Groin Pain Syndrome Italian Consensus Conference update 2023.

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Long-standing groin pain syndrome in athletic women: a multidisciplinary assessment in keeping with the Italian Consensus Agreement.

BACKGROUND: Long-standing groin pain syndrome (LSGPS) is a form of groin pain syndrome in which the cohort of symptoms reported by patients is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. The aim of this prospective epidemiological study was to describe the clinical causes of LSGPS in 37 female athletic subjects in Italy through the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athletes' classification and guidelines. METHODS: Thirty-seven female athletes affected by LSGPS were evaluated following the guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes. RESULTS: In the considered population, each patient presented only one pathological cause for LSGPS. The most frequent etiologies were inguinal pathologies (54.05% of the cases), acetabular labrum tear (18.92%) and pelvic floor disorders (8.11%). Adductor tendinopathy represented only 2.70% of cases. CONCLUSIONS: Female athletic patients affected by LSGPS show a similar incidence of inguinal and hip pathologies as in male populations. However, these clinical situations do not seem to be associated in women unlike in the male population. This difference is probably due to particular anatomical differences related to gender. For this reason, women affected by LSGPS represent an important subset of patients. Moreover, adductor tendinopathy is probably overrated as an etiopathogenetic source of LSGPS in women.

A multidisciplinary assessment of 320 athletes with long-standing groin pain syndrome in keeping with the Italian consensus agreement: the high incidence and the multiple causes of inguinal and hip pathologies and pubic osteopathy.

BACKGROUND: Groin pain syndrome is an important and increasing problem in numerous sports (e.g. soccer, football, ice hockey, handball and rugby). Long-standing groin pain syndrome is a form of groin pain syndrome in which the cohort of symptoms reported by the patient is experienced for a long period, typically for over 12 weeks, and is recalcitrant to any conservative therapy. Long-standing groin pain syndrome is potentially career-ending for elite athletes. METHODS: A descriptive epidemiological study was carried out on 320 athletes (290 men and 30 women) affected by long-standing groin pain syndrome, following the Guidelines issued by the Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athlete. RESULTS: Amongst the clinical tests for inguinal pathologies, only the External Inguinal Ring Exploration proved conclusive (sensitivity: 0.97; specificity: 0.95; positive predictive value: 0.98; negative predictive value: 0.90; likelihood ratio: 19.4). In testing for adductor tendinopathies, only the Isometric Squeeze with flexed knee and distal resistance (sensitivity: 0.86; specificity: 0.45; positive predictive value: 0.48; negative predictive value: 0.85; likelihood ratio: 5.7) and the Palpatory Test at the pubic insertion of the adductor longus (sensitivity: 0.93; specificity: 0.89; positive predictive value: 0.96; negative predictive value: 0.79; likelihood ratio: 8.5) proved, respectively, useful at times and moderately useful. Among the tests for hip pathologies, only the Flexion Abduction External Rotation Test was seen to be conclusive (sensitivity: 0.90; specificity: 0.93; positive predictive value: 0.98; negative predictive value: 0.72; likelihood ratio: 12.9). In the male population on average, long-standing groin syndrome presents either a single cause or multiple causes in respectively 74% and 26% of cases. Furthermore, almost 58% of all cases traced to a single clinical cause can be attributed to inguinal pathologies alone. Long-standing groin syndrome in the female population shows only one pathological cause with inguinal pathologies, and acetabular labrum tear representing the most frequent etiologies. CONCLUSIONS: Men and women exhibit different causes for long-standing groin pain syndrome. Several routine tests used in the clinical evaluation of this condition furnish a low likelihood ratio. Consequently, in order to optimize clinical evaluation and minimize patient discomfort, clinical evaluation should be based on tests with a greater likelihood ratio.

Mid-term outcome after arthroscopic treatment of femoroacetabular impingement: development of a predictive score.

PURPOSE: To build a post-arthroscopy outcome-predictive score (POPS) associated with the likelihood of lasting benefit after arthroscopic treatment of femoroacetabular impingement (FAI) and based solely on unambiguous preoperative information. METHODS: A population of 220 FAI patients, operated on with standard techniques by orthopaedic surgeons trained in hip arthroscopy in 6 different centres, was evaluated physically or by telephone interview 2 to 5 years after surgery. The criteria of successful mid-term outcome (SMO) were agreed upon by all authors. A multivariate logistic regression, adjusted for patient's age and centre, was applied to predict SMO. In the model, the variables associated with the outcome were included and the relative ORs (odds ratios) were used to compute the FAI-POPS (FAI - post-arthroscopy outcome-predictive score). A ROC (receiver operating characteristic) curve was plotted and the optimum cut-off was calculated. RESULTS: 155 patients out of 220 showed a successful mid-term outcome. The optimum cut-off of FAI-POPS was calculated to be 6.3 and with this threshold it proved a sensitivity of 0.66 and a specificity of 0.69, a positive predictive value of 0.84 and a negative predictive value of 0.46. CONCLUSIONS: The standard arthroscopic treatment of FAI resulted in satisfactory persistent symptom relief for about 70% of patients. No or minimal osteoarthritis, short time elapsed from the appearance of symptoms and high preoperative modified Harris Hip Score are independent predictive factors of SMO. The FAI-POPS is obtained as sum of 3 odds ratios corresponding to the above prognostic factors and is a useful predictor of mid-term outcome after conventional arthroscopic FAI treatment.

Post-traumatic ossifications of the rectus femoris: Arthroscopic treatment and clinical outcome after 2 years.

Injuries of the rectus femoris tendon origin could result in a chronic tendinopathy, leading to groin pain and loss of function. Conservative treatment with analgesics and physical therapy is the gold standard, but in some cases excessive bone formation after avulsion injuries, can lead to a post-traumatic heterotopic ossification (PHO) and may benefit from surgical removal. METHODS: Outcome was evaluated in 16 top soccer players (age 24-43 years) affected by calcification of the proximal rectus who underwent arthroscopic excision (6-12 and 24 months). X-ray and 3D CT was collected for all patients. Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score, Modified Harris Hip Score, together with visual analog scales (VAS) for pain, sport activity level (SAL), and activities of daily living (ADL) were used to evaluate clinical outcome. TECHNICAL PROCEDURE: after central compartment examination and treatment was accomplished, attention was focused to the ossification of the rectus femoris. A complete exposure of the ossification was achieved; when possible attention was taken in detaching the minimum amount of fibers of the direct head of the rectus femoris from its insertion site. During the entire procedure, both dynamic direct visualization and fluoroscopic evaluation of the amount of resection were performed. RESULTS: Clinical outcome was excellent; the percentage of return to pre-injury level sport was 68.75 % (11 athletes), with significant statistical improvement of MHHS, OHS and all 3 VAS subscales in all patients at 2 years follow-up. CONCLUSION: Arthroscopic removal using conventional hip arthroscopic portals represent both effective and safe procedure to adequately treat post-traumatic ossification of the rectus femoris.

Reliability of forced internal rotation and active internal rotation to assess lateral instability of the biceps pulley.

PURPOSE: the aim of this study was to investigate the relationship between positive painful forced internal rotation (FIR) and lateral pulley instability in the presence of a pre-diagnosed posterosuperior cuff tear. The same investigation was conducted for painful active internal rotation (AIR). METHODS: a multicenter prospective study was conducted in a series of patients scheduled to undergo arthroscopic posterosuperior cuff repair. Pain was assessed using a visual analog scale (VAS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) was administered. The VAS score at rest, DASH score, and presence/absence of pain on FIR and AIR were recorded and their relationships with lesions of the lateral pulley, cuff tear patterns and shape of lesions were analyzed. RESULTS: the study population consisted of 115 patients (mean age: 55.1 years) recruited from 12 centers. The dominant arm was affected in 72 cases (62.6%). The average anteroposterior extension of the lesion was 1.61 cm. The mean preoperative VAS and DASH scores were 6.1 and 41.8, respectively. FIR and AIR were positive in 94 (81.7%) and 85 (73.9%) cases, respectively. The lateral pulley was compromised in 50 cases (43.4%). Cuff tears were partial articular in 35 patients (30.4%), complete in 61 (53%), and partial bursal in 19 (16.5%). No statistical correlation between positive FIR or AIR and lateral pulley lesions was detected. Positive FIR and AIR were statistically associated with complete lesions. Negative FIR was associated with the presence of partial articular tears. CONCLUSIONS: painful FIR in the presence of a postero-superior cuff tear does not indicate lateral pulley instability. When a cuff tear is suspected, positive FIR and AIR are suggestive of full-thickness tear patterns while a negative FIR suggests a partial articular lesion. LEVEL OF EVIDENCE: level I, validating cohort study with good reference standards.

Rectus Femoris Tendon Calcification: Arthroscopic Excision in 6 Top Amateur Athletes.

BACKGROUND: Since it was developed, hip arthroscopy has become the favored treatment for femoroacetabular impingement. Due to recent considerable improvements, the indications for this technique have been widely extended. Injuries of the rectus femoris tendon origin, after an acute phase, could result in a chronic tendinopathy with calcium hydroxyapatite crystal deposition, leading to pain and loss of function. Traditionally, this condition is addressed by local injection of anesthetic and corticosteroids or, when conservative measures fail, by open excision of the calcific lesion by an anterior approach. PURPOSE: To assess whether arthroscopic excision of calcification of the proximal rectus is a safe and effective treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Outcomes were studied from 6 top amateur athletes (age range, 30-43 years; mean, 32.6 years) affected by calcification of the proximal rectus who underwent arthroscopic excision of the calcification. Patients were preoperatively assessed radiographically, and diagnosis was confirmed by a 3-dimensional computed tomography scan. To evaluate the outcome, standardized hip rating scores were used pre- and postoperatively (at 6 and 12 months): the Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score, and Modified Harris Hip Score. Moreover, visual analog scales (VAS) for pain, sport activity level (SAL), and activities of daily living (ADL) were also used. RESULTS: One year after surgery, all patients reported satisfactory outcomes, with 3 of 6 rating their return-to-sport level as high as preinjury level, and the remaining 3 with a percentage higher than 80%. Five patients ranked their ability to carry on daily activities at 100%. Statistical analysis showed significant improvement of the Oxford Hip Score, the Modified Harris Hip Score, and all 3 VAS subscales (pain, SAL, and ADL) from pre- to latest postoperative assessment (P < .05). CONCLUSION: Arthroscopic excision of rectus femoris tendon calcification yields satisfying results with few risks to the patient as well as rapid recovery. CLINICAL RELEVANCE: The recent improvements in hip arthroscopy give the opportunity to address an increasing number of hip conditions effectively and safely, with rapid recovery for the patient. Arthroscopic excision of rectus femoris tendon calcification can be considered a feasible option, with few risks to the patient, rapid recovery, and satisfying outcomes.

Remplissage repair--new frontiers in the prevention of recurrent shoulder instability: a 2-year follow-up comparative study.

BACKGROUND: An engaging Hill-Sachs lesion is a defect of the humeral head, large enough to cause locking of the humeral head against the anterior corner of the glenoid rim when the arm is at 90° of abduction and more than 30° of external rotation. HYPOTHESIS: When Bankart lesions are associated with engaging Hill-Sachs defects, simultaneous Bankart repair and remplissage provide lower recurrence rates than does Bankart repair alone. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Fifty patients (36 men, 14 women) with combined engaging Hill-Sachs and Bankart lesions were evaluated, before and after arthroscopic management, at a minimum follow-up of 2 years. After imaging and arthroscopic assessment, 25 patients underwent remplissage and Bankart repair, and 25 patients received Bankart repair alone. Patients were evaluated using the UCLA, Constant, and Rowe scores, and range of motion was measured using a goniometer. Postoperatively, all patients underwent magnetic resonance imaging to assess the status of healing of the anterior labrum and whether the tenodesis of the infraspinatus covered the Hill-Sachs defect. RESULTS: At the last appointment, active forward elevation, external rotation beside the body, internal rotation, and all administered scores were significantly improved compared with baseline assessment, with no statistically significant intergroup differences. A new posttraumatic dislocation occurred in 5 patients, all from the Bankart-only group (20%). CONCLUSION: Remplissage is a safe, relatively short procedure that allows the surgeon to address large humeral defects with a low postoperative recurrence rate. Humeral head large defects predispose to recurrent instability of the shoulder and deserve surgical management.

Full thickness tears: retaining the cuff.

Repair of rotator cuff tears is technically challenging. Full thickness rotator cuff tears have no potential for spontaneous healing, no reliable tendons substitutes are available, and their management is only partially understood. Many factors seem to contribute to the final outcome, and considerable variations in the decision-making process exist. For these reasons, decisions are often taken on the basis of surgeon's clinical experience. Accurate and prompt diagnosis is fundamental to guide correct management, and the tear pattern should be carefully evaluated to planning the most appropriate repair.

Italian translation of the Manchester-Oxford Foot Questionnaire, with re-assessment of reliability and validity.

PURPOSE: To cross-culturally adapt and validate the Italian version of the Manchester-Oxford Foot Questionnaire (MOXFQ) in patients affected by hallux valgus. METHODS: The MOXFQ was translated into Italian and culturally adapted following the forward and backward translation method. A sample of 172 patients with hallux valgus was asked to fill in the MOXFQ and the Short-Form 36 Health Survey (SF-36). Two-week retest was performed on a random sub-sample of 40 patients. Internal consistency and test-retest reliability were assessed using Cronbach's alpha and intraclass correlation coefficient (ICC), respectively. Construct validity was assessed with the use of Spearman's rank correlation coefficient, using a priori hypothesized correlations with SF-36 domains. RESULTS: The internal consistency reliability was acceptable for all MOXFQ domains (Pain, Walking/standing and Social interaction) with Cronbachs' alpha coefficients ranging from 0.72 to 0.83. The assessment of test-retest reliability reveals satisfactory values with ICCs ranging from 0.85 to 0.92. Construct validity was supported by the presence of all the hypothesized correlation, with the exception of Italian Walking/standing domain with the SF-36 Role-Physical domain (rho = -0.29). CONCLUSIONS: The Italian version of MOXFQ is a valid and reliable instrument for evaluating foot pain and functional status in patients affected by hallux valgus.