My name is Per Hulmik. I'm an orthopedic surgeon from University of Copenhagen, Denmark, and my subject today is groin pain in athletes with a focus on adductor injuries. I have no disclosures. One of the main problems dealing with groin pain is that we have a very, or at least have had a very unspecific terminology. In a systematic review from 15 looking at 72 studies, 33 different diagnoses were identified describing groin pain in athletes. Among those were for instance osteitis pubis, describing the changes you see in the pubic bone with bone marrow edema itself not a diagnosis. Core muscle injury, some sort of a diagnosis describing maybe what others call spartania or pulbelgia, not quite sure, a diagnosis that primarily is used in North America. Athletic pulbelgia, well it just means that it's athletes with pain in the pubic region. It could just as well be like knee algae if you have pain in the knee or shoulder algae and so on. Athletic groin pain means that you have groin pain in athletes. Again, very unspecific. Pubic aponeurosis injury, an injury describing an aponeurosis in front of the pubic bone where everything is inserting and where all the injuries come from. Again, a misinterpretation of the anatomy. So we feel that it's extremely important to look at the anatomy and know your anatomy. Know that all these muscles and tendons are inserting into the bone. Know where they're inserting. It's in a small area which makes it a little bit difficult, but at the end of the day it is clearly possible to palpate the most important and identify them either with palpation or with various tests, and I'll come back to that. Dissection is here where you have the forceps placed under the anterior pubic ligament over the pubic symphysis, and you can see the adductors, the abdominal muscles, and so on. A number of illustrations here from papers published in the recent 10 years describing some of the misunderstandings. On the left side, you can see that the rectus abdominis muscle is illustrated as if it goes down in front of the pubic bone. We all know that, of course, the rectus abdominis muscle is inserting on top of the pubic bone, and there is no rectus abdominis muscle in front of the pubic bone, and the injury as described here cannot exist. On the right side, you see in the upper corner an illustration showing that the external oblique muscles are going directly away in the adductor longus muscles as if it was one muscle pulling in each end. We know, as surgeons, of course, that muscles are acting from bone to bone, and what has been described is more or less the fascial covering of the muscles. For instance, here you see the rectus abdominis insertion on top of the pubic bone. Down here, you have the adductor longus insertion into the pubic bone, far away from where the external oblique is inserting at the conjoined tendon at the pubic bone. What we have been working with is a clinical entity approach, where we describe the various symptoms and clinical findings related to specific anatomical structures, iliopsoas, adductor, inquinal, hip joint. This description has been the basis of the further development into the Doha Agreement on Groin Injury Terminology, where we in 2015 in BJSM published the adductor-related groin pain, iliopsoas-related, inquinal-related, pubic-related, and hip-related groin pain, describing each of these entities and how they are diagnosed. This agreement meeting was a meeting of orthopedic surgeons, general surgeons, sports physicians, physiotherapists and physiologists, and radiologists from all over the world. This consensus agreement, called the Doha Agreement, is now widely used all over the world. It is the far most used terminology used in scientific papers and also in a survey we did asking the doctors in the FIFA Medical Centers of Excellence and the IOC Research Centers, 58 centers from all over the world, and we found that up to two-thirds of the clinicians was using the Doha Agreement. The characteristics of the physically active patient who comes to you with groin pain is that there is pain during fast turns, sprinting, running on a slippery surface, kicking and tackling. When they do long runs, it's often when they get tired that the pain starts. Some have pain with coughing and sneezing, always standing on one leg, putting on socks type of activities. One-third can describe an acute incident where it started. About two-thirds will have a more gradual onset, characterizing the overuse injury. To examine these patients, you will need reproducible clinical tests. I will use and show some of these tests in the following slides. To diagnose adductor-related groin pain, there are two tests that you need to do. One is the squeeze test. You can do squeeze tests in many ways, but we find that this test is the best way to do it, and also to identify the adductor longus, which is far the most commonly injured muscle in these patients. You do it with the patient's legs extended, both knee and hip, and in a neutral position, no external rotation. You need to adduct with the adductors. You ask to adduct with the adductors. You ask for pain in this position. Palpation of the adductor origin is extremely important, and you can do it standing in this position with the patient's leg a little flexed and abducted, externally rotated, so that you can find the adductor longus tendon, which is quite easy, and then you follow it all the way up to the bone, because this is where the tendon inserts, and this is where the pain is in the long-standing patients. In the acute injured patients, of course, you will find it also in the muscle and further down the tendon, but in the long-standing problems, you need to go all the way up to the bone insertion. Treatment of patients with long-standing adductor-related groin pain is, in far the most patients, based on exercise therapy. We published this study back in 1999 in The Lancet, showing that an active physical training program with exercises aimed at strengthening the adductors and pelvic stability was far better than a passive treatment program. The program looks like this. It has been further developed, but in the essence of it, this is still the way to treat patients with adductor-related groin pain. You gradually start with simple exercises, isometrics, dynamics exercises, and gradually increasing the level of load and the level of complexity, increasing both strengthening and coordination exercises. We did actually a 10-year follow-up on these patients and found that those who did the adductor protocol still had significant effect of the program. Adductor tenotomy is also a possibility that has been used and described. There's no really good studies on it. All of it is level 5 or 4. I made an unsystematic review, looking at five level 4 studies with great variety in design. As you can see, excellent results in 54% up to 75%, poor results up to 17%, and complications in up to 34%. The active exercise program that I described from 1999 showed excellent results in 79%, poor results in 3%, and no complications. I'd really recommend that you take a look on this adductor protocol and use that for your patients with long-standing adductor-related problems. You can find the program in this app or just put adductor protocol into the web and you will find the very nice videos describing how to do it. What about the acute adductor injuries? Well, again, they are very much like many other muscle injuries, but you have to be careful because they can, as you could see before, develop into long-standing problems if they're not treated properly. If we do a criteria-based exercise protocol like we have described in OGSM in 20, most of the adductor injuries, grade 0 to 2, can return pain-free to sport in two to four weeks. Those with a total proximal tendon rupture, and that is the adductor longus rupture, grade 3 injuries, actually also can return pain-free to sport, but it will take two to three months before they can do this. It's almost never indicated to do acute surgery in these patients, at least it's not necessary, but there will be rare occasions where it doesn't heal, and of course, in these situations, you will need to consider surgery. What about the inguinal-related groin pain? Well, what we mean by inguinal-related groin pain is that there is no hernia. There's a tender conjoined tendon at the insertion. As you can see in the illustration here, you have the inguinal ligament inserting into the pubic tubercle, and just medial to that is where the conjoined tendon of the external oblique and the transverse abdominis is inserting. They constitute the posterior wall of the inguinal canal, the so-called fascia transversalis. So this insertion will be tender, and when you palpate through the scrotum, the inguinal canal, with the patient standing up, the external opening will be tender, and the posterior wall that you can palpate through the external opening will be soft, and there is a clear difference to the good side. We believe that inguinal-related groin pain actually is a muscle injury, muscle tendon injury, because what probably happens is that you have a weakness of the posterior wall of the inguinal canal. It can be an acute injury, or it can be a long-standing overuse injury, but you develop a weakness. This weakness will lead to a dilation of the fascia, which actually isn't a fascia, but it's a tendon, the extended tendon transversalis, at its weakest point. The inguinal triangle becomes wider, and there will be increased tension on the stabilizing tendons and muscles around the region, which will create pain. Compression and irritation of the genitofemoral nerve, also creating pain, can be the next step. So if this is a muscle tendon injury, then again, as we saw with the adopters, this must be something that you can treat with exercise treatment. And it can actually be done. There's a nice RCT here with 40 football players who had exercise treatment in one arm, and 75% returned to sport without groin pain after two to three months. It's a small study. We need more studies, but it's probably a good direction of how to do it. If exercise is not enough, surgery is definitely an option. And the basic principles are similar to the treatment of hernias, but remember, this is not a hernia. There is no hernia sac to invert or remove. But there's no need for big, complicated surgery for these patients. In most cases, it can be done using the same techniques, sometimes putting in a net, either laparoscopically or open, or doing a plication of the fascia. The last problem I'm going to touch upon is the iliopsoas-related groin pain. Iliopsoas is a very important muscle in all of these injuries. Often you have secondary iliopsoas problems with many of the diagnoses here, but especially with the hip and the hip joint, this is the most important differential diagnosis to hip-related groin pain. It's very important that you, as a hip surgeon, are able to diagnose the iliopsoas. Remember that the iliopsoas is a deeply situated muscle, but as it comes up through the pelvis and enters in front of the hip joint, it is possible to palpate it. You can palpate it either abdominally at the level of the anterior iliac spine, lateral to the rectus abdominis muscle, get the patient to relax, put your fingers down there, then the patient lifts the leg a few centimeters, and you can feel the muscle under your fingers and ask if there's any palpation or pain, if it's tender, and remember to compare to the other side because this is, of course, uncomfortable. You can also find it just under the inguinal ligament, medial to the sartorius. This is actually the only side where the iliopsoas is located subcutaneously. So my take-home message today is that groin pain in athletes is primarily the result of four entities, adductor-related, inguinal-related, iliopsoas-related, and hip joint-related groin pain. The DOHA agreement terminology is recommended because it's easy to work with, it makes sense from an anatomical point of view, and it's also already widespread all over the world, both clinically and scientifically. We have excellent exercise-based treatment options for a doctor, and also iliopsoas and inguinal-related groin pain is being developed. Surgical options are almost never indicated for a doctor and iliopsoas-related groin pain, except for the snapping iliopsoas, where you will find further information in the lecture here by Stephen Aoki. Surgical treatment for inguinal-related groin pain in athletes is simple, hernia-like surgery, either open or laparoscopic. Thank you very much for your attention.

groin pain

adductor injuries

anatomy of the groin region

Doha Agreement on Groin Injury Terminology

diagnosing specific anatomical structures