Treatment of the Sportsman's Groin' British Hernia Society Position
Total Page：16
File Type：pdf, Size：1020Kb
Consensus statement Br J Sports Med: first published as 10.1136/bjsports-2013-092872 on 22 October 2013. Downloaded from ‘Treatment of the Sportsman’s groin’: British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference Aali J Sheen,1 B M Stephenson,2 D M Lloyd,3 P Robinson,4 D Fevre,5 H Paajanen,6 A de Beaux,7 A Kingsnorth,8 O J Gilmore,9 D Bennett,10 I Maclennan,1 PO’Dwyer,11 D Sanders,8 M Kurzer12 For numbered affiliations see ABSTRACT groin.6 Chronic groin pain is most often found in end of article. Introduction The aim was to produce a athletes who undertake sports involving kicking 7 Correspondence to multidisciplinary consensus to determine the current and twisting movements while running. The pain Aali J Sheen, Honorary Senior position on the nomenclature, definition, diagnosis, is often experienced at the common point of origin Lecturer, University of imaging modalities and management of Sportsman’s of the rectus abdominis muscle and the adductor Manchester and Consultant groin (SG). longus tendon on the pubic bone and the insertion Surgeon, Department of Methods Experts in the diagnosis and management of of the inguinal ligament on the pubic bone.5 Surgery, Central Manchester Foundation Trust, Manchester SG were invited to participate in a consensus conference Furthermore, it is important to remember that Royal Infirmary, Manchester held by the British Hernia Society in Manchester, UK on there is to date no clear consensus as to what spe- M13 9WL, UK; 11–12 October 2012. Experts included a physiotherapist, cifically constitutes this diagnosis8 and in addition [email protected] a musculoskeletal radiologist and surgeons with a proven it has been recognised that treatment relies on both track record of expertise in this field. Presentations conservative measures as well as open and laparo- Accepted 24 September 2013 9 Published Online First detailing scientific as well as outcome data from their own scopic surgical approaches. 22 October 2013 experiences were given. Records were made of the It is well recognised from previous studies and presentations with specific areas debated openly. areas of research in this field that a careful history Results The term ‘inguinal disruption’ (ID) was agreed as and examination are required as other possible the preferred nomenclature with the term ‘Sportsman’s causes of chronic groin pain must ideally be hernia’ or ‘groin’ rejected, as no true hernia exists. There excluded. These include adductor muscle injuries, was an overwhelming agreement of opinion that there was osteitis pubis and pubic symphysitis although it is abnormal tension in the groin, particularly around the also accepted that they can coexist with an ID.710 inguinal ligament attachment. Other common findings Following the history and physical examination, included the possibility of external oblique disruption with some musculoskeletal investigations such as ultra- consequent small tears noted as well as some oedema of sound or MRI may be helpful in evaluating these – the tissues. A multidisciplinary approach with tailored patients and ruling out other pathologies,11 14 physiotherapy as the initial treatment was recommended although no radiographic study can rule out ID.15 with any surgery involving releasing the tension in the Bone marrow oedema, osteitis pubis, tendon dis- http://bjsm.bmj.com/ inguinal canal by various techniques and reinforcing it with ruption as well as fluid in the symphysis have all a mesh or suture repair. A national registry should be been described to be present in varying degrees in developed for all athletes undergoing surgery. this cohort of patients through MRI findings.16 17 Conclusions ID is a common condition where no true In an effort to better define the pathophysiology, hernia exists. It should be managed through a nomenclature, diagnostic modalities used, conserva- multidisciplinary approach to ensure consistent standards tive treatment options and the most appropriate and outcomes are achieved. surgical options available as well as to consider the on 15 May 2018 by guest. Protected copyright. Open Access development of a national registry, the British Scan to access more free content Hernia Society (BHS) convened a meeting of recog- nised chartered physiotherapists, musculoskeletal INTRODUCTION radiologists and surgeons with an interest in this Over the last four decades, the condition of difficult subject. ’ chronic pain in an athlete s groin, sometimes This meeting took place in October 2012, in ’ described as a Sportsman s groin (SG) or inguinal Manchester, UK with an audience of 150 surgeons. disruption (ID) has been attributed to a hernia, a ▸ http://dx.doi.org/10.1136/ groin disruption, an incipient hernia or ‘athletic bjsports-2013-092958 pubalgia’ as well as a simple chronic groin pain.12 Statement on background to consensus process There has been no clear consensus on this condi- Conference tion, especially on its nomenclature (SG or ID), In Manchester in October 2012, as part of the BHS which has been regarded as difficult to accurately annual scientific meeting a plenary session was dedi- diagnose and manage.34Many athletes, elite and cated to produce the first consensus statement on amateur, can be affected by groin pain, which is the management of groin pain in athletes, which is 5 ’ To cite: Sheen AJ, also prevalent in non-athletes. Cyclists and swim- commonly described as a Sportsman s hernia or Stephenson BM, Lloyd DM, mers are less commonly affected as these sports do groin. To this end, a range of experts in this field et al. Br J Sports Med not lead to the increased pelvic and torso move- were invited and asked to present their experiences – 2014;48:1079 1087. ments that are known to predispose to a painful and data in their area of practice. Prior to the Sheen AJ, et al. Br J Sports Med 2014;48:1079–1087. doi:10.1136/bjsports-2013-092872 1 of 9 Consensus statement Br J Sports Med: first published as 10.1136/bjsports-2013-092872 on 22 October 2013. Downloaded from meeting the speakers were consulted with an agreement made on Consensus presentations the specific questions that were to be asked. The questions were Six keynote lectures were given on three topics to a learned aimed at areas not fully addressed on the SG in the literature to audience of predominantly hernia surgeons. date. The meeting used the term SG throughout the discussion in The topics included were order to maintain the use of a well recognised description for 1. Physiotherapy and active sports rehabilitation (DF) chronic or persistent groin pain experienced by athletes. 2. Imaging investigations (PR) The basic principles governing the conduct of a consensus 3. Four lectures on surgical techniques and indications (HP,IM, development conference are summarised below: OJG and DML) 1. All the invited panellists provided keynote lectures in their area of expertise. Consensus questions 2. The panellists were drawn from a multidisciplinary field of After all the lectures, the speakers were all invited for their clinical practice in the field of sports-related groin pain. They respective opinions on the following questions: do not represent organisations per se but were selected for 1. What appropriate nomenclature would be acceptable for this their expertise, experience and understanding of this field. condition? 3. Each lecture was supplemented by a panel discussion with 2. What pathology if any is present? an open audience forum in an attempt to forge a consensus 3. What imaging modalities or diagnostic techniques are on eight key questions. advised? 4. Prior to the conference a literature review was undertaken 4. Is surgery always advised? by the Board of the Society, to identify controversial points 5. If yes to surgery, then what operation should be undertaken? in the literature regarding the management of SG using bio- 6. What other treatment modalities would you use? medical databases through the PUBMED platform. 7. What repair would you undertake for a primary 5. The panellists were all contacted prior to the meeting to presentation? ascertain the extent of their lectures. 8. What repair or management would you recommend for a 6. All the panellists were given access to the key questions to recurrence? be asked at the consensus statement. 7. A systematic literature review was prepared for use in addressing the conference questions. Consensus document 8. The consensus statement is intended to serve as the scien- This manuscript first lists all the specific questions that were tific record of the conference. raised at the meeting. 9. The consensus statement will be widely disseminated to Second, all questions are followed by the four specific areas achieve maximum impact on both current practice and to discussed at the meeting including: aid in future medical research. A. Definition of the condition commonly described as SG 10. The panel Chairperson (AJS) did not identify with any advo- B. Physiotherapy techniques employed cacy position. The Chairperson was responsible for directing C. Imaging investigations undertaken the consensus session and guiding the panel’s deliberations. D. Surgical procedures carried out These headings are followed by a review of the literature encompassing the key presentations at the meeting followed by Consensus meeting literature review the views of the panellists on the relevant consensus questions. http://bjsm.bmj.com/ 1. Searches were performed independently by two members of The consensus was reached at the end of each discussion by a the BHS board using relevant medical subject headings and majority of the panel reaching an agreement, in all cases a free-text terms. No language restrictions were applied to the unanimous conclusion was reached. searches. Both generic and specially developed search filters Finally a summary and final conclusion is presented with were employed when necessary. Databases searched were recommendations for future research.