Latest Review Date: February 2024

Category: Surgery     

POLICY:

Surgical treatment of groin pain in athletes (also known as athletic pubalgia, Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia or core muscle injury) is considered investigational in all situations.

DESCRIPTION OF PROCEDURE OR SERVICE:

Sports-related groin pain, commonly known as athletic pubalgia or sports hernia, is characterized by disabling activity-dependent lower abdominal and groin pain that is not attributable to any other cause. Athletic pubalgia is most frequently diagnosed in high-performance male athletes, particularly those who participate in sports that involve rapid twisting and turning such as soccer, hockey, and football. Alternative names include Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia and core muscle injury. For patients who fail conservative therapy, surgical exploration and repair of any defects identified in the muscles, tendons or nerves has been proposed.

Some believe the groin pain is an occult hernia process, a prehernia condition, or an incipient hernia, with the major abnormality being a defect in the transversalis fascia, which forms the posterior wall of the inguinal canal. Another theory is that injury to soft tissues that attach to or cross the pubic symphysis is the primary abnormality. The most common of these injuries are thought to be at the insertion of the rectus abdominis onto the pubis, with either primary or secondary pain arising from the adductor insertion sites onto the pubis. It has been proposed that muscle injury leads to failure of the transversalis fascia, with a resultant formation of a bulge in the posterior wall of the inguinal canal. Osteitis pubis (inflammation of the pubic tubercle) and nerve irritation/entrapment of the ilioinguinal, iliohypogastric, and genitofemoral nerves are also believed to be sources of chronic groin pain. A 2015 consensus agreement has recommended the more general term groin pain in athletes, with specific diagnoses of adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain.

An association between femoroacetabular impingement (FAI) and groin pain in athletes has been proposed (see medical policy #421- Surgical Treatment of Femoroacetabular Impingement). It is believed that if FAI presents with limitations in hip range of motion, compensatory patterns during athletic activity may lead to increased stresses involving the abdominal obliques, distal rectus abdominis, pubic symphysis, and adductor musculature. A 2015 systematic review of 24 studies that examined the co-occurrence of FAI and groin pain in athletes found an overlap of the 2 conditions that ranged from 27% of hockey players to 90% of college football players who presented with hip and groin pain. Surgery for sports-related groin pain has been performed concurrently with treatment of FAI or following FAI surgery if symptoms did not resolve.

Diagnosis

A diagnosis of athletic pubalgia is based primarily on history, physical exam, and imaging. The clinical presentation will generally be one of gradual onset of progressive groin pain associated with activity. Physical exam will not reveal any evidence for a standard inguinal hernia or groin muscle strain. Imaging with MRI or ultrasound is generally done as part of the workup. In addition to exclusion of other sources of lower abdominal and groin pain (e.g. stress fractures, femoroacetabular impingement, labral tears), imaging may identify injury to the soft tissues of the groin and abdominal wall.

Conservative Treatment

Many injuries will heal with conservative treatment, which includes rest, icing, nonsteroidal anti-inflammatory drugs, and rehabilitation exercises. A physical therapy program that focuses on strength and coordination of core muscles acting on the pelvis may improve recovery. In a 1999 study, 68 athletes with chronic adductor-related groin pain were randomized to 8 to 12 weeks of an active training program (physical therapy, PT) that focused on strength and coordination of core muscles, particularly adductors (PT+), or to standard physical therapy without active training (PT-). At 4 months after treatment, 68% of patients in the active training group had returned to sports without groin pain compared with 12% in the PT- group. At 8 to 12 year follow-up, 50% of athletes in the active training group rated their outcome as excellent compared with 22% in the PT- group. For in-season professional athletes, injections of corticosteroid or platelet-rich plasma, or a short corticosteroid burst with taper have also been used.

Surgical Treatment

Surgical treatment is typically reserved for patients who have failed at least three months of conservative treatment. One approach consists of either open or laparoscopic sutured hernia repair with mesh reinforcement of the posterior wall of the inguinal canal. Laparoscopic procedures may use either a transabdominal preperitoneal or a totally extraperitoneal (TEP) approach. A variety of musculotendinous defects, nerve entrapments, and inflammatory conditions have been observed with surgical exploration.  Meyers proposes that any of the 17 soft tissues that attach or cross the pubic symphysis can be involved, leading to as many as 26 surgical procedures and 121 different combinations of procedures that address the various core muscle injuries. The objective of this approach to surgical treatment is to stabilize the pubic joint by tightening or broadening the attachments of various structures to the pubic symphysis and/or loosening the attachments or other supporting structures via epimysiotomy or detachment.

Because there are a variety of surgical procedures used to treat athletic pubalgia that have all reported success, it has been proposed that general fibrosis from any type of surgery may act to stabilize the anterior pelvis and thus play a role in improved surgical outcomes.

KEY POINTS:

The most recent literature review has been updated regularly with searches of the PubMed database. The most recent literature update was performed through December 19, 2023.

Summary of Evidence

For individuals who have sports-related groin pain who receive mesh reinforcement, the evidence includes 2 randomized controlled trials (RCTs), and a large prospective series. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. Results of the RCTs have suggested that, in carefully selected patients, mesh reinforcement results in an earlier return to play. However, a large prospective series from 2016 has indicated that only about 20% of patients with chronic groin pain benefit from inguinal surgery. Further study is needed to define the patient population that would benefit from this treatment approach. The evidence is insufficient to determine the effects of the technology results in an improvement in the new health outcome.

For individuals who have sports-related groin pain who receive surgical repair and release of soft tissue, the evidence includes a large case series. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. An alternative approach for the treatment of groin pain in athletes involves repair or release of soft tissue. This approach has been reported in a large series. It included a 2008 review of medical records spanning 2 decades and over 5,000 cases. More recent reports on these procedures from other institutions are needed. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Practice Guidelines and Position Statements

American Academy of Orthopaedic Surgeons

Reviewed in 2022, the American Academy of Orthopaedic Surgeons has an online educational website on sports hernia (athletic pubalgia). AAOS indicated that a sports hernia is a painful soft tissue injury that occurs in the groin area. AAOS advised that “in many cases, 4 to 6 weeks of physical therapy will resolve any pain and allow an athlete to return to sports. If, however, the pain comes back when you resume sports activities, you may need to consider surgery to repair the torn tissues.”

American College of Occupational and Environmental Medicine

The American College of Occupational and Environmental Medicine (ACOEM) released a guideline on hip and groin disorders in 2019. For the treatment of groin strains, sports hernias, or adductor-related groin pain, the ACOEM recommends work and activity modifications (strength of evidence [SOE]: recommended, insufficient evidence; level of confidence [LOC]: moderate), nonsteroidal anti-inflammatory drugs (SOE: recommended, insufficient evidence; LOC: moderate), and ice or heat or wraps (SOE: recommended, insufficient evidence; LOC: low).

U.S. Preventative Services Task Force Recommendations

Not applicable.

KEY WORDS:

Sports Hernia, Gilmore’s groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen’s groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia, core muscle injury, athletic pubalgia

APPROVED BY GOVERNING BODIES:

Surgical procedures do not require U.S. Food and Drug Administration (FDA) approval.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply.

FEP: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING: 

CPT Codes:

REFERENCES:

1. Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A et al. Athletic pubalgia: definition and surgical treatment. Ann Plast Surg Oct 2005; 55(4):393-396.
2. American Academy of Orthopaedic Surgeons, Wilkerson R. OrthoInfo: Sports Hernia (Athletic Pubalgia). 2022; orthoinfo.aaos.org/topic.cfm?topic=A00573.
3. American College of Occupational and Environmental Medicine. Hip and Groin Disorders. 2019;www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Evidence-Based-Updates-August2019/Final-Regulations/Hip-Groin-DisordersGuidelines.pdf.pdf.
4. Ekstrand J, Ringborg S. Surgery versus conservative treatment in soccer players with chronic groin pain: A prospective randomised study in soccer players. Eur J Sports Traumatol Rel Res. 2001; 23:141-145.
5. Holmich P, Nyvold P, Larsen K. Continued significant effect of physical training as treatment for overuse injury: 8- to 12-year outcome of a randomized clinical trial. Am J Sports Med Nov 2011; 39(11):2447-2451.
6. Holmich P, Uhrskou P, Ulnits L et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet Feb 06 1999; 353(9151):439-443.
7. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press
8. Irshad K, Feldman LS, Lavoie C et al. Operative management of "hockey groin syndrome": 12 years of experience in National Hockey League players. Surgery Oct 2001; 130(4):759-764; discussion 764-766.
9. Khan W, Zoga AC, Meyers WC. Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice. Magn Reson Imaging Clin N Am Feb 2013; 21(1):97-110.
10. Kopelman D, Kaplan U, Hatoum OA, et al. The management of sportsman's groin hernia in professional and amateur soccer players: a revised concept. Hernia. Feb 2016; 20(1):69-75.
11. Kraeutler MJ, Mei-Dan O, Belk JW, et al. A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/InguinalDisruption. Arthroscopy. Jul 2021; 37(7): 2377-2390.e2.
12. Kumar A, Doran J, Batt ME et al. Results of inguinal canal repair in athletes with sports hernia. J R Coll Surg Edinb Jun 2002; 47(3):561-565.
13. Litwin DE, Sneider EB, McEnaney PM et al. Athletic pubalgia (sports hernia). Clin Sports Med Apr 2011; 30(2):417-434.
14. Meuzelaar RR, Visscher L, den Hartog FPJ, et al. Athletes treated for inguinal-related groin pain by endoscopic totallyextraperitoneal (TEP) repair: long-term benefits of a prospective cohort. Hernia. Oct 2023; 27(5): 1179-1186.
15. Meyers WC, McKechnie A, Philippon MJ et al. Experience with "sports hernia" spanning two decades. Ann Surg Oct 2008; 248(4):656-665.
16. Munegato D, Bigoni M, Gridavilla G, et al. Sports hernia and femoroacetabular impingement in athletes: A systematic review. World J Clin Cases. Sep 16 2015; 3(9):823-830.
17. Paajanen H, Brinck T, Hermunen H et al. Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia). Surgery Jul 2011; 150(1):99-107.
18. Paajanen H, Syvahuoko I, Airo I. Totally extraperitoneal endoscopic (TEP) treatment of sportsman's hernia. Surg Laparosc Endosc Percutan Tech Aug 2004; 14(4):215-218.
19. Roos MM, Bakker WJ, Goedhart EA, et al. Athletes with inguinal disruption benefit from endoscopic totally extraperitoneal(TEP) repair. Hernia. Jun 2018; 22(3): 517-524.
20. Steele P, Annear P, Grove JR. Surgery for posterior inguinal wall deficiency in athletes. J Sci Med Sport Dec 2004; 7(4):415-421; discussion 422-423.
21. Thorborg K, Holmich P, Christensen R, et al. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist. Br J Sports Med. May 2011; 45(6):478-491.
22. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med. Jun 2015; 49(12):768-774.

POLICY HISTORY:

Medical Policy panel, July 2014

Medical Policy Group, July 2014 (5): New policy created related to Surgery for Athletic Pubalgia which has been on investigational listing; no change in coverage, remains investigational.

Medical Policy Administration Committee, August 2014

Available for comment July 17 through September 1, 2014

Medical Policy Panel, July 2015

Medical Policy Group, July 2015 (2): 2015 Updates to Key Points; no change in policy statement.

Medical Policy Panel, February 2016

Medical Policy Group, February 2016 (2): 2016 Updates to Description, Key Points, & References; no change in policy statement.

Medical Policy Panel, February 2017

Medical Policy Group, March 2017 (7): 2017 Updates to Title, Description, Key Points, and References. Policy statement reworded for clarification. No change in intent.

Medical Policy Panel, February 2018

Medical Policy Group, February 2018 (7): 2018 Updates to Key Points, and References. No change in Policy Statement.

Medical Policy Panel, February 2019

Medical Policy Group, March 2019 (7): 2019 Updates to Key Points, no new literature to add. No change in Policy Statement.

Medical Policy Panel, February 2020

Medical Policy Group, February 2020 (7): 2019 Minor updates to Key Points, no new literature to add. No change in Policy Statement.

Medical Policy Panel, February 2021

Medical Policy Group, February 2021 (7): Update to Key Points and References. Policy section updated to remove not medically necessary from statement, no change to intent.

Medical Policy Panel, February 2022

Medical Policy Group, March 2022 (7): Update to Key Points and References. No change in Policy Statement.

Medical Policy Panel, February 2023

Medical Policy Group, February 2023 (7): Update to Key Points, Benefit Application, and References. No change in Policy Statement.

Medical Policy Panel, February 2024

Medical Policy Group, February 2024 (7): Update to Key Points, Benefit Application, and References. No change in Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.