AbstractOBJECTIVE: The adductor related groin pain syndrome is a common overuse injury in sports which require quick accelerations and decelerations, changes of direction and kicking. If conservative treatment fails, adductor related groin pain syndrome can be surgically treated with adductor longus tenotomy. The purpose of this study was to perform a systematic review of the literature regarding the efficacy of the different types of adductor longus tenotomy available in literature.
MATERIALS AND METHODS: This systematic review was conducted in accordance with the PRISMA guidelines. After screening 191 articles, 10 were included and summarized in this study.
RESULTS: Three different types of adductor longus tenotomy were present in the literature. Two over the three types of adductor longus tenotomy described represent a potential solution that offers athletes good prospects and a relatively quick return to sporting activity. However, one of the three types of partial tenotomy described presents a high rate of complications.
CONCLUSIONS: The adductor longus tenotomy is a valid solution in case of failure of conservative treatment. However, one of three types of tenotomy described is not recommendable until further studies completely clarify the issue of its possible complications.
Groin pain syndrome (GPS) is an important and frequent clinical condition both in professional and amateur athletes, particularly in sports that require quick accelerations and decelerations, changes of direction and/or kicking1,2. GPS is frequently associated with major time loss from sporting activity and sometimes can even be a career-ending injury3. In some sporting activities, like football (soccer), adductor-related GPS is one of the most common occurrences4. In the “Groin Pain Syndrome Italian Consensus Conference”3 adductor-related GPS is included in category IV (i.e., musculo-tendinous causes), while in the “Doha agreement meeting on terminology and definitions in groin pain in athletes”5 it is included in category III (i.e., adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain). The adductor longus tendon (AL) is generally the most affected structure in GPS6,7. Unfortunately, conservative programmes for severe chronic AL tendinopathy generally have low success rates8-11. For this reason, a surgical solution is often considered. In current literature, three types of AL tenotomy are substantially described: one type of total- and two types of partial-tenotomy12,13. However, to date, AL tenotomy seems to have resulted in mixed and unpredictable outcomes in all techniques considered11. The aim of the current systematic review is to analyze the outcomes of partial and total AL tenotomy in adductor-related GPS, performed on athletic populations suffering from adductor-related GPS.
Materials and Methods
This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines14. The protocol of this study was registered at the PROSPERO register for systematic reviews (number CRD42018091020).
Data Extraction and Quality Assessment
Prior to this systematic review, the Cochrane Database of Systematic Reviews, MEDLINE and PEDro were consulted for systematic reviews on the comparison of different surgical techniques of AL tenotomy, in order to ensure that similar systematic reviews were not already present in literature. After this verification, two authors (BGN and ZV) independently screened the literature using a string of keywords: “adductor-related groin pain”, “adductor tendinopathy”, “tenotomy”, “groin pain syndrome”, “pubalgia”, “Gilmore’s groin”, “groin disruption”, “inguinal disruption”, “sportsman’s groin” and “sport hernia”, fittingly connected by Boolean operators. When appropriate, medical subject headings (MeSH) and wild-card options were used. Furthermore, target journals were reviewed, in order to increase the possibility of collecting all the relevant articles. The research was conducted on 2 December 2018. Neither data restriction nor language limitation were applied. “Grey literature” (i.e., conference, abstracts, thesis and unpublished reports) was not taken into consideration. Cross-references from the selected articles were screened to verify their possible relevance. All double citations were removed. For each article, the relevant information was extracted and recorded on an ad hoc Excel spreadsheet. The details of the search strategy are shown in Table 1, while the PRISMA flow diagram of the study search and selection procedure is shown in Figure 1. The Methodological Index for Non-Randomized Studies (MINORS)15 was used to assess the quality of each individual study considered.
|Search strategy items
|Searched databases||PubMed/MEDLINE, Scopus, ISI, EXCERPTA MEDICA.|
|Searched string||(tenotomy) AND (adductor-related groin pain) AND (adductor tendinopathy) AND (groin pain syndrome OR pubalgia OR Gilmore’s groin OR Gilmore’s groin OR inguinal disruption OR sportsman’s groin OR sport hernia).|
|Inclusion criteria||P: Articles investigating adductor tenotomy performed on an athletic population suffering adductor-related GPS. I: complete and partial tenotomy C: comparison of the outcome between the two different considered technical surgery O: level of post-surgery satisfaction, return to sport activity.|
|Exclusion criteria||P: Articles investigating adductor tenotomy performed for clinical frameworks other than adductor-related GPS (i.e. cerebral palsy, management of coxa vara, developmental hip dislocation etc). I: Articles in which the tenotomy was coupled with another surgical intervention (i.e. hernia repair) C: Articles that did not give enough data to allow comparison between total and partial tenotomy. O: Articles not focused on surgical intervention for adductor-related GPS.|
|Time filter||None set|
|Language filter||None set|
|Target journals||All the peer-review and indexed journal present in the considered database.|
Data Extraction, Synthesis and Analysis
Two authors (GNB and ZV) extracted the following data in a standardized form from studies that proved relevant:
I. Study design;
II. Level of evidence;
IV. Study setting (sport type, level, gender, age);
VI. Type of surgical treatment;
VII. Time loss injury;
For the data on time loss injury, descriptive standard statistical indices (average ± standard deviation) were calculated. Data were analyzed and, when possible, were treated statistically for a quantitative analysis. The effect size was computed based on the summary data provided for comparing two groups using a two-sample t-test. Frequency and percentage were used to describe the categorical outcomes, such as overall complications, complications due to a revision of AL tenotomy and return to sports activity. The categorical outcomes were compared with PT1, PT2 and TT to determine any statistical association using the Chi-square test. The statistical difference was set at p<0.05.
After screening 191 articles, 10 were included and summarized in this current systematic review. The characteristics of the studies considered are shown in Supplementary Table 1. All studies were checked to identify any potential conflicts of interest. The quality appraisal of individual studies evaluated with MINORS criteria is shown in Table 2. The average score of the quality appraisal calculated with MINORS criteria was equal to 11.55±2.1 (over a maximum score of 16).
|Akermark and Johansson12||2||2||2||1||0||2||2||0||11|
|Atkinson et al20||2||2||1||1||0||2||2||1||11|
|Dojčinović et al6||2||2||1||1||1||2||2||1||12|
|Maffulli et al17||2||2||1||1||1||2||2||1||12|
|Mei-Dan et al10||1||1||0||2||0||0||2||1||2||0||2||2||13|
|Sansone et al21||2||2||1||1||1||2||2||2||13|
|Schilders et al11||2||2||2||2||0||2||2||2||14|
|Robertson et al16||2||2||2||2||0||2||2||2||14|
|Garvey and Hazard19||1||1||1||1||0||2||0||1||7|
|De Queiroz et al18||1||2||1||1||0||2||2||1||10|
Among the selected articles, one10 was a case-control study (Level of evidence: III), five11,16-19 were case series (Level of evidence: IV), two12,20 were observational cross-sectional studies (Level of evidence: IV), one21 was a retrospective case series (Level of evidence: IV) and one6 was an observational prospective study (Level of evidence: IV).
Participants and Study Setting
In the different studies, a total of 411 subjects were considered in the study groups (SG) and 59 subjects in the control groups (CG) (467 men and 3 women in total), whose average age was 27.5±3.9 years (range 13-56 years). With reference to sports activities, 239 subjects (58.2%) practiced soccer, 74 (18.0%) Gaelic football, 31 (7.5%) Australian football, 15 (3.6%) hurling, 9 (2.2%) rugby, 8 (1.9%) hockey, 6 (1.5%) athletics, six (1.5%) martial arts, 5 (1.2%) cricket, 5 (1.2%) tennis and racket sports, 3 (0.7%) indoor soccer, 2 (0.5%) orienteering, 1 (0.2%) bandy, 1 (0.2%) basketball, 1 (0.2%) cross country skiing, 1 (0.2%) handball, 1 (0.2%) lacrosse, 1 (0.2%) swimming, 1 (0.2%) triathlon and 1 (0.2%) weight lifting. Among the subjects considered, 393 (95.6%) played field-based ball sports.
The terminology used for the classification of the sport level practiced by the subjects was rather heterogeneous and confusing, since 73 (17.8%) subjects were classified as professionals, 16 (3.9%) as competitive athletes, 112 (22.2%) as amateurs, 133 (32.4%) without a distinction between categories, and 77 (18.7%) were not classified at all.
In four studies11,16,18,19 (40%), the diagnosis of inclusion was “chronic adductor dysfunction/tendinopathy” and in the other six studies6,10,12,17,20,21 (60%) it was “chronic/recalcitrant/long-standing GPS”.
Types of Surgical Treatment
In six studies6,10,12,17,20,21 (60% of the studies comprising 226 subjects, 55% of all the considered subjects), the patients underwent AL total tenotomy (TT). Among all patients subjected to total tenotomy, 16 (7.1%) subjects underwent a unilateral tenotomy of the affected side only, while 162 (71.7%) subjects underwent a bilateral tenotomy and for the remaining 48 (21.2%) subjects, this information was not reported.
In four studies11,16,18,19 (40% of the studies comprising 185 subjects, 45% of all the considered subjects), the patients underwent a partial tenotomy of the AL. Among all patients subjected to partial tenotomy, 142 (76.7%) had unilateral tenotomy at the affected side only, 40 (21.6%) subjects underwent bilateral tenotomy and for the remaining three (1.6%) subjects this information was not reported. In the studies in question, partial tenotomy (PT) was performed with two different surgical techniques called PT1 and PT2, respectively (described in the details under)
Types of Rehabilitation
In seven studies6,10,11,17,18,20,21 (70%) the rehabilitation programme was based on early stretching avoiding hip adduction, and in the remaining three studies12,16¸19 (30%) the rehabilitation program was not specified.
The average of follow-up in the 10 studies was 29.0±38.8 months (range 0.5-300).
Time Loss Injury
Time loss injury, i.e., the time necessary for full recovery and therefore missed in training and competition, was on average 13.1±3.1 weeks. In two studies19,21, the time loss injury value was not reported.
Time loss value for TT, PT1 and PT2 groups was equal to 12.9±3.3, 9.2±4.6 and 15.5±7.1 weeks, respectively.
As with the terminology used for the classification of the practiced sport level, there was an excessive heterogeneity in the terms used for classifying outcome.
Indeed, 207 subjects (50.4%) judged the outcome as “excellent”, 84 (20.4%) as “good”, 110 (26.8%) as “improved”, 3 (0.73%) as “fair” and seven (1.70%) as “deterioration” compared to pre-surgery.
Complications occurred in 26 patients (6.3% of the total patients) for whom: 11 patients (42.3%) underwent a revision of AL tenotomy, four (15.4%) suffered of dysuria, three (11.5%) had superficial wound infection, two (7.7%) had sub-cutaneous hematoma, two (7.7%) complained of unilateral adduction weakness, one (3.8%) had persistent pain for two months post-surgery, one (3.8%) complained of numbness around the wound, one (3.8%) presented a painful scar and one (3.8%) reported painful intercourse.
The percentage of complications for PT1, PT2 and TT groups are subdivided in 2 sub-groups: 1) overall complications and 2) complications due to revision of AL tenotomy.
Results of Statistical Analysis
The time loss injury value for PT1, PT2 and TT groups was of 9.2±4.6, 15.5±7.7 and 12.9±3.3 weeks, respectively. The statistical significance of the difference in the average is shown in Figure 2.
The percentages of overall complications for PT1, PT2 and TT groups were of 33±46.7%, 8.0±7.5% and 9.5±8.3%, respectively. The statistical significance of the difference in the average is shown in Figure 3.
(**): p<0.001; N.S.: not significant.
The percentages of complications due to a revision of AL tenotomy for PT1, PT2 and TT groups were of 33±46.7%, 1.4±1.9 and 0.7±1.0%, respectively. The statistical significance of the difference in the average is shown in Figure 4.
The PT1, PT2 and TT interventions were associated with an improvement in symptoms and a return to sporting activity in 98.8±1.6%, 95.5±6.4% and 88.2±8.6% of the cases. The statistical significance of the difference in the average is shown in Figure 5.
The AL arises as a flat and narrow tendon from the anterior surface of the pubic bone, medial to the pubic tubercle and is distally inserted on the aponeurosis into the linea aspera of the femur22. Proximally, it presents a poorly vascularized fibrocartilaginous enthesis23,24. It is innervated by the obturator nerve. Several anatomical studies show that the AL anterior origin is tendinous, while the posterior origin is muscular24-26. Indeed, at its origin, AL is composed of ~38% tendon and ~62% muscle tissue. About ~1.0 cm from the origin, the tendon percentage is ~34%, while at ~2.0 cm from the origin the tendon represents ~27% of the total cross section25 (Figure 6). AL is the muscle belonging to the adductor muscle complex most often implicated in the adductor-related GPS3,5,27. It has been hypothesized that AL’s strong involvement in the adductor-related GPS etiology may be referred both to its poor entheseal blood supply24 and by the fact that AL proximal insertion undergoes strong mechanical stress during the transmission of the force generated by muscle contraction22,28.
Figure 6. AL sagittal schematic view. At its origin AL is composed of ~38% tendon and ~62% muscle tissue. At ~1.0 cm from the origin, the tendon percentage is ~34% and muscle tissue ~66% while at ~2.0 cm from the origin, the tendon represents ~27% and the muscle tissue ~73%.
P: pubis bone; TP: tendinous part; M: muscle part.
AL tenotomy was described for the first time by Akermark and Johansson12 for cases of chronic adductor-related GPS, at the 1981 AOSSM annual meeting. AL tenotomy can be performed in cases of chronic adductor-related GPS, refractory to conservative treatments, in young and athletic populations playing field-based ball-sports2,29,30.
Three different adductor tenotomy techniques are described in literature:
AL Partial Tenotomy (PT1 Technique)
This type of AL partial tenotomy (PT1) is performed under general anesthesia following antibiotic prophylaxis. The patient is positioned in a so-called “frog-leg position”. A transverse incision is made below the scrotum and the AL fascia is divided to identify the AL tendon. The procedure continues with a tenotomy (performed 2-4 cm from the tendon origin) (Figure 7) of the anterior tendinous fibres19,31¸32. The AL direct muscular attachments to the pubis are left intact33. Once the tenotomy is completed, the wound is sutured after accurate hemostasis. After surgery, a compressive bandage is applied. The patients may leave the hospital either the same day or the day after surgery. The compressive bandage is generally removed 2 days after the operation.
Figure 7. Sagittal schematic view of the PT1 technique. In the PT1, the partial tenotomy is performed 2–4 cm from the tendon origin on the superficial fibers of the tendon. The AL direct muscular attachments to the pubis are left intact.
P: pubis bone; TP: tendinous part; M: muscle part.
AL Partial Tenotomy (PT2 Technique)
In this variant of AL partial tenotomy (PT2)16,34, the AL tendon release is performed just below the pelvic attachment. The remaining part of the surgical procedure corresponds to that previously described (Figure 8).
Figure 8. Oblique sagittal schematic view of the PT2 technique. In the PT2, the tenotomy is performed just below the pelvic attachment. As in PT1, the AL direct muscular attachments to the pubis are left intact.
P: pubis bone; TP: tendinous part; M: muscle part.
AL Total Tenotomy
In the AL total tenotomy (TT) technique, both the tendon and the direct muscle attachment are fully released from their pubic attachment, about 2 cm distal to its origin. The muscular fascia attaching the AL directly to the pubis is then released. Finally, the freed tendon and muscular stump are then manually displaced approximately 5-cm distally to prevent its reattachment7,35 (Figure 9).
Figure 9. Sagittal schematic view of the TT technique. In the TT technique the AL tendon and the AL direct muscular attachments to the pubis are fully released at about 2 cm distally from their origin The released tendon and muscle attachment are then pushed down about 4-5 cm to prevent reattachment.
P: pubis bone; TP: tendinous part; M: muscle part.
The justification for an AL PT (both PT1 and PT2) is that the superficial tendon fibers of the AL tendon are subjected to a relatively greater tensile load in comparison to the direct muscle attachment fibers11. Furthermore, since the AL tendon/muscle ratio decreases in a proximal to distal direction25, in performing a more distal release (2-4 cm from the tendon origin), a greater proportion of the AL muscle fibers is preserved11.
We must remember that some authors justify the AL PT both with the “compression theory”36 and the “stress shielding theory”31. The theory behind both the compression and the stress-shielding theory for insertional tendinopathy is that the superficial portion of the tendon insertion undergoes greater tension than the deeper portion. Some histological studies36 show that in tendinopathy the pathological part of the insertional tendon is the deeper portion, whilst the superficial insertional portion usually remains unaffected. The stress shielding theory explains this situation by sustaining that the process of tendinopathy arises through a combination of overuse-underuse in which the superficial portion of the tendon bears the maximum tensile force, whilst the deeper portion is under-stimulated. This under stimulation may induce important biological changes in the tendon leading to the condition of tendinopathy31 very similar to that observed in a tendon suffering from compression, for example the rotator cuff tendons affected by tendinopathy36. However, the “stress shielding theory” applied to adductor-related GPS31 is very open to criticism: in taking into account the particular anatomy of the proximal attachment of the AL24-26 and in considering the anatomical situation described by the above-mentioned studies, it would be more correct to affirm that, in releasing the tendon fibers, the AL PT1 and PT2 surgical techniques may well be responsible for transferring the tensile forces from the anterior, superficial, tendinous portion of the AL to its deeper muscular portion directly attached to the pubis.
However, the AL shows many anatomical variations24-26 that must be taken into account when choosing the appropriate surgical technique12,20. Furthermore, it is important to note that TT does not involve any loss of muscle strength and power production in the lower limb8,20. In fact, the AL loss of strength and power production may be compensated by an increased strength and power production of the agonistic adductor muscles12,37,38.
In all 3 techniques investigated, the most worrying and widespread complication seems to be the need to repeat the AL tenotomy. Indeed, AL tenotomy revision accounts for 100%, 17.5% and 7.3% of all recorded complications associated with the PT1, PT2 and TT surgical techniques, respectively.
A revision of AL tenotomy may be necessary whenever the proximal part of the adductor longus tendon is left either intentionally rather long (as in PT1 technique)19 or it has remained long due to a surgical error16,20,21,32. Indeed, a too-long tendon stump can give rise to regrowth and to the formation of a scar area that may become the anatomical location of re-injury16,20,21,32,39-41. The need to prevent the regrowth of the tendon stump is also confirmed by the fact that, in seven studies (70%), the rehabilitation programme was based on early stretching exercises in order to avoid the bridging of the two severed tendon stumps6,10,17,18-21. It should be noted that in PT1 intervention, 33±46.7% of the patients displayed recurrent AL tendinopathy due to regrowth of the tendon stumps, for which a revision of tenotomy was necessary. On the contrary, this complication arose in only 1.4±1.9% (p<0.001; CI=95%) of patients undergoing PT2 intervention and in 0.7±1.0% (p<0.001¸ CI=95%) of patients undergoing TT intervention; both of which are significantly much lower than the PT1 relapse.
Statistical analysis showed that the PT1 intervention resulted in the lowest time loss. This apparent paradox can be explained by two factors. The first is represented by the fact that PT1 is less invasive than the PT2 and TT interventions from a surgical point of view and, as a result, it allows for a quicker return-to-play. However, this prompt return-to-play is in conflict with the higher number of tenotomy revisions required in comparison to PT1 (p<0.001; CI=95%) and TT interventions (p<0.001; CI=95%). This could be because the decision to intervene with a second tenotomy is taken in the long run, a long time after the return-to-play20,16,19,21. In other words, PT1 intervention allows for a quicker return-to-play but is related to a higher risk of AL tenotomy revision, probably due to the excessive proximity of the two stumps of the severed tendon, which could favor their reattachment. As already mentioned, this “bridge of scar tissue” represents a weak spot where injuries can easily reoccur16,20,21,32. It is important to underline that the apparently most appealing technique, with speedy return-to-play, actually results to be less efficient in the long run. This must be taken into account when explaining surgical outcomes to high-profile athletes and their coaches, who often focus on the short-term return-to-play.
Comparing PT2 and TT interventions, the main points to underline are:
– In PT2 and TT groups, there is no statistical difference between the overall complications (8.0±7.5% vs. 9.5±8.3%), whilst the complications due to AL tenotomy revision are lower in TT group (0.7±1.0% vs. 1.4±1.9%, p<0.001; CI=95%).
– PT2 intervention allows for a greater outcome of return-to-play than TT (95.5±6.3% vs. 88.2±8.6%, p<0.001; CI=95%).
Here, in light of the data analyzed in literature, PT2 and TT seem to be the most favorable interventions. Indeed, both allow for a substantial return-to-play and a low incidence of complications (risk for the patient to undergo a tenotomy revision). In any case, the PT1 intervention should be discouraged, due to the high number of complications involving tenotomy revisions.
Limitations of the Study and Further Developments
The most important limitations of this study are:
– More data (currently not present in literature due to the lack of pertinent studies) are needed to establish the clear correlation between tendon-stump re-growth and the PT1 surgical technique. Furthermore, additional in-depth investigations are necessary to establish the complications linked to the PT1 technique.
– The heterogeneity of the terms used to verify the outcome in the various studies makes a rational comparison relatively difficult to compile and not thoroughly objective.
AL tenotomy performed by PT2 and TT interventions are reliable techniques in the field of adductor-related GPS which allow a high percentage of athletes to return to sporting activities in a relatively short period of time. On the contrary, PT1 is not recommended, despite the relatively quick return to play, as it is associated with numerous complications.
Conflict of Interest
The Authors declare no conflict of interest.
This research received no external funding
Availability of Data and Materials
The data presented in this work is available upon request from the corresponding author.
Not required by the nature of the study.
Bisciotti Gian Nicola: 0000-0003-1346-320X
Corsini Alessandro: 0000-0001-5793-3221
Chamari Karim: 0000-0001-9178-7678
Zini Raul: 0000-0001-6227-833X
Volpi Piero. 0000-0001-7938-4964
Canata Pier Luigi: 0000-0002-6079-4071
Zarko Vuckovic: 0000-0003-0068-2024
- Macintyre J, Johson C, Schroeder EL. Groin pain in athletes. Curr Sports Med Rep 2006; 5: 293-299.
- Gerodimos V, Karatrantou K, Paschalis V, Zafeiridis A, Katsareli E, Bilios P, Kellis S. Reliability of concentric and eccentric strength of hip abductor and adductor muscles in young soccer players. Biol Sport 2015; 32: 351-356.
- Bisciotti GN, Volpi P, Zini R, Auci A, Aprato A, Belli A, Bellistri G, Benelli P, Bona S, Bonaiuti D, Carimati G, Canata GL, Cassaghi G, Cerulli S, Delle Rose G, Di Benedetto P, Di Marzo F, Di Pietto F, Felicioni L, Ferrario L, Foglia A, Galli M, Gervasi E, Gia L, Giammattei C, Guglielmi A, Marioni A, Moretti B, Niccolai R, Orgiani N, Pantalone A, Parra F, Quaglia A, Respizzi F, Ricciotti L, Pereira Ruiz MT, Russo A, Sebastiani E, Tancredi G, Tosi F, Vuckovic Z. Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete. BMJ Open Sport Exerc Med 2016; 2: e000142.
- Mosler AB, Weir A, Eirale C, Farooq A, Thorborg K, Whiteley RJ, Hӧlmich P, Crossley KM. Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players. Br J Sports Med 2018; 52: 292-297.
- Weir A, Brukner P, Delahunt E, Ekstrand J, Griffin D, Khan KM, Lovell G, Meyers WC, Muschaweck U, Orchard J, Paajanen H, Philippon M, Reboul G, Robinson P, Schache AG, Schilders E, Serner A, Silvers H, Thorborg K, Tyler T, Verrall G, de Vos RJ, Vuckovic Z, Hölmich P. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med 2015; 49: 768-774.
- Dojčinović B, Sebečić B, Starešinić M, Janković S, Japjec M, Čuljak V. Surgical treatment of chronic groin pain in athletes. Int Orthop 2012; 36: 2361-2365.
- Gill TJ, Carroll KM, Makani A, Wall AJ, Dumont GD, Cohn RM. Surgical technique for treatment of recalcitrant adductor longus tendinopathy. Arthrosc Tech 2014; 3: e293-e297.
- Martens MA, Hansen L, Mulier JC. Adductor tendinitis and musculus rectus abdominis tendopathy. Am J Sports Med 1987; 15: 353-356.
- Weir A, Jansen J, van Keulen J, Mens J, Backx F, Stam H. Short and mid-term results of a comprehensive treatment program for longstanding adductor-related groin pain in athletes: a case series. Phys Ther Sport 2010; 11: 99-103.
- Mei-Dan O, Lopez V, Carmont MR, McConkey MO, Steinbacher G, Alvarez PD, Cugat RB. Adductor tenotomy as a treatment for groin pain in professional soccer players. Orthopedics 2013; 36: e1189-1197.
- Schilders E, Dimitrakopoulou A, Cooke M, Bismil Q, Cooke C. Effectiveness of a selective partial adductor release for chronic adductor-related groin pain in professional athletes. Am J Sports Med 2013; 41: 603-607.
- Akermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med 1992; 20: 640-643.
- Van Der Donckt K, Steenbrugge F, Van Den Abbeele K, Verdonk R, Verhelst M. Bassini’s hernial repair and adductor longus tenotomy in the treatment of chronic groin pain in athletes. Acta Orthop Belg 2003; 69: 35-41.
- Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA; PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4: 1.
- Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003; 73: 712-716.
- Robertson IJ, Curran C, McCaffrey N, Shields CJ, McEntee GP. Adductor tenotomy in the management of groin pain in athletes. Int J Sports Med 2011; 32: 45-48.
- Maffulli N, Loppini M, Longo UG, Denaro V. Bilateral mini-invasive adductor tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes. Am J Sports Med 2012; 40: 1880-1886.
- de Queiroz RD, de Carvalho RT, de Queiroz Szeles PR, Janovsky C, Cohen M. Return to sport after surgical treatment for pubalgia among professional soccer players. Rev Bras Ortop 2014; 49: 233-239.
- Garvey JF, Hazard H. Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up. Hernia 2014; 18: 815-823.
- Atkinson HD, Johal P, Falworth MS, Ranawat VS, Dala-Ali B, Martin DK. Adductor tenotomy: its role in the management of sports-related chronic groin pain. Arch Orthop Trauma Surg 2010; 130: 965-970.
- Sansone M, Ahldén M, Jonasson P, Thomeé R, Falk A, Swärd L, Karlsson J. Can hip impingement be mistaken for tendon pain in the groin? A long-term follow-up of tenotomy for groin pain in athletes. Knee Surg Sports Traumatol Arthrosc 2014; 22: 786-792.
- Tuite DJ, Finegan PJ, Saliaris AP, Renström PA, Donne B, O’Brien M. Anatomy of the proximal musculotendinous junction of the adductor longus muscle. Knee Surg Sports Traumatol Arthrosc 1998; 6: 134-137.
- Koulouris G. Imaging review of groin pain in elite athletes: an anatomic approach to imaging findings. AJR Am J Roentgenol 2008; 191: 962-972.
- Davis JA, Stringer MD, Woodley SJ. New insights into the proximal tendons of adductor longus, adductor brevis and gracilis. Br J Sports Med 2012; 46: 871-876.
- Strauss EJ, Campbell K, Bosco JA. Analysis of the cross-sectional area of the adductor longus tendon: a descriptive anatomic study. Am J Sports Med 2007; 35: 996-999.
- El Hage S, Rachkidi R, Noun Z, Haidar R, Dagher F, Kharrat K, Ghanem I. Is percutaneous adductor tenotomy as effective and safe as the open procedure? J Pediatr Orthop 2010; 30: 485-458.
- Serner A, Weir A, Tol JL, Thorborg K, Roemer F, Guermazi A, Yamashiro E, Hölmich P. Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes. Scand J Med Sci Sports 2018; 28: 667-676.
- Renström P, Peterson L. Groin injuries in athletes. Br J Sports Med 1980; 14: 30-36.
- Bisciotti GN, Di Marzo F, Auci A, Parra F, Cassaghi G, Corsini A, Petrera M, Volpi P, Vuckovic Z, Panascì M, Zini R. Cam morphology and inguinal pathologies: is there a possible connection? J Orthop Traumatol 2017; 18: 439-450.
- Bisciotti GN, Auci A, Di Marzo F, Galli R, Pulici L, Carimati G, Quaglia A, Volpi P. Groin pain syndrome: an association of different pathologies and a case presentation. Muscles Ligaments Tendons J 2015; 5: 214-222.
- Orchard JW, Cook JL, Halpin N. Stress-shielding as a cause of insertional tendinopathy: the operative technique of limited adductor tenotomy supports this theory. J Sci Med Sport 2004; 7: 424-428.
- Jans C, Messaoudi N, Pauli S, Van Riet RP, Declercq G. Results of surgical treatment of athletes with sportsman’s hernia. Acta Orthop Belg 2012; 78: 35-40.
- Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000; 28: 2-8.
- Harr JN, Brody F. Sports hernia repair with adductor tenotomy. Hernia 2017; 21: 139-147.
- Messaoudi N, Jans C, Pauli S, Van Riet R, Declercq G, Van Cleemput M. Surgical management of sportsman’s hernia in professional soccer players. Orthopedics 2012; 35: e1371-1375.
- Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med 2003; 22: 703-710.
- Bogey RA, Barnes LA. Estimates of individual muscle power production in normal adult walking. J Neuroeng Rehabil 2017; 14: 92.
- Cross MR, Rivière JR, Coulmy N, Morin JB, Samozino P. Lower limb force-production capacities in alpine skiing disciplines. Scand J Med Sci Sports 2021; 31: 848-860.
- Jørgensen SG, Öberg S, Rosenberg J. Treatment of longstanding groin pain: a systematic review. Hernia 2019; 23: 1035-1044.
- Lenton GK, Doyle TLA, Lloyd DG, Higgs J, Billing D, Saxby DJ. Lower-limb joint work and power are modulated during load carriage based on load configuration and walking speed. J Biomech 2019; 83: 174-180.
- Le CB, Zadeh J, Ben-David K. Total extraperitoneal laparoscopic inguinal hernia repair with adductor tenotomy: a 10-year experience in the treatment of athletic pubalgia. Surg Endosc 2021; 35: 2743-2749.
To cite this article
Adductor longus tenotomy in the treatment of groin pain syndrome in athletes: a systematic review
Submission date: 18 Apr 2023
Revised on: 30 Apr 2023
Accepted on: 03 May 2023
Published online: 26 May 2023