Sports Hernias

By admin On Nov 9, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Sports Hernias

Aaron Lee

William W. Briner Jr.

Basics

Description

The sports hernia is a syndrome of chronic pain owing to weakness or injury to the posterior inguinal canal, conjoined tendon, and common adductor origin.
Described as a “phenomenon of chronic activity-related groin pain that is unresponsive to conservative therapy and significantly improves with surgical repair” (1)[C]
Historically, it was considered to be an early direct inguinal hernia, but more recently this has been called into question because there is no palpable hernia on physical exam, and hernia has not been evident at surgery in these patients. Thus the term sports hernia may in fact be considered a misnomer (1,2,3)[C].
Synonym(s): Athletic pubalgia; Sportsman's hernia; Inguinal ligament sprain; Gilmore groin; Footballer's groin/hernia

Epidemiology

Incidence

Unknown; far more common in soccer players
Also described in football, hockey, and baseball players in the U.S. and rugby players abroad
Predominant gender: Males account for >90% of cases.

Risk Factors

Activities with high-speed twisting and turning, such as soccer and rugby

General Prevention

Strength and conditioning programs that stress flexibility, core strength and sport specific movements have been suggested. There may be a strength imbalance of musculature below the pubic symphysis over muscles above, so abdominal oblique and rectus strengthening may be beneficial, however research is currently lacking (1)[C]

Etiology

Pathogenesis is unclear but:

May involve some aspect of congenital inguinal wall weakness
Likely related to overuse with some combination of muscle strength, balance, stability, or endurance inequality between the abdominal musculature and the adductor muscle group
A resulting tear in the rectus complex and conjoined tendon may extend into the internal or external ring of the inguinal canal, causing pain and weakness and contributing to the sports hernia.

Commonly Associated Conditions

Groin pain is often multifactorial. In particular, chronic adductor strain may coexist with athletic pubalgia.

Diagnosis

History

Early in course, groin pain is felt after activity or toward the end of activity.
As condition progresses, pain is more severe and occurs earlier in activity. Decreased ability to twist, turn, or stride out is observed. Later in course, pain occurs with running and may progress to affect daily activities.
Pain may radiate to uninvolved side or scrotum.
Painful intercourse
Pain with coughing/Valsalva maneuver
Often more intense and felt more “internally” than groin strains
Resolves with prolonged abstinence from training but recurs with return to activity
Groin pain with exercise
Exacerbated by sudden movements
Usually unilateral
Often insidious in onset but may occur after sudden tearing sensation
Chronic in nature; may progress to affect daily activities, even getting out of bed
In soccer players, pain worse with long kicks and hard shots

Physical Exam

Inversion of scrotal skin and palpation along inguinal canal is the essential physical exam technique.
- Most tender posteriorly in midinguinal canal and at pubic tubercle
- Dilated superficial ring
- Inguinal floor tear that may be palpable and cause tenderness inside the external inguinal ring
- Pain worse with Valsalva or sit-ups, with minimal bulging occasionally palpable
Lack of palpable hernia
Also have tenderness of the conjoined tendon
Hip adductor origin tenderness and pain with resisted adduction suggest chronic adductor strain.
Careful hip/genitourinary exam should be performed.
Palpate pubic symphysis for tenderness that would be consistent with osteitis pubis.

Diagnostic Tests & Interpretation

Imaging

There is no diagnostic imaging test for athletic pubalgia. Imaging studies likely will all be negative if this is the lone diagnosis.
Primarily to rule out other causes of chronic groin pain
Plain films to rule out fracture and pubic symphysis asymmetry

P.553

Bone scan/CT scan may identify stress fractures, osteitis pubis.
MRI/MR arthrography may be helpful to identify muscle, tendon, or intraarticular pathology.
MRI survey of the pelvis is recommended initially to identify areas of possible pathology that allow a more specific, high-resolution, small field of view study to take place (3)[C].
US is emerging as a diagnostic tool, particularly in Europe, but it is highly operator-dependent; allows dynamic visualization of tissues.
Herniography used in Europe

Differential Diagnosis

Inguinal hernia
Chronic adductor strain
Chronic rectus abdominis strain
Bursitis: Especially iliopectineal bursa
Ilioinguinal nerve entrapment
Snapping hip syndrome
Femoral hernia
Femoral neck stress fracture
Pubic ramus fracture
Osteitis pubis
Intraarticular hip pathology
Testicular/ovarian pathology
Referred pain from herniated disk or spondyloarthropathy
Chronic groin pain is often multifactorial. Sports hernia often coexists with one or more of these diagnoses owing to the close proximity of anatomic structures.

Treatment

Long-term rehabilitation
Special considerations (1)[C]:
- Conservative measures may not be effective.
- A rest period of 6–8 wks followed by a rehabilitation program focusing on abdominal oblique and rectus strengthening and hip adductor stretching with sport-specific functional exercises may be beneficial.
- A gradual return to full sports activity should be attempted.
- Entire process may take as long as 10–12 wks.
Rehabilitation (1)[C]:
- Mainly postoperative
- Pelvic strength/flexibility exercises
- Non-weight-bearing exercises as tolerated
- Return to running at 3–5 wks, avoiding twisting and cutting movements
- Return to prior level of activity at 6–8 wks, possibly sooner with close attention to functional rehabilitation

Surgery/Other Procedures

Herniorrhaphy is the definitive treatment. Anatomic repair of all layers of tissue must be undertaken. Anchoring sutures to the pubic symphysis are usually necessary.
Open or laparoscopic surgical techniques have both been reported to be effective at similar rates.
Laparoscopic technique generally allows for an earlier return to functionality but may have a slightly lower success rate because the involved structures may not be fully visualized and repaired (1,2)[C].

References

1. Caudill PH, Nyland JA, Smith CE, et al. Sports hernias: a systematic literature review. Br J Sports Med. 2008.

2. Johnson JD, Briner WW: Primary care of the sports hernia: Recognizing an often-overlooked cause of pain. The Physician and Sportsmedicine, 2005;33:35–39.

3. Meyers WC, McKechnie A, Philippon MJ, et al. Experience with “sports hernia” spanning two decades. Ann Surg. 2008;248:656–665.

Additional Reading

Omar IM, Zoga AC, Kavanagh EC, et al. Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics. 2008;28:1415–1438.

Codes

ICD9

848.8 Other specified sites of sprains and strains

Clinical Pearls

In a true hernia, there is protrusion of bowel into the inguinal canal. A sports hernia is a weakness or injury of the posterior inguinal canal with no protrusion of bowel into the canal.
Symptoms are likely to resolve with prolonged rest. Rehabilitation to strengthen the abdominal muscles may be helpful. However, symptoms often recur with resumption of activity. Therefore, surgery with herniorrhaphy is the treatment of choice.
Prognosis:
- Studies seem to indicate at least an 80–90% rate of return to prior level of activity. Although groin pain is often multifactorial, if sports hernia is the only source of pain, surgery is curative. Although there is no definitive diagnostic test readily available, surgery is often both diagnostic and therapeutic. If there are other components to the pain, they also need to be addressed, ideally prior to surgery.