RECONSTRUCTIVE Denervation of the Periosteal Origin of the Adductor Muscles in Conjunction with Adductor Fasciotomy in the Surgical Treatment of Refractory Groin Pull A. Lee Dellon, M.D., Ph.D. Eric H. Williams, M.D. Gedge D. Rosson, M.D. Shahreyar S. Hashemi, M.D. Timothy Tollestrup, M.D. Robert R. Hagen, M.D. Ziv Peled, M.D. Georg Furtmueller, M.D. Johannes Ebmer, M.D. Baltimore, Md.; Henderson, Nev.; St. Louis, Mo.; San Francisco, Calif.; and Vienna and Salzburg, Austria
Background: The purpose of this study was to determine whether resection of the nerve that innervates the origin of the adductor muscle group in addition to an adductor fasciotomy will decrease pain and improve function in patients with a chronic “groin pull.” Methods: The authors conducted a retrospective multicenter chart review of 12 patients presenting with refractory groin pull. In two patients, the problem was bilateral. There were eight female and four male patients. Injuries were related to sports (n ⫽ 6), gynecologic procedures (n ⫽ 3), and other injuries (n ⫽ 3). Surgery included adductor fasciotomy plus resection of a nerve to the periosteal origin of the adductor muscles. Cadaver dissections were performed to identify the nerve’s origin. Results: In 13 of the 14 patient specimens, nerves were identified histologically: each of the five cadaver dissections demonstrated the anterior branch of the obturator nerve to be this nerve’s origin. At a mean of 16.7 months after surgery, 11 of the 12 patients (92 percent) and 13 of the 14 limbs (93 percent) responded with relief of pain and improved activities of daily living. Of the 14 patients, eight had an excellent result (67 percent), three had a good result (25 percent), and one experienced a failure (7 percent). Conclusions: Chronic impairment related to a groin pull injury may be considered caused by a contracture of the adductor muscle group, which can be treated with fasciotomy. A branch of the obturator nerve is shown to innervate the origin of these muscles, and denervation can be performed simultaneously with fasciotomy, improving pain and function. (Plast. Reconstr. Surg. 128: 926, 2011.)
T
he term “groin pull” is commonly used in our society to describe athletic injuries to the lay public. Groin pull has a wide variety of connotations in the medical literature and lacks a specific definition. For the patient with chronic groin pain, making a diagnosis and prescribing a nonoperative or an operative treatment requires From the Department of Plastic Surgery, The Johns Hopkins University; the Dellon Institute for Peripheral Nerve Surgery; Hand and Peripheral Nerve Surgery, Henderson; Hand and Peripheral Nerve Surgery, St. Louis; Plastic Surgery and Peripheral Nerve Surgery; Plastic Surgery, University of Vienna; and Internal Medicine, Paracelsus Medical University and Department of Anatomy and Neurobiology, University of Maryland. Received for publication January 29, 2011; accepted April 11, 2011. Copyright ©2011 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182268cbf
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precision which, by definition, currently is difficult to achieve. For example, following a hernia repair, groin pain of neural origin has now been well described and analyzed, and surgical procedures have been used with predictable outcomes for the iliohypogastric,1–5 ilioignuinal,2–5 lateral femoral cutaneous,2– 6 and genitofemoral nerves.2–5,7 Groin pain related to the origin of the adductor muscles, however, remains an enigma variously referred to
Disclosure: Dr. Dellon has a proprietary interest in the Pressure-Specified Sensory Device, which he invented and which is marketed by Sensory Management Services, LLD; this conflict of interest is managed by The Johns Hopkins University. None of the other authors has a financial interest in any of the products or devices mentioned in this article.
www.PRSJournal.com
Volume 128, Number 4 • Treatment of Refractory Groin Pull as athletic pubalgia,8 “sports hernia,”9 –12 true injury to the adductor muscles themselves,13,14 pelvic floor dysfunction,15 and osteitis pubis (gracilis syndrome).16 Although increasing attention has been paid to the adductor origin from a musculoskeletal injury approach in recent years, especially in hockey and soccer players,17–22 surgical intervention for refractory groin pain has focused on adductor tenotomy. Recent success rates for adductor tenotomy approach 80 percent for relief of pain21,22; however, in one of these studies, only 54 percent of patients returned their to preinjury level of activity at a mean of 18.5 weeks.21 In contrast, another review concluded that “adductor release and tenotomy was reported to have limited success in athletes.”14 In the present report, we apply the principle that the pain perceived in patients with a groin pull is transmitted through a nerve that innervates the periosteum from which the adductor muscles arise. This is similar to the concepts applied with lateral23 and medial24 humeral epicondylitis, where a release of the damaged tendon is not performed, but rather a selective denervation is performed.24 –26 For the adductor muscle group, an approach to the obturator nerve (neurectomy) has been included traditionally in the pediatric population with adductor spasm.27 More recently, neurolysis of the obturator motor branch has been included with adductor tenotomy.12 We report a cohort of patients with chronic groin pain in whom we tested the hypothesis that their disability was related to the adductor muscles and in whom neurectomy of the obturator branch to the pubic origin of the muscles combined with adductor fasciotomy (instead of tenotomy) would improve their pain and level of function. This is the first documentation of this nerve.
PATIENTS AND METHODS Over a period of 6 years, 12 patients with refractory groin pain not related to the ilioinguinal, iliohypogastric, lateral femoral cutaneous, or genitofemoral nerve were evaluated in a retrospective level IV study Additional inclusion criteria included absence of an inguinal or abdominal wall hernia. Each patient had a history of trauma. Each had in common that, with the knee and hip flexed, external rotation of the hip was limited by pain referred to the adductor muscle origin from the pubis, this site of origin was painful to touch, and there was a lack of complete external rotation because of a palpable thickening in the adductor muscle group (Fig. 1). No patients with these symptoms were excluded from this study.
Fig. 1. Groin pull related to stretch/traction or tear of the adductor muscle group is demonstrated by tightness in this muscle group manifested by loss of external rotation at the hip with the knee flexed and pain referred to the pubic bone origin of these muscles. The adductor group, primarily the adductor longus muscle, has a visible thickened, contracted region. (Above) Male patient with inability to externally rotate the right leg. (Center) Female patient with inability to externally rotate the left leg. (Below) Female patient viewed from above with inability to externally rotate the left leg.
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Plastic and Reconstructive Surgery • October 2011 Each of these 12 patients had a mechanism of injury consistent with a stretch/traction of the adductor muscles, and in two patients this pain was bilateral. Eight of these patients were female and four were male. The mean age of the patients at the time of study entry was 36.6 years (range, 20 to 49 years). In six patients, the mechanism of injury was sports-related (i.e., soccer, basketball, or swimming). In three patients, the mechanism was related to being placed in the lithotomy position (i.e., one vaginal hysterectomy, one endoscopic oophorectomy, and one prolonged labor). Three patients had a non–sports-related injury. Intraoperative exploration of the origin of the adductor muscles from the pubic tubercle and ramus in the first patient in this cohort suggested a small neurovascular bundle arising between the pectineus muscle and the adductor longus muscle (Fig. 2). Histologic evaluation of this structure revealed the presence of a small nerve bundle. Therefore, in each subsequent patient, this structure was identified using 3.5⫻ loupe magnification and submitted for pathologic evaluation, with subsequent identification of neural tissue, confirming the original observation. Five fresh cadaver dissections were performed to identify the origin of this nerve, which had been presumed to originate from the obturator nerve, the same nerve that innervate these muscles. The operative approach included a fasciotomy of the adductor muscles, primarily the adductor longus, without dividing the adductor tendon from its pubic origin or dividing the muscle (Figs. 3 and 4). In addition, the obturator nerve branch to the muscle origin was resected and the proximal end implanted into the adductor muscle. Pain was evaluated using an 11-point Likert scale. Excellent results were defined as complete relief of a pain and return to preinjury level of function. A good result was defined as improvement on the Likert scale of greater than five points and improved function. Failure was defined as no improvement in pain and/or no improvement in function. Statistical Analysis Change in pain level was evaluated with the t test.
RESULTS In 13 of the 14 specimens (11 of the 12 patients), nerves were identified: two of the 12 specimens required S100 staining for this identification.
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Fig. 2. Location of the obturator sensory nerve to the pubic bone origin of the adductor muscles, arising from the anterior division of the obturator nerve, between the pectineus and the adductor longus muscle. (Above) On the right side, the small neurovascular bundle is noted arising lateral to the abductor longus, crossing its fascia, and traveling toward the pubic tubercle. (Center) This bundle has been divided proximally and is under tension to demonstrate its distal direction toward the pubic tubercle. (Below) In another patient, on the right side, the adhesion of this neurovascular bundle to the muscle at the site of injury is noted.
Volume 128, Number 4 • Treatment of Refractory Groin Pull
Fig. 3. The thickened fascia covering the adductor muscles has been released. The undivided muscles are noted deep to this fasciotomy. The true tendinous origin at the pubic bone has not been divided. (Above, left) Female, left side. (Above, right) Male, right side. (Below, left) Female, right side, showing a 2-cm gain in length after fasciotomy. (Below, right) Male, right side, showing a 4-cm gain in length after fasciotomy.
Cadaver dissection demonstrated the anterior branch of the obturator nerve to be the origin of this nerve to the periosteum of the pubic origin of the adductor muscles. In each of the five fresh cadaver dissections, the nerve identified clinically in the operating room was found to arise from the anterior branch of the obturator nerve, and to travel, with a small artery and vein from the obturator vessels, superiorly and medially, medial to the pectineus muscle and over the surface of the adductor longus to innervate the periosteum of the pubic tubercle and ramus, the site of origin of the adductor muscles. At a mean of 16.7 months after surgery (range, 6 to 36 months), 11 of the 12 patients (92 percent) and 13 of the 14 limbs (93 percent) responded with relief of pain and improved activities of daily living. Furthermore, these people returned to sports and work. Of the 12 patients, eight had an
excellent result (67 percent), three had a good result (25 percent), and one experienced a failure (7 percent). The mean preoperative “daily pain” was 7.7, with six patients having a maximum pain of 10 and four more having a maximum pain of 9. The mean postoperative daily pain” was 0.9 (p ⬍ 0.001), with seven patients having a score of 0, four having a score of 1, and the one failure having a score of 6, not changed from his or her preoperative score. The one patient who did not have a nerve demonstrated on histologic examination was also the one patient who failed to improve. Retrospective review of her intraoperative photograph demonstrates that the wrong structure was removed (Fig. 5), being a vascular bundle from the medial side of the adductor longus. This patient also had previous iliopsoas lengthening and adductor canal release without improvement, and may have
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Fig. 5. Intraoperative photograph of a patient with failure to improve after fasciotomy and resection of the obturator sensory nerve to the pubic bone origin. It is clear in retrospect that the “neurovascular” bundle was from the medial side of the adductor longus, and the pathology report failed to show a nerve. In contrast, the lateral location of the sensory branch of the obturator nerve can be identified in the photograph. It was not resected.
Fig. 4. Intraoperative demonstration of increase in hip external rotation after fasciotomy. (Above) Before fasciotomy. (Below) After fasciotomy.
had the genitofemoral nerve injured during her iliopsoas intrapelvic lengthening procedure. There were no postoperative hematomas, infections, or wound healing problems.
DISCUSSION The clinical aspect of this study demonstrated that in 12 patients (14 limbs) with chronic pain resulting from a groin injury, a small nerve and accompanying vessels can be identified crossing the adductor longus muscle and traveling to the periosteal origin of the adductor muscle group from the pubic tubercle and pubic ramus, just inferior to the pectineal ridge. Cadaver dissection demonstrated that this nerve originates from the anterior branch of the obturator nerve. The patients in this study were demonstrated to have a groin pull, with a contracted adductor muscle (inability to fully externally rotate the hip with the knee flexed), and had pain at the exact origin of the adductor muscles from the pubic
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bone. The literature contains a confusing set of diagnostic terms for groin pain that include athletic pubalgia, sportsman’s hernia, and osteitis pubis. None of the patients in this study had a demonstrable hernia, and none of them had a repair of their abdominal wall. The 14 limbs in this study had adductor fasciotomy and resection of the nerve to the pubic origin of the muscles. Although this study did not compare more than one treatment approach, it suggests that the patient with a groin pull who does not have a demonstrable hernia does not need to have the rectus sheath reconstructed or the ilioinguinal nerve resected. In the absence of the physical findings that document a problem with the adductor muscles, and in the presence of groin pain with point tenderness in the distribution of the ilioinguinal nerve, the presence of a sports hernia, a stretch traction injury to the ilioinguinal nerve in the abdominal wall, should be considered, and the approach to “groin pain of neural origin” should be considered.3 One of the patients in this study sustained an injury while swimming competitively. Although groin pull has been described extensively in hockey and soccer players, to our knowledge, there has been only one other report of a female swimmer with chronic groin pain described.28 In that case, unilateral adductor tenotomy was performed, resulting in only partial resolution of the patient’s symptoms. In the patient in our series,
Volume 128, Number 4 • Treatment of Refractory Groin Pull before she underwent adductor fasciotomy and resection of the obturator nerve branch to the pubic origin of the adductor muscles, she had previous inguinal hernia surgery and both cryoablation and phenol injections to attempt to stop pain from the ilioinguinal nerve, highlighting the fact that the concept of an adductor muscle injury must be included in the concept of groin pain. The pain component surrounding the insertion site of the adductor longus tendon on the pubic tubercle is one aspect that is not fully understood. One theory, termed “stress-shielding,” states that the abnormality involves an overuseunderuse injury, where the superficial portion of the tendon bears too much of the tensile load and the deep portion bears too little of the same load.29 This results in abnormality of the deep portion of the adductor longus tendon and increased bony stress in the area of the pubic symphysis corresponding to the classic point tenderness over the insertion site. The authors theorize that the clinical success of adductor tenotomy lies in the resultant change in mechanics of the disordered tendon, with a more even distribution of tensile stress across both superficial and deep portions of the tendon. With the findings being clear on physical examination, a nerve block or trigger point injection at the adductor tendon origin is not necessary. It should be appreciated that the force that tears the adductor tendon also injures the nerve at the periosteal origin, and therefore the appropriate treatment is to perform the fasciotomy and resect the nerve. There is a great deal of variation in the musculotendinous origin of the adductor longus muscle as described in cadaver studies; however, the most common organization has the anterior portion fibrous and the posterior portion muscular,30 with the average origin containing 37.9 percent tendon and 62.1 percent muscle at the pubic bone origin, decreasing to 26.7 percent tendon 2 cm distal to this origin.31 Therefore, it is not surprising perhaps to find the literature also confusing with respect to the meaning of “adductor tenotomy,” with some reports dividing just the tendon and muscle at its origin,21,32 some dividing the fascia but not the muscle or tendon (which is the approach reported here), and some reattaching the adductor muscle in a lengthened position.8 In the present study, just the contracted fascia was divided: the muscle was not divided and the adductor origin from the pubis was not divided (Fig. 2). Recently, it has been reported that a percutaneous adductor tenotomy accomplishes as much as an open adductor tenotomy in terms of releas-
ing the adductor contracture.31 In this well-described technique, it is clear that the goal is division of the entire adductor tendon and muscle from the pubic bone. Reading the description of the technique suggests that this approach must divide the nerve innervating the origin of the adductor from the pubic bone, the nerve described in the present report. Similarly, the complete adductor tenotomy used by Robertson et al.,22 which enabled 32 of 38 players disabled at level 4 (unable to play) to return to level 1 (unlimited play) and gave improvement in 91 percent of their patients, also must include a denervation of the adductor longus muscle origin. This suggests that, in patients with a chronic groin pull who have chronic pain and do not need the muscle released to gain better hip function, it would be possible, as is now suggested for chronic lateral humeral epicondylitis,25,26 to just denervate this muscle origin instead of performing the fasciotomy plus the denervation. This will require a prospective study in which nerve blocks are performed before surgery. A nerve block was not a criterion for inclusion in this study. The limitations of this study include its being retrospective and multiauthored, with patients accrued over several years. Furthermore, the outcomes were assessed by the surgeons and the patients themselves rather than by an independent observer. However, the findings were anatomically consistent and the clinical improvement following surgery was excellent, and thus these limitations do not detract from the conclusions. A. Lee Dellon, M.D., Ph.D. The Exchange Building, Suite 18 1122 Kenilworth Drive Towson, Md. 21204
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