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When EB White, the author of Charlotte's web, said “there is nothing more likely to start disagreement among people or countries than an agreement” he may not have had medical consensus statements in mind, but his words hold true. Keep this in mind when you read the British Hernia Society's 2014 position statement based on the Manchester Consensus Conference: ‘Treatment of the Sportsman's groin’.1 While it is easy to be critical we should give credit where it is due.
Aali Sheen and his coauthors are to be congratulated for their achievement of reaching an agreement in the field of groin injuries. It is a tremendous advance to bring together a coauthor group of surgeons from different countries, who have published different opinions as to aetiology, use differing terminology and advocate different surgical techniques. Their statement does not however signify that the mission to solve the groin's mysteries has been accomplished. As the title of this editorial suggests, we should see this agreement as the first step on a long journey.
Inguinal disruption (ID) was agreed on as being the preferred term to use when describing athletes with ‘groin pain predominantly in the groin area near the pubic tubercle’. The term was chosen as it was felt to most accurately reflect the underlying pathology. While I follow the reasoning behind the choice, the effect of adding yet another term into the groin literature to accompany sportsman's hernia, sportsman's groin, Gilmore's groin, etc should be considered. Without placing the injury definition into a bigger picture or context that also considers injuries affecting other structures in the groin, it could well be that introducing yet another term further disrupts the field of groin taxonomy.
I.D.ing ID (making the diagnosis)
The statement provides a five-item list of symptoms and signs, of which three are needed to diagnose an athlete as having inguinal disruption. The fact that these are five clinical signs meaning that history and examination remain the cornerstone to making a diagnosis, a point also emphasised in the statement, is a strength of the paper. While we know that palpation of the adductors for the presence of pain is reliable2 some of the other techniques required to diagnose ID still need to examined. To reliably identify ID in athletes the examination techniques and five-item list suggested will have to be examined themselves.
The section on imaging concludes that MRI is the preferred method of imaging while at the same time stating that it is not usual to see oedema or structural disruption in the inguinal region. While I understand the statement made that MRI may be inevitable in elite athletes in this day and age, this should not be seen as an argument for recommending MRI. If there are no diagnostic changes that can be reliably found on MRI to confirm the presence of ID perhaps we should consider the true value? The statement correctly recommends that more research on the diagnostic accuracy of MRI is needed.
Rehabbing disrupted groins
The authors strongly recommend physiotherapy and rehabilitation for all athletes with ID. While it is hard to disagree with this fact, the dearth of evidence on the outcome of conservative treatment does not come to the forefront in the statement. Few studies have investigated the outcome of rehabilitation and physiotherapy for pain in the inguinal region in athletes. This means that the protocols suggested are not supported with any data on their efficacy. Interestingly there are two randomised controlled trials in the field where surgery has been compared to conservative treatment3 ,4 with only one of these being mentioned in the paper.3 While both these studies have methodological shortcomings, especially in their level of detail in reporting the conservative therapy used, they both showed surgery to be more effective. It would have been nice to have some guidance as to why the group felt that conservative treatment to be the primary choice. The statement concludes that more research on conservative treatment algorithms needs to be gathered. More information on prognostic factors would also add much needed guidance, and tools to predict who will not do well with rehabilitation are sorely needed.
All surgeries are equal
The clear consensus in the statement is that there is no clear favourite in terms of surgical technique. The choice of the surgeon is then the paramount factor when deciding what to do. This seems odd considering the vast array of techniques described and some fundamental differences in ideas behind them; mesh versus no mesh, open versus laparoscopic, dividing the inguinal ligament or leaving intact. There is no attempt at explaining how these differing techniques all appear to have equal outcomes.
There is little discussion as to the levels of evidence of most of the studies referenced in the statement. In addition many of the studies referenced in the statement are actually papers that assess the efficacy of conservative treatment of adductor-related groin pain5 ,6 or osteitis pubis7 once again adding confusion to the terminology discussion.
With the exception of the one RCT discussed in the statement, all other outcome studies on surgery are case series. One should be aware of the possibility of the ‘Coleman effect’, where the success rate found in the study is inversely related to the methodological quality used. This has been shown to be the case in both Achilles and patella tendinopathy surgical outcome studies.8 ,9 The field of groin injuries with treatments for adductor-related groin pain is no different; an initial case series10 being found to be less effective when studied in an RCT fashion5 in studies I was involved in myself.
As Thorborg et al 11 noted “nothing ruins good results like valid follow-up.” In the future, the use of simple return to sport, with results measured in weeks, should be used with caution as we now have valid and sensitive patient-related outcome (PRO) scores developed specially for groin pain in athletic individuals.12 As suggested in the statement, it would be nice to have trials where different surgeries are compared to one another to assist in clinical decision-making, we should endeavour to ensure these trials use appropriate PROs.
The thousand mile journey
As is to be expected from a consensus meeting on such a disparate topic the paper gives rise to as many questions as it does answers. The statement has achieved success in reaching agreement among surgeons that there is no clear favourite surgical method at the present time. The position statement also highlights that there are still some major limitations in the field. Time will tell whether the introduction of another new term in the field of groin taxonomy is a useful development. The inclusion of a number of studies in the statement, on the treatment of other entities adds to confusion in the field. A clear overview of the current evidence on the subject matter and to grade this in a structured and critical fashion is needed to allow a better weighting of the advice given. The topic of PROs and valid outcome measures is not discussed at all and needs to be included in the future.
In summary, I applaud the authors of the ‘British Hernia Society's 2014 position statement on Treatment of the Sportsman's groin’ for adopting a collaborative approach and for publishing a position statement in a field plagued by disruption. This is an important first step on a long journey towards consensus in the field of athletic groin injuries.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.