Sports Hernia

Sports Hernia (Athletic Pubalgia, External Ring Tear, Groin Disruption)
1. Lower abdominal or inguinal pain, outside the ball and socket Hip Joint, in athletes
Posterior Inguinal Canal Weakness or Transversalis Fascia Tear (Sportsman's Hernia, Gilmore Groin)
1. Non-palpable Hernia (posterior to canal)

First described in 1980-1990s with rupture of the oblique aponeurosis and conjoined tendon
As of 2019, there are 19 distinct syndromes of defects grouped under Sports Hernia

Male gender (>85% of cases)
Participation in kicking, cutting, sudden forceful twisting and turning (e.g. american football, ice hockey, baseball)

See Pubic Joint for anatomy of Muscle complex insertions (abdominal and thigh flexors, abductors and rotators)
1. Strength, flexibility or coordination imbalance of these opposed Muscles places the athlete at risk of injury
2. Sudden hyperextension and twisting of the trunk combined with Muscle imbalance results in injury
Weakening of posterior Inguinal Canal wall (85% of cases)
1. Results in occult, non-palpable Hernia

Characteristics
1. Chronic, progressive unilateral deep Groin Pain and hip adductor pain in athlete
Timing
1. Insidious onset with gradual worsening, worse with activity and better with rest
Radiation
1. Inguinal ligament
2. Thigh and Perineum
3. Rectus Muscles
4. Testicular Pain (30%)
Provocative
1. Increased intra-abdominal pressure (Valsalva Maneuver, coughing, sneezing, sit-ups)
2. Resistance Training of abdominal Muscles
3. Sprinting, kicking or cutting in sports

See Hip Pain for full exam
Difficult to diagnose except during surgery
Inguinal Canal palpation during valsalva may exacerbate pain
1. Inguinal Hernia is not detectable in most cases (affects posterior wall in most cases)
Tenderness to palpation over conjoint tendon, pubic tubercle, midinguinal
Provocative Tests
1. Also see diagnosis as below
2. Direct Stress Test (with Straight Leg Raise)
  1. Examiner palpates Superficial Inguinal Ring, while patient lies supine
  2. Increased pain when patient performs Straight Leg Raise (reproduces patient's symptoms)
3. Abdominal Muscle resistance testing (Resisted Sit-ups)
  1. Tenderness on palpation of rectus abdominis insertion on pubic ramus while patient performs sit up
  2. Resisted sit-up also provokes pain
4. Other positive findings
  1. Adductor Squeeze Test
  2. Resisted hip adduction related pain (at 0, 45 or 90 degrees of hip flexion)

Pubic tubercle point tenderness (conjoint tendon insertion)
Deep Inguinal Ring point tenderness
Superficial Inguinal Ring tenderness or dilation without obvious Hernia (scrotal inversion with finger)
Adductor longus tendon origin pain
Groin Pain that is dull, diffuse
1. May radiate to perineum, inner thigh or across the perineum

Imaging typically rules out other diagnoses and in some cases may identify findings suggestive of Sports Hernia
XRay
1. Evaluates for Fractures and Stress Fractures
2. Femoroacetabular Impingement (FAI) is found in 80% of surgery confirmed Athletic Pubalgia
Dynamic Ultrasound (preferred first-line in most cases)
1. In skilled hands, exam augmented by Bedside Ultrasound can be useful
2. May demonstrate Tendinopathy (hypoechoic regions)
3. Herniation during valsalva may be visualized in some patients
MRI Pelvis
1. Indicated for non-diagnostic Ultrasound and refractory to conservative therapy
2. Identifies common rectus abdominis - adductor longus aponeurosis Injury

Conservative therapy trial for 8-12 weeks (if no obvious Hernia on exam or dynamic Ultrasound)
1. Relative rest from provocative activity
2. NSAIDS
3. Physical therapist directed program
  1. Core Muscle Strength
  2. Neuromuscular rehabilitation
4. Other measures to consider in non-surgical cases
  1. Ultrasound-guided injection of Corticosteroids (acute) or plasma-rich Platelets (chronic)
Surgical exploration if conservative therapy fails (or Hernia identified on dynamic Ultrasound)
1. Multiple repair strategies exist
2. Successful return to sport in 90% of cases