Research Review By Dr. Joseph Brence©

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Date Posted:

November 2014

Study Title:

‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference

Authors:

Sheen AJ, Stephenson BM, Lloyd DM, et al.

Author's Affiliations:

Department of Surgery, Central Manchester Foundation Trust, Manchester Royal Infirmary, Manchester, UK; Department of Surgery, Royal Gwent Hospital, Newport, UK; Department of Surgery, Leicester General Hospital, Leicester, UK.

Publication Information:

British Journal of Sports Medicine 2014; 48(14):1079-87. doi: 10.1136/bjsports-2013-092872.

Background Information:

Sportsman’s Groin (SG), also known as ‘athlete’s groin’ or (more recently) ‘inguinal disruption’ (ID), is a painful and disabling condition affecting elite and amateur athletes. Chronic pain in this region is often attributed to participating in sports that involve kicking and twisting movements, particularly while running (ex. soccer). The pain experienced with SG is often located at the common point of origin of the rectus abdominis, adductor longus tendon and the insertion of the inguinal ligament on the pubic bone.

This condition is considered by many as difficult to diagnose and manage, because there is no clear consensus on what the condition is, or what actually constitutes a diagnosis. The authors of this paper acknowledge that SG has been attributed to a hernia, groin disruption, an incipient hernia (athletic publagia), as well as simple groin pain, and their aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging and management of SG. This article is the result of a consensus development conference that was attended by 150 surgeons.

Overview of Sportsman’s Groin:

Summary of Nomenclature:
  • The expert panel arrived at a consensus regarding the term for this condition – inguinal disruption (ID). The researchers believed this more accurately described the condition compared to other terms such as ‘sportsman’s groin’ (it can happen in non-athletes) and ‘athlete’s/sportsman’s hernia’ (there is typically no actual hernia). This consensus is in agreement with other recent publications (1).
  • ID can be defined as pain, either of an insidious or acute onset, which occurs predominantly in the groin area near the pubic tubercle where no obvious other pathology, such as a hernia, exists to explain the symptoms.
Pathology:
  • Inguinal disruption appears to result from weakening of the posterior wall of the inguinal canal. This appears in up to 85% of athletes with this condition (2).
  • In some athletes, there is also evidence for disruption of the external oblique aponeurosis.
  • Other pathology, such as dilation of the external ring, conjoint tendon tears and inguinal ligament splitting (dehiscence) might also be present.
Clinical Presentation/Diagnosis:
  • The patient will complain about pain experienced at the common pubic bone attachment region of the rectus abdominis, adductor longus tendon and inguinal ligament.
  • The clinical diagnosis of inguinal disruption can be made if at least three out of the five clinical signs below are detectable:
    1. Pinpoint tenderness over the pubic tubercle at the point of insertion of the conjoint tendon;
    2. Palpable tenderness over the deep inguinal ring;
    3. Pain and/or dilation of the external ring with no obvious hernia evident;
    4. Pain at the origin of the adductor longus tendon;
    5. Dull, diffuse pain in the groin, often radiating to the perineum and inner thigh (or across the midline).
Clinical Examination:
  • Inguinal disruption is essentially a diagnosis of exclusion and other causes of chronic groin pain must be ruled out such as osteitis pubis, pubic rami fractures, bursitis, slipped epiphysis, acetabular injury, femoroacetabular impingement and early osteoarthritis.
  • Pain below and lateral to the inguinal ligament may indicate hip pathology or adductor longus injury with pain above the inguinal ligament more indicative of ID.
Imaging Considerations:
  • Imaging is recommended in all patients with inguinal disruption to rule out other differential diagnoses.
  • Conventional X-rays and CT do not appear to aid in this diagnosis, as bone morphology does not correlate with symptoms. In this condition, these imaging techniques are insensitive to soft tissue changes and edema.
  • Therefore, groin MRI is the preferred method of imaging in patients with suspected ID. The two MRI patterns that one would expect to see in athletes with groin pain are:
    1. Young athletes < 18 years of age – diffuse bilateral edema which can be equivalent to a stress response;
    2. Older athletes > 18 years of age – more focal edema in subcortical bone and capsule/enthesis, usually bilateral but asymmetrical.
  • Ultrasound of the pubic symphysis/enthesis and/or inguinal canal is rarely of value as the osseous, capsular and entheseal edema seen on MRI is not visible. Although ultrasound is accurate for complete or partial adductor tears (an important differential diagnosis), these are rarely present in these athletes despite marked soft tissue edema on MRI.
Management of Inguinal Disruption/Sportsman’s Groin:

The consensus is that an athlete should undergo individualized training, with an emphasis of care placed on the stabilizing role of the internal obliques, transverses abdominis, gluteals and adductors. Throughout the rehabilitation program, it is important to make exercises and movements as sport/occupation specific as possible. The authors gave general guidelines for a rehabilitation program:
  • Week 1: Initiation of the functional program emphasizing spinal mobilization and isometric contractions of the abdominals and hip musculature.
  • Week 2: Increase walking time, using time as a limiting factor, increasing by 5 minutes each day.
  • Week 3: Begin more functional rehabilitation such mobility and stability work, as well as cardiovascular activities such as swimming and cycling.
  • Week 4: Return to active assisted work and early sport/occupational specific rehabilitation.
  • Week 5: Work on concentric/eccentric lower limb muscle patterns and return to play/work activity.
The Role of Surgery:

The panel also suggested that if symptoms persist for more than 2 months (they considered this chronic groin pain), surgical evaluation/correction should be considered (open or laparoscopic). The role of surgery is to release the abnormal tension in the inguinal canal and reconstruct the weakness in the posterior wall with a mesh.

Clinical Application & Conclusions:

Inguinal disruption (ID) has been defined as a condition often seen in athletes, who present to your clinic with groin pain (near the pubic tubercle). A multidisciplinary approach is recommended for care and radiological imaging is recommended in many cases to exclude other conditions. MRI is recommended as the best imaging modality to help rule in ID. Lastly, this condition should be treated conservatively for the first two months. If the patient still experiences significant discomfort or is failing to progress during a treatment and rehabilitation program, a surgical consultation should be pursued.

Study Methods:

This was a publication based upon the results of a consensus development conference held in Manchester, United Kingdom, attended by 150 surgeons.

Study Strengths / Weaknesses

Strengths:
  • There is little established and accepted research about the etiology and diagnosis of ID. This conference led to the formulation of general guidelines for the condition.
Weaknesses:
  • This article was based on conference discussion and expert opinion. Conference participants were surgeons, and this consensus statement would have been strengthened by the addition of experts from other disciplines (ex. physiotherapy, chiropractic, physical rehabilitation). Having said that, attendees were deemed experts in this condition, and therefore are presumably familiar with the research (we hope!).
  • Recommendations were provided in several portions of this article, without citing evidence for those recommendations.

Additional References:

  1. Garvey JFW, Hazard H. Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia 2013. DOI: 10.1007/s10029-013-1161-0.
  2. Kesek P, Ekberg O, Westlin N. Herniographic findings in athletes with unclear groin pain. Acta Radiol 2002; 43: 603–8.