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


Abstract

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


Abstract

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.

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

Journal of Science and Medicine in Sport
Volume 13, Issue 3, May 2010, Pages 295-298

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doi:10.1016/j.jsams.2009.09.007 | How to Cite or Link Using DOI Copyright © 2009 Sports Medicine Australia Published by Elsevier Ltd	Cited By in Scopus (0)
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Original paper

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

This article is not included in your organization's subscription. However, you may be able to access this article under your organization's agreement with Elsevier.

Joel Humphrey^a, Otto Chan^b, Tom Crisp^{a, b}, Nat Padhiar^{a, b}, Dylan Morrissey^a, Richard Twycross-Lewis^a, John King^b and Nicola Maffulli^{a, ,}

^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.

Abstract

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

Acknowledgements

References

Fig. 1. Transverse plane of an Achilles tendon under ultrasound. Medial approach of the needle. Stripping of the paratenon from the surrounding soft tissues, at the anterior aspect of the Achilles tendon.

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Table 1. Sports activities of the 11 patients with resistant tendinopathy of the main body of the Achilles tendon prior to their symptoms.

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Corresponding author.

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.

Ryan M, Wong A, Taunton J.

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

Abstract

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.