The “Sports Hernia” Russell Steves M.Ed, ATC, PT Princeton 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. 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 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%).