The Core Muscle Injury is a medical condition characterized by pain in the inguinal and pubic region, resulting from inflammation or injury to the muscles and tendons in that area.1 It is common among athletes participating in sports with repetitive movements such as soccer, hockey, and rugby, as well as individuals engaged in activities requiring constant physical effort in the abdominal and pelvic region.2,3 According to the FIFA (Fédération Internationale de Football Association)4 ranking, athletic groin pain is considered a severe pathology due to the extended absence from the game required for its treatment.1 The diverse range of injuries affecting the pubic region, associated with various classifications, presents significant challenges in the clinical presentation of this condition.5,6

Pain in the pubic region is a frequent issue in sports involving rapid changes of direction.7–9 Several studies report incidence rates of all injuries in the pubic symphysis of up to 19 % of the total injuries,4,10–13 with it representing up to 10 % of all absences from sports activities in soccer alone.13,14 When comparing between men and women, the proportion of groin injuries in soccer ranges from 4 % to 19 % in men and 2 % to 14 % in women during the annual season,11 often leading to the absence from athletic activities7,8 and a decline in athletic performance.9

The groin region has a complex anatomy with numerous structures that can cause pain during physical activity.14 The forces exerted on the myofascial structures attached to crucial points can result in tissue injury or compression of pelvic anatomical structures, leading to pain.13 Symptoms may arise from systemic, gynecological, urogenital, gastrointestinal, neurological, and musculoskeletal structures,14 making the terminology surrounding groin pain confusing and challenging for research interpretation.15

After a brief period of relative rest, the disease's natural history may evolve favorably in some cases, but certain injuries may result in a longer rehabilitation time or become chronic.16,17 Some studies have established a direct relationship between injuries and the success of professional teams.6,18,19 Ekstrand19 demonstrate that sports injuries are so costly that coaches and administrators should be involved in the treatment and prevention process, as it is estimated to cost €500,000 per injury per athlete in total.19 Due to the multifactorial origin, controlling groin pain becomes a challenge, and the treatment may involve various approaches, including physiotherapy programs, pharmacological treatments, outpatient interventions, and surgical interventions. Long-term groin pain is known to be resistant to many treatment options and may have slow recovery times.20–22

A recent systematic review on the management of athletic groin pain highlighted the ongoing challenge posed by the low methodological quality of studies in this area.20 Furthermore, while some studies have explored both conservative and surgical treatment options for this pathology, clear evidence-based recommendations remain elusive. Similarly, Ramazzina et al.1 underscored the persistent challenge faced by physicians and researchers in effectively managing inguinal pain in athletes. Generally, conservative treatment is initially attempted, with surgery being considered after failed conservative measures.14,21,22

The methodologies used in previous studies involving available literature did not provide a clear answer on the optimal way to treat this multifactorial pathology concerning the goal of a faster return to the game. Thus, this study aims to systematically review pubalgia in athletes, considering treatment methods and successful return to sports with the associated time frame.

This systematic review aimed to study the comparison of available treatment options for groin injuries in athletes and their impact on success rates and injury recurrence. Additionally, the analysis also took into consideration the type of treatment, follow-up duration, site of participants' injuries, and sports specialization. Key findings revealed a trend towards surgical intervention in cases of persistent groin pain, with a notable success rate reported for procedures such as adductor tenotomy combined with hernioplasty. Conservative treatments, including shockwave therapy, manual therapy, and exercise, demonstrated promising results in facilitating a quicker return to sports activity. Notably, the success of treatment varied based on individual response and the severity of the injury. These findings underscore the importance of tailored treatment approaches and further research to establish evidence-based recommendations for the management of athletic groin pain.

The wide variety of treatment approaches, etiology, and the location of the injury for groin injuries in athletes reflects the complexity of this condition. From surgical interventions to conservative therapies, each approach provides a pathway to recovery and return to sports. The results of this systematic review emphasize the importance of carefully considering the most appropriate treatment approach for each athlete based on their specific condition and recovery needs.

Firstly, it is observed that the review covered a total of 30 studies,29–58 in which a total of 1931 athletes participated. The breadth of this sample provides a robust foundation for analysis and drawing conclusions, despite the high heterogeneity regarding injury sites and different athletes in relation to treatment options for groin injuries. The follow-up period varied among studies, with an average of 19.19 months, allowing for a long-term assessment of treatment effectiveness.

The main findings of this review were observed with a higher prevalence of adductor injuries in sports such as football and athletics. Various treatment strategies, both surgical and conservative, were identified. Surgeries included adductor tenotomies, selective partial release of the long adductor, and repairs with endoscopic mesh.29–33,37,38,42 These procedures showed success rates in return to sports of around 75–80 %. Conservative therapies, such as shock wave therapy, manual therapy, and exercise, also proved effective in accelerating the return to sports activity.34–36 The effectiveness of the "Modified Hölmich Therapeutic Exercise Protocol" in improving clinical measures in 10 weeks was highlighted.38

However, it is important to note that 13 studies did not specify the type of pubalgia that was studied. This lack of specificity could hinder a comprehensive understanding of the different types of groin injuries and their associated treatments. The broad diversity of injuries impacting the pubic region, in conjunction with the various classifications described, poses some of the main challenges that this clinical condition faces, as evidenced by Weir et al.5 and Serner et al.6 It is crucial for future research to address this issue more clearly to establish conclusions between types of injuries and treatment options.

Furthermore, the presence of other injury sites such as adductor tendons, insertion into the pubic bone, long adductor, and proximal adductor rupture adds an additional layer of complexity to the landscape of groin injuries.59 These findings suggest that injuries can be multifactorial and affect various structures in the inguinal region. Ellsworth et al.60 discuss the relevance of accurate assessment and more precise diagnosis to identify and distinguish between athletic pubalgia and other inguinal disruptions, for example. This allows for an improved rehabilitation care plan and advances in recovery therapies such as shockwave therapy, manual therapy, and targeted exercise regimens.

Research in the field of surgeries for groin pain in athletes has yielded promising results in terms of recovery and return to the previous sports level. This review has explored various surgical techniques, such as "Adductor Tenotomy" and "Rectus Abdominis Tenotomy," as well as their combination. These interventions have shown long-term success, as evidenced by Sansone et al.29 and Harr et al.37 with approximately 75 % of athletes successfully returning to their previous sports level after undergoing these surgeries. This finding is relevant and supports the effectiveness of these techniques in athlete rehabilitation and performance restoration.

A particularly interesting approach has been the "Selective Partial Release of the Long Adductor," as highlighted by Schilders et al.30 This technique has presented even more impressive recovery rates, with research indicating that 42 out of 43 athletes were able to return to their previous sports level after undergoing this technique, equating to a success rate close to 98 %. Furthermore, these results were achieved in an average period of 9.21 weeks, emphasizing the speed at which athletes can return to competing at the highest level with this technique according to this study. These findings are consistent with previous research by Boykin et al.61 which also emphasized the effectiveness of "Selective Partial Release of the Long Adductor" in athlete rehabilitation and their successful return to competition but with an association with femoroacetabular diseases.

Regarding the technique of Adductor Tenotomy combined with hernioplasty for the treatment of groin pain, primarily addressing adductor dysfunction, Mei-Dan et al.31 reveal that it has achieved success rates, with 80 % of cases reporting good or excellent results. These findings highlight the effectiveness of surgery in addressing specific injuries and restoring desired functionality in athletes according to the authors.

Comparing these findings with previous studies by Machotka et al.21 and Almeida et al.22 in the field of sports medicine, a significant advancement in the approach to athlete injuries and rehabilitation is evident. Earlier research may have underestimated the ability of surgery to achieve such positive outcomes in terms of recovery and return to activity.1,14

From the "Placement of an endoscopic mesh after reducing a possible hernia" to "Open repair with sutures of 'Minimal Repair,'" diverse approaches have been developed to address groin pain as well. These procedures have provided a pathway to recovery, enabling athletes to return to physical activity with the least discomfort and downtime possible according to the authors.42,53 The placement of an endoscopic mesh proposed by Van Veen et al.42 has solidified as an effective technique in inguinal hernia repair. The study involved 38 athletes from various sports such as football, triathlon, athletics, tennis, cycling, baseball, and speed skating over a 3-month follow-up. The results indicate that this technique has achieved significant success rates in reducing and stabilizing hernias, allowing athletes to recover more efficiently.

On the other hand, open repair with sutures of minimal repair by Muschaweck et al.53 has also proven to be a valuable alternative in the treatment of groin injuries in various sports. This approach focuses on suturing the affected tissues, minimizing surgical invasion, and reducing the risk of complications. When comparing this procedure with previous studies by Ahumada et al. 39 and supporting more invasive approaches, the shift in technique toward less aggressive yet equally effective approaches is highlighted.39,53 The current trend towards less invasive procedures, such as Muschaweck et al.'s53 minimal repair with sutures, suggests a greater consideration for faster and more comfortable long-term recovery for athletes, thus highlighting what appears to be the most effective option thus far.

Beyond surgical interventions, this review has explored conservative approaches that have also yielded encouraging results. Shockwave therapy, for example, proposed by Schöberl et al.,34 has emerged as a viable option to reduce pain and facilitate the return to sports. This non-invasive form of therapy presents promising potential and could represent an effective and preferred alternative to surgical interventions, according to the author. Shockwave therapy stimulates healing by increasing blood flow, promoting cell repair, reducing pain, and can also break down calcified deposits. These metabolic alterations allowed for a significant reduction in pain, enabling a return to football within 3 months following the trauma.34

Manual therapy and exercise therapy have also proven their worth in the recovery of sports injuries, according to Weir et al.35 This controlled and randomized clinical trial demonstrated that manual manipulation therapy is a safe and effective treatment for athletes with chronic groin pain related to the adductors, compared to an exercise therapy program. After 4 months, both groups showed a significant decrease in pain scores on the Visual Analog Scale (VAS) during sports activities. Moreover, athletes in the manual therapy group who fully returned to sports did so significantly faster than those who underwent the exercise therapy program. This suggests an advancement in our understanding of how physical manipulation can influence the recovery and functioning of injured athletes.35

Building on existing evidence for manual and exercise therapies, incorporating insights into stretching and multifactorial prevention strategies could enhance rehabilitation and injury prevention for athletes with core muscle injuries. Stretching's role in groin pain rehabilitation remains debated, with literature gaps in its isolated impact. Afonso et al.62 reviewed studies on stretching within multimodal recovery but found no trials assessing its effectiveness as a standalone intervention, highlighting the need for further research.62 Similarly, Zilles et al.63 emphasized the multifactorial nature of groin pain risk and prevention, supporting factors like previous groin pain, hip adductor strength, and the FIFA 11+ Kids program. These findings suggest that while stretching may contribute to broader prevention strategies, its specific role requires further investigation to guide evidence-based interventions.63

Regarding the modified Hölmich Therapeutic Exercise Protocol, which has shown promising results in the rehabilitation of athletes with groin pain by Mazbouh et al.,38 this protocol has been able to generate significant improvements in all clinical measures over a period of 10 weeks, suggesting its effectiveness in addressing this specific injury. Comparing these results with previous research by Yousefzadeh et al.,36 there is an advancement in optimizing exercise protocols with the modification of exercises in the protocol. This indicates progress in our understanding of how to design specific exercise programs for groin injuries as initial treatment in athletes. The "Modified Hölmich Therapeutic Exercise Protocol" could represent an efficient approach tailored to the needs of athletes in recovery.

However, it is important to consider the individuality of each patient and the variability in response to exercise protocols. What works for one athlete may not be equally effective for another. Additionally, it is crucial to evaluate how this protocol compares to other therapeutic alternatives, such as conservative therapies like "Shockwave Therapy" and "Manual Therapy," as well as surgical interventions. Integrating these approaches into a comprehensive treatment plan could provide a more holistic and effective perspective for addressing groin injuries.

In addressing groin and adductor injuries, the conclusion drawn from the results suggests a stepped treatment strategy. It is recommended to start with conservative approaches such as shockwave therapy, manual therapy, and exercise therapy, aiming to alleviate pain and improve symptoms. Most studies indicate a time window of 3 to 6 months to assess the evolution of symptoms before considering surgical options.30,34,35,42,43

In cases where conservative treatment fails to achieve satisfactory improvement, surgical intervention emerges as an effective alternative. Various surgical procedures, such as adductor tenotomy, selective partial release of the long adductor, and other repair approaches, have shown encouraging results in athletes returning to their sports activities. The choice between these approaches should be based on an individual assessment of the severity of the injury and the patient's response to conservative treatment. Ultimately, the goal is to facilitate complete and safe recovery, allowing athletes to resume their sports activities under optimal conditions.42,43

The concept of success in the recovery of sports injuries, as emphasized by Mei-Dan et al.,31 is closely linked to the athlete's ability to return to their pre-injury performance level, encompassing not only resuming participation in the sport but also returning to their usual training and competition activities with a comparable level of effectiveness.34,35 However, it's important to consider the potential influence of publication bias (RoBias) on understanding of recovery success. Studies reporting positive outcomes, such as athletes returning to pre-injury performance levels without recurrent symptoms, may be more likely to be published than studies with less favorable outcomes, potentially skewing the perceived success rates of different therapeutic approaches. Nonetheless, successful recovery also necessitates the absence of recurrent symptoms such as pain and dysfunction, ensuring that athletes can perform movements and exercises without significant physical limitations. The variety of therapeutic approaches mentioned, from surgical interventions to conservative therapies, illustrates the complexity of the recovery process. However, success in recovery ultimately extends beyond merely curing the ailment, encompassing the restoration of athletic performance and the athlete's overall quality of life (Chart 1).

Chart 1.

Proposed intervention algorithm for monitoring groin pain.

(0.7MB).

Treating groin and adductor injuries requires personalized approaches based on individual responses to treatments. Conservative options like shockwave therapy, manual therapy, and exercise regimens are effective, with shockwave therapy providing quick pain relief and faster return to sports. If these methods fail after 3 to 6 months, surgery becomes an effective option, with procedures such as adductor tenotomy combined with hernioplasty showing excellent results. Open repair with sutures offers minimally invasive alternatives. The treatment choice depends on injury severity and previous response, aiming for a safe and complete recovery for athletes to return to optimal sports performance.

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

Not applicable

Systematic review

A systematic review was conducted following the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA3 The study was pre-registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023430694)

João Vitor de Castro Fernandes: Conceptualization, Visualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Andre Pedrinelli: Conceptualization, Visualization, Data curation, Formal analysis, Writing – review & editing. Jacobo Ángel Rubio-Arias: Conceptualization, Visualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing.