sports herniassports hernia: pathophysiology • athletic activity, particularly pivoting, cutting,...
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Sports Hernias
Matthew Gimre, MD
ATC Conference, June 20, 2015
Sports hernia: So what is it?
• An injury to the rectus abdominis-common adductor aponeurosis, at the anterior/inferior aspect of the pubic bone. This can be a tear, partial tear, disruption, or avulsion.
• This initially was a diagnosis of exclusion, typically found during exploratory surgery (this is no longer the case).
• The term is a misnomer – it is not a true hernia!
• The term has fallen out of favor in the academic setting, and it is recommended to avoid its use.
Sports hernia: So what do we call it?
• Athletic pubalgia. “A clinical spectrum of disease associated with lower abdomen and groin injuries.”
• Inguinal-related groin pain.
• Core muscle injury.
• Huh?
• Are these any better?
Sports hernia: So what do we call it?
• I use “sports hernia”!
• Shhhh!
• If you use “sports hernia”, just know it is not the favored academic term.
• But, at least most people in the sports medicine community will know what you mean.
Sports hernia: pathophysiology
• Athletic activity, particularly pivoting, cutting, and kicking cause significant torque at the pelvis, including the rectus abdominis, adductor, and iliopsoas.
• Significant relationship between the core and hips.
• Any weakness or imbalance can cause overload, and lead to soft tissue injury.
• Typically, this is an overuse injury.
Sports hernia: pathophysiology
• The opposing forces of the rectus abdominis and adductor longus at the pubic bone cause the injury.
Sports hernia: diagnosis
• Groin pain, adductor pain, and or lower abdominal pain with athletic activity.
• Variable intensity and level of dysfunction.
• Possible tenderness at the pubic bone and lower rectus abdominis insertion.
• In my opinion, there typically is minimal to no tenderness along the adductor longus.
Sports hernia: diagnosis.
• Exam findings can include weakness and provocative pain with resisted hip adduction, abdominal crunch, and with a combined maneuver of simultaneous abdominal crunch and resisted hip adduction.
Sports hernia: diagnosis
• Direct examination of the inguinal canal may find mild dilatation of the external inguinal ring compared to the contralateral side, and possible pain with posterior inguinal wall pressure.
• No bulge.
Sports hernia: diagnosis
• Pelvis x-ray negative.
• With x-ray, you are looking for other possible pathology.
Sports hernia: diagnosis
• In the past, MRI could not find this.
• Today, a good MRI can find this, and is very useful!
• Findings are subtle!
• Normal appearance on sagittal cut through the pubic bone.
• Abnormal finding, with abnormal soft tissue edema consistent with injury.
Sports hernia: diagnosis
• Abnormal coronal plane.
• Abnormal transverse plane.
Simple, right?
• Maybe, but the history, exam, and diagnostics can be subtle.
• Plus …
Differential diagnosis
• True inguinal hernia.
• Osteitis pubis.
• Stress fracture.
• Intra-articular pathology, including hip impingement.
• Apophysitis/avulsion.
• Peripheral neuropathy.
• Radiculopathy.
• Other muscle/tendon injuries.
•
• Other!
Treatment
• Non-surgical. Rest. Rehab to balance/strengthen hip and core musculature.
• Surgical. Can be considered if non-surgical treatment is not working after about 6 weeks.
Treatment• Surgical treatment consists of repair
and tightening of pelvic floor. This is general surgery, not orthopaedic surgery.
• Open. Typical return to sports in 12-16 weeks.
• Laparoscopic with mesh. Return to play in about 6 weeks.
• Minimally invasive open, with localized repair (guided by high-res ultrasound), and decompression of genital branch of genitofemoral nerve. Pioneered in Germany. Return to play in 4-5 weeks, sometimes sooner (!).
• All can have good results.
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