The “Sports ”

Russell Steves M.Ed, ATC, PT Princeton University Why Should I Care?

• You may run into it – An athlete with 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 ” 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 – flexors – Hip adductors – Abdominals –Enthesopathy • Adductor longus • Rectus abdominus Groin Pain Pathologies

• Hip pathology – – Arthritis •OA •DJD – Acetabular labral tear – Femoral head/ AVN Groin Pain Pathologies

• Stress fractures – Pubic rami – Femoral head/neck • Avulsion fractures – AIIS/ASIS – Lesser trochanter – 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 Physical Exam

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

• Resisted hip motions – Flexion ( 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 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 • 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

Gilmore J. Clinics in Sports Med. 1998. 17. 787-793. 1 3

2

Netter FH. Atlas of Human Anatomy. Teterboro,NJ. Icon Learning Sys. 2003. 253. 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. 1 2

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. Sports(man’s) Hernia

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

Direct

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

Femoral

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