Literature review
Imaging and clinical tests for the diagnosis of long-standing groin pain in athletes. A systematic review

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Abstract

Objectives: To examine the validity of clinical tests available for the diagnosis of longstanding groin pain in athletes. Design: Systematic review. Method: A published search strategy of MeSH terms in MEDLINE, CINAHL, EMBASE, and SportDiscuss. Inclusion criteria: diagnostic studies relating to athletic groin pain, professional or semi-professional athletes, symptoms lasting for more than six weeks, and not limited by age or gender. A priori exclusion criteria were utilised. Outcome measures: QUADAS tool, sensitivity and specificity, likelihood ratios and predictive values of the reported tests and investigations. Results: 577 Journal articles were identified. Five studies met all requirements. Sensitivity and specificity of clinical tests ranged between 30 and 100% and 88 and 95% respectively with negative likelihood ratio of 0.15–0.78 and positive likelihood ratios of 1.0–11.0. Sensitivity and specificity of investigations (MRI, herniography, and dynamic ultrasound) ranged between 68% and 100% as well as 33% and 100% respectively with negative likelihood ratios between 0 and 0.32 and positive likelihood ratios between 1.5 and 8.1. Conclusion: There is a lack of validated diagnostic clinical tests available for clinicians and a lack of symptomology being evaluated. It is recommended that a reference standard should be applied and data should be reported in sufficient detail to calculate diagnostic statistics that is useful to the clinician.

Introduction

Groin injuries are common in sports that require cutting and sprinting manoeuvres such as soccer, rugby league, rugby union, cricket, ice hockey and Australian Rules football (Brown et al., 2008, O'Connor, 2004, Orchard et al., 2002, Orchard and Verrall, 2000, Verrall et al., 2001, Werner et al., 2009). They account for between 4% and 16% of all injuries each season (Orchard and Verrall, 2000, Werner et al., 2009) and have an estimated incidence of 0.59–3.5 injuries per 1000 hours of activity (Ekstrand and Hilding, 1999, Orchard and Verrall, 2000, Werner et al., 2009). Groin injuries have a high recurrence rate, reported between 15% and 31% (Werner et al., 2009). In Australian Rules Football they are the second most common injury behind hamstring muscle strains and have been estimated to be responsible for 11–18 competition games per team being missed by players due to injury in a season (Orchard & Verrall, 2000). Confusion regarding the clinical presentation of groin pain and inadequate differential diagnosis of groin pathology is likely to result in inappropriate management and consequently ongoing pain or re-injury for the injured athletes.

The hip joint is a potential source of groin pain and is associated with the development of long-standing groin pain in athletes (Bradshaw, Bundy, & Falvey, 2008). Sacroiliac joint (SIJ) pathology and degeneration seen on plain X-ray is also associated with long-standing groin pain (LGP) (Harris and Murray, 1974, Major and Helms, 1997). Entrapment of the obturator nerve has been diagnosed and described in athletic populations with long-standing groin pain (C. Bradshaw & Holmich, 2006; C. Bradshaw, McCrory, Bell, & Brukner, 1997; C. J. Bradshaw et al., 2008, Brukner et al., 1999). Tearing of the external oblique muscle aponeurosis has frequently been described in hockey players and has been associated with ilioinguinal nerve entrapment (Irshad, Feldman, Lavoie, Lacroix, Mulder, & Brown, 2001).

Within the medial thigh compartment, the adductor longus muscle is commonly implicated in long-standing groin pain (Albers et al., 2001, Renstrom and Peterson, 1980, Robinson et al., 2004). It has been hypothesised that the forces created by the rectus abdominis and adductor longus muscles control the shearing force across the anterior pubic arch and pubic symphysis (Meyers, Greenleaf, & Saad, 2005). Disruption of this equilibrium is likely to impact on these shearing forces. This can occur in adductor longus enthesopathies and rectus abdominis tendinopathies, as diagnosed via MRI (Robinson et al., 2004, Zoga et al., 2008). Neutralising these forces surgically by either reinforcing the rectus abdominis enthesis or performing an adductor longus tenotomy has been shown to improve function (Meyers et al., 2000, Meyers et al., 2008).

The inguinal canal is frequently injured and can also exhibit dysfunction under load in athletes (Cohen et al., 1990, Kesek et al., 2002, Smedberg et al., 1985, Taylor et al., 1991, Yilmazlar et al., 1996). “Sportsman's hernia” or posterior inguinal wall deficiency occurs when the posterior wall bulges under increased abdominal pressure (Orchard, Read, Neophyton, & Garlick, 1998). It has been reported that direct hernias account for over half of hernias in athletes and can occur in combination with indirect hernia and posterior wall weakness (Smedberg et al., 1985). Contradicting this, a later study found unilateral indirect hernias to be the most common type of hernia in athletes with long-standing groin pain (Yilmazlar et al., 1996). Femoral hernias are rare in this population (Robinson et al., 2004, Yilmazlar et al., 1996).

It is important to note that many diseases and conditions of non-musculoskeletal origin may refer symptoms to this region. These include gynaecological, urological, malignancies, sexually transmitted and rheumatological conditions (Bradshaw and Holmich, 2006, Ekberg et al., 1988, Harris and Murray, 1974, Smedberg et al., 1985). It is therefore important to consider a multidisciplinary approach to both diagnosis and treatment of long-standing groin pain in athletes. Additionally, other factors may also influence the patient's experience and outcome from the injury. These include the emotional, social or cognitive in origin and should be considered in a biopsychosocial assessment framework. It is therefore important to consider a multidisciplinary approach which includes physical and psychological aspects to both the diagnosis and treatment of long-standing groin pain in athletes.

Several approaches to the diagnosis of LGP have been proposed including patho-anatomical models (Falvey, Franklyn-Miller, & McCrory, 2008) and the clinical entity approach (Holmich, 2007). Physical examination can be reliable (Holmich et al., 2004, Malliaras et al., 2010) however, while reliable many tests have not been evaluated for their diagnostic accuracy. Physical tests have been used to classify groin pain into three main pathological entities; adductor-related, iliopsoas-related and rectus abdominis-related dysfunctions. Holmich (2007) studied 207 athletes and found 119 (57.5%) had adductor-related dysfunction as their primary entity followed by iliopsoas-related (36%) and rectus abdominis-related (10%) dysfunctions. Notably, multiple pathologies were found in 69 (33%) patients, with 16 (7.7%) having all three pathological entities and rectus abdominis-related dysfunction rarely occurring in isolation (Holmich et al., 2004).

Falvey et al. (2008) systematically considered the anatomical structures that are located within or around the “groin triangle”. Structures were classified by their region; pubic tubercle region, medial to the triangle, superior to the base, lateral to the triangle and within the triangle. This systematic approach allows the clinician to consider all the structures potentially implicated. This patho-anatomical approach provides an intuitively meaningful framework when diagnosing the source of LGP, the clinical entity approach as demonstrated by Holmich et al. (2004) has merit when considering conservative clinical examination and treatment options.

However, a lack of evaluation of clinical tests for the purpose of diagnosis is evident. There may be several reasons for this; poor consensus on pathology and terminology, lack of specific tests implicating individual structures, absence of an accepted and available reference standard against which test performance may be assessed. The complexity of this region with its overlapping anatomy and interdependence of structure means that a specific tests and/or imaging is challenging to develop and difficult to evaluate. There is also a deficiency of literature on the symptomology of athletes with long-standing groin pain with reference to diagnoses.

The purpose of this review is to evaluate the current literature pertaining clinical tests, symptomology and investigations available to the clinician working with athletes with long-standing groin pain and to examine their validity.

Section snippets

Methods

A search was performed using published strategies for searching diagnostic studies (Deville et al., 2002). Databases searched included MEDLINE, CINAHL, EMBASE, and SportDiscuss (to August 2009) using the MeSH terms: groin, athletic injuries, abdominal muscles, sportsm* and hernia, abdominal pain, pelvis pain, athletic pubalgia, pubalgia, rheumatic diseases, enthesopathy, inguinal canal, hockey groin syndrome, Gilmore's groin, adductor longus, rectus abdominis, pubic bone, pubic symphysis,

Results

The database search retrieved 577 journal articles of which five met the inclusion criteria.

Fig. 1 indicates the flow of studies. Results of the QUADAS tool evaluation are presented in Table 1. The compliance to individual items in the QUADAS tool varied with all studies compliant with items 1, 3, and 7. Items 6, 11 and 14 had the poorest compliance with only one study per item satisfying the relevant measurement.

The five studies considered six different pathologies with four physical

Discussion

While accurate and timely diagnosis of long-standing groin pain is imperative for professional athletes, a diagnostic test, even with good diagnostic statistics, is only important if it impacts positively on the outcome of the patient (Ferrante, Hyde, McCaffery, Bossuyt, & Deeks, 2012). It is unknown whether the tests highlighted in this systematic review improve either treatment choices or outcomes. However, as multiple structures can be implicated diagnosis can be difficult. Many of the

Conclusion

Clinicians should place more emphasis on specifically identifying the patho-anatomical disorder(s). This should also be reflected to a far greater extent in current literature. Many commonly used clinical tests are reliable and may have a place in reassessment and guidance of treatment progression. However, more work is needed examining the properties of these diagnostic tests. There is no ‘gold standard’ to compare clinical test findings. This is mainly due to the variety of possible

Conflict of interest

None declared.

Funding

None declared.

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