An Original Study Referral Patterns for Chronic Groin Pain and Athletic Pubalgia/Sports Hernia: Magnetic Resonance Imaging Findings, Treatment, and Outcomes Mark P. Zoland, MD, Matthew E. Maeder, MD, Joseph C. Iraci, MD, and Devon A. Klein, MD, MPH Abstract Chronic groin pain is a common problem MRI protocol increased sensitivity for certain and has been well-described in high- pathologies. Of positive athletic pubalgia performance athletes. Its presentation in the cases, 49% went on to have surgical repair. recreational athlete has been less frequently The satisfaction rate in the surgical group described. We present the experience of a was 90% at follow up. tertiary group of physicians specializing in Advances in MRI have increased our groin pain and athletic pubalgia. ability to characterize and diagnose specif- Dynamic magnetic resonance imaging ic injuries causing groin pain. We present (MRI) protocol was employed. Surgery was our diagnostic algorithm, including an MRI performed in patients failing non-surgical protocol that not only evaluates the groin, management. A retrospective review was but has increased sensitivity for additional performed. findings such as inguinal hernia and abdom- Of 117 mostly non-professional athletes, inal wall deficiencies. A targeted work-up there were 79 MRI-positive cases of athletic and subsequent surgical treatment in the pubalgia (68%). Other common findings appropriate patient, even in the recreational were acetabular labral tear (57%) and ingui- athletic population, has yielded a 90% satis- nal hernia (35%). Employment of a dynamic faction rate. he past 3 decades have seen an evolution noses, which now constitute a knowledge base.1,3-5 in the understanding, diagnosis, and treat- As stated in almost every article on groin pain T ment of groin pain, both chronic and acute, in and diagnosis, lack of cohesive agreement and vo- athletes and non-athletes alike. Groin pain and groin cabulary, and consistent protocols and procedures, injury are common. Most cases are transient, with has abounded, making general understanding and patients returning to their activities within weeks or agreement in this area inconsistent.1,6-8 months. There has also been increasing awareness In this article, members of a tertiary-care group of a definitive population of patients who do not get specializing in chronic groin pain, athletic pubalgia better, or who improve and plateau before reaching (sports hernia), and inguinal herniorrhaphy outline preinjury level of performance.1-3 Several authors their clinical examination, diagnostic algorithm, im- have brought more attention to the injury, introduc- aging protocol, treatment strategy, and outcomes ing vocabulary, theories, diagnostic testing, and diag- for a population of patients referred by physicians Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com July/August 2017 The American Journal of Orthopedics ® E251 Referral Patterns for Chronic Groin Pain and Athletic Pubalgia/Sports Hernia and allied health professionals for a suspected the P-PAC, which has several fascial components, diagnosis of athletic pubalgia. attaches posteriorly to the pubic bone and, to a degree, the pubic symphyseal cartilaginous disc. Background Major contributions to the P-PAC are fibers from The pubic symphysis acts as a stabilizing central the rectus abdominis tendon, the medial aspect of anchor with elaborate involvement of the ante- the transversalis and internal oblique muscles (the rior structures, including the rectus abdominis, conjoint tendon, according to some), the inguinal adductor longus, and inguinal ligaments.3,7,9 ligament, and the adductor longus tendon.26 Literature from Europe, Australia, and the United When communicating with referring physicians, States has described groin pain, mostly in profes- we use the term athletic pubalgia to indicate a sional athletes, involving these pubic structures specific injury. The athletic pubalgia injury can be and attachments. Several publications have been defined as serial microtearing,1 or complete tear- addressing chronic groin pain, and each has its ing, of the posterior attachment of the P-PAC off own diagnostic algorithm, imaging protocol, and the anterior pubis.3,10 Complete tearing or displace- treatment strategy.3,6,9-18 ment can occur unilaterally or across the midline to Terminology specific to groin pain in athletes is the other side. As athletic pubalgia is a specific an- not new, and has a varied history dating to the ear- atomical injury rather than a broad category of find- ly 20th century. Terms such as sportsman hernia19 ings, an additional pathologic diagnosis, such as and subsequently sports hernia20, have recently inguinal hernia, does not exclude the diagnosis of been embraced by the lay population. In 1999, athletic pubalgia. Unfortunately, the terms sports Gibbon21 described shearing of the common hernia and sportsman hernia, commonly used in adductor–rectus abdominis anatomical and func- the media and in professional communities, have tional unit and referenced a 1902 anatomical text largely confused the broader understanding of nu- that describes vertical ligamentous fibers contig- ances and of the differences between the specific uous with rectus sheath and adductor muscles, injuries and MRI findings.18 both attaching to the pubis. Injury to this region is the basis of pubalgia, a term originally used in Our Experience 1984 by Brunet to describe a pain syndrome at the In our practice, we see groin pain patients referred pubis.22 by internists, physiatrists, physical therapists, train- Many authors have proposed replacing sports ers, general surgeons, urologists, gynecologists, hernia with athletic pubalgia.1,3,6,7,10,14,18,23 These and orthopedic surgeons. In many cases, patients terms refer to a group of musculoskeletal process- have been through several consultations and work- es that occur in and around the pubic symphysis ups, as their pain syndrome does not fall under a and that share similar mechanisms of injury and specific category. Patients without inguinal hernia, common clinical manifestations. The condition was hip injury, urologic, or gynecologic issues typically originally described in high-performance athletes, are referred to a physiatrist or a physical therapist. and at one point the term sports hernia was Often, there are marginal improvements with phys- reserved for this patient population.5 According ical therapy, but in some cases the injury never to many authors, presence of an inguinal hernia completely resolves, and the patient continues to excludes the diagnosis.1,2,5 have pain with activity or return to sports. Magnetic resonance imaging (MRI) has helped Most of our patients are nonprofessional ath- to advance and define our understanding of the letes, men and women who range widely in age injury.10 As the history of the literature suggests, and participate casually or regularly in sporting earlier concepts of chronic pain focused either events. Most lack the rigorous training, condi- on the medial aspect of the inguinal canal and its tioning, and close supervision that professional structures or on the pubic attachments. Many spe- athletes receive. Many other patients are nonpro- cialists in the area have concluded that the chronic fessional but elite athletes who train 7 days a week groin pain injury can and often does embody both for marathons, ultramarathons, triathlons, obstacle elements.3,9 Correlation with MRI findings, injury course races (“mudders”), and similar events. seen during surgical procedures, and cadaveric studies have directed our understanding to a struc- Work-Up ture, the pre-pubic aponeurotic complex (P-PAC), A single algorithm is used for all patients initially or rectus aponeurotic plate.12,24,25 Anatomically, referred to the surgeon’s office for pelvic or groin E252 The American Journal of Orthopedics ® July/August 2017 www.amjorthopedics.com M. P. Zoland et al pain. The initial interview directs attention to injury onset and mechanism, duration of rest or phys- ical therapy after surgery, pain quality and pain levels, and antagonistic movements and positions. Examination starts with assessment for inguinal, femoral, and umbilical hernias. Resisted sit-up, leg-raise, adduction, and hip assessment tests are performed. The P-PAC is examined with a maneu- ver similar to the one used for inguinal hernia, as it allows for better assessment of the transver- salis fascia (over the direct space) to determine if the inguinal canal floor is attenuated and bulges A B forward with the Valsalva maneuver. Then, the lateral aspect of the rectus muscle is assessed for pain, usually with the head raised to contract the muscle, to determine tenderness along the lateral border. The rectus edge is traced down to the pubis at its attachment, the superolateral border of the P-PAC. Examination proceeds medially, over the rectus attachment, toward the pubic symphy- sis, continuing the assessment for tenderness. Laterally, the conjoint tendon and inguinal ligament medial attachments are assessed at the level of the pubic tubercle, which represents the lateral border of the P-PAC. Finally, the examination C D continues to the inferior border with assessment Figure 1. Athletic pubalgia on magnetic resonance imaging. (A) Axial oblique proton density of the pubic symphysis. (B) Axial and (C) sagittal T2-weighted fat suppressed of the adductor longus attachment, which is best