Laparoscopic repair of groin pain in athletes

BACKGROUND: There has been increasing interest regarding the cause and treatment of groin pain in athletes. The most common finding is a deficiency of the posterior wall of the inguinal canal, often repaired with bilateral inguinal myorrhaphy. HYPOTHESIS: Laparoscopic repair will offer a shorter convalescent period and better results as compared with open myorrhaphy. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Between October 1993 and October 2002, 131 athletes with groin pain unrelieved after 2 to 8 months of conservative management underwent bilateral laparoscopic repair with the transabdominal preperitoneal technique for hernias. In 123 (94%) patients, physical examination revealed a dilated external ring, unilateral or bilateral, of the inguinal canal, and in 8 patients (6%) it was normal. RESULTS: During laparoscopy, a deficiency of the posterior inguinal wall was seen in all athletes. All patients left the hospital 24 hours after the procedure, discontinued oral analgesics within 72 hours of surgery, and were back to full sporting activities within 2 to 3 weeks. Four patients (3%) complained of thigh pain. After a mean follow-up of 5 years (range, 4 months to 10 years), there was 1 recurrence (0.76%). CONCLUSIONS: Laparoscopic repair is an efficient method for the treatment of groin pain originating from a deficiency of the posterior inguinal wall, having fast recovery and excellent long-term results.     

Surgery for posterior inguinal wall deficiency in athletes

This study retrospectively evaluated the outcome for patients undergoing herniorraphy for chronic groin pain due to posterior inguinal wall deficiency, and correlated the outcome with preoperative investigation findings. There were 47 patients (with a total of 52 herniorraphies) who were contacted by phone between six and 50 months post surgery. Subjects had a diagnosis of posterior inguinal wall deficiency made on history and clinical examination. Thirty seven patients had an ultrasound scan prior to the surgery (three bilateral) with a total of 40 symptomatic groins scanned. There were 26 abnormal scans (22 posterior inguinal wall deficiency and four hernias) and 14 normal scans. Twenty nine patients had a technetium-99m bone scan with 22 having increased uptake at the symptomatic pubic tubercle, while 13 had increased uptake at other sites in the groin. Seventy seven percent of patients had a full return to sport after surgery and the average time to return to sport was four months. There was no significant difference in outcome between subjects who had an abnormal ultrasound scan on the symptomatic side and those who had a normal scan. There was a significant difference in outcome between patients who had a bone scan with increased uptake at the symptomatic pubic tubercle and those who did not (p < 0.04). Our study supports previous research that good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. Ultrasound scan does not appear to aid in predicting surgical outcome, while the role of isotope bone scanning requires further study.     

Isokinetic strength testing does not predict hamstring injury in Australian Rules footballers

OBJECTIVE: To determine the relation of hamstring and quadriceps muscle strength and imbalance to hamstring injury using a prospective observational cohort study METHOD: A total of 102 senior male Australian Rules footballers aged 22.2 (3.6) years were tested at the start of a football season. Maximum voluntary concentric and eccentric torque of the hamstring and quadriceps muscles of both legs was assessed using a Kin-Com isokinetic dynamometer at angular velocities of 60 and 180 degrees/second. Twelve (11.8%) players sustained clinically diagnosed hamstring strains which caused them to miss one or more matches over the ensuing season. RESULTS: There were no significant differences for any of the isokinetic variables comparing the injured and non-injured legs in players with unilateral hamstring strains (n=9). Neither the injured nor the non-injured leg of injured players differed from the mean of left and right legs in non-injured players for any isokinetic variable. The hamstring to opposite hamstring ratios also did not differ between injured and non-injured players. A hamstring to opposite hamstring ratio of less than 0.90 and a hamstring to quadriceps ratio of less than 0.60 were not associated with an increased risk of hamstring injury. A significantly greater percentage of players who sustained a hamstring strain reported a history of hamstring strain compared with non-injured players (p=0.02). However, this was not related to muscle weakness or imbalance. CONCLUSIONS: Isokinetic muscle strength testing was not able to directly discriminate Australian Rules football players at risk for a hamstring injury.


     

Sutureless tension-free hernia repair with human fibrin glue (tissucol) in soccer players with chronic inguinal pain: initial experience

Chronic groin pain is a common symptom experienced by soccer players, resulting in many athletes undergoing prolonged periods of conservative treatment. In a high proportion of these cases, however, the cause of groin pain is due to impalpable hernias, thus nullifying the usefulness of a conservative approach. Of the current surgical procedures for inguinal hernia repair, the Lichtenstein technique is widely used. The present study aims to evaluate the efficacy of mesh fixation with human fibrin glue (Tissucol) in open, tension-free inguinal repair, in the treatment of soccer players with groin hernia. A sutureless Lichtenstein technique was employed in 16 consecutive soccer players with primary groin hernia. Inguinal nerves were prepared and preserved. Human fibrin glue was used for mesh fixation, in place of conventional sutures. Results were rated as excellent in all cases, with no reported intra- or postoperative complications. All patients were discharged 4 - 5 h after the operation, and all returned to full pre-injury level sporting-activity, on average, 31 days (range 24 - 42 days) post surgery. This study confirms the efficacy of sutureless tension-free hernia repair with human fibrin glue for the treatment of soccer players suffering from chronic groin pain due to impalpable groin hernia.     

Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain

OBJECTIVES: To examine the relation between the clinical features of groin pain and groin magnetic resonance imaging (MRI) appearances in a group largely comprising elite Australian Rules football players. The incidence of bone marrow oedema and other MRI findings in the pubic symphysis region was noted. The relation between a past history of groin pain and these other MRI findings was also examined. METHOD: In a prospective study, 116 male subjects (89 footballers, 17 umpires, 10 sedentary men) were examined before history taking and groin MRI. The clinical history was not known to the examiner (GMV) and radiologists (JPS, GTF). Clinical evidence of groin pain and examination findings were correlated with the presence of increased signal intensity within the pubic bone marrow. A past history of groin pain was correlated with the presence of other MRI findings such as cyst formation, fluid signal within the pubic symphysis disc, and irregularity of the pubic symphysis. RESULTS: Fifty two athletes (47 footballers, five umpires) had clinical features of groin pain with pubic symphysis and/or superior pubic ramus tenderness. A high incidence of increased signal intensity (77%) within the pubic bone marrow was identified in this group. There was an association between this group of athletes and the MRI finding of increased signal intensity (p<0.01). There was also an association between a past history of groin pain and the presence of other MRI findings (p<0.01). CONCLUSIONS: Athletes with groin pain and tenderness of the pubic symphysis and/or superior pubic ramus have clinical features consistent with the diagnosis of osteitis pubis. The increased signal intensity seen on MRI is due to pubic bone marrow oedema. An association exists between the clinical features of osteitis pubis and the MRI finding of pubic bone marrow oedema. A high incidence of pubic bone marrow oedema was also noted. Degenerative features visualised by MRI, such as subchondral cyst formation, were associated with a past history of groin pain. A stress injury to the pubic bone is the most likely explanation for these MRI findings and may be the cause of the clinical entity osteitis pubis.     

The sports hernia: a cause of chronic groin pain.

The management of chronic pain in sportsmen and women requires consideration of a wide differential diagnosis. A syndrome caused by a distension of the posterior inguinal wall is described, effectively an early direct inguinal hernia. The diagnosis can be made from certain aspects of the history and examination, which are described. The results of surgical repair to the posterior inguinal wall are excellent. The procedure was carried out on 14 sportsmen and one woman. There is an 87% return to full sporting activity, with a follow-up of 18 months to 5 years. The remaining 13% were improved by the repair. Many of the athletes had received other treatments without success. The sports hernia should be high on the list of differential diagnoses in chronic groin pain.     

Herniographic findings in athletes with unclear groin pain

BACKGROUND: Groin pain in athletes is a common symptom and may, among many other entities, be caused by skeletal changes in the symphysis and the pubic bone or hernia. MATERIAL AND METHODS: Herniographies in 51 athletes -- mainly soccer players -- with unclear groin pain were reviewed. The prevalence of various hernias and skeletal changes at the symphysis and os pubis was registered. A questionnaire was also sent to the patients 3-20 years after the herniography. RESULTS: A hernia was found in 13 patients. Four patients had an indirect inguinal hernia. Eight patients had a direct inguinal hernia and 1 had an obturator hernia. The prevalence of direct inguinal hernia was higher than expected in young men. This may be explained by strain at physical exercise. Bone changes at the pubic symphysis were found in 32 patients, 21 of whom had advanced changes. CONCLUSION: A hernia can be found with herniography in one-fourth of athletes with long-standing unclear groin pain. Therefore herniography should be included in the diagnostic procedure. Lesions of the symphysis may be the result of strain of tendons, ligaments and fascias. This may predispose for an inguinal hernia as well.     

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome

BACKGROUND: Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation. HYPOTHESIS: Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season. RESULTS: Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not. CONCLUSION: Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.     

Imaging features of pubalgia

Pubalgia is a generic term used to describe groin pain due to a multitude of different etiologies such as skeletal (microtraumatic pubic symphysis arthropathy), muscular (adductor or rectus abdominis disorders), or abdominal wall (inguinal hernia) disorders. Diagnosis relies mainly on MRI for musculoskeletal disorders and ultrasound for abdominal wall disorders.     

Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia.

There has been increasing interest within the European sports medicine community regarding the etiology and treatment of groin pain in the athlete. Groin pain is most commonly caused by musculotendinous strains of the adductors and other muscles crossing the hip joint, but may also be related to abdominal wall abnormalities. Cases may be termed "pubalgia" if physical examination does not reveal inguinal hernia and there is an absence of other etiology for groin pain. We present nine cases of patients who underwent herniorrhaphies for groin pain. Two patients had groin pain without evidence of a hernia preoperatively (pubalgia). In the remaining seven patients we determined the presence of a hernia by physical examination. At operation, eight patients were found to have inguinal hernias. One patient had no hernia but had partial avulsion of the internal oblique fibers from their insertion at the public tubercle. The average interval from operation to return to full activity was 11 weeks. All patients returned to full activity within 3 months of surgery. One patient had persistent symptoms of mild incisional tenderness, but otherwise there were no recurrences, complications, or persistence of symptoms. Abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the internal oblique muscle, can be an overlooked source of groin pain in the athlete. Operative treatment of this condition with herniorrhaphy can return the athlete to his sport within 3 months.     

When to use mesh in inguinal hernia repair

With people living longer today, averaging 73 years old, the type of patients with inguinal hernias are different than in the past. At the present time, to avoid the high incidence of recurrence due to the aged and weakened tissue component of the groin area, we reinforce the posterior wall of the inguinal canal with Mersilene (dacron) mesh. Most surgeons agree to use a prosthetic mesh in recurrent inguinal hernia repairs. Moreover, sometimes it is necessary to use mesh in patients with connective tissue disorders like Ehlers syndrome, Marfan syndrome, and acquired absence of the posterior wall fascia transversalis. Currently, polypropylene and dacron mesh are the most satisfactory, since they are readily available and become well incorporated by connective tissue.     

Groin injuries in sport: treatment strategies.

Groin pain in athletes is a common problem that can result in significant amounts of missed playing time. Many of the problems are related to the musculoskeletal system, but care must be taken not to overlook other more serious and potentially life threatening medical cases of pelvis and groin pain. Stress fractures of the bones of the pelvis occur, particularly after a sudden increase in the intensity of training. Most of these stress fractures will heal with rest, but femoral neck stress fractures can potentially lead to more serious problems, and require closer evaluation and sometimes surgical treatment. Avulsion fractures of the apophyses occur through the relatively weaker growth plate in adolescents. Most of these will heal with a graduated physical therapy programme and do not need surgery. Osteitis pubis is characterised by sclerosis and bony changes about the pubic symphysis. This is a self-limiting disease that can take several months to resolve. Corticosteroid injection can sometimes hasten the rehabilitation process. Sports hernias can cause prolonged groin pain, and provide a difficult diagnostic dilemma. In athletes with prolonged groin pain, with increased pain during valsalva manoeuvres and tenderness along the posterior inguinal wall and external canal, an insidious sports hernia should be considered. In cases of true sports hernia, treatment is by surgical reinforcement of the inguinal wall. Nerve compression can occur to the nerves supplying the groin. In cases that do not respond to desensitisation measures, neurolysis can relieve the pain. Adductor strains are common problems in kicking sports such as soccer. The majority of these are incomplete muscle tendon tears that occur just adjacent to, the musculotendinous junction. Most of these will respond to a graduated stretching and strengthening programme, but these can sometimes take a long time to completely heal. Patience is the key to obtain complete healing, because a return to sports too early can lead to chronic pain, which becomes increasingly difficult to treat. Management of groin injuries can be challenging, and diagnosis can be difficult because of the degree of overlap of symptoms between the different problems. By careful history and clinical examination, with judicious use of special tests and good team work, a correct diagnosis can be obtained.     

Distance Bicycling May Cause Ischemic Neuropathy of Penis

The cause of groin pain, common in kicking sports, is obvious when a patient suffers an acute muscle strain. However, a case study involving a 16-year-old male high school athlete demonstrates how gradual-onset groin pain can open up a multitude of orthopedic and nonorthopedic diagnostic possibilities including avulsion fracture, osteitis pubis, and inguinal hernia. Muscle strains usually resolve with RICE therapy and a focused rehabilitation program. Conservative treatment is also appropriate in the initial workup of inguinal canal weakness. Surgery may be needed to repair severely torn muscles or to correct an inguinal canal defect.     

Nutrition for the Australian rules football player

This review summarises past and present nutritional practices of Australian Rules Football players, noting changes that have occurred as the footballers have become more receptive to scientific input. Australian Rules Football is a unique sport, with matches involving intermittent high intensity sprints between periods of jogging and walking and repeated physical contact. Endurance, speed, strength, power and agility are essential physical characteristics. Australian Rules footballers exhibit a wide range of anthropometrical attributes due to the positional requirements of the game. Dietary surveys indicate that footballers of the 1980's consumed a diet similar to that of the general Australian population consisting of 44%, 37.5%, 15% and 3.5% of carbohydrate (CHO), fat, protein and alcohol, respectively. However, as dietitians are becoming an integral part of the support staff of teams there is evidence that nutritional practices conducive to optimal sporting performance are now being followed. Due to the prolonged duration and intermittent high intensity activity pattern of Australian Rules, nutritional supplementation such as fluid and CHO intake during training and competition and creatine intake may be beneficial; however, further research needs to be conducted in the field to determine its importance in Australian Rules Football.     

Herniography in 79 patients with unexplained pain in the groin: a retrospective study

To assess the safety and accuracy of herniography for the diagnosis of inguinal hernia in young military men with unexplained pain in the groin, a retrospective study in 79 patients with unexplained pain in the groin who underwent a herniography is presented. Nineteen patients (24%) showed a positive herniogram which was confirmed in 15 out of 16 patients who subsequently underwent surgery. All 60 (76%) patients with a negative herniography were followed-up. An inguinal hernia was subsequently found at surgery in two patients out of eight who were operated on later. In our series no serious complications occurred. Herniography has been shown to be a safe and reliable method to demonstrate or exclude an inguinal hernia in young military men with unexplained pain in the groin. The differential diagnosis in this specific patient group is discussed.     

Chronic groin pain in an athlete: an unusual presentation

Persistent disabling groin pain in an active sportsman is a frustrating diagnostic and management problem for both the athlete and physician. After clinical examination and investigation there remains a group of patients who have unexplained groin pain, and may undergo lengthy periods of conservative management with numerous radiological investigations. Here we highlight such a case.




     

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

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.     

Delayed onset of transversus abdominus in long-standing groin pain

Long-standing groin pain is a persistent problem that is commonly difficult to rehabilitate. Theoretical rationale indicates a relationship between the motor control of the pelvis and long-standing groin pain; however, this link has not been investigated. PURPOSE: The current experiment aimed to evaluate motor control of the abdominal muscles in a group of Australian football players with and without long-standing groin pain. METHODS: Ten participants with long-standing groin pain and 12 asymptomatic controls were recruited for the study. Participants were elite or subelite Australian football players. Fine-wire and surface electromyography electrodes were used to record the activity of the selected abdominal and leg muscles during a visual choice reaction-time task (active straight leg raising). RESULTS: When the asymptomatic controls completed the active straight leg raise (ASLR) task, the transversus abdominus contracted in a feed-forward manner. However, when individuals with long-standing groin pain completed the ASLR task, the onset of transversus abdominus was delayed (P < 0.05) compared with the control group. There were no differences between groups for the onset of activity of internal oblique, external oblique, and rectus abdominus (all P > 0.05). CONCLUSIONS: The finding that the onset of transversus abdominus is delayed in individuals with long-standing groin pain is important, as it demonstrates an association between long-standing groin pain and transversus abdominus activation.     

Hip adductor muscle strength is reduced preceding and during the onset of groin pain in elite junior Australian football players

Groin pain is a condition with a high prevalence in young Australian football players. It is considered that early identification of this condition allows for optimal management. Eighty-six players from two elite under-age Australian football sides were screened weekly for hip adductor muscle strength, using a hand-held dynamometer and for the onset of groin pain. The maximum variation in the average hip adductor muscle strength values of the sample was a 2.6% decrease from baseline in week 7 of the study. Twelve players (14% of the sample studied) reported groin pain for two consecutive weeks and were considered to have an onset of groin injury. The mean hip adductor muscle strength of these players was decreased significantly from baseline by an average of 11.75 ± 2.50% at the week of pain onset (F = 264.76 (1,11), p < 0.001), and 5.82 ± 5.16% in the week preceding the onset of pain (F = 14.03 (1,10), p = 0.004). These results confirm that hip adductor muscle strength is decreased both preceding and during the onset of groin injury in elite under-age Australian footballers.     

Emergencies in sports

Groin injury is common in sports that involve high-speed torsion of the trunk, especially soccer, as in this case of a 28-year-old goalie. The sports hernia, a syndrome of pain caused by disruption of the inguinal canal without a clinically detectable hernia, is often initially overlooked. Examination reveals maximal tenderness over the pubic tubercle and posterior inguinal canal. The diagnosis is clinical, but x-rays and bone scanning may help rule out a concurrent injury. The pain may be multifactorial, with coexisting hip or adductor muscle pathology complicating the clinical picture. Rehabilitation, particularly core strengthening with emphasis on the abdominal obliques, is the first line of treatment. If this is ineffective, surgery is usually successful, and most athletes return to a high level of sports participation 6 to 8 weeks postsurgery.