The Sports Hernia Russell Steves M.Ed, ATC, PT Princeton University - - PowerPoint PPT Presentation

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,
• nly 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.

1 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.

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

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%)