The treatment of longstanding groin pain in athletes is a challenging problem in sports medicine. The possibility of multiple co-existing pathologies complicate the diagnostic process. A complicating factor is the poor validity of diagnostic tests. As a consequence, it is hard to choose the optimal treatment strategy. The aims of this study were to determine: 1) what kinds of treatments are applied in practice for longstanding groin pain in athletes; 2) what the results are of these interventions; and 3) what the levels of evidence are of the studies describing these interventions. A literature search was performed in the digital databases Pubmed, Embase, Science Direct, Scopus, Doconline and Cochrane from 1966 till 1 April 2006. The search retrieved 135 relevant titles. A total of 92 were excluded because they were reviews, small case reports, comments or letters, or not written in English, German or Dutch. Of the resulting 43 articles evidence levels were determined using the method described by the North American Spine Society* and the Delphi list by Verhagen et al. Treatment for longstanding groin pain in athletes consists mostly of conservative measures like rest or restricted activity, physical therapy. If this does not give the desired effects, steroid injections or dextrose prolotherapy can be applied. When this remains unsuccessful, explorative surgery is the next option. A reinforcement of the abdominal wall (sometimes in combination with adductor tenotomy) is applied in most cases, using an open or laparoscopic approach. There is high quality evidence that physical therapy aiming at the strength and coordination of the muscles stabilizing the pelvis has positive effects compared with passive therapy. Based on one moderate quality study, there are indications that surgery will result in earlier return to sport compared with conservative therapy in patients with positive herniography and/ or positive ilioinguinal or iliohypogastric nerve block tests.6 In surgery, laparoscopic intervention results in earlier return to sport compared with an open approach (Level III). Thirty-six studies were retrospective case series (level IV) and no valid conclusions can be drawn based on these studies. It was concluded that there is lack of high quality research in international literature considering treatment of longstanding groin pain in athletes. Reinforcement of the abdominal wall by means of a mesh is performed in most studies, since migration of the content of the abdominal cavity into the pre-peritoneal space is thought to be the underlying mechanism. However, it is noticeable, that several authors agree on the causal mechanism of some kind of imbalance over the anterior pelvis, which causes the weakest link in the kinetic chain (abdominal wall, symphysis, adductor muscle) to give complaints. Therefore, the interventions performed in these studies, whether conservative by physical therapy,6 surgical by reattachment of the tendon of the straight oblique for abdominal wall problems,8 or mesh placement for osteitis pubis,9 interventions are always focused at balancing forces acting on the pelvis, and are reported.
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