Medial Groin and Hernia:
Sonographic Evaluation
Adam M. Pourcho DO
Swedish Sports Medicine
Disclosures
Hernia Eval Takes Practice: Fake it till you make it
Objectives
• Understand anatomy of medial hip and hernias
• Go over inguinal, direct, indirect, Spigelian, and “sports
hernia”
• Scanning protocols for each
Ways to illicit a Hernia
• 1. Bearing down(Valsalva)
– Try blowing on back of hand
• 2. Lifting shoulders
• 3. Bearing down while lifting shoulders
• 4. Coughing
• 5. Standing Evaluation
Femoral Triangle Anatomy
• Femoral Canal
– Femoral artery and vein
– Femoral Br.
Genitofemoral nrv
– lymph nodes
– Femoral nerve is
separate
• More common in
females
– Common post-pardum
Femoral Canal Scanning
n av
RT FC SAX MED
Femoral Hernia Valsalva: Normal
RT FC SAX MED
Femoral Hernia
RT FC LAX DISTRT FC SAX MED
Inguinal Canal Anatomy
• Deep and superficial rings
• Females
– Round ligament of Uterus
• Males
– Spermatic cord
– Testicular artery and vein
– Artery to Vas Deferens
– Pampiniform Plexus
– Genital br. Genitofemoral
Nrv
– Vas deferens
– Lymph
– Processus Vaginalis
– Autonomic nerves
Scanning for Direct/indirect hernias
a
v
RT FC SAX MED
Inguinal Canal Males vs Females
a
v
RT MALE IC SAX MEDRT FEM IC SAX MED
a v
Female Male
Finding Inferior Epigastric Arteries
RT IEA SAX MEDRT IEA SAX MED
RA
Inguinal Canal: Normal
RT IC SAX MED
SAX to IEA
Indirect Inguinal Hernia
SAX to IEALAX to IEA
Slides courtesy of Doug Hoffman, MD
Direct Inguinal Hernia
Slides courtesy of Doug Hoffman, MD
Spigelian Hernia
• Spigelian hernia (1-2% of all hernias) is the protrusion of
preperitoneal fat, peritoneal sac, or organ(s) through a congenital
or acquired defect in the spigelian aponeurosis
– the aponeurosis of the transverse abdominal muscle limited by
the linea semilunaris laterally and the lateral edge of the rectus
muscle medially
Skandalakis, PN. Et al. 2006
Scanning for Spigelian Hernia
RT ABD SAX MED
Spigelian Hernia
Slides courtesy of Doug Hoffman, MD
“Sports Hernia” / Athletic Pubalgia
• Its not athletic pubalgia
• Its not osteitis pubis/ pubic instability
• Its not adductor/gracillis tendinopathy
• Its not rectus abdominus or conjoint
tendinopathy
• Its not a hernia
• It is tranversalis diastasis with deformation
of the spermatic cord or round ligament
Scanning for “Sports Hernia”
• Pubic symphysis
• Adductor tendons
– Esp adductor longus
• Gracilis
• Rectus abdominus
aponeurosis/tendon
• Conjoint tendon
• Direct region
– Laxity of transversalis
fascia-Valsalva
Transversalis Fascia Insufficiency/ Direct region
Transversalis Fascia Insufficiency
Transversalis Fascia Insufficiency
Slides courtesy of Doug Hoffman, MD
Scanning for Medial Groin
RT MED HIP LAX PROX
L
B
M
PR
Adductor Longus Tear With Calcification
RT MED HIP LAX DIST
Adductor Longus and PF, and ICH Add Magnus tears
Obey, 2016
Distal and Proximal Adductor Longus Tear
RT MED HIP LAX DIST
Pubic Symphysis
RT LT
Pubic Symphysis
RT LT
Distal Rectus Abdominus
RT RA LAX DIST
Questions?
References
• The Athletic Hernia-A Systemic Review; Swan and Wolcott:Clinical Orthopaedics and Related
Research; 2006 455:78-87
• Sportsmen’s Groin-Diagnostic Approach and Treatment With the Minimal Repair Technique: A
Single-Center Uncontrolled Clinical Review; Muschaweck /Berger: Sports Health 2010 2:216-
220
• Santilli, O. L., et al. (2015). "Sports hernias: experience in a sports medicine center."Hernia.
• Steele, P., et al. (2004). "Surgery for posterior inguinal wall deficiency in athletes." J Sci Med
Sport 7(4): 415-421; discussion 422-413.
• Orchard, J. W., et al. (1998). "Groin pain associated with ultrasound finding of inguinal canal
posterior wall deficiency in Australian Rules footballers." Br J Sports Med 32(2):134-139.
• Hackney, R. G. (1993). "The sports hernia: a cause of chronic groin pain." Br J Sports Med
27(1): 58-62.
• Obey MR1, Broski SM2, Spinner RJ3, Collins MS2, Krych AJ4. Anatomy of the Adductor
Magnus Origin: Implications for Proximal Hamstring Injuries. Orthop J Sports Med. 2016
Jan 11;4(1):2325967115625055. doi: 10.1177/2325967115625055. eCollection 2016 Jan.