Comparing Outcomes after Core Muscle Repair by Repair Technique: A Systematic Review

Abstract

Background:

Core muscle injuries (CMIs) are a common cause of chronic groin pain in athletes. Numerous surgical techniques have been described, ranging from abdominal wall reinforcement to direct muscle and tendon repair; nonetheless, the optimal surgical strategy remains unclear. We aimed to systematically review and compare clinical outcomes associated with different surgical techniques used for CMIs.

Methods:

A search was conducted according to Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) guidelines. Included studies evaluated surgical interventions and reported one or more clinical outcome: return-to-sport (RTS), patient-reported outcome measures, pain scores, and/or complications. Surgical techniques were grouped into predefined repair categories based on repair construct and use of adductor longus (AL) tenotomy.

Results:

Twenty-seven studies (1803 patients) met inclusion criteria. In total, seven general repair categories were reported. Among 21 studies (1433 patients) reporting RTS, 95.7% returned to sport at final follow-up. The RTS rate was 97.5% after laparoscopic approaches and 94.7% after open procedures. Mesh-based repairs demonstrated 83.9% to 99.3% RTS (n = 12 studies), while rectus abdominis repair with AL tenotomy demonstrated 90.2% to 96.5% RTS (n = 3 studies), often with longer rehabilitation time lines. Overall complication rates were low (5.2%), although higher with mesh or primary tissue repair plus AL tenotomy (16.7%). High heterogeneity was observed in reporting methods of measures of pain/satisfaction/function, limiting comparisons to RTS and complications only.

Conclusion:

Many surgical techniques for CMIs yield high RTS and low complication rates. Treating CMIs as either a hernia-type structural deficiency or a muscle/tendinous injury seems effective when tailored to the underlying pathology.

Core muscle injuries (CMIs)—also referred to as sports hernia, athletic pubalgia, or inguinal disruption—are a notable source of groin pain and functional impairment in active individuals and athletes, particularly those participating in sports that involve sudden directional changes, kicking, and twisting movements.^1-3 These injuries typically result from weakening or tearing of the abdominal wall, most commonly at the adductor longus-rectus abdominis common aponeurosis or the posterior inguinal wall, often in the absence of a true herniation.^4,5 Diagnosis is primarily clinical and based on a combination of symptomatology, including chronic groin and lower abdominal pain radiating to the adductors, and physical examination findings, such as pain with resisted sit-ups and tenderness at the rectus abdominis insertion.^4-8 Imaging modalities, although not diagnostic, are frequently used to rule out alternative pathologies and to help identify specific muscle or tendon involvement.^4-8 Although many patients experience improvement with conservative management, a notable subset requires surgical intervention.⁹ However, there remains no clear consensus on which surgical approach is superior or better suited to specific patient populations.

A wide variety of surgical interventions have been described for the treatment of CMIs, with considerable differences in technique and philosophy across approaches.⁷ Philosophically, CMIs are most often approached surgically as a posterior abdominal wall deficiency or as partial tearing of the rectus abdominis-adductor longus aponeurosis on the pubic bone. Options range from open or laparoscopic mesh repair for abdominal wall reinforcement to direct rectus abdominis repair, adductor tenotomy, or a combination of both procedures.^7,10-12 More recently, ultra-minimally invasive and robotic-assisted techniques have also been introduced.¹³ These variations likely stem from the overlap in surgical specialties—such as general surgery, orthopaedic surgery, and urology—that manage patients with CMIs.⁷ However, surgical decision making should ideally be guided by patient characteristics and clinical outcomes to optimize results.

Despite the variety of available techniques and philosophical differences in the surgical approach to treating CMIs, there remains a gap in the literature directly comparing these approaches in terms of clinical outcomes and relative benefits over conservative treatment. The purpose of this systematic review was to synthesize and compare current evidence regarding surgical techniques used in the management of CMIs. Ultimately, this analysis may inform future research efforts aimed at developing a standardized treatment algorithm tailored to patient type (e.g., athletes vs nonathletes) and expected outcomes.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and appropriate International Prospective Register of Systematic Reviews (PROSPERO) registration was conducted (CRDXXXXXXXXXXXX). A comprehensive search was conducted on July 22, 2025, across PubMed, Embase, and the Cochrane Library to identify studies reporting outcomes of core muscle repair using different surgical techniques. The following Boolean search terms were used: PubMed: (“sports hernia”[Title/Abstract] OR “core muscle injury”[Title/Abstract] OR “athletic pubalgia”[Title/Abstract] OR “inguinal disruption”[Title/Abstract]); Embase: “sports hernia”:ab,ti OR “core muscle injury”:ab,ti OR “athletic pubalgia”:ab,ti OR “inguinal disruption”:ab,ti OR “sports hernia”/exp OR “core muscle injury”/exp OR “athletic pubalgia”/exp OR “inguinal disruption”; Cochrane: “sports hernia” OR “core muscle injury” OR “athletic pubalgia” OR “inguinal disruption.”

All identified studies were imported into Rayyan, where duplicates were manually removed. Two independent reviewers then screened titles and abstracts for eligibility. Full texts of potentially relevant studies were assessed in detail, and reference lists of included articles were hand-searched to identify additional studies. The study selection process is summarized in the PRISMA flow diagram (Figure 1).

Figure 1.

Flowchart demonstrating Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) diagram.

Inclusion and Exclusion Criteria

Studies were included if they met the following criteria: (1) original human clinical studies, including randomized controlled trials, cohort studies, case-control studies, or case series; (2) evaluation of a surgical or other nonconservative intervention for core muscle injury, sports hernia, athletic pubalgia, or inguinal disruption; (3) reporting of either comparative outcomes (e.g., between different surgical techniques or versus conservative treatment) or clinically meaningful outcomes such as RTS (return-to-sport), patient-reported outcome measures (PROMs), quality of life, pain, or satisfaction; and (4) publication in English. Studies were excluded if they met any of the following criteria: (1) review articles, abstracts, posters, surgical technique articles, or expert opinions; (2) preclinical or animal studies; or (3) lack of relevant surgical outcomes or failure to focus on core muscle injury–related conditions.

Data Extraction and Quality Assessment

Data from included studies were extracted into a structured Excel sheet that captured study design, population demographics, surgical technique, comparator (if applicable), follow-up duration, and relevant clinical outcomes. Methodological quality of noncomparative studies (case series studies) was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.¹⁴ Risk of bias of nonrandomized comparative studies (cohort and case-control studies) was evaluated using the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool.¹⁵ Finally, risk of bias of randomized controlled trials (RCTs) was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB 2).¹⁶

Outcome Measures

The primary outcome of this systematic review was postoperative clinical outcome after core muscle repair stratified by surgical technique, including return-to-sport (RTS) rates and patient-reported outcome measures (PROMs) when available. Secondary outcomes included postoperative pain, patient satisfaction, quality-of-life measures, complication rates, recurrence of symptoms, revision surgery rates, and comparative outcomes with conservative management or alternative surgical techniques when reported by the included studies.

Results

Study Characteristics

A total of 27 studies met inclusion criteria, comprising 1803 patients. Study designs included 18 case series studies (1254 patients), four prospective cohort studies (337 patients), three randomized controlled trials (250), 1 case-control study (28), and one retrospective cohort study (28). All studies clearly reported inclusion and exclusion criteria, and study characteristics are summarized in Table 1.

Table 1.

Summary of Study Designs, Patient Demographics, and Reported Outcomes

Study	Study Design and Level of Evidence	Sample Size (male, n)	Age at Surgery, yr	Technique (s) Compared	Follow-up, mo	Main Findings
Ahamuda et al,17 2005	Case series, level IV	12 (11)	25 (median)	Open primary tissue repair with internal oblique muscle flap; n = 9 were reinforced with mesh, and n = 4 had concomitant adductor tenotomy	4 (median)	10/12 has excellent results 2/12 had satisfactory results, 100% returned to sports
Bernhardt et al18 2014	Case-control, level III	28 (21)	41.7	TAPP repair	94	Preoperative VAS: 6.7 ± 2.4 Postoperative VAS: 3.9 ± 2.4 Final f/u VAS: 0.8 ± 1.7 Postoperative SF-36 PF 90.4 ± 16.3 RP 86.6 ± 21.5 BP 78.3 ± 21.6 GH 78.2 ± 22.6 VT* 68.5 ± 17.5 SF 86.2 ± 25.5 RE 86.0 ± 24.8 MH* 78.9 ± 16.9 PCS 53.4 ± 7.4 MCS* 48.4 ± 8.2 *Superior to sex-matched and age-matched normal population
Brans et al,19 2019	Prospective cohort study, Level II	31 (31)	27.6	TEP repair	1.5	At 6 weeks postoperatively, there was significant improvement in every subscale of HAGOS and 26/31 (83.9%) returned to sports activity by 6 weeks
Dojčinović et al,20 2012	Case series, Level IV	99 (99)	23.9	Shouldice technique for reinforcement of the posterior inguinal canal, ilioinguinal neurolysis, and resection of the genital branch of the genitofemoral nerve; n = 24 had concomitant bilateral AL tenotomy	3	Preoperative VAS: 6.9 VAS at 4 weeks: 1.23 VAS at 8 weeks: 0.81 VAS at 12 weeks: 0.54 VAS at 1 year: 0.217 Average RTP: 4.23 weeks 70/75 (93.3%) with sports hernia surgery alone and 24/24 (100%) with concomitant adductor tenotomy returned to sports All but 2/71 (2.8%) with sports hernia procedure alone were satisfied with their outcome
Economopoulos et al,21 2013	Retrospective cohort study, level III	Bassini: 14 (14) Minimal repair: 14 (14)	Bassini: 25 Minimal repair: 22 (median)	Modified Bassini: aponeurosis of the transverse abdominis sutured to the shelving edge of the inguinal ligament to reinforce the entire pelvic floor Minimal repair: repair of the pelvic floor with sutures in a running fashion	Bassini: 54 Minimal repair: 28 (median)	Comparing the minimal repair and modified Bassini repair groups, patients felt back to normal after a median 5.9 vs 19.9 weeks, returned to work or school in 4.6 vs 11.8 days, and returned to sport after 5.6 vs 25.8 weeks; 13/14 (93%) vs 11/14 (89%) were satisfied, 13/14 (93%) vs 9/14 (64%) returned to the same sport level, the current VAS score was 1.1 vs 1.5, and the change in Tegner score was 0.733 vs 1
Edelman and Selesnick,22 2006	Case series, level IV	10 (9)	31.9	TEP	12	All patients resumed their normal activity within 1 month; one patient did not improve after surgery; two patients had persistent pain
Emblom et al,10 2018	Case series, level IV	85 (73)	26	Open adductor to rectus abdominis turn-up flap + AL tenotomy	25.8	82/85 (96.5%) returned to sports with a mean recovery time of 4.1 ± 2.3 months; the mean HOS score for all patients was 99.1 ± 3.7, and the HOS Sport subscore was 96.4 ± 9.7; patients subjectively rated their hip function as 98% of normal and sports function as 92% of normal
Gill et al,23 2020	Case series, level IV	32 (32); 12 had adductor tenotomy only, 20 had concomitant sports hernia repair	24.5	AL tenotomy	68.3	31/32 (96.8%) were able to return to their previous sport, with a mean return-to-play rate of 12 weeks, 30/32 (93.7%) were able to return at their previous level of play, 30/32 (93.7%) were satisfied with their decision to have surgery, and 24/32 (75%) were able to compete without symptoms resulting from the injury
Harr and Brody,11 2016	Case series, level IV	22 (20)	32 (median)	Open suture herniorrhaphy with fascial release of the RA + AL tenotomy	2	All athletes returned to full activity within 6–8 weeks and were eventually able to return to their sport; no additional surgery has been required
Le, Zadeh, and Ben-David, 12 2020	Case series, level IV	93 (86)	23.4	TEP repair + ipsilateral AL tenotomy	0.5 (time to first f/u); mean total f/u NR	All patients returned to athletic activity in 28 days; 7/93 (7.5%) had recurrence of pain or symptoms (2/7 of these reported contralateral groin pain)
Matikainen et al,24 2017	Prospective cohort study, level III	45 (30)	33.7	TEP repair	12	Female patients with BME at the pubis symphysis had more pain than the patients without BME (Numeric Rating Scale [NRS] scores 8.13 ± 0.99 vs 6.43 ± 1.2; P = 0.0122). NRS scores of male patients were similar in the BME group versus normal MRI group (7.0 ± 0.74 vs 6.6 ± 1.2; P = 0.2970) Mean pain scores during exercise were higher in female patients compared with male patients at 1 (NRS scores 2.9 ± 1.7 vs 1.3 ± 1.6, P = 0.0034) and 6 (1.1 ± 1.5 vs 0.3 ± 1.0, P = 0.0387) months postoperatively The number of female patients with poor/moderate outcomes was 8/15 compared with 4/30 for male patients (P = 0.001) Mean time to return to sport was 5.6 ± 1.2 months in female patients and 3.5 ± 1.1 months in male patients with BME. The corresponding values in non-BME athletes were 3.6 ± 1.2 and 2.0 ± 1.1 months for female and male patients, respectively
Mei-Dan et al,25 2013	RCT, level I	155 (155)	23	n = 96 had adductor tenotomy; n = 59 had combined adductor tenotomy and hernioplasty using a TAPP approach	NR	Mean RTP was 11.6 ± 5.4 weeks (11.7 ± 5.4 weeks for tenotomy only, 10.3 ± 3.8 for combined group); the mean postoperative Tegner score was the same as the preoperative score (8.3), with 4/14 (2.8%) having reduced follow-up score; there were no differences between groups for postoperative Tegner score, RTP time, and patient's subjective assessment of outcome
Meyers et al,26 2000	Case series, level IV	157 (157)	NR	“Pelvic floor repair”: broad reattachment of the inferolateral edge of RA muscle with its fascial investment to the pubis and adjacent anterior ligaments (similar to Bassini hernia repair but differing in the orientation of sutures); n = 36 had concomitant adductor releases	46.8	152/157 (96.8%) returned to previous level of performance Of total surgeries, 142/160 (88.8%) were successful, 10 (6.3%) were moderately successful, 3 (1.9%) were minimally successful, and 5 (3.1%) were unsuccessful
Muschaweck and Berger,27 2010	Prospective cohort study, level IV	129 (128)	25 (median)	“Minimal repair” technique: open suture method with stabilization of the posterior wall with nearly tension-free sutures	1	Athletes group: 85/86 (98.8%) resumed sporting activity within 28 days, with a median time of 7 days; 72/86 (83.7%) returned to full sporting activity within 28 days, with a median time of 14 days; 68/86 (79.1%) had a complete relief of pain within 28 days; VAS scores decreased from a median of 6–0.5; and 86/86 (100%) reported perfect satisfaction with the procedure Nonathletes group: 39/42 (92.8%) resumed sporting activity within 28 days, with a median time of 7 days; 25/42 (59.5%) returned to full sporting activity within 28 days, with a median time of 21 days; 33/42 (78.6%) had a complete relief of pain within 28 days; VAS score decreased from a median of 6–1; and 41/42 (97.6%) reported perfect satisfaction with the procedure
Paajanen et al,28 2011	RCT, level I	30 (25)	NR	TEP repair; n = 6 had concomitant AL tenotomy	12	Mean pain scores decreased more rapidly in the surgical group Full return to sports activity was achieved in 20/30 (66.7%) at 1 month, 27/30 (90%) at 3 months, and 29/30 (96.7%) at 12 months after TEP surgery compared with 6/30 (20%), 8/30 (26.7%), and 18/30 (60%) in the nonsurgical group Patients in the surgical group were more satisfied with their treatment after 12 months 6 patients underwent TEP and simultaneous adductor tenotomy; they had slower recovery (none returned to sport after 1 month, 4/6 returned to sport after 3 months, all free of pain by 6 months)
Pedrinelli et al,29 2024	Case series, level IV	45 (45)	23.4	Release of the anterior portion of the RA tendon near the pubic symphysis and tenotomy of the AL	NR	Mean return to sport time was 135 days The symptom resolution rate was 93.3%
Pilkington et al,30 2021	Case series, level IV	144 (144)	33 (median)	“Manchester groin repair”: laparoscopic TEP repair but uses a larger 15 × 12-cm mesh placed with atraumatic fixation	38.6 (median)	Median return to sport time was 4.5 weeks, with 141/142 returning to sporting activity The mean preoperative VAS scores compared with those at 1 month showed significant reduction (P < 0.001), and no patients have returned for additional management of inguinal-related pain
Piozzi et al,31 2019	Case series, level IV	198 (185)	24	TAPP repair	12	Mean return to routine daily life was 48 hours Return to full sport activity was 94.4% (187/198) at 4 weeks and 98.5% (195/198) at 12 months
Preskitt,32 2011	Case series, level IV	100 (NR)	NR	Modification of the Lichtenstein technique (open mesh repair)	NR	98% of athletes have returned to sport at a competitive level, usually in less than 3 months and occasionally in 3–6 months
Rezaie et al,33 2024	Case series, level IV	104 (98)	23	Open adductor to rectus abdominis turn-up flap + AL tenotomy (n = 48)	52.8	83/92 (90.2%) returned to sport overall (12 retired without attempting to return to sport) At f/u, the mean HOS Sport score was 94.0 ± 10.8 and mean NPRS score was 0.31 ± 1.26, with no differences in HOS Sport scores (P = 0.380), NPRS scores (P = 0.465), or successful return to preinjury sport (P = 0.407) when comparing patients with and without amniotic patches
Roos et al,34 2018	Prospective cohort study, level IV	32 (32)	22 (median)	TEP repair	19 (median)	Median pain during exercise decreased from 8 preoperatively to 2 at 3 month f/u and 0 at long-term f/u, with 62% being pain free 60% were able to complete a full training and match at 3-month f/u Median maximum intensity of sport increased significantly from 40% preoperatively to 95% at 3 months and 100% at long-term f/u, with 72% able to perform at full intensity An improvement was observed in all HAGOS subscales from preoperative to 3-month f/u, with the biggest improvement being in the sports participation subscale
Rossidis et al,35 2015	Case series, level IV	54 (41)	22.4	TEP repair + ipsilateral AL tenotomy	18	All patients were able to return to full sports-related activity in 24 days (range 21-28 days)
Sheen et al,36 2019	RCT, level I	65 (60)	29 (median)	Open minimal suture repair (n = 31) vs TEP repair (n = 34)	12	Comparing minimal repair with TEP, 28/31 (90.3%) vs 32/34 (94.1%) achieved full recovery, 2/31 (6.5%) vs 2/34 (5.9%) achieved partial recovery, and one patient who underwent OMS repair did not recover A decrease was observed between preoperative VAS scores and those measured at 4 weeks in both minimal repair and TEP groups (P < 0.001) No difference was observed in median postoperative VAS scores between groups at any time point The primary end point, relief of pain (VAS score ≤ 20) during sporting activity, 4 weeks after surgery was achieved in 14/31 patients (41.2%) in the minimal repair group and 24/34 (70.6%) in the TEP group (P = 0.047) Comparing minimal repair with TEP, 6/31 (19.4%) vs 12/34 (35.3%) were totally pain free (VAS score 0) after 1 month (P = 0.176) and 8 (25.8%) vs 12 (35.3%) had a VAS score of 10 to 20 (P = 0.435)
Srinivasan and Schuricht,37 2002	Case series, level IV	15 (15); 10 bilateral, 5 unilateral	27.1	TEP repair	12.1	The average recovery time was 4 weeks with 13 of 15 (87.1%) returning to sport by 4 weeks and all patients returning within 8 weeks
Van Meierhaeghe et al, 38 2019	Case series, level IV	33 (32)	28.8	“Pelvic floor repair” combined with bilateral adductor brevis and gracilis muscle release	120	27 of 33 (81.8%) had very successful result and returned within 16 weeks to preoperative level of play without any pain; 3 had moderately successful result (returned to same level of play but were not pain free); and 3 had unsuccessful result and could not return to preoperative level of play, had pain during sport, or would not recommend the procedure 30/33 returned to the same higher level of sports within 2 years At 10 years, 31/33 did not experience any groin pain and 31/33 would recommend the operation to others 19/20 were pain free till the end of their careers, and the other 13 are still performing sports
Wilson and Hickey,39 2019	Case series, level IV	40 (NR), 4 bilateral	NR	TAPP repair	29 (median)	Patient-initiated follow-up appointments were triggered in 10 of 179 patients (5.6%). These were related to: groin lump in 2 patients, port site lump in 1 patient, and chronic pain in 7 patients. Those patients requesting a follow-up for chronic pain had all undergone repair for inguinal disruption. In all patients, postoperative pain resolved within 4 months
Ziprin et al,40 2008	Case series, level IV	17 (17)	27 (median)	TAPP repair	6 (median)	At 3-week f/u, 5/28 groins had mild pain, which had resolved in all but 1 patient at 24-week f/u 16/17 returned to the level of sporting activity before injury by 24 weeks, with a median time of 42 days

AL = adductor longus, BME = bone marrow edema, f/u = follow-up, HAGOS = Copenhagen Hip and Groin Outcome Score, HOS = Hip Outcome Score, NPRS = Numeric Pain Rating Scale, NR = not recorded, RA = rectus abdominis, SF = short form, TAPP = transabdominal preperitoneal, TEP = totally extraperitoneal, VAS = visual analog scale.

Substantial heterogeneity was observed in surgical techniques and approach. In total, 16 study arms reported the use of a laparoscopic approach, including 10 totally extraperitoneal (TEP) and six transabdominal preperitoneal (TAPP) repairs, while 16 study arms used open techniques with considerable procedural variability. The most frequently reported open procedure was isolated adductor longus (AL) tenotomy.

Three studies directly compared two surgical techniques; therefore, a total of 30 surgical technique arms were analyzed and grouped into seven predefined repair categories originally proposed by Kraeutler et al⁷ in 2021 based on repair construct and use of AL tenotomy: mesh repair (n = 12), mesh repair + AL tenotomy (n = 4), primary tissue repair (n = 5), primary tissue repair + AL tenotomy (n = 3), rectus abdominis (RA) repair + AL tenotomy (n = 3), isolated AL tenotomy (n = 2), and combined primary tissue repair + AL tenotomy + RA repair (n = 1) (Figure 2). Outcomes by repair category are summarized in Table 2.

Figure 2.

Chart demonstrating procedures performed for core muscle injuries. *In this case, study arms were reported (n = 30) as opposed to total studies included (n = 27). AL = adductor longus, RA = rectus abdominis.

Table 2.

Summary of Key Outcomes by Repair Type

Repair Type	Author	Percent Return to Sport	Mean RTS Time	Percent Satisfaction	Complications	Complication Rate
Mesh	Bernhardt et al18 2014	NR	NR	NR	NR	NR
Mesh	Brans et al,19 2019	26/31 (83.9%) in 6 weeks	NR	NR	None	0.0%
Mesh	Edelman and Selesnick,22 2006	NR	NR	NR	2 patients had persistent pain; one of them developed a groin seroma	20.0%
Mesh	Matikainen et al,24 2017	NR	5.6 ± 1.2 mo in female patients and 3.5 ± 1.1 mo in male patients with BME; 3.6 ± 1.2 and 2.0 ± 1.1 mo for female patients and male patients without BME	8/15 (53.3%) female patients vs 4/30 (13.3%) male patients had poor/moderate outcome	NR	NR
Mesh	Pilkington et al,30 2021	141/142 (99.3%)	Median of 4.5 weeks	NR	1 had intraoperative bladder injury, 1 underwent revision surgery for evacuation of a hematoma, as well as hematoma formation, urinary retention, and transient orchialgia	5.6%
Mesh	Piozzi et al,31 2019	187/198 (94.4%) at 4 weeks and 195/198 (98.5%) at 12 months	NR	NR	1 underwent revision surgery due to small bowel obstruction with evidence of an internal hernia, 3 had small periumbilical hernia, 3 had subcutaneous seroma in the inguinal region, and 18 had inguinal pain	12.6%
Mesh	Preskitt,32 2011	98/100 (98%)	NR	NR	NR	NR
Mesh	Roos et al,34 2018	60% were able to complete a full training and match at 3 months; 72% were able to exercise with 100% intensity at long-term f/u	NR	NR	1 had urinary retention	3.1%
Mesh	Sheen et al,36 2019	18/34 (52.9%) at 1 month 32/34 (94.1%) at 3 months	NR	NR	None	0.0%
Mesh	Srinivasan and Schuricht,37 2002	13/15 (87.1%) at 4 weeks, 15/15 (100%) at 8 weeks	4 weeks	NR	None	0.0%
Mesh	Wilson and Hickey,39 2019	NR	NR	NR	1 had urinary retention, 1 had surgical emphysema, 6 had groin seroma, 1 had groin hernia recurrence, 1 had lateral port site hematoma, 2 had umbilical port site hernia, and 1 had lateral port site hemorrhage; however, none of these were for inguinal disruption procedures	0.0%
Mesh	Ziprin et al,40 2008	16/17 by 24 weeks	Median time of 42 days	NR	None	0.0%
Primary tissue	Economopoulos et al,21 2013	Bassini: 9/14	Bassini: 25.8 weeks	Bassini: 11/14	Bassini: none	Bassini: 0%
Primary tissue	Economopoulos et al,21 2013	Minimal repair: 13/14	Minimal repair: 5.6 weeks	Minimal repair: 13/14	Minimal repair: 2 wound infections	Minimal repair: 14.3%
Primary tissue	Muschaweck and Berger,27 2010	124/128 (96.9%) within 28 days	Median 14 days for athletes, 21 days for nonathletes	NR	None	0.0%
Primary tissue	Sheen et al,36 2019	16/31 (51.6%) at 1 month 28/31 (90.3%) at 3 months	NR	NR	None	0.0%
Primary tissue	Van Meierhaeghe et al, 38 2019	27/33 (81.8%) returned to sport pain free within 16 weeks, 3/33 (9.1%) returned to sport not pain free, 3 did not return to sport	NR	31/33 (93.9%) would recommend at 10-year follow-up	1 had superficial wound infection, and 1 had scrotal hematoma	6.1%
Mesh + AL tenotomy	Le, Zadeh, and Ben-David, 202012	86/93 (92.5%) within 28 days	NR	NR	7 had recurrence of pain/symptoms, 2 had urinary retention, 1 had pain along the adductor magnus/brevis group with activity, and 1 had adductor brevis hematoma at 3 months postoperatively	11.8%
Mesh + AL tenotomy	Mei-Dan et al,25 2013	NR	10.3 ± 3.8 weeks	NR	3 hematomas and 3 infections out of 48	12.5%
Mesh + AL tenotomy	Paajanen et al,28 2011	20/30 (66.7%) at 1 month, 27/30 (90%) at 3 months, and 29/30 (96.7%) at 12 months	NR	20/30 (66.7%) at 1 month, 27/30 (90%) at 3 months, and 30/30 (100%) at 12 months	1 had superficial infection with open tenotomy	16.7%
Mesh + AL tenotomy	Rossidis et al,35 2015	54/54 (100%)	24 days	NR	1 had urinary retention, and 1 had adductor brevis hematoma at 3 months postoperatively	3.7%
Primary tissue + AL tenotomy	Ahamuda et al, 17 2005	12/12 (100%)	NR	10/12 (83.3%) excellent, 2/12 (16.7%) satisfactory	1 had postoperative epididymitis, and 1 underwent revision surgery due to persistent pain	16.7%
Primary tissue + AL tenotomy	Dojčinović et al, 20 2012	70/75 with sports hernia surgery alone, 24/24 with concomitant adductor tenotomy	11.6 weeks	69/71 (97.2%) satisfied	None	0.0%
Primary tissue + AL tenotomy	Meyers et al,26 2000	152/157 (96.8%)	NR	142/160 (88.8%) successful, 10 (6.3%) moderately successful, 3 (1.9%) minimally successful, 5 (3.1%) unsuccessful	2 had superficial wound infections, and 1 had hematoma	1.9%
RA repair + AL tenotomy	Emblom et al,10 2018	82/85 (96.5%)	4.1 ± 2.3 mo	NR	2 had unconfirmed retears, 2 had superficial wound infections, 1 had hematoma, and 1 underwent revision surgery for heterotopic ossification; 8 experienced transient sexual dysfunction	7.1%
RA repair + AL tenotomy	Pedrinelli et al,29 2024	NR	135 days	NR	Infection, scar tissue formation, bleeding, delayed healing, recurrence of symptoms, and adductor magnus weakness	6.7%
RA repair + AL tenotomy	Rezaie et al,33 2024	83/92 (90.2%)	NR	NR	NR	NR
AL tenotomy	Gill et al,23 2020	31/32 (96.9%)	12 weeks	30/32 (93.8%)	None	0.0%
AL tenotomy	Mei-Dan et al,25 2013	NR	11.7 ± 5.4 weeks	NR	1 had hematoma out of 27 patients	3.7%,
Primary tissue + AL tenotomy + RA repair	Harr and Brody,11 2016	22/22 (100%)	NR	NR	None	0.0%

+ = plus, % = percentage, AL = adductor longus, mo = months, NR = not registered, RA = rectus abdominis, RTS = return-to-sport.

Among the 21 studies reporting RTS outcomes, 1372 of 1433 patients (95.7%) returned to sport at final follow-up. RTS rates were slightly higher after laparoscopic approaches (97.5%) compared with open procedures (94.7%). Overall complication rates were low, with 74 of 1435 patients (5.16%) experiencing a perioperative complication. Complications were more frequent after TAPP repair (9.8%) compared with TEP repair (3.8%).

Outcomes by Surgical Repair Category

Although PROM and pain scores were predefined outcomes of interest, substantial heterogeneity in measurement instruments, reporting methods, and follow-up intervals precluded meaningful cross-study comparison or pooled analysis. Accordingly, these outcomes are reported descriptively in Table 1 rather than synthesized across surgical technique categories.

Mesh Repair

Twelve studies evaluated mesh-based repairs.^{18,19,22,24,30-32,34,36,37,39,40} RTS rates were consistently high, ranging from 83.9% to 99.3%, with several studies reporting RTS within 4 to 6 weeks. Complication rates ranged from 0% to 12.6%, most commonly involving postoperative inguinal pain, seroma, urinary retention, or hematoma.

Primary Tissue Repair

Four studies assessed primary tissue repair techniques.^21,27,36,38 RTS rates ranged from 81.8% to 96.9%, with many patients returning to sports within 2 to 4 weeks. Reported complication rates were low (0-14.3%) and primarily consisted of superficial wound infection or hematoma.

Mesh Repair with Adductor Longus Tenotomy

Four studies evaluated mesh repair combined with AL tenotomy.^12,25,28,35 RTS rates ranged from 90% to 100%, often within 3 to 4 weeks, with high patient satisfaction when reported. Complication rates ranged from 3.7% to 16.7%, predominantly transient urinary retention, hematoma, or superficial infection.

Primary Tissue Repair with Adductor Longus Tenotomy

Three studies assessed primary tissue repair combined with AL tenotomy.^17,20,26 RTS rates were consistently high (96.8% to 100%), with reported RTS times between 4 and 12 weeks. Complication rates were low (0-16.7%).

Rectus Abdominis Repair with Adductor Longus Tenotomy

Three studies evaluated RA repair combined with AL tenotomy.^10,29,33 RTS rates ranged from 90.2% to 96.5%, with reported RTS times of approximately 4 months when available. Complication rates ranged from 6.7% to 7.1%, including superficial infection, hematoma, and transient postoperative symptoms.

Isolated Adductor Longus Tenotomy

Two studies evaluated isolated AL tenotomy.^23,25 RTS rates were high (96.9% in one study), with return to sport at approximately 12 weeks. Complication rates were minimal (0-3.7%).

Primary Tissue Repair with Adductor Longus Tenotomy and Rectus Abdominis Repair

One study evaluated a combined approach incorporating primary tissue repair, AL tenotomy, and RA repair.¹¹ All patients (100%) returned to sport, with no reported complications, although conclusions are limited by the single-study design.

Quality Assessment

Across the 18 noncomparative included studies, MINORS scores ranged from 5 to 12 with a mean of 8.4 (Table 3).¹⁴ The category that comprised the most “lack of report (0)” was the “prospective calculation of the study size,” with only one study conducting it. Using the ROBINS-I tool for nonrandomized comparative studies, six were included studies and five were judged to carry a serious risk of bias, while one was judged to carry a moderate risk (Table 4).¹⁵ The measurement of outcomes domain was the most likely domain to be judged as having a serious risk of bias, with three studies being assigned a serious risk. The most pervasive issue was the absence of blinding in reporting outcomes. Furthermore, many studies relied on subjective, retrospective data (such as long-term follow-ups through telephone) or used nonvalidated, internally defined metrics of success (such as measuring outcomes as “satisfactory”). The 3 RCTs included in this systematic review were judged based on the RoB2 criteria, with the 100% of them having a low overall risk of bias (Table 5).¹⁶

Table 3.

Quality Assessment of Studies Using the MINORS Criteria

Study	A Clearly Stated Aim	Inclusion of Consecutive Patients	Prospective Collection of Data	End Points Appropriate to the Aim of the Study	Unbiased Assessment of the Study End Point	Follow-up Period Appropriate to the Aim of the Study	Loss to Follow-up Less Than 5%	Prospective Calculation of the Study Size	An Adequate Control Group	Contemporary Groups	Baseline Equivalence of Groups	Adequate Statistical Analyses	Total Score
Ahamuda et al, 200517	2	1	0	1	0	1	2	0	N/A	N/A	N/A	N/A	7
Dojčinović et al, 201220	2	1	2	2	0	2	2	0	N/A	N/A	N/A	N/A	11
Edelman and Selesnick,22 2006	2	1	0	2	0	2	2	0	N/A	N/A	N/A	N/A	9
Emblom et al,10 2018	2	2	0	2	0	2	0	0	N/A	N/A	N/A	N/A	8
Gill et al,23 2020	2	1	0	2	0	2	0	0	N/A	N/A	N/A	N/A	7
Harr and Brody,11 2016	2	1	0	2	0	0	2	0	N/A	N/A	N/A	N/A	7
Le, Zadeh, and Ben-David,12 2020	2	1	0	2	0	0	0	0	N/A	N/A	N/A	N/A	5
Meyers et al,26 2000	2	1	2	2	1	2	2	0	N/A	N/A	N/A	N/A	12
Pedrinelli et al,29 2024	2	1	0	1	0	1	2	2	N/A	N/A	N/A	N/A	9
Pilkington et al,30 2021	2	1	1	2	0	2	0	0	N/A	N/A	N/A	N/A	8
Piozzi et al,31 2019	2	1	0	1	0	2	2	0	N/A	N/A	N/A	N/A	8
Preskitt,32 2011	2	1	0	2	0	1	2	0	N/A	N/A	N/A	N/A	8
Rezaie et al,33 2024	2	1	0	2	1	2	0	0	N/A	N/A	N/A	N/A	8
Rossidis et al,35 2015	2	1	1	1	0	1	2	0	N/A	N/A	N/A	N/A	8
Srinivasan and Schuricht,37 2002	2	1	0	1	0	2	0	0	N/A	N/A	N/A	N/A	6
Van Meierhaeghe et al,38 2019	2	2	1	2	0	2	2	0	N/A	N/A	N/A	N/A	11
Wilson and Hickey,39 2019	2	2	1	2	0	2	2	0	N/A	N/A	N/A	N/A	11
Ziprin et al,40 2008	2	2	0	1	0	1	2	0	N/A	N/A	N/A	N/A	8

MINORS = Methodological Index for Non-Randomized Studies, N/A = not applicable.

Table 4.

Risk of Bias Assessment of Studies Using the ROBINS-1-v2 Tool

Study	Confounding	C Of I	Selection of Participants	Deviations from II	Missing data	Measurement of outcomes	Selection of RR	OR
Bernhardt et al18 2014	Serious	Moderate	Low	Moderate	Serious	Serious	Moderate	Serious
Brans et al,19 2019	N/A	Moderate	Low	Low	Serious	Moderate	Moderate	Serious
Economopoulos et al,21 2013	Serious	Serious	Low	Moderate	Low	Serious	Moderate	Serious
Matikainen et al,24 2017	N/A	Moderate	Low	Low	Low	Low	Low	Moderate
Muschaweck and Berger,27 2010	N/A	Moderate	Low	Low	Low	Serious	Low	Serious
Roos et al,34 2018	N/A	Moderate	Low	Low	Serious	Moderate	Moderate	Serious

C of I = classification of interventions, II = intended interventions, N/A = not applicable, OR = overall risk, ROBINS = Risk of Bias in Non-Randomized Studies of Interventions, RR = reported results.

Table 5.

Cochrane Risk-of-Bias Tool for Randomized Trials

Study	D1	D2	D3	D4	D5	Overall
Mei-Dan et al,25 2013	+	+	+	+	+	+
Paajanen et al,28 2011	+	+	+	+	+	+
Sheen et al,36 2019	+	+	+	+	+	+

Cochrane risk-of-bias tool for randomized trials = RoB2, + = low risk of bias.

Discussion

This systematic review highlights a meaningful clinical and surgical dichotomy in the management of CMIs: treating CMI as a hernia-type structural deficiency versus treating it as a muscle/tendinous injury involving direct rectus abdominis and adductor longus pathology. Both approaches seem to have merit, with high RTS rates and low complication rates reported regardless of approach. Viewing the evidence through this framework clarifies how surgical philosophy relates to outcomes such as return to sport, recovery time lines, and pain resolution. However, highly variable reporting of patient-reported outcome measures, including pain, satisfaction, or function, limits direct comparison of approach beyond RTS or complication rates.

Limitations and Future Directions

The evidence base for CMI surgical outcomes remains dominated by observational case series and expert cohort studies. Substantial variation in surgical techniques, rehabilitation protocols, and follow-up timing limits definitive conclusions about the superiority of any single approach. An additional limitation of this review is the marked heterogeneity in patient-reported outcome measures (PROMs), including the use of nonvalidated instruments, inconsistent definitions of clinical success, and variable follow-up intervals, which limited direct comparison across studies. Because most included studies were single-arm case series and definitions of return to sport and other clinical outcomes varied substantially across studies, comparisons between surgical techniques should be interpreted as descriptive rather than comparative, and no conclusions regarding the superiority of one technique over another can be made based on the current evidence. The absence of standardized outcome reporting reduces the ability to determine relative effectiveness between surgical techniques. Future research should prioritize prospective, comparative trials using uniform criteria and standardized functional outcomes to clarify optimal treatment pathways for specific CMI subtypes.

Hernia-type Repair: Posterior Wall Reinforcement (Mesh or Nonmesh)

A substantial body of evidence conceptualizes CMI and athletic pubalgia as a form of posterior inguinal wall dysfunction, even in the absence of a classic anatomic hernia defect. Sports hernia repair techniques focus on reinforcing the inguinal floor and restoring the abdominal wall, sometimes using mesh and sometimes suture-based reinforcement.^5,6,10 These approaches align with conventional hernia repair principles applied in the athletic population.

Surgical outcomes in this domain are consistently favorable, with most athletes returning to sport within 6 to 12 weeks and over 90% achieving successful return to preinjury activity levels.^5,6,10,41 Posterior wall repair may be performed open or laparoscopically (e.g., totally extraperitoneal or transabdominal preperitoneal techniques).^5,6,10,35 Systematic reviews show surgical return-to-play success rates between 90 and 100%, with no clear superiority between approaches, and a median time to activity around 4 weeks in many cohorts.^6,10,41 The studies included in this review demonstrate favorable outcomes after posterior wall reinforcement in appropriately selected patients. However, given the predominance of noncomparative studies and substantial heterogeneity, these findings should be interpreted as descriptive rather than evidence of superiority over alternative surgical paradigms.

Muscle/Tendinous Repair: Direct Rectus Abdominis and AL Management

By contrast, another widely used surgical paradigm treats CMI as primarily a muscle or tendinous disruption, particularly at the rectus abdominis insertion and its confluence with the adductor complex.^6,7,29 Surgical techniques within this paradigm include direct repair of the rectus abdominis to the pubis and, commonly, AL tenotomy/release to address chronic adductor-related groin pain and tension across the conjoined tendon region.^6,23,29

Evidence from case series of elite athletes demonstrates high RTS percentages (often >95%) and good functional recovery after direct muscle repair with AL release.^6,23,29 When direct rectus repair is combined with selective AL release, several series describe near-universal return to preinjury levels of competition, typically by approximately 12 weeks postoperatively.^6,23,29 The favorable outcomes reported in studies using direct rectus abdominis repair with adductor longus management suggest that this approach may be beneficial in patients with predominant musculotendinous pathology. However, the available evidence is largely derived from case series, precluding definitive conclusions regarding patient selection or comparative effectiveness.

Adductor Longus Management Across Paradigms

The favorable outcomes reported in studies using direct rectus abdominis repair with adductor longus management suggest that this approach may be beneficial in patients with predominant musculotendinous pathology. However, the available evidence is largely derived from case series, precluding definitive conclusions regarding patient selection or comparative effectiveness. Adductor tenotomy or release, when added to either repair strategy, was frequently performed in athletes with notable adductor tendinopathy.^6,23,29 Several cohorts show expedited resolution of adductor-related pain and strong return rates when AL management is included, suggesting that this adjunct may be instrumental for select athletes with mixed pathology.^6,23,29

When procedures were broadly categorized according to whether adductor longus management was included, both repair-only procedures (mesh or primary tissue repair) and repair procedures combined with adductor longus tenotomy demonstrated high RTS rates and low complication profiles. Although AL-inclusive procedures frequently reported RTS rates exceeding 90%, these findings should be interpreted cautiously because adductor management was generally reserved for patients with concomitant adductor pathology and the available evidence is predominantly derived from noncomparative case series. Consequently, the independent contribution of AL tenotomy to postoperative outcomes remains uncertain and warrants investigation in future comparative studies.

Comparative Interpretation and Clinical Implications

Both surgical strategies generally yield high levels of return to sport, with evidence indicating ≥90% success in return to preinjury competition.^6,7,10,35,41 The choice of technique should be influenced by

• Pathology pattern: Hernia-type posterior wall reinforcement may be preferable when clinical and imaging findings point toward posterior wall weakness without discrete tendon disruption.^5,6,10

• Direct tendon injury: When clear rectus or adductor tendinous disruption is present, direct muscle/tendon repair with AL management seems logical and effective.^6,23,29

• Adjunctive procedures: AL release enhances outcomes across approaches when adductor pathology coexists.^6,23,29

However, the literature is limited by heterogeneity in diagnostic criteria, surgical techniques, and outcome measures, with few high-level comparative studies directly contrasting these paradigms. Standardization in terminology and routine use of validated outcome measures is needed to enable future comparative effectiveness research. Instruments such as the Copenhagen Hip and Groin Outcome Score (HAGOS), Hip Outcome Score (HOS), and Tegner Activity Scale, all of which were used in several included studies, represent promising candidates for standardized reporting in future multicenter investigations. Nevertheless, these instruments are relatively broad and are not specifically designed to assess core muscle injury–related symptoms or function. Future studies would benefit from the development and adoption of more disease-specific patient-reported outcome measures, standardized RTS definitions, and uniform reporting of sport-specific performance metrics to facilitate more meaningful comparisons across surgical techniques and patient populations.^5-7,10,35

Conclusion

Both hernia-type posterior wall reinforcement and direct rectus abdominis repair, with or without adductor longus release, are effective for treating core muscle injuries in athletes, with high RTS rates. Future research should prioritize the use of validated and standardized PROMs with clearly defined RTS criteria to allow meaningful comparison across surgical techniques. Establishing uniform outcome reporting standards is essential to advance evidence-based surgical decision making in the management of core muscle injury. Surgical choice should be guided by the underlying pathology, with posterior wall reinforcement preferred for chronic abdominal wall attenuation and direct muscle repair for discrete tendon disruptions. Adductor longus release is a valuable adjunct when adductor involvement is present, and individualized treatment remains essential to optimize functional recovery.