Purpose
To perform a systematic review of reported terminologies, surgical techniques, preoperative
diagnostic measures, and geographic differences in the treatment of core muscle injury
(CMI)/athletic pubalgia/inguinal disruption.
Methods
A systematic review was performed by searching PubMed, the Cochrane Library, and Embase
to identify clinical studies or articles that described a surgical technique to treat
CMI refractory to nonoperative treatment. The search phrase used was “core muscle
injury” OR “sports hernia” OR “athletic pubalgia” OR “inguinal disruption.” The diagnostic
terminology, country of publication, preoperative diagnostic measures, surgical technique,
and subspecialty of the operating surgeons described in each article were extracted
and reported.
Results
Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical
technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level
III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology
used to describe the diagnosis was “athletic pubalgia,” followed by “sports hernia.”
Plain radiographs and magnetic resonance imaging of the pelvis were the most common
imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal
disruption. Tenderness-to-palpation testing was the most common technique performed
during physical examination, although the specific locations assessed with this technique
varied substantially. The operating surgeons were general surgeons (16 articles),
a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons
(5 articles). The most common procedures performed were open or laparoscopic mesh
repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair.
The procedures performed differed on the basis of surgeon subspecialty, geographic
location, and year of publication.
Conclusions
A variety of diagnostic methods and surgical procedures have been used in the treatment
of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are
performed by orthopaedic and/or general surgeons, with the procedures performed differing
on the basis of surgeon subspecialty and geographic location.
Level of Evidence
Level V, systematic review of Level I to V studies.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to ArthroscopyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Core muscle injury/sports hernia/athletic pubalgia, and femoroacetabular impingement.Sports Med Arthrosc. 2015; 23: 213-220
- Athletic pubalgia secondary to rectus abdominis-adductor longus aponeurotic plate injury: Diagnosis, management, and operative treatment of 100 competitive athletes.Orthop J Sports Med. 2018; 6 (2325967118798333)
- Surface mapping of the musculotendinous attachments at the pubic symphysis in cadaveric specimens: Implications for the treatment of core muscle injury.Arthroscopy. 2019; 35: 2358-2364
- 'Treatment of the sportsman's groin'; British Hernia Society's 2014 position statement based on the Manchester Consensus Conference.Br J Sports Med. 2014; 48: 1079-1087
- Athletic hip injuries.J Am Acad Orthop Surg. 2017; 25: 269-279
- The effect of dynamic femoroacetabular impingement on pubic symphysis motion: A cadaveric study.Am J Sports Med. 2012; 40: 1113-1118
- Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: A case series.Arthroscopy. 2011; 27: 768-775
- The role of femoroacetabular impingement in core muscle injury/athletic pubalgia: Diagnosis and management.Front Surg. 2016; 3: 6
- The prevalence of athletic pubalgia imaging findings on MRI in patients with femoroacetabular impingement.Skeletal Radiol. 2020; 49: 1249-1258
- Increased prevalence of femoroacetabular impingement in patients with proximal hamstring tendon injuries.Arthroscopy. 2019; 35: 1396-1402
- Correlation between femoroacetabular impingement and hamstring tendon pathology on magnetic resonance imaging and arthrography.Orthopedics. 2017; 40: e1086-e1091
- The hip-spine effect: A biomechanical study of ischiofemoral impingement effect on lumbar facet joints.Arthroscopy. 2017; 33: 101-107
- Diagnostic accuracy of physical examination tests in core muscle injury.Am J Sports Med. 2020; 48: 1983-1988
- Sports hernia: Definition, evaluation, and treatment.JBJS Rev. 2017; 5: e6
- The use of platelet-rich plasma to augment conservative and surgical treatment of hip and pelvis disorders.Muscles Ligaments Tendons J. 2016; 6: 410-419
- Mini-open incision sports hernia repair: A surgical technique for core muscle injury.Arthrosc Tech. 2017; 6: e1281-e1284
- High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement.Arthroscopy. 2012; 28: 1388-1395
- Results of inguinal canal repair in athletes with sports hernia.J R Coll Surg Edinb. 2002; 47: 561-565
- Adductor tenotomy as a treatment for groin pain in professional soccer players.Orthopedics. 2013; 36: e1189-e1197
- “Sports” hernia: Treatment with biologic mesh (Surgisis): A preliminary study.Surg Endosc. 2006; 20: 971-973
- Multicenter outcomes of endoscopic pubic symphysectomy for osteitis pubis associated with femoroacetabular impingement.Arthroscopy. 2015; 31: 1255-1260
- Cochrane handbook for systematic reviews of intervention.The Cochrane Collaboration, London2011
- Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia).Surgery. 2011; 150: 99-107
- Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia.Br J Surg. 2019; 106: 837-844
- Studies of surgical outcome after patellar tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group.Scand J Med Sci Sports. 2000; 10: 2-11
- Effect of pubic bone marrow edema on recovery from endoscopic surgery for athletic pubalgia.Scand J Med Sci Sports. 2015; 25: 98-103
- Health-related quality of life after TAPP repair for the sportsmen’s groin.Surg Endosc. 2014; 28: 439-446
- Sports hernia treatment: Modified Bassini versus minimal repair.Sports Health. 2013; 5: 463-469
- Athletic pubalgia in females: Predictive value of MRI in outcomes of endoscopic surgery.Orthop J Sports Med. 2017; 5 (2325967117720171)
- Athletic pubalgia: Definition and surgical treatment.Ann Plast Surg. 2005; 55: 393-396
- Early recovery after endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption: A prospective cohort study.PLoS One. 2019; 14e0226011
- Surgical treatment of chronic groin pain in athletes.Int Orthop. 2012; 36: 2361-2365
- Sports hernia or groin disruption injury? Chronic athletic groin pain: A retrospective study of 100 patients with long-term follow-up.Hernia. 2014; 18: 815-823
- Laparoscopic repair of sportsman's hernia—The Trinidad experience.J Natl Med Assoc. 2014; 106: 69-72
- Sports hernia repair with adductor tenotomy.Hernia. 2017; 21: 139-147
- Athletic pubalgia: Return to play after targeted surgery.Orthop Traumatol Surg Res. 2018; 104: 469-472
- 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; 28: 2-8
- Minimal repair technique of sportsmen's groin: An innovative open-suture repair to treat chronic inguinal pain.Hernia. 2010; 14: 27-33
- Sportsmen's groin-diagnostic approach and treatment with the minimal repair technique: A single-center uncontrolled clinical review.Sports Health. 2010; 2: 216-221
- Laparoscopic approach to inguinal disruption in athletes: A retrospective 13-year analysis of 198 patients in a single-surgeon setting.Sports Med Open. 2019; 5: 25
- Sports hernia: The experience of Baylor University Medical Center at Dallas.Proc (Bayl Univ Med Cent). 2011; 24: 89-91
- Athletes with inguinal disruption benefit from endoscopic totally extraperitoneal (TEP) repair.Hernia. 2018; 22: 517-524
- Laparoscopic hernia repair with adductor tenotomy for athletic pubalgia: An established procedure for an obscure entity.Surg Endosc. 2015; 29: 381-386
- 10-year results of the Nesovic procedure combined with adductor release for groin pain in 33 competitive athletes.Acta Orthop Belg. 2019; 85: 169-181
- Groin defects seen at extra-peritoneal laparoscopic dissection during surgical treatment of athletic pubalgia.Surg Endosc. 2015; 29: 1695-1699
- Laparoscopic transabdominal preperitoneal (TAPP) groin hernia repair using n-butyl-2-cyanoacrylate (LiquibandFix8) for mesh fixation and peritoneal closure: Learning experience during introduction into clinical practice.Hernia. 2019; 23: 601-613
- Arthroscopic pubic symphysis debridement and adductor enthesis repair in athletes with athletic pubalgia: Technical note and video illustration.Arch Orthop Trauma Surg. 2014; 134: 1595-1599
- Endoscopic rectus abdominis and prepubic aponeurosis repairs for treatment of athletic pubalgia.Arthrosc Tech. 2017; 6: e183-e188
- The thigh adductor squeeze test: 45° of hip flexion as the optimal test position for eliciting adductor muscle activity and maximum pressure values.Man Ther. 2011; 16: 476-480
- Experience with "sports hernia" spanning two decades.Ann Surg. 2008; 248: 656-665
- The sportsman's groin.Br J Surg. 1999; 86: 849-850
- Performance and return to sport after sports hernia surgery in NFL players.Orthop J Sports Med. 2017; 5 (232596711769959)
- The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: A new anatomical concept.Knee Surg Sports Traumatol Arthrosc. 2017; 25: 3969-3977
- Hip and groin injuries in baseball players.Curr Rev Musculoskelet Med. 2018; 11: 19-25
- Increasing alpha angle is predictive of athletic-related "hip" and "groin" pain in collegiate National Football League prospects.Arthroscopy. 2013; 29: 405-410
- Correlation between cam-type femoroacetabular impingement and radiographic osteitis pubis.Orthopedics. 2016; 39: e417-e422
- Athletic osteitis pubis.Sports Med. 2011; 41: 361-376
- A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes.Sports Health. 2010; 2: 211-215
- Treatment of osteitis pubis in non-athletic female patients.Open Orthop J. 2011; 5: 331-334
- Surgery for osteitis pubis.Can J Surg. 2006; 49: 170-176
- Doha agreement meeting on terminology and definitions in groin pain in athletes.Br J Sports Med. 2015; 49: 768-774
- Anatomical differentiation of direct and indirect inguinal hernias: Is it worthwhile in the modern era?.Clin Anat. 2010; 23: 848-850
- 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; 15: 36-42
Article Info
Publication History
Published online: April 09, 2021
Accepted:
March 17,
2021
Received:
August 4,
2020
Footnotes
See commentary on page 2391
The authors report the following potential conflicts of interest or sources of funding: O.M-D. receives intellectual property royalties from Stryker, owns stock or stock options in MITA, and receives research support from Stryker, outside the submitted work. C.M.L. is a consultant for Smith & Nephew, outside the submitted work. A.J.S. is a consultant for Mitek and receives research support from Biologics, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Identification
Copyright
© 2021 by the Arthroscopy Association of North America
