Athletic Hernias

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Hernia Anatomy

 

A Chronic Groin Strain or Hernia?

A wide receiver catches the ball and jukes to elude the defensive back. After the play he complains of groin pain. After a careful history and examination is conducted the conclusion is a simple groin strain. Therapy is performed for four (4) weeks and the athlete seems to be pain free, except for when he makes sudden explosive motions. Rehabilitation is continued for another four (4) weeks with out improvement.

This injury progression may seem familiar. The term “groin strain” can be equated to the phrase “shin splints”; both can represent multiple clinical conditions. The athlete above needs to be evaluated by a sports medicine physician to determine if the injury was an adductor strain, athletic hernia, or perhaps osteitis pubis. This evaluation should include a detailed history, physical examination, plain film radiographs, and possibly other detailed imaging studies.

One condition that has received more attention in the last few years is the ’sports hernia’. It is estimated that as many as 28% of male and female athletes with a history of groin pain suffer from this injury. The condition is more common in boys than girls.

The ‘sports hernia’ is described as a disruption to the inguinal canal that is resistive to treatment in the absence of a clinically detectable hernia.

Pathology

The inguinal canal, which carries the spermatic cord in males and the round ligament in females, is a passage that runs downward and medially parallel to and just above the inguinal ligament. The anterior wall consists of the external oblique aponeurosis and the internal oblique muscle. The posterior wall is formed by the fascia transversalis, which is reinforced in its medial third by the conjoined tendon, the common tendon of insertion of the internal oblique and transversus, which attaches to the pubic crest and the pectineal line. The superficial inguinal ring lies anterior to the strong conjoined tendon. Disruption to the conjoined tendon is most often seen in the operative findings.

The actual injury is probably caused by the adductor action during sports participation. The resulting stress creates shearing forces across the pubic symphysis that can stress the posterior inguinal wall. Repeated stretching or a more intense sudden force can lead to separation of the tissues from the inguinal ligament. Many of the athletes that exhibit a ‘sports hernia’ also have coexisting osteitis pubis (bone inflammation adjacent to the pubic symphysis) and adductor tenoperiostitis (inflammation of the tendon and periostium at the adductor origin on the ischium).

Examination

A complete physical examination should be performed to differentiate a ‘groin strain’ from a ‘sports hernia’. The history may provide all or some of these symptoms:

  • Insidious onset of pain,

  • Pain localized to conjoined tendon and inguinal canal,

  • Pain may radiate to the adductor region and testicles,

  • Pain increased by sudden movements,

  • Pain exacerbated by coughing or sneezing, and/or

  • Pain resistant to conservative treatment.

The physical examination may product the following findings:

  • Dilated superficial inguinal ring,

  • Local tenderness over the conjoined tendon and inguinal canal,

  • Cough impulse test may be unequivocal,

  • Tenderness exacerbated by resisted sit-up, and/or

  • Signs may be similar to those of osteitis pubis and adductor tendonopathy

Approximately 25% of athletes diagnosed with a ‘sports hernia’ also exhibited a secondary problem such as those mentioned above. Diagnostic testing may be ordered to assist in the differential diagnosis. Plain film x-rays, bone scans, CT, MRI, or diagnostic ultrasound may be ordered to rule out other conditions.

The mnemonic below may be of assistance in dealing with a systematic evaluation of groin injuries:

  • How = Hip/Pelvis

  • To = Thigh

  • Approach = Abdomen

  • Groin = Genitalia

  • Pain = Pain (referred)

(“A Complete Approach to Groin Pain”, Vincent J. Lacroix, Physician & Sports Medicine, Vol. 28, No. 1)

Treatment

Conservative treatment for a suspected ‘sports hernia’ usually fails. Diagnostic imaging offering little definitive objective findings and continued pain usually results in surgery for the affected athlete. Conservative therapy and rehabilitation for concomitant injuries should be prescribed prior to surgical intervention.

Surgical treatment will vary by physician. Procedural differences among treating physicians are essentially the same. The objective of the surgery is to correct the cause of the pain. This may be repair of the conjoined tendon with reattachment to the pubic tubercle and inguinal ligament or approximation of the torn structures held in place with suture. Rates of surgical success, with full return to participation, have been reported as 63 - 93%. None of the studies reporting this data were controlled or randomized, rendering them statistically insignificant.

Rehabilitation should be targeted at pelvic flexibility, strength and stability. This should incorporate core strength, proprioception, aerobic conditioning, and sport specific exercises. Most rehabilitation protocols will allow isometric abdominal and adductor exercises at one day post-op, increasing the number of sets and repetitions during the first week. Progressing to concentric and eccentric strengthening of the hip flexors, abductors, adductors, abdominals, and pelvic stabilizers should be gradual and controlled during the next few weeks of rehab. Do not neglect flexibility training during the rehabilitation process. A walk-jog program can be phased in during the first week post-op (jogging targeted at 10 days). This can be progressed to sprinting by day 21. Full return to participation should be targeted at 6 to 8 weeks post-op.

 Groin Strain Rehab Sheet in PDF Form

 

©2000 - 2009 David Edell

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Last Update for AthleticAdvisor.com: 10/24/2009 12:09:35 AM