Prior Authorization Review Panel MCO Policy Submission...Athletic pubalgia (AP) has been reported to...

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review.

Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date:03/01/2019

Policy Number: 0750 Effective Date: Revision Date: 02/23/2018

Policy Name: Athletic Pubalgia Surgery

Type of Submission – Check all that apply: New Policy Revised Policy Annual Review – No Revisions*

*All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:

CPB 0750 Athletic Pubalgia Surgery

Clinical content was last revised on 02/23/2018. No additional non-clinical updates were made by Corporate since the last PARP submission.

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

Page 1 of 22

http://aetnet.aetna.com/mpa/cpb/700_799/0750.html 02/19/2019

(https://www.aetna.com/)

Athletic Pubalgia Surgery

Number: 0750

Policy *Please see amendment for Pennsylvania Medicaid

at the end of this CPB.

Aetna considers surgical treatment (e.g., pelvic floor repair) for

athletic pubalgia (also known as core muscle injury or "sports

hernia") experimental and investigational because the

effectiveness of this approach has not been established.

Aetna considers intra-tissue percutaneous electrolysis for the

treatment of chronic groin pain experimental and

investigational because the effectiveness of this approach

has not been established.

Aetna considers pulse-dose radiofrequency for the treatment

of athletic pubalgia experimental and investigational

because the effectiveness of this approach has not been

established.

See

CPB 0736 - Femoro-Acetabular Surgery for Hip

also Impingement Syndrome (0736.html)

.

Policy History Last Review 02/23/2018

Effective: 03/21/2008

Next Review: 08/09/2018

Review History

Definitions

Additional Information Clinical Policy Bulletin

Notes

http://aetnet.aetna.com/mpa/cpb/700_799/0750.html

http://www.aetna.com/)

Page 2 of 22


Background

Athletic pubalgia, also known as groin distruption

or sportsman’s or sports hernia (SH), is a condition involving

persistent groin pain during exercise when there is no

evidence of a clinically detectable hernia. Athletic pubalgia is

not a true hernia, but is considered an overuse injury in which

the external oblique muscle and surrounding tendons and/or

the transverse abdominis or internal oblique muscles are worn

down or partially torn.

Conservative treatment generally consists of rest, medications

and physical therapy. If conservative treatment fails, surgical

treatment may be suggested as an alternative. The procedure

may be performed using a laparoscopic or open anterior

approach. Polypropylene or polyester mesh is suggested to

correct the identified abnormality. However, there are no data

from randomized studies to confirm effectiveness of this

surgery.

Athletic pubalgia (AP) has been reported to afflict athletes who

participate in sports that entail repetitive twisting and turning

while moving (e.g., hurdling, rugby, skiing, soccer, tennis, field

hockey and ice hockey). Previously described in high-

performance athletes, AP has also been reported to occur in

recreational athletes. Athletic pubalgia has

been characterized as chronic groin pain in conjunction with

a dilated superficial ring of the inguinal canal. However, the

term hernia is a misnomer because of the absence of a hernia

on physical examination or imaging (e.g., magnetic resonance

imaging [MRI]), and a hernia is not revealed during surgery.

The following operative findings have been reported to occur

commonly in persons with AP (Swan and Wolcott, 2007):

Abnormal insertion of the rectus abdominis muscle

Conjoint tendon torn from pubic tubercle

Deficient posterior wall of the inguinal canal


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Dehiscence between conjoined tendon and inguinal

ligament

Entrapment of the ilio-inguinal nerve or genito-femoral

nerve

Tear in the conjoint tendon

Tear in the fascia transversalis

Tear of the abdominal internal oblique muscle from the

pubic tubercle

Torn external oblique aponeurosis.

According to descriptions of AP, symptoms of this

condition include pubic point tenderness accentuated by

resisted adduction of the hip as well as pain during sporting

activities, especially twisting and turning, and hip extension. It

has been reported that patients often present with an insidious

onset of activity-related, unilateral, deep groin pain that abates

with rest. Furthermore, exertions that increase intra-abdominal

pressure (e.g., coughing and sneezing) can result in pain. In

the early stages, patients may be able to continue participating

in athletic activities, but the problem usually worsens.

Diesen and Pappas (2007) stated that the definition of SH/AP

is controversial. Diagnosis of AP is established by medical

history and physical findings. Although the physical

examination reveals no detectable inguinal hernia, it has been

reported that a tender, dilated superficial inguinal ring as well

as tenderness of the posterior wall of the inguinal canal are

frequently found. The role of imaging studies in this condition

is unclear; most imaging studies will be normal (Ahumada et

al, 2005; Farber and Wilckens, 2007). Some authorities state

that imaging studies (e.g., ultrasonography or MRI) may be

helpful in evaluating these patients and ruling out other

pathology, although no imaging study can rule out SH.

Conservative treatments of AP consist of rest, application of

ice 3 to 4 times daily for about 20 to 30 mins, non-steroidal

anti-inflammatory drugs, and physical therapy. Patients who


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fail conservative treatments may be referred for surgical

repair. Surgical procedures for athletic pubalgia can be

performed laparoscopically. To reinforce the repair and make

it stronger, a synthetic mesh-like material is often used.

Ahumada et al (2005) stated that surgical intervention with an

internal oblique flap reinforced with mesh alleviates

symptoms.

Meyers and colleagues (2000) examined the

pathophysiological processes of severe lower abdominal or

inguinal pain in high-performance athletes. These

investigators evaluated 276 patients; 175 underwent pelvic

floor repairs. Of the 157 athletes who had not undergone

previous surgery, 124 (79 %) participated at a professional or

other highly competitive level, and 138 patients (88 %) had

adductor pain that accompanied the lower abdominal or

inguinal pain. More patients underwent related adductor

releases during the later operative period in the series.

Evaluation revealed 38 other abnormalities, which included

severe hip problems as well as malignancies. There were 152

athletes (97 %) who returned to previous levels of

performance. The syndrome was uncommon in women and

the results were less predictable in non-athletes. A distinct

syndrome of lower abdominal/adductor pain in male athletes

appears correctable by a procedure designed to strengthen

the anterior pelvic floor. The location and pattern of pain and

the operative success suggested the cause to be a

combination of abdominal hyper-extension and thigh hyper-

abduction, with the pivot point being the pubic symphysis. The

authors stated that diagnosis of AP and surgery should be

limited to a select group of high-performance athletes. The

major drawback of this study was that it was an uncontrolled

study; a control group is important because many athletes with

groin injuries improve without surgical interventions.

Fon and Spence (2000) performed a systematic Medline

search and all literature pertaining to chronic groin pain, groin

injury, SH and sportsman's groin from 1962 to 1999 was


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retrieved for analysis. The costs of computed tomography

and MRI are such that their routine use for assessment of

patients with groin pain can not be justified. They may,

however, be employed in difficult cases to help define the

anatomical extent of a groin injury. Plain radiography,

ultrasonography and scintigraphy should be the usual first-line

investigations to supplement clinical assessment.

Herniography may help in situations of obscure chronic groin

and pelvic pain. There is no consensus view supporting any

particular surgical procedure for SH. A number of reports have

been published describing different repairs of the posterior

inguinal wall deficiency. The authors said that appropriate

repair of the posterior wall may result in therapeutic benefit in

selected cases. The authors concluded that the diagnosis

of SH is difficult. The condition must be distinguished from the

more common osteitis pubis and musculo-tendinous injuries.

Early surgical intervention is usually, although not always,

successful when conservative management has failed.

On the other hand, Fredberg and Kissmeyer-Nielsen (1996)

reported that the final diagnosis (and treatment) of SH often

reflects the specialty of the doctor and the present literature

does not supply proper evidence to the theory that SH

constitutes a credible explanation for chronic groin pain.

These investigators reviewed the results of 308 operations for

unexplained, chronic groin pain suspected to be caused by

SH. No differences in peri-operative findings between cured

and non-cured athletes were found. However, there was a

remarkable difference between the various peri-operative

findings in the studies. It was characteristic that further clinical

investigation of the non-cured, operated athletes gave an

alternative and treatable diagnosis in more than 80 % of

cases. Herniography was used consistently in the diagnostic

process in all the studies on SH. However, in 49 % of cases

hernias were also demonstrated on the opposite,

asymptomatic groin side.


Page 6 of 22


Kaplan and Arbel (2005) stated that findings from medical

imaging were found to be inconclusive regarding SH. These

researchers also noted that various types of operations, based

on the variable theories regarding the pathophysiological

process, have been developed for the treatment of this

syndrome. Some surgeons focus on the external elements of

the inguinal canal, and repair the external oblique fascia or

enforce the groin with the rectus abdominis. Others perform

an inguinal hernia repair procedure, either with sutures,

synthetic mesh, or laparoscopically. Some researchers

believe that the problem is in the lower abdominal muscles, or

is caused by nerve entrapment, and treat it accordingly.

However, there are no controlled comparative data on the

results of the various surgical approaches, and there is no

evidence that surgical treatment is more beneficial than

conservative treatments.

Currently, there are no data from randomized studies to

confirm the effectiveness of surgical exploration and repair for

AP (Brook, 2007). Randomized studies are especially

important for pain interventions because of the susceptibility of

this symptom to placebo effects. There is also a lack of

guidelines/position statements from specialty medical societies

regarding the management of this condition. In particular, the

Society for Surgery of the Alimentary Tract's guideline on

surgical repair of groin hernias (2003) as well as the National

Institute for Clinical Excellence's guideline on laparoscopic

surgery for inguinal hernia repair (2004) did not mention AP as

an indication of hernia repair.

In a systematic review on SH, Caudill and colleagues (2008)

summarized existing knowledge regarding SH pathogenesis,

differential diagnosis, conservative treatment, surgery, and

post-surgical rehabilitation. The likely causative factor for SH

is posterior inguinal wall weakening from excessive or high

repetition shear forces applied through the pelvic attachments

of poorly balanced hip adductor and abdominal muscle

activation. There is currently no consensus as to what


Page 7 of 22


specifically constitutes this diagnosis. Since it can be difficult

to make a definitive diagnosis based on conventional physical

examination, other modalities such as MRI and diagnostic

ultrasound are often employed, primarily to rule out other

conditions. Surgery appears to be more effective than

conservative treatment and laparoscopic techniques generally

enable a quicker recovery time than open repair. However, in

addition to better descriptions of surgical anatomy and

procedures, and conservative and post-surgical rehabilitation,

well-designed research studies are needed with more detailed

serial patient outcome measurements in addition to basing

success solely on return to sports activity timing. Only with

this information will investigators be able to better understand

SH pathogenesis, verify superior surgical approaches, develop

evidence-based screening and prevention strategies, and

more effectively direct both conservative and post-surgical

rehabilitation.

In the discussions following a review article by Meyers et al

(2008), several concerns were raised regarding their

therapeutic approaches for SH: (i) the time to recovery and

any adverse outcomes or complications associated with the

procedures should be reported, (ii) a lack of comparative

data between surgical procedures and non-operative

management, and (iii) a number of patients with normal

imaging were operated on; how does one determine who is

likely to benefit in this group?

Omar et al (2008) noted that many athletes with a diagnosis of

SH or AP have a spectrum of related pathological conditions

resulting from musculo-tendinous injuries and subsequent

instability of the pubic symphysis without any finding of

inguinal hernia at physical examination. The actual causal

mechanisms of AP are poorly understood, and imaging studies

have been deemed inadequate or unhelpful for clarification.


Page 8 of 22


Morales-Conde and colleagues (2010) stated that SH is a

controversial cause of chronic groin pain, as it is difficult to be

defined. In the majority of athletic maneuvers, a tremendous

amount of torque or twisting occurs in the mid-portion of the

body as well as the front of the pelvis accounts for the majority

of the force. The main muscles inserting at or near the pubis

are the rectus abdominis muscle, which combines with the

transversus abdominis. Across from these muscles, and

directly opposing their forces, is the abductor longus. These

opposing forces cause a disruption of the muscle/tendon at

their insertion site on the pubis, so the problem could be

related to the fact that the forces are excessive and

imbalanced, and a weak area at the groin could be increased

due to the forces produced by the muscles. The forces

produced by these muscles may be imbalanced and could

produce a disruption of the muscle/tendon at their insertion

site on the pubis or/and a weak area may be increased due to

the forces produced by the muscles, and just this last

possibility could be defined as "SH". The authors concluded

that this global entity could be considered to be an imbalance

of the muscles (abductor and abdominal) at the pubis, that

leads to an increase of the weakness of the posterior wall of

the groin and produces a tendon enthesitis, once a true origin

is not detected, that may lead to a degenerative arthropathy of

the pubic symphysis in the advanced stages. Based on this,

this entity could be re-named as "syndrome of muscle

imbalance of the groin" and SH could be considered as an

entity included in this syndrome. It is recommended that a multi-

disciplinary approach is given to this entity, since the present

literature does not supply the proper diagnostic studies and

the correct treatment that should be performed in these

patients.

In a cross-sectional study, Silvis et al (2011) examined the

prevalence of pelvic and hip MRI findings and association with

clinical symptoms in professional and collegiate hockey

players. The study included 21 professional and 18 collegiate

hockey players. Self-reported symptoms were measured


Page 9 of 22


using a modified Oswestry Disability Questionnaire.

Participants underwent 3-T MRI evaluation of the pelvis and

hips. The MRI scans were interpreted independently by 3

musculo-skeletal radiologists in 2 sessions separated by 3

months using a 5-point Likert scale to assess for features

associated with common adductor-abdominal rectus

dysfunction and hip pathology. To estimate prevalence, MRI

findings rated 4 or higher on 4 of the 6 interpretations were

considered positive. A variance component analysis was

applied to determine intra-reader and inter-reader reliability

and the lower 95 % confidence limits (CLs). No participants

reported symptoms related to pelvic or hip disorders. The MRI

findings of common adductor-abdominal rectus dysfunction

were observed in 14 of 39 participants (36 %) and hip

pathologic changes in 25 of 39 (64 %). There was moderate

agreement between readings, with intra-reader and inter-

reader reliabilities ranging from 0.37 to 1.00. The inter-reader

reliability was less for evaluation of hip pathologic

abnormalities than for groin pathologic abnormalities, with the

lowest reliability observed in reporting of hip osteochondral

lesions (0.37 with lower 95 % CL of 0.22) and fluid in the

primary cleft (0.45 with lower 95 % CL of 0.29) and perfect

reliability in the absence of effusion and abdominal rectus

tendon tears. Overall, 30 of 39 (77 %) asymptomatic hockey

players demonstrated MRI findings of hip or groin pathologic

abnormalities. The authors concluded that given the high

prevalence of MRI findings in asymptomatic hockey players, it

is necessary to cautiously interpret the significance of these

findings in association with clinical presentation. They noted

that future investigations will determine whether these

asymptomatic findings predict future disabilities.

Litwin and colleagues (2011) stated that AP or SH is a

syndrome of chronic lower abdomen and groin pain that may

occur in athletes and non-athletes. Because the differential

diagnosis of chronic lower abdomen and groin pain is so

broad, only a small number of patients with chronic lower

abdomen and groin pain fulfill the diagnostic criteria of AP


Page 10 of 22


(SH). The authors noted that the literature published to date

regarding the cause, pathogenesis, diagnosis, and treatment

of SH is confusing.

In a case-series study, Larson and colleagues (2011)

evaluated the results of surgical treatment in athletes with

associated intra-articular hip pathology and extra-articular

sports pubalgia. Between December 2003 and September

2009, a total of 37 hips (mean patient age of 25 years) were

diagnosed with both symptomatic AP and symptomatic intra-

articular hip joint pathology. There were 8 professional

athletes, 15 collegiate athletes, 5 elite high school athletes,

and 9 competitive club athletes. Outcomes included an

evaluation regarding return to sports and modified Harris Hip

Score, Short-Form 12 score, and visual analog scale score.

These investigators evaluated 37 hips at a mean of 29 months

(range of 12 to 78 months) after the index surgery. Thirty-one

hips underwent 35 AP surgeries. Hip arthroscopy was

performed in 32 hips (30 cases of femoro-acetabular

impingement [FAI] treatment, 1 traumatic labral tear, and 1

borderline dysplasia). Of 16 hips that had AP surgery as the

index procedure, 4 (25 %) returned to sports without

limitations, and 11 (69 %) subsequently had hip arthroscopy at

a mean of 20 months after AP surgery. Of 8 hips managed

initially with hip arthroscopy alone, 4 (50 %) returned to sports

without limitations, and 3 (43 %) had subsequent pubalgia

surgery at a mean of 6 months after hip arthroscopy. Thirteen

hips had AP surgery and hip arthroscopy at one setting.

Concurrent or eventual surgical treatment of both disorders led

to improved post-operative outcomes scores (p < 0.05) and an

unrestricted return to sporting activity in 89 % of hips (24 of

27). The authors concluded that when surgery only addressed

either the AP or intra-articular hip pathology in this patient

population, outcomes were suboptimal. Surgical management

of both disorders concurrently or in a staged manner led to

improved post-operative outcomes scoring and an unrestricted

return to sporting activity in 89 % of hips.


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Hammond et al (2012) identified the incidence of symptoms

consistent with AP in athletes requiring surgical treatment for

FAI and the frequency of surgical treatment of both AP and

FAI in this group of patients. A total of 38 consecutive

professional athletes, with a mean age of 31 years, underwent

arthroscopic surgery for symptomatic FAI that limited their

ability to play competitively. In all cases a cam and/or focal rim

osteoplasty with labral refixation or debridement was

performed. In 1 case concomitant intra-muscular lengthening

of the psoas was performed. Retrospective data regarding

prior AP surgery and return to play were collected. Thirty-two

percent of patients had previously undergone AP surgery, and

1 patient underwent AP surgery concomitantly with surgical

treatment of FAI. No patient returned to his previous level of

competition after isolated AP surgery. Thirty-nine percent had

AP symptoms that resolved with FAI surgery alone. Of the 38

patients, 36 returned to their previous level of play; all 12

patients with combined AP and FAI surgery returned to

professional competition. The mean duration before return to

play was 5.9 months (range of 3 to 9 months) after

arthroscopic surgery. The authors concluded that there is a

high incidence of symptoms of AP in professional athletes with

FAI of the hip. This study drew attention to the overlap of

these 2 diagnoses and high-lighted the importance of

exercising caution in diagnosing AP in a patient with FAI.

There is limited evidence that compare the effectiveness of

surgical intervention to conservative management of AP.

While some studies found that open or laparoscopic surgery

may provide successful outcomes in treating this condition,

these studies were usually of low quality and did not

appropriately compare the effectiveness of AP surgery to

conservative management. Furthermore, there is a lack of

consensus regarding the etiology, diagnosis, and treatment of

AP; more research is needed to ascertain the clinical value of

surgical treatment for AP.


Page 12 of 22


An UpToDate review on “Sports-related groin pain or 'sports

hernia'” (Brooks, 2014) states that “Surgical exploration and

repair is the mainstay of treatment for sports hernia, although

few randomized trials have been performed to confirm the

effectiveness of this approach …. When symptoms do not

resolve with rest and appropriate conservative therapy, we

suggest surgical repair (Grade 2C)”. (A Grade 2

recommendation is a weak recommendation; and Grade C

means low-quality evidence: Evidence from observational

studies, unsystematic clinical observations, or from

randomized trials with serious flaws).

In a multi-center, retrospective, case-series study, Matsuda

and colleagues (2015) examined the outcomes of athletic

patients treated with concurrent FAI and osteitis pubis (OP)

surgery including endoscopic pubic symphysectomy. A total of

7 consecutive adult patients (4 men) with a mean age of 33

years with symptomatic FAI and OP who underwent

arthroscopic surgery for the former and endoscopic pubic

symphysectomy for the latter with a mean follow-up period of

2.9 years (range of 2.0 to 5.0 years) were included in the

study. The visual analog scale (VAS) score, the Non-Arthritic

Hip Score (NAHS), and patient satisfaction were measured.

Complications and revision surgical procedures were reported,

and pre-operative and post-operative radiographs were

assessed. The mean pre-operative VAS score of 6.7 (range of

4 to 8) improved to a mean post-operative VAS score of 1.5

(range of 0 to 7) (p = 0.03). The mean pre-operative NAHS of

50.2 points (range of 21 to 78 points) improved to a mean post-

operative NAHS of 84.7 points (range of 41 to 99 points) (p =

0.03). The mean patient satisfaction rating was 8.3 (range of 3

to 10). Two male patients had post-operative scrotal swelling

that resolved spontaneously. There were no other

complications. Pre-operative and post-operative radiographs

showed no anterior or posterior pelvic ring instability. One

patient underwent pubic symphyseal arthrodesis because of

continued pain. The authors concluded that endoscopic pubic


Page 13 of 22


symphysectomy is a minimally invasive treatment for athletic

OP with encouraging early outcomes that may be performed

concurrently with surgery for FAI in co-afflicted patients.

Serner et al (2015) stated that groin pain in athletes is frequent

and many different treatment options have been proposed.

The current level of evidence for the effectiveness of these

treatments is unknown. These investigators systematically

reviewed the literature on the effectiveness of treatments for

groin pain in athletes; 9 medical databases were searched in

May 2014. Inclusion criteria were treatment studies in athletes

with groin pain; randomized controlled trials (RCTs), controlled

clinical trials or case series; n greater than 10; outcome

measures describing number of recovered athletes, patient

satisfaction, pain scores or functional outcome scores. One

author screened search results, and 2 authors independently

assessed study quality. A best evidence synthesis was

performed. Relationships between quality score and outcomes

were evaluated. A total of 72 studies were included for quality

analysis; 4 studies were high quality. There is moderate

evidence that, for adductor-related groin pain, active exercises

compared with passive treatments improve success, multi-

modal treatment with a manual therapy technique shortens the

time to return to sports compared with active exercises and

adductor tenotomy improves treatment success over time.

There is moderate evidence that for athletes with sportsman's

hernia, surgery results in better treatment success then

conservative treatment. There was a moderate and inverse

correlation between study quality and treatment success (p <

0.001, r = -0.41), but not between study quality and publication

year (p = 0.09, r = 0.20). The authors concluded that only 6 %

of publications were high quality. Low-quality studies showed

significantly higher treatment success and study quality has

not improved since 1985. They stated that there is moderate

evidence for the effectiveness of conservative treatment

(active exercises and multi-modal treatments) and for surgery


Page 14 of 22


in patients with adductor-related groin pain. There is moderate

evidence for effectiveness of surgical treatment in sportsman's

hernia.

Elattar and colleagues (2016) stated that AP is increasingly

recognized as a common cause of chronic groin and adductor

pain in athletes. It is considered an overuse injury

predisposing to disruption of the rectus tendon insertion to the

pubis and weakness of the posterior inguinal wall without a

clinically detectable hernia. These patients often require

surgical therapy after failure of non-operative measures. A

variety of surgical options have been used, and most patients

improve and return to play. These investigators performed a

search on PubMed databases to identify relevant scientific and

review articles from January 1920 to January 2015 using the

search terms groin pain, sports hernia, athletic pubalgia,

adductor strain, osteitis pubis, stress fractures,

femoroacetabular impingement, and labral tears. The authors

concluded that AP is an overuse injury involving a weakness in

the rectus abdominis insertion or posterior inguinal wall of the

lower abdomen caused by acute or repetitive injury of the

structure. A variety of surgical options have been reported

with successful outcomes, with high rates of return to the sport

in the majority of cases. The level of evidence for this review

was IV.

In summary, there is a lack of evidence-based consensus/data

regarding the surgical treatment of athletic pubalgia.

Core Muscle Injury:

Ross and associates (2015) stated that core muscle

injury/AP/SH is an increasingly recognized source of pain,

disability, and time lost from athletics. Groin pain among

athletes, however, may be secondary to various etiologies. A

thorough history and comprehensive physical examination,

coupled with appropriate diagnostic imaging, may improve the

diagnostic accuracy for patients who present with core


Page 15 of 22


muscular injuries. Outcomes of non-operative management

have not been well-delineated, and multiple operative

procedures have been discussed with varying return-to-athletic

activity rates.

de Sa and colleagues (2016) noted that athletic groin pain

requiring surgery remains a diagnostic and therapeutic

challenge. In a systematic review, these researchers identified

the most common causes of groin pain in athletes requiring

surgery. They also characterized susceptible athlete profiles,

common physical examination and imaging techniques, and

surgical procedures performed. The electronic databases

Medline, PubMed and Embase were searched from database

inception to August 13, 2014 for studies in English that

addressed athletic groin pain necessitating surgery. The

search was updated on August 4, 2015 to find any articles

published after the original search. The studies were

systematically screened and data were abstracted in duplicate,

with descriptive data presented. A total of 73 articles were

included within this review, with data from 4,655 patients

abstracted. Overall, intra-articular and extra-articular causes

of groin pain in athletes requiring surgery were equal. The top

5 causes for pain were: (i) FAI (32 %), (ii) AP (24 %), (iii)

adductor-related pathology (12 %), (iv) inguinal pathology

(10 %), and (v) labral pathology (5 %), with 35 % of this labral

pathology specifically attributed to FAI. The authors

concluded that given the complex anatomy, equal intra-

articular and extra-articular contribution, and potential for

overlap of clinical entities causing groin pain leading to surgery

in athletes, further studies are needed to ascertain the finer

details regarding specific examination maneuvers, imaging

views and surgical outcomes to best treat this patient

population.

Intra-Tissue Percutaneous Electrolysis:

Moreno et al (2016) stated that rectus abdominis-related groin

pain (RAGP) is one of the possible clinical patterns that


Page 16 of 22


determine pubalgia. It is one of the typical clinical patterns in

footballers and is due to the degeneration/tendinopathy of the

distal tendon at the level of the 2 pubic tubercles. Intra-tissue

percutaneous electrolysis (EPI) is a recent technique used in

the treatment of tendinopathies. In a consecutive case-series,

pilot study, these researchers examined the therapeutic

benefits of EPI by contrasting the 2 basic components that

characterize RAGP: (i) painful symptoms and (ii) resultant

functional deficits. A total of 8 professional footballers

were enrolled in this study. The footballers underwent

ultrasound-guided EPI treatment. No other type of treatment

was combined with EPI. Pain was monitored with the Verbal

Rating Scale, while functional deficit was monitored using the

Patient Specific Functional Scale. The scales implementation

took place before treatment, then 24 hours, 1 week, 1 month

and 6 months after the end of treatment. Treatment with EPI

produced a complete reduction of pain symptoms in 1 month

and enabled excellent functional recovery for walking and

jogging in 1 week; getting out of bed, running, jumping and

kicking within 1 month from the end of the treatment. The

authors concluded that treatment with ultrasound-guided EPI

has shown encouraging clinical results for RAGP. They stated

that data are preliminary considering the limitations of this

study; and more complex study designs are needed to

determine the effectiveness of the technique.

In a randomized trial, Moreno and associates (2017) evaluated

the effectiveness of EPI technique in combination with an

active physical therapy (APT) program in the treatment of

adductor longus enthesopathy-related groin pain (ALErGP). A

total of 24 non-professional male soccer players diagnosed

with ALErGP were included in this study and randomly divided

into 2 groups: Group A was treated with EPI technique in

combination with a standardized APT program; Group B only

underwent the APT program. The Numeric Rating Scale

(NRS) and the Patient Specific Functional Scale (PSFS) were

used to evaluate the effectiveness of the 2 interventions. The


Page 17 of 22


follow-up covered a 6-month period. Both groups significantly

improved pain and functional scores after treatment and

maintained this therapeutic result throughout the follow-up.

The combined intervention of APT program and EPI ensured a

greater and faster reduction of pain in Group A. In addition,

functional recovery tended to be greater in Group A than B

after the treatment and throughout the follow-up by 7.8 ± 3.8 %

(p = 0.093). The authors concluded that EPI treatment in

association with APT ensured a greater and more rapid

reduction of pain and tended to promote greater functional

recovery in soccer players with ALErGP compared to APT

only. This positive therapeutic result lasted for at least 6

months after the end of the treatment. They stated that these

findings support the combined use of EPI and APT for the

treatment of ALErGP. The drawbacks of this study was its

small sample size (n = 24) and relative short follow-up period

(6 months). Furthermore ,the findings were confounded by the

combined use of EPI and a PT program.

Pulse-Dose Radiofrequency:

In a prospective non-randomized, single-group, study, Masala

and colleagues (2015) examined the role of pulse-dose

radiofrequency (PDR) in athletes with chronic pubalgia. Pulse-

dose radiofrequency was carried out in 32 patients with a

chronic pain refractory to conservative therapies during the

last 3 months. The genital branches of the genitor-femoral,

ilio-inguinal and ilio-hypogastric nerves and the obturator

nerve were the targets of treatment. A 10-cm, 20-gauge

cannula was inserted with a percutaneous access on the

upper and lower edge of the ilio-pubic branch. After the

spindle was removed, a radiofrequency needle with a 10- mm

"active tip" was inserted. The radiofrequency technique was

performed with 1,200 pulses at 45 V and 20 milliseconds

duration, followed by a 480 milliseconds silent phase. The

follow-up with a clinical examination was performed at 1, 3, 6

and 9 months after the procedure. During the follow-up visits,

the patients were asked to rate their pain on a 0 to 10 VAS


Page 18 of 22


Scale. All of the enrolled patients completed the study. Mean

VAS score before the treatment was 8.4 ± 0.6; 24 patients

reported a reduction of pain VAS scores of more than 50 %

during all follow-up visits and started trainings and

physiotherapy the following days after the radiofrequency

procedure; 6 patients, who were treated 2 times, reported a

reduction more than 50 % of VAS scores and were able to

start trainings and physiotherapy, only after the 2d procedure.

A patient had no pain relief with 2 treatments. Pain intensity

decreased up to 9 months in 31 patients (means VAS scores

of 3.4 ± 0.5 at 6 months and 3.8 ± 0.9 at 9 months). No

complications were observed. The authors concluded that

PDR is a safe and effective technique in management of

chronic pubalgia in athletes. These preliminary findings need

to be validated by well-designed studies.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

The above policy is based on the following references:

Code Code Description

There is no specific code for athletic pubalgia surgery:

ICD-10 codes not covered for indications listed in the CPB: R10.30 - Pain localized to other parts of lower abdomen

R10.33 [groin pain] S39.013+ Strain of muscle, fascia and tendon of pelvis

[athletic pubalgia]

Other specified injuries of pelvis [athletic

pubalgia]

S39.83X+


Page 19 of 22


1. Fredberg U, Kissmeyer-Nielsen P. The sportsman's

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Alimentary Tract (SSAT); 2003.

5. National Institute for Clinical Excellence (NICE).

Laparoscopic surgery for inguinal hernia repair.

Technology Appraisal 83. London, UK: National

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2004.

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Ann Plast Surg. 2005;55(4):393-396.

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9. Farber AJ, Wilckens JH. Sports hernia: Diagnosis and

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Page 20 of 22


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UpToDate [serial online]. Waltham, MA:

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Page 21 of 22


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Page 22 of 22


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2019 Aetna Inc.


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: CPB 0750 Athletic

Pubalgia Surgery

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania annual 03/01/2019

http://www.aetnabetterhealth.com/pennsylvania

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