Professor David Lloyd – Surgery for Groin Pain – The Lloyd Release Procedure – Injury Rehab Network Event

The Injury Rehab Network event in November 2023 with BASRaT featured Professor David Lloyd. The online event took place on the evening of 8th November with 175 sports rehabilitation professionals in attendance.

Professor Lloyd’s presentation discussed surgery for groin pain. The recording is available to watch here

Professor David Lloyd (MBBS, FRCS, PhD)

Professor David Lloyd is Professor of Hepatobiliary, Laparoscopic and Groin Surgery at the University of Leicester, UK. He trained as a liver transplant surgeon in London, Chicago and Hamburg and has pioneered many laparoscopic procedures and developed a microwave machine to treat liver cancer, which is now being used all around the world.

He has a special interest in groin surgery and groin anatomy and has described a new third type of inguinal hernia, which challenges the current definition of only having two. He has also developed a new procedure for the treatment of groin pain known as the Lloyd Release Procedure, which releases the tension in the inguinal ligament and strengthens the groin. This procedure has proven successful for elite athletes and is beneficial for the treatment of some patients with chronic groin pain, particularly those who have undergone previous open mesh repair of an inguinal hernia.

He has an international practice attracting elite athletes from around the world. He has operated on many elite rugby players, including Shane Williams and Stuart Lancaster and hundreds of elite football players. Glen Murray, Michael Carrick, Peter Crouch, and Scott McTominay from Manchester United have all had the Lloyd Release Procedure. It was Jamie Vardy’s successful operation which focussed the sporting world. Professor Lloyd operated on Jamie Vardy in the middle of the 2015-6 season when he scored 11 goals in 11 successive games. Jamie then helped Leicester City win the Premier League. The Lloyd Release Procedure was hailed as a success, and Professor Lloyd now has an international practice.

Surgery for Groin Pain – The Lloyd Release Procedure

Approximately 5% of athletes will suffer from groin strain during their sporting career. Most of whom will recover with conservative treatment and physiotherapy. However, some will require specialist surgery, particularly those with high-impact sports such as football and rugby.

Most clinicians agree that there is a weakness in the groin which needs to be strengthened either by open surgery or laparoscopic surgery. Professor Lloyd believes that many athletes develop a strain or a repetitive injury to the inguinal ligament at the attachment to the pubic tubercle, which causes increased tension and pain. If the ligament and tension are released and the groin reinforced with a soft mesh, then most athletes can return to their sport within weeks.

International guidelines suggest that all groin hernias should be treated laparoscopically and not by open surgery. Therefore, if there is a weakness or small hernia, then these athletes should have a mesh repair performed laparoscopically and not undergo open surgery. The Lloyd Release Procedure is performed laparoscopically, releases the tension in the inguinal ligament and reinforces the whole groin area with a mesh.

Over 90% of professional athletes return to sport within four weeks. Professor Lloyd believes that vague terminologies such as sports hernia, sportsman’s groin and Gilmore’s groin should be abandoned and replaced with more anatomical terms such as inguinal ligament disruption, adductor tendinopathy, and posterior inguinal wall weakness.

For information and resources, please visit The Lloyd Release Procedure website

Introduction

Professor Lloyd discussed the aims of the presentation, including:

• Review of groin anatomy
• Concept of inguinal ligament disruption
• Release procedure for groin pain

David considered the incidence of groin pain, which is very common (5% of athletes), is more common in twisting sports and more common in men.

Terminology

Professor Lloyd discussed how terminology surrounding groin pain can be very confusing, with many practitioners even wrongly referring to the groin when discussing thigh, hamstring or hip injuries. The correct definition is that the groin is on either side of the Inguinal Ligament.

Professor Lloyd described how upper groin pain is commonly associated with the Inguinal Ligament and Pubic Tubercle.

Many confusing eponyms are used to describe groin pain, which causes mass confusion among patients and practitioners. Professor Lloyd’s advice is to avoid vague terms such as sportsman’s hernia and to instead use anatomical terms including Inguinal ligament disruption. David stated that groin pain is groin pain and is not a hernia.

Inguinal Ligaments

Professor Lloyd described the clinical presentation of Inguinal Ligament Disruption where he thinks of the anatomy as a Pubic Clock. Tension in the Inguinal Ligament causes pain (not dissimilar to tennis elbow). A careful clinical examination is essential. Professor Lloyd considered the mechanism of injury. An MRI is not usually helpful for the assessment of groin pain.

Treatment

Professor Lloyd initially advises conservative treatment and may undertake a diagnostic test with 10mls of local anaesthetic.

If groin pain persists, further treatment of a 40mg Depo plus 10 ml local anaesthetic may be injected into the affected area.

If the above treatment is not successful, then Professor Lloyd will perform the Release Procedure.

Case Studies

Professor Lloyd presented case studies of football and rugby players who had suffered groin pain/ injuries. David discussed the mechanism of injury, treatment and return to play with one player who competed just eight days post-surgery.

Professor Lloyd also discussed a case study of a young woman who was using a wheelchair due to the severity of groin pain. Following surgery with the Lloyd Release Procedure, the patient was able to walk and improved markedly.

Another 18-year-old woman injured her right groin while doing ballet. Treatment included the Release Inguinal Ligament, and Meralgia Parasthetica was treated with neurolysis.

An SAS soldier was able to return to training with a 40kg backpack four weeks after the operation.

David discussed how many football and rugby players have had successful Lloyd Release Procedures (some now 10 or 20 years after the Release Procedure).

Evidence and Conclusions

Professor Lloyd discussed how consensus has been reached with clinicians in agreement with the term Inguinal Disruption to describe groin pain associated with abnormal tension in the groin, particularly around the inguinal ligament.

David concluded the presentation with a summary of the key points covered:

• Inguinal ligament disruption is a proven pathological entity.
• The term Sportsman’s Hernia should never be used.
• Careful clinical examination is paramount.
• The Lloyd Release is an excellent treatment for groin pain.

Q&A

Professor Lloyd answered questions put forward by practitioners who attended the session. Please see the presentation recording for the insights from David to the questions.

Presentation Recording

The recording of Professor Lloyd’s presentation is available to watch here

Follow Professor David Lloyd

• Professor David Lloyd Website
• The Lloyd Release Procedure website includes groin anatomy, post-surgery recovery, rehabilitation and return to play resources

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