Ancillary Modalities in the Treatment of Athletic Groin Pain: Local Anesthetics, Corticosteroids, and Orthobiologics

David R. Diduch and L. Michael Brunt (eds.)Sports Hernia and Athletic Pubalgia2014Diagnosis and Treatment10.1007/978-1-4899-7421-1_16
© Springer Science+Business Media New York 2014

16. Ancillary Modalities in the Treatment of Athletic Groin Pain: Local Anesthetics, Corticosteroids, and Orthobiologics

Michael B. Gerhardt , Bert R. Mandelbaum  and William B. Hutchinson 

Division of Sports Medicine, Santa Monica Orthopaedic and Sports Medicine Group, Institute for Sports Sciences, Cedars-Sinai Medical Center, 2020 Santa Monica Blvd., 4th Floor, Santa Monica, CA 90404, USA

Santa Monica Orthopaedic and Sports Medicine Group, Institute of Sports Sciences, Santa Monica, CA, USA

Department of General Surgery, Pacific Coast Hernia Center, St. John’s Health Center, Santa Monica, CA, USA



Michael B. Gerhardt (Corresponding author)


Bert R. Mandelbaum


William B. Hutchinson


Athletic groin pain is a complex entity with a multitude of varying subtypes. It is important to best understand the anatomic structures that are affected in each particular situation and devise a treatment plan based on the affected structures. While it is certainly true that most elite athletes with chronic unremitting pubalgia will ultimately require a surgical solution, there are some who may respond favorably to conservative treatment. We have found injection therapy to be an important part of our conservative treatment algorithm and recommend that the type of injection be considered on a case by case basis.


The groin represents a crossroads of multiple organ systems that can make athletic groin pain a challenging diagnostic dilemma. Despite a thorough history and physical exam and exhaustive imaging studies, it is not uncommon for the diagnosis to remain elusive. Diagnostic injections can help to quickly and easily narrow down the differential diagnosis in many of these athletes with groin pain. These localized injections can be both diagnostic and potentially therapeutic and are commonly employed for both of these reasons.

Once the diagnosis of pubalgia has been established then the algorithm for treatment in the athlete can be developed [1]. As with any sports injury, the initial treatments focus on conservative management. Although sports hernias typically require surgical intervention, a small percentage of these athletes will respond to conservative measures [2]. The mainstay of conservative treatment includes temporary activity modification, soft tissue therapy modalities, and injection therapy [3, 4]. The focus of this chapter will be on the various injection options available to the clinician treating these challenging disorders.

A wide spectrum of injectables has been used with varying degrees of success. Many of these injections were given in the past without imaging guidance; however, a recent improvement in our imaging techniques has allowed more accurate delivery of injectable medication to the desired area. The most commonly employed modality is ultrasonography. It is highly recommended that ultrasound guidance be used for these groin injections. The biggest risk of peri-inguinal injection is direct introduction of the injectable solution into a large blood vessel, nerve, or urologic structure such as the vas deferens or spermatic cord. Therefore, it is highly recommended that these peri-inguinal injections be given with imaging assistance such as ultrasound and/or fluoroscopy.

A variety of injectable compounds have been used for chronic groin pain. The options employed in our clinic include local anesthetics, corticosteroids, and orthobiologics such as platelet-rich plasma (PRP). The type of injection employed depends on several variables. The exact location of the pain and the focal area of the tenderness are the most important determinants as to the type of injection given. The athlete’s circumstances with regards to their career and any upcoming events must also be taken into consideration and may influence the type of injection being given as well. Also, the severity of the athlete’s pain may be a factor in deciding the type of injection delivered.

Local Anesthetics and Corticosteroids

Local anesthetics are typically recommended for diagnostic purposes. The local anesthetic delivered directly to the area of pain is a rapid way to confirm that the area being injected is truly the pain generator. It also will help to determine if subsequent injections with the other agents listed above may be helpful. If temporary relief of the groin pain is accomplished, then it makes it more likely that they will respond to a therapeutic intervention.

Corticosteroid injections are also an option for chronic groin pain, depending on the area of involvement. Corticosteroids provide a rapid anti-inflammatory effect to the targeted area. We have found that corticosteroids when delivered judiciously can serve as a powerful modality for alleviating the pain and soreness associated with the sports hernia.

Our preferred technique for injections in and around the peri-inguinal region is with ultrasound guidance. Deleterious effects can occur if a corticosteroid is injected directly into a major nerve branch or other important structure such as the vas deferens, spermatic cord, or other nearby urologic structures. The ultrasound is used in an effort to ensure safe delivery of the corticosteroid into a zone that is free of one of these important anatomic structures. Therefore, our goal for injection is first and foremost the avoidance of important traversing structures as per above, and secondly to deliver the corticosteroid into the area of maximal tenderness. With recent improvements in high resolution ultrasound probes, previously unrecognizable sensory nerve branches can sometimes be visualized. Therefore, an effort is made to identify the suspected entrapped nerve branches. However, delivery of the corticosteroid is performed regardless of direct identification of the sensory nerve.

Unfortunately, the relief is often short-lived and many of the athletes develop a recurrence of pain. When the athlete does respond favorably to the injection, significant relief can be expected for an average of 4–6 weeks at which time the decision for re-injection can be entertained. It is our opinion that one or two mid-season injections can be administered with minimal risk; however, further injections should be given cautiously for fear of weakening the already compromised surrounding soft tissue structures that could theoretically place the athlete at risk for more significant injury and microtrauma. If the athlete has a recurrence after two corticosteroid injections into the same area in a single season then the recommendation for surgical intervention is made at that time.

Perhaps the clearest indication for use of corticosteroids is for the treatment of osteitis pubis. Many athletes with pubalgia will present with concomitant tenderness in the pubic symphysis. Pubic symphysitis or osteitis pubis can also present as a stand-alone diagnosis in and of itself. In an effort to treat the symphyseal pain in a conservative fashion, image-guided symphyseal cleft injection can prove useful in mitigating this pain [5]. Typically, a low-dose injectable corticosteroid is delivered to the symphyseal cleft in an effort to diminish the inflammation in this joint. This can be an effective technique for not only allowing the athlete to continue to compete through the remainder of a season but in some cases can obliterate the osteitis pubis altogether and, therefore, allow successful treatment of this disorder without the need for surgical intervention.

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Mar 26, 2017 | Posted by in SPORT MEDICINE | Comments Off on Ancillary Modalities in the Treatment of Athletic Groin Pain: Local Anesthetics, Corticosteroids, and Orthobiologics

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