In this presentation I’m going to inform you briefly about a novel arthroscopic technique for athletic pubalgia. You may have heard it as “sports hernia or groin injury………” but in fact is a groin pain syndrome, particularly common in sports that require athletes to perform repetitive kicking..

1. A
NOVEL ARTHROSCOPIC TECHNIQUE
(bilateral fractional lengthening of adductor longus)
FOR
ATHLETIC PUBALGIA
STAVROS ALEVROGIANNIS, MD, Ph.D
ORTHOPAEDICS & SPORTS MED.
CONSULTANT

2. DEFINITION
GROIN PAIN IS PARTICULARLY COMMON IN SPORTS THAT
REQUIRE ATHLETES TO PERFORM REPETITIVE KICKING,
TWISTING,OR TURNING AT HIGH SPEEDS, SUCH AS
SOCCER,FOOTBALL,BASKETBALL,TRACK AND FIELD TENNIS
AND HOCKEY
• SPORTS HERNIA
• GROIN INJURY/PAIN
• SPORTSMAN’S HERNIA
• GILMORE GROIN
• HOCKEY COALIE SYNDROME
• ADDUCTOR DYSFUNCTION
• OSTEITIS PUBIS

3. DIFFERENTIAL DIAGNOSIS OF GROIN PAIN IN ATHLETES
VISCERAL CAUSES
INGUINAL HERNIA
OTHER ABDOMINAL HERNIAS
TESTICULAR TORSION
HIP ASSOCIATED CAUSES
ACETABULAR LABRAL TEAR
FAI
OSTEOARTHRITIS
SNAPPINH HIP SYNDROME
ILIOPSOAS TENDINITIS
AVN
ILIOTIBIAL BAND SYNDROME
PUBIC SYMPHYSEAL CAUSES
RECTUS ABDOMINIS STRAIN
ADDUCTOR MUSCLE- TENDON DYSFUNCTION
RECTUS ABDOMINIS-ADDUCTOR LONGUS APONEUROSIS TEAR
OSTEITIS PUBIS
INFECTIOUS CAUSES
SEPTIC ARTHRITIS
OSTEOMYELITIS
PELVIC INFLAMMATORY DISEASES
PROSTATITIS
EPIDIDYMITIS
ORCHITIS
HERPES INFECTION
INFLAMMATORY CAUSES
ENDOMETRIOSIS
INFLAMMATORY BOWEL DISEASE
PELVIC INFLAMMATORY DISEASE
TRAUMATIC CAUSES
STRESS FRACTURE
TENDON AVULSION
MUSCLE CONTUSION
BASEBALL PITCHER
HOCKEY GOALIE SYNDROME
DEVELOPMENTAL CAUSES
APOPHYSITIS
GROWTH PLATE STRESS INJURY OR FRACTURE
LEGG-CALVE-PERTHES DISEASE
DEVELOPMENTAL DYSPLASIA
SLIPPED CAPITAL FEMORAL EPIPHYSIS
NEUROLOGICAL CAUSES
NERVE ENTRAPMENT SYNDROME (e.g, ilioinguinal nerve)
REFERRED CAUSES
SACROILIITIS
SCIATIC ENTRAPMENT ( PIRIFORMIS SYNDROME)
HAMSTRING STRAIN
KNEE PAIN
NEOPLASTIC CAUSES
TESTICULAR CARCINOMA
OSTEOID OSTEOMA

4. DEMOGRAPHICS
Between 2% and 8% of all athletic injuries involve the groin
• Up to 13% of all soccer injuries are groin related
Ekstrand J., et al, Scand. J.Med., Sci. Sports 1999;9:98-103
Emery et al, J.Med., Sci. Sports Exerc 2001;33:1423-1433
• 58% of soccer players had a history of groin injury
Harris NH, et al, Br Med J 1974; 4(5938):211-214
• 5-18% of athletes present to their physicians with activity-restricting groin pain
Holmich P., et al Br J Sports Med 2007;41:247-252
Moeller JL, et al, Curr Sports Med Rep 2007;6: 111-114
• Higher incidence in males versus females, may be explained by a greater level of
participation in highly competitive sports and/or gender differences in hormones
and pelvic anatomy
Meyers et al, Clin. Sports Med, Rep.,2002;1: 301-305
Moeller JL et al, Curr,Sports Med Rep., 2007;6:111-114

5. CLINICAL SIGNS
• Pain in the inguinal region, which may radiate to the thigh adductor
muscle origins or to the scrotum and testicles, deeper , more
proximal and more intense than an adductor or iliopsoas strain
• Symptoms are usually unilateral (usually progresses to bilateral)
• Point tenderness to the external ring of the inguinal canal and the
pubis tubercle, the lower rectus abdominis musculature, or the
pubic symphysis, without any palpable hernia.
• Acute or chronic
• Symptoms are usually exacerbated by kicking, sprinting, side-
stepping, cutting, and/or performing sit-ups.
• May complain of point tenderness over the superior-lateral pubis.
• Pain exacerbation with cough or sneezing, or testicular pain in
males

6. TREATMENT
• CONSERVATIVE (6-8 weeks)
1. NSAID’s
2. Rest
3. Physiotherapy (3 times a week for 4 weeks)
4. Corticosteroid injections
5. Daily strength training
• SURGICAL
1. Open/ laparoscopic repair with preperitoneal insertion of polypropylene mesh
2. Herniorrhaphy
3. Adductor tenotomy
4. Pelvic floor relaxation
5. Surgical repair of the posterior wall of the inguinal ring

7. THE SURGICAL PROBLEM
• The association of this process with herniation
may be misleading, and surgery performed to
repair an inguinal hernia may not necessarily
address the cause of groin pain
Meyers WC et al, Curr Sports Med Rep 2002;1:301–305

8. PATHOPHYSIOLOGY 1
• Complicated and poorly understood because of :
1. Complex anatomy of number of interrelated
muscle attachment in close proximity to another
to the pubic symphyseal region
2. Various pathologic entities may cause similar
clinical signs and symptoms and overlap findings
at physical examination
3. Multiple coexisting injuries could cause groin
pain. And that makes it difficult to establish
which injury is the major contributor

9. PATHOPHYSIOLOGY 2
• Most commonly, chronic repetitive torque on the
pubic symphysis during aggressive abduction of
the thigh and hyperextension of the trunk, injure
the common aponeurosis of the rectus abdominis
and adductor longus tendons,
which is located along the anterior aspect of the
pubic symphysis, and may lead to eventual
avulsion of the tendon and a tear in the
aponeurosis.
Meyers WC et al, Am J Sports Med 2000;28:2–8.
Taylor DC et al, Am J Sports Med 1991;19:239–242.
Meyers WC et al, Curr Sports Med Rep 2002;1:301–305
Overdeck KH et al, Semin Musculosk. Radiol 2004;8:41–55.
Ahumada LA et al, Ann Plast Surg 2005;55:393–396.
Saggittal schematics of the pubic symphysis
show the common aponeurosis of the rectus
abdominis and adductor longus muscles,
immediately anterior to the midline of the pubic
body.

10. COMMON APONEUROSIS
Photograph of a cadaveric specimen shows the common
attachment (straight arrow) of the right rectus abdominis
(arrowheads) and adductor longus (curved arrow) tendons.
Saggittal intermediate-weighted MR image obtained
at 3 T shows the aponeurosis (straight arrow) of the
rectus abdominis (arrowheads) and adductor longus
(curved arrow) as a dark band of fibers extending
along the anterior-inferior aspect of the pubic body,
1–2 cm from the symphyseal midline.

11. BIBLIOGRAPHIC ANNOTATIONS
• At MR imaging and surgery in patients with
clinical athletic pubalgia, we have most
commonly observed injury along the lateral
border of the rectus abdominis, just cephalad to
its pubic attachment, or at the origin of the
adductor longus.
After an injury to either the rectus abdominis
muscle or the adductor muscle, there is a
repetitive unbalanced contraction in the other
muscle
Meyers WC et al, Am J Sports Med 2000;28:2–8.
• Lack of opposing force leads to degeneration
and tearing of the tendon not initially torn
• Hernia-like symptoms may be related to the
proximity of the injury site to the medial margin
of the superficial ring of the inguinal canal
Imran M. Omar et al, RadioGraphics 2008; 28:1415–1438
The rectus abdominis & adductor longus
muscles = relative antagonists of one
another during rotation and extension
from the waist
Normal anatomy of the pubic symphysis.
Yellow arrowheads indicate the directions
of major force vectors to which the pubic
bone is commonly subjected during athletic
activities

12. CRITICAL QUESTIONS
1. WHY ARE WE TALKING ABOUT ADDUCTOR LONGUS TENOTOMY?
2. IS ONLY ONE SURGICAL PROCEDURE ENOUGH FOR EVERY “SPORTS
HERNIA” CASE?
3. WHY DO WE CALL THIS TECHNIQUE “NOVEL”? ISN’T THERE ANY
OTHER SIMILAR REFERRENCE IN THE LITERATURE?
4. WHY SHOULD AN ATHLETE PREFER TO UNDERGO THIS PROCEDURE
INSTEAD OF ANOTHER?

13. SURGICAL PROCEDURE
• Under general anesthesia
• Prophylactic 2gr cafazolin i.v at induction
• “frog-leg” patient position
• Two 1cm transverse arthroscopic portals were performed in the
groin region, the first one 2.5cm from its origin for the scope and
the second one, 1cm from its origin as a “working portal”
• A small gauze- a blade No 11, no water pump, no specific
instrumentation needed
• Trephinations using a spine needle on the pubic bone (common
aponeurosis )
• Partial adductor longus tenotomy as a “z” plasty
• Reabsorbable sutures
• Bilateral procedure

14. PATIENT POSITIONING

15. PATIENT POSITIONING

18. POST-OP. REHAB
• No hospitalization
• Icing 10min twice a day for 1st w.p.o
• No crutches for walking
• Anti-inflammatory medication for couple of days
• Specific adductor stretches (closed or open chain
exercises) program
• Return to competitive training, 6th w.p.o
• Return to sprinting & kicking 8th w.p.o

19. MATERIAL
• March-June 2013
• 9 (5 professional- 4 semiprofessional) athletes - all male
• Sports participation : 8 football players- 1 basketball player
• Median age 27 years, range; 19-32 years
• Median duration of symptoms: 6.2m., range 5-8m.
• All patients were referred due to groin pain and functional limitation
• The clinical diagnosis was positive if there was tenderness localized to the adductor longus origin,
pain on passive stretching of the adductors, and pain on adduction of the thigh against resistance
• The absence of sports hernia had been excluded after consultation with a general surgeon
• All underwent a conservative management including rest, ice, and/or nonsteroidal anti-
inflammatory drugs, and physical therapy including adductor stretching and closed/open chain
strengthening exercises
• The severity of pain was stage III in 7 patients and stage IV in 2 patients, according to the functional
classification of Puffer and Zachazewski
• MRI findings: 1 with pure adductor longus dysfunction, 8 with pubic symphysis bone marrow
oedema
• Ethics
• All were managed with the same surgical procedure and postoperative rehabilitation

20. Case 1
A 24-year-old male football player, with marrow oedema associated with common
aponeurosis injury
Coronal STIR image of the pubic symphysis demonstrates disruption of the left rectus
abdominis–adductor longus aponeurosis (arrow) and associated marrow edema in the pubic
body (arrowhead). (b) Axial T2-weighted image shows the localization of marrow edema
(arrow) to the anterior aspect of the pubic body.

21. Case 2
A 30-year-old soccer player with left-sided athletic pubalgia, due to tear of the
left rectus abdominis–adductor longus aponeurosis
Coronal STIR image of the pelvis demonstrates an accessory cleft sign alongside the left pubic body (arrow) and a
grade 1 strain of the left adductor longus muscle (arrowheads). (b, c) Axial (b) and sagittal (c) T2-weighted fat-
suppressed images obtained 1 cm lateral to the pubic midline show the typical appearance of a tear (straight arrow),
with signal intensity similar to that of fluid, in the aponeurosis. In c, the relationship of the rectus abdominis
(arrowheads) and adductor longus (curved arrow) muscles is more clearly visible.

22. Normal MR imaging appearance of the rectus abdominis–
adductor longus aponeurosis.
Saggittal T2-weighted fat-suppressed image obtained 1–2 cm from the pubic
symphyseal midline in a patient without injury shows the aponeurosis (curved
arrow) of the rectus abdominis (arrow) and adductor longus (arrowhead) muscles.

23. Normal MR imaging appearance of the rectus abdominis–adductor
longus aponeurosis.
Axial T2-weighted image of the pelvis shows the sites of muscle attachment in the anterior pubic
region. The rectus abdominis–adductor longus (AL) aponeurosis (arrows) appears as a band of
low signal intensity across the anterior-inferior margin of the pubic symphysis (PS). OI =
obturator internus, Pec = pectineus.

24. FOLLOW-UP
• CLINICAL ASSESSMENT (pre-op, 2 w, 3,6,12m. p.o, once a year after)
1. Pain score (functional classification of Puffer and Zachazewski)
2. Functional outcome and health status
- Hip Disability and Osteoarthritis Outcome Score (HOOS)
- Short Form Health Survey (SF-36)
- European Quality of Life–5 Dimensions scale (EQ-5D)
• IMAGING ASSESSMENT
1. Pelvic plain A/P & L x-rays pre-op (exclude evidence of FAI or
fractures
2. MRI pre-op (exclude intra-articular hip joint disorders, such as
labrum tears and chondral lesions, osteitis pubis and iliopsoas
strains/bursitis

25. DEMOGRAPHIC DETAILS & CLINICAL OUTCOMES
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
OUTCOME SCORES
---------------------------------------------------------------------------------------
LEVEL OF SPORT EQ-5D SF-36 HOOS
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ATHLETE SPORT PREINJURY POST-OP. PREINJURY POST-OP. PREINJURY POST-OP. PREINJURY POST-OP.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1 SOCCER semiprof. semiprof. 54 96 52 95 75 96
2 SOCCER profess. profess. 52 92 50 95 72 92
3 SOCCER semiprof. semiprof. 56 89 53 91 68 94
4 BASKETBALL profess. profess. 53 95 53 92 71 97
5 SOCCER semiprof. semiprof 62 91 59 90 66 92
6 SOCCER profess. profess. 59 92 55 92 64 97
7 SOCCER profess. profess 56 95 52 97 68 91
8 SOCCER semiprof. semiprof 61 95 58 91 71 91
9 SOCCER profess. profess. 59 91 57 92 68 98
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
EQ-5D: European Quality of Life–5 Dimensions scale; SF-36 : Short Form Health Survey; HOOS : Hip Disability and Osteoarthritis
Outcome Score.

26. CLINICAL OUTCOMES (3m.p.o)
• Median time of operation (bilaterally): 26± 7min (range, 19-34)
• All pts returned to pre-injury level of sports activity
• Median time to return to competitive training: 4.5 w.p.o
• Median time to return to competitive sport: 6.2 w.p.o
• No strength deficit of the adductors was measured postoperatively
0
10
20
30
40
50
60
70
80
90
100
EQ-5D SF-36 HOOS
56,8 54,3
69,2
92.8 92.7 94,2
PRE INJ
POST OP

27. PAIN SCORE (3m.p.o)
6,1
0,21
0
1
2
3
4
5
6
7
PRE INJURY POST OP
VAS SCORE
VAS SCORE

28. COMPLICATIONS
• No surgery-related complication was recorded
• Wound infections : 
• Hematoma with bruising : 
• Scar dissociation : 
• Numbness around the wound : 1
• Painful scar : 

29. CONCLUSIONS-LIMITATIONS
• A novel technique- bilaterally performed
• Extended indications ( clinically & MRI dependant)
• Fully arthroscopically performed (direct visualization)
• Minor/No complications
• Small learning curve
• No specific instrumentation needed
• No time consuming procedure
• No hospitalization- early mobilization
• Minimal invasive procedure
• No mesh or other allogenic graft needed
• Quicker return to full sports
• Efficacy of the method
• Patient compliance
• More patients needed
• More time for FU needed
• Lack of a control group