Groin pain

Groin pain is a common complaint amongst sportsmen and women and members of the public alike. It affects many athletes particularly those participating in sports involving kicking, rapid acceleration and deceleration and sudden change of direction. It has been shown to be particularly common amongst football, rugby and hockey players. However, all athletes could develop this condition as it has been described in cricketers, marathon runners, equestrian eventers, baseball players and ice-hockey players to name but a few. The true incidence is unknown and estimates have been as high as 30 - 40% but severe groin pain which significantly disrupts performance and which requires surgical intervention has a reported career-incidence of 4 - 6 % in professional football players. Most players undergo routine hernia surgery with unpredictable results. The Lloyd Release procedure has been specifically developed to address the cause of groin pain which is due to tension in the ligaments which attach to the pubic tubercle.

Pain tends to be of insidious onset and is exacerbated by exercise. It may radiate into the groin, adductor muscles or rectus muscle. Occasionally there is a documented precipitating injury or event but many athletes complain of pain during or even after rigorous exercise. The pain is located near the pubic bone at the insertion of the inguinal ligament onto the pubic tubercle. Most commonly, the athlete has rested the injury, undergone physiotherapy, and subsequently developed a recurrence of the pain upon recommencing activity. Other conditions in this area may include pain arising from the adductor muscles, the hip joint and obturator nerve. Osteitis pubis, inflammation of the pubic bones, is very often over-diagnosed. There is, however, an extensive list of differential diagnoses. Clinical examination and a sound knowledge of groin anatomy are of paramount importance in reaching an exact diagnosis. An MRI scan may exclude significant other pathology but exact localisation of the pain must be done by an expert with full knowledge of the underlying anatomy. Many specialists consider that athletes with groin pain have some kind of hernia and call it a 'sportsman's hernia' despite the fact that often a hernia does not exist.

THE TERM 'SPORTSMAN'S HERNIA' SHOULD BE ABANDONED - IT SHOULD BE REFERRED TO AS A GROIN STRAIN

A hernia is defined as a lump or protrusion yet in most athletes a lump cannot be felt. Therefore these patients do not have a hernia and the term ‘sportsman's hernia' should be abandoned as it is wrong and misleading. Athletes with groin pain have a stain injury in and around the pubic tubercle; there may be additional small tears of the tissues in the groin region but the actual cause of the painful symptoms is due to ligamental strain of the inguinal ligament, rectus sheath attachment, lacunar ligament or pectineal ligament. The condition is analogous to tennis elbow whereby it has been proven to be due to an ‘enthesopathy' of the insertion of the extensor tendon onto the periostium of the lateral epicondyle of the humerus. That is to say the insertion (the enthesis) has become inflamed and pathological. In severe case of tennis elbow dividing the extensor tendon surgically improves the pain and allows full recovery. Using similar principles, dividing the ligamentous attachments around the pubic tubercle will relieve groin pain in athletes. This cannot be done through open surgery using an incision in the groin as patients require the placement of a mesh internally to prevent hernias from forming in the future. This procedure therefore can only be performed laparoscopically i.e. using key hole surgery.