Surgical Management of Chronic Lower Abdominal and Groin Pain in High-performance Athletes

Abstract

Formerly, most of the causes and treatments of chronic lower abdominal and groin pain in high-performance athletes eluded sports medicine specialists. Now we are much better at identifying and managing the different syndromes. Most of the advances are based on empiric evidence, although many pitfalls remain with respect to diagnosis and management of the various syndromes. This article reviews our current understanding of several of these clinical entities. We focus on lessons learned from a large 15-year experience.

Proposed Algorithm for the Management of Athletes With Athletic Pubalgia (Sports Hernia): A Case Series

“…Pain without exertion should be further evaluated for potential systemic pathology. Complaints of testicular or epididymal pain, or cyclic pain accompanying menstruation, 59 should be examined carefully to rule out genitourinary abnormalities. 1,23 Neurological symptoms in the groin or upper scrotum may suggest entrapment of the genital branches of the ilioinguinal, obturator, or genitofemoral nerves.…”

“…40,52,59,75 The higher reported incidence of this condition in males versus females 4,37,46,52,61 may be explained by a greater level of participation in highly competitive sports and/or gender differences in pelvic anatomy. 58 Further evaluation of female athletes often reveals a gynecological source to their symptoms, including endometriosis and ovarian cysts.…”

“…1,22,58,61,80 Symptom presentation is typically insidious; however, most patients recall a subsequent acute event occurring after groin pain was already present. 39,53,59,61,75,80 The pain is usually exacerbated by kicking, sprinting, sidestepping, cutting, and/or performing sit-ups. 22,39,40,80 Some patients may complain of referred pain along the adductor longus tendon(s) with forceful or resisted hip adduction, 22,58,66 and most report point tenderness over the superior-lateral pubis.…”

“…79 Many diagnoses (snapping hip syndrome, hip subluxation/dislocation, acetabular labral tears, and bursitis) were immediately ruled out due to the absence of various signs and symptoms. 5,59,62,63 Others were omitted based on a negative radiograph or MRI report (avulsion fracture, proximal hip fracture, stress fracture) 5,51,53,[61][62][63]73 or based on the absence of neurological signs and symptoms (lumbar radiculopathy, pudendal/genitofemoral neuropathy, obturator nerve entrapment, ilioinguinal neuralgia). 5,51,62,63,73 Inguinal hernia was ruled out, as there was no palpable hernia.…”

“…5,28,37,52,53,62 Although the investigators believed these conditions were not the primary source of the athletes' exertional pain, they might have coexisted and/or contributed to the etiology and progressed accordingly. Because evidence suggests poor surgical outcomes in nonathletes, 59 rehabilitation is currently advocated as the only course of action with these patients. Patients 1 through 3 elected for surgical repair of their sports hernia at varying points of their rehabilitation and thus the diagnosis of a sports hernia was made endoscopically.…”