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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 109-116

Chronic groin pain in young sportsmen: Algorithm of assessment and treatment


Centro de Patología Herniaria Argentina (C.P.H.), Bueno Aires, Argentina

Date of Submission21-May-2021
Date of Decision05-Jul-2021
Date of Acceptance07-Aug-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Osvaldo Santilli
Centro de Patología Herniaria Argentina (C.P.H.), Bueno Aires.
Argentina
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_30_21

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  Abstract 

Background: Chronic groin pain (CGP) is a syndrome characterized by pain in the pubic and inguinal-crural regions, resulting in a functional deficit that can lead to severe impairment of different motor tasks. Objective: The main objective of this study is to describe and analyze an algorithm used for the assessment and treatment of chronic groin pain in young sportsmen used for 10 years. Methods: Descriptive, observational, and retrospective study, adapted with recommendations of the STROBE Declaration (Strengthening Reporting of Observational Studies in Epidemiology) for its design. The study was carried out at an Hernia Pathology Center. It is a multidisciplinary team formed by surgeons, physiotherapists, orthopedists, and imaging specialists, with extensive experience in the research field. This team had developed an assessment, diagnosis, and treatment algorithm for CGP which was implemented for more than 15 years. Results: After clinical examination and complementary imaging, 3,858 patients were included to follow the algorithm. A total of 3,289 patients completed the sports physiotherapy and rehabilitation protocol. The most frequent clinical entities registered were tendinopathies: 1,649 iliopsoas-pectineus-related groin pain (42.7%) and 1,522 adductor-related groin pain (39.5%). A total of 569 patients with sportsman’s hernia diagnosis required surgical intervention. There were no intraoperative complications; furthermore, all patients discharging after 6 hours of hospital stay. Conclusions: The assessment, diagnosis, and treatment algorithm used by a multidisciplinary team to treat patients with chronic groin pain has proven to be safe and successful.

Keywords: Algorithm, chronic groin pain, sportsmen hernia, young athletes


How to cite this article:
Santilli O, Ostolaza M, Santilli H, Nardelli N, Etchepare H, Scaravonati R, Estevez M, Rolon A, Pascual T, Siedi A, Munafo Dauccia R, Perea A. Chronic groin pain in young sportsmen: Algorithm of assessment and treatment. Int J Abdom Wall Hernia Surg 2021;4:109-16

How to cite this URL:
Santilli O, Ostolaza M, Santilli H, Nardelli N, Etchepare H, Scaravonati R, Estevez M, Rolon A, Pascual T, Siedi A, Munafo Dauccia R, Perea A. Chronic groin pain in young sportsmen: Algorithm of assessment and treatment. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Dec 6];4:109-16. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/3/73/327064




  Introduction Top


Chronic groin pain (CGP) is a syndrome characterized by pain in the pubic and inguinal-crural regions, resulting in a functional deficit that can lead to severe impairment of different motor tasks such as kicking and twisting movements while running, triggering the cessation of sports activities.[1],[2],[3],[4]

The term longstanding CGP is often used to describe the impact in the long period, as it is one of the most difficult diagnostic challenges. Furthermore, being an anatomically complex region, many different conditions that cause CGP can be considered in a differential diagnosis.[5],[6],[7],[8],[9],[10]

It is common in sports which require sharp cutting movements, as in kicking and running sports. Despite the difficulties in diagnosis, adductor-related CGP has been the most common clinical pattern of CGP in soccer players.[11],[12],[13],[14],[15],[16]

There are a wide variety of terms to describe CGP: “Sportsman Groin,” “Sportsman’s Hernia,” “Athletic Pubalgia,” “Gilmore groin syndrome,” “Pubis Osteitis,” generating confusion in understanding this pathology.[17],[18]

Sportsman’s groin or athletic pubalgia is a syndrome characterized by CGP during physical exertion and pelvic traction maneuver, during or after sports. These athletes will present with ongoing complaints which may have been present for months to years. In these athletes, determining the exact cause of the pain may prove quite elusive due to the lengthy differential diagnostic possibilities.[19]

The incidence had increased in the last 10 years, being one of the most frequent athlete consultations.[20]

There are clinical guidelines with recommendations, considering the use of algorithms for assessment, diagnosis, and treatment.[21],[22],[23],[24]

The main objective of this study is to describe and analyze an algorithm used for the assessment and treatment of CGP in young sportsmen for 10 years.


  Materials and Methods Top


This is a descriptive, observational, and retrospective study, adapted with recommendations of the STROBE Declaration (Strengthening Reporting of Observational Studies in Epidemiology) for its design.

The study was carried out at a Hernia Pathology Center. The Center has provided health care for 20 years and is a reference in treating patients with abdominal wall pathologies. It is a multidisciplinary team formed by surgeons, physiotherapists, orthopedists, and imaging specialists, with extensive experience in the research field. This team had developed an assessment, diagnosis, and treatment algorithm for CGP, which was implemented for more than 15 years.

For the present study, data were collected from patients admitted in the last 10 years, from June 1, 2009 to June 1, 2019. The recruitment of patients was through a non-probabilistic sample consecutively.

Inclusion criteria are young patients (16–30 years old), chronic groin pain (more than 30 days with inguinal pain), insidious groin pain appearance, no apparent reason, related to physical activity and sports, tendinopathy, and sportsman’s hernia. Exclusion criteria are pain of known traumatic cause (such as a fracture), pain of known organic cause (such as ovarian pain and urovesical pain), pain which has not been assessed by the entire multidisciplinary team, patients older than 30 and younger than 16 years, and patients with less than 30 days of symptoms. Elimination criteria include diagnosis of inguinal hernia, femoroacetabular impingement, hip dysplasia, incomplete physiotherapy treatment protocol, and lack of diagnostic data.

Assessment, diagnosis, and treatment algorithm

The algorithm was developed and applied by the multidisciplinary team for more than 15 years. It was revised and modified over the years to arrive at the one that is currently being used. The reviews and modifications are carried out based on clinical experience, available evidence, and observations made at the assessment, diagnosis, and treatment.

Application method

The algorithm [Figure 1] has the following order: First, a clinical assessment performed by a surgeon, orthopedists, and an imaging specialist [Table 1]. With the information collected in the assessment form, the surgeon makes an initial diagnosis [Table 2]. Each professional assesses the patient separately so as not to be influenced at the time of doing the initial clinical impression. After the clinical examination finishes, the surgeon makes a provisional diagnosis based on the data obtained from an assessment form [Figure 2]. If a red flag is identified, representing a potential life threat (infection, tumor, or fracture), the patient is excluded from the protocol.
Figure 1: Algorithm

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Table 1: Clinical evaluation

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Table 2: Initial diagnosis

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Figure 2: Clinical file

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Next step, the patient is re-assessed and treated by a physiotherapist according to the initial diagnosis [Table 3]. Once patients complete the rehabilitation program, they return to the surgeon office to be re-evaluated in order to confirm or not the initial diagnosis. Finally, a definitive diagnosis is made and the respective treatment is indicated.
Table 3: Physiotherapist assessment

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When the main symptom is produced by sportsman’s hernia and does not respond to physiotherapy, we used laparoscopic trans-abdominal-pre-peritoneal (TAPP) hernioplasty followed by Sports Rehabilitation Protocol (SRP) (second-line treatment). No complementary images were used because diagnosis was confirmed during physical examination [Table 4].
Table 4: First-line treatment

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  Results Top


A total of 4,049 patients were assessed by the multidisciplinary team from June 2009 to June 2019; 191 patients were excluded because they did not meet the inclusion criteria or were lost during follow-up. After clinical examination and complementary imaging, 3,858 patients were included to follow the algorithm. Age, gender, practiced sport, and initial diagnosis are shown in [Table 5].
Table 5: Demographic features

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First-line treatment

A total of 3,289 patients completed the sports physiotherapy and rehabilitation protocol. The most frequent clinical entities registered were tendinopathies: 1,649 iliopsoas-pectineus-related groin pain (42.7%) and 1,522 adductor-related groin pain (39.5%) [Table 6]. When we analyzed clinical presentation according to age, 93% of the patients were younger than 20 years. Functional movement tests reported dysfunctions and were treated with individualized corrective exercises and tissue regeneration therapy designed by the physical therapist for each patient.
Table 6: Clinical diagnoses

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About 3,171 patients (82.2%), concerning groin pain related to the adductor and iliopsoas-pectineus tendinopathy, presented total recovery with physical therapy and SRP in 45 days; 260 patients did not respond to initial physical therapy treatment, an additional intra-tissue percutaneous electrolysis (EPI) was used on them with excellent response. Pain was assessed after initial treatment using VAS and by questioning about its presence during exercise.

Second-line treatment

A total of 569 patients with sportman hernia (SH) diagnosis required surgical intervention. In all cases, a laparoscopic transabdominal preperitoneal hernioplasty was performed. Most of them were bilateral (91.74%), corresponding to a total of 1,091 hernioplasties. The most frequent lesions finding was bilateral medial interruptions smaller than 20 mm. Preperitoneal tissue protrusion was also observed during the procedure, and a weakness in the posterior wall with an increase of the tension of the inguinal ligament was noted. Tendinopathy was associated in a group of patients (82%).

There were no intraoperative complications; furthermore, all patients were discharged after 6 h of hospital stay.

During the postoperative period, a total of 30 patients (5.27%) registered complications. The most frequent complication was omphalitis,[9] followed by tendinopathies,[7] epididymitis,[3] hematoma,[1] paresthesia,[1] and a serohematoma.[1] Nobody required hospital admission or surgical intervention. Two patients presented an umbilical trocar site hernia and required surgical repair.

There were no long-term complications related to surgery or mesh implantation. There is no registry of patients with CGP, infertility, chronic infection, or autoimmune responses.

Patients were telephoned 1 month after discharge from physical therapy to inquire about symptoms. After this call, patients have the telephone contact and email of the Hernia Pathology Center to communicate about new symptoms. Along 10 years of follow-up, we registered 15% of recurrent pectineal iliopsoas tendinopathy and 6% of recurrent adductor tendinopathy. All patients were diagnosed after 1 year of clinical discharge; furthermore, tendinopathy was improved with first-line treatment. We did not have recurrences of sports hernia or hip pathology.


  Discussion Top


There are a wide variety of terms to describe CGP, including “Sportsman’s Hernia,” “Athletic Pubalgia,” “Gilmore groin syndrome,” and “Pubis Osteitis,” which shows confusion in understanding this pathology. Athletic pubalgia or sportsman’s groin is a syndrome characterized by CGP during physical exertion and pelvic traction maneuver, during or after sports. The incidence had increased in the last 10 years, being one of the most frequent athlete medical consultations. In our population, rugby, football, and tennis are the most common sports involved in this pathology; this could be due to rapid acceleration and deceleration movements and repetitive twist and turning movements at high speeds. Currently, we know that imbalanced vector forces between abdominal and adductors muscles would produce chronic micro-tears with abnormal repairing known as tendinosis. The Doha agreement defines appropriate terminologies for inguinal pain: adductor-related, iliopsoas-related, inguinal-related, pubic-related, and hip-related. Other musculoskeletal causes of inguinal pain were infrequent (post-hernioplasty pain, nerve entrapment, stress fractures).

“Sportsman’s hernia” is a tendinosis process that affects the joint tendons and the inguinal ligament with the frailty of the posterior wall. The sensitive branches of the genitor-femoral nerve produce local pain that radiates in the nerve direction.

Our experience allowed us to define two principal entities of inguinal pain: tendinopathies and sportsman’s hernias. The conclusion of initial assessment is a provisional diagnosis according to the physical examination, followed by a multidisciplinary assessment based on clinical findings. Patients with a diagnosis of tendinopathy or sportsman’s hernia initiate physical therapy as first-line treatment.

We use the SRP phases as a reference for recovery. The progression of the phases is possible due to the absence of a considerable decrease in pain. An objective measure of physical improvement is allowed. Sports rehabilitation should be started immediately after diagnosis and is focussed on restoring a sportsman’s functional skills, considering dysfunctions and asymmetries in strength, flexibility, motor control, and posture.

After sports rehabilitation ended and without recurrences of the symptoms, the provisional diagnosis is confirmed and most probably matches the initial diagnosis. If there is a recurrence in patients with a sportsman’s hernia, a laparoscopic TAPP hernioplasty is performed; 24 h after the procedure is done, rehabilitation program is restored.

This algorithm was able to diagnose causes of tendinopathy in more than 80% of the consulted population. The most frequent pathologies were the iliopsoas-pectineal tendinopathy followed by adductor tendinopathy. According to this, an initial symptom of inguinal pain mostly corresponds to tendinopathy, which suggests that following the multidisciplinary assessment, diagnosis, and treatment algorithm, diagnostic error is avoided in most cases (persistence of symptoms) to a specific clinical presentation that matches with the correct diagnosis.

Furthermore, this provides information to clinicians for decision-making when a patient presents to the medical office with different clinical characteristics and allows a provisional diagnosis to be made and subsequently confirmed with physiotherapy.

This study provides descriptive data on the findings of clinical entities in CGP in young athletes. There was a high prevalence of tendinopathy and SH clinical entities. The physical examination has been helpful in reaching the differential diagnosis. The ultrasound has been used to document the causes of pain, but there must be a correlation with the physical sign examination.

This study has limitations of a retrospective study but reflects the multidisciplinary approach performed in a sports medicine center. The article presents methodological difficulties mainly attributable to the randomizing treatment in groups of performance athletes.


  Conclusion Top


The assessment, diagnosis, and treatment algorithm used by a multidisciplinary team to treat patients with CGP has proven to be safe and successful. About 3,858 patients over 10 years treated following the algorithm improved their symptoms, either during the first or second line of treatment. Also, we evidenced a high frequency of iliopsoas-pectineus tendinopathy and adductor tendinopathy compared with a low rate of sportsman’s hernia.

Ethics approval

Approval from the Institutional Review Board was not required for this study.

Financial support and sponsorship

No funding.

Conflicts of interest

None of the authors has conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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