Pubic inguinal pain syndrome: the so-called sports hernia

Abstract

Sports hernia (SH) is a controversial condition which presents itself as chronic groin pain. It is responsible for signiWcant time away from work and sports competition, with an incidence of between 0.5 and 6.2% [1–3]. Groin injury is common in soccer and ice hockey players, but SH can be encountered in a variety of sports, and even in normally physically active people [1, 3]. For this reason, we think that it is more appropriate to speak of pubic inguinal pain syndrome (PIPS). Over the past decade, the number of sports-related injuries has increased as a function of increased athletic activities, and the demand for an early return to work and competitive sports puts pressure on the doctor for immediate diagnosis and treatment [1–3]. The anatomy involved, diagnostic criteria and treatment modalities are inconsistently described in the medical, surgical and orthopaedic literature. In fact, there is no evidence-based consensus available to guide the decisionmaking, and most of the studies are level IV investigations [1, 3, 4]. A literature search for SH produces a list of various conditions which may or may not include the real disease: “athletic pubalgia,” incipient hernia, osteitis pubis, “Gilmore’s groin,” “hockey groin syndrome” and “Ashby’s inguinal ligament enthesopathy” are several of the terms that have complete or partial overlap with SH and pubalgia; this is another reason to unite the terminology as PIPS [4]. The diYculty in giving a correct deWnition of this obscure cause of chronic groin pain is due to its unclear aetio-pathophysiology. The majority of the published studies and reviews articles include young adult soccer players as the most frequent victims of SH; however, runners, American football players and ice hockey players frequently suVer groin injuries [1, 5]. It does appear that kicking sports and those involving rapid changes of direction while running predispose an athlete to this condition. Chronic groin pain may originate from the muscles, tendons, bones, bursas, fascial structures, nerves and joints, both in the athletes and in the general population [2, 6]. A deWciency of the posterior inguinal wall is the most common operative Wnding in these patients [7, 8]. A weakened posterior inguinal wall develops an imbalance between the adductors and lower abdominal musculature in these athletes. The strong pull of the adductors, particularly against a Wxed lower extremity, in the presence of relatively under-conditioned abdominal muscles creates a shearing force across the hemipelvis, resulting in attenuation or tearing of the transversalis fascia and/or overlying musculature [1–3, 8–10]. Malycha, Lovell et al. reported an incidence of incipient direct hernia of 50% in their series of 189 athletes. The herniography study revealed a symptomatic impalpable hernia in 51% of male and 21% of female patients, and another study reported a hernia in 84% of elite athletes with groin pain [2, 11]. Gilmore has described a more extensive injury and he has coined the term “Gilmore’s groin.” The injury, which has primarily been described in soccer players with chronic groin pain, consists of a torn external oblique aponeurosis, a torn conjoined tendon, with avulsion of the conjoined tendon and inguinal ligament, and the absence of a hernia [2, 3, 11–13]. Some have disputed Gilmore’s description of G. Campanelli (&) Unit of General Surgery, Day and Week Surgery, Department of Surgical Sciences, University of Insubria, Varese, Multimedica Holding S.p.A., Castellanza, Italy e-mail: giampiero.campanelli@uninsubria.it