Tuesday, 11 May 2010

Pubic Inguinal Pain Syndrome - Sports Hernia ?

G. Campanelli

Received: 28 September 2009 / Accepted: 4 December 2009 / Published online: 6 January 2010

Sports hernia (SH) is a controversial condition which presents

itself as chronic groin pain. It is responsible for signiWcant

time away from work and sports competition, with

an incidence of between 0.5 and 6.2% [1–3]. Groin injury is

common in soccer and ice hockey players, but SH can be

encountered in a variety of sports, and even in normally

physically active people [1, 3]. For this reason, we think

that it is more appropriate to speak of pubic inguinal pain

syndrome (PIPS).

Over the past decade, the number of sports-related

injuries has increased as a function of increased athletic

activities, and the demand for an early return to work and

competitive sports puts pressure on the doctor for immediate

diagnosis and treatment [1–3].

The anatomy involved, diagnostic criteria and treatment

modalities are inconsistently described in the medical,

surgical and orthopaedic literature. In fact, there is no

evidence-based consensus available to guide the decisionmaking,

and most of the studies are level IV investigations

[1, 3, 4].
Click on the enclosure link for article

The groin triangle: a patho-anatomical approach to the diagnosis of chronic groin pain in athletes.

Br J Sports Med. 2009 Mar;43(3):213-20. Epub 2008 Nov 19.

Falvey EC, Franklyn-Miller A, McCrory PR.

Centre for Health, Exercise and Sports Medicine, School of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Victoria, Australia. e.falvey@mac.com


Chronic groin pain is a common presentation in sports medicine. It is most often a problem in those sports that involve kicking and twisting movements while running. The morbidity of groin pain should not be underestimated, ranking behind only fracture and anterior cruciate ligament reconstruction in terms of time out of training and play. Due to the insidious onset and course of pathology in the groin region it commonly presents with well-established pathology. Without a clear clinical/pathological diagnosis, the subsequent management of chronic groin pain is difficult. The combination of complex anatomy, variability of presentation and the non-specific nature of the signs and symptoms make the diagnostic process problematical. This paper proposes a novel educational model based on patho-anatomical concepts. Anatomical reference points were selected to form a triangle, which provides the discriminative power to restrict the differential diagnosis and form the basis of ensuing investigation. This paper forms part of a series addressing the three-dimensional nature of proximal lower limb pathology. The 3G approach (groin, gluteal and greater trochanter triangles) acknowledges this, permitting the clinician to move throughout the region, considering pathologies appropriately.

A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes.

Sports Med Arthrosc Rehabil Ther Technol. 2009 Mar 31;1(1):5.

Machotka Z, Kumar S, Perraton LG.

Centre for Allied Health Evidence, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia. saravana.kumar@unisa.edu.au.


ABSTRACT: BACKGROUND: Athletes competing in sports that require running, changes in direction, repetitive kicking and physical contact are at a relatively higher risk of experiencing episodes of athletic groin pain. To date, there has been no systematic review that aims to inform clinicians about the best available evidence on features of exercise interventions for groin pain in athletes. The primary aim of this systematic review was to evaluate the available evidence on the effectiveness of exercise therapy for groin pain in athletes. The secondary aim of this review was to identify the key features of exercise interventions used in the management of groin pain in an athletic population. METHODS: MEDLINE, CINAHL, PubMed, SPORTSDiscus, Embase, AMED, Ovid, PEDro, Cochrane Controlled Trials Register and Google Scholar databases were electronically searched. Data relating to research design, sample population, type of sport and exercise intervention was extracted. The methodological evaluation of included studies was conducted by using a modified quantitative critical appraisal tool. RESULTS: The search strategy identified 468 studies, 12 of which were potentially relevant. Ultimately five studies were included in this review. Overall the quality of primary research literature was moderate, with only one randomised controlled trial identified. All included studies provided evidence that an exercise intervention may lead to favourable outcomes in terms of return to sport. Four of the five studies reviewed included a strengthening component and most utilised functional, standing positions similar to those required by their sport. No study appropriately reported the intensity of their exercise interventions. Duration of intervention ranged from 3.8 weeks to 16 weeks. All five studies reported the use of one or more co-intervention. CONCLUSION: Best available evidence to date, with its limitations, continues to support common clinical practice of exercise therapy as a key component of rehabilitation for groin pain in athletes. Overall, the available evidence suggests that exercise, particularly strengthening exercise of the hip and abdominal musculature could be an effective intervention for athletes with groin pain. Literature provides foundational evidence that this may need to be in the form of progressive exercises (static to functional) and performed through range. There is currently no clear evidence regarding the most effective intensity and frequency of exercise, because of a lack of reporting in the primary literature.

The inguinal release procedure for groin pain: initial experience in 73 sportsmen/women.

Br J Sports Med. 2009 Aug;43(8):579-83. Epub 2009 Jan 21.

Mann CD, Sutton CD, Garcea G, Lloyd DM.

Department of Surgery, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester, UK. chris.mann@doctors.org.uk


OBJECTIVE: To assess the impact of the laparoscopic inguinal release procedure with mesh reinforcement on athletes with groin pain. DESIGN: Prospective cohort study. SETTING: Private sector. PATIENTS: Professional and amateur sportsmen/women undergoing the inguinal release for groin pain. MAIN OUTCOME MEASUREMENTS: Change in patient's symptoms, functional limitation and time to resuming sporting activity following surgery. RESULTS: 73 sportsmen/women underwent laparoscopic inguinal release in the study period, 37 (51%) of whom were professionals. 95% were male with a median age of 30 years. Following operation, patients returned to light training at a median of 1 week, full training at 3 weeks (professionals-2 weeks) and playing competitively at 4 weeks (professionals-3 weeks). 74% considered themselves match-fit by 4 weeks (84% of professionals). Following surgery, there was a highly significant improvement in frequency of pain, severity of pain and functional limitation in both the whole cohort and professional group. 88% reported a return to full fitness at follow-up, with 73% reporting complete absence of symptoms. 97% of the cohort thought the operation had improved their symptoms. CONCLUSIONS: This study shows that the laparoscopic inguinal release procedure may be effective in the treatment of a subgroup of athletes with groin pain.

Adductor-related groin pain in recreational athletes: role of the adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections.

J Bone Joint Surg Am. 2009 Oct;91(10):2455-60.

Schilders E, Talbot JC, Robinson P, Dimitrakopoulou A, Gibbon WW, Bismil Q.

Department of Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, England. e.schilders@btopenworld.com


BACKGROUND: Adductor dysfunction can cause groin pain in athletes and may emanate from the adductor enthesis. Adductor enthesopathy may be visualized with magnetic resonance imaging and may be treated with entheseal pubic cleft injections. We have previously reported that pubic cleft injections can provide predictable pain relief at one year in competitive athletes who have no evidence of enthesopathy on magnetic resonance imaging and immediate relief only in patients with findings of enthesopathy on magnetic resonance imaging. In this follow-up study, we attempted to determine if the same holds true for recreational athletes. METHODS: We reviewed a consecutive case series of twenty-eight recreational athletes who had presented to our sports medicine clinic with groin pain secondary to adductor longus dysfunction. A period of conservative treatment had failed for all of these athletes. The adductor longus origin was assessed with magnetic resonance imaging for the presence or absence of enthesopathy. All patients were treated with a single pubic cleft injection of a local anesthetic and corticosteroid into the adductor enthesis. The patients were assessed for recurrence of symptoms at one year after treatment. RESULTS: On clinical reassessment five minutes after the injection, all twenty-eight athletes reported resolution of the groin pain. Fifteen patients (Group 1) had no evidence of enthesopathy on magnetic resonance imaging, and thirteen patients (Group 2) had findings of enthesopathy on magnetic resonance imaging. At one year after the injection, five of the fifteen patients in Group 1 had experienced a recurrence; these recurrences were noted at a mean of fourteen weeks (range, seven to twenty weeks) after the injection. Four of the thirteen patients in Group 2 had experienced a recurrence of the symptoms at one year, and these recurrences were noted at a mean of eight weeks (range, two to nineteen weeks) after the injection. Overall, nineteen (68%) of the twenty-eight athletes had a good result following the injection. Of the remaining nine athletes, two were treated successfully with repeat injection; therefore, overall, twenty-one (75%) of the twenty-eight athletes had a good result after entheseal pubic cleft injection. CONCLUSIONS: Most recreational athletes with adductor enthesopathy have pain relief at one year after entheseal pubic cleft injection, regardless of the findings on magnetic resonance imaging. There were similarities between this group of recreational athletes and the competitive athletes in our previous study, in that the adductor enthesis was the source of pain and entheseal pubic cleft injection was a valuable treatment option. The main difference was that, in this group of recreational athletes, magnetic resonance imaging evidence of adductor enthesopathy did not correlate with the outcome of the injection.

Adductor tenotomy: its role in the management of sports-related chronic groin pain.

Arch Orthop Trauma Surg. 2009 Dec 24.

Atkinson HD, Johal P, Falworth MS, Ranawat VS, Dala-Ali B, Martin DK.

Department of Trauma and Orthopaedics, University College London Medical School, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK, dusch1@gmail.com.


PATIENTS AND METHODS: Chronic adductor-related groin pain in athletes is debilitating and is often challenging to treat. Little is published on the surgical treatment when conservative measures fail. This single center study reviews the outcomes of 48 patients (68 groins) who underwent percutaneous adductor tenotomy for sports-related chronic groin pain. Questionnaire assessments were made preoperatively and at a minimum follow-up of 25 months. RESULTS: Mean pre-injury Tegner activity scores of 8.8 reduced to 6.1 post-injury and these improved to 7.7 following surgery (p < 0.001). Sixty percent of patients regained or bettered their pre-injury Tegner activity scores after the adductor surgery; however, mean post-surgical Tegner scores still remained lower than pre-injury scores (p < 0.001). No patient had been able to engage in their chosen sport at their full ability pre-operatively, and 40% had been unable to participate in any sporting activity. The mean return to sports was at 18.5 weeks postoperatively, with 54% returning to their pre-injury activity levels, and only 8% still unable to perform athletic activities at latest follow-up. Seventy-three percent patients rated the outcome of their surgery as excellent or very satisfactory, and only three patients would not have wished to undergo the procedure again if symptoms recurred or developed on the opposite side. No patients reported their outcome as worse. A 78.1% mean improvement in function and an 86.5% mean improvement in pain were reported, and these two measures showed statistically significant correlation (p = 0.01). Groin disability scores improved from a mean of 11.8 to 3.9, post-operatively (p < 0.001). Bruising was seen in 37% of procedures, 3 patients developed a scrotal hematoma and 1 patient had a superficial wound infection. One patient developed recurrent symptoms following re-injury 26 months post-surgery, and fully recovered following a further adductor tenotomy. CONCLUSIONS: Adductor tenotomy provides good symptomatic and functional improvement in chronic adductor-related groin pain refractory to conservative treatment.

Minimal Repair technique of sportsmen's groin: an innovative open-suture repair to treat chronic inguinal pain.

Hernia. 2010 Feb;14(1):27-33.

Muschaweck U, Berger L.

Hernia Center Dr. Muschaweck, München, Germany. UM@hernien.de


BACKGROUND: Sportsmen's groin, also known as sportsman's hernia, sports hernia, (athletic) pubalgia or athletic hernia, especially in professional sportsmen, is a difficult clinical problem, and may place an athlete's career at risk. It presents with acute or chronic inguinal pain exacerbated with physical activity. So far, the diagnostic criteria and treatment modalities are inconsistently described and there is no evidence-based consensus available to guide decision-making. OBJECTIVES: We developed an innovative open suture repair, called the "Minimal Repair" technique. With this technique, the defect of the posterior wall of the inguinal canal is not enlarged, the suture is nearly tension-free and the patient can, therefore, return to full training and athletic activity within the shortest time. METHODS: In September 2008, we started a prospective cohort study to evaluate the outcome of patients undergoing operations under the Minimal Repair technique for sportsmen's groin. Between September 2008 and May 2009, 129 patients were included in the study and were questioned at entry and 4 weeks after the operation. The primary endpoints were time to complete freedom of pain and time to resumption of exercise and sport. Here, we present the results observed 4 weeks after operation under the Minimal Repair technique. RESULTS: At enrollment, all but three patients reported a significant restriction of physical activities due to severe groin pain (median duration of pain 142 days, interquartile range [IQR] 57-330 days). Four weeks after operation under the Minimal Repair technique, 96.1% had resumed training (median 7 days, IQR 5-14 days). At this time, there was a full return to pre-injury sports activity levels in 75.8% (median 18.5 days, IQR 11.75-28 days). Focusing on the group of professional athletes, 83.7% had returned to unrestricted sports activities (median 14 days, IQR 10-28 days). In this subgroup, the median time to complete pain relief was 14 days (IQR 6-28 days). DISCUSSION: The surgical treatment of sportsmen's groin is common practice when non-surgical treatment has failed over a period of 6 weeks or more. However, there is no evidence-based data on the type of treatment. A wide variety of techniques with and without mesh are being performed. So far, laparoscopic repair is believed to enable a faster recovery and return to unrestricted sports activities. Our results, however, show that the outcome after operation under the Minimal Repair technique is very fast, without exposing the patient to possible risks related to mesh insertion or laparoscopic procedures. CONCLUSION: The Minimal Repair technique is an effective and safe way to treat sportsmen's groin.

Resting thickness of transversus abdominis is decreased in athletes with longstanding adduction-related groin pain.

Man Ther. 2010 Apr;15(2):200-5. Epub 2010 Jan 13.

Jansen J, Weir A, Dénis R, Mens J, Backx F, Stam H.

University Medical Center Utrecht, Department of Rehabilitation and Sport Medicine, Utrecht, The Netherlands. jjansen4@umcutrecht.nl


The purpose of the study was to compare thickness of the transversus abdominis (TA) and obliquus internus (OI) muscles between athletes with and without longstanding adduction-related groin pain (LAGP). Forty two athletes with LAGP and 23 controls were included. Thickness of TA and OI were measured with ultrasound imaging on the right side of the body during rest. Relative muscle thickness (compared to rest) was measured during the active straight leg raise (ASLR) left and right, and during isometric hip adduction. TA resting thickness was significantly smaller in injured subjects with left-sided (4.0+/-0.82mm; P<0.001) or right-sided (4.3+/-0.64mm; P=0.015) groin complaints compared with controls (4.9+/-0.90mm). No significant differences between patients and controls in TA or OI relative thickness during the ASLR and isometric hip adduction were found (all cases P>/=0.15). In conclusion, TA resting thickness is smaller in athletes with LAGP and may thus be a risk factor for (recurrent) groin injury. This may have implications for therapy and prevention of LAGP. Copyright 2009 Elsevier Ltd. All rights reserved.

Monday, 10 May 2010

The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy

doi:10.1016/j.jsams.2009.09.007 | How to Cite or Link Using DOI
Copyright © 2009 Sports Medicine Australia Published by Elsevier Ltd
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Original paper

The short-term effects of high volume image guided injections in resistant non-insertional Achilles tendinopathy
Joel Humphreynext terma, Otto Chanb, Tom Crispa, b, Nat Padhiara, b, Dylan Morrisseya, Richard Twycross-Lewisa, John Kingb and Nicola Maffullia, Corresponding Author Contact Information, E-mail The Corresponding Author
a Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
b Department of Imaging, The London Independent Hospital, London, UK
Received 16 January 2009; 
revised 24 September 2009; 
accepted 25 September 2009. 
Available online 27 November 2009.


We investigated neovascularisation, tendon thickness and clinical function in chronic resistant Achilles tendinopathy following high volume image guided injections (HVIGI). The subjects involved 11 athletes (mean age 43.5 years ± 11.6, range 22–59) with resistant tendinopathy of the main body of the Achilles tendon for a mean of 51.4 months (±55.56, range 4–144) who failed to improve with an eccentric loading program (mean 11.8 months ± 2.6, range 8–16). The morphological features, neovascularisation and maximal tendon thickness were assessed with power Doppler ultrasound. Clinical function was measured with the Victorian Institute of Sports Assessment-Achilles tendon (VISA-A) questionnaire. All the tendinopathic Achilles tendons were injected with 10 mL of 0.5% bupivacaine hydrochloride, 25 mg of hydrocortisone acetate, and 40 mL of 0.9% NaCl saline solution under real time ultrasound guidance. All outcome measures were recorded at baseline and after a short-term follow-up (mean 2.9 weeks, range 2–4). The results showed a statistically significant difference between baseline and 3-week follow-up in all the outcome measures after HVIGI. The grade of neovascularisation reduced (3–1.1, p = 0.003), the maximal tendon diameter decreased (8.7–7.6 mm, p < 0.001), and the VISA-A scores improved (46.3–84.1, p < 0.001). In conclusion, HVIGI for resistant tendinopathy of the main body of the Achilles tendon is effective to improve symptoms, reduce neovascularisation, and decrease maximal tendon thickness at short-term follow-up.
Keywords: Tendinopathy; Non-operative management; Peritendinous injection; Ultrasound

Article Outline

1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion
Practical implications
Conflict of interest
Ethical standards

Corresponding author.

Sunday, 9 May 2010

Favorable outcomes after sonographically guided intratendinous injection of hyperosmolar dextrose for chronic insertional and midportion achilles tendinosis.

AJR Am J Roentgenol. 2010 Apr;194(4):1047-53.
Experimental Medicine Programme, University of British Columbia, Allan McGavin Sports Medicine Centre, John Owen Pavilion, 3055 Westbrook Mall, Vancouver, BC, Canada V6T 1Z3. mryan76@gmail.com


OBJECTIVE: The objective of our study was to report on changes in the short-term sonographic appearance and 2-year follow-up for pain outcomes in a large patient population with chronic Achilles tendinosis who underwent sonographically guided dextrose injections. SUBJECTS AND METHODS: One hundred eight tendons (86 midportion and 22 insertional) from 99 patients experiencing pain for greater than 6 months at either the Achilles tendon insertion or midportion were included in the study. Gray-scale (5-12 and 7-15 MHz) and color Doppler sonography examinations preceded the injection procedure using a 27-gauge needle administering a net 25% dextrose-lidocaine solution intratendinously. Structural features of each tendon and presence of neovascularity were noted. Visual analog scale (VAS) items were recorded at baseline, posttest, and 28.6 months follow-up. RESULTS: A median of five (range, 1-13) injection consultations were needed for each patient, spaced 5.6 +/- 3.1 (SD) weeks apart. There was a significant improvement in pain scores for both midportion (rest: 34.1 +/- 27.7-3.3 +/- 7.4, activities of daily living (ADL): 50.2 +/- 25.6-9.5 +/- 16.2, and sport: 70.7 +/- 23.3-16.7 +/- 22.0) and insertional (rest: 33.0 +/- 26.5-2.7 +/- 6.0, ADL: 51.3 +/- 25.4-10.0 +/- 16.3, and sport: 69.6 +/- 24.5-17.7 +/- 29.1) patients from baseline to follow-up for all VAS items. There were reductions in the size and severity of hypoechoic regions and intratendinous tears and improvements in neovascularity. CONCLUSION: Dextrose injections appear to present a low-cost and safe treatment alternative with good long-term evidence for reducing pain from pathology at either the insertion or midportion of the Achilles tendon.


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