Clinical results of surgical treatment for athletic pubalgia

doi:10.21203/rs.3.rs-2113130/v1

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Clinical results of surgical treatment for athletic pubalgia

https://doi.org/10.21203/rs.3.rs-2113130/v1

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Athletic pubalgia, first described in 1916 and first related to sport in a publication in 1932, is a condition characterized by pain in the inguinal region that causes a large number of absences from competitive physical activity, being very common in soccer. There is a wide variety of lesions that can affect the pubic symphysis region, which is composed of different musculoskeletal structures. The taxonomies described also vary and constitute additional diagnostic difficulties. This injury occurs by repetitive overload and not counterbalanced by the abdominal muscles, hip flexors and adductors in susceptible athletes. Pubis's injury may be related to the adductor or iliopsoas musculature, disorders in the inguinal canal, pubic symphysis, hip joint, or be due to other causes, such as occult hernias. Pubic symphysis injuries in athletes can affect not only the athlete's career, but also have a major financial impact on both the athlete and his team. Due to the low specificity of the symptoms in an anatomical region with multiple diagnostic possibilities, it is difficult to confirm the diagnosis and, consequently, the most appropriate therapy in disorders of the pubic symphysis. The main objective was to evaluate the outcomes of the surgical treatment of pubalgia with the technique used by the Sports Medicine Group (GME) of the Institute of Orthopedics and Traumatology of Hospital das Clínicas - Universidade de São Paulo. The secondary objective is to characterize and standardize the diagnostic and therapeutic methods used in the management of this complex musculoskeletal dysfunction. The present study is a consecutive historical cohort analysis of the medical records of the cases examined and operated on from 01/01/2002 to 12/31/2016 by the same surgeon. A total of 45 medical records were evaluated. All athletes are male, 75.6% professional soccer athletes, with a mean age of 23.9 years (SD5.86), 80.5% without associated trauma, 58.5% with progressive pain. The time to return to competitive sport was 94 days (median), with 93.3% of good results. The start of symptoms, attacker position and age included in the model were overall significant in predicting discharge period. But only the attacker 's position had a statistically significant value. The outcome of the procedure occurred in 94 days (median) in professional athletes, showing a positive relationship with the playing position (attackers), with 93.7% of good results, proving to be a good option for the treatment of this disease.

Background: This text represents our institution's experience concerning the athletic pubalgia treatment. As we are a FIFA Medical Center of Excellence we are entitled to study and understand football lesions.

Purpose: Athletic pubalgia is characterized by pain in the inguinal region. Taxonomies vary and account for difficulties in diagnosis. The injury may be related to the adductor musculature, inguinal canal disorders, pubic symphysis, hip joint or occult hernias. As symptoms lack specificity, it is difficult to confirm diagnosis and the appropriate treatment. To assess the outcome of surgical treatment of myotendinous athletic pubalgia.

Methods: This study is a consecutive cohort analysis of 45 patients operated between 11 2002 and 2016.

Results: All athletes were male, 75.6% professional soccer players, their mean age was 23.9 (SD 5.86), 80.5% had no trauma and 58.5% progressive pain. Return time to sport was 94 days.

Conclusion: The procedure outcome showed 93.7% of good results, proving to be a good treatment option.

Pubic symphysis

Tenotomy

Athletic injuries

Return to sport

Soccer

We have a lot of different treatments addressed in the current literature and we describe here our diagnostic protocol and preferencial method of treatment.

What this study adds to existing knowledge: It shows a somewhat different approach to this pathology, emphasizing the correct diagnosis and ensuring good surgical indication and post op results.

Athletic pubalgia is a disease characterized by pain in the inguinal region which keeps a large number of athletes away from competitive physical activities, and it is very frequent in soccer [1]. The pathogenesis of athletic pubalgia - myotendinous etiology is often associated with micro traumas in athletes presenting risk factors, such as pelvic muscle imbalance, joint movement restriction, pubic anteversion, hyperlordosis, varus thigh [2].

This disease keeps 5 to 10% of soccer athletes away from the activity [3]. Recent epidemiological analyses have shown a 4–19% prevalence of athletic pubalgia in men, and 2–14% in women [4], whereas data from the Brazilian literature shows a 0.5–28% incidence in male athletes [5].

Apart from its high prevalence, athletic pubalgia is considered to be a severe injury, due to the time length the athletes are forced to be away from sport activities, according to FIFA (Federation of International Football Association) classification [6]. The sport injuries are so important and costly that both coaches and administrative staff should be involved in their prevention and treatment. The average injury cost per athlete is 500,000 Euros [7].

Hölmich (2007) [8] described 13 different clinical possibilities related to pubalgia, and the adductor-related pain was considered the primary clinical entity to be the most common in soccer. The inadequate specific sport training, the errors in periodization and training quantity and intensity, apart from previous injury existence, are also considered as risk factors for athletic pubalgia [9].

The etiology based on overload and muscle imbalances in the hip region requires physical rehabilitation as a first-choice treatment for pubalgia, leaving surgical treatment for specific diseases (femoroacetabular impingement, occult hernia or tendinopathies and the few cases of clinical treatment failure (5–10% average) [7, 10, 11].

The technique proposed by this group aims to release the anterior rectus abdominis tendon along the pubic symphysis in association with a proximal tenotomy of the long adductor tendon in the same surgery procedure.

The aim of this study is to present a cross-sectional study about Athletic Pubalgia comparing the outcome of surgical treatment of athletic pubalgia with myotendinous etiology using the technique implemented by this sports medicine group. Secondly, it aims to standardize a diagnostic and therapeutic approach of this complex disease, since there is no consensus in the research literature.

The study scope is a historical consecutive cohort analysis. After the study had been approved by the Ethics Committee for Research Project Analysis, the medical records of patients registered at this Sports Medicine Group (GME) of the Institute of Orthopedics and Traumatology of Hospital das Clínicas - Universidade de São Paulo, between 01/01/2002 and 31/12/2016 were analyzed. The study focused on the records of patients complaining of pubic pain of myotendinous etiology diagnosed by clinical examination and imaging exams, when requested, and submitted to surgical intervention. For proper diagnosis, a standardized clinical-radiological evaluation was applied. The patients who did not improve after clinical treatment underwent surgery, and then were followed up by the responsible researcher [12].

Inclusion criteria

a) Active professional or amateur athlete regularly registered at GME at the time of the complaint onset.

b) Age between 18 and 40 years old;

c) Chief complaint of pain or functional limitation in pubic symphysis region, restricting or preventing the athlete's sports performance;

d) Athletic pubalgia of Myotendinous etiology diagnosis in conformity with GME protocol;

e) Presence of pain in pubic symphysis and tendon region of adductor thigh musculature in clinical-radiological evaluation, functional limitation when running or kicking, without restricted hip mobility, no signs of shortening lower limbs in imaging exams, femoroacetabular impingement or occult inguinal hernia;

f) Medical treatment and physical therapy failure after, at least, three months;

g) Surgery undergone at the institution.

Non-inclusion criteria

a) Athletic pubalgia diagnosis not related to myotendinous etiology (eg, stress fractures, tumors, inguinal hernias, hip diseases);

b) Neurological lesions on dorsolumbar spine;

c) Previous muscle injuries in: abdominal, lumbar, pelvic (or abductor) or adductor musculatures;

d) Joint instability or previous knee ligament injury;

e) Shortening of one of the lower limbs greater than 1(one) cm;

f) Previous fractures of dorsal and lumbar spine, pelvis or lower limbs;

g) Previous pubic and / or inguinal surgeries;

h) Psychiatric disorders that may interfere with the understanding of the proposed treatment or its follow-up;

i) Active infection or previous infections in pubic region;

j) Cases resolved after non-surgical treatment;

Exclusion criteria

a) Treatment abandonment;

b) Infection not related to the performed surgical procedure;

c) Bone tumor;

d) Lower limb muscle injury intervening in rehabilitation process;

e) Fracture of the dorsal and lumbar spine, pelvis or lower limbs;

f) Death not connected to intervention or loss of sequence before 6 months of follow- up.

A total of 52 cases met the inclusion criteria, 5 of them had incomplete medical 109 records, and 2 had no medical records. 45 patients underwent surgery from 2002 to 2016 110 111 and were included in this historical cohort.

Clinical criteria used for athletic pubalgia diagnosis

To reach diagnosis, clinical examinations were performed in all patients by the researcher in charge of GME ambulatory care [8,13].

The examinations included:

a) Inspection and palpation of the pubic symphysis in search for local or irradiated pain;

b) Measurement of lower limbs. Shortening lower than 1 (one) cm were not considered for non-inclusion;

c) Active, passive and resistance muscle maneuvers: iliopsoas, rectus abdominis, abdominal oblique, transverse abdominis, adductors, and hip abductors;

d) Research of hips and lumbar spine movement amplitude;

e) FADIR and FABER tests [14].

f) Inspection and palpation of the inguinal ligament region, followed by Valsalva maneuver to detect inguinal hernia;

g) Grava Maneuver [11].

h) Squeeze test [15].

The cases with pain complaints during direct palpation of the pubic symphysis and adductor muscles tendon along the symphysis were considered eligible for surgical treatment. So were those who tested positive for the Grava's Maneuver and Squeeze test. When a clinical examination was deemed insufficient for proper diagnosis, additional exams were requested.

The time to return to sport was obtained by comparing the date of the operation with the date of release for training. The date of the athlete's first unrestricted training was used as the definition of return to sport. The etiology was defined as being secondary to trauma occurring in sports activity or unrelated to trauma. Also, only infiltration performed with glucocorticoids in information collected from medical records of the GME were considered.

Imaging exams

Radiography

Radiography Radiographs were taken from the pelvis anteroposterior (AP) projection in dual support position and flamingo view (AP radiographs of the pubic symphysis alternating double-and single-leg stance positions on the right and left legs). Dunn, Lequesne or cross table incidences were also used when needed [16-19].

Ultrasonography

A 9-13 MHz linear transducer ultrasound examination was performed [20-22]. Concomitantly, the patient was evaluated with and without Valsalva maneuver.

Magnetic Resonance Imaging (MRI)

MRI was performed using two 1.5 T magnets (Aera, Siemens and HDX, General Electric Medical Systems). MRI sections and measurements are described in table 1.

Table 1 - Standardization of performed imaging exams

Radiography	AP projection of the pelvis in dual support: search for signs of hip impingement, discrepancies in limbs length, sacroiliac alterations, and other alterations with no clinical suspicion;
Radiography	Flamingo view: pelvic instability.
Ultrasonography	Dynamic evaluation of true inguinal, femoral and sports hernias.
Magnetic Resonance Imaging (MRI)	- At least one T1-weighted sequence: morphological structural evaluation, bone marrow infiltrative processes (infection, tumors, etc.);
	- Sagittal T2-weighted sequence with fat suppression (including femoral head): evaluation of labral lesions and rectus abdominis/adductor longus aponeurosis injuries.
	- Coronal/axial T2-weighted sequence with fat suppression: bone (pubic osteitis) and soft parts edema, muscle and tendon injuries, rectus abdominis/adductor longus aponeurosis injuries, and other pelvic alterations;
	- Oblique, axial, T2-weighted sequence: rectus abdominis muscle attachment and muscles origins of the adductor compartment;
	- Coronal T2-weighted sequence with fat suppression (large FOV): reveals other conditions manifesting inguinal pain.

Isokinetic evaluation of the hip

The isokinetic tests were performed on the dynamometer (Biodex System 3 Pro® manual, 2014) of the GME Movement Study Laboratory.

SURGICAL TECHNIQUE

Patients were operated in supine frog-leg position with lower limbs in abduction, hips in lateral rotation, knee flexed and feet plantar lined and tape-fixed to the operating table. A 5cm thick squab cushion was placed below the patient's sacrum in order to lift the pubic symphysis, as shown in figure 1.

1) A Pfannenstiel-type median transverse incision about 10cm long is made directly over the pubic bone; figure 2.

2) After dissecting the subcutaneous planes, the spermatic cords are located and isolated;

3) As the pyramidalis muscle is identified, a transverse incision is made over the pubic symphysis using an electric scalpel;

4) The pubic symphysis is identified by placing a thick bevel needle (30x9cm) inside it to ensure its correct location and serve as anatomic and symmetric parameters for the procedures performed (figure 3).

5) After opening the fascia, the superficial portion of the rectus abdominis tendon is located, extending from the anterior pubis to the inguinal ligament. A prior disinsertion is done with the use of electrocautery, being careful to preserve both inferior and posterior pubic ligaments;

6) After the disinsertion, approximately 2cm of the proximal portion of the tendon is detached; (figure 4)

7) The same incision allows the bilateral visualization of the long adductor muscle tendon.

8) After opening the peri-tendon, a tendon hook is applied to separate the long adductor tendon from its muscle portion and other adjacent muscles; (figure 5)

9) Tenotomy with electric scalpel is performed while the assistant abducts the hip by pushing the ipsilateral knee down. The same procedure is performed on the contralateral tendon;

10) A meticulous hemostasis of the incision and dissection planes are made, as well as an exhaustive cleaning with saline. Subcutaneous planes and skin were closed after placement of a 3.2mm deep aspiration drain. The wound was occluded with a compressive dressing.

STATISTICAL ANALYSIS

Data was obtained from patients’ medical records and stored on an Excel® spreadsheet for MAC, for statistical analysis purposes. The spreadsheet was exported to 197 SPSS 23® for MAC.

Descriptive statistics was used for data analysis of all ordinal sample values (quantitative): mean, standard deviation, mean standard error, maximum value, minimum value, number of cases, plus absolute and relative frequency distribution (percentage) of nominal sample values (qualitative).

Categorical data was described based on their frequency and respective percentage of the total sample. Continuous data was mean-based, with 95% confidence interval, standard deviation, median, interquartile range, amplitude, minimum and maximum values, and all data was tested for normality distribution as per Shapiro-Wilk test.

The primary outcome was athletes’ return-to-sport time. The chosen time unit was the day, and the outcome was compared to several categories of sample collected by independent sampling. Moreover, the outcome was tested by a multiple linear regression model with (hypothetical) variables age, player position and time of symptoms’ existence, which are regarded as possible prognostic predictors. The accepted value for statistically significant difference was 5%.

The patients’ mean age was 24-25 years (ages ranging from 17 to 46), and 100% was male. 86.7% were soccer and futsal players, and the evaluation of these sport groups showed a similar number of defenders and strikers (24%) (table 2). The mean return-to- sport time was 135 days, all patients considered, while the strikers took 156 days longer to recover compared to other players. Another variable displayed a small statistical correlation with return-to-sport time: the affected side (unilateral or bilateral), with a positive unilateral inclination. As for the surgery, data showed a 1.68-day mean time of hospitalization and 87.39 minutes of surgery time length. A 6.7 % complication index and 93.3% symptoms resolution rate were also found.

Table 2 – Studied variables referring to classification, total number collected on medical records of athletic pubalgia patients and occurrence frequency.

Variables	Classification	Number	Frequency (%)
Gender	Male	45	100
	Athletics	2	4.4
Sport	Firefighter	1	2.2
Sport	Soccer	4	75.6
	Futsal	5	11.1

	Physical Education Teacher	1	2.2
	Rugby	1	2.2
	Volleyball	1	2.2
Category	Amateur	10	22.2
Category	Professional	35	77.8
	Striker	11	24.4
	Center Back	2	4.4
	Goalkeeper	3	6.7
Position	Winger	4	8.9
Position	Midfielder	8	17.8
	Professional	1	2.2
	Defender	11	24.4
	Others	5	11.1
Dominance	Right	42	93.3
Dominance	Left	3	6.7
	Central	1	2.2
Affected side	Right	8	17.8
Affected side	Right and Left	30	66.7
	Left	6	13.3
Affected side	Unilateral	14	31.1
Affected side	Bilateral	31	68.9
	Progressive	28	62.2
Pain intensity	Limiting	14	31.1
	Omitted	3	6.7

Variables	Classification	Number	Frequency (%)
	No	37	82.2
Trauma	Yes	6	13.3
	Omitted	2	4.4
	Adductor	14	31.1
	Adductor/pubic symphysis	7	15.6
	Adductor/rectus abdominis	15	33.3
Pain site	Adductor/rectus abdominis
Pain site	Rectus abdominis	1	2.2
	Pubic symphysis	6	13.3
	Pubic symphysis + perianal region	1	2.2
	Omitted	1	2.2
Infiltration procedure	No	31	68.9
	Yes	11	24.4
	Omitted	3	6.7
	-1	9	20

Infiltration number	-2	2	4.4
Infiltration number	Omitted	34	75.6
Associated disease	No	41	91.1
	Yes	2	4.4
	Omitted	2	4.4
Which one?	Asthma	1	2.2
Which one?	Dyslipidemia	1	2.2
Complications	No	42	93.3
Complications	Yes	3	6.7
	Adductor pain	1	2.22
Which one?	Adductor partial injury	1	2.22
	Pneumonia	1	2.22
Reoperations	No	42	93.3
Reoperations	Yes	3	6.7

practice with professional soccer athletes who remained in clinical treatment for a long period of time, around six months, without any satisfactory results. This injury is considered to be severe, due to the long time it keeps athletes away from sports, which is not only harmful to the athlete, whose professional life spans around 10 to 15 years - therefore being regarded as a short career when compared to others - but it is also harmful to the sports club, on behalf of its financial impact [7,9].

We consider this condition to be multifactorial and related to the increment of physical activity [23]. We also believe that local previous injuries, increased training intensity, decreased hip mobility and inadequate levels of specific training are relevant risk factors [4]. Our research illustrated that amateur players take a longer time to recover after surgical procedure (113 x 94 days, median).

The scope of this study comprehends the most significant assessment of the national literature so far, including 52 operated cases, although only 45 medical records were utilized. Other studies in the literature mentioned above have a smaller population sample (23 or 30 cases)[17-24] or only patients treated with clinical treatment [25,26].

Our pre and postoperative rehabilitation protocol was based on Core training, balance and proprioception exercises [24].

Regarding the surgical technique, several procedures were described:

1) Resection of the symphysis block [27];

2) Symphysis curettage and applied local methylprednisolone [28];

3) Symphysis curettage local drilling and adductor tenotomy [11];

4) Symphysis wedge resection associated with plate osteosynthesis [29];

5) Wedge resection and release of the anterior rectus abdominis [5].

From our perspective, the symphysis responds to forces acting on it, thus in most cases it is not the problem source, but rather its consequence. Therefore, the routine removal of wedges or drilling to prevent the increase of procedure morbidity and return-to-sport time is not justified.

None of the techniques described above handled the joint tendon, which is the continuity of distal rectus abdominis and long adductor fibers. Bearing above reasons in mind, we gave preference to the disinsertion of the superficial distal portion of rectus abdominis in pubic symphysis and to the partial proximal tenotomy of the bilateral long adductor. These procedures promoted a strength rebalancing of the pubic structure and reduced the stress over it, particularly when it comes to efforts for turning, changing directions abruptly and kicking.

The applied outcome followed the recommendations of Waldén et al. (2015) [30] who considered the return-to-sport time to be the most used, although it is subject to some biases. We found a low complication index, of 6.7%. All cases requiring revision involved re-tenotomy of the long adductor. This finding urged us to emphasize the need for early mobility in the immediate postoperative period. All reoperated cases belonged to the first phase of the performed treatments. Perhaps on account of the technique learning curve. The symptom resolution rate was 93.3%, which makes us believe that the procedure is adequate to solve the addressed problem.

The research limitations are those of a retrospective study performed without a control group. The difficulty of contacting the athletes (35 were professional) after discharge hindered the long-term review of cases. Almost none of them could be located after discharge. Some parameters change or development over time also created deviations that may have impacted results. The inconsistency of information obtained from medical records is always a problem to be remembered in this type of research. The failure to use a system of rating and evaluation could also be considered as a study flaw.

Future prospects of this research line should include detailed study of patient examinations findings, besides better quantifying or qualifying data on force balance and adductors symmetry by modifying the Squeeze test, perhaps with the use of a manual dynamometer, as suggested by Mosler et al. (2018) [31].

The validation of Copenhagen hip and groin outcome score (HAGOS) [32], may add greater reliability to the data, since the usage of scales on which patients express their perception of results is a current trend.

The procedure outcome took place 94 days (median) for professional athletes, showing a positive relation to the game position (striker), with 93.7% good results, thus proving to be a good treatment option for this disease.

Ethical Approval

Approval by the Scientific Committee of the Institute of Orthopedics and Traumatology (IOT Protocol No. 1280) and by the Ethics Committee for the Analysis of Research Projects of the Hospital das Clínicas, Faculty of Medicine, University of São Paulo - CAPPesq, 2,225,179 (CAEE-73405517.0 .0000.0068)

Competing interests

All authors declare that they have no conflicts of interest for this project.

Authors' contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by André Pedrinelli and Arnaldo José Hernandez. The first draft of the manuscript was written by André Pedrinelli and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

All authors declare that they have non-financial support for this project.

Study Design: Cross-sectional study.

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No competing interests reported.

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Clinical results of surgical treatment for athletic pubalgia

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