Sports Hernia: diagnostic and therapeutic approach

Sports hernias refer to a group of lesions of the lower abdominal wall and of the muscular and tendon structures of groin canal which are among the causes of the groin pain syndrome. It is a painful disorder that affects predominantly male athletes, common in soccer players and in those who practice other sports that involve sudden changes of direction (ice hockey, rugby). It can represent the end of a sports career.

The weakening and tearing of the lower abdominal muscula-ture, in particular of the posterior wall of the groin canal, causes a pain that radiates from the inguinal and pubic region to the scrotum and to the proximal region of the thigh, caused by irritation of the rich local enervation.

Manual exploration of the inguinal canal that elicits pain is the cornerstone for diagnosis. The dynamic ultrasound and magnetic resonance imaging are indicated for diagnostic confir-mation. Conservative treatment with anti-inflammatory and physical therapy is indicated up to 12 weeks from onset. After this period, if symptoms persist, open repair or laparoscopic surgery is indicated, with the aim to reconstruct the abdominal wall and the inguinal canal structures, in addition, if necessary, local neurolysis.

In the last years the term Sport hernia has been used in sports medicine to define one of the causes of groin pain syndrome. The absence of a hernia can sometimes confuse the true meaning of the term. The surgeon Jerry Gilmore in the 90s described a pathology with muscular and nervous aetiology also called Gilmore’s groin, groin strain or sportsman’s groin, distinct from classical inguinal hernia that presents a visceral extrusion.

It refers to a group of lesions of the lower abdominal wall and in particular localized at the muscular, tendons and nerve structures of the inguinal canal.

It is a painful disorder that affects predominantly male athletes and is common in sports that involve rapid acceleration accompanied by sudden changes in direction, cutting and kicking, sneezing, turning and twisting. Soccer players are the sportsmen in which we found the largest number of this type of lesions, with lower frequency in rugby and ice hockey players and in runners.

Numerous causes have been hypothesized but it is very difficult to establish from which it originated. We have to consider the multifactorial genesis of these lesions. An imbalance between the weaker lower abdominal muscles and the stronger hip adductor muscles that depends from the physical characteristics of the athlete or more frequently from the different typology of athletic preparation.

The trainers tend to prefer to work on strengthening of the leg muscle than on trunk muscles. Currently the diffusion of soccer in young people shows a growing incidence of this pathology as a result of incorrect training. The result is a great difference of force distribution in these areas. During trunk flexion and rotation, the oblique internal and external abdominal muscles, both inserted onto the pubic bone, exert an upward traction, while the hip adductor muscles also inserted onto the pubic bone, exert a downward traction. The muscular simultaneous contraction, for example during a contrast in the match, exert a traction on the pubic bone due to opposing forces.

The gender difference of the musculoskeletal anatomy in this area may explain why the sports hernia is more common in males than females. For example there is a different insertion of the rectus abdominis in females which inserts onto the antero-superior part of the symphysis, while in men, there is a continuity of these ligaments, one for each medial half of rectus with the gracilis and fascia lata.

The pubic instability due to an altered coordination of muscular synergy, necessary for efficacious control of hip dynamics, may be the cause of sport hernia. Muscular imbalance and functional instability of the pubic symphysis leads to small tears in the muscle wall and in the aponeurotic fascia, resulting in entrapment of the inguinal nerves and with low frequency of the iliohypogastric nerves, thus causing pain typically associated with sports hernia. Gullmo suggested that the underlying cause of chronic groin pain is related to repeated stretching of the peritoneum or of the sensory fibres of the ilioinguinal nerve along its course. The ilioinguinal nerve, because its anatomic course and its length, is easily exposed to injury and can be compressed or entrapped by tears in the abdominal muscle fascia.

Another anatomic structure responsible for pain is the genital branch of the genitofemoral nerve which can be compressed by bulging of the posterior wall of a weak or incompetent inguinal canal, including laceration of the transverse fascia with protrusion of the preperitoneal fat. This condition may be associated to increased size of the angle of convergence between the insertion of the rectus muscle along with the conjoint tendon and the inguinal ligament resulting in an enlarged external inguinal ring. In addition, an alteration of the confluence between this tendon and the adductor muscle may be present, observing a fibrosis of these structures in chronic forms above the pubic crest.

In current reports there is a discussion about the biomechanical alterations determined from “Femoro-acetabular impingement, in particular Cam type, and development of sports hernia.

The frequent association of these diseases should make us reflect on which disease starts first, in any event there is an agreement on the treatment of both after a multidisciplinary evaluation.

Pain develops during or at the end of exercise, or the day after the game. It is usually unilateral but occasionally bilateral, and is located above the projection of the inguinal ligament to the lower lateral edge of the rectus abdominis muscle and often radiating to the scro-tum (30%) and the proximal region of the thigh that is along the path of adductor longus. Pain persists after a game and is accompanied by a difficulty in getting out of bed during the next two days.

The onset is insidious, it subsides with rest and reappears with sport activity return. The player is not able to kick with a combined movement of hip extra rotation. Pain is exacerbated by movement that involves sudden twisting and acceleration of the torso, by sneezing and coughing.

Clinical examination starts with the patient standing upright; occasionally a slight bulge in the groin is observed. The simple palpation of the inguinal area above the pubic insertions of conjoint rectal muscle generally doesn’t elicit pain.

The exploration through the scrotum reveals a dilated superficial inguinal ring due to the external oblique aponeurosis and/or conjoint tendon tear.

The thrust of the explorer finger will cause a deep and sharp pain enhanced by a crunch movement. If the patient coughs during this maneuver, you can feel a weak impulse of the posterior wall of the inguinal canal, and when a dislocated or entrapped nerve is found, the pain may continue even after the exploration. This is a specific hallmark. To confirm the origin of pain it is possible to make a Lidotest with the injection of local anesthetic medially to the superior anterior iliac spine. The immediate but temporary resolution of pain can help in differential diagnosis.

In order to exclude other associated diseases, you must carry out some semeiological maneuvers. The frequent association with CAM FAI may be hypothesized with positive impigement test. The pressure exerted on the pubic symphysis should suggest a osteitis. A positive squeeze test can highlight insertional lesions of the adductor muscles.

Dynamic ultrasound examination is certainly the most accessible but highly operator-dependent procedure [16]. An excellent knowledge of normal and pathologic groin anatomy is required. The examination may show macroscopic injuries of the conjoint tendon and of the aponeurosis of oblique external muscle. The  lesions of the posterior wall of the inguinal canal are distinguished by a moderate and convex bulging associated with tear of the transversalis fascia and  very small protrusions of peritoneal fat.

The picture is of an incipient direct inguinal hernia. The image capture is performed starting from the baseline condition, during a sit-up or when asked to contract the abdominal muscles (Valsalva). The local innervation and its course can not be shown by ultrasound, but this is the area where we find entrapment or compression of the ilioinguinal nerve during open surgery. MRI is a examination of high diagnostic accuracy for muscle and tendon injuries; it allows us to define many associated diseases. It is required in second line to define more complex situa-tions such as hip pathologies and pubis osteitis. The test is also made in basal condition and during Valsalva.

The athlete’s history helps us to decide between a conservative or surgical treatment. The acute onset of symptoms suggests a conservative approach with antinflammatory therapy and rest. The specific physiotherapy required to redress the balance between the abdominal muscles, rectum, external oblique, internal and transverse and the most powerful adductor muscles will have to continue for a period of 8-12 weeks, depending on the severity of injury. The difference in the competitive level will have to be considered in choosing treatment. After 12 weeks, if there are still conditions for not playing a match, surgical treatment is called for. Although symptoms mainly refer to one side, it is preferable to operate on both sides in order to restore fair distribution of lines of force.

Surgical techniques proposed in the treatment derive from those used in traditional surgery for hernias. The open techniques with or without the mesh implant are designed to reconstruct the transversalis fascia, to reduce the angle between conjoint tendon and inguinal ligament and in strengthening the internal inguinal ring. The association of a decompression or neurolysis of ilioinguinal nerves and genitofemoral and more rarely of iliohypogastric nerve depends on their anatomical position in the context of the injury observed. The observation is possible only with open repair techniques.

The most current video-assisted techniques (TAPP, TEP) with the placement of a polypropylene mesh report a faster return to sports activity. The possibility of positioning a prosthesis of a larger size allows us to stabilize different lesions of the posterior abdominal wall. Laparoscopic technique require a longer learning curve than open surgery. Risks associated with general anaesthesia required for laparoscopic procedures, possible injury to the abdominal organs and vascular structures will have to be considered as in most cases we are dealing with very young and healthy patients.

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