Athletic Pubalgia Surgery

Number: 0750

Table Of Contents

Policy

Scope of Policy

This Clinical Policy Bulletin addresses athletic pubalgia surgery.

1. Experimental, Investigational, or Unproven

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

   1. Intra-tissue percutaneous electrolysis for the treatment of chronic groin pain.
   2. Pulse-dose radiofrequency for the treatment of athletic pubalgia, 
   3. Surgical treatment (e.g., pelvic floor repair) for athletic pubalgia (also known as core muscle injury or "sports hernia").

2. Related Policies

   • CPB 0736 - Femoro-Acetabular Surgery for Hip Impingement Syndrome

Background

Athletic pubalgia, also known as groin disruption 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):

• Abnormal insertion of the rectus abdominis muscle
• Conjoint tendon torn from pubic tubercle
• Deficient posterior wall of the inguinal canal
• Dehiscence between conjoined tendon and inguinal ligament
• Entrapment of the ilio-inguinal nerve or genito-femoral nerve
• Tear in the conjoint tendon
• Tear in the fascia transversalis
• Tear of the abdominal internal oblique muscle from the pubic tubercle
• Torn external oblique aponeurosis.

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 sports hernia/athletic pubalgia (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 definitively rule out SH.

Conservative treatments for AP consist of rest, application of ice 3 to 4 times daily for about 20 to 30 minutes, 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 the 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 uncontrolled; 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 the assessment of patients with groin pain cannot 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 stated 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 support 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 provided 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 reinforce 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 lies 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 and 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) and the National Institute for Clinical Excellence's guideline on laparoscopic surgery for inguinal hernia repair (2004) did not mention AP as an indication for 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, as well as conservative and post-surgical rehabilitation, well-designed research studies are needed with more detailed serial patient outcome measurements, rather than 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 sports hernia (SH) is a controversial cause of chronic groin pain, as it is difficult to define. In the majority of athletic maneuvers, a tremendous amount of torque or twisting occurs in the mid-portion of the body, with the front of the pelvis accounting 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. Opposing these muscles is the adductor longus. The opposing forces can cause a disruption of the muscle/tendon at their insertion site on the pubis, suggesting that the problem may be related to excessive and imbalanced forces, leading to a weak area in the groin. This imbalance could be defined as "SH." The authors concluded that this global entity could be considered an imbalance of the abductor and abdominal muscles at the pubis, leading to increased weakness of the posterior wall of the groin and producing tendon enthesitis, which may progress to degenerative arthropathy of the pubic symphysis in advanced stages. Based on this, the entity could be re-named as "syndrome of muscle imbalance of the groin," with SH considered an entity included in this syndrome. They recommend a multidisciplinary approach to this condition, as the current literature does not provide adequate diagnostic studies or appropriate treatments for these patients.

In a cross-sectional study, Silvis et al. (2011) examined the prevalence of pelvic and hip MRI findings and their 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, with scans interpreted independently by three musculoskeletal radiologists in two sessions separated by three months, using a 5-point Likert scale to assess features associated with common adductor-abdominal rectus dysfunction and hip pathology. To estimate prevalence, MRI findings rated 4 or higher on four of the six 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. MRI findings of common adductor-abdominal rectus dysfunction were observed in 14 of 39 participants (36%), and hip pathologic changes were found 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 lower for evaluation of hip pathologic abnormalities than for groin pathologic abnormalities, with the lowest reliability observed in reporting 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), while perfect reliability was noted 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 relation to clinical presentation. They noted that future investigations will determine whether these asymptomatic findings predict future disabilities.

Litwin and colleagues (2011) stated that athletic pubalgia (AP) or sports hernia (SH) is a syndrome of chronic lower abdomen and groin pain that may occur in both athletes and non-athletes. Due to the broad differential diagnosis of chronic lower abdomen and groin pain, only a small number of patients with this pain fulfill the diagnostic criteria for AP (SH). The authors noted that the existing literature 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. The cohort included 8 professional athletes, 15 collegiate athletes, 5 elite high school athletes, and 9 competitive club athletes. Outcomes included evaluations regarding return to sports, 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, and hip arthroscopy was performed in 32 hips (30 cases of femoro-acetabular impingement [FAI] treatment, 1 traumatic labral tear, and 1 borderline dysplasia). Of the 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 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 one 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 one 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 highlighted the overlap of these two diagnoses and emphasized the importance of exercising caution in diagnosing AP in patients with FAI.

There is limited evidence comparing 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.

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, who had symptomatic FAI and OP, underwent arthroscopic surgery for FAI and endoscopic pubic symphysectomy for OP, with a mean follow-up period of 2.9 years (range of 2.0 to 5.0 years). 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 due to 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; nine 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; and outcome measures describing the number of recovered athletes, patient satisfaction, pain scores, or functional outcome scores. One author screened search results, and two 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; four 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 than 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 of 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 the effectiveness of surgical treatment in sportsman's hernia.

Elattar and colleagues (2016) stated that athletic pubalgia (AP) is increasingly recognized as a common cause of chronic groin and adductor pain in athletes. It is considered an overuse injury that predisposes individuals to disruption of the rectus tendon insertion to the pubis and weakness of the posterior inguinal wall without a clinically detectable hernia. Patients often require surgical therapy after failing non-operative measures. A variety of surgical options have been employed, 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 search terms such as 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 weakness in the rectus abdominis insertion or posterior inguinal wall of the lower abdomen caused by acute or repetitive injury to the structure. A variety of surgical options have been reported with successful outcomes, with high rates of return to 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 without a hernia present has not been designated. In a systematic review, these investigators examined whether surgical or conservative treatment is more effective in reducing pain and returning patients to habitual activity. They searched PubMed, Embase, and Cochrane databases and included adults diagnosed with chronic groin pain without a hernia. Treatments included inguinal hernia repair, tenotomy, and non-surgical management. Outcomes assessed included return to habitual activity, pain, patient satisfaction, re-operations for operated patients, and shifts to surgery for non-operated patients. They included randomized controlled trials (RCTs) and observational studies with more than 10 subjects, totaling 72 studies with 3,629 subjects. Only 5 studies used a comparison group. After inguinal hernia repair, 94% returned to habitual activity after a median of 10 weeks, 92% became pain-free, and 92% were satisfied with their treatment. After adductor tenotomy, 90% returned to habitual activity after a median of 12 weeks, 90% became pain-free, and 84% were satisfied. After combined inguinal hernia repair and adductor tenotomy, 97% returned to habitual activity after a median of 10 weeks, 92% became pain-free, and 91% were satisfied with their treatment. After non-surgical management, 80% returned to habitual activity after a median of 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 achieving patient satisfaction compared to conservative treatment.

Koutserimpas and associates (2020) noted that AP is an obscure sports injury, primarily presenting with groin pain during twisting movements. This 15-year study reported outcomes, intra-operative findings, and complications of endoscopic surgical treatment in competitive athletes. All competitive athletes suffering from AP, treated with the laparoscopic Total Extra-Peritoneal technique at the Department of General, Laparoscopic, Oncologic, and Robotic Surgery of the Athens Medical Center from 2004 to 2018, were included in this retrospective cohort. Post-operative pain, complications, return to previous training routines, and patient satisfaction were evaluated. A total of 130 patients (115 males and 15 females) with a mean age of 26.7 ± 7.5 years were evaluated. Pre-operatively, the mean numeric pain scale (NPS) was 7.7 ± 1.7. Three days post-operatively, the mean NPS was 3.4 ± 1.5, showing a 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%) experienced slight numbness in the groin area during the first 6 post-operative months, and 1 patient (0.8%) suffered from a post-operative hematoma. No recurrences were observed. At the final follow-up (mean of 76.58 ± 46.5 months), 97 patients (74.7%) were very satisfied, 31 (23.8%) were satisfied, and 2 (1.5%) were not satisfied with the outcome. The authors concluded that laparoscopic operative treatment in competitive athletes suffering from AP offers rapid recovery, a quick return to sports, a very low complication 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 based on intra-operative findings. Outcome measures included the 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), consisting of 94.0% males and 6.0% females. Nerve entrapment was demonstrated in 96.2% of cases, with involvement of the ilio-inguinal nerve in 92.5%, the ilio-hypogastric nerve in 30.8%, and the genito-femoral nerve 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, with 2 athletes requiring 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 the limitations of this study were similar to those of other studies reporting 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 a homogeneous group of athletes. This highlights the point that groin injuries vary widely in their pathology, and therefore surgical repair involves a variety of techniques. The authors believe that the visualized pathology should dictate the surgical technique employed, differing from many previous reports where the same surgery is performed regardless of clinical presentation. The inclusion of patients post-hip arthroscopy is a limitation of this study, as the condition can overlap. However, all patients previously treated with hip arthroscopy for femoroacetabular impingement (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. Lastly, this series mixed all levels of athletes, allowing readers to make generalizations 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 would be an effective method of treatment for recalcitrant groin/adductor pain in these athletes. This trial was conducted on NFL players and NCAA Division I college athletes who underwent an adductor longus tendon release with or without sports hernia repair by one of two fellowship-trained orthopedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to perform effectively 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 follow-up time of 6.2 ± 4.2 years (range of 12 to 178 months). Of the 32 patients, 20 had a concomitant sports hernia 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 satisfaction with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. The mean return-to-play time was 12 weeks from the 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 athlete performance scores (p = 0.74) and the percentage of games started versus played (p = 0.46). After separating players who had a concomitant sports hernia repair from those 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 sports hernia 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. The level of evidence was 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 due to 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 one or more of the authors declared potential conflicts of interest or sources 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 healthcare clinicians and aggravating for those experiencing pain. Frequently referred to as sports hernia (SH) or athletic pubalgia (AP), many surgeons continue to refute the diagnosis due to a lack of consensus and clear understanding of the basic pathophysiologic features of this groin pain syndrome. Understanding the anatomic and pathophysiologic findings of groin pain syndrome is necessary for appropriate treatment. In general, the level of evidence in the literature is relatively low quality. Exercise-based therapy can be an effective first-line treatment for individuals who develop groin pain syndrome. Surgical therapies are typically reserved for those who experience failure of non-operative management. Common features of the varied surgical procedures include changes in the vectors of pull on the pubic bone or joint, defects in the inguinal canal, and 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 a return to an active lifestyle and sport. Regarding operative therapies, these researchers stated that most studies were single-center case series with low-quality evidence, and the patient populations described were predominantly high-performance male athletes, with the most common endpoint 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 endpoint has been return-to-sport or resolution of symptoms. The mean length of follow-up varied widely; 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."

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 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 that inguinal hernia repair with adductor tenotomy is 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 multifactorial disease to improve 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 two academic institutions. The average age of patients was 23.4 years. Athletic activities reported by the patients included 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). The mean operative time was 72.4 minutes. Most patients returned to athletic activity within 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 out of 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 noted on the contralateral side. The main drawbacks of this study were its retrospective design and that all surgeries were performed by one surgeon.

Kraeutler and colleagues (2021) conducted a systematic review of reported terminologies, surgical techniques, pre-operative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI), athletic pubalgia (AP), and inguinal disruption. The systematic review involved searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to non-operative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The review extracted and reported the diagnostic terminology, country of publication, pre-operative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article. A total of 31 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 (MRI) of the pelvis were the most common imaging modalities used in the pre-operative evaluation of CMI/AP/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 orthopedic and general surgeons (7 articles), or orthopedic 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 based on surgeon subspecialty, geographic location, and year of publication. The authors concluded that a variety of diagnostic methods and surgical procedures have been used in the treatment of CMI/AP/sports hernia/inguinal disruption, with procedures differing based on surgeon subspecialty and geographic location. Level of Evidence = V.

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. They searched the PubMed and Embase databases for articles reporting surgical treatment of inguinal-, pubic-, or adductor-related CGP in athletes. Inclusion criteria included levels I to IV evidence, a mean patient age of greater than 15 years, and results presented as return-to-sport, pain, or functional outcomes. Quality assessment was carried out using 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, involving 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 over 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 levels was observed in 92% (95% CI: 88% to 95%) of 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 levels was more likely after surgery for inguinal-related CGP (92%) compared to adductor-related CGP (75%); however, the majority of studies reviewed were methodologically low-quality due to the lack of comparison groups. They 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 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) were runners, and 3.8% (18 of 468) were 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 that of 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, as it should be the cornerstone of conservative treatment. The quality of the studies detailing the results of conservative management was higher than that of surgical procedures. These researchers stated that for future studies, it is important to use standard measures and criteria for return to sport. They emphasized that studies with better methodological controls, including larger sample sizes, are important to generalize results to a larger population, enhancing external validity.

The authors noted several drawbacks of this systematic review. First, the different methods used between studies made it difficult to generalize the findings. Second, the description of the diagnosis of pubalgia was not always clear in all studies, with varying diagnostic approaches influencing the non-standardization of outcomes. Third, regarding the outcomes, the different health indicators used and the fact that few studies had criteria for RTS increased heterogeneity between studies, contributing to the inability to perform a meta-analysis. Fourth, follow-up studies can be more reliable for examining the success of RTS, a fact that did not always occur and varied in timing between 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 an 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 the distance from surrounding anatomy. The RA insertional footprint was measured at 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, while 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 located 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 positioned just lateral to the ilio-inguinal nerve, at distances of 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 aware 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 acknowledged several drawbacks of this study. First, it was a cadaveric study of uninjured patients, and as such, the distances between structures may vary in injured, pathologic tissue compared to healthy tissue. However, the footprints for the tendons should not change, except for variations 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 to maintain consistency in anatomy across all specimens. Since female patients account for only 5% to 15% of patients with AP, the researchers chose to focus their examination on male specimens only, eliminating any between-sex differences that may have been observed. Fourth, the authors were unable to isolate and describe the ilio-hypogastric nerve because it was not included within their cadaveric tissue due to processing of the cadavers. This nerve has been implicated in lower abdominal and pelvic neurogenic pain.

Rezaie et al. (2024) noted that if non-operative treatment for sports hernia (SH) fails, surgical repair may be necessary. Bilateral repair can occur in up to 45% of surgically treated patients. In a single-surgeon, case-series study, these researchers examined the clinical outcomes of athletes who underwent unilateral SH repair and determined the proportion of patients who required contralateral SH repair. They identified patients at their center who underwent primary unilateral SH repair (rectus abdominis-adductor longus aponeurotic plate repair and adductor lengthening) with a single surgeon between 2015 and 2020. They evaluated patient-reported outcomes (PROs) using the Hip Outcome Score-Sport (HOS-Sport), the numeric pain scale (NPS) score, and an internally developed return-to-play questionnaire. They also collected data regarding subsequent SH procedures on the ipsilateral or contralateral side. Summary statistics for outcomes were calculated, and the association between pre-injury patient characteristics and the HOS-Sport score at follow-up or successful return to pre-injury sport was examined using linear and logistic regression, respectively. A total of 104 of 128 (81.3%) eligible patients (mean age at surgery of 23.0 ± 6.2 years; 94.2% male; 51.9% American football athletes) completed follow-up at a mean time of 4.4 ± 1.5 years. Overall, 79.8% of athletes (n = 83) were able to return to their pre-injury sport/activity, but 90.2% (83/92) who attempted to return were able to do so. When examining reasons for not returning to pre-injury sport, only 9 patients reported not returning due to limitations or persistent symptoms from their original injury. Only 4 patients underwent subsequent SH procedures (3 contralateral, 1 ipsilateral revision) after their index unilateral SH repair. At follow-up, the mean HOS-Sport score was high (94.0 ± 10.8), and the mean NPS score was low (0.31 ± 1.26). There were no pre-injury patient characteristics associated with either the HOS-Sport score at follow-up or the successful return to pre-injury sport. The authors concluded that patients with unilateral SH symptoms could undergo repair and return to sport at the pre-injury level with little concern for injuries to the contralateral groin. In this cohort, patient-reported hip function and pain outcomes at follow-up were excellent.

In a narrative review, Dudai and Paajanen (2026) reviewed sportsman’s hernia and athletic pubalgia (SH/AP) and described diagnostic evaluation, indications for surgery, surgical approaches, rehabilitation, and outcomes based on the published literature and approximately 30 years of clinical experience. The review stated that surgical intervention was considered after 2–3 months of failed conservative treatment or when athletes had recurrent or worsening pain, grade 4–5 injury, complete tendon or muscle tears, or inguinal nerve entrapment. Surgical approaches included open repair, transabdominal preperitoneal repair (TAPP), totally extraperitoneal repair (TEP), and TEP with Release and Reinforce Technique (TEP-RRT). The review described TEP-RRT as a two-stage endoscopic procedure consisting of a release phase with adhesiolysis, scar tissue and lipoma excision, pubic symphysis and pubic bone debridement, neurolysis, and inguinal ligament division for nerve decompression, followed by a reinforce phase with placement of a 13 × 16 cm midweight mesh and biologic glue fixation to reinforce the posterior wall and pubic region. The review reported that TEP repair reinforced the posterior wall and pubic region and was performed extraperitoneally to avoid intra-abdominal complications. Reported outcomes from a prospective study of 150 athletes undergoing TEP-RRT showed thigh nerve entrapment decreased from 96% preoperatively to 1.3% at 8 weeks postoperatively, 100% returned to sport within 5–10 weeks, recurrence was 0%, and complications occurred in 1.3% of patients. A retrospective study of 461 athletes reported 98.5% returned to sport and remained active, 75% returned within 8 weeks and 25% within 12 weeks, recurrence was 0%, complications occurred in 1%, 10% required additional physiotherapy or pharmacologic treatment, and 96% rated outcomes as very good. The review concluded that TEP and TEP-RRT were preferred endoscopic approaches for athletes because they addressed posterior wall instability, pubic bone pathology, and nerve compression and were followed by a structured rehabilitation program. Existing TEP-RRT studies lacked a control group, and the review stated that prospective randomized controlled trials were needed.

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. PDR was performed on 32 patients who experienced chronic pain refractory to conservative therapies over the last three months. The treatment targeted the genital branches of the genitofemoral, ilio-inguinal, and ilio-hypogastric nerves, as well as the obturator nerve. A 10-cm, 20-gauge cannula was inserted percutaneously at the upper and lower edges of the ilio-pubic branch. After removing the spindle, a radiofrequency needle with a 10-mm "active tip" was inserted. The radiofrequency technique involved delivering 1,200 pulses at 45 V for 20 milliseconds, followed by a 480 milliseconds silent phase. Follow-up clinical examinations were conducted at 1, 3, 6, and 9 months post-procedure, during which patients rated their pain on a 0 to 10 Visual Analog Scale (VAS). All enrolled patients completed the study. The mean VAS score before treatment was 8.4 ± 0.6; 24 patients reported a reduction of more than 50% in VAS scores during all follow-up visits and were able to start training and physiotherapy shortly after the radiofrequency procedure. Six patients, who received treatment twice, reported a similar reduction in VAS scores and began training and physiotherapy only after the second procedure. One patient did not experience pain relief after two treatments. Pain intensity decreased over the nine months, with mean 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 for managing chronic pubalgia in athletes, although these preliminary findings need validation through well-designed studies.

McKeeman et al. (2025) stated that athletic pubalgia (AP) is a relatively uncommon injury that is not fully understood, and there are few high-level studies comparing treatments for AP. In a systematic review, these investigators compared two common techniques—rectus abdominis repair and posterior wall reinforcement—for the treatment of AP. Inclusion and exclusion criteria were established and applied to search strategies in PubMed and Medline. Two reviewers screened studies based on the agreed-upon criteria, first reviewing titles and abstracts and then conducting a secondary screen of full-text studies. A total of 59 full-text articles were reviewed, and 13 were selected for this study. The study designs included 7 prospective studies, 5 retrospective studies, and 1 randomized controlled trial (RCT). Five studies involved rectus abdominis repair, while 8 studies focused on posterior wall reinforcement. The median age range of participants was 22 to 32 years, and the mean follow-up time ranged from 1 month to 12.5 years. The success rate for rectus abdominis repair ranged from 76% to 96%, while the success rate for posterior wall reinforcement ranged from 72% to 98%. Both procedures performed similarly, with success rates ranging from about 70% to 90%. The authors concluded that the lack of standardization in clinical outcomes made comparisons across studies difficult, making it challenging to determine which procedure performed better. They emphasized the need for future research to focus on more specific outcomes, frequent follow-up, and standardization of outcome measures.

The authors noted that this study was narrow in scope and limited by the targeted procedures. Although these procedures comprised the bulk of operations performed for AP, several others not included in this study may perform as well or better than the two included procedures. A second limitation was that both screeners worked to extract abstracts from the databases without being blinded to the authorship of the studies, which could introduce bias in the screening process. However, to mitigate this, both screeners worked independently and had substantial agreement. When disagreements occurred, the article in question was fully reviewed, except for one article that both reviewers agreed to exclude. All studies in question were not included in the final 13 articles, and the reviewers achieved 100% agreement after an independent review of the full-text articles. Finally, most of the included articles exhibited lower levels of evidence (II to III), which reduced the overall level of evidence of this systematic review to level III. The scarcity of RCTs in this research area further lowered the level of evidence, highlighting the need for further investigations in the form of RCTs.

References