Inguinal-Related Groin Pain in Athletes +MP3
Research Review By Dr. Joshua Plener©
Audio:
Date Posted:
February 2023
Study Title:
Inguinal-related groin pain in athletes: a pathological potpourri
Authors:
Vuckovic Z, Serner A, Heijboer W, et al.
Author's Affiliations:
Sports Groin Pain Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar; Amsterdam UMC location University of Amsterdam, Academic Center for Evidence Based Medicine, Amsterdam IOC Center; Amsterdam Movement Sciences, Sports, Amsterdam, The Netherlands
Publication Information:
British Medical Journal Open Sport & Exercise Medicine 2022; 8: e001387.
Background Information and Summary:
Athletes with pain in the inguinal canal region with no palpable hernia present a challenge for clinicians. Pain within this region can be a result of several conditions, many of which are musculoskeletal in nature and form the focus of this editorial paper.
When it comes to pain within the inguinal canal region due to musculoskeletal causes, there is still a lack of consensus on the appropriate terminology that should be used. For instance, a survey of 23 international groin pain experts were presented a case of a male football player with inguinal region pain and were asked which term they would use to describe the diagnosis (1). The experts used 22 different terms, including but not limited to: inguinal related groin pain, sportsman’s hernia, and incipient hernia (1). A subsequent expert consensus meeting was able to achieve consensus on a new, preferred term: inguinal-related groin pain (2).
In addition to the debate on the appropriate name, there are also numerous hypotheses on the pathology of inguinal-related groin pain, resulting in uncertainty surrounding its pathogenesis. The leading theories include:
When it comes to pain within the inguinal canal region due to musculoskeletal causes, there is still a lack of consensus on the appropriate terminology that should be used. For instance, a survey of 23 international groin pain experts were presented a case of a male football player with inguinal region pain and were asked which term they would use to describe the diagnosis (1). The experts used 22 different terms, including but not limited to: inguinal related groin pain, sportsman’s hernia, and incipient hernia (1). A subsequent expert consensus meeting was able to achieve consensus on a new, preferred term: inguinal-related groin pain (2).
In addition to the debate on the appropriate name, there are also numerous hypotheses on the pathology of inguinal-related groin pain, resulting in uncertainty surrounding its pathogenesis. The leading theories include:
Nerve Entrapment Theories:
- Entrapment of the peripheral nerves (ilioinguinal, iliohypogastric and genitofemoral). This may occur with direct trauma and/or inflammatory conditions.
- Posterior abdominal wall weakness and/or bulge (‘incipient’ or ‘sports hernia’) that results in: 1) insufficient strength of the fascia to withstand the repeated high intra-abdominal pressure created by sport activities; 2) distension of the peritoneum or stretching of the ilioinguinal nerve; 3) painful coughing or potential surgical findings; 4) nerve irritation/entrapment; 5) tension via cranial/medial retraction of the rectus abdominus, leading to possible pubalgia; or 6) protrusion of preperitoneal fat in the deep (widened) inguinal orifice due to a higher conjoint tendon attachment.
- Tear of the external oblique muscle resulting in nerve irritation when a tear occurs at the emergence of the neurovascular bundle containing the terminal branches of the iliohypogastric nerve.
Musculoskeletal Pathology Theories:
- Muscle imbalance causing pain and changes at the public bones due to a weak anterior abdominal wall and/or hypertrophic lower limb muscles. This could lead to excessive functional overload of muscular and tendon insertions at the pubic bone.
- Severe musculotendinous injury such as a torn external oblique aponeurosis.
- Pain due to an insertional shearing injury of the muscular attachments at the pubis, mainly the inguinal canal, rectus abdominis, and adductor muscles.
- Inguinal ligament enthesopathy at the pubic tubercle due to excessive stress during lateral abdominal muscle contraction.
Most theories are based on a combination of two main ideas: 1) nerve irritation of the ilioinguinal, iliohypogastric and/or genitofemoral nerve in the inguinal region, and 2) a musculoskeletal pathology including aponeurotic tears and inguinal ligament enthesopathy.
Further to the pathophysiology of inguinal-related groin pain, patients can present in many ways. Some patients present with a brief history of pain related to specific explosive movements, while others have pain for weeks to months following sporting activity. The character of pain can be described by individuals through various terms such as electric, burning, and stabbing. The examination of an individual with inguinal-related groin pain includes palpating the different structures to elicit tenderness. However, some individuals will be pain free in clinic, and only the case history and sport-specific testing, combined with appropriate imaging can help lead to the correct diagnosis (remember, imaging may not always provide a clear answer!).
Currently, the literature on inguinal-related groin pain is heavily focused on surgical treatment including anterior open mesh or non-mesh reinforcement of the posterior wall, and posterior endoscopic mesh reinforcement of the posterior wall with or without an inguinal ligament ‘release’. Interestingly, a recent multicentre RCT comparing open and endoscopic repair did not find any clinically relevant difference in the outcomes (3).
Further to the pathophysiology of inguinal-related groin pain, patients can present in many ways. Some patients present with a brief history of pain related to specific explosive movements, while others have pain for weeks to months following sporting activity. The character of pain can be described by individuals through various terms such as electric, burning, and stabbing. The examination of an individual with inguinal-related groin pain includes palpating the different structures to elicit tenderness. However, some individuals will be pain free in clinic, and only the case history and sport-specific testing, combined with appropriate imaging can help lead to the correct diagnosis (remember, imaging may not always provide a clear answer!).
Currently, the literature on inguinal-related groin pain is heavily focused on surgical treatment including anterior open mesh or non-mesh reinforcement of the posterior wall, and posterior endoscopic mesh reinforcement of the posterior wall with or without an inguinal ligament ‘release’. Interestingly, a recent multicentre RCT comparing open and endoscopic repair did not find any clinically relevant difference in the outcomes (3).
Clinical Application & Conclusions:
This article presents a short, yet informative synopsis of inguinal-related groin pain, a challenging clinical entity. Individuals presenting with signs and symptoms of pain in the inguinal region require a thorough history and physical examination in order to identify the correct course of action. Despite inguinal-related groin pain being a vague term, based on the leading theories for this pathology, further distinction into the exact pathology can’t be supported. To advance this field, future research needs to further define a comprehensive approach, including:
- Reliable tests of the suggested pathologies.
- Knowledge of normal findings in the athletic population.
- Acceptance of various pathologies that may co-exist and are not mutually exclusive.
- Understanding that there is significant variation between individual anatomy and nerve distribution.
Study Methods:
There were no methods presented for this article, as it was an editorial.
Study Strengths / Weaknesses:
Strengths:
- This editorial provides clinicians with a concise, contemporary understanding of inguinal-related groin pain.
- This article provides an understanding of the current state of the literature and where future research can help fill in some knowledge gaps.
Weaknesses:
- There is no specific methodology for this article and therefore the information presented may be a biased view of the literature.
Additional References:
- Weir A, Hölmich P, Schache AG, et al. Terminology and definitions on groin pain in athletes: building agreement using a short Delphi method. Br J Sports Med 2015; 49: 825–7.
- Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49: 768–74.
- Sheen AJ, Montgomery A, Simon T, et al. Randomized clinical trial of open suture repair versus totally extraperitoneal repair for treatment of sportsman's hernia. Br J Surg 2019; 106: 837–44.
