Sports Hernia

Other Names

• Sports Hernia
• Athletic Pubalgia
• Gilmore's groin
• Sportsman's hernia

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Background

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Sports Hernia/Athletic Pubalgia Review Pod

• This page reviews the so-called Sports Hernia

History

• The first case published was by British surgeon Dr Jerry Gilmore in 1980

Epidemiology

• Males account for more than 90% of cases

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Introduction

Musculotendinous and aponeurotic attachments of the anterior pubis. AB, adductor brevis; AL, adductor longus; EO, external oblique aponeurosis; G, gracilis; IO, internal oblique; RA, rectus abdominis; TA, transversus abdominis

Injury to the abdominal wall at the fascial attachments of the rectus and adductors onto the pubis is implicated in athletic pubalgia

Sports hernia via description illustration

General

• Complex and often under-recognized cause of groin pain in athletes
• Poses a diagnostic and treatment challenge for clinicians

Etiology

• Hypothesis One
  • Related to overuse injuries in the context of underlying muscle imbalances
  • Mismatch between weak abdominal muscles/ stronger hip adductor leads to stress on inguinal wall structures
  • Mullens: deficient posterior wall of the inguinal canal in 85% of surgical cases
  • Posterior wall defect most commonly seen in transversalis tendon, less commonly internal inguinal ring and conjoined tendon
  • Weakness is thought to be exacerbated by repetitive twisting, turning, or kicking movements
• During surgery, multiple injured structures are often identified
  • Distal Rectus Abdominis
  • Conjoint Tendon
  • External Oblique Aponeurosis
  • Inguinal Ligament
  • Adductor Longus muscle/tendon

Pathophysiology

• Underlying pathophysiology remains illusive
• No single anatomic structure is implicated in its development

Matrix Metalloproteinases and Genetic Underpinnings

• Structural integrity of the extracellular matrix is paramount for maintaining tissue resilience
• Elevated levels of MMPs in hernia-affected tissues hint at a potential weakening or compromise of the matrix
• Interplay between these MMPs and their natural inhibitors, tissue inhibitors of metalloproteinases (TIMPs), is significant

Definition

• The term sports hernia is a misnomer, majority of cases are not associated through a fascial defect
• Lack of consensus definition on what constitutes a sports hernia
• Leads to diagnostic challenges, varied treatment approaches

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Risk Factors

Sports

• Soccer
• Football
• Ice Hockey
• Rugby
• Baseball
• Track and Field: sprinting, hurdling

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Differential Diagnosis

Differential Diagnosis Groin Pain

• Intra-articular / Hip Etiology
  • Femoroacetabular Impingement
  • Acetabular Labral Tears
  • Injuries to the Ligamentum Teres
  • Hip Osteoarthritis
  • Avascular Necrosis of the Femoral Head
  • Osteochondral Defect of the Hip (Loose Bodies)
  • Hip Microinstability
• Extra-articular Causes
  • Pelvic Stress Fracture
  • Osteitis Pubis
  • Sports Hernia (Athletic Pubalgia)
  • Avulsion Fractures of the Pelvis
  • Snapping Hip Syndrome
  • Iliopsoas Tendinopathy
  • Rectus Femoris Strain
  • Rectus Abdominal Strain
  • Myositis Ossificans
  • Iliac Apophysitis (AIIS, ASIS, Iliac Crest)
  • Inguinal Hernia
  • Femoral Hernia
  • Adductor Tendonitis
  • Adductor Strain
• Neuropathic/ Nerve Entrapment Syndromes
  • Obturator Neuropathy
  • Femoral Neuropathy
  • Iliohypogastric Nerve Injury
  • Genitofemoral Nerve Injury
  • Ilioinguinal Nerve Injury
  • Meralgia Paresthetica (Lateral Femoral Cutaneous Nerve)
  • Pudendal Neuralgia
• Axial/Spinal Etiology
  • Lumbar Disc Disease
  • Facet Arthropathy
  • Sacroiliitis
  • Sacroiliac Joint Dysfunction
• Pediatric Considerations
  • Legg Calve Perthes Disease
  • Slipped Capital Femoral Epiphysis
  • Transient Synovitis of the Hip
  • Idiopathic Chondrolysis of the Hip
• Intra-abdominal Considerations
  • Abdominal Aortic Aneurysm
  • Appendicitis
  • Diverticulitis/ Diverticulosis
  • Lymphadenitis
  • Inflammatory Bowel Disease
• Genitourinary Considerations
  • Ovarian/Testicular Torsion
  • Ectopic Pregnancy
  • Nephrolithiasis
  • Epididymo-Orchitis
  • Ovarian Cyst
  • Pelvic Inflammatory Disease
  • Round ligament pain
  • Urinary Tract Infection
  • Endometriosis
  • Prostatitis
  • Testicular cancer

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Clinical Features

Locations of pain

Pain with resisted sit-ups is a classic physical examination finding of sports hernia

History

• Activity pain that relives with rest, returns upon resumption of sports
• Onset is insidious and worsens over time
• May or may not affect activities of daily living
• Distribution of pain is usually unilateral, may radiate to uninvolved side/ scrotum
• Pain is provoked by sudden movement, sit-ups, coughing, sneezing, valsalva

Physical Exam

• Palpate along the inguinal canal
• Inversion of scrotal skin
• Hip adductor origin tenderness, pain with resisted adduction suggest adductor-related groin pain
• Tenderness at the pubic symphysis indicates pubic-related groin pain
• Pain with resisted hip flexion and/or stretching of hip flexors suggests iliopsoas-related groin pain

Diagnostic Criteria: Physical Exam

• Diagnosis of sports hernia may be made if at least three of the following five signs are present
  • 1: Pinpoint tenderness to the pubic tubercle at the conjoint tendon insertion
  • 2: Tenderness over the deep inguinal ring
  • 3: Pain and/or dilation of the external ring without a palpable hernia
  • 4: Pain at the origin of the adductor longus tendon
  • 5: Dull, diffuse groin pain that often radiates to the perineum and inner thigh or across the midline

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Evaluation

Osteitis pubis. Pelvic radiograph in a 21-year-old soccer player presenting with left groin pain demonstrating symphyseal cortical enthesiopathic changes on the left (white arrow). See Figure 6 for correlative MRI. There is also incidental cam-type femoro-acetabular impingement morphology.

Posterior inguinal wall deficiency. Axial proton density-weighted image in a 26-year-old male recreational soccer player with left-sided groin pain shows anterior bulging of posterior inguinal wall on left side (arrow), consistent with posterior inguinal wall deficiency. This results in a more anteriorly positioned spermatic cord (S) when compared with right side.

General

• Challenging diagnostic entity due to non-specific nature of symptoms
• Sports Hernia is a clinical diagnosis and can't be ruled out by any single imaging study

MRI

• Most sensitivity imaging modality for sports hernias
• Useful to exclude alternative causes of groin pain
• Potential findings not specific to athletic pubalgia
  • Tears of the rectus abdominis, adductor aponeurosis
  • Erosion and/or osteitis of the pubic bodies
• Pelvis MRI
  • Recommended imaging modality for suspected sports hernia
  • Use of IV contrast may be useful
• Clinicians should communicate their clinical suspicion to the radiologist

Dynamic Ultrasound

• Can identify posterior inguinal wall insufficiency which is common in sports hernias
  • Presence of posterior inguinal wall insufficiency has low sensitivity/ specificity for sports hernia
• Advantages
  • Real-time assessment
  • Minimal discomfort
  • Ability to evaluate structures during different phases of movement
• Potential Soft Tissue Findings
  • Anechoic defects and/or partial or full-thickness discontinuities of the tendon insertions, indicative of tears
  • Loss of normal fibrillary architecture, thickening, and hypoechogenicity of tendon insertions, suggestive of tendinopathy
• Potential Bone Changes
  • Spurring and irregularities of the pubic bone, indicative of chronic stress or injury
  • Symphyseal effusion, representing joint inflammation or injury
  • Periarticular hyperemia on color Doppler, revealing increased blood flow around the affected area
• Sonopalpation reproducing symptoms is particularly useful
• Potential pitfall: per-peritoneal fat can protrude through Hesselbach triangle during abdominal strain, mimicking appearance of hernia

Radiographs

• Standard Radiographs Pelvis
  • Routinely obtained in the evaluation of groin pain
  • Useful to identify/exclude alternative diagnoses
• Potential findings
  • Fractures
  • Degenerative disease
  • FAI
  • Dysplasia
  • Pubic symphysis asymmetry

CT Scan

• Provides better detail on osseous structures
• Can help identifyt widening of the pubic symphysis
• Other potential findings
  • Sclerosis
  • Marginal erosion
  • Capsular thickening

Herniography

• Involves injection of contrast material into the peritoneal cavity
• Highly sensitive/ specific at diagnosing "true" hernias
• Not recommended as first line diagnostic tool due to invasive nature

Nuclear Medicine Bone Scintigraphy

• Not indicated for the diagnosis of athletic pubalgia

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Classification

• Not applicable

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Management

Prevention

• Currently, no evidence based recommendations
• Strength and conditioning
  • Emphasize flexibility, core strength, and sport-specific movements
  • Tailored to individual athlete, sport, skill level and physical condition
• Correct imbalances between musculature above/below the pubic symphysis
  • Strengthen abdominal musculature may reduce risk of injury

Nonoperative

• First line therapy in most cases
  • Conservative management is often successful in managing sports hernia
• Relative rest for 6-8 weeks
• Supportive care with NSAIDS, ice, heat
• Rehabilitation
  • Roughly 6 weeks
  • Gradual return to sport specific activity
• Consider injection of
  • Rectus Abdominis Insertion
  • Conjoint Tendon
  • Adductor Tendon

Operative

• Indications
  • Failure of at least 2-3 months of conservative management
• Technique
  • Herniorrhaphy

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Rehab and Return to Play

Rehabilitation

• Initial: Hip adductor stretching, Core stabilization exercises
• Second Phase: eccentric strengthening of abdominal oblique, rectus abdominis, and adductors
• Third Phase: progress to sports specific exercises
• Typically takes 2-3 months

Return to Play/ Work

• General considerations shaping RTP:
  • Treatment modalities
  • Individual factors
  • Injury severity
• Average return to sports ranges from 4 to 12 weeks

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Prognosis and Complications

Prognosis: Return to Play

• General
  • Return to play rates generally exceed 90%
• Rate of return to play following surgery
  • Return to prior level activity ranges from 80% to 95%
• Return to play timeline
  • Kajetanek et al: following surgery, 92.6% of subjects returned to play at average of 112 days
  • Castle et al: 91% of NBA players returned to play following surgery at average of 4.73 months
• Surgical vs nonsurgical management
  • Serafim et al: athletes managed surgically often rejoin their sport sooner than those adopting conservative treatments

Complications

• Inability to return to sport
• Chronic Groin Pain

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See Also

• Groin Pain Main
• Physical Exam Groin
• Groin Anatomy Main

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