Rehabilitation and Return to Play Following Surgery for Inguinal-Related Groin Pain
Introduction
Inguinal-related groin pain (IRGP) in athletes is infamous and shrouded with confusion and controversy. This clinical entity has had many different terms used to describe the diagnosis along with multiple definitions. Similar clinical presentation in different global regions lead to the emergence of multiple terms such as “incipient hernia,” “Gilmore’s groin,” “hockey groin,” “posterior inguinal wall weakness,” “groin disruption,” “sportsman groin,” “sports hernia,” and “sportsman hernia.” More recently after the British hernia society consensus meeting, the term “inguinal disruption” was also suggested.1 In this article, we use the term Inguinal related groin pain, which was agreed upon during the 2014 Doha Agreement meeting on Terminology and Definitions of Groin Pain in Athletes.2 This classification system also defined other common clinical entities in athletes with groin pain; adductor, iliopsoas, or pubic-related groin pain. An emphasis should be placed on the importance of the hip as a possible cause of groin pain in athletes, as well as the need for careful examination of other possible causes, such as entrapment neuropathy or an actual inguinal hernia.
Please note that in all cases, a complete examination of the entire groin region should be conducted, as multiple clinical entities can be present in a single athlete presenting with groin pain.3, 4 In the same regard, treatment expectations should be aligned as concomitant entities such as adductor-related groin pain that is frequently present.
Section snippets
Defining IRGP
According to the Doha agreement, IRGP is defined as2:
- •
Pain in the inguinal canal region and tenderness of the inguinal canal; no palpable inguinal hernia is present.
- •
IRGP is more likely if the pain is aggravated with abdominal resistance testing or Valsalva or cough or sneeze.
This definition describes the clinical presentations and examination findings, without attempting to describe what the underlying pathology may be. There are almost as many theories to explain the underlying pathology of
Treatment of IRGP
A systematic review on the treatment of groin pain in athletes in 2015 included 72 different studies.13 Most studies were case series (90%) and most studies were retrospective (80%). There was a significant association found where studies with lower quality reported better treatment success. These factors should also be considered when interpreting the conclusions of the current studies on the outcomes of IRGP. No studies on the conservative treatment of IRGP with a well-described treatment
Postoperative Rehabilitation
There are several studies on surgical treatment of IRGP; however, these generally do not provide detailed reproducible information regarding the postoperative rehabilitation. In general, studies range from an omission of a rehabilitation protocol description,14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 general brief advice on the immediate postop days, recommended time to resumption of daily activities, exercise or sports, or all of these7, 10, 37, 38, 39, 40, 41,
Conclusion
This article provides an overview of rehabilitation following surgery for IRGP in athletes. It presents a simple, expert opinion-based 4-phase rehabilitation and return-to-sport program for athletes who have undergone inguinal surgery. Progress between phases is based upon achieving clinical milestones and is not time contingent.
Acknowledgments
We would like to thank the team of physiotherapists from Aspetar rehabilitation department, specifically, Sean Lanzinger, Dermot Simpson, Jonas Grani Gardarsson, and Einar Einarsson, who have played an important part in the development of the treatment protocols for athletes with groin pain, and who are ensuring continuous improvements in the treatment of the athletes.
References (47)
- et al.
Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: A randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (athletic pubalgia)
Surgery
(2011) - et al.
Athletic pubalgia (sports hernia)
Clin Sports Med
(2011) - et al.
Herniography in athletes with groin pain
Am J Surg
(1985) - et al.
Sports hernia
Oper Tech Sports Med
(2005) - et al.
Treatment of the sportsmans groin': British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference
Br J Sports Med
(2014) - et al.
Doha agreement meeting on terminology and definitions in groin pain in athletes
Br J Sports Med
(2015) Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: A prospective study of 207 patients
Br J Sports Med
(2007)- et al.
The diagnosis of longstanding groin pain: A prospective clinical cohort study
Br J Sports Med
(2008) Pubic inguinal pain syndrome: The so-called sports hernia
Hernia J Hernias Abdom Wall Surg
(2010)- et al.
Sports hernia: Diagnosis and treatment highlighting a minimal repair surgical technique
Am J Sports Med
(2011)
Sportsmen’s groin-diagnostic approach and treatment with the minimal repair technique: A single-center uncontrolled clinical review
Sports Health
Sports hernias: Experience in a sports medicine center
Hernia J Hernias Abdom Wall Surg
External oblique aponeurosis nerve entrapment as a cause of groin pain in the athlete
Br J Surg
The inguinal release procedure for groin pain: Initial experience in 73 sportsmen/women
Br J Sports Med
Management of severe lower abdominal or inguinal pain in high-performance athletes
Am J Sports Med
Gilmore’s groin repair in athletes
J Orthop Sports Phys Ther
Study quality on groin injury management remains low: A systematic review on treatment of groin pain in athletes
Br J Sports Med Published Online First
Athletic groin pain: A systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes
Br J Sports Med
Gilmore’s groin: Ten years experience of groin disruption—A previously unsolved problem in sportsmen
Sports Med Soft Tissue Trauma
Sports Hernia and Athletic Pubalgia
Inguinal surgery in athletes with chronic groin pain: The “sportsman’s” hernia
Aust N Z J Surg
Totally extraperitoneal endoscopic (TEP) treatment of sportsman’s hernia
Surg Laparosc Endosc Percutan Tech
Laparoscopic and conventional repair of groin disruption in sportsmen
Br J Surg
Cited by (1)
Postoperative MR Imaging of the Pubic Symphysis and Athletic Pubalgia
2022, Magnetic Resonance Imaging Clinics of North AmericaCitation Excerpt :Hip arthroscopy may also be combined with core muscle repair to address associated hip pathology, such as femoroacetabular or psoas impingement.25 Laparoscopic techniques are also frequently used, including transabdominal preperitoneal repair (TAPP) and total extraperitoneal repair, both of which predominantly use mesh placement.18,21,24,26 Adductor tenotomy/release has been performed in isolation or in conjunction with mesh repair.