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Surgical Treatments of Athletic Pubalgia
11.14.26a

Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

The surgical treatments of athletic pubalgia, in the absence of a preoperative demonstrable defect, are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Note: For individuals diagnosed with pubalgia who present with a demonstrable anatomical defect, established alternatives, including standard surgical procedures (e.g., repair of torn muscle), may be considered safe and/or effective, and therefore covered, according to the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Subject to the terms and conditions of the applicable benefit contract, surgical treatments of athletic pubalgia are not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Surgical treatments of athletic pubalgia are not regulated by the FDA.

Description

Athletic pubalgia (AP) is a condition associated with chronic groin pain and primarily affects professionally trained athletes. Groin injuries have been reported to account for up to 6% of all athletic injuries. AP has only recently been recognized as a common source of unresponsive groin pain. It is a condition that occurs more frequently in male athletes, although there has been an increased prevalence among female athletes. AP is most prevalent among athletes who participate in sports that require running, changes in direction, and repetitive kicking such as ice hockey, soccer, rugby, or football.

AP has also been called athletic hernia, sports hernia, sportsman’s hernia, sportsman’s groin, soft groin, Gilmore’s groin, and inguinal disruption, among other names. The precise etiology is unknown; the difficulty in selecting a disease name may lie in the wide differences of opinion that exist regarding the exact cause of pain and pathoanatomy. The term “hernia” is a misnomer as AP does not describe a classic herniation of soft tissue and, frequently, there is no demonstrable defect in the groin or abdominal wall. Some physicians have defined AP as a weakness in the posterior wall of the inguinal canal that results in neuritis (i.e., nerve irritation) and pubalgia (i.e., insertional tendon pain on the bone). Others have described AP as one component of a broader group of conditions caused by pelvic instability, including osteitis pubis, adductor tendinopathy, and obturator nerve entrapment. Additional causes of pain include a generalized weakness of the pelvic floor.

AP is characterized by insidious onset and progressively worsening groin pain that may radiate to the perineum and upper medial thigh. While the signs and symptoms of chronic groin injury are well described, how they contribute to the differential diagnosis of AP is unclear. Between 27% and 90% of athletes with AP symptoms have multiple pathologies, making accurate diagnosis difficult. Some studies suggest that at least 43 other diagnoses must be excluded before AP can be diagnosed.

DIAGNOSIS

Based on patterns of symptoms and the anatomy involved, several definitions have been developed to categorize these individuals with chronic groin pain. However, there is currently no consensus as to what specifically constitutes an AP diagnosis. The etiology, onset, involved anatomy, and terminology used to define AP vary widely in the literature. The available published peer-reviewed literature suggests that there are at least 17 different soft-tissue structures that are believed to be causes of AP. Therefore, it is primarily a diagnosis of exclusion. Included in this differential are osteitis pubis, distal rectus strain or avulsion, adductor tenoperiostitis, rupture adductor longus, and other inflammatory, infectious, or musculoskeletal causes of chronic groin pain. While physical examination typically reveals no demonstrable inguinal hernia, individuals can often identify the exact site of pain. The following elements are typically found during physical examination: inguinal canal tenderness, dilated superficial inguinal ring, pubic tubercle tenderness, and hip adductor origin tenderness.

PEER-REVIEWED LITERATURE
In a literature review, Harmon (2007) reported that due to the complex anatomy of the groin, evaluation and treatment in athletes is challenging. Different pathologies can coexist and cause symptoms similar to AP. Oftentimes, the diagnosis can depend on a physician’s specialty. Many question the validity of the AP diagnosis, the underlying pathology, and the optimal and safest treatment. The majority of the available published peer-reviewed literature involves level IV hierarchy of evidence (i.e., retrospective case series).

In a literature review, Garvey et al. (2010) reported that there is no general consensus as to the actual existence of AP, the relevant pathology, or even the name that should apply to the condition; the etiology is debatable. Frequently, AP is a component of a more extensive pattern of "groin disruption injuries," which can include osteitis pubis, conjoint tendinopathy and/or tear, adductor tendinopathy and/or tear, and obturator nerve entrapment and/or irritation. Risk factors for AP as a specific entity cannot be clearly separated from those associated with chronic groin pain. Reduced range of hip motion and poor muscle balance around the pelvis are potential risk factors. Moreover, it is not uncommon for an athlete to have co-existing hip joint pathology and AP. In fact, femoroacetabular impingement (FAI) may be a potential precursor for AP.

Litwin et al. (2011) reported that AP is a poorly understood disease complex that is generally not well accepted by general surgeons as a real syndrome warranting surgical therapy, and for which there is a paucity of good clinical trials. The authors assert that two schools of thought have emerged regarding the cause and pathogenesis of AP. The first is characterized by the concept of muscular injury and disruption. The second school of thought focuses on the concept of AP as an occult hernia process, a pre-hernia condition, or an incipient hernia, and not necessarily a muscle tear. Before diagnosing AP, there are at least 43 other diagnoses that must be excluded. FAI may co-exist with AP, but it may be difficult to distinguish between the two. In many cases, AP goes on to heal with conservative treatment (CT), but surgery may be warranted for individuals with chronic AP. However, CT should be the first treatment plan and it is unusual to perform surgery earlier than 3 months from the onset of symptoms.

IMAGING

Physical examination is the primary means of diagnosing AP. While diagnostic imaging does not typically reveal AP, it is often employed to rule out other conditions, including pubic symphysis widening or erosion, fractures, or skeletal disease. This is due to the overlapping symptoms between AP and other sources of chronic groin pain such as FAI or developmental dysplasia of the hip (DDH). Radiographs can identify osteitis pubis (noninfectious inflammation of the pubic symphysis), which typically produces symmetric bone resorption and may cause symphyseal widening. Bone scans can diagnose stress fractures that are too subtle to interpret on radiographs. Dynamic ultrasound is one modality that shows promise in diagnosing AP as distinct protrusions of the transversalis fascia that can be detected using a Valsalva maneuver.

Magnetic resonance imaging (MRI) is useful in diagnosing FAI and other subtle abnormalities in the musculofascial layers of the abdominal wall that correlate closely to surgical findings of AP. MRI has mostly been negative in identifying AP; however, some studies have suggested that findings in individuals with AP can include rectus abdominis injury, thigh adductor injury, and articular diseases at the pubic symphysis. MRI for pain after surgical treatment for AP, which can include various pelvic floor repairs, mesh reinforcements, and tendon releases, reveals that individuals may have persistent or refractory groin pain, with some individuals developing new injuries in the pubic region or elsewhere about the pelvic girdle. While studies have suggested that the use of MRI as a primary imaging modality can result in more accurate diagnoses, Mullens et al. (2011) suggest that there is still more to be learned about prevention and treatment plans for AP.

PEER-REVIEWED LITERATURE
In a retrospective cohort study, Zoga et al. (2008) examined the sensitivity and specificity of MRI findings in individuals with clinical AP (n = 141), with either surgical or physical examination findings as the reference standard. These findings were compared to MRI studies in asymptomatic individuals (n = 25). Ninety-eight percent of study participants diagnosed with clinical AP (n = 138) had MRI findings that could cause groin pain. Among individuals who had surgery to address their AP symptoms, MRI had a sensitivity and specificity of 68% and 100%, respectively, for rectus abdominis tendon injury, and 86% and 89% for adductor tendon injury. Among asymptomatic individuals, there were very few MRI findings in the region of the pubic symphysis. The authors concluded that true hernias were exceedingly rare among those with AP symptoms and that future efforts should be centered on improved MRI techniques to diagnose AP. They also called for studies designed to include activity and age-matched control populations to increase statistical power. Limitations of this retrospective cohort study include its small sample size and a lack of matching with the control group. In addition, due to different imaging techniques from three different imaging sites, the internal validity of the study may be questioned.

In a cross-sectional study, Silvis et al. (2010) examined the prevalence of pelvic and hip MRI findings and their associations with clinical symptoms in asymptomatic, male professional and collegiate hockey players (n = 39). The primary outcome measurement was abnormal MRI findings indicative of AP or hip pain. The authors found that 56% had asymptomatic labral tears and none had asymptomatic abdominal rectus tears. Overall, 77% of asymptomatic hockey players (n = 30) demonstrated abnormal hip or groin pathology in their MRI. The authors admitted that their results were limited to this male athletic population and could not be generalized to other sports. Limitations of this cross-sectional study include its small sample size and limited external validity. In addition, this study was not designed to analyze treatment outcomes and included athletes who did not necessarily have AP symptoms.

CONSERVATIVE TREATMENT (CT)

Conservative treatment (CT) is traditionally employed as a first-line therapy for the treatment of AP. It involves 6 to 8 weeks of rest followed by focused physiotherapy, which can include progressive resistance hip adductor strengthening and stretching exercises, sports-specific functional tasks, and a gradual return to full activities. At approximately 10 to 12 weeks following CT initiation and when the athlete is pain-free, return to sports activity is attempted. As with most other chronic groin injuries, AP is also initially treated with non-steroidal anti-inflammatory medications (NSAIDS), heat or ice, and massage. Active physiotherapy involving isometric and progressive resistance hip abduction, adduction, flexion, and extension exercises has been shown to achieve better patient outcomes than a more passive treatment intervention for AP. Studies have shown that athletes with groin injuries may improve with appropriate CT.

PEER-REVIEWED LITERATURE
In a prospective randomized controlled trial, Holmich et al. (1999) examined the safety and effectiveness of an active training program (AT) aimed at improving strength and coordination of the muscles acting on the pelvis when compared to physiotherapy treatment without active training (PT) for the treatment of adductor-related groin pain. The individuals in this study (n = 68) were male athletes with long-standing pain (median of 40 weeks). Treatment in the AT group was given three times a week while treatment in the PT group was given twice a week. No stretching of the adductor muscles was allowed in the AT group. The minimum treatment period was 8 weeks. Outcome measurements included return to sport at the same level without groin pain, pain during sports activity, active adduction against resistance, and at palpation of the adductor tendons and insertions at the pubic bone. Of the 68 initial male athletes, 59 completed the study with 29 athletes included in the AT group and 30 included in the PT group. In the AT group, 79% (n = 23) of the athletes returned to sports at their previous level without any symptoms of groin pain compared to 14% (n = 4) of the athletes in the PT group. The median time to recovery was 18.5 weeks (13 to 26 weeks). The authors reported that AT with a program aimed at improving the strength and coordination of the muscles acting on the pelvis, in particular the adductor muscles, is very effective in the treatment of athletes with long-standing adductor-related groin pain when compared to PT. They also noted that stretching exercises are commonly recommended in the treatment of long-standing adductor-related pain and that their results do not support these recommendations. The authors called for future randomized clinical trials, especially those with shorter AT programs.

In a literature review, Morales-Conde et al. (2010) reported that AP is a cause of chronic groin pain in athletes and presents a major diagnostic and therapeutic challenge; there is no evidence-based consensus available to guide decision-making and most studies are level IV. Only MRI has shown some evidence of being a potential tool to diagnose AP. However, abnormal MRI findings are common in asymptomatic athletes, which decreases the value of MRI in surgical decision-making. There is no consensus view supporting any particular surgical procedure for AP. There are various types of operations based on various theories including external oblique fascia repair, inguinal hernia repair with sutures or mesh (laparoscopic or open), and Bassini’s hernia repair. The authors concluded that there is no controlled comparative data on the results of the various surgical approaches, and there is no evidence that surgical treatment is more beneficial than conservative treatment.

In a literature review, Campanelli (2010) reported that AP is a controversial condition that presents itself as chronic groin pain and can have an incidence between 0.5 and 6.2%. The anatomy involved, diagnostic criteria, and treatment modalities are inconsistently described in the available published peer-reviewed medical, surgical, and orthopedic literature. The systematic review of AP is limited due to the paucity of quality studies. While the author mentioned there was one prospective controlled trial indicating that operative treatment was superior to non-operative management in athletes, upon review, the study was actually a case series (n = 64) indicating that surgical exploration and repair of the posterior wall of the inguinal canal in athletes achieved excellent or good pain relief. In the study referenced, there was no evidence suggesting that surgical treatment was more beneficial than conservative treatment.

SURGICAL TREATMENTS

When CT fails to relieve pain, a variety of surgical techniques have been performed to treat AP. Surgical techniques include both laparoscopic and open approaches.

Laparoscopic approaches can include:
  • Transabdominal pre-peritoneal (TAPP) repair
  • Totally extraperitoneal (TEP) repair
Open approaches can include:
  • Mesh Repair
    • Lichtenstein hernia repair
    • Mesh-plug hernia repair
  • Sutured
    • Pelvic floor repairs
    • “Minimal repair”
    • Bassini hernia repair
    • Shouldice hernia repair
    • McVay hernia repair
    • Maloney hernia repair
As with the actual diagnosis of AP, there is a lack of consensus supporting any one particular procedure. Surgical treatment modalities can encompass as many as 26 different procedures and 121 different combinations of procedures. There is a paucity of studies that compare the effectiveness of the various surgical procedures with CT. Surgical interventions have varied from 63% to 90% success in resolving AP symptoms. While some surgeons maintain that an open approach offers a superior outcome, studies have shown that the laparoscopic approach may be able to resolve AP symptoms. However, there are surgeons that attribute this resolution to general fibrosis that occurs after any surgery, which acts to stabilize the anterior pelvis. Currently, there is a lack of guidelines from relevant medical societies and professional organizations as to the safety and effectiveness of the surgical treatments of AP.

PEER-REVIEWED LITERATURE
In a systematic review, Fon et al. (2000) reported that the major causes of groin pain are muscle/tendon injury, osteitis pubis (noninfectious inflammation of the pubic symphysis), nerve entrapment, and bone/joint diseases. The role of laparoscopy is still being evaluated for AP since it does not permit the assessment of the anterior wall of the inguinal canal, restricting access to the conjoint tendon. Many symptoms will resolve with conservative treatment or non-operative measures. Surgical intervention should be contemplated when conservative treatment has failed, yet there is no consensus to support any specific surgical procedure. Moreover, surgical interventions have varied in success, ranging from 63% to 90%.

In a retrospective study of 256 male and 20 female athletes with severe lower abdominal or inguinal pain, Meyers et al. (2000) examined the diagnostic criteria for high-performance athletes. Of the 157 athletes who had not previously undergone surgery, 79% (n=124) participated at a professional or highly competitive level, and 88% (n=138) had adductor pain that accompanied the lower abdominal or inguinal pain. 97% (n=152) were able to return to previous levels of performance. Of the 276 individuals evaluated, 175 underwent pelvic floor repairs to address their lower abdominal or inguinal pain. Eighty-two male individuals were evaluated and did not undergo pelvic floor repair; 3 of the 20 female individuals did not undergo pelvic floor repair. The authors noted that AP is uncommon in women, due to the relatively low participation (until recently) and due to differences in pelvic anatomy. Moreover, the diagnosis of AP and subsequent surgery should be limited to a select group of high-performance athletes. Specifically, the authors state that AP’s features include disabling lower-abdominal/inguinal pain at extremes of exertion; progression of pain over months or years to involve the adductor longus tendons as well as contralateral inguinal and adductor regions; pain with resisted hip adduction or with resisted sit-ups; a relative lack of affliction in women; and unpredictable surgical results in non-athletes. The consideration of other causes of groin pain in individuals is critical because evaluation revealed 38 other abnormalities, including severe hip problems and malignancies. The authors admit that this is a potential pitfall in the evaluation of athletes. Limitations of this study include its subjective outcome measurements and a lack of a control group, which is particularly important because many athletes with groin injuries improve with conservative treatment. Therefore, this study does not establish the effectiveness of the surgical treatment of AP.

In a retrospective study, Kumar et al. (2002) evaluated the role of two open approaches in the treatment of suspected AP: Lichtenstein mesh repair and external oblique tear repair. Study participants were followed for 6 months and evaluated by a self-administered questionnaire (SAQ). Ninety-three percent of individuals (n = 25) returned to sports at a pre-injury level, 41% (n = 11) rated the operative results as excellent, and 41% (n =11) rated the operative results as good. Return to full sports activity took an average of 14 weeks [6 to 24 weeks]. Three individuals complained of recurrence after 4 to 5 months of strenuous exercise, which indicates recurrence of AP despite surgical treatment. Of the 35 individuals, only 78% (n = 27) of the study participants responded to the questionnaire. The authors concluded that AP presents with a spectrum of surgical findings and athletes with AP should be considered for routine hernia repair. They also indicated that the debate still persists over the specific pathophysiology and operative repair in athletes with AP. Limitations of this study include its retrospective study design and small sample size. This study was subject to nonresponse bias as well, which limits the internal validity of the results.

In a retrospective study, Ahumada et al. (2005) evaluated 1 female and 11 male athletes who were treated for AP by open mesh repair. The duration of symptoms was a median of 9 months to time of presentation for operative repair. Conservative treatment was not indicated to have been a preoperative regimen in this study. Study participants were followed for a median of 4 months. The authors reported that of the 12 individuals, 83.3% (n = 10) had excellent results, and 16.7% (n = 2) had satisfactory results. One patient required reoperation for persistent pain created by the mesh repair and another patient developed postoperative epididymitis. The authors did not elaborate on what constituted excellent or satisfactory results and did not define outcome measurements. They concluded that an open approach using mesh relieves AP pain and restores activity. Limitations of this study include its retrospective study design, small sample size, lack of definitive outcome measurements, and lack of long-term follow-up.

In a literature review, Harmon (2007) reported that operative findings are dependent on whether an open or laparoscopic approach is taken. Laparoscopic approaches assume that the cause of pain is from subtle wall deficiencies; inserting a mesh can reinforce the area and should resolve the underlying pain. Harmon reports that “Meyers claims that he has performed successful open procedures on 200 athletes who had previous laparoscopic or ‘incorrect’ open procedures.” This is attributed to the fact that if the defect occurs in the external oblique aponeurosis, the conjoint tendon, or the insertion of the rectus, the laparoscopic repair cannot address these causative pathologies. However, Harmon notes that the results reported in the available published peer-reviewed literature suggest that laparoscopic repair can indicate uniformly good results. However, there are others that believe that successful outcomes from laparoscopic procedures may be due to general fibrosis occurring after any surgery, which may act to stabilize the anterior pelvis.

In a systematic review, Caudill et al. (2008) reported that there is no consensus as to what constitutes an AP diagnosis. Because it is difficult to make a definitive diagnosis based on conventional physical examinations, other diagnostic modalities such as MRI or ultrasound are often employed to rule out other conditions. Conservative treatment entails 6 to 8 weeks of rest, following physiotherapy. Return to sports should commence at 10 to 12 weeks. While surgery appears to be more effective than conservative treatment, there is difficulty in assessing the superiority of surgical approaches due to the heterogeneity of the different patient populations. Laparoscopic procedures allow for a quicker recovery time, but may not address causative pathology and are less likely to have a successful outcome. However, studies have suggested that a laparoscopic approach can be effective in addressing AP. The authors admit that well-designed prospective, randomized controlled studies are greatly needed to establish the true effectiveness of these different surgical approaches. More detailed and standardized patient outcome measurements are needed because current success is attributed to return to sports time, which can have limited validity in that professional athletes may return to sports despite incomplete treatment and persistent pain.

In a retrospective study of the senior author’s experience with 8,490 individuals and 5,460 operations, Meyers et al. (2008) examined the changes in patient characteristics for AP over the past two decades. This case series involved directly examined individuals seen at 3 different academic institutions and in locker rooms and training facilities from 1986 through 2008. Follow-up occurred at 7 days and at 7 weeks post-operation. Postoperative sequelae (patient complaints within 6 weeks post-operation) included reports of minor bruising, abdominal edema, hematomas, and superficial wound infections. The most common reason for reoperation was the development of AP on the contralateral side after unilateral surgery (n = 182). The second most common reason for reoperation was adductor release for new or persistent adductor problems post-operation (n = 28). The authors found that surgery for AP can entail 26 different procedures and 121 different combinations of procedures. There are various syndromes that can afflict these individuals with AP symptoms and there are at least 17 distinct musculoskeletal structures that can be involved. Moreover, the authors assert they average over 3 “redo” operations per week on individuals who have failed previous AP surgery. The authors concluded that the proportion of female athletes, age, number of different sports, soft tissue structures, number of syndromes, and different types of operations associated with AP have increased. Limitations of this study include its retrospective study design, lack of long-term follow-up, and its inability to present data on a sub-cohort of MRI-diagnosed findings and subsequent AP surgery.

In a literature review, Minnich et al. (2011) reported that the initial treatment for AP should be conservative treatment. If non-operative treatment fails, surgical exploration may be warranted. This can be classified into 3 general categories: primary pelvic floor repair without mesh, open anterior mesh repair, and laparoscopic mesh repair. The primary pelvic floor repair can be divided into a modified Bassini-type repair and a “minimal repair.” The role of laparoscopic repair continues to be debated. The authors assert that only a small subset of athletes with AP will respond to non-operative treatment and most will require surgical repair for satisfactory return to activity. However, due to a lack of high-quality evidence, the effectiveness of surgical repair cannot be established when compared to CT.

In 2013, Schilders et al published an uncontrolled, case series on the presence of a selective partial adductor release for groin pain in professional athletes. The primary outcome was VAS pain score reported at two years. The study documented VAS score improvements compared to pre-operative mean of 5.76 to 0.23 postoperatively (p<0.001). Schilders et al reported on 01 surgical intervention for the treatment of chronic groin pain, atypical for standard medical treatment in this population. The study was limited since there was not a comparison group, and the overall homogeneity of participants and small sample size.

In 2017, Zoland et al performed a retrospective analysis comparing individuals treated either surgically or conservatively at a single clinic. The article described the process by which the researchers evaluate to recommend treatment course based on individual injury progression at their clinic. MRI was performed on 117 participants, of which 79 were considered to present with athletic pubalgia, and 39 individuals underwent surgical intervention. The authors report on telephonic follow-up questionnaire results for 31 persons. 28 participants report satisfactory results, and 23/31, or 74%, were able to return to previous activity levels. Comparatively, 40 participants were treated nonoperatively. Of these, 28 were available for follow up, and 19, or 68 % returned to previous activity levels. The results were not significantly different between the two treatment groups. This article was limited by retrospective design, single center experience, and small sample size, which was not powered to draw firm conclusions on overall net health outcomes.

Zoland et al (2018) assessed sports hernia/athletic pubalgia in women. This article is an uncontrolled, case series evaluating 18 women. Of these, 9 had an injury in combination with one or more inguinal, obturator, or femoral hernias present on imaging. The article suggests treatment success based on responses to self-questionnaires at 1 year of follow-up post-surgery. 15/17 women available for follow-up report successful surgery. Results demonstrated a mean reduction of pain from 7.82 to 1.76 on VAS score for the total study participants. The study presented with limitations, such as no control group, single center experience and a small sample size. A larger, prospective study examining surgical outcomes is needed to validate these findings.

A 2017 ERCI response for treating AP reported that the available studies (n=28 publications) provide evidence suggestive of support for the safety and effectiveness of surgery after conservative treatment failure. However, the report states the overall quality of the evidence assessing surgical treatments was low because no studies compared surgical and conservative treatment in independent groups and the studies comparing surgical procedures were not randomized. Additional larger, prospective studies with direct comparators are warranted.

"Minimal Repair"

In a prospective cohort study, Muschaweck and Berger (2010) examined the safety and effectiveness of the “minimal repair” technique to treat AP in both athletes and non-athletes. The authors developed this new surgical technique, which is an open-suture method to stabilize the posterior wall. The authors assert that this new “minimal repair” technique offers the following advantages: (1) no insertion of prosthetic mesh, (2) no general anesthesia, (3) less trauma, and (4) lower risk of severe complications when compared to laparoscopic methods such as TAPP and TEP. The individuals in this study (n = 128 males, 1 female) were followed for 4 weeks at the time of publication (though the study was designed for 6-month, 1-year, and 5-year follow-up). Primary outcomes were time to resuming low-level training, full training/competing, and complete relief of pain. Secondary outcomes were postoperative complications and level of post-operative pain. Of all individuals, 78.9% reported that they were completely free of pain (median of 14 days). At 4-week follow-up, there was a statistically significant difference in time to resume low-level training and full return to sport within 28 days when comparing athletes and non-athletes. However, there was no statistically significant difference in time to full return to sport (regardless of time period) and complete relief of pain when comparing athletes and non-athletes. The authors reported no post-operative complications at 30-day follow-up. There was no statistically significant difference in post-operative pain when comparing athletes and non-athletes. The authors admit that they were unable to randomize study participants into two different interventional treatment groups for ethical reasons. The study is limited by its small sample size and short follow-up period, post-hoc analyses, and lack of randomization into two intervention groups. Despite these limitations, the authors conclude that the “minimal repair” technique is “probably superior to other currently used techniques.”

Transabdominal Pre-Peritoneal (TAPP)

In a retrospective study, Ziprin et al. (2008) evaluated 17 male athletes who were treated for suspected AP by diagnostic laparoscopy followed by TAPP mesh repair. Study participants were followed for a median of 23 weeks with pain defined as the primary outcome measurement. Sixteen of the 17 individuals returned to sports at pre-injury levels within a median of 42 days. Five individuals had mild pain 3 weeks after surgery. This pain was resolved at 24 weeks of follow-up for all but 1 patient. The authors admitted that there was insufficient evidence to suggest that either TAPP or TEP was more effective and safe for the repair of groin hernias. The authors concluded that TAPP is safe and effective in the diagnosis and treatment of AP. Limitations of this study include its retrospective study design, small sample size, and lack of long-term follow-up.

In a retrospective study, Santilli et al. (2015) evaluated laparoscopic TAPP in 590 athletes with diagnosed AP, including 414 amateurs and 176 professionals. Thirty days post-procedure, the athletes were evaluated to assess pain and the degree of physical activity as a sign of functional outcome. In 573 of the athletes, ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, of which 498 coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. Ultrasound had a sensitivity of 95.42% and a specificity of 100%, with positive and negative predictive values at 100% and 99.4%, respectively. No postoperative complications were reported and seven athletes suffered recurrence of pain at 30 days post-procedure. The authors concluded that AP was often associated with adductor muscle strains and other injuries of the groin. The study is limited in its retrospective study design, lack of long-term follow-up, and lack of comparison to CT.

Totally Extraperitoneal (TEP)

In a retrospective study, Srinivasan and Shuricht (2002) evaluated 15 male professional athletes who were treated for AP by laparoscopic TEP. Study participants were followed for a mean of 12.1 months by telephone survey; 3 individuals were lost to follow-up. There was no indication as to whether a pre-treatment survey was conducted. 87% of individuals (n = 13) could fully return to sports activity within 4 weeks of treatment. One study participant reported soreness 4 years after surgery; the authors claimed that they felt it was unrelated to surgery. No other adverse sequelae or recurrence of symptoms was reported. The authors admitted that there was no control group in the study. They reasoned that the study participants could not be randomized due to their need and desire to return to competitive competition quickly. The authors concluded that laparoscopic TEP should be considered as a treatment modality in athletes presenting with chronic groin pain. The study was limited as there was no comparative analysis with other surgical approaches or CT. The lack of control, small sample size, and retrospective study design were limitations as well.

In a prospective randomized controlled trial, Paajanen et al. (2011) examined the safety and effectiveness of TEP when compared to CT for the treatment of AP. The individuals in this study (n = 60) were mostly athletes at an elite level (9 were non-elite athletes) and were randomized 1:1 to TEP or CT. Primary outcome measurements were pre- and post-operative pain using a visual analog scale (VAS) and partial or full recovery to sports activity. Individuals had persistent groin pain for 3 to 6 months and prior to treatment randomization, had pelvic x-rays and MRIs to rule out avulsion fractures, and other musculoskeletal abnormalities except AP. TEP involved mesh placement behind the pubic symphysis. CT involved at least 2 months of active physiotherapy, including corticosteroid injections and oral anti-inflammatory analgesics. Of the 60 individuals in the study, 6 had simultaneous insertion tendonitis of the adductor magnus or longus. Open tenotomy was performed concurrent to the TEP surgery. Study participants were followed after 1, 3, 6, and 12 months; none were lost to follow-up. Patients in both treatment groups had similar characteristics and VAS pain scores. Mean pain scores during exercise decreased more rapidly in the TEP group. Full return to sports activity was achieved in 67% and 90% of athletes after 1 and 3 month follow-up respectively in the TEP group, compared to 20% and 27% in the CT group (p < 0.0001). After 6 months of follow-up, 7 of the 30 athletes in the CT group crossed-over to the TEP group due to persistent pain. After 12 months of follow-up, the authors reported that individuals in the TEP group were more satisfied with the treatment than the individuals in the CT group. The authors concluded that TEP was more effective than CT for the treatment of AP and suggested that professional athletes should receive at least 2 months of CT prior to surgery; nonprofessionals should wait 4-6 months prior to surgery. Limitations of this study include its small sample size and patient cross-over into the TEP arm of the study. Statistical analyses do not appear to take this cross-over into account, which potentially confound the statistically significant difference in patient satisfaction reported by the authors.

Athletic Pubalgia and Femoroacetabular Impingement

In a retrospective study, Larson et al. (2011) evaluated 9 female and 21 male athletes who were treated for associated FAI pathology and AP by hip arthroscopy and/or AP surgery, respectively. AP surgical procedures included laparoscopic repair, open pelvic floor repair, and mesh reinforcement repair; 13 adductor tenotomies were additionally performed. Patients were followed for a mean of 29 months. Of the 16 individuals who had AP surgery as the index procedure, 25% (n = 4) of the individuals returned to sports without limitations and 69% (n = 11) of the individuals had subsequent hip arthroscopy at a mean of 20 months after AP surgery. Of the 8 individuals who had hip arthroscopy as the index procedure, 50% (n = 4) of the individuals returned to sports without limitations, and 43% (n = 3) of the individuals had subsequent AP surgery at a mean of 6 months after hip arthroscopy. Thirteen individuals had concurrent hip arthroscopy and AP surgery. Concurrent and eventual surgical treatment of FAI and AP led to improved postoperative outcome scores (p < 0.05) and an unrestricted return to sporting activity in 89% of study participants. The authors concluded that when surgery only addresses FAI or AP individually, outcomes are suboptimal.

In a retrospective study, Hammoud et al. (2012) evaluated 38 male professional athletes who were surgically treated for AP and required subsequent surgical treatment for FAI. Specific AP surgical procedures were not clarified. Moreover, no standardized follow-up regimen was designated. Twelve individuals (32%) were unable to return to sports after isolated AP surgery, but were able to return after subsequent hip arthroscopy to treat FAI. The remaining individuals were able to return to sports with hip arthroscopy alone, though were not necessarily pain free. The mean time between hip arthroscopy and return to sports was 5.9 months. Thirty-nine percent (n = 15) of the athletes with concomitant AP and FAI had complete resolution of pain and dysfunction with hip arthroscopy alone. The authors concluded that there was a high incidence of AP symptoms in professional athletes with FAI and that athletes may manifest AP symptoms due to stresses from FAI.

Summary

The evidence supporting the surgical treatments of AP is limited for a number of reasons. There is a lack of consensus regarding the diagnostic criteria. Due to this uncertainty, studies have suggested that surgical treatment be limited to a select group of high-performance athletes. Additionally, based on an established consensus meeting of the British Hernia Society, Sheen et al. (2014) recommended that initial treatment should consist of a multidisciplinary approach with tailored physiotherapy. Among those that advocate surgical treatment, some believe that laparoscopic TEP or TAPP may be superior in terms of post-operative pain, rehabilitation, and time to return to sports. However, others suggest that laparoscopic surgery is often inconsistent and requires a steep learning curve. In fact, Meyers et al. (2002) maintain that they have performed open procedures on many athletes who had previous laparoscopic or ‘incorrect’ open procedures. They believe that a laparoscopic approach cannot address causative pathology and though available published peer-reviewed literature suggests successful results, this may be attributed to general fibrosis that may act to stabilize the anterior pelvis. Among those that advocate an open approach, there is no general consensus as to the best surgical procedure. Muschaweck et al. (2010) assert that an open-suture “minimal repair” technique without prosthetic mesh placement offers successful outcomes. Meyers et al. (2008) primarily advocate an open pelvic floor repair, though admit that there are up to 26 different procedures and 121 different combinations of procedures to treat AP.

There are limited studies that are appropriately designed to compare the effectiveness of any particular surgical approach to conservative treatment. Bringman et al. (2003) describe a randomized controlled trial that compares the effectiveness of laparoscopic TEP to open mesh-plug and to Lichtenstein hernia repair. They reported that a laparoscopic approach offered shorter recovery times and that there were no statistically significant differences in recurrence or post-operative complications between the three treatment groups. However, these results cannot necessarily be generalizable to individuals with AP because the patient population was diagnosed with unilateral inguinal hernias. Furthermore, the patient population was not athlete-dense, and there was no comparison to CT.

Additionally, there is one prospective cohort study evaluating “minimal repair” surgery to treat AP. However, the comparison groups are not appropriate to examine the safety and/or effectiveness of “minimal repair” surgery to other surgical approaches or CT. Muschaweck et al. (2010) compared the outcomes between athletes and non-athletes and did not assess the “minimal repair” technique vs. CT. The study was also limited in its small sample size (n = 87). To date, there is one randomized controlled trial that compares the effectiveness of laparoscopic TEP to CT. However, this study is limited in its small sample size (n = 60) and there are issues with patient cross-over, which were not fully detailed in the statistical analysis comparing the two treatment methods. Once the cross-over is taken into account, the statistically significant difference between the two treatment groups reported by the authors may be called into question. Moreover, as with many of the studies that evaluate AP surgery, there are issues with outcome measurements.

Most studies attribute AP surgical success to time to return to sports activity. This outcome is subjective and has potentially limited validity. Particularly in a patient population of professional athletes, where time to return to sports activity is of pressing concern, this outcome measurement may not necessarily indicate the complete resolution of symptoms. Athletes may feel the need to return to sports activity despite persistent pain. Furthermore, studies that utilize pain scores as an outcome measurement have presented with inconsistent survey techniques. To measure these outcomes, Bringman et al. (2003) utilized a self-administered questionnaire (SAQ), which is subject to reporting and recall bias when compared to questionnaires administered by trained clinicians. Moreover, there is a lack of consistency because these measurements were not collected at regular intervals; lack of participation is also a concern. Objective and effective outcome measurements should include standardized diagnostic inclusion criteria, recurrence of AP symptoms, and VAS pain scores prior to surgery and at standardized follow-up intervals with appropriate length. In addition, the literature and clinical guidance suggests that potential surgical treatment of AP be limited to elite athletes. The aforementioned outcome measurements should be conducted when these individuals have returned to sports. Oftentimes, individuals with suspected AP symptoms have pain during sports activity, but may otherwise be fine during non-sports activity.

Studies have suggested a possible association between FAI and AP. Hammoud et al. (2012) were able to conclude that athletes may manifest AP symptoms due to stresses from FAI. The authors found that 32% of the treated individuals were unable to return to sports after isolated AP surgery, but were able to return after subsequent hip arthroscopy to treat FAI. The remaining study participants were able to return to sports activity with hip arthroscopy alone. Studies have also suggested that FAI is a possible precursor to AP. This may indicate the need to consider FAI before AP, especially when there is no general consensus concerning the actual existence of AP and its etiology is debatable.

In summary, although there have been studies that suggest that either an open or laparoscopic surgical approach to treat AP may provide successful outcomes, these studies are of low quality. There exist very few randomized controlled trials that appropriately compare the effectiveness of AP surgery to CT. Moreover, heterogeneity of patient populations and study designs indicate a need for further longer-term, randomized prospective controlled trials comparing the effectiveness of the various surgical approaches with CT. Issues with subjective outcome measurements and a lack of consensus regarding the etiology, diagnosis, and treatment of AP warrant the need for further research.

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Coding

CPT Procedure Code Number(s)
THE FOLLOWING CODE IS USED TO REPRESENT THE SURGICAL TREATMENTS OF ATHLETIC PUBALGIA: 

49999
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
There is no specific code for Athletic Pubalgia.
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 11.14.26a:​​
​05/31/2023
​This policy has been reissued in accordance with the Company's annual review process.​
​05/18/2022

​The policy has been reviewed and reissued to communicate the Company’s continuing position on Surgical Treatments of Athletic Pubalgia.
06/16/2021The policy has been reviewed and reissued to communicate the Company’s continuing position on Surgical Treatments of Athletic Pubalgia.​
​06/03/2020

The policy has been reviewed and reissued to communicate the Company’s continuing position on Surgical Treatments of Athletic Pubalgia.
​12/04/2019

​The policy has been reviewed and reissued to communicate the Company’s continuing position on Surgical Treatments of Athletic Pubalgia.
​04/25/2018
​This policy has undergone a routine review, and no revisions have been​ made.

Effective 10/05/2017 this policy has been updated to the new policy template format.
6/3/2015
6/3/2015
5/31/2023
11.14.26
Medical Policy Bulletin
Commercial
No
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