Primary Care of the Sports Hernia
Recognizing an Often-Overlooked Cause of Pain
Jason D. Johnson, MD; William W. Briner, Jr, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 2 - FEBRUARY 2022
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In Brief: Groin injury is common in sports that involve high-speed torsion of the trunk, especially soccer, as in this case of a 28-year-old goalie. The sports hernia, a syndrome of pain caused by disruption of the inguinal canal without a clinically detectable hernia, is often initially overlooked. Examination reveals maximal tenderness over the pubic tubercle and posterior inguinal canal. The diagnosis is clinical, but x-rays and bone scanning may help rule out a concurrent injury. The pain may be multifactorial, with coexisting hip or adductor muscle pathology complicating the clinical picture. Rehabilitation, particularly core strengthening with emphasis on the abdominal obliques, is the first line of treatment. If this is ineffective, surgery is usually successful, and most athletes return to a high level of sports participation 6 to 8 weeks postsurgery.
Sports hernia is a syndrome of chronic pain caused by weakness or disruption of the posterior inguinal canal and conjoined tendon. Although limited literature on the subject exists, many consider sports hernia to be an early form of direct inguinal hernia. The exact incidence is unknown, but the condition is seen in activities involving high-speed twisting and turning, such as soccer, rugby, and ice hockey.1 An estimated 5% of all soccer injuries are groin injuries, but this injury accounts for a disproportionately large amount of time lost from sport.2
Because this is a chronic condition and is often initially overlooked, most affected athletes present to a specialist many months after symptoms begin. However, the primary care physician may often be the first physician to encounter an athlete with groin pain. Early recognition of this syndrome will lead to expedient treatment.
A 28-year-old male professional soccer goalkeeper experienced 2 months of intermittent left groin pain. He described his pain as radiating up into the left lower quadrant of the abdomen and occasionally distally into the medial aspect of the thigh. He was right-foot dominant, and long kicks, especially goal kicks, particularly irritated the region. He did not recall a traumatic event. Symptoms were insidious in onset and gradually progressed, causing an antalgic gait and pain with jogging. Abstinence from soccer decreased symptom severity, but all symptoms recurred with increased activity.
On examination, he was tender to palpation over the pubic symphysis and along the origin of the adductor muscles from the inferior pubic ramus. The patient also had tenderness over the left pubic tubercle on palpation through the inguinal rings. He was minimally tender over the left inferior inguinal canal. No inguinal hernia was palpable. Abdominal examination was otherwise unremarkable. His left hip had full and pain-free range of motion and was remarkable only for moderate pain and slight weakness (4+/5 strength) with resisted hip adduction. The exam on the contralateral hip was normal. Radiographs of the pelvis were essentially normal, with the exception of a slight asymmetry of the pubic symphysis.
The patient's symptoms appeared to be multifactorial, with likely components of left-sided adductor strain, sports hernia, and osteitis pubis. He was treated with oral nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy consisting of eccentric adductor, rectus abdominis, and abdominal oblique strengthening. His proximal adductor pain and tenderness improved, but he still had groin pain with running.
A corticosteroid was injected into the pubic symphysis after physical therapy was completed, with subsequent improvement in his focal midline pain. His pain with activity improved but remained significant.
Surgical exploration revealed disruption of the posterior inguinal canal and conjoined tendon. Repair was performed with an open Bassini's herniorrhaphy using anchoring sutures to the pubic symphysis. Postoperatively, he no longer had pain or tenderness anywhere along the inguinal canal or pubic symphysis.
Physical therapy after surgery again included specific attention to strengthening the rectus and abdominal oblique muscles. The athlete had some mild residual proximal adductor pain that hindered his return to activity. Flexibility and eccentric strengthening of the affected musculature allowed for his eventual return to professional soccer and performing long kicks for his team.
Pinpointing the Cause of Pain
This case demonstrates that sports hernia is often an aspect of multifactorial groin pain. Any condition in the broad differential diagnosis (table 1) may coexist and complicate the picture. Osteitis pubis and adductor strains are common comorbidities. Adductor strain can be a difficult diagnosis to make; however, many athletes with sports hernia report pain and tenderness over the proximal adductors, even in the absence of a true strain. All aspects of the athlete's pain must be carefully addressed for treatment to be efficacious.
In sports hernia, the athlete's pain localizes to the inguinal canal, usually in the posterior aspect (figure 1). The injury or disruption may be of the conjoined tendon, the tendinous insertion of the transversus abdominis and internal oblique, or of the transversus abdominis itself (figure 2). Less commonly, the injury may also involve the aponeurosis of the internal or external oblique.
Chronic shear forces across the pubic symphysis, caused by repetitive adductor muscle firing, can stress the posterior wall of the inguinal canal and ultimately lead to disruption. While theoretical, this could account for the high rates of coexistent osteitis pubis and adductor tendinopathy.3,4
Athletes who have sports hernias typically report chronic groin pain with exercise, and the pain is usually insidious and progressive in nature. Pain may also occur acutely in association with a tearing sensation. Some athletes describe this as an intense sensation, felt more proximal and "internally" than groin strains.3 The condition is much more common in men, with one study5 finding less than 5% of cases occurring in women.
In the early stages, the pain often occurs after or near the end of activity. As the condition progresses, however, the pain worsens and occurs earlier in activity. Pain begins to inhibit the athlete's ability to cut, turn, or stride out. Eventually, straight-ahead running and even activities of daily living may become difficult. Affected athletes often report long-standing pain. A typical duration of symptoms at diagnosis is 20 months, ranging from 6 weeks to 5 years.3,6
Although the condition is usually unilateral, Gilmore2 reported bilateral pain in 12% of cases. Pain may radiate contralaterally, to the perineum, rectus or adductor muscles, or to the scrotum.6 Coughing and the Valsalva's maneuver, as well as sexual intercourse, may aggravate the pain. Testicular pain has been noted in 30% of affected males.5 Symptoms tend to improve dramatically with prolonged abstinence from sporting activity, only to recur when high-intensity activity is resumed.
Focused Physical Exam
On inversion of the scrotal skin, the external inguinal ring may be dilated or tender to palpation. Typically, maximal tenderness at the pubic tubercle on the involved side is a reliable sign to diagnose sports hernia, although other potential areas of tenderness include the posterior or lateral inguinal canal.
Sit-ups or Valsalva's maneuver may worsen the symptoms and occasionally will cause a slight but appreciable distention of the posterior inguinal canal. An obvious, palpable hernia is notably absent. In some cases, manual resistance of the adductors may be painful. Careful hip, abdominal, back, sacroiliac, and genitourinary examinations should also be performed. If the sports hernia is the sole cause of the athlete's symptoms, these exam results should be within normal limits.
If the athlete has an imposed period of rest, physical exam findings may be absent or substantially decreased. Re-examination after a return to strenuous activity can help elicit important findings.
Helpful Diagnostic Imaging
The sports hernia is a clinical diagnosis, with no definitive diagnostic test available. Plain films of the pelvis are appropriate to look for fractures (especially stress fractures of the inferior pubic ramus), asymmetry of the pubic symphysis, or other injury. Hip films may also be indicated if pain occurs with hip rotation on physical exam. Bone scans may help rule out associated pathologies, including stress fractures or osteitis pubis.
Herniography, often used in Europe, may demonstrate a small hernia in 25% of patients.6 The technique is quite dependent on the experience of the radiologist, however, and is not generally available in the United States. Orchard et al7 described the use of ultrasound to diagnose posterior inguinal wall deficiency. The technique shows promise, but needs further evaluation, and again would likely be dependent on experienced interpretation. Both herniography and ultrasound suffer from low specificity for diagnosing sports hernia.6,7
Conservative Treatment First
Several weeks of relative rest, followed by functional rehabilitation for 3 to 4 months and gradual resumption of strenuous activities, is reasonable as first-line treatment.
An important consideration in rehabilitation is the likelihood of a strength imbalance that results in core instability. Athletes who have chronic adductor tendinosis may respond favorably to an eccentric strengthening program for the pelvic adductors.8 Hip flexor strengthening exercises may also be helpful. Conversely, abdominal oblique strengthening may improve symptoms in athletes who generally do far more lower-extremity exercise and whose abdominal muscles are relatively weaker than their thigh muscles. When other abdominal, hip, or groin problems coexist, appropriate treatment or rehabilitation may provide some degree of pain relief.
Sports hernia is often a difficult diagnosis to make, often with comorbities confusing the issue. In most cases, it may not be the correct diagnosis. It is certainly reasonable, and actually prudent, to empirically try a course of conservative therapy and rehabilitation before committing to an invasive procedure. The patient could have tendinopathy that very well may respond to rehabilitation techniques, rather than complete tendon disruption. However, a conservative approach will not work in most cases of sports hernia, and the majority go on to surgery.
If conservative measures fail, referral to a general surgeon for herniorrhaphy becomes necessary. In fact, surgery is often both diagnostic and therapeutic. Operative findings commonly include weakening of the transversalis fascia and separation of the inguinal ligament from the conjoined tendon, a torn conjoined tendon, a torn external oblique aponeurosis, or tearing of the conjoined tendon from the pubic tubercle.2,3,5,9-11
An open Bassini-type repair seems to be the most effective procedure.12 Meticulous repair of all anatomic layers is important, usually with anchoring sutures to the pubic symphysis.3,5,9 Some have reported success with endoscopic herniorrhaphy with mesh insertion.13 Adductor longus tenotomy in conjunction with hernia repair resulted in more than 90% success in one series.12 Although success rates have been reported anywhere from 63% to 93%, most surgeons report greater than 90% success at returning athletes to their prior level of sport.2,5,13
Of course, surgery necessitates rest from activity during the postoperative period, which may contribute to the benefit of this treatment. While this is a well-described and appreciated condition in Europe, the most difficult step in treatment in the United States is often finding a general surgeon who can be convinced of the existence of sports hernia.10 In fact, the Bassini-type open repair favored by Gilmore2 is well within the scope of general surgeons.
It may be helpful to discuss the first few referrals with a trusted surgeon before each patient's initial surgical consultation. Making copies of the relevant literature available to our surgical colleagues may also help to facilitate timely management.
A Proactive Stance
Patients who have sports hernias report chronic groin pain, and the diagnosis can be difficult to make. A primary care physician who is aware of this condition can make an early diagnosis and help the injured athlete seek appropriate medical treatment as quickly as possible.
Dr Johnson is a sports medicine and family practice physician in private practice and Dr Briner is the sports medicine fellowship director and member of the family practice faculty at Advocate Lutheran General Hospital in Park Ridge, Illinois. Each of them also holds a certificate of added qualifications in sports medicine. Address correspondence to Jason D. Johnson, MD, 1170 E Belvedere, Ste 107, Grayslake, IL 60030.
Disclosure information: Drs Johnson and Briner disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.