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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70 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
7. Groin Pain Etiology: Athletic Pubalgia Evaluation… 71 Diagnosis Occult Hernia Osteitis Pubis Adductor Longus Nerve Entrapment Hip/Femur injury Inguinal Floor Weakness Athletic Pubalgia Algorithm First Line Therapy Operative Hernia Repair NSAIDS, Rest & Rehab NSAIDS, Rest & Rehab Diagnostic/Theraputic Nerve Block Refer to Orthopedic Surgeon NSAIDS, Rest & Rehab Second Line Therapy Operative Hernia Repair NSAIDS, Rest & Rehab Adductor Longus Release Neurectomy +/- Hernia Repair Refer Back to Orthopedic Surgeon Operative Hernia Repair Fig. 7.4. Treatment algorithm for athletic pubalgia. include dermatome mapping of the sensory of pain symptoms. If the pain correlates with the sensory dermatome distribution of a specific nerve, trigger point injections can be given for both diagnostic and therapeutic effect. The toughest dilemma comes when the patient’s exam has no major physical findings, a normal CT and MRI, little relief from the trigger point injections, and continued patient pain that limits competitive performance. This is the point at which the scope of the work-up should be widened and alternative clinical opinions sought. Figure 7.4 demonstrates a treatment algorithm for athletic pubalgia. References 1. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett Jr WE. Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia. Am J Sports Med. 1991;19(3):239–42. 2. Depasquale R, Landes C, Doyle G. Audit of ultrasound and decision to operate in groin pain of unknown aetiology with ultrasound technique explained. Clin Radiol. 2009;64(6):608–14. 3. Deitch EA, Soncrant MC. Ultrasonic diagnosis of surgical disease of the inguinalfemoral region. Surg Gynecol Obstet. 1981;152(3):319–22. 4. Robinson P, Hensor E, Lansdown MJ, Abrose NS, Chapman AH. Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. Am J Roentgenol. 2006;187(5):1168–78.
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Brian P. Jacob · David C. Chen Bru
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The SAGES Manual of Groin Pain Bria
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Foreword Inguinal hernia repair is
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Contents Part I Primary Groin Pain
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Contents ix 22 Management of Inguin
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Contents xi 45 Value-Based Clinical
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xiv Editors and Contributors Jeffre
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xvi Editors and Contributors David
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xviii Editors and Contributors Greg
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xx Editors and Contributors David S
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1. Introduction to Primary and Seco
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10 I.A. Gawlas and W.J. Peacock Ili
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12 I.A. Gawlas and W.J. Peacock Tra
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14 I.A. Gawlas and W.J. Peacock Var
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3. Complex Regional Pain Syndrome T
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10. Groin Pain Etiology: Spermatic
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138 M. Hibner and C. Coyne Piriform
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140 M. Hibner and C. Coyne Fig. 11.
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142 M. Hibner and C. Coyne Table 11
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144 M. Hibner and C. Coyne present
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146 M. Hibner and C. Coyne Table 11
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148 M. Hibner and C. Coyne Once the
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150 M. Hibner and C. Coyne 3. Hibne
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12. Chronic Pelvic Pain in Women M.
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12. Chronic Pelvic Pain in Women 15
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174 J.M. Miller et al. Knowing the
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176 J.M. Miller et al. Fig. 13.2. A
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182 J.M. Miller et al. Fig. 13.9. C
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184 J.M. Miller et al. Fig. 13.14.
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192 J.M. Miller et al. Cardiac Cath
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194 B.J. Dunkin Noxious peripheral
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196 B.J. Dunkin Table 14.1. Summary
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198 B.J. Dunkin Rectus abdominis Ex
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200 B.J. Dunkin COX-1 COX-2 Celecpx
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202 B.J. Dunkin Table 14.2. Common
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204 B.J. Dunkin Possible Preoperati
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206 B.J. Dunkin Postoperative Pain
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208 B.J. Dunkin Summary Understandi
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15. Chronic Groin Pain Following An
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222 E.L. Felix not seem to alter th
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224 E.L. Felix nerves from the surg
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226 E.L. Felix Fig. 16.2. Lateral f
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228 E.L. Felix It has been establis
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230 E.L. Felix 18. Pollak R, Nyhus
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17. The Orthopedic Perspective on G
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246 J.F.M. Lange Jr. examination an
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248 J.F.M. Lange Jr. and remedial s
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250 J.F.M. Lange Jr. Best available
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252 J.F.M. Lange Jr. Neuropathic pa
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254 J.F.M. Lange Jr. This algorithm
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19. Radiologic Evaluation for Posto
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19 Radiologic Evaluation for Postop
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268 A. Malhotra extended variant of
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270 A. Malhotra steroid injections,
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272 A. Malhotra located just below
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274 A. Malhotra Nociceptive Acute N
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276 A. Malhotra 20. Rozen D, Parvez
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278 R. Álvarez intentionally or in
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Fig. 21.1. Material: A ballpoint pe
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Fig. 21.5. Dermatome mapping compat
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Fig. 21.9. Dermatome mapping compat
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286 R. Álvarez Subsequently, we mu
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288 R. Álvarez G : Granuloma H : H
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290 R. Álvarez Fig. 21.14. Same pa
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292 R. Álvarez 6. Lermite E, Arnau
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294 K.A. Seymour and J.S. Yoo Table
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296 K.A. Seymour and J.S. Yoo repro
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298 K.A. Seymour and J.S. Yoo Recur
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23. Mesh Removal for Chronic Pain:
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23. Mesh Removal for Chronic Pain
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320 I.T. MacQueen et al. inguinodyn
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322 I.T. MacQueen et al. Fig. 24.2.
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324 I.T. MacQueen et al. Timing and
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326 I.T. MacQueen et al. Fig. 24.4.
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328 I.T. MacQueen et al. Posthernio
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330 I.T. MacQueen et al. never be e
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25. Laparoscopic Triple Neurectomy
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26. Chronic Orchialgia: Workup and
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27. The Role of Bioactive Prostheti
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376 G. Campanelli et al. affecting
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378 G. Campanelli et al. into the w
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380 G. Campanelli et al. chronic gr
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382 G. Campanelli et al. A prospect
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384 G. Campanelli et al. open mesh
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386 G. Campanelli et al. 38. Alfier
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29. Prevention of Pain: Optimizing
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30. Prophylactic Neurectomy Versus
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Table 31.1. Selective neurectomy wi
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408 W.M.J. Reinpold and A.D. Schroe
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32. Chronic Groin Pain: Mesh or No
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Part IV Case Reports and Patients
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430 S. Towfigh were irregular and s
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432 S. Towfigh in addressing her sy
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434 S. Towfigh Conclusion We have y
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436 K.W. Kercher Physical Examinati
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438 K.W. Kercher Fig. 34.4. Left ad
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440 K.W. Kercher Fig. 34.5. After d
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442 K.W. Kercher the posterior wall
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444 K.W. Kercher Table 34.2. Surgic
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35. Chronic Post-inguinal Herniorrh
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35 Chronic Post-inguinal Herniorrha
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35 Chronic Post-inguinal Herniorrha
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36. Sports Hernia with Adductor Ten
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464 C.G. DuCoin and G.R. Jacobsen P
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466 C.G. DuCoin and G.R. Jacobsen O
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468 J.A. Blatnik and A.S. Prabhu a
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470 J.A. Blatnik and A.S. Prabhu Fi
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472 J.A. Blatnik and A.S. Prabhu ma
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474 S. Towfigh Physical Exam The pa
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476 S. Towfigh The patient’s loca
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478 S. Towfigh Fig. 39.2. Diagram o
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480 S. Towfigh periphery. He is 2+
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482 S. Towfigh References 1. Matthi
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484 N.A. Al-Enazi and B.P. Jacob
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486 N.A. Al-Enazi and B.P. Jacob Fi
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488 N.A. Al-Enazi and B.P. Jacob pu
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42. Patient with Chronic Pelvic Pai
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42. Patient with Chronic Pelvic Pai
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43. Thoracolumbar Syndrome James A.
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43. Thoracolumbar Syndrome 497 The
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43. Thoracolumbar Syndrome 499 Groi
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44. Patient with Referred Hip Pain
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44. Patient with Referred Hip Pain
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45. Value-Based Clinical Quality Im
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46. Patient Care Manager Perspectiv
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47. Workers’ Compensation: An Occ
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532 Index Athletic pubalgia (cont.)
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534 Index Chronic post-herniorrhaph
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536 Index Groin pain (cont.) magnet
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538 Index Ilioinguinal nerve (IIN)
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540 Index Local anesthetics (cont.)
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542 Index Peripheral nerve entrapme
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544 Index S Sacroiliac (SI) joint d
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546 Index Transperineal pudendal ne
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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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