Pulse-Dose Radiofrequency in Athletic Pubalgia: Preliminary Results

Abstract

PDRF is an effective and safe technique in management of chronic pubalgia in athletes.

A qualitative literature review exploring the role of the inguinal ligament in the context of inguinal disruption management

“…63/65 (97%) at 10 weeks; 65/65 (100%) at 2 yearsLloyd et al 2008 [13]Retrospective cohort study (with prospective questionnaire)Level IVStudy population: 48 participants (37/48 (77%) were amateur athletes and 11/48 (23%) were manual labourers)Age: median age 38.5 years (min–max range 24–71 years)Gender: 42/48 (87.5%) maleClinical presentation: median duration of pain 18 months; participants with pain > 8 weeks and refractory to conservative management; all participants had localised tenderness over the inguinal ligament and superficial inguinal ringLaparoscopic TAPP repair with inguinal ligament tenotomyPain: pain severity pre-operative 7 to post-operative 3 ( p  < 0.0001); pain frequency score pre-operative 3 to post-operative 1 ( p  = 0.0012)Return to play: of 28/48 (58.3%) who returned questionnaires, 26/28 (92%) returned to normal sporting activity, although time period was not stated; return to strenuous sport median 28 daysMann et al 2009 [19]Prospective cohort studyLevel IVStudy population: 73 athletes (37/73, 51% professional athletes)Age: median age 30 years (min–max range 16–50 years)Gender: 70/73 (96%) maleClinical presentation: median symptom duration 6 months with no improvement following conservative management, parenteral corticosteroids or previous surgery; all participants had symptoms suggestive of inguinal ligament pathologyLaparoscopic TAPP repair with inguinal ligament tenotomyPain: pain severity from pre-op 7 to post-op 0 ( p  = 0.005); improvement in frequency of pain ( p  < 0.001). 97% reported improvement in symptoms, 73% free of symptomsReturn to play: 73/73 (100%) for all sports return to competitive play at median 28 days’ post-op; 54/73 (74%) reported themselves match-fit by 28 days (31/37 (84%) professionals); 64/73 (88%) reported a return to full-fitness at follow-upComin et al 2013 [4]Randomised controlled trialLevel IIStudy population: 46 participants (20/46, 43% professional athletes)Age: mean age 43.2 years (min–max range 18–67 years)Gender: 46/46 (100%) maleClinical presentation: participants had chronic groin pain > 6-month duration with no obvious structural cause refractory to conservative managementRFD of both ilioinguinal nerve and inguinal ligament versus local anaesthetic and steroid injectionPain: group 1 ( n  = 18) significant improvement in mean visual analogue scale with activity (VASa) at 6 months’ post-treatment ( p  < 0.001) and visual analogue scale at rest (VASr) score at 6 months’ post-treatment ( p  < 0.001); group 2 ( n  = 18) significant improvement in mean VASa at 1-week post-treatment ( p  < 0.001) with no significant difference from baseline at subsequent measurements; group 3 ( n  = 10) significant improvement in mean VASa scores ( p  = 0.007) at 6 months’ post-treatment and mean VASr scores at 6 months’ post-treatment ( p  = 0.017)Return to play: return to play time not measured with functional limitation used insteadMasala et al 2017 [20]Prospective cohort studyLevel IVStudy population: 32 high performance athletes (32/32, 1...…”

“…However, one patient received no pain relief following two treatments, although this patient had no evidence of pathology on MRI. 24 of the 32 participants commenced physiotherapy within days of treatment, although the number of days was not specified (Table 2) [20]. …”

“…Comin et al studied participants who suffered chronic groin pain of no clearly identifiable cause, evaluating whether RFD of the inguinal ligament and ilioinguinal nerve was superior to conservative therapy comprised of local anaesthetic bupivacaine and corticosteroid triamcinolone [4]. Those who underwent RFD in Masala et al experienced pain around the pubic symphysis and tenderness over the superficial inguinal ring [20]. None of the 264 patients were reported to have a demonstrable lump upon cough impulse, which is a cardinal feature of inguinal hernias [11].…”

“…Those whose symptoms extend beyond 2–3 months should be investigated by MRI with orthopaedic review to exclude relevant orthopaedic conditions. The scan may also demonstrate pathologies associated with ID such as tendinopathies of adductor longus and rectus abdominis as they insert upon the pubis [20]. Athletes who remain symptomatic should be seen by an experienced general surgeon for thorough clinical examination to elicit any tenderness over the inguinal ligament or its attachments in addition to the superficial and deep inguinal rings and exclude the possibility of herniation.…”

“…A secondary aim was to discuss the anatomical reclassification of the inguinal ligament to a tendon based on the above information and drawing from structural and functional evidence supporting this argument. The hypothesis was that direct inguinal ligament tenotomy [13, 19] or radiofrequency denervation (RFD) [4, 20] would be clinically beneficial in the context of ID management in athletes and that the published literature would support the reclassification of the inguinal ligament to a tendon.…”