Return to sport after conservative versus surgical treatment for pubalgia in athletes: a systematic review

Time of return to sport

The most clinically relevant finding of this study was that athletes who underwent surgery for the treatment of pubalgia started to RTS three weeks after the index procedure. However, clinical trials reporting the outcome of surgery are lacking. In general, the studies detailing the results of conservative management show that these athletes RTS three weeks later than those managed surgically. However, the investigations on conservative management are more articulated and include more and better validated outcome measures.

The most common form of surgery is Total Endoscopic Extraperitoneal (TEP) repair of a sportsman hernia [12, 13]. In the studies where this procedure was performed, athletes returned to the sports on a median time of 12 weeks. Other surgical procedures resulted in RTS at six [20] to 12 weeks [12].

The time from onset of symptoms to surgery ranged from six weeks [12] to 6 months [13]. The fact that patients with a short duration of symptoms underwent surgery may have been a factor contributing to their rapid RTS, with an average of 4.3 weeks. These athletes probably underwent less invasive or less extensive surgery [22, 23]. In any case, it is recommended that conservative treatment should be attempted before surgery is recommended, although it is unclear for how long conservative management should be implemented [7, 24, 25].

Rate of return to sport

The rate of RTS in athletes who underwent surgery was 90% [12, 13] to 100% [20, 21], while it ranged from 14% [14] to 100% [18] in those who underwent conservative management, showing great differences in rates of RTS between the different conservative management regimens.

Holmich et al. [14] divided their participants into two groups: their novel physical exercises activity group vs conventional physiotherapy group, in both groups undertaken for 12 weeks. The conventional physiotherapy group received only passive techniques, as in Weir et al.’s [16] investigation. Gore et al. [18] used an active treatment with a more structured time-dependent program.

Other studies demonstrated how important exercise therapy is to increase the RTS rating. Ramazzina et al. [6] showed that active treatment provides a faster RTS. Abouelnaga et al. [26] demonstrated that active rehabilitation training resulted in a higher rate of RTS and reduced the pain associated with a sports hernia.

Other results

Explicit criteria to allow an individual to RTS were described in five studies [14, 15, 17,18,19], all of them reporting the results of conservative management. Except for the two studies by Yousefzadeh et al. [17, 19], all used different criteria for RTS.

Functional tests [27], such as hop tests [28] and Star excursion balance test [29], should be part of the assessment process. Only three studies used functional tests [17,18,19]. However, normative values are unclear, and athletes may perform well and still have symptoms [30]. It is possible that the functional tests in this field do not engage the relevant muscles involved in pubalgia.

The addition of clinical tests should be performed to monitor athlete readiness to RTS. The absence of pain in the tests such as Copenhagen five-second squeeze [31], FADIR test, FABER test, abdominal test and absence of palpation pain [32] should, for example, be considered. Only two studies used a clinical test (the squeeze test). Gore et al. [18] tested the athletes at three angles (0º, 45º and 90º) of hip flexion and compared the values obtained before and after treatment. Yousefzadeh et al. [19] also used the squeeze test but did not specify angulation.

Athletes with pubalgia often demonstrated reduced mobility [33] and strength in the hip [34]. When allowed to RTS, athletes should have a difference in range of motion of the hip of less than 5 degrees [34]. Muscle strength differences should not exceed 10% to 15% [33], and the ratio between agonist/antagonist contraction should be above 80%. A ratio between adductor and abductor muscles below 80% is associated with a 17-fold increase in adductor injury [24].

Only one in one study was a patient reported outcome measure standardized questionnaires used [18], and the Copenhagen Hip and Outcome Score (HAGOS) [31] could be introduced in routine clinical practice.

The sport contributing most athletes with pubalgia was soccer, followed by running and ice hockey. All these sports involve unipodal support [35], associated in some with sudden change of direction, and excessive use of repetitive ballistic movements such as kicking and hopping [36].

Studies quality and evidence level

Two studies scored “Excellent” [12, 13] in Downs and Black evaluation [10], and six were classified as “Good” [14,15,16,17,18,19]. The main issue was internal validation [10]. Most of the studies were randomized clinical trials, but more quantity and quality studies, especially on operative treatment [12, 13, 20, 21], are needed.

More studies were classified in high quality of evidence [12, 13, 15, 18, 33] in GRADE analysis [11], meeting the results found in the Downs and Black evaluation. The main difficulty found in the studies was in the item regarding the dose–response gradient. However, as the analysis was made by clinical trials, the quality of the evidence has a greater tendency to be high.

Practical implications

Return to sport after treatment of athletic pubalgia should involve a multifaceted assessment process. Obviously, neither approach (operative or conservative) can ensure that a given athlete will return to sports. Conservative treatment is classically recommended before surgery is performed. However, the length of conservative management before failure of such modality is declared is undefined.

Even if successful, conservative management of pubalgia resulted in slower return to sport compared with operative treatment, but it should consider that the studies are not directly comparable in terms of criteria of inclusion of athletes, and outcome measures. If conservative management, surgery should be considered, as it allows a relatively fast return to sport, provided that a well-controlled and active postoperative rehabilitation regime is introduced.

Limitations

Some points are important to be considered in this systematic review. The different methods used between the studies make it difficult to generalize the results.

The description of the diagnosis of pubalgia was not always clear in all studies, with different ways of diagnosing it. Consequently, the different treatments used, whether surgical or conservative, influence the non-standardization of outcomes. Regarding the outcomes, the different health indicators used and the fact that few have criteria for return to sport makes the heterogeneity between the studies even greater. This fact also contributed to the failure to carry out a meta-analysis.

Follow-up studies can be more reliable to assess the success of return to sport, a fact that did not always occur and also occurred in different periods between the studies. Postoperative rehabilitation needs to be better described in surgical studies, as it is also part of treatment success.

Studies with better methodological controls, including some with a larger sample, are important to take such results to a larger population, adopting greater external validity.

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