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Sports Hernia Or Groin Disruption Injury? Chronic Athletic Groin Pain: a Retrospective Study of 100 Patients with Long-Term Follow-Up

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Sports Hernia Or Groin Disruption Injury? Chronic Athletic Groin Pain: a Retrospective Study of 100 Patients with Long-Term Follow-Up Hernia (2014) 18:815–823 DOI 10.1007/s10029-013-1161-0 ORIGINAL ARTICLE Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up J. F. W. Garvey • H. Hazard Received: 4 April 2013 / Accepted: 13 September 2013 / Published online: 12 October 2013 Ó Springer-Verlag France 2013 Abstract incipient) hernia (16), groin disruption injury (16), classical Introduction and objectives Chronic groin pain (athletic hernia (11) traumatic osteitis pubis (5), and avulsion frac- pubalgia) is a common problem in sports such as football, ture of the pubic bone (4). Surgical management was hockey, cricket, baseball and athletics. Multiple co-existing generally undertaken only after failed conservative therapy pathologies are often present which commonly include of 3–6 months, but some professionals who have physio- posterior inguinal canal wall deficiency, conjoint tendin- therapy during the football season went directly to surgery opathy, adductor tendinopathy, osteitis pubis and periphe- at the end of the football season. A variety of operations ral nerve entrapment. The mechanism of injury remains were performed including groin reconstruction (15), open unclear but sports that involve either pivoting on a single hernia repair with or without mesh (11), sports hernia leg (e.g. kicking) or a sudden change in direction at speed repair (Gilmore) (7) laparoscopic repair (3), conjoint ten- are most often associated with athletic pubalgia. These don repair (3) and adductor tenotomy (3). Sixty-six patients manoeuvres place large forces across the bony pelvis and were available for follow at an average of 13 years after its soft tissue supports, accounting for the usual clinical initial consultation and the combined success rate for both presentation of multiple symptomatic abnormalities form- conservative treatment and surgery was 94 %. ing one pattern of injury. Conclusion The authors believe that athletic pubalgia or Results The diagnoses encountered in this series of 100 sports hernia should be considered as a ‘groin disruption patients included rectus abdominis muscle atrophy/asym- injury’, the result of functional instability of the pelvis. The metry (22), conjoint tendinopathy (16), sports (occult, surgical approach is aimed at strengthening the anterior pelvic soft tissues that support and stabilise the symphysis pubis. Presented at the 5th International Hernia Congress, New York, USA 29 March 2012. Keywords Sports hernia Á Conjoint tendinopathy Á This research complies with the laws of the commonwealth of Adductor tendinopathy Á Osteitis pubis Á Athletic Australia. pubalgia Á Groin disruption injury Electronic supplementary material The online version of this article (doi:10.1007/s10029-013-1161-0) contains supplementary material, which is available to authorized users. Introduction & J. F. W. Garvey ( ) Chronic groin pain is one of the least understood and Groin Pain Clinic, BMA House, Suite G01, 135 Macquarie St, Sydney, Australia poorly explained conditions in clinical medicine. There is e-mail: [email protected] no consensus on nomenclature, duration, diagnosis, path- URL: www.groinpainclinic.com.au ophysiology or management, yet it is a common diagnostic and management challenge for the Clinician and team H. Hazard Sydney, Australia Physician in sports such as football, hockey, cricket, ath- e-mail: [email protected] letics, basketball, etc. ‘‘Pubalgia’’ is defined by Orchard 123 816 Hernia (2014) 18:815–823 et al. [1] as chronic groin pain that presents with no professional or amateur athletes and injured workers pre- obvious hernia, and no clear-cut cause arising from the senting with undiagnosed chronic groin or lower abdominal structures in the pubic region. This pattern of injury pain, with either negative or equivocal physical examina- includes sports (occult, incipient) hernia, conjoint tendon tion findings, were assessed by various diagnostic images. lesions, adductor tendinopathy, osteitis pubis and periphe- The average time to presentation was not recorded. Forty- ral nerve entrapment. We regard sports hernia as a pre- three patients have previously been reported in a study of sentation of groin pain with an impalpable inguinal bulge occult groin hernia [2]. This study group also included some demonstrated by diagnostic imaging (ultrasound or CT) as sports people with a clinically obvious hernia and some opposed to a ‘‘classical’’ hernia in which there is a palpable patients who had undergone a previous open or laparo- defect and a protrusion which increases with abdominal scopic repair. Several patients had previously undergone a pressure and which is readily reducible. local anaesthetic/corticosteroid test injection into the area of In clinical practice, chronic groin pain is usually well pain but the actual number is not known. Many patients who localised, and tends to be focused on the pubic bone with were referred had prior MRI or ultrasound examinations radiation superiorly to the rectus abdominis insertion and that were either negative inconclusive or unreliable, so inferiorly to the adductor longus insertion. The site of pain management decisions were based on the current physical is typically provoked by athletic activities of kicking, examination and diagnostic imaging findings. Follow-up sprinting and changing direction, and the symptoms was mainly carried out by questionnaire to the patient or improve after resting. But chronic groin pain recurs if referrer, and/or telephone enquiry, email, social media and vigorous activity is resumed. Physical examination reveals physical examination when requested. tenderness and pain over the pubic crest on resisted sit-up The imaging investigations used were initially obtained (abdominal ‘‘crunch test’’). There may be pain and ten- without using any consistent examination protocol (typical derness at the superficial inguinal ring, but a visible and outpatient referral practice). Until a reliable diagnostic palpable lump indicating classical inguinal hernia is absent pathway evolved, diagnostic tests could variously include in sports hernia. Decreased range of hip joint motion may plain radiographs, ultrasound, CT, MRI. Electromyography be elicited, and decreased range of internal rotation is a (EMG), contrast herniography and isotope bone scan were frequent finding. There is no consensus on the significance occasionally utilised. of either clinical or the radiological imaging findings of pubic structures in athletes with groin pain. This diverse X-ray group is the subject of this research. We reviewed our first 10 years experience in managing Radiographs included a standing anterior–posterior (AP) chronic groin pain between 1990 and 1999 focussing on the view of the pelvis and flamingo stress views of the sym- types of pathology encountered, and the implications for physis pubis. Flamingo stress views were considered diagnosis and management and have observed a fairly positive if C2 mm vertical displacement across the sym- consistent pattern of multiple concurrent injuries in cases physis pubis could be demonstrated. of chronic athletic pubalgia. These include the sports (occult, incipient) hernia, conjoint tendon lesions, adductor Ultrasound tendon lesions, osteitis pubis and various peripheral nerve irritations. The objective evidential base supporting the Real-time ultrasound was used to (1) assess the conjoint concept of sports hernia and groin disruption injury is tendons for size, integrity, echotexture and tenderness; (2) primarily radiological utilising a variety of imaging detect conjoint tendon dysfunction appreciated as protru- modalities including plain X-ray, computed tomography sion of the posterior inguinal canal wall when actively (CT), ultrasound (US) and magnetic resonance imaging straining (e.g. during a ‘half sit-up’); (3) assess the sym- (MRI). physis pubis for irregularity and tenderness; and (4) assess the adductor longus origins for size, integrity, echotexture and tenderness. Materials and methods CT Patient entry Dynamic helical non-contrast scans were obtained both This is an uncontrolled surgical case series and the publi- resting and straining, usually with the patient supine (and cation of this research is approved by the Medical Advisory occasionally prone). Straining and non-straining views Board of Sydney Private Hospital. In the period between were compared to determine if any abnormal movement of 1990 and 1999, 100 consecutive patients including abdominal contents occurred through a hernial orifice. 123 Hernia (2014) 18:815–823 817 MRI Table 1 Predominant clinical and radiological findings in 100 patients presenting with chronic groin pain between 1990 and 1999 Non-contrast 1.5T scans were centred on the symphysis Rectus abdominis muscle atrophy 22 pubis using a phased-array surface coil, multiple imaging Sports hernia (including bilateral 8) 16 planes, and a variable combination of (1) non-fat-sup- Conjoint tendinopathy 16 pressed T1 and/or PD-weighted, and (2) fat-suppressed Groin disruption injury (bilateral 2) 16 fluid-sensitive sequences (STIR or fat-suppressed PD). Classical hernia (bilateral 3, indirect 3, direct 2, spigelian 2, 11 pantaloon 1) Herniography Adductor tendinopathy 5 Rectus abdominis syndrome 4 Herniography was initially considered to be a useful test Avulsion (‘‘flake’’) fracture of pubic bone 4 for classical hernia, but the false positive and false negative Traumatic osteitis pubis 3 rate due to occlusion of a hernia sac by a plug of
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