Sports Hernia Research Articles

“Sports” hernia: treatment with biologic mesh (Surgisis)

Groin pain in athletes is caused by a wide range of musculoskeletal disorders. Occasionally, a palpable bulge at the external ring or ultrasound may not demonstrate a hernia. When athletes do not respond to conservative treatment, a "sports" hernia should be considered. A retrospective review of 750 laparoscopic preperitoneal hernias was performed. A sports hernia was defined as a tear in the transversalis fascia that was not evident by preoperative physical exam. A 7 x 10-cm biologic mesh, Surgisis, was placed, uncut, over the myopectinate orifice and fixed with five tacks or fibrin glue. Patients were followed up at 2 and 6 weeks, 6 months, and 1 year. Ten professional and amateur athletes were found to have sports hernias. Operative time averaged 32 min. There were no major complications. All athletes returned to full activities in 4 weeks. Only one patient did not show improvement in his symptoms. No patient developed a recurrent hernia. Laparoscopic exploration should be considered in athletes with chronic groin pain that does not improve after conventional treatments have failed. Furthermore, biologic mesh (Surgisis) should be considered for the repair of inguinal sports hernias.

Athletic Pubalgia

Athletic pubalgia, or "sports hernia," affects people actively engaged in sports. Previously described in high-performance athletes, it can occur in recreational athletes. It presents with inguinal pain exacerbated with physical activity. Examination reveals absence of a hernia with pubic point tenderness accentuated by resisted adduction of the hip. Diagnosis is by history and physical findings. Treatment with an internal oblique flap reinforced with mesh alleviates symptoms. A retrospective review from December 1998 to November 2004 for patients with athletic pubalgia who underwent operative repair was performed. Descriptive variables included age, gender, laterality, sport, time to presentation, outcome, anatomy, and length of follow-up. Twelve patients, 1 female, with median age 25 years were evaluated. Activities included running (33%), basketball (25%), soccer (17%), football (17%), and baseball (8%). The majority were recreational athletes (50%). Median time to presentation was 9 months, with a median 4 months of follow-up. The most common intraoperative findings were nonspecific attenuation of the inguinal floor and cord lipomas. All underwent open inguinal repair, with 9 being reinforced with mesh. Four had adductor tenotomy. Results were 83.3% excellent and 16.7% satisfactory. All returned to sports. Diagnosis of athletic pubalgia can be elusive, but is established by history and physical examination. It can be found in recreational athletes. An open approach using mesh relieves the pain and restores activity.

An Overview of Hip Injuries in Running

Running has steadily gained in worldwide popularity and is the primary exercise modality for many individuals of all ages. Its low cost, versatility, convenience and related health benefits appeal to men and women of broad cultural, ethnic and economic backgrounds. With more children and adults participating in recreational and competitive running, the incidence of injuries has steadily increased. Most running-related injuries affecting the lower extremities are due to preventable training errors, and some may necessitate medical evaluation or a significant reduction in training. Hip injuries in runners are due to interactions of intrinsic and extrinsic factors that adversely affect the complex regional anatomy. Acute or chronic hip pain presents a diagnostic and therapeutic challenge because the vague, nonspecific symptoms and signs may originate from local, regional or distant foci. Muscle strains and tendonitis are the most common aetiologies of hip pain and typically result from sudden acceleration/deceleration manoeuvres, direction changes or eccentric contractions. Apophysitis and avulsion fractures may affect younger runners and produce localised pain at muscle attachment sites. Iliotibial band syndrome is a common cause of lateral hip and knee symptoms characterised by sharp or burning pain that is exacerbated by activity. Bursitis, due to repetitive activity or acute trauma, may affect the trochanteric, ischial or iliopectineal bursae. Hip osteoarthritis may also produce persistent pain that worsens with running. Stress fractures are potentially serious conditions that affect women more frequently than men. Snapping hip syndrome is a benign condition that results from tight connective tissues' passing repeatedly over the greater trochanter, anterior hip capsule, lesser trochanter, femoral head or iliopectineal eminence. Acetabular labral tears, sports hernias and nerve entrapment syndromes are also potential causes of persistent hip pain in runners. Treatment of hip pain in running should focus not only on addressing the symptoms but also identifying the underlying conditions that precipitated the injury. Injury prevention and comprehensive rehabilitation are essential, since prior hip injuries increase the risk of subsequent ones. Coaches, trainers and medical personal who care for runners should advocate running regimens, surfaces, shoes, technique and individualised conditioning programmes that minimise the risk of initial or recurrent hip injuries.

Sports hernia

Pubalgia is a general term used to describe severe groin and hip pain in the professional athlete. The etiology of this condition can range from adductor tendon injuries, to hip injuries, to abdominal wall injuries. One of the least understood and most perplexing problems is the sports hernia. This diagnosis should be considered in athletes who do not respond to conservative treatment of pubalgia. Only recently has this entity become a known cause of persistent groin pain in the athlete. Some surgeons still do not believe this condition exists. We evaluated 96 professional athletes who underwent surgery for sports hernias. Thirty patients (31%) had adductor pain associated with either lower abdominal or inguinal pain. There were 92 patients (96%) who returned to their preinjury levels of performance. One should not offer surgery unless the groin pain has been present for at least 3 months. The authors describe the laparoscopic preperitoneal approach to repair these injuries. With the proper method of diagnosis and the expertise of an experienced laparoscopic surgeon, the athlete can return to active participation in sports within 3 to 6 weeks after surgery.

Anatomic basis for evaluation of abdominal and groin pain in athletes

c ( fi l p c o he term athletic pubalgia describes a group of sometimes surgically correctable syndromes that are relaively common in athletes. In this article, we aim to highight key parts of the pelvic anatomy that are involved in hese types of syndromes. One important concept deserves pecial emphasis. Most exertional abdominal and groin ains in high performance athletes have no association ith actual hernias. The term sports hernia mischaracterzes the pathology and misleads surgeons to perform inorrect operations. Therefore, we recommend the latter erm be abandoned. The athletic pubalgia syndrome is not ssociated with abdominal wall defects that resemble herias. Unlike hernias, the pain of athletic pubalgia occurs in variety of locations consistent with multiple sets of forces nteracting pathophysiologically around a fulcrum—a oncept that helps define joint instability. We refer to the oint involved in this case as the “pubic joint.” While herias certainly can occur in athletes, most abdominal and roin pain in athletes have nothing to do with hernias and o, in fact, have specific mechanisms of injury. Like the knee and other joints, the “pubic joint” has a umber of musculoskeletal attachments that serve as ligaents and functionally stabilize this joint. The pubic joint is ndoubtedly complex, which probably explains why these yndromes have remained mysterious for so long. The purpose of this article is twofold: (1) to depict the elvic anatomy pertinent to the clinical problems, and (2) to orrelate this anatomy with a number of syndrome variants hat we have come to recognize in an experience of over ,000 athletes. While these diagnoses are for the most part mpiric, they result from multiple observations on multiple resh and fixed cadaveric dissections as well as careful folow-up of large contingents of patients who have had various perations designed with the above concepts in mind.

Groin pain in athletes

Groin pain in athletes is not infrequently a cause of frustration and aggravation to both doctor and patient. Complaints in the groin region can prove difficult to diagnose, particularly when they are of a chronic nature. These injuries are seen more commonly in sports that require specific use (or overuse) of the proximal musculature of the thigh and lower abdominal muscles. Some of the more common sports would be soccer, skiing, hurdling, and hockey. The differential diagnosis can cover a rather broad area of possibilities. Most common groin injuries are soft-tissue injuries, such as muscular strains, tendinitis, or contusions. More difficult areas to pinpoint are such entities as osteitis pubis, nerve entrapment, the so-called "sports hernia," or avulsion fractures, to name but a few. The evaluation of such patients includes a familiarity with the sport and possible mechanism of injury (i.e., taking a careful history), meticulous physical examination of the groin, abdomen, hips, spine, and lower extremities. Diagnostic examinations may or may not prove helpful in formulating a final diagnosis. Some patients may be required to undergo procedures, such as laparoscopic evaluation of the region to obtain adequate information that allows a proper diagnosis and treatment plan. This article describes many of the possible causes of groin pain in athletes. The list is quite lengthy, and only the more common problems will be discussed in detail.

Surgical options in the treatmentof sports hernia

Groin injuries in athletes are seen with increasing frequency. The insidious onset of groin pain in professional athletes may be caused by a range of musculoskeletal conditions and injuries. The diagnosis of occult or hernia must be considered in athletes who do not respond to conservative treatment modalities directed at these entities. A review of diagnostic workup and presenting symptomatology is given. In addition, a retrospective literature review of the surgical treatment of sports hernias is presented, including the lead author's personal experience with laparoscopic hernia repair. Comparison is made between operative findings, surgical techniques, and long-term results. Although length of recovery and return to activity varied from series to series, laparoscopic hernia repair provided the quickest return to full, unrestricted athletic activity in 4 weeks or less. Laparoscopic preperitoneal hernia repair should be considered as a treatment modality in athletes presenting with chronic groin pain. Groin injuries in athletes are seen with increasing frequency. Estimates suggest that 5% of all sports injuries occur in the groin. It has been postulated that such injuries are more common from sports that require repetitive fast twisting and turning movements (eg, soccer and hockey). I Injuries to the adductor longus, iliopsoas, and rectus femoris muscles are the most common causes of groin pain in athletes. Other causes of groin pain include ilioinguinal neuralgia, osteitis pubis, genitourinary sources (prostatitis, epididymitis, urethritis, hydrocele), bursitis, arthritis of the hip, and sports hernias. Sports hernias can best be described as incompetence of the abdominal wall musculature in the absence of a clinically detectable hernia bulge. The prevalence of such hernias found at surgical exploration in athletes with chronic groin pain is reported to be as high as 80%. 2,3 However, since up to 50% of these athletes have an occult hernia in the contralateral groin, the presence of a hernia does not necessarily correlate with symptoms. 4

Long-Term Follow-Up of Laparoscopic Preperitoneal Hernia Repair in Professional Athletes

"Athletic pubalgia" is a term often used to describe the insidious onset of groin pain in professional athletes. This pain may be caused by a range of musculoskeletal conditions. The diagnosis of occult or "sports" hernia must be considered in athletes who do not respond to conservative treatment modalities directed at these entities. Fifteen professional athletes were treated for sports hernia by a single surgeon between February 1994 and June 2000. Laparoscopic hernia repairs were performed using an extraperitoneal approach. Athletes presented with symptoms lasting several months to several years. Long-term follow-up was obtained by phone to assess overall patient satisfaction, efficacy of surgery, and effect on athletic performance. Nearly all (87%) of the athletes were able to return to full, unrestricted athletic activity in 4 weeks or less. Overall long-term satisfaction was high. Long-term follow-up revealed no adverse sequelae or recurrence of symptoms at a median of 46 months. Laparoscopic preperitoneal hernia repair should be considered as a treatment modality in athletes presenting with chronic groin pain.

Hip and groin injuries in athletes.

Although athletic injuries about the hip and groin occur less commonly than injuries in the extremities, they can result in extensive rehabilitation time. Thus, an accurate diagnosis and well-organized treatment plan are critical. Because loads of up to eight times body weight have been demonstrated in the hip joint during jogging, presumably even greater loads can occur during vigorous athletic competition. The available imaging modalities are effective diagnostic tools when selected on the basis of a thorough history and physical examination. Considerable controversy exists as to the cause and optimal treatment of groin pain in athletes, or the so-called "sports hernia." There has also been significant recent attention focused on intraarticular lesions that may be amenable to hip arthroscopy. This article briefly reviews several common hip and groin conditions affecting athletic patients and highlights some newer topics.

GROIN PAIN IN A RUNNER

HISTORY - 18-year-old female presents with a 2-year history of left groin discomfort. She is able to recall “pulling” the groin at the time. This was followed by approximately 2 months of waxing and waning pain. She noted increased pain with standing. She had 12 weeks of physical therapy with no improvement in symptoms. Pain occurred with and without activity. She also experienced pain with weight bearing. She also noted low back pain, which occurred in association with the groin pain. PHYSICAL EXAMINATION - Functional range of motion was grossly intact for both lower limbs. Tenderness was palpable over the gracilis muscle insertion near the public bone. No obvious hernias were palpable. Internal rotation of the left hip passively increased discomfort. Muscle power was otherwise intact, except for pain limitations of the left lower limb. Sensation was intact and reflexes were 2+ bilaterally at L4, L5, and S1. Straight leg raising caused mild hamstring pain on the left. Reverse straight leg raising caused a mild ache in the area of the left groin. Pulses were 2+ in the BLE. DIFFERENTIAL DIAGNOSIS Chronic adductor muscle strain Avascular necrosis of the left hip Peripheral nerve entrapment i.e.: ilioinguinal nerve Osteitis Pubis Sports hernia Femoral hernia Inguinal hernia TESTS AND RESULTS X-rays left hip and pelvis - normal MRI - No osseous, articular cartilaginous or soft - tissue abnormalities are seen at the left hip. Triple Phase Bone Scan - normal EMG - normal lower extremity examination. Surgical consult - femoral hernia FINAL WORKING DIAGNOSIS Femoral hernia and Sports Hernia TREATMENT Surgical repair of the Femoral and Sports hernia. Physical therapy emphasizing both static and dynamic core stabilization activities, pelvic stabilization exercises, generalized lower extremity training, and proprioception training. Cleared to walk and run without limitation one-month post op.

Anatomic basis of chronic groin pain with special reference to sports hernia

Anatomic basis of chronic groin pain with special reference to sports hernia

Groin injuries in sport: treatment strategies.

Groin pain in athletes is a common problem that can result in significant amounts of missed playing time. Many of the problems are related to the musculoskeletal system, but care must be taken not to overlook other more serious and potentially life threatening medical cases of pelvis and groin pain. Stress fractures of the bones of the pelvis occur, particularly after a sudden increase in the intensity of training. Most of these stress fractures will heal with rest, but femoral neck stress fractures can potentially lead to more serious problems, and require closer evaluation and sometimes surgical treatment. Avulsion fractures of the apophyses occur through the relatively weaker growth plate in adolescents. Most of these will heal with a graduated physical therapy programme and do not need surgery. Osteitis pubis is characterised by sclerosis and bony changes about the pubic symphysis. This is a self-limiting disease that can take several months to resolve. Corticosteroid injection can sometimes hasten the rehabilitation process. Sports hernias can cause prolonged groin pain, and provide a difficult diagnostic dilemma. In athletes with prolonged groin pain, with increased pain during valsalva manoeuvres and tenderness along the posterior inguinal wall and external canal, an insidious sports hernia should be considered. In cases of true sports hernia, treatment is by surgical reinforcement of the inguinal wall. Nerve compression can occur to the nerves supplying the groin. In cases that do not respond to desensitisation measures, neurolysis can relieve the pain. Adductor strains are common problems in kicking sports such as soccer. The majority of these are incomplete muscle tendon tears that occur just adjacent to, the musculotendinous junction. Most of these will respond to a graduated stretching and strengthening programme, but these can sometimes take a long time to completely heal. Patience is the key to obtain complete healing, because a return to sports too early can lead to chronic pain, which becomes increasingly difficult to treat. Management of groin injuries can be challenging, and diagnosis can be difficult because of the degree of overlap of symptoms between the different problems. By careful history and clinical examination, with judicious use of special tests and good team work, a correct diagnosis can be obtained.

Anatomic basis of chronic groin pain with special reference to sports hernia.

Chronic pain on the ventral surface of the scrotum and the proximal ventro-medial surface of the thigh especially in athletes has been diagnosed in various ways; recently, in Europe the concept of "sports hernia" has been advocated. However, since few reports discuss the detailed course of the nerves in association with the pain, we examined the cutaneous branches in the inguinal region in 54 halves of 27 adult male cadavers. From our results, in addition to the cutaneous branches from the ilioinguinal n. (in 49 of 54: 90.7%), cutaneous branches originating from the genital branches of the genitofemoral nerve were found in the inguinal region in 19 of 54 halves (35.2%). In 7 cases (in 7 of 54: 13.0%) the genital branch and the ilioinguinal nerve united in the inguinal canal. In 6 cases the genital branch pierced the inguinal lig. to enter the inguinal canal, and in three cases the genital branch pierced the border between the ligament and the aponeurosis of the obliquus externus m. to be distributed to the inguinal region. Therefore, the courses of the genital branches vary considerably, and may have a very important role in chronic groin pain produced by groin hernia. In addition, entrapment by the ligament may be a reasonable candidate for the cause of chronic groin pain.

Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers.

OBJECTIVES: To investigate the prevalence of inguinal canal posterior wall deficiency (sports hernia) in professional Australian Rules footballers using an ultrasound technique and correlate the results with the clinical symptom...

The ‘Sports Hernia’

Athletes who participate in sports brief that require repetitive twisting and turning at speed, such as soccer or ice hockey, may be at risk of developing a 'sports hernia'—disruption of the inguinal canal without a clinically detectable hernia. Insidious onset of unilateral groin pain is the most common symptom. Concurrent pathologies, such as osteitis pubis and adductor tenoperiostitis, may complicate diagnosis. Plain radiographs and a bone scan can aid differential diagnosis, but herniography is not recommended. Surgery is the preferred treatment. Structured rehabilitation should enable athletes to return to sports activity 6 to 8 weeks after surgery.

サッカー選手のスポーツヘルニア

Recently, incomplete inguinal hernias have been reported as a cause of incurable groin pain in young athletes. In 1993, Hackney proposed that such injuries be called sports hernia. We experienced 16 patients with 19 sports hernias. Subjects were all soccer player at senior high school in Saga city ranging in age from 16 to 18 years, who complained of groin pain when performing full exercises. Most patients had tender points at the anulus inguinalis superficialis; at the lateral edge of the adductor longus tendon and at the anterior superior iliac spine. Pain was caused when performing hip adduction under resistance. Patients also had a sensory disturbance in the region of the ilioinguinalis nerve. We used ultrason ography and MRI under abdominal pressure to diagnose the presence of a sports hernia, and whether this was complicated by inflammation of symphysis pubis.All patients were treated with surgical repair of the inguinal hernia, and became pain-free, however 5 patients with the added complication of inflammation of the symphysis pubis still had motion pain.We propose that the mechanism causing this groin pain involves an exertional entrapment neuropathy around the annulus inguinalis as radial tunnel syndrome.

The sports hernia: a cause of chronic groin pain.

The management of chronic pain in sportsmen and women requires consideration of a wide differential diagnosis. A syndrome caused by a distension of the posterior inguinal wall is described, effectively an early direct inguinal hernia. The diagnosis can be made from certain aspects of the history and examination, which are described. The results of surgical repair to the posterior inguinal wall are excellent. The procedure was carried out on 14 sportsmen and one woman. There is an 87% return to full sporting activity, with a follow-up of 18 months to 5 years. The remaining 13% were improved by the repair. Many of the athletes had received other treatments without success. The sports hernia should be high on the list of differential diagnoses in chronic groin pain.