Coverage Policy Manual
Policy #: 2020019
Category: Surgery
Initiated: July 2020
Last Review: March 2024
  Surgery for Groin Pain in Athletes (Athletic Pubalgia; Sports Hernia)

Description:
Sports-related groin pain, commonly known as athletic pubalgia or sports hernia, is characterized by disabling activity dependent lower abdominal and groin pain not attributable to any other cause. Athletic pubalgiais most frequently diagnosed in high-performance male athletes, particularly those who participate in sports that involve rapid twisting and turning such as soccer, hockey, and football. For patients who fail conservative therapy, surgical repair of any defects identified in the muscles, tendons, or nerves has been proposed.
 
Diagnosis
A diagnosis of groin pain in athletes is based primarily on history, physical exam, and imaging. The clinical presentation will generally be a gradual onset of progressive groin pain associated with the activity. A physical exam will not reveal any evidence for a standard inguinal hernia or groin muscle strain. Imaging with magnetic resonance imaging (MRI) or ultrasound is generally done as part of the workup. In addition to the exclusion of other sources of lower abdominal and groin pain (eg, stress fractures, femoroacetabular impingement, labral tears), imaging may identify injury to the soft tissues of the groin and abdominal wall (Khan et al, 2013).
 
Treatment
Conservative
Many injuries will heal with conservative treatment, which includes rest, icing, nonsteroidal anti-inflammatory drugs, and rehabilitation exercises. A physical therapy (PT) program that focuses on strength and coordination of core muscles acting on the pelvis may improve recovery. In a 1999 study, 68 athletes with chronic adductor-related groin pain were randomized to 8 to 12 weeks of an active training PT program that focused on strength and coordination of core muscles, particularly adductors, or to standard PT without active training (Holmich et al, 1999). At 4 months post-treatment, 68% of patients in the active training group had returned to sports without groin pain compared with 12% in the standard PT group. At 8- to 12-year follow-up, 50% of athletes in the active training group rated their outcomes as excellent compared with 22% in the standard PT group (Holmich et all, 2011). For in-season professional athletes, injections of corticosteroid or platelet-rich plasma, or a short corticosteroid burst with taper have also been used.
 
Surgical
Surgical treatment is typically reserved for patients who have failed at least 3 months of conservative treatment. One approach consists of open or laparoscopic sutured hernia repair with mesh reinforcement of the posterior wall of the inguinal canal. Laparoscopic procedures may use either a transabdominal preperitoneal or an extraperitoneal approach. A variety of musculotendinous defects, nerve entrapments, and inflammatory conditions have been observed with surgical exploration. Meyers et al. (2008) have proposed that any of the 17 soft tissues that attach or cross the pubic symphysis can be involved, leading to as many as 26 surgical procedures and 121 different combinations of procedures that address the various core muscle injuries. The objective is to stabilize the pubic joint by tightening or broadening the attachments of various structures to the pubic symphysis and/or by loosening the attachments or other supporting structures via epimysiotomy or detachment. Because various surgical procedures used to treat sports-related groin pain have reported success, it has been proposed that general fibrosis from any surgery may act to stabilize the anterior pelvis and thus play a role in improved surgical outcomes.
 
Regulatory Status
Treatment of sports-related groin pain is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
 
Coding
There are not specific CPT codes for these types of surgery for groin pain in athletes.  The following codes might be used for reporting.
 
49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999 Unlisted procedure, abdomen, peritoneum and omentum

Policy/
Coverage:
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Surgical treatment of groin pain in athletes (also known as athletic pubalgia, Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia, or core muscle injury) does not meet primary coverage criteria that there be scientific evidence of effectiveness.   
 
 For members with contracts without primary coverage criteria, surgical treatment of groin pain in athletes (also known as athletic pubalgia, Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia, or core muscle injury) is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.

Rationale:
This evidence review has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through December 9, 2019.
 
Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life, and ability to function--including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.
 
To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.
 
Groin Pain in Athletes
Groin pain in athletes is a poorly defined condition for which there is no consensus on cause and/or treatment (Litwin et al, 2011). Alternative names include Gilmore groin, osteitis pubis, pubic inguinal pain syndrome, inguinal disruption, slap shot gut, sportsmen groin, footballers groin injury complex, hockey groin syndrome, athletic hernia, sports hernia, and core muscle injury. Some believe the groin pain is an occult hernia process, a prehernia condition, or an incipient hernia, with the major abnormality being a defect in the transversalis fascia, which forms the posterior wall of the inguinal canal. Another theory is that injury to soft tissues that attach to or cross the pubic symphysis is the primary abnormality. The most common of these injuries are thought to be at the insertion of the rectus abdominis onto the pubis, with either primary or secondary pain arising from the adductor insertion sites onto the pubis. It has been proposed that muscle injury leads to failure of the transversalis fascia, with a resultant formation of a bulge in the posterior wall of the inguinal canal (Litwin et al, 2011). Osteitis pubis (inflammation of the pubic tubercle) and nerve irritation/entrapment of the ilioinguinal, iliohypogastric, and genitofemoral nerves are also believed to be sources of chronic groin pain. A 2015 consensus agreement has recommended the more general term groin pain in athletes, with specific diagnoses of adductor-related, iliopsoas-related, inguinal-related, and pubic-related groin pain (Weir et al, 2015). An association between femoroacetabular impingement (FAI) and groin pain in athletes has been proposed. It is believed that if FAI presents with limitations in hip range of motion, compensatory patterns during athletic activity may lead to increased stresses involving the abdominal obliques, distal rectus abdominis, pubic symphysis, and adductor musculature. A 2015 systematic review of 24 studies that examined the co-occurrence of FAI and groin pain in athletes found an overlap of the 2 conditions that ranged from 27% of hockey players to 90% of college football players who presented with hip and groin pain (Munegato et al, 2015). Surgery for sports-related groin pain has been performed concurrently with treatment of FAI or following FAI surgery if symptoms did not resolve. Sports-related groin pain has a variable natural history, with an uncertain time course of the disorder. Also, pain and functional ability are subjective outcomes and, thus, may be particularly susceptible to placebo effects. Because of these factors, controlled trials are essential to demonstrate the clinical effectiveness of surgical treatment of athletic pubalgia compared with alternatives such as continued medical management.
 
In 2015, a consensus report called the Doha agreement recommended the use of specific diagnoses of adductor-related, iliopsoas-related, inguinal-related, or pubic-related groin pain in place of athletic pubalgia or sportsman’s hernia. However, these terms have yet to be routinely used in the published literature. Because it is not possible to determine which patient subgroups were studied, the terminology from the published reports is used. The only validated patient reported outcome measure for pain and dysfunction in the groin area in young and middle-aged patients that were identified in the Doha report is the Copenhagen Hip and Groin Outcome Score (Thorborg et al, 2011).
 
Mesh Reinforcement
Randomized Controlled Trials
Paajanen et al. (2011) reported on a multicenter RCT comparing surgical treatment with conservative therapy in 60 athletes who had suspected sports hernia. Of the 60 (including 31 national-level soccer players), 36 (60%) were totally disabled from their sport and 24 (40%) had a marked limitation in training and competing. For inclusion in the trial, the location of pain had to be rostral to the inguinal ligament in the deep inguinal ring at palpation or the insertion point of the adductor tendons. Exclusion criteria were isolated tendonitis of the adductor muscles or tendons without groin pain rostral to the inguinal ligament, obvious inguinal hernias, or suspicion of inguinal nerve entrapment. Participants had to have the desire to continue sports at the same level as before the groin injury. Pubic bone marrow edema was identified by magnetic resonance imaging (MRI) in 58% of patients. For participants (38%) who had a normal MRI in the pubic area, the pain was attributed to the insufficiency of the posterior wall of the inguinal canal. After at least 3 months of groin symptoms, patients were randomized to surgical or conservative treatment groups. Conservative treatment included at least 2 months of active physical therapy that focused on improving coordination and strength of core muscles, along with corticosteroid injections and oral anti-inflammatory analgesics. Surgical treatment consisted of laparoscopic total extraperitoneal repair with mesh placed behind the pubic bone and/or posterior wall of the inguinal canal. Ten percent of the patients also underwent open tenotomy of the adductor magnus or longus. Of the 30 surgically treated athletes, 27 (90%) returned to sports activities by 3 months compared with 8 (27%) of the nonoperative group. At 1, 3, 6, and 12 months after treatment, visual analog scale (VAS) scores for pain were significantly lower in the surgically treated group (p<0.001). At 12 months, mean VAS scores for pain were less than 2 in both groups. However, among the 30 patients assigned to the conservative treatment group, 7 (23%) crossed over to surgery after 6 months with successful return to sport, 4 (13%) discontinued their sport of choice, and 16 (53%) were left with disabling symptoms after 12 months but chose not to undergo surgery.
 
An RCT by Ekstrand and Ringborg (2001) randomized 66 male soccer players to hernioplasty plus neurotomy (n=17), physical therapy (n=14), strength training of abdominal muscles (n=18), or a no-treatment control (n=17). All patients had an incipient hernia determined by herniography and/or positive nerve block test of the ilioinguinal or iliohypogastric nerves. VAS scores for pain were assessed at 3 and 6 months during coughing, sit-ups, jogging, kicking, and sprinting. VAS scores for pain in the control, physical therapy, and training groups were generally unchanged at 3 and 6 months, although results were analyzed using nonparametric tests instead of the more appropriate repeated-measures or mixed effects
analysis. VAS scores improved significantly more for the surgery group than for the 3 other groups (p<0.01). Strengths of this study included the active comparison groups and careful selection of patients. However, results are difficult to interpret due to the combined surgical procedure of hernioplasty plus neurotomy.
 
Observational Studies
Nonrandomized comparative and uncontrolled studies can sometimes provide useful information on health outcomes but are prone to biases such as noncomparability of treatment groups, the placebo effect, and variable natural history of the condition. A number of observational series have reported on surgical outcomes.4,11,12,13,14,15, However, these studies enrolled variable patient populations and used different surgical techniques. All studies reported that a high percentage of patients returned to full sports activities, but there were no control groups for comparison.
 
Kopelman et al. (2016) reported on a prospective series of 246 male patients with chronic groin pain. All patients underwent an ultrasound, and 98 also underwent an MRI. Of the 246 patients, 209 underwent conservative treatment with rest and nonsteroidal anti-inflammatory drugs, after which 51 (21%) of 246 underwent inguinal surgery. Another 37 (15%) patients were diagnosed by imaging with noninguinal pathologies such as inflammation of the pubic bone and symphysis pubis, rectus abdominis muscles, and hip joint pathologies. Of the 51 who underwent surgery (mesh repair, oblique aponeurosis release, neurolysis), a direct or an indirect hernia was observed in 18 (35%) patients. In the remainder (65%), no abnormalities were found. There were 2 surgical failures, and all other patients returned to full sports activity within 4.3 weeks. In this series, most patients did not require surgery, and the authors commented that pubic and suprapubic symptomatology should be differentiated from inguinal and adductor complaints.
 
Surgical Repair or Release of Soft Tissue
Observational Studies
There is more limited literature on the repair or release of soft tissue. An example of a large case series is a retrospective review by Meyers et al. (2008) that reported on the surgical treatment of 5218 patients diagnosed with athletic pubalgia over the prior 2 decades. Initially, diagnoses were made by history and physical examination, with MRI used in more recent years. Referrals increased from 3 per week in 1987 to 25 per week in 2008. Patients treated with surgery ranged from 11 to 71 years of age; women comprised about 8% of the group. The surgeries involved 26 different procedures of reattachments and/or releases of soft tissues that normally attach or cross the pubic symphysis. The authors reported that 95.3% of the patients returned to full play within 3 months of surgery. For a subgroup of athletes treated in-season, 90% were able to return to full play within 3 weeks. Adverse surgery-related events included dysesthesias (0.3%), significant hematomas (0.3%), and vein thrombosis (0.1%), all of which resolved within 1 year.
 
Summary of Evidence
For individuals who have sports-related groin pain who receive mesh reinforcement or who receive surgical repair and release of soft tissue, the evidence includes 2 randomized controlled trials (RCTs) and a number of case series. Relevant outcomes are symptoms, functional outcomes, and treatment-related morbidity. The evidence on mesh reinforcement for inguinal-related groin pain includes 2 RCTs and a large prospective series. Results of the RCTs have suggested that, in carefully selected patients, mesh reinforcement results in an earlier return to play. However, a large prospective series from 2016 indicated that only about 20% of patients with chronic groin pain benefit from inguinal surgery. Further study is needed to define the patient population that would benefit from this treatment approach. An alternative approach to the treatment of groin pain in athletes involves repair or release of soft tissue. This approach has been reported in a large series. It included a 2008 review of medical records spanning 2 decades and over 5000 cases. More recent reports on these procedures from other institutions are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
Practice Guidelines and Position Statements
Reviewed in 2017, the American Academy of Orthopaedic Surgeons (AAOS) has an online educational website on sports hernia (athletic pubalgia).  The Academy indicated that a sports hernia is a painful soft tissue injury that occurs in the groin area. The Academy advised that “In many cases, 4 to 6 weeks of physical therapy will resolve any pain and allow an athlete to return to sports. If, however, the pain comes back when you resume sports activities, you may need to consider surgery to repair the torn tissues.”
 
Ongoing and Unpublished Clinical Trials
NCT01876342 - Total ExtraPeritoneal (TEP) Versus Open Minimal Suture Repair for Treatment of Sportsman's Hernia/Athletic Pubalgia: A Randomized Multi-center Trial
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through June 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through June 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In a systematic review involving 1571 patients, Kraeutler et al found that the most common terminology used to describe the diagnosis was "athletic pubalgia" followed by "sports hernia" (Kraeutler, 2021).
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through June 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Reviewed in 2022, the American Academy of Orthopaedic Surgeons (AAOS) has an online educational website on sports hernia (athletic pubalgia) (AAOS, 2022). The Academy indicated that a sports hernia is a painful soft tissue injury that occurs in the groin area. The Academy advised patients that: “In many cases, 4 to 6 weeks of physical therapy will resolve any pain and allow an athlete to return to sports. If, however, the pain comes back when you resume sports activities, you may need to consider surgery to repair the torn tissues.”
 
The American College of Occupational and Environmental Medicine (ACOEM) released a guideline on hip and groin disorders in 2019 (AAOS, 2022). For the treatment of groin strains, sports hernias, or adductor-related groin pain, the ACOEM recommends work and activity modifications (strength of evidence [SOE]: recommended, insufficient evidence; level of confidence [LOC]: moderate), nonsteroidal anti-inflammatory drugs (SOE: recommended, insufficient evidence; LOC: moderate), and ice or heat or wraps (SOE: recommended, insufficient evidence; LOC: low).
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
49659Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999Unlisted procedure, abdomen, peritoneum and omentum

References: Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al(2005) Athletic pubalgia: definition and surgical treatment Ann Plast Surg Oct 2005;55(4):393-396 PMID 16186706

American Academy of Orthopaedic Surgeons (AAOS), Wilkerson R.(2022) OrthoInfo: Sports Hernia (Athletic Pubalgia). 2022; http://orthoinfo.aaos.org/topic.cfm?topic=A00573. Accessed January 2, 2023.

American Academy of Orthopaedic Surgeons, Wilkerson R(2017) OrthoInfo: Sports Hernia (Athletic Pubalgia) 2017; http://orthoinfo.aaos.org/topic.cfm?topic=A00573

Ekstrand J, Ringborg S(2001) Surgery versus conservative treatment in soccer players with chronic groin pain: A prospective randomised study in soccer players Eur J Sports Traumatol Rel Res 2001;23:141-145

Holmich P, Nyvold P, Larsen K(2011) Continued significant effect of physical training as treatment for overuse injury: 8-to-12-year outcome of a randomized clinical trial Am J Sports Med Nov 2011;39(11):2447-2451 PMID 21813441

Holmich P, Uhrskou P, Ulnits L, et al(1999) Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial Lancet Feb 6 1999;353(9151):439-443 PMID 9989713

Irshad K, Feldman LS, Lavoie C, et al(2001) Operative management of hockey groin syndrome: 12 years of experience in National Hockey League players Surgery Oct 2001;130(4):759-764; discussion 764-756 PMID 11602909

Khan W, Zoga AC, Meyers WC(2013) Magnetic resonance imaging of athletic pubalgia and the sports hernia: current understanding and practice Magn Reson Imaging Clin N Am Feb 2013;21(1):97-110 PMID 23168185

Kopelman D, Kaplan U, Hatoum OA, et al(2016) The management of sportsman's groin hernia in professional and amateur soccer players: a revised concept Hernia Feb 2016;20(1):69-75 PMID 25380561

Kraeutler MJ, Mei-Dan O, Belk JW, et al.(2021) A Systematic Review Shows High Variation in Terminology, Surgical Techniques, PreoperativeDiagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/InguinalDisruption. Arthroscopy. Jul 2021; 37(7): 2377-2390.e2. PMID 33845134

Kumar A, Doran J, Batt ME, et al(2002) Results of inguinal canal repair in athletes with sports hernia J R Coll Surg Edinb Jun 2002;47(3):561-565 PMID 12109611

Litwin DE, Sneider EB, McEnaney PM, et al(2011) Athletic pubalgia (sports hernia) Clin Sports Med Apr 2011;30(2):417-434 PMID 21419964

Meyers WC, McKechnie A, Philippon MJ, et al(2008) Experience with sports hernia spanning two decades Ann Surg Oct 2008;248(4):656-665 PMID 18936579

Munegato D, Bigoni M, Gridavilla G, et al(2015) Sports hernia and femoroacetabular impingement in athletes: A systematic review World J Clin Cases Sep 16 2015;3(9):823-830 PMID 26380829

Paajanen H, Brinck T, Hermunen H, et al(2011) Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman's hernia (athletic pubalgia) Surgery Jul 2011;150(1):99-107 PMID 21549403

Paajanen H, Syvahuoko I, Airo I(2004) Totally extraperitoneal endoscopic (TEP) treatment of sportsman's hernia Surg Laparosc Endosc Percutan Tech Aug 2004;14(4):215-218 PMID 15472551

Steele P, Annear P, Grove JR(2004) Surgery for posterior inguinal wall deficiency in athletes J Sci Med Sport Dec 2004;7(4):415-421; discussion 422-413 PMID 15712496

Thorborg K, Holmich P, Christensen R, et al(2011) The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist Br J Sports Med May 2011;45(6):478-491 PMID 21478502

Weir A, Brukner P, Delahunt E, et al(2015) Doha agreement meeting on terminology and definitions in groin pain in athletes Br J Sports Med Jun 2015;49(12):768-774 PMID 26031643


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2024 American Medical Association.