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Clinical Policy Bulletin:
Athletic Pubalgia Surgery
Number: 0750


Policy

Aetna considers surgical treatment for athletic pubalgia experimental and investigational because the effectiveness of this approach has not been established.

See also CPB 0736 - Femoro-Acetabular Surgery for Hip Impingement Syndrome.



Background

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

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

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

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

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

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

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

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

In the discussions following a review article by Meyers et al (2008), several concerns were raised regarding their therapeutic approaches for SH: (i) the time to recovery and any adverse outcomes or complications associated with the procedures should be reported, (ii) a lack of comparative data between surgical procedures and non-operative management, and (iii) a number of patients with normal imaging were operated on; how does one determine who is likely to benefit in this group?

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

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

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

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

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

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

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

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

 
CPT Codes / HCPCS Codes / ICD-9 Codes
There is no specific code for athletic pubalgia surgery:


The above policy is based on the following references:
  1. Fredberg U, Kissmeyer-Nielsen P. The sportsman's hernia -- fact or fiction? Scand J Med Sci Sports. 1996;6(4):201-204.
  2. Meyers WC, Foley DP, Garrett WE, et al. 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(1):2-8.
  3. Fon LJ, Spence RA. Sportsman's hernia. Br J Surg. 2000;87(5):545-552.
  4. Society for Surgery of the Alimentary Tract (SSAT). Surgical repair of groin hernias. SSAT Guidelines for Physicians. Manchester, MA: Society for Surgery of the Alimentary Tract (SSAT); 2003. Available at: http://www.ssat.com/cgi-bin/guidelines.cgi. Accessed February 20, 2008.
  5. National Institute for Clinical Excellence (NICE). Laparoscopic surgery for inguinal hernia repair. Technology Appraisal 83. London, UK: National Institute for Clinical Excellence (NICE); September 2004. Available at: http://www.nice.org.uk/guidance/index.jsp?action=download&o=32924. Accessed February 20, 2008.
  6. Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: Definition and surgical treatment. Ann Plast Surg. 2005;55(4):393-396.
  7. Kaplan O, Arbel R. Sportsman's hernia -- a plea for conservative therapeutical approach. Harefuah. 2005;144(5):351-356, 381.
  8. Swan KG Jr, Wolcott M. The athletic hernia: A systematic review. Clin Orthop Relat Res. 2007;455:78-87.
  9. Farber AJ, Wilckens JH. Sports hernia: Diagnosis and therapeutic approach. J Am Acad Orthop Surg. 2007;15(8):507-514.
  10. Diesen DL, Pappas TN. Sports hernias. Adv Surg. 2007;41:177-187.
  11. Brooks DC. Sports-related groin pain or 'sports hernia'. Waltham, MA: UpToDate [online serial]; 2007.
  12. Caudill P, Nyland JA, Smith CE, et al. Sports hernias: A systematic literature review. Br J Sports Med. 2008;42(12):954-964.
  13. Meyers WC, McKechnie A, Philippon MJ, et al. Experience with "sports hernia" spanning two decades. Ann Surg. 2008;248(4):656-665.
  14. Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and "sports hernia": Optimal MR imaging technique and findings. Radiographics. 2008;28(5):1415-1438.
  15. Morales-Conde S, Socas M, Barranco A. Sportsmen hernia: What do we know? Hernia. 2010;14(1):5-15.
  16. Muschaweck U, Berger L. Minimal repair technique of sportsmen's groin: An innovative open-suture repair to treat chronic inguinal pain. Hernia. 2010;14(1):27-33.
  17. Silvis ML, Mosher TJ, Smetana BS, et al. High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players. Am J Sports Med. 2011;39(4):715-721.
  18. Litwin DE, Sneider EB, McEnaney PM, Busconi BD. Athletic pubalgia (sports hernia). Clin Sports Med. 2011;30(2):417-434.
  19. Larson CM, Pierce BR, Giveans MR. Treatment of athletes with symptomatic intra-articular hip pathology and athletic pubalgia/sports hernia: A case series. Arthroscopy. 2011;27(6):768-775.
  20. Hammoud S, Bedi A, Magennis E, et al. High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement. Arthroscopy. 2012;28(10):1388-1395.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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