscopy in the athlete. Clin Sports Med. 2006Apr;25(2):279-92, ix.

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; eric.strauss@nyumc.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


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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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