Sports HerniasSports hernia: pathophysiology • Athletic activity, particularly pivoting, cutting,...

Sports Hernias

Matthew Gimre, MD

ATC Conference, June 20, 2015

Sports hernia: So what is it?

• An injury to the rectus abdominis-common adductor aponeurosis, at the anterior/inferior aspect of the pubic bone. This can be a tear, partial tear, disruption, or avulsion.

• This initially was a diagnosis of exclusion, typically found during exploratory surgery (this is no longer the case).

• The term is a misnomer – it is not a true hernia!

• The term has fallen out of favor in the academic setting, and it is recommended to avoid its use.

Sports hernia: So what do we call it?

• Athletic pubalgia. “A clinical spectrum of disease associated with lower abdomen and groin injuries.”

• Inguinal-related groin pain.

• Core muscle injury.

• Huh?

• Are these any better?

Sports hernia: So what do we call it?

• I use “sports hernia”!

• Shhhh!

• If you use “sports hernia”, just know it is not the favored academic term.

• But, at least most people in the sports medicine community will know what you mean.

Sports hernia: pathophysiology

• Athletic activity, particularly pivoting, cutting, and kicking cause significant torque at the pelvis, including the rectus abdominis, adductor, and iliopsoas.

• Significant relationship between the core and hips.

• Any weakness or imbalance can cause overload, and lead to soft tissue injury.

• Typically, this is an overuse injury.

Sports hernia: pathophysiology

• The opposing forces of the rectus abdominis and adductor longus at the pubic bone cause the injury.

Sports hernia: diagnosis

• Groin pain, adductor pain, and or lower abdominal pain with athletic activity.

• Variable intensity and level of dysfunction.

• Possible tenderness at the pubic bone and lower rectus abdominis insertion.

• In my opinion, there typically is minimal to no tenderness along the adductor longus.

Sports hernia: diagnosis.

• Exam findings can include weakness and provocative pain with resisted hip adduction, abdominal crunch, and with a combined maneuver of simultaneous abdominal crunch and resisted hip adduction.

Sports hernia: diagnosis

• Direct examination of the inguinal canal may find mild dilatation of the external inguinal ring compared to the contralateral side, and possible pain with posterior inguinal wall pressure.

• No bulge.

Sports hernia: diagnosis

• Pelvis x-ray negative.

• With x-ray, you are looking for other possible pathology.

Sports hernia: diagnosis

• In the past, MRI could not find this.

• Today, a good MRI can find this, and is very useful!

• Findings are subtle!

• Normal appearance on sagittal cut through the pubic bone.

• Abnormal finding, with abnormal soft tissue edema consistent with injury.

Sports hernia: diagnosis

• Abnormal coronal plane.

• Abnormal transverse plane.

Simple, right?

• Maybe, but the history, exam, and diagnostics can be subtle.

• Plus …

Differential diagnosis

• True inguinal hernia.

• Osteitis pubis.

• Stress fracture.

• Intra-articular pathology, including hip impingement.

• Apophysitis/avulsion.

• Peripheral neuropathy.

• Radiculopathy.

• Other muscle/tendon injuries.

•

• Other!

Treatment

• Non-surgical. Rest. Rehab to balance/strengthen hip and core musculature.

• Surgical. Can be considered if non-surgical treatment is not working after about 6 weeks.

Treatment• Surgical treatment consists of repair

and tightening of pelvic floor. This is general surgery, not orthopaedic surgery.

• Open. Typical return to sports in 12-16 weeks.

• Laparoscopic with mesh. Return to play in about 6 weeks.

• Minimally invasive open, with localized repair (guided by high-res ultrasound), and decompression of genital branch of genitofemoral nerve. Pioneered in Germany. Return to play in 4-5 weeks, sometimes sooner (!).

• All can have good results.

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