Athletic pubalgia, also known as groin distruption or sportsman’s or sports hernia (SH), is a condition involving persistent groin pain during exercise when there is no evidence of a clinically detectable hernia. Athletic pubalgia is not a true hernia, but is considered an overuse injury in which the external oblique muscle and surrounding tendons and/or the transverse abdominis or internal oblique muscles are worn down or partially torn.

Conservative treatment generally consists of rest, medications and physical therapy. If conservative treatment fails, surgical treatment may be suggested as an alternative. The procedure may be performed using a laparoscopic or open anterior approach. Polypropylene or polyester mesh is suggested to correct the identified abnormality. However, there are no data from randomized studies to confirm effectiveness of this surgery.

Athletic pubalgia (AP) has been reported to afflict athletes who participate in sports that entail repetitive twisting and turning while moving (e.g., hurdling, rugby, skiing, soccer, tennis, field hockey and ice hockey). Previously described in high-performance athletes, AP has also been reported to occur in recreational athletes. Athletic pubalgia has been characterized as chronic groin pain in conjunction with a dilated superficial ring of the inguinal canal. However, the term hernia is a misnomer because of the absence of a hernia on physical examination or imaging (e.g., magnetic resonance imaging [MRI]), and a hernia is not revealed during surgery. The following operative findings have been reported to occur commonly in persons with AP (Swan and Wolcott, 2007):

According to descriptions of AP, symptoms of this condition include pubic point tenderness accentuated by resisted adduction of the hip as well as pain during sporting activities, especially twisting and turning, and hip extension. It has been reported that patients often present with an insidious onset of activity-related, unilateral, deep groin pain that abates with rest. Furthermore, exertions that increase intra-abdominal pressure (e.g., coughing and sneezing) can result in pain. In the early stages, patients may be able to continue participating in athletic activities, but the problem usually worsens.

Diesen and Pappas (2007) stated that the definition of SH/AP is controversial. Diagnosis of AP is established by medical history and physical findings. Although the physical examination reveals no detectable inguinal hernia, it has been reported that a tender, dilated superficial inguinal ring as well as tenderness of the posterior wall of the inguinal canal are frequently found. The role of imaging studies in this condition is unclear; most imaging studies will be normal (Ahumada et al, 2005; Farber and Wilckens, 2007). Some authorities state that imaging studies (e.g., ultrasonography or MRI) may be helpful in evaluating these patients and ruling out other pathology, although no imaging study can rule out SH.

Conservative treatments of AP consist of rest, application of ice 3 to 4 times daily for about 20 to 30 mins, non-steroidal anti-inflammatory drugs, and physical therapy. Patients who fail conservative treatments may be referred for surgical repair. Surgical procedures for athletic pubalgia can be performed laparoscopically. To reinforce the repair and make it stronger, a synthetic mesh-like material is often used. Ahumada et al (2005) stated that surgical intervention with an internal oblique flap reinforced with mesh alleviates symptoms.

Meyers and colleagues (2000) examined the pathophysiological processes of severe lower abdominal or inguinal pain in high-performance athletes. These investigators evaluated 276 patients; 175 underwent pelvic floor repairs. Of the 157 athletes who had not undergone previous surgery, 124 (79 %) participated at a professional or other highly competitive level, and 138 patients (88 %) had adductor pain that accompanied the lower abdominal or inguinal pain. More patients underwent related adductor releases during the later operative period in the series. Evaluation revealed 38 other abnormalities, which included severe hip problems as well as malignancies. There were 152 athletes (97 %) who returned to previous levels of performance. The syndrome was uncommon in women and the results were less predictable in non-athletes. A distinct syndrome of lower abdominal/adductor pain in male athletes appears correctable by a procedure designed to strengthen the anterior pelvic floor. The location and pattern of pain and the operative success suggested the cause to be a combination of abdominal hyper-extension and thigh hyper-abduction, with the pivot point being the pubic symphysis. The authors stated that diagnosis of AP and surgery should be limited to a select group of high-performance athletes. The major drawback of this study was that it was an uncontrolled study; a control group is important because many athletes with groin injuries improve without surgical interventions.

Fon and Spence (2000) performed a systematic Medline search and all literature pertaining to chronic groin pain, groin injury, SH and sportsman's groin from 1962 to 1999 was retrieved for analysis. The costs of computed tomography and MRI are such that their routine use for assessment of patients with groin pain can not be justified. They may, however, be employed in difficult cases to help define the anatomical extent of a groin injury. Plain radiography, ultrasonography and scintigraphy should be the usual first-line investigations to supplement clinical assessment. Herniography may help in situations of obscure chronic groin and pelvic pain. There is no consensus view supporting any particular surgical procedure for SH. A number of reports have been published describing different repairs of the posterior inguinal wall deficiency. The authors said that appropriate repair of the posterior wall may result in therapeutic benefit in selected cases. The authors concluded that the diagnosis of SH is difficult. The condition must be distinguished from the more common osteitis pubis and musculo-tendinous injuries. Early surgical intervention is usually, although not always, successful when conservative management has failed.

On the other hand, Fredberg and Kissmeyer-Nielsen (1996) reported that the final diagnosis (and treatment) of SH often reflects the specialty of the doctor and the present literature does not supply proper evidence to the theory that SH constitutes a credible explanation for chronic groin pain. These investigators reviewed the results of 308 operations for unexplained, chronic groin pain suspected to be caused by SH. No differences in peri-operative findings between cured and non-cured athletes were found. However, there was a remarkable difference between the various peri-operative findings in the studies. It was characteristic that further clinical investigation of the non-cured, operated athletes gave an alternative and treatable diagnosis in more than 80 % of cases. Herniography was used consistently in the diagnostic process in all the studies on SH. However, in 49 % of cases hernias were also demonstrated on the opposite, asymptomatic groin side.

Kaplan and Arbel (2005) stated that findings from medical imaging were found to be inconclusive regarding SH. These researchers also noted that various types of operations, based on the variable theories regarding the pathophysiological process, have been developed for the treatment of this syndrome. Some surgeons focus on the external elements of the inguinal canal, and repair the external oblique fascia or enforce the groin with the rectus abdominis. Others perform an inguinal hernia repair procedure, either with sutures, synthetic mesh, or laparoscopically. Some researchers believe that the problem is in the lower abdominal muscles, or is caused by nerve entrapment, and treat it accordingly. However, there are no controlled comparative data on the results of the various surgical approaches, and there is no evidence that surgical treatment is more beneficial than conservative treatments.

Currently, there are no data from randomized studies to confirm the effectiveness of surgical exploration and repair for AP (Brook, 2007). Randomized studies are especially important for pain interventions because of the susceptibility of this symptom to placebo effects. There is also a lack of guidelines/position statements from specialty medical societies regarding the management of this condition. In particular, the Society for Surgery of the Alimentary Tract's guideline on surgical repair of groin hernias (2003) as well as the National Institute for Clinical Excellence's guideline on laparoscopic surgery for inguinal hernia repair (2004) did not mention AP as an indication of hernia repair.

In a systematic review on SH, Caudill and colleagues (2008) summarized existing knowledge regarding SH pathogenesis, differential diagnosis, conservative treatment, surgery, and post-surgical rehabilitation. The likely causative factor for SH is posterior inguinal wall weakening from excessive or high repetition shear forces applied through the pelvic attachments of poorly balanced hip adductor and abdominal muscle activation. There is currently no consensus as to what specifically constitutes this diagnosis. Since it can be difficult to make a definitive diagnosis based on conventional physical examination, other modalities such as MRI and diagnostic ultrasound are often employed, primarily to rule out other conditions. Surgery appears to be more effective than conservative treatment and laparoscopic techniques generally enable a quicker recovery time than open repair. However, in addition to better descriptions of surgical anatomy and procedures, and conservative and post-surgical rehabilitation, well-designed research studies are needed with more detailed serial patient outcome measurements in addition to basing success solely on return to sports activity timing. Only with this information will investigators be able to better understand SH pathogenesis, verify superior surgical approaches, develop evidence-based screening and prevention strategies, and more effectively direct both conservative and post-surgical rehabilitation.

Omar et al (2008) noted that many athletes with a diagnosis of SH or AP have a spectrum of related pathological conditions resulting from musculo-tendinous injuries and subsequent instability of the pubic symphysis without any finding of inguinal hernia at physical examination. The actual causal mechanisms of AP are poorly understood, and imaging studies have been deemed inadequate or unhelpful for clarification.

Morales-Conde and colleagues (2010) stated that SH is a controversial cause of chronic groin pain, as it is difficult to be defined. In the majority of athletic maneuvers, a tremendous amount of torque or twisting occurs in the mid-portion of the body as well as the front of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. These opposing forces cause a disruption of the muscle/tendon at their insertion site on the pubis, so the problem could be related to the fact that the forces are excessive and imbalanced, and a weak area at the groin could be increased due to the forces produced by the muscles. The forces produced by these muscles may be imbalanced and could produce a disruption of the muscle/tendon at their insertion site on the pubis or/and a weak area may be increased due to the forces produced by the muscles, and just this last possibility could be defined as "SH". The authors concluded that this global entity could be considered to be an imbalance of the muscles (abductor and abdominal) at the pubis, that leads to an increase of the weakness of the posterior wall of the groin and produces a tendon enthesitis, once a true origin is not detected, that may lead to a degenerative arthropathy of the pubic symphysis in the advanced stages. Based on this, this entity could be re-named as "syndrome of muscle imbalance of the groin" and SH could be considered as an entity included in this syndrome. It is recommended that a multi-disciplinary approach is given to this entity, since the present literature does not supply the proper diagnostic studies and the correct treatment that should be performed in these patients.

In a cross-sectional study, Silvis et al (2011) examined the prevalence of pelvic and hip MRI findings and association with clinical symptoms in professional and collegiate hockey players. The study included 21 professional and 18 collegiate hockey players. Self-reported symptoms were measured using a modified Oswestry Disability Questionnaire. Participants underwent 3-T MRI evaluation of the pelvis and hips. The MRI scans were interpreted independently by 3 musculo-skeletal radiologists in 2 sessions separated by 3 months using a 5-point Likert scale to assess for features associated with common adductor-abdominal rectus dysfunction and hip pathology. To estimate prevalence, MRI findings rated 4 or higher on 4 of the 6 interpretations were considered positive. A variance component analysis was applied to determine intra-reader and inter-reader reliability and the lower 95 % confidence limits (CLs). No participants reported symptoms related to pelvic or hip disorders. The MRI findings of common adductor-abdominal rectus dysfunction were observed in 14 of 39 participants (36 %) and hip pathologic changes in 25 of 39 (64 %). There was moderate agreement between readings, with intra-reader and inter-reader reliabilities ranging from 0.37 to 1.00. The inter-reader reliability was less for evaluation of hip pathologic abnormalities than for groin pathologic abnormalities, with the lowest reliability observed in reporting of hip osteochondral lesions (0.37 with lower 95 % CL of 0.22) and fluid in the primary cleft (0.45 with lower 95 % CL of 0.29) and perfect reliability in the absence of effusion and abdominal rectus tendon tears. Overall, 30 of 39 (77 %) asymptomatic hockey players demonstrated MRI findings of hip or groin pathologic abnormalities. The authors concluded that given the high prevalence of MRI findings in asymptomatic hockey players, it is necessary to cautiously interpret the significance of these findings in association with clinical presentation. They noted that future investigations will determine whether these asymptomatic findings predict future disabilities.

Litwin and colleagues (2011) stated that AP or SH is a syndrome of chronic lower abdomen and groin pain that may occur in athletes and non-athletes. Because the differential diagnosis of chronic lower abdomen and groin pain is so broad, only a small number of patients with chronic lower abdomen and groin pain fulfill the diagnostic criteria of AP (SH). The authors noted that the literature published to date regarding the cause, pathogenesis, diagnosis, and treatment of SH is confusing.

In a case-series study, Larson and colleagues (2011) evaluated the results of surgical treatment in athletes with associated intra-articular hip pathology and extra-articular sports pubalgia. Between December 2003 and September 2009, a total of 37 hips (mean patient age of 25 years) were diagnosed with both symptomatic AP and symptomatic intra-articular hip joint pathology. There were 8 professional athletes, 15 collegiate athletes, 5 elite high school athletes, and 9 competitive club athletes. Outcomes included an evaluation regarding return to sports and modified Harris Hip Score, Short-Form 12 score, and visual analog scale score. These investigators evaluated 37 hips at a mean of 29 months (range of 12 to 78 months) after the index surgery. Thirty-one hips underwent 35 AP surgeries. Hip arthroscopy was performed in 32 hips (30 cases of femoro-acetabular impingement [FAI] treatment, 1 traumatic labral tear, and 1 borderline dysplasia). Of 16 hips that had AP surgery as the index procedure, 4 (25 %) returned to sports without limitations, and 11 (69 %) subsequently had hip arthroscopy at a mean of 20 months after AP surgery. Of 8 hips managed initially with hip arthroscopy alone, 4 (50 %) returned to sports without limitations, and 3 (43 %) had subsequent pubalgia surgery at a mean of 6 months after hip arthroscopy. Thirteen hips had AP surgery and hip arthroscopy at one setting. Concurrent or eventual surgical treatment of both disorders led to improved post-operative outcomes scores (p < 0.05) and an unrestricted return to sporting activity in 89 % of hips (24 of 27). The authors concluded that when surgery only addressed either the AP or intra-articular hip pathology in this patient population, outcomes were suboptimal. Surgical management of both disorders concurrently or in a staged manner led to improved post-operative outcomes scoring and an unrestricted return to sporting activity in 89 % of hips.

Hammond et al (2012) identified the incidence of symptoms consistent with AP in athletes requiring surgical treatment for FAI and the frequency of surgical treatment of both AP and FAI in this group of patients. A total of 38 consecutive professional athletes, with a mean age of 31 years, underwent arthroscopic surgery for symptomatic FAI that limited their ability to play competitively. In all cases a cam and/or focal rim osteoplasty with labral refixation or debridement was performed. In 1 case concomitant intra-muscular lengthening of the psoas was performed. Retrospective data regarding prior AP surgery and return to play were collected. Thirty-two percent of patients had previously undergone AP surgery, and 1 patient underwent AP surgery concomitantly with surgical treatment of FAI. No patient returned to his previous level of competition after isolated AP surgery. Thirty-nine percent had AP symptoms that resolved with FAI surgery alone. Of the 38 patients, 36 returned to their previous level of play; all 12 patients with combined AP and FAI surgery returned to professional competition. The mean duration before return to play was 5.9 months (range of 3 to 9 months) after arthroscopic surgery. The authors concluded that there is a high incidence of symptoms of AP in professional athletes with FAI of the hip. This study drew attention to the overlap of these 2 diagnoses and high-lighted the importance of exercising caution in diagnosing AP in a patient with FAI.

There is limited evidence that compare the effectiveness of surgical intervention to conservative management of AP. While some studies found that open or laparoscopic surgery may provide successful outcomes in treating this condition, these studies were usually of low quality and did not appropriately compare the effectiveness of AP surgery to conservative management. Furthermore, there is a lack of consensus regarding the etiology, diagnosis, and treatment of AP; more research is needed to ascertain the clinical value of surgical treatment for AP.

An UpToDate review on "Sports-related groin pain or 'sports hernia'" (Brooks, 2014) states that "Surgical exploration and repair is the mainstay of treatment for sports hernia, although few randomized trials have been performed to confirm the effectiveness of this approach …. When symptoms do not resolve with rest and appropriate conservative therapy, we suggest surgical repair (Grade 2C)". (A Grade 2 recommendation is a weak recommendation; and Grade C means low-quality evidence: Evidence from observational studies, unsystematic clinical observations, or from randomized trials with serious flaws).

In a multi-center, retrospective, case-series study, Matsuda and colleagues (2015) examined the outcomes of athletic patients treated with concurrent FAI and osteitis pubis (OP) surgery including endoscopic pubic symphysectomy. A total of 7 consecutive adult patients (4 men) with a mean age of 33 years with symptomatic FAI and OP who underwent arthroscopic surgery for the former and endoscopic pubic symphysectomy for the latter with a mean follow-up period of 2.9 years (range of 2.0 to 5.0 years) were included in the study. The visual analog scale (VAS) score, the Non-Arthritic Hip Score (NAHS), and patient satisfaction were measured. Complications and revision surgical procedures were reported, and pre-operative and post-operative radiographs were assessed. The mean pre-operative VAS score of 6.7 (range of 4 to 8) improved to a mean post-operative VAS score of 1.5 (range of 0 to 7) (p = 0.03). The mean pre-operative NAHS of 50.2 points (range of 21 to 78 points) improved to a mean post-operative NAHS of 84.7 points (range of 41 to 99 points) (p = 0.03). The mean patient satisfaction rating was 8.3 (range of 3 to 10). Two male patients had post-operative scrotal swelling that resolved spontaneously. There were no other complications. Pre-operative and post-operative radiographs showed no anterior or posterior pelvic ring instability. One patient underwent pubic symphyseal arthrodesis because of continued pain. The authors concluded that endoscopic pubic symphysectomy is a minimally invasive treatment for athletic OP with encouraging early outcomes that may be performed concurrently with surgery for FAI in co-afflicted patients.

Serner et al (2015) stated that groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the effectiveness of these treatments is unknown. These investigators systematically reviewed the literature on the effectiveness of treatments for groin pain in athletes; 9 medical databases were searched in May 2014. Inclusion criteria were treatment studies in athletes with groin pain; randomized controlled trials (RCTs), controlled clinical trials or case series; n greater than 10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and 2 authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. A total of 72 studies were included for quality analysis; 4 studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multi-modal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman's hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p < 0.001, r = -0.41), but not between study quality and publication year (p = 0.09, r = 0.20). The authors concluded that only 6 % of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. They stated that there is moderate evidence for the effectiveness of conservative treatment (active exercises and multi-modal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for effectiveness of surgical treatment in sportsman's hernia.

Elattar and colleagues (2016) stated that AP is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury predisposing to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. These patients often require surgical therapy after failure of non-operative measures. A variety of surgical options have been used, and most patients improve and return to play. These investigators performed a search on PubMed databases to identify relevant scientific and review articles from January 1920 to January 2015 using the search terms groin pain, sports hernia, athletic pubalgia, adductor strain, osteitis pubis, stress fractures, femoroacetabular impingement, and labral tears. The authors concluded that AP is an overuse injury involving a weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury of the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to the sport in the majority of cases. The level of evidence for this review was IV.

Jorgensen and colleagues (2019) stated that the most effective treatment for longstanding groin pain with no hernia present has not been designated. In a systematic review , these investigators examined if surgical or conservative treatment are the most effective in reducing pain and thereby returning patients to habitual activity. PubMed, Embase, and Cochrane were searched. These researchers included adults diagnosed with chronic groin pain with no hernia. Treatment included inguinal hernia repair, tenotomy, and non-surgical management. Outcomes included return to habitual activity, pain, patient satisfaction, re-operations for the operated patients, and shift to surgery for the non-operated patients. They included RCTs and observational studies with more than 10 subjects. A total of 72 studies with 3,629 subjects were included. Only 5 studies used a comparison group. After inguinal hernia repair, 94 % returned to habitual activity after median 10 weeks, 92 % became pain-free, and 92 % were satisfied with their treatment. After adductor tenotomy, 90 % returned to habitual activity after median 12 weeks, 90 % became pain-free, and 84 % were satisfied. After combined inguinal hernia repair and adductor tenotomy, 97 % returned to habitual activity after median 10 weeks, 92 % became pain-free, and 91 % were satisfied with their treatment. After non-surgical management, 80 % returned to habitual activity after median 12 weeks, 67 % became pain-free, 56 % were satisfied, and 21 % shifted to surgery. The authors found that surgery appeared to be more efficient in returning patients to habitual activity, reducing their pain, and satisfying them than conservative treatment.

Koutserimpas and associates (2020) noted that AP is an obscure sport injury, presenting mainly with groin pain during twisting movements. The present 15-year study reported outcomes, intra-operative findings and complications of the endoscopic surgical treatment in competitive athletes. All competitive athletes, from 2004 to 2018, suffering from AP, treated with laparoscopic Total Extra-Peritoneal technique, at the Department of General, Laparoscopic, Oncologic and Robotic Surgery of the Athens Medical Center were included in this retrospective cohort. Post-operative pain, complications, return to previous training routine and patients' satisfaction were evaluated. A total of 130 patients (115; 88.5 % males and 15; 11.5 % females) with a mean age of 26.7 ± 7.5 years were evaluated. Pre-operatively, mean numeric pain scale (NPS) was found to be 7.7 ± 1.7. Three days post-operatively, the mean NPS was 3.4 ± 1.5, showing 55.8 % decrease. The mean time for return to sports activity was found to be 6.27 ± 3.02 weeks. Regarding complications, 6 patients (4.6 %) had slight numbness at the groin area during the first 6 post-operative months and 1 patient (0.8 %) suffered from a post-operative hematoma. No recurrence was observed. At the final follow-up (mean of 76.58 ± 46.5 months), a total of 97 (74.7 %) patients were very satisfied, 31 (23.8 %) satisfied and 2 (1.5 %) not satisfied with the outcome. The authors concluded that laparoscopic operative treatment in competitive athletes suffering from AP appeared to offer rapid recovery, rapid return-to-sports, as well as very low complications rate and no recurrence.

In a retrospective, case-series study, Gerhardt and co-workers (2020) examined the outcomes of a limited surgical intervention, consisting of neurolysis, inguinal wall repair and/or adductor debridement of adhesions based on intra-operative findings. A total of 51 athletes treated surgically for inguinal-related groin pain from 2009 to 2015 were included in this trial. They underwent limited surgical intervention, consisting of neurolysis, inguinal wall repair and/or adductor debridement based on intra-operative findings. Outcome measures were ability to return-to-sport at the same level, and time to return-to-play; follow-up averaged 4.42 years (range of 2.02 to 7.01). The average age was 24.2 years (range of 16 to 49) and consisted of 94.0 % males and 6.0 % females. Nerve entrapment was demonstrated in 96.2 % of cases with involvement of the ilio-inguinal in 92.5 %, the ilio-hypogastric in 30.8 % and the genito-femoral in 13.2 %. Attenuation of the posterior inguinal wall was present and repaired in 79.3 % of cases. Scar tissue was present around the adductor origin and needed debridement in 56.7 % of cases; 49 (96.1 %) athletes returned to sport at the same level of play at an average of 5.9 weeks; 2 athletes required a revision surgery. The authors concluded that high rates of return-to-sport were achieved following surgery for inguinal-related groin pain that addressed the varying pathology and associated nerve entrapment.

The authors stated that limitations of this study were similar to those of other studies that reported on surgical outcomes for groin pain. The most significant limitation stemmed from discussing outcomes of surgical treatment for a clinical entity that includes varying combinations of injured abdominal wall, pelvic and proximal thigh structures. Thus, the specific details of each procedure vary, making it difficult to present an homogeneous group of athletes. This reverberates the point that groin injuries vary widely in the constellation of pathology and therefore surgical repair involves a variety of techniques. The authors’ belief is that the visualized pathology should dictate the surgical technique to be employed. This differs from many previous reports in which the same surgery is performed regardless of clinical presentation. The inclusion of patients post-hip arthroscopy is a limitation to this study as the condition can overlap. However, all patients previously treated with hip arthroscopy for FAI had fully recovered and returned to competitive sports before presenting with new symptoms. Additionally, as a retrospective review, this study was inherently subject to selection bias. Last, this series mixed all levels of athletes, which allowed readers to make generalizations that are applicable to everyday clinical practice, but less so to specific athletic populations.

In a case-series, cohort study, Gill et al (2020) evaluated return-to-sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. These researchers hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes. This trial was carried out in NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to examine long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which "performance scores" were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or FAI, prostatic or urinary tract disease, or nerve entrapment of the ilio-inguinal, genito-femoral, or lateral femoral cutaneous nerves were excluded from the study. A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range of 12 to 178 months). Of the 32 patients, 20 had a concomitant SH repair in addition to an adductor longus tenotomy; 31 patients (97 %) were able to return to their previous sport, and 30 (94 %) were able to return at their previous level of play; 30 patients (94 %) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return-to-play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus post-operative comparisons of the athlete performance scores (p = 0.74) and the percentage of the games started versus played (p = 0.46). After separation of players who had a concomitant SH repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started. The authors concluded that in this study of elite athletes, adductor longus tenotomy with or without a concomitant SH repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain; return-to-play in an NFL game averaged 12 weeks following surgery. Level of Evidence = IV.

The authors stated that limitations of this study included its retrospective design. These researchers obtained subjective outcomes for non-professional athletes, and future directions are aimed at evaluating objective outcomes for these patients, including strength measurements. While the NFL players studied were evaluated with a performance score metric, offensive linemen could not be analyzed given the limits of the game statistics used in the calculation. However, surgery did not adversely affect the percentage of games started in this group. It should also be noted that 1 or more of the authors has declared potential conflict of interest or source of funding.

Zuckerbraun et al (2020) noted that groin pain in active individuals and athletes without clinical evidence of hernia or hip pathologic findings is challenging for health care clinicians and aggravating for those experiencing pain. Frequently called SH or AP, many surgeons continue to refute the diagnosis because there is a lack of consensus and clear comprehension of the basic pathophysiologic features of this groin pain syndrome. Understanding the anatomic and pathophysiologic findings of groin pain syndrome is necessary to appropriately treat this problem. In general, the level of evidence of the literature is of relatively low quality. Exercise-based therapy can be an effective 1st-line therapy in individuals who develop groin pain syndrome. Surgical therapies are typically reserved for those who experienced non-operative management failure. The common features of the varied surgical procedures include the resultant changes in the vectors of pull on the pubic bone or joint, the defects in the inguinal canal, and the inguinal sensory nerve compression or bow-stringing. The authors concluded that the diagnosis of non-hip, non-hernia, chronic groin pain is common. Understanding the diagnosis and therapeutic options may facilitate recovery and allow return to an active lifestyle and sport. Regarding operative therapies, these researchers stated that most studies were single-center case series with low-quality level of evidence, and the patient populations described were predominantly high-performance male athletes, with the most common end-point reported being return-to-sport. They also noted that regardless of the approach, most authors reported success rates ranging from 85 % to 100 %. The most common end-point has been return-to-sport or restitution of symptoms. The mean length of follow-up was wide ranging; however, longer follow-up was more informative because recurrence of symptoms may occur after return to activity and chronic use. These investigators stated that "Consensus as to nomenclature and evaluation as well as recognition of the low level of evidence around this syndrome are necessary to develop successful therapeutic trials. Accurate determination of outcomes of the various therapeutic and surgical approaches with comparison of presenting symptoms, imaging, and operative findings are needed to augment the care of patients with groin pain syndromes".

An UpToDate review on "Sports-related groin pain or 'sports hernia'" (Brooks, 2020) states that "When symptoms do not resolve with rest and appropriate physical therapy, we suggest surgical repair (Grade 2C). For high performance athletes unwilling to accept the lengthy delays in return to play required for appropriate rest or physical therapy, surgical referral is appropriate. Both laparoscopic and anterior approaches have been used with equivalent outcomes". A Grade 2C recommendation is a very weak recommendation; other alternatives may be equally reasonable. Explanation: A Grade 2 recommendation is a weak recommendation.

Le and associates (2021) noted that AP, commonly referred to as a "sports hernia," is a disease process characterized by groin pain produced by physical exertion often occurring in patients whose athletic activities require them to make rapid changes in direction. The groin pain is due to the traction-countertraction relationship between the adductor muscles and the weaker abdominal muscles. A few studies have shown inguinal hernia repair with adductor tenotomy to be an effective treatment for this pathology; however, these studies were small and few in quantity; but have demonstrated promising results. These investigators further examined this combined surgical approach as a treatment for this multi-factorial disease to improve the understanding and outcomes. With institutional review board (IRB) approval, these researchers retrospectively reviewed the charts of all patients who underwent adductor tenotomy and inguinal hernia repair for the treatment of AP at Mount Sinai Medical Center, Miami Beach FL. Parameters gathered included basic demographics, past medical and surgical history, athletic activity, length of surgery, length of time between surgery and follow-up, intra-operative and post-operative complications, and time to return to athletic activities. A total of 93 patients underwent inguinal hernia repair with adductor tenotomy. These procedures were all carried out by a single surgeon at 2 academic institutions. The average age of patients was 23.4 years. Athletic activities reported by the patients were as follows: American football (n = 36), soccer (n = 18), triathlon (n = 11), track and field (n = 8), and baseball (n = 5). Less-represented activities included swimming (n = 3), tennis (n = 2), lacrosse (n = 1), golf (n = 1), and other (n = 8). Mean operative time was 72.4 mins. Most patients were found to return to athletic activity in 28 days following a standardized physical therapy regimen (92.5 %). Post-operative complications included recurrence of pain/symptoms (7.5 %, n = 7), urinary retention (2.2 %, n = 2), pain along the adductor magnus/brevis muscle group with more extraneous activity (1.1 %, n = 1), and adductor brevis hematoma 3 months following surgery and rehabilitation (1.1 %, n = 1). Of the patients with recurrent pain, 2/7 reported contralateral pain. The authors concluded that total extra-peritoneal laparoscopic inguinal hernia repair with adductor tenotomy appeared to be a relatively quick and safe procedure with few post-operative complications. The majority of treated athletes were able to return to full athletic activities within 28 days of operation. While a return of symptoms has been observed in some patients, it was frequently observed on the contralateral side. The main drawbacks of this study were its retrospective design, and that all surgeries were performed by 1 surgeon.

Hatem et al (2021) stated that controversies remain regarding the surgical treatment of inguinal-, pubic-, and adductor-related chronic groin pain (CGP) in athletes. In a systematic review, these investigators examined the outcomes of surgery for CGP in athletes based on surgical technique and anatomic area addressed. The PubMed and Embase databases were searched for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria were level I to IV evidence, mean patient age of greater than 15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was carried out with the CONSORT (Consolidated Standards of Reporting Trials) statement or MINORS (Methodological Index for Non-randomized Studies) criteria. Techniques were grouped as inguinal, adductor origin, pubic symphysis, combined inguinal and adductor, combined pubic symphysis and adductor, or mixed. A total of 47 studies published between 1991 and 2020 were included. There were 2,737 patients (94 % male) with a mean age at surgery of 27.8 years (range of 12 to 65 years). The mean duration of symptoms was 13.1 months (range of 0.3 to 144 months). The most frequent sport involved was soccer (71 %), followed by rugby (7 %), Australian football (5 %), and ice hockey (4 %). Of the 47 articles reviewed, 44 were classified as level IV evidence, 1 study was classified as level III, and 2 RCTs were classified as level Ib. The quality of the observational studies improved modestly with time, with a mean MINORS score of 6 for articles published between 1991 and 2000, 6.53 for articles published from 2001 to 2010, and 6.9 for articles published from 2011 to 2020. Return-to-play at pre-injury or higher level was observed in 92 % (95 % CI: 88 % to 95 %) of the athletes after surgery to the inguinal area, 75 % (95 % CI: 57 % to 89 %) after surgery to the adductor origin, 84 % (95 % CI: 47 % to 100 %) after surgery to the pubic symphysis, and 89 % (95 % CI: 70 % to 99 %) after combined surgery in the inguinal and adductor origin. The authors concluded that return-to-play at pre-injury or higher level was more likely after surgery for inguinal-related CGP (92 %) versus adductor-related CGP (75 %); however, the majority of studies reviewed were methodologically of low-quality owing to the lack of comparison groups. These researchers stated that future research on the surgical treatment of CGP in athletes should employ quantitative and validated functional scores to facilitate comparison among surgical techniques. Level of Evidence = IV.

In a systematic review, Serafim et al (2022) examined the time required to return-to-sport (RTS) after conservative versus surgical treatment in athletes for pubalgia. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, SportDiscus and Web of Science were last accessed in September 2022. All the studies examining the time to RTS after conservative versus surgical treatment in athletes for pubalgia were included for assessment. A total of 33 studies were selected for full text assessment, and 10 studies were included in the qualitative analysis; 7 studies reported data on conservative management, 2 on surgical management and 1 compared both. A total of 468 subjects were included for analysis; 58.7 % (275 of 468) were soccer players, 5.9 % (28 of 468) runners, and 3.8 % (18 of 468) hockey players; 2 studies did not specify the type of sport. The quality of the studies detailing the results of conservative management was higher than surgical procedures. The authors concluded that individuals undergoing surgery for pubalgia may return-to-sport earlier than those receiving conservative treatment; however, conservative management should be considered before surgical treatment is indicated. If surgery is undertaken, an active rehabilitation program should be preferred. Active rehabilitation programs should be the cornerstone of conservative treatment. The quality of the studies detailing the results of conservative management was higher than surgical procedures. These researchers stated that for future studies, it is important to use standard measures and criteria for return-to-sport. They stated that studies with better methodological controls, including some with a larger sample, are important to take such results to a larger population, adopting greater external validity.

The authors stated that this systematic review had several drawbacks. First, the different methods used between the studies made it difficult to generalize the findings. Second, the description of the diagnosis of pubalgia was not always clear in all studies, with different ways of diagnosing it; thus, the different treatments used, whether surgical or conservative, influence the non-standardization of outcomes. Third, regarding the outcomes, the different health indicators used and the fact that few had criteria for RTS made the heterogeneity between the studies even greater. This fact also contributed to the failure to perform a meta-analysis. Fourth, follow-up studies can be more reliable to examine the success of RTS, a fact that did not always occur and also occurred in different periods between the studies. These investigators stated that post-operative rehabilitation needs to be better described in surgical studies, as it is also part of treatment success.

In a cadaveric model, O'Donnell et al (2023) proposed to establish in-depth inspection of the anatomic structures involved with the pathology of AP. A total of 8 male fresh frozen cadavers were dissected in a layered fashion. The rectus abdominis (RA) and adductor longus (AL) tendon insertions were isolated to quantify the size of the anatomic footprint and distance from the surrounding anatomy. The RA insertional footprint was 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, and the AL insertional footprint on the underside of the pubis was 1.95 cm (SD, 0.28) in length by 1.23 cm (SD, 0.33) in width. The ilio-inguinal nerve was 2.49 cm (SD, 0.36) lateral to the center of the RA footprint and 2.01 cm (SD, 0.37) lateral to the center of the AL footprint. The spermatic cord and the genito-femoral nerve were just lateral to the ilio-inguinal nerve and were 2.76 cm (SD, 0.44) and 2.66 cm (SD, 0.46) from the rectus and AL footprints, respectively. The authors concluded that surgeons should be cognizant of these anatomic relations during both initial dissection and tendon repair to optimize repair and avoid iatrogenic injury to critical structures in the anterior pelvis.

The authors stated that this study had several drawbacks. First, this was a cadaveric study of uninjured patients, and as such, the distances between structures may vary in injured, pathologic tissue compared with healthy tissue. However, the footprints for the tendons should not change, except for the variation from specimen to specimen. Second, the overall age of the cadavers in this study was more advanced (67 years) than the typical age observed in younger athletes undergoing athletic hernia repair. Third, only male cadavers were studied as to keep the anatomy consistent between all specimens. Because female patients accounted for only 5 % to 15 % of patients with AP, these researchers chose to focus their examination on male specimens only. This eliminated any between-sex differences that may have been observed. Fourth, the authors were unable to isolate and describe the ilio-hypogastric nerve because this was not included within their cadaveric tissue because of processing of the cadavers. This nerve has been implicated in lower abdominal and pelvic neurogenic pain.

In summary, there is a lack of evidence-based consensus/data regarding the surgical treatment of athletic pubalgia.

Core Muscle Injury

Ross and associates (2015) stated that core muscle injury/AP/SH is an increasingly recognized source of pain, disability, and time lost from athletics. Groin pain among athletes, however, may be secondary to various etiologies. A thorough history and comprehensive physical examination, coupled with appropriate diagnostic imaging, may improve the diagnostic accuracy for patients who present with core muscular injuries. Outcomes of non-operative management have not been well-delineated, and multiple operative procedures have been discussed with varying return-to-athletic activity rates.

Intra-Tissue Percutaneous Electrolysis

In a randomized trial, Moreno and associates (2017) evaluated the effectiveness of EPI technique in combination with an active physical therapy (APT) program in the treatment of adductor longus enthesopathy-related groin pain (ALErGP). A total of 24 non-professional male soccer players diagnosed with ALErGP were included in this study and randomly divided into 2 groups: Group A was treated with EPI technique in combination with a standardized APT program; Group B only underwent the APT program. The Numeric Rating Scale (NRS) and the Patient Specific Functional Scale (PSFS) were used to evaluate the effectiveness of the 2 interventions. The follow-up covered a 6-month period. Both groups significantly improved pain and functional scores after treatment and maintained this therapeutic result throughout the follow-up. The combined intervention of APT program and EPI ensured a greater and faster reduction of pain in Group A. In addition, functional recovery tended to be greater in Group A than B after the treatment and throughout the follow-up by 7.8 ± 3.8 % (p = 0.093). The authors concluded that EPI treatment in association with APT ensured a greater and more rapid reduction of pain and tended to promote greater functional recovery in soccer players with ALErGP compared to APT only. This positive therapeutic result lasted for at least 6 months after the end of the treatment. They stated that these findings support the combined use of EPI and APT for the treatment of ALErGP. The drawbacks of this study was its small sample size (n = 24) and relative short follow-up period (6 months). Furthermore ,the findings were confounded by the combined use of EPI and a PT program.

Pulse-Dose Radiofrequency

In a prospective non-randomized, single-group, study, Masala and colleagues (2017) examined the role of pulse-dose radiofrequency (PDR) in athletes with chronic pubalgia. Pulse-dose radiofrequency was carried out in 32 patients with a chronic pain refractory to conservative therapies during the last 3 months. The genital branches of the genitor-femoral, ilio-inguinal and ilio-hypogastric nerves and the obturator nerve were the targets of treatment. A 10-cm, 20-gauge cannula was inserted with a percutaneous access on the upper and lower edge of the ilio-pubic branch. After the spindle was removed, a radiofrequency needle with a 10- mm "active tip" was inserted. The radiofrequency technique was performed with 1,200 pulses at 45 V and 20 milliseconds duration, followed by a 480 milliseconds silent phase. The follow-up with a clinical examination was performed at 1, 3, 6 and 9 months after the procedure. During the follow-up visits, the patients were asked to rate their pain on a 0 to 10 VAS Scale. All of the enrolled patients completed the study. Mean VAS score before the treatment was 8.4 ± 0.6; 24 patients reported a reduction of pain VAS scores of more than 50 % during all follow-up visits and started trainings and physiotherapy the following days after the radiofrequency procedure; 6 patients, who were treated 2 times, reported a reduction more than 50 % of VAS scores and were able to start trainings and physiotherapy, only after the 2d procedure. A patient had no pain relief with 2 treatments. Pain intensity decreased up to 9 months in 31 patients (means VAS scores of 3.4 ± 0.5 at 6 months and 3.8 ± 0.9 at 9 months). No complications were observed. The authors concluded that PDR is a safe and effective technique in management of chronic pubalgia in athletes. These preliminary findings need to be validated by well-designed studies.

Scope of Policy

This Clinical Policy Bulletin addresses athletic pubalgia surgery.

Experimental and Investigational

The following procedures are considered experimental and investigational because the effectiveness of these approaches has not been established: