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128
A. Salles and L. M. Brunt
terms in the eld and are both rmly ingrained
in the popular and surgical literature. Thus,
throughout this chapter we will use the terms athletic pubalgia and sports hernia interchangeably
to refer to pathology related to the abdominal rectus or inguinal oor with or without associated
adductor pathology.
Pathophysiology
Groin injuries occur due to the high degree of
strain placed across the pubis in the region of the
insertion of the rectus abdominis, inguinal ligament, and adductor longus tendon. Such injuries
may be acute from a sudden force applied with
one or more muscle groups eccentrically contracted or can result from a more gradual process
due to an imbalance in forces. Most commonly
this results from the force of the powerful thigh
muscles (mainly the adductor group) across the
pubis which is transmitted to the distal rectus
and inguinal oor [8]. The three major categories of anatomical ndings in these athletes
are (1) rectus tendon injury [8, 9], (2) posterior abdominal wall/inguinal oor defect [10],
and (3) adductor- related groin injury. Rectus
abdominis insertion injuries typically occur at
the attachment of the rectus aponeurosis to the
pubis (Fig.17.1). Similarly, there can be a tear
or tendinopathy in the adductor longus leading
to pain at the tendinous insertion into the pubis
with any adduction- related movements. The
second type of injury, related to weakness of the
posterior abdominal wall or inguinal disruption,
(Fig.17.2) may be a more gradual result from
an imbalance in forces across the pubis, particularly if the adductors are much stronger than the
rectus and associated lower abdominal muscles.
A common associated nding in this setting
is an attenuated external oblique aponeurosis,
although it is unclear to what extent this contributes to symptoms (Fig.17.3). It is also not
uncommon for these different injuries to coexist
in one athlete.
Pathology of the inguinal or genital nerves
has been postulated to contribute to athletic
groin pain in some cases, but this is rarely the
a
b
Fig. 17.1 Pelvic MRI that shows a rectus abdominal tear.
(a) Normal side. (b) Rectus aponeurosis tear at pubis
(arrow). P pubis, R rectus
sole source of pain [11]. However, this theory is
countered by the fact that most authorities have
good outcomes, regardless of approach, without
resecting either the ilioinguinal or genital nerves.
The role of neurectomy in the treatment of athletic groin injuries is, therefore, controversial. It
should also be stated that athletic pubalgia is not
just one isolated condition but rather comprises
a spectrum of pathology that mandates an individualized approach to the evaluation and assessment of a given athlete.
a
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b
129
Table 17.1 Differential diagnosis for groin pain
General
Abdominal muscle strain/tear of rectus abdominis or
obliques
Osteitis pubis
Pubic rami stress fracture
Adductor strain
Hip exor strain
Inguinal hernia
Nerve entrapment
Hip-related
Labral tear
Femoroacetabular impingement
Osteoarthritis
Femoral neck stress fracture
Avascular necrosis
In women
Endometriosis
Ovarian pathology
Other gynecologic abnormalities
In men
Prostatitis
Fig. 17.2 Operative photo of a weakened posterior ingui-
nal oor. (a) The dotted circle outlines the area of weakness in the inguinal oor. Also seen is the healthy
transversalis fascia (TF) medially and the inguinal ligament laterally (arrows). (b) Magnied view of the bulging
posterior oor
groin injuries. Among the causes of groin pain
are abdominal muscle strains, osteitis pubis,
pubic rami stress fractures, adductor strain, hip
exor strains, inguinal hernias, and nerve entrapment (Table
17.1). Hip-related etiologies of
groin pain include labral tears, femoroacetabular
impingement, osteoarthritis, femoral neck stress
fractures, and avascular necrosis. In women,
gynecologic etiologies of groin pain, such as
endometriosis and ovarian pathology, may enter
into the differential diagnosis as does prostatitis in
men. In 1 recent systematic literature review of 73
articles on the treatment of athletic groin injuries,
the 5 most common entities that required surgical
intervention were femoroacetabular impingement
(32%), athletic pubalgia (24%), adductor-related
pathology (12%), inguinal-
related pathology
(10%), and labral pathology (5%) [12].
Fig. 17.3 Operative view of a markedly attenuated exter-
nal oblique aponeurosis (arrows)
Some of these problems may coexist in the
same athlete. For example, Hammoud et al.
noted signicant overlap in symptoms between
athletes with athletic pubalgia, as dened by
Dierential Diagnosis
lower abdominal or adductor pain, and femoroacetabular impingement (FAI) [13]. In their
Groin anatomy is complex, and there are a number of other conditions that need to be considered when evaluating a patient for sports-related
series, 32% of patients had persistent symptoms
after surgery for athletic pubalgia which did not
resolve until arthroscopic management of FAI
130
A. Salles and L. M. Brunt
was undertaken. These ndings highlight the difculty of making the correct diagnosis and the
importance of a thorough history and physical
exam as well as multidisciplinary evaluation.
A diagnosis of inguinal disruption or inguinalrelated groin injury should be suspected when
an athlete presents with exertional pain in the
lower abdomen or groin, in the absence of an
inguinal hernia, which does not improve with
non- operative treatments. Adductor injuries typically present with pain in the adductor longus
tendon region which is exacerbated with resisted
adduction.
Clinical Evaluation
History
While groin injuries are common, their evaluation
is nuanced and requires a thorough history and
physical exam. Initial evaluation is often multidisciplinary, involving orthopedic surgeons or
sports medicine physicians, athletic trainers, and
physical therapists with referral to a general surgeon after failure of conservative management.
During the history, one should ask about the
onset and duration of symptoms as well as the precise location and quality of pain. An effort should
be made to determine if the symptoms originate
from the inguinal region, abdominal muscles, the
hip, adductors, or a combination thereof. A history
of a bulge in the groin that would suggest a true
inguinal hernia is rarely present. Typically, the
pain from a groin injury does not occur at rest or
sitting but may be aggravated with activities such
as running, skating, cutting, coughing, sneezing,
and getting in and out of bed. Since one of the risk
factors for a groin injury is previous groin injury
[7], this should be inquired about as well.
With the patient standing, it is important to evaluate for inguinal hernias or testicular pathology
which could be contributing to pain. The external inguinal ring should be examined for laxity
or tenderness. With the patient supine, one should
begin by palpation over the pubic symphysis to
elicit tenderness there which could suggest osteitis pubis. Both inguinal oors should be palpated
to assess for weakness or asymmetry (Fig.17.4a).
Pelvic stability should be assessed by pressing
down on the iliac wings bilaterally. Resisted situps and trunk rotation may reveal pain related
to the rectus abdominis insertion or the oblique
muscles. A thorough hip exam is recommended
to rule out hip pathology and should include exion/adduction/internal rotation (FADIR) as well
as exion/abduction/external rotation (FABER)
which may indicate a labral inury [12]. The thigh
exam should include testing of strength and pain
with straight leg raising, resisted hip exion, and
passive and resisted adduction and abduction.
Any other sites of pain should be examined as
well. Finally, the adductor insertion site should be
palpated to identify tightness or tenderness.
Physical Exam
A careful physical exam is essential to reach the
correct diagnosis. A complete exam will include
both standing and supine assessment of the patient.
Fig. 17.4 Inguinal oor exam with palpation of inguinal
oors and distal rectus insertion at rest and during a
sit-up
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Imaging
There is no clear consensus on the use of imaging to evaluate groin injuries. Plain x-rays [4],
ultrasound [14], and MRI [4, 6] have been
used and advocated by different groups. Plain
x-rays are effective for ruling out avulsion
of bony fragments but are rarely informative
in this population of athletes. Dynamic ultrasound can be helpful in identifying inguinal
hernias or posterior weakness in the inguinal
oor but does not typically identify rectus
injuries or adductor pathology. Ultrasound is
also operator dependent and does not allow
assessment of pubis-, adductor-, or hip-related
pathology. In the authors’ experience, a pelvic
MRI is the most useful imaging modality for
the evaluation of acute and chronic athletic
groin injuries. Findings that may be seen on
MRI include bone marrow edema (Fig.17.5),
stress fractures, rectus or adductor aponeurosis tears (Fig.17.6), and hip pathology. MRI,
combined with a careful history and physical exam, should allow a precise diagnosis of
sports-related groin injury in the vast majority
of cases.
Fig. 17.5 Pelvis MRI that shows right-sided pubis
edema (short arrows) and a secondary cleft (longer
arrow). R rectus, P pubis. The secondary cleft is a cur-
vilinear uid cleft extending from the inferior aspect of
the pubis
Surgical Treatment
The majority of sports-related groin injuries resolve with rest, ice, nonsteroidal antiinammatory drugs, and physical therapy. Deep
tissue massage, or active tissue release, may also
be effective in the appropriate setting. Injections
with local anesthetic and steroids may be both
diagnostic and therapeutic in the treatment algorithm if the pain is well-localized on the abdominal wall. Some centers have used platelet-rich
plasma (PRP) injections at the site of injury, but
reports have been limited to isolated case reports
[15–17] and use of PRP for treatment of other
sports-related injuries [18]. Anecdotally, PRP
has been associated with heterotopic calcication
and should be avoided in the area of the adductor
tendon or insertion.
Abdominal Wall Repair
Surgery is indicated in athletes who fail
2–3months of conservative management and who
have the appropriate clinical features and supportive imaging ndings. In some cases, earlier
intervention may be warranted in high-level athletes who have an acute rectus insertional injury
that is seen on MRI. There have been two randomized clinical trials that compared operative
treatment to non-operative treatment for sportshernia-type groin pain [19–20]. In both series,
athletes who underwent surgical management
had signicantly reduced pain at 3–6months and
returned to sports sooner than those who received
non-operative management. In addition, there
was signicant crossover from the nonarms to the operative arm in each study (51%
[19] and 23% [20]) due to persistent pain. In both
studies, participants who crossed over experienced signicant improvement in their pain after
surgery. These trials support the use of surgical
intervention to treat athletes who have failed conservative management and have the appropriate
exam and imaging ndings.
The rst key to choosing the proper surgical
intervention is accurate diagnosis of the problem.
operative
132
A. Salles and L. M. Brunt
Fig. 17.6 Pelvic MRI that shows an adductor tear (arrows). Left panel, coronal view; right panel, axial image
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133
A variety of operative approaches have been utilized by various groups to treat the abdominal/
inguinal oor pathology of athletic pubalgia.
Broadly, these consist of (1) open primary suture
repairs, (2) open tension-free mesh repairs, and
(3) laparoscopic mesh repairs. Regardless of
the approach, the goal of surgery is to provide
support and stability to the posterior inguinal
oor and rectus insertion at the pubis, thereby
strengthening the latter.
Primary Repairs
Two principal types of primary suture repairs
have been described. Meyers, who has the world’s
largest experience with surgical treatment of athletic pubalgia injuries, sutures the inferolateral
edge of the rectus fascia to the pubis and adjacent
anterior ligaments [21]. This approach differs
from a standard Bassini inguinal hernia repair
in that the sutures are oriented in a near vertical
line and the internal ring is not tightened since
it is usually normal caliber. Muschawek and colleagues carry out a “minimal” repair technique in
which only the weakened posterior inguinal oor
is opened [22] The repair then consists of running
two imbricating monolament sutures up and
down the inguinal oor between the transversalis/internal oblique layers and the iliopubic tract
and inguinal ligament. This repair is analogous
somewhat to a Shouldice repair except only the
weakened section of the oor is repaired with the
goal to lateralize the rectus. In selected cases, a
genital neurectomy is also performed.
Tension-Free Mesh Repairs
The rationale for a tension-free mesh repair is
that these repairs have largely replaced primary
suture repairs over the last 20years, and, for athletes who exert tremendous forces around the
pubic region, this should result in a durable longterm repair. For open mesh repairs, the mesh is
placed similar to a Lichtenstein repair with two
exceptions: (1) the mesh is anchored medially to
the rectus sheath and (Fig.17.7), when possible,
(2) the internal oblique is brought over the mesh
and sutured to the inguinal ligament to insinuate
native tissue between the mesh and the spermatic
cord (Fig.17.7c). Splitting the mesh and bringing
a
b
c
Fig. 17.7 Open repair of inguinal oor. (a) Sutures
anchored to healthy transversalis fascia and rectus sheath.
(b) Completed tension-free mesh repair of oor. SC=spermatic cord. (c) Internal oblique (IO) covering the mesh
oor repair by suturing it to the inguinal ligament
the two tails around the spermatic cord is done
not because the internal ring is abnormal but so
that the mesh lies at and evenly along the oor.
An additional advantage of the open approach is
that it allows repair of the external oblique which
is often markedly attenuated in these athletes.
Some groups [20, 23] have advocated a laparoscopic approach to this problem. Paajanen etal.
describe a total extraperitoneal (TEP) approach
with dissection of the preperitoneal plane in the
134
a
A. Salles and L. M. Brunt
same fashion as one would do for an inguinal
hernia repair [20]. The preperitoneal space is initially developed with a balloon dilator and then
is dissected bluntly from the pubic symphysis to
the inferior epigastric vessels bilaterally as well
as caudally behind the pubic symphysis. A lightweight polypropylene mesh is xed to the rectus abdominis, conjoined tendon, and Cooper’s
ligament (Fig. 17.8). This procedure may also
be carried out using a transabdominal preperitoneal (TAPP) approach. Some groups advocate bilateral oor repair laparoscopically even
when patients have unilateral injuries or symptoms, although repair of an asymptomatic groin
is controversial. Lloyd etal. release the inguinal
ligament by detaching the medial insertion of the
inguinal ligament at the pubis based on the concept that the pain is primarily related to tension
at the inguinal ligament [23]. This approach is
followed by placement of a large polypropylene
mesh in the preperitoneal plane to buttress the
entire inguinal oor on the side of the injury.
The senior author’s practice is to perform an
open tension-free mesh repair in most cases for
the reasons given above. For young athletes who
are still in their growth phase or women athletes,
a primary suture repair is preferred analogous to
that described above in which the lateral rectus is
sutured to the pubis and inguinal ligament with
interrupted nonabsorbable sutures [21]. In a series
of 257 cases treated at our institution over the
past 12years, 83% underwent open mesh repair,
5% were treated with primary tissue repairs, and
13% underwent laparoscopic TEP repair with an
overall success rate of return to sports of 90%.
The laparoscopic approach was used primarily in
athletes who had prior open inguinal surgery and
demonstrable rectus aponeurosis tears on imaging.
No comparative trials have been done to assess
outcomes of the different surgical approaches
for the treatment of sports-hernia-related inguinal pain, although a trial is currently underway
in Finland to compare laparoscopic vs. open
minimal suture repair in athletes who have failed
conservative management (NCT01876342).
Reported series have also not shown differences in outcomes between open or laparoscopic
approaches [24], but this issue remains controversial. Athletes are in most cases able to return
to competitive sports within 5–8weeks of surgery [4, 13, 23].
b
Fig. 17.8 Laparoscopic view of right inguinal oor. (a)
The dotted circle shows a defect in the medial posterior
inguinal oor similar to that on the anterior view seen in
Fig.17.7. (P=pubis, R=rectus, IE=inferior epigastrics).
(b) Mesh repair of inguinal oor, laparoscopic approach
Adductor Tenotomy
If the symptoms, exam, and imaging ndings are
primarily related to adductor tendon pathology,
an adductor tenotomy can be performed, either
as an isolated procedure or in conjunction with
inguinal oor repair. In these cases, patients have
pain inferior to the inguinal ligament near the
attachment of the adductor longus tendon to the
pubis and have discomfort with resisted adduction on that side. MRI typically shows adductor
tendon thickening, chronic tendinopathy, or a
tear at the insertion site. A small incision is made
2–3cm below the adductor insertion on the pubis.
a
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135
Several incisions are made into the tendon sheath
to stimulate neovascularity and to release tension
in the adductor compartment. Occasionally, calcications in the tendon are found and should be
debrided (Fig.17.9). Percutaneous approaches to
adductor tenotomy have also been described [25].
athletes were able to return to sports at a mean
of 13 weeks after repair (range 10–21 weeks).
Seven of these athletes also underwent simultaneous mesh repair of an injury on the abdominal
side. No recurrences were observed over 1year
of follow- up [4].
Return to sports with these approaches has been
reported at 4–14weeks postoperatively [25–27].
The role of primary surgical repair vs. con-
Postoperative Care
servative management of adductor tendon tears
is unclear. In one study of National Football
League players, the mean time to return to play
was 6.1±3.1weeks in 12 conservatively treated
athletes compared to 12. 0±2.5weeks in 5 surgically managed patients [28]. In a second study of
15 elite athletes, adductor repair was performed
between 5 and 34 days from injury using bone
anchors to reattach the tendon at the pubis. These
Rehabilitation after surgery for a sports-related
groin injury should entail a structured approach
with gradually increasing activity levels.
Ellsworth etal. have published a detailed, welldened regimen [29]. Regardless of the type
of surgery performed, patients in the senior
author’s practice are instructed to resume light
activities and stretching from the day of surgery.
Within 5 days they should begin a program of
structured walking progressing to light running
within 2 weeks. Cycling for conditioning and
light resistance exercises may begin as soon as
is comfortable for the athlete. Light sports-specic activities (e.g., dribbling a soccer ball, light
skating, or football drills) may also be resumed
within 2–3 weeks according to comfort level
with gradual progression to higher-level drills.
Functional strengthening and core stabilization
exercises should be included in the rehabilitation
along with scar mobilization with deep tissue
massage. Finally, progression to team practices,
scrimmage, and simulated game conditions
b
should precede return to play. It is important to
note that progression of recovery should be based
on function and symptoms and not a rigid timebased approach. Recovery will vary according
to the athlete, sports, and extent of injury. Most
athletes can return to competitive sports within
5–8 weeks, though longer may be required for
more complex injuries and those with adductor
involvement.
Summary
Fig. 17.9 (a) Operative view of partial adductor longus
release. (b) Calcied adductor tendon (arrows) that is
undergoing debridement
Sports-related groin injuries are common and
can be difcult to diagnose and manage. Surgical
treatment is indicated for athletes who fail
136
A. Salles and L. M. Brunt
conservative therapy and who have the appropriate exam and radiographic features. Hernia surgeons who become involved in the evaluation of
these athletes should understand the diverse conditions that cause athletic groin pain, be familiar
with the special exam and imaging components
necessary to make the diagnosis, and have a wellconstructed surgical approach to management. A
multidisciplinary approach with the sports medicine or orthopedist specialist, musculoskeletal
radiologist, and athletic trainer/physical therapist
with experience in managing these athletes is
also essential to successful outcomes.
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