Laparoscopic Hernia Repair with Adductor Tenotomy for Athletic Pubalgia: an Established Procedure for an Obscure Entity

Georgios Rossidis, MD, Andrew Perry, MD, Husain Abbas, MD, Isaac Motamarry, MD, Tamara Lux, PA, Kevin Farmer, MD, Michael Moser, MD, Jay Clugston, MD, Angel Caban, MD, Kfir Ben-David, MD. University Of Florida College Of Medicine.

INTRODUCTION:
Athletic pubalgia, also known as sports hernia, is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is an entity that is not well understood but has been popularized through the treatment of professional athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor.

METHODS:
Under IRB approval we conducted a retrospective review of our prospectively followed database on competitive athlete patients with athletic pubalgia from 2007-2013.

RESULTS:
A cohort of 54 patients was examined. Mean age was 22.4 years. Most of the patients were football players (n=23), triathlon (n=11), track and field (n=6), soccer players (n=5), baseball players (n=4), swimmers (n=3), golfer (n=1) tennis player (n=1). 51 were males and 3 were females. All patients failed medical therapy with physiotherapy prior to the surgical consultation. 76% of patients had an MRI performed. The MRI findings were as follows: 26% of patients had a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7% of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Two patients had evidence of marrow edema in the left pubic body and two patients had evidence of obturator externus strain and osteitis pubis. Twenty patients had no findings on their preoperative MRI and only one patient was noted to have an inguinal hernia present on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients followed a strict rehabilitation regimen and all patients were able to return to full sports related activity in 24 days (range, 21-28 days). One patient experienced urinary retention, another developed subsequent pain 6 months following his initial operation requiring a contralateral adductor longus tentomy, and one patient sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months.

CONCLUSION:
Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy. Strict rehabilitation program following surgical repair and tenotomy can provide excellent results and early return to sports related activity with minimal complications.