Surgical Management of Chronic Lower Abdominal and Groin Pain In
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Surgical Management of Chronic Lower Abdominal and Groin Pain in High-performance Athletes 08/02/2019 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD33D9/FQ5Fz8lUYgSwgVMpoyvWKSXvZI2V7wPePfaqAcGjSNveYeZYww== by https://journals.lww.com/acsm-csmr from Downloaded William C. Meyers, MD, Anthony Lanfranco, BAS, and Andres Castellanos, MD Downloaded from https://journals.lww.com/acsm-csmr Address pubalgia, and a similar number of patients who have not Drexel University College of Medicine, Department of Surgery, required surgery. Much of the specific data on these patients Mail Stop 413, 245 North 15th Street, Philadelphia, PA 19102, USA. will be documented in that study. We are compelled to E-mail: [email protected] mention one preliminary observation: there are still too Current Sports Medicine Reports 2002, 1:301–305 many patients undergoing incorrect operations! This Current Science Inc. ISSN 1537-890x by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD33D9/FQ5Fz8lUYgSwgVMpoyvWKSXvZI2V7wPePfaqAcGjSNveYeZYww== Copyright © 2002 by Current Science Inc. observation comes from data that show more than 200 patients who, having undergone various unsuccessful opera- tions, did well after a second surgery or other treatments. Formerly, most of the causes and treatments of chronic lower Before outlining our current approach to these types of abdominal and groin pain in high-performance athletes eluded problems, five general comments are necessary. sports medicine specialists. Now we are much better at To begin, athletic pubalgia is but one such diagnosis that identifying and managing the different syndromes. Most of the occurs in high-performance athletes. It should be under- advances are based on empiric evidence, although many stood that there are many other potential diagnoses. The pitfalls remain with respect to diagnosis and management pelvis has a great number of bones, projections, and soft tis- of the various syndromes. This article reviews our current sue structures, and the considerable movement to which the understanding of several of these clinical entities. We focus pelvis is subjected should qualify it as either a huge, com- on lessons learned from a large 15-year experience. plex joint or a number of “mini-joints.” Therefore, it seems logical that a variety of diagnoses might occur in this area. A glaring lack of scientific knowledge about the pelvis empha- Introduction sizes that many of these diagnoses are empiric ones. Never- Athletic pubalgia is now better understood as an important theless, the various syndromes mentioned in this paper are cause of lower abdominal or groin pain in high-performance distinct, and probably recognizable to most experienced athletes [1••,2••,3•]. Players, team physicians, and trainers sports medicine specialists. are making the diagnosis earlier, and many high-level Because there are a number of potential diagnoses athletes are continuing their careers beyond what was pre- that pertain to this large, complex anatomic area, there are viously possible. For the most part, there has been consider- also a number of different possible surgical and nonsurgi- able progress. However, some misunderstanding remains. cal treatments. One particularly important ingredient of Clearly, more surgeons are performing predictably unsuc- success in treating empiric diagnoses is experience. There- cessful operations [1••]. Other important and under- fore, it is difficult to describe a precise algorithm that out- on 08/02/2019 appreciated causes of chronic pain that also afflict these lines a flawless method of sorting out these diagnoses athletes must be considered [4]. A better appreciation of the according to treatment. history underlying the identification of these syndromes may Likewise, when experience is important and impre- help surgeons predict which operations will fail. This article cision is the rule for treatment algorithms, success reviews some of our current understanding of these clinical demands that one stick dogmatically to the principles of entities. We recognize that alternative successful methods others who have long track records of success. For example, may exist for dealing with some of these chronic conditions, one of the more common successfully reparable syn- but the focus is on our own experience and some of the dromes among these empiric entities is athletic pubalgia lessons we have learned over the past 15 years. [5]; yet, we have seen an increasing number of poor results from a combination of incorrect diagnoses and operations that could have been predicted to fail. It should not seem General Comments “rocket science” that successful repair requires both mak- We will soon be publishing a review of slightly more than ing the right diagnosis and adhering to certain empiric 1500 patients who have undergone surgery for athletic principles in attempting repair. 302 Sport-specific Illness and Injury A reminder of the history associated with the diagnosis attached tissue include the adductor muscles, pectineus, of athletic pubalgia is also helpful [1••]. For many years, gracilis, obturator internus, quadratus femoris, and gluteus general surgeons have attempted, without predictable suc- muscles. A series of ligamentous arches also exist between cess, various hernia repairs for this pain syndrome in high- the pelvic bones, further stabilizing the joint [8]. performance athletes. There is no reason that those previous In addition to these various and complex insertions, operations, or operations like them, should now suddenly there are a number of bursae of the anterior pelvis, several produce miraculous success! The principle reason that we of which potentially communicate with each other. published our initial manuscript [5] on this subject was for Although the psoas inserts principally onto the femur, that reason; that is, most attempts at surgery for this its bursa is rather large and complexly shaped so that it syndrome had been unsuccessful. In particular, most hernia may even touch the above-described joint. There are also operations did not work, so we developed an operation potentially clinically significant bursae behind the based on some concepts first suggested by the work of a symphysis and near the lesser and greater trachanters. Yugoslavian surgeon named Nesovic. Another significant consideration is the number of Finally, most empiric evidence points to the fact that this potentially important projections. Two that seem assoc- syndrome is not an occult hernia. The pattern of symptoms, iated with several of the syndromes described below operative findings, and reported results all suggest that the include the pectineus insertion, where a relatively lower-abdominal/inguinal pain in these athletes is not common magnetic resonance imaging (MRI) finding of due to occult hernia [1••]. Instead, this syndrome, as well as avulsion fracture occurs [9], and an anterior projection possibly several others, should be thought to result from of the inferior pubic ramus. The latter projection sits rela- injury to attachments that stabilize the complex joint of the tively close behind the adductor muscular insertions onto pelvis. In other words, the best way to think of some of these the pubis and may contribute to the adductor pain of injuries is that we are dealing with a subtly unstable pelvis. athletic pubalgia. We presume that the relatively weak rectus insertion onto the pubis results in overcompen- sation by the relatively unopposed adductor [1••] and a Pelvic Anatomy kind of compartment syndrome. For the purpose of this review, we describe the pelvis as a girdle, with two pairs of innominate bones, plus the sacrum and the coccyx [6–8]. The innominate bone is Most Commonly Seen Entities composed of the ileum, the ischium, and the pubis, which We will not describe such problems as avascular necrosis of also forms a portion of the acetabulum. One common the hip or various stress fractures, which are relatively easy concept is that there is little motion across the joints of the to recognize on MRI. Most of the entities described here pelvis in the normal state. Another, perhaps more are difficult ones, from the standpoint that they have applicable, concept is that there is a lot of motion across escaped MRI diagnosis. The problems listed below have these joints, but because there are so many tiny joints here, also been disabling from the viewpoint of the high-per- any one mini-joint ordinarily receives just a small fraction formance athletes. By disabling, we mean they prevent the of this motion. Certainly, athletes may stretch these athlete from performing at desired levels of ability, thereby ordinarily relatively static joints and cause excess motion at greatly diminishing his or her quality of life. In actuality, various sites within the pelvis. some of these diagnoses are occasionally made definitively If this anatomy is so incredibly complex, how does one by MRI. For example, a disruption of the rectus insertion make enough sense of it to create any meaningful clinical onto the pubis can be seen in approximately 12% of significance? Consider simply that many athletes with patients with athletic pubalgia. One source that describes chronic pain can pinpoint the precise time when their these entities in more detail is Chapter 13 of Principles and pelvic pain began, and often remember the locations of the Practice of Orthopaedic Sports Medicine [4]. distinct “rips,” “pops,” or “tears.” If one were to map out these described locations of initial