the “sports hernia”€¢ no visible or palpable signs of “hernia” • pain with resisted...

The “Sports Hernia”

Russell Steves M.Ed, ATC, PTPrinceton University

Why Should I Care?

• You may run into it– An athlete with groin pain not getting better

• You may read about it– An athlete may read about it

• It’s a difficult diagnosis to get right

Why Is It Tough to Get Right?

• Broad area for symptoms• Many possible diagnoses• Unfamiliar anatomy• Interchangeable names for “sports

hernias”

Today’s Purpose

• Explain the different pathologies that are described as “sports hernias”

• Teach clinicians how to identify sports hernias in their athletes

• Describe the effective treatments for sports hernias– Surgery

Where does it hurt?

Many Causes of Groin Pain

Groin Pain Pathologies

• Musculo-tendinous Injury– Hip flexors– Hip adductors– Abdominals– Enthesopathy

• Adductor longus• Rectus abdominus

Groin Pain Pathologies

• Hip joint pathology– Sprain– Arthritis

• OA• DJD

– Acetabular labral tear– Femoral head/neck AVN

Groin Pain Pathologies

• Stress fractures– Pubic rami– Femoral head/neck

• Avulsion fractures– AIIS/ASIS– Lesser trochanter– Pubic symphysis

Groin Pain Pathologies

• Iliopectineal bursitis• Osteitis pubis• Pelvic girdle dysfunction• Lumbar spine pathology

– Facet joint injury– Disk protrusion– Spondylolysis/spondylolisthesis

Groin Pain Pathologies

• Nerve entrapment– Ilioinguinal– Genitofemoral– Obturator

• Prostatitis• Varicocele testis• Osteomyelitis at pubic symphysis

Groin Pain Pathologies

• “Sports hernias”– Gilmore’s groin– Athletic Pubalgia– Symphysis syndrome– Hockey groin syndrome– Hernia

• Conventional• Occult (Sportsman’s)

Regional Anatomy

Clemente CD. Anatomy. Baltimore. Williams & Wilkins. 1997. 253.

Fitzgibbons RJ Jr. Nyhus-Condon’s Hernia. Phila. Lippincott Williams & Wilkins. 2002. 22.

Netter FH. Atlas of Human Anatomy. Teterboro,NJ. Icon Learning Sys. 2003. 253.

Identifying Sports Hernias

Common History

• Gradual onset• Unilateral pain, but not exclusively• Males• Pain in groin and lower abdominal regions

– May extend into genitals• Pain with activity and ceases with rest,

only to return with activity• Doesn’t “feel” like a muscle strain

Physical Exam

• Hip ROM– Flexion– Flexion and IR– Flexion, adduction, IR– IR and ER– FABERE’s

Physical Exam

• Resisted hip motions– Flexion (knee flexed/SLR)– Adduction– Diagonal adduction

• Passive hip motions– Hip extension– Abduction

Physical Exam

• Resisted abdominal movements– Sit-up– Sit-up with rotation– Pelvic curl-up

Physical Exam

• Palpation– Inguinal ligament as dividing line

• Special tests– Bilateral adduction– Bilateral adduction with fingertip pressure

Physical Examination

• No visible or palpable signs of “hernia”• Pain with resisted bilateral hip adduction• Provocative test

– Fingertip pressure over inguinal canal• Palpable tenderness

– Inguinal canal– Adductor longus

Physical Examination

• Doesn’t fit with other pathologies• Negative x-ray and MRI

– Herniography?– Diagnostic US?

Typical MRI

Typical MRI

Diagnostic US

Diagnostic US

Diagnostic US

Types of Sports Hernias

Gilmore’s Groin

• Pathology– Tear in external oblique aponeurosis– Conjoined tendon tears from pubic tubercle– Conjoined tendon splits from inguinal ligament

Gilmore J. Clinics in Sports Med. 1998. 17. 787-793.

Netter FH. Atlas of Human Anatomy. Teterboro,NJ. Icon Learning Sys. 2003. 253.

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2

3

Gilmore’s Groin

• Identified by tenderness and dilation of external inguinal ring

• Repaired by suturing tears• Return to full activity in 4 weeks

Athletic Pubalgia

• Chronic inguinal or pubic area pain• Pain only on exertion• No other medical diagnosis• Biomechanical injury

– Weak lower abdominals– Resulting in anterior pelvic tilt– Overuse of adductors and lower abs

Meyers WC et al. Am J Sports Med. 2000. 28. 2-8.

Athletic Pubalgia

• Identified by tenderness in the region and frustration

• Surgical repair– Reinforce conjoined area with suturing and

adductor release• Full recovery in 3 months

Skandalakis JE et al. World J Surg. 1989. 13. 493.

Rohen JW et al. Color Atlas of Anatomy. Phila. Lippincott Williams & Wilkins. 2002. 438.

Symphysis Syndrome

• Dilation of superficial inguinal ring• “Weakness” of external oblique

aponeurosis• Deficiency of inguinal canal posterior wall• Identified by tenderness in inguinal region

Biedert RM et al. Clin J of Sports Med. 2003. 13. 278-284.

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3

Fitzgibbons RJ Jr. Nyhus-Condon’s Hernia. Phila. Lippincott Williams & Wilkins. 2002.69.

Symphysis Syndrome

• Surgical repair– Reinforce conjoined area– Release and denervation of rectus abdominus

insertion– Release of adductor longus and gracilis

• Full recovery in 8-12 weeks

Hockey Groin Syndrome

• Tear of external oblique aponeurosis• Entrapment of ilioinguinal nerve

Irshad K et al. Surgery. 2001. 130. 759-766.

Hockey Groin Syndrome

• Identified by– Tenderness in inguinal region– Dilated external inguinal ring– Gap in external oblique aponeurosis upon

exertion• Surgery

– Repair tear with synthetic mesh– Excise nerve– Full Recovery in 8 weeks

Fitzgibbons RJ Jr. Nyhus-Condon’s Hernia. Phila. Lippincott Williams & Wilkins. 2002.69.

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Sports(man’s) Hernia

• “Conventional” hernias– Femoral– Obturator– Umbilical– Inguinal

• Direct• Indirect

Fitzgibbons RJ Jr. Nyhus-Condon’s Hernia. Lippincott Williams & Wilkins. 2001.

Indirect

Direct

Fitzgibbons RJ Jr. Nyhus-Condon’s Hernia. Lippincott Williams & Wilkins. 2001.

Both

Femoral

Sports Hernia

• Occult hernia– Not visible or palpable

• Defect in the posterior wall of inguinal canal– A hole or a thinning of the tissue – Genetic?

Sports Hernia

• Identified by tenderness in inguinal region• Herniography

– Dye injected into peritoneum– Not common in US

• Diagnostic ultrasound– Exertion manuever– Also not common in US

Sports Hernia

• Surgical repair same as “conventional”hernias– Suture posterior wall– Synthetic mesh over posterior wall– Laparoscope with mesh

• Full recovery in 4 to 6 weeks

Open Surgical Repair

• Modified Bassini procedure• Shouldice technique

Open Surgical Repair

Fitzgibbons RJ Jr. Nyhus-Condon’s Hernia. Lippincott Williams & Wilkins. 2001.

Open Surgical Repair

Open Surgical Repair

Open Repair with Mesh

• Lichtenstein technique– Tension-free procedure

Mesh Repair

Bendavid R. World J Surg. 1989. 13. 525.

Closed Surgical Repair

• Laparoscopic technique with mesh• TAPP repair

– TransAbdominal Pre-Peritoneal

Laparoscopic Repair

Laparoscopic Repair

Rehabilitation

• Conservative management– Get through season, then surgery– Post-operative rehab

Conservative Treatment

• Pain Control– NSAIDs– Therapeutic modalities– Cortico-steroid injections– Spica wrap or girdle

• Therapeutic Exercise– Muscle balancing about the pelvis

Therapeutic Exercise

• Leg raises (with draw-in)– Flexion– Abduction– Extension– Adduction– Horizontal abduction– Diagonal adduction

Therapeutic Exercise

• Core exercises– Partial sit-up– Sit-up with rotation– Pelvic curl-up– Side lifts– Opposite arm/leg lift– Double leg lifts

Therapeutic Exercise

• Flexibility exercises– Hamstrings– Adductors– Hip flexors– Posterior hip– Modified hurdler’s stretch

Post-op Rehab

• 0-2 Weeks– Rest

• Allow incision to heal• Post-op pain to subside

– After 1 week, begin walking• Not power walking

2 – 4 Weeks

• Begin strengthening/stretching exercises– Leg raises– Core activation (draw-in)– Passive hip stretches

• Stationary bike for fitness• Wall squats

– Without, then with, ball squeeze

4 – 6 Weeks

• Progress to more intense exercises– Partial sit-ups

• Begin skating or jogging– Progress to running

• Initiate sport-specific drills– Shooting, kicking, or throwing

• Continue with lower intensity weight lifting

6 Weeks

• Resume normal conditioning and weight lifting programs

• Return to full sports activity with asymptomatic:– Full speed sprint– Lateral movement– Cutting/pivotting– Shuttle sprint

Princeton’s Program

• Athlete presents to ATC with groin pain• ATC evaluation raises suspicions

– Begin conservative care• Refer to MD

– Early, if suspicions are high– After no progress

Princeton’s Program

• MD evaluation– Hernia check– Get x-ray and MRI

• General surgeon consult– Diagnostic US in office

• Schedule surgery – When schedule allows

Princeton’s Program

• Return to ATC for post-op rehab• Return to full participation

– Excellent results in 26/26 patients

Key Points

• Groin pain is fairly common in athletes• Some problems are very resistant to

getting better• Keep in mind that these pathologies exist• Realize there are very few ways to

accurately identify their presence• Very commonly identified outside US

Key Points

• Which pathology applies is very surgeon dependent

• All have in common a reinforcement of the inguinal region

• Recovery rates after surgery are excellent

Thank You

References

• Sports hernia– Joesting DR. Curr Sports Med Rep. 2002;1:121-24.– Fon LJ, Spence RAJ. Br J Surg. 2000;87:545-52.– Azurin DJ, et al. J Lap Adv Surg Tech. 1997;7:7-12.– Ingoldby CJH. Br J Surg. 1997;84:213-5.– Malycha P, Lovell G. Aust NZ J Surg. 1992;62:123-5.– Polglase AL, et al. Med J Aust. 1991;155:674-7.

References

• Gilmore’s groin– Gilmore J. Clinics in Sports Med. 1998;17:787-93.

• Athletic pubalgia– Meyers WC, et al. Am J Sports Med. 2000;28:2-8.

• Symphysis syndrome– Biedert RM, et al. Clin J Sports Med. 2003;13:278-84.

• Hockey groin syndrome– Irshad K, et al. Surgery. 2001;130:759-66.

References

• Herniography– Kesek P et al. Acta Radiol. 2002 Nov;43(6):603-8.– Helse CP et al. Ann Surg. 2002 Jan;235(1):140-4.– Gwanmesia II et al. Postgrad Med J. 2001

Apr;77(906):250-1.– Leander P et al. Eur Radiol. 2000;10(11):1691-6.– Yilmazlar T et al. Acta Chir Belg. 1996 Jun;96(3):115-

8.– Makela JT et al. Ann Chir Gynaecol. 1996;85(4):300-

4.

References

• Diagnostic US– Steele P et al. J Sci Med Sport. 2004 Dec;7(4):415-

21.– Bradley M et al. Ann R Coll Surg Engl. 2003

May;85(3):178-80.– Lilly MC, Arregui ME. Surg Endosc. 2002

Apr;16(4):659-62.– Orchard JW et al. Br J Sports Med. 1998

Jun;32(2):134-9.

Literature Review

• Rates of full recovery – Gilmore’s groin – 1164/1200 (97%)– Athletic pubalgia – 152/169 (90%)– Symphysis syndrome – 24/24 (100%)– Hockey groin syndrome – 52/56 (93%)– Sports hernia – 219/243 (90%)– Combined - 1611/1692 (95%)