Introduction

Pubalgia is common, especially in sports such as football, hockey, rugby, running, and tennis athletes[1]. Pubalgia is prevalent in males and in soccer players [2, 3]. Pubalgia manifests with pain in the inguinal region, impairing athletic performance [3]. Pubalgia can be due to acute trauma or to chronic overuse [4, 5]. Given the multifactorial aetiogenesis, the approach to manage pubalgia is challenging [6]. The management of pubalgia involves physiotherapy programs, pharmacological treatments, and surgical intervention [7].

Pubalgia negatively impacts athlete performance, causing prolonged absence or even prematurely retirement from sports [8]. Its treatment is a challenge, and finding the best way for the athlete to return to the sport is fundamental to his career or quality of life. For this purpose, this systematic review wished to assess whether there is a difference in the time required to RTS after conservative or surgical treatment using clinical trials. We also examined the various modalities of treatment, and the criteria used to clear the patients for RTS.

Materials and methods

Study protocol

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [9]. This study was registered in PROSPERO (ID CRD42018098922).

Search strategy

The literature search was performed independently by two authors (TTS and ESO). The PICO algorithm was preliminary pointed out:

  • P (Problem): pubalgia;

  • I (Intervention): conservative management;

  • C (Comparison): surgical management;

  • O (Outcomes): return to sport time

The literature search was performed in Pubmed, SportDiscus, and Web of Science in September 12, 2022. The Medical Subject Headings (MeSH) terms were used: "Pubalgia" or "Groin pain" or "Osteitis pubis" combined with "Treatment" or "Physical therapy" or "Surgery" (Table 1). There was no time limit set for the search.

Table 1 Search strategy on electronic database
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All the titles of the resulting articles were screened by the author in a separate fashion, and, if of interest, the full-text was accessed. The bibliographies of the full-text were also accessed. Disagreements between the authors were solved by a third author (RO).

Eligibility

All the published clinical studies which investigated the role of conservative and/or operative management for pubalgia in athletes were accessed. Comments, reviews, case reports, editorials, letters to the editor, technical notes were not eligible. Given the authors language capabilities, articles in English, Portuguese, and Spanish were considered. Only studies that reported quantitative data with regards to the RTS were included in the present investigation. Only studies that clearly indicated the nature of the treatment were eligible.

Data extraction and outcomes of interest

Data extraction was performed by two reviewers (TTS and ESO). Patient demographic was extracted. Furthermore, study objective, type of treatment (surgical or conservative), characteristics of the intervention postoperative, duration of preoperative symptoms, return to sport time, return to sport rate, return to sport criteria and other results.

Methodological quality assessment

To evaluate the methodological quality assessment, the Downs and Black checklist [10] was used. This checklist is composed by 27 items divided into 4 main categories: Reporting, External validity, Interval validity—Bias and Confounding, and Power. The final classification of the studies is based on the sum of each items: excellent (24–28 points), good (19–23 points), fair (14–18 points) and poor (< 14 points).

Quality of evidence

To assess the quality of evidence, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). For the purpose of this review, we examined the following GRADE aspects: risk of bias, inconsistency, indirectness, imprecision. Based on these criteria, the quality of evidence of a study is classified as high, moderate, low, or very low [11].

Results

Literature search

The initial search identified 4264 articles. After reading the titles, 172 studies remained for reading the abstracts. After reading the resulting abstracts, other 139 articles were excluded as the title did not match the topic and not reported any quantitative data on RTS. Thus, 33 studies were selected for full text assessment, and 10 studies were included in the qualitative analysis (Fig. 1).

Fig. 1
figure 1

PRISMA flowchart of the literature search

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Quality of studies

Applying Downs and Black checklist, two studies were classified as "Excellent" [12, 13], six were rated as “Good” [14,15,16,17,18,19], none were rated as “Fair”, and two studies [20, 21] were rated as “Poor”. The final value was 19.5 ± 5.0, attesting to this review a good quality of the methodological assessment (Table 2).

Table 2 Evaluation of the quality of studies with Downs and Black checklist
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Quality of evidence

Based on the GRADE assessment (Table 3), five included analyses were classified as high quality [12, 13, 15, 16, 18], three were moderate quality [14, 17, 19] and two studies very low quality [20, 21].

Table 3 GRADE
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Characteristics of the studies

Seven studies performed patient randomisation clinical trials. Seven studies reported data on conservative management, two on surgical management and one compared A total of 468 subjects were included for analysis. 58.7% (275 of 468) were soccer players, 5.9% (28 of 468) runners, and 3.8% (18 of 468) hockey players. Two studies [18, 19] did not specify the type of sport. Study characteristics is shown in greater detail in Table 4.

Table 4 Results of studies performing conservative strategies
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Conservative management

A total of seven studies verified the effects of conservative treatment on athletes with pubalgia. The time to RTS ranged from 9.14 weeks [18] to 18.5 weeks [14], and the percentage of athletes who were able to RTS ranged from 14% [14] to 100% [18, 21] (Table 4). Four studies reported criteria for discharge. Data concerning the conservative management are shown in greater detail in Table 5.

Table 5 Results of studies performing surgical strategies
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Surgical management

Three studies described the results of surgical treatment for pubalgia [12, 13, 20]. Time to RTS ranged from 6 weeks [20] to 12 weeks [12, 13]. The postoperative rehabilitation protocols were well structured in two studies [12, 20] and ranged from immediate return to sport [12] to 6 weeks [20]. The studies which investigated the actual rate of RTS reported a success rate of 90% [12, 13] to 100% [20]. Data concerning the surgical management are shown in greater detail in Table 6.

Discussion

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.

Conclusion

This review highlights that individuals undergoing surgery for pubalgia may return to sport earlier than those receiving conservative treatment. However, conservative management should be considered before surgical treatment is indicated. If surgery is undertaken, an active rehabilitation program should be preferred. Active rehabilitation programs should be the stalwart of conservative treatment. The quality of the studies detailing the results of conservative management was higher than surgical procedures. For future studies, it is important to use standard measures and criteria for return to sport.