Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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G.J. Mancini
abdominis has a reported success rate of 70–85 % [ 18 , 22 ]. This success
rate mirrors the surgical cure rates published for chronic inguinodynia in
post-hernia surgery nerve injury. For the obturator nerve, since its main
function is motor innervation, neurectomy would not be tolerated. In this
case, surgical neurolysis, or nerve decompression, is the best option.
This technique requires careful dissection of the nerve as it courses
through the different fascial compartments of the adductor muscle
groups. Release of the tendon and fascial fibrotic bands around the nerve
allows release of the nerve from its entrapment. In a case series of 29
elite athletes, all with clinical obturator nerve entrapment symptoms and
validated with abnormal EMGs, all 29 had significant recoveries in 2–6
weeks of neurolysis and returned to competition [ 19 ].
Summary: Putting It All Together
Athletic pubalgia has been described here as three distinct clinical
entities: as an occult hernia, osteitis pubis, or a regional nerve entrapment
syndrome. As clinicians, we are tasked in evaluating the patient,
accounting for the signs and symptoms, and making the right diagnosis
to help the patient make a full recovery. My goal is to take the presumptive
diagnosis of a sports hernia and more clearly define it as one of the
three diagnoses. My evaluation process begins by interviewing to the
patient’s complaints to listen for clues that point to a hernia, a musculoskeletal
injury, or nerve-related pain. I then begin the conversation by
saying that chronic groin pain can be very difficult to treat and a quick
fix is not likely to occur. If the patient, parent, coach, or trainer does not
walk out the door at this point, I will walk them through the diagnostic
testing process as well as the likely timeline for treatment, rehabilitation,
and return to competitive training. If the patient has had no prior inguinal
or pelvic surgery in the past, my first test of choice is an MRI of the
abdomen and pelvis (to the mid-thigh). In my practice, two-thirds of
patients with no prior inguinal or pelvic surgery are most likely to have
osteitis pubis as the diagnosis. MRI is the best modality for this, and
MRI will show inguinal hernias as well. In contrast, athletes with presumptive
athletic pubalgia who have had prior inguinal or pelvic surgery
are more likely to have a hernia recurrence, meshoma, or regional nerve
entrapment syndrome. I therefore obtain a CT of the abdomen and pelvis
with Valsalva completed. Positive findings on CT or MRI will guide the
medical, surgical, and rehabilitation plans, as previously described.
Normal CT and MRI will prompt a more thorough neurologic exam to