The sportsman's hernia--fact or fiction?

The value of laparoscopy in the management of chronic groin pain

BACKGROUND

Chronic groin pain problem represents a diagnostic and management challenge. This study is reporting all patients who underwent laparoscopic exploration of the groin and pelvis for undiagnosed chronic groin pain.

MATERIALS AND METHODS

A retrospective cohort study. Evaluators were not involved in the operations. Laparoscopic exploration and mesh insertion using Trans-Abdominal Pre-Preitoneal (TAPP) approach was performed for all patients. Follow up in the; clinic at 2 weeks and 6 months was arranged. This was a consecutive series of patients who were presented with chronic groin pain and no pre-operative radiological, orthopedic, gynecological or urologic abnormalities. Patients who were diagnosed with clinical hernia or other positive finding were excluded.

RESULTS

Data were collected and analyzed for 92 patients. The operation had successfully managed the groin pain in 81 patients (88.04%), and the pain was improved in another 3 patients (3.26%). Six patients (6.52%) had no change in their symptoms, and worse pain was reported in two patient (2.17%).

CONCLUSION

Laparoscopic groin exploration is an effective method to diagnose the chronic groin pain that under diagnosed by clinical, ultrasound and MRI tests. Laparoscopic management had resulted in resolution of the pain in the majority of the patients. The procedure is effective in athletes' patients who did not have clinical, radiological and laparoscopic evidence of groin hernia.

Sports hernias: experience in a sports medicine center

PURPOSE

Chronic pain of the inguino-crural region or "pubalgia" explains the 0.5-6.2% of the consultations by athletes. Recently, areas of weakness in the posterior wall called "sports hernias," have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by "pubalgia".

METHODS

1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic "TAPP" repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U Mann-Whitney test for continuous scale variables and the chi-square test for dichotomous variables with p < 0.05 as a level of significance.

RESULTS

In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1%) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 "sport hernias" in 769 patients with previous diagnosis of adductor muscle strain (10.92%); on the other hand, in 127 (21.52%) of our patients with "sport hernias" US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42% and a specificity of 100%; the positive and negative predictive values were 100 and 99.4% respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81%); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle.

CONCLUSIONS

Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of "pubalgia". "Sports hernias" are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care.

A literature review on the role of totally extraperitoneal repairs for groin pain in athletes

A literature review was made on the role of totally extraperitoneal (TEP) hernia repairs for groin pain in athletes. Electronic databases were searched for literature published from January 1993 to November 2011. There were 10 articles incorporating 196 patients included in this review. Thirty percent of patients were reported to have direct inguinal hernias, 22% had indirect inguinal hernias, and 41% had dilated internal rings. Of note, 30% of cases had no macroscopic abnormality. Four studies reported on an early follow-up ranging between 3 and 6 weeks. Only minimal or mild symptoms were reported. Up to 33% of patients had impaired ability to perform at peak levels. Up to 53% of patients had persistence of symptoms at the early follow-up. Total follow-up time ranged from 3 to 80 months, and most patients were active (90%-100%). At long-term follow-up, 3% to 10% were unable to play, and 5% were reported as being unable to train. Two studies from the same center reported on TEP surgery for osteitis pubis, and most patients returned to sporting activity after 4 to 8 weeks. TEP repair is a good operative intervention in athletes with chronic groin pain not relieved by conservative measures. Athletes recover quickly and return to sport early.

Eccentric and Isometric Hip Adduction Strength in Male Soccer Players With and Without Adductor-Related Groin Pain: An Assessor-Blinded Comparison

BACKGROUND

Adductor-related pain is the most common clinical finding in soccer players with groin pain and can be a long-standing problem affecting physical function and performance. Hip adductor weakness has been suggested to be associated with this clinical entity, although it has never been investigated.

PURPOSE

To investigate whether isometric and eccentric hip strength are decreased in soccer players with adductor-related groin pain compared with asymptomatic soccer controls. The hypothesis was that players with adductor-related groin pain would have lower isometric and eccentric hip adduction strength than players without adductor-related groin pain.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Male elite and subelite players from 40 teams were contacted. In total, 28 soccer players with adductor-related groin pain and 16 soccer players without adductor-related groin pain (asymptomatic controls) were included in the study. In primary analysis, the dominant legs of 21 soccer players with adductor-related groin pain (≥4 weeks duration) were compared with the dominant legs of 16 asymptomatic controls using a cross-sectional design. The mean age of the symptomatic players was 24.5 ± 2.5 years, and the mean age of the asymptomatic controls was 22.9 ± 2.4 years. Isometric hip strength (adduction, abduction, and flexion) and eccentric hip strength (adduction) were assessed with a handheld dynamometer using reliable test procedures and a blinded assessor.

RESULTS

Eccentric hip adduction strength was lower in soccer players with adductor-related groin pain in the dominant leg (n = 21) compared with asymptomatic controls (n = 16), namely 2.47 ± 0.49 versus 3.12 ± 0.43 N·m/kg, respectively (P < .001). No other hip strength differences were observed between symptomatic players and asymptomatic controls for the dominant leg (P = .35-.84).

CONCLUSION

Large eccentric hip adduction strength deficits were found in soccer players with adductor-related groin pain compared with asymptomatic soccer players, while no isometric strength differences were observed between the groups.

Laparoscopic Repair of Sportman's Hernia - The Trinidad Experience

Sportman's hernia: (Athletic pubalgia) is an uncommon and poorly understood condition afflicting athletic individuals. Sufferers complain of chronic groin pain and often present diagnostic dilemmas to physicians and physiotherapists. We present a series of cases illustrating the varying presentations of sportman's hernia and diagnostic approaches that can be utilized to exclude common differentials. We also describe laparoscopic mesh repair as an effective treatment option for this condition.

Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up

INTRODUCTION AND OBJECTIVES

Chronic groin pain (athletic pubalgia) is a common problem in sports such as football, hockey, cricket, baseball and athletics. Multiple co-existing pathologies are often present which commonly include posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis and peripheral nerve entrapment. The mechanism of injury remains unclear but sports that involve either pivoting on a single leg (e.g. kicking) or a sudden change in direction at speed are most often associated with athletic pubalgia. These manoeuvres place large forces across the bony pelvis and its soft tissue supports, accounting for the usual clinical presentation of multiple symptomatic abnormalities forming one pattern of injury.

RESULTS

The diagnoses encountered in this series of 100 patients included rectus abdominis muscle atrophy/asymmetry (22), conjoint tendinopathy (16), sports (occult, incipient) hernia (16), groin disruption injury (16), classical hernia (11) traumatic osteitis pubis (5), and avulsion fracture of the pubic bone (4). Surgical management was generally undertaken only after failed conservative therapy of 3-6 months, but some professionals who have physiotherapy during the football season went directly to surgery at the end of the football season. A variety of operations were performed including groin reconstruction (15), open hernia repair with or without mesh (11), sports hernia repair (Gilmore) (7) laparoscopic repair (3), conjoint tendon repair (3) and adductor tenotomy (3). Sixty-six patients were available for follow at an average of 13 years after initial consultation and the combined success rate for both conservative treatment and surgery was 94%.

CONCLUSION

The authors believe that athletic pubalgia or sports hernia should be considered as a 'groin disruption injury', the result of functional instability of the pelvis. The surgical approach is aimed at strengthening the anterior pelvic soft tissues that support and stabilise the symphysis pubis.

Health-related quality of life after TAPP repair for the sportsmen's groin

BACKGROUND

Sportsmen's groin (SG) is a clinical diagnosis of chronic, painful musculotendinous injury to the medial inguinal floor in the absence of a groin hernia. Long-term results for laparoscopic inguinal hernia repair, especially data on health-related quality of life (HRQOL), are scant and there are no available data whatsoever on HRQOL after SG. The main goal of this study was to compare postoperative QOL data in the long term after transabdominal preperitoneal hernioplasty (TAPP) in groin hernia and SG patients with QOL data of a normal population.

METHODS

This study included all patients (n = 559) who underwent TAPP repair between 2000 and 2005. Forty seven patients (8.4 %) were operated on for SG. We sent out the Short Form 36 Health Survey (SF-36) questionnaire for QOL evaluation. QOL data were compared with data from an age- and sex-matched normal population.

RESULTS

Ultimately, 383 completed questionnaires were available for evaluation (69 % response rate). The mean follow-up time was 94 ± 20 months. In the SG group there were statistically significant differences in three subscales of the SF-36 and the mental component summary measure, showing better results for the SG group compared to the sex- and age-matched normal group data. There were no statistically significant differences between groin hernia patients and the sex- and age-matched normal population.

CONCLUSION

TAPP repair for SG as well as groin hernia results in good HRQOL in the long term. Results for SG patients are comparable with QOL data of a normal population or even better.

Surgical management of sportsman's hernia in professional soccer players

Soccer players frequently experience acute and chronic groin pain. Sportsman's hernia is a common injury in professional soccer players, that causes inguinal pain. The authors discuss their experience with the management of sportsman's hernia in professional soccer players competing in national and international competition in a retrospective review of prospectively collected data. Between March 2004 and December 2009, seventy-one professional soccer players were surgically treated for sportsman's hernia. Average age at surgery was 24 years, and average duration of symptoms from onset to surgical repair was 11 months. Conservative treatment improved symptoms temporarily or to some extent in 18 athletes. All athletes underwent a bilateral open hernia repair with concurrent adductor tendon release. Average follow-up was 4 years, and average time to return to competitive sport was 4 months. At final follow-up, 95% of soccer players were still active, 48 at the same level and 19 at a lower level. Four athletes had stopped their careers because of another injury (n=2) or recurrence (n=2). Sportsman's hernia is a potentially career-ending injury in professional soccer players. Conservative management is often unsuccessful. An open surgical hernia repair combined with an adductor longus tenotomy relieves the symptoms caused by a sportsman's hernia and restores activity in 95% of athletes. This study offers insight into the management of sportsman's hernia and offers a successful treatment to salvage the careers of professional soccer players.

Bilateral mini-invasive adductor tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes

BACKGROUND

To date, the best management of chronic groin pain related to adductor longus tendinopathy has not been defined. Although there have been some studies investigating the effectiveness of adductor longus tenotomy, none have investigated bilateral adductor tenotomy for unilateral tendinopathy.

HYPOTHESIS

The use of bilateral percutaneous adductor tenotomy for the management of chronic unilateral groin pain as a result of adductor longus tendinopathy will result in improvement of overall function and facilitate a return to athletic activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

During the period from 2004 to 2007, we prospectively enrolled 29 consecutive athletes (26 male and 3 female; median age, 28 years) with chronic groin pain from unilateral adductor longus tendinopathy who underwent bilateral adductor tenotomy. Functional outcome and health status were assessed with the Hip Disability and Osteoarthritis Outcome Score (HOOS), Short Form Health Survey (SF-36), and European Quality of Life-5 Dimensions scale (EQ-5D). The ability to participate in sport before and after surgery and the time to return to training and return to sport were also recorded. The median follow-up after surgery was 36 months.

RESULTS

All questionnaires showed a statistically significant improvement (P < .0001) after surgery. At the time of latest follow-up, 20 of 29 patients (69%) returned to their preinjury level of sport and 2 of 29 patients (7%) to higher levels compared with preinjury status. However, 4 of 29 patients (14%) returned to sport at lower levels than those of preinjury status, and 3 of 29 patients (10%) ceased to participate in sport. The median time to return to training was 11 weeks and to return to sport was 18 weeks.

CONCLUSION

Bilateral mini-invasive adductor tenotomy can be an effective treatment for athletes suffering from unilateral chronic groin pain associated with adductor longus tendinopathy refractory to nonoperative management.

Conservative care of sports hernias within soccer players: a case series

OBJECTIVE

To detail the progress of 2 high-level soccer players and 1 recreational soccer player with chronic groin pain that was exacerbated by participation in sports and relieved by rest. The patients under went a conservative treatment plan featuring manual therapy, therapeutic modalities, and plyometric training.

CLINICAL FEATURES

The most important examination findings were palpable tenderness over the internal oblique fascia and anterior pubic tubercle, pain with resisted hip adduction, and pain with a resisted abdominal curl-up. Conventional treatment aimed at decreasing healing time of the injury through manual therapy, including soft tissue and modality techniques; rehabilitative exercises, focusing on the pelvic muscles; and plyometric training, aiming at sport specific functional improvement.

INTERVENTION

The conservative treatment approach utilized in this case series involved manual therapy, 1-2 times a week for 6-8 weeks, consisting of soft tissue, laser, microcurrent, and acupuncture; rehabilitative exercise and plyometric training, 3 times a week for 8 weeks, to help improve strength, coordination, and correct pelvic muscle imbalances. Outcome measures included visual analog scale scores and resisted muscle testing.

SUMMARY

Three soccer players, of varying levels of ability, presenting with a suspected sports hernia (chronic groin pain exacerbated by sports and relieved by rest) were relieved of their pain after 8 weeks of conservative care featuring manual therapy, rehabilitative exercises, and plyometric training.

Sportsmen hernia: what do we know?

Athletes and other physically active people often suffer prolonged inguinal pain, which can become a serious debilitating condition and may place an athlete's career at risk. A sportsmen hernia is a controversial cause of this chronic groin pain, as it is difficult to be defined. From an anatomical point of view, the definition and the name of this entity should be reviewed. In the majority of athletic manoeuvres, a tremendous amount of torque or twisting occurs in the mid-portion of the body and the front, or anterior portion, of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. These opposing forces cause a disruption of the muscle/tendon at their insertion site on the pubis, so the problem could be related to the fact that the forces are excessive and imbalanced, and a weak area at the groin could be increased due to the forces produced by the muscles. The forces produced by these muscles may be imbalanced and could produce a disruption of the muscle/tendon at their insertion site on the pubis or/and a weak area may be increased due to the forces produced by the muscles, and just this last possibility could be defined as "sportsmen hernia." In conclusion, this global entity could be considered to be an imbalance of the muscles (abductor and abdominal) at the pubis, that leads to an increase of the weakness of the posterior wall of the groin and produces a tendon enthesitis, once a true origin is not detected, that may lead to a degenerative arthropathy of the pubic symphysis in the advanced stages. Based on this, this entity could be re-named as "syndrome of muscle imbalance of the groin" and the sportsmen hernia could be considered as an entity included in this syndrome. It is recommended that a multidisciplinary approach is given to this entity, since the present literature does not supply the proper diagnostic studies and the correct treatment which should be performed in these patients.

Rehabilitation of the hip following sports injury

An athlete often presents to the rehabilitation specialist with either a nonspecific referral, such as "hip pain," or with a diagnosis of a more specific hip pathology. The highly skilled clinician is trained to look at the "linkage" between the trunk and all parts of the lower extremity. Why is the hip not transferring the load well? Where is the breakdown? The gluteus medius, pelvic stability, and supportive muscular slings are of great importance when optimizing the function of the hip. The hip is subjected to forces equal to multiples of the body weight and requires osseous, articular and myofascial integrity for stability. This is the mind set when devising an athlete's rehabilitative program, looking at all influential factors that affect joint movement and integrity.

Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis

OBJECTIVE

The purpose of this article is to define the relations of the symphysis pubis and capsular tissues to the adductor and rectus abdominis soft-tissue attachments on cadaver dissection and correlate with MRI of the anterior pelvis.

SUBJECTS AND METHODS

Seventeen cadavers (8 males and 9 females; mean age, 80 years) were dissected bilaterally. Rectus abdominis and adductor muscles were traced to the pubis and further attachments to the pubic symphysis were defined. Ten asymptomatic (mean age, 17; age range, 16.5-29 years) male athletes underwent 1.5-T MRI of the anterior pelvis with two surface microcoils (each 42 mm in diameter). An axial T2-weighted turbo spin-echo (TSE) sequence (TR/TE, 2,609/106; voxel size, 0.4 mm) was obtained. Axial and sagittal 3D T1-weighted fast-field echo (FFE) sequences (25/4.9; voxel size, 0.3 mm) were obtained. Sequences were repeated incorporating fat suppression and i.v. gadolinium. The relation of the symphysis pubis, disk, and capsular tissues to the insertions of the rectus abdominis, adductor muscles, and gracilis were independently evaluated by two experienced radiologists blinded to all clinical details.

RESULTS

In all 17 cadaver specimens, the adductor longus and rectus abdominis attached to the capsule and disk of the symphysis pubis, whereas the adductor brevis had an attachment to the capsule in seven specimens and the gracilis in one. All adductor tendons attached to the pubis. In all 10 athletes, the adductor longus and rectus abdominis bilaterally contributed to the capsular tissues and disk. This was only the case for the adductor brevis in four athletes. No other tendons involved the capsular tissues.

CONCLUSION

Cadaver and MRI findings show an intimate relationship between the adductor longus; rectus abdominis; and symphyseal cartilage, disk, and capsular tissues.

Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury

BACKGROUND

Little data exist on the results of treatment for sports-related chronic groin injury.

HYPOTHESIS

Sports-related chronic groin injury treated with a conservative (rest) program results in a satisfactory outcome.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Professional Australian male football players, at the end of the playing season, had their groin injury diagnosed using specific clinical and magnetic resonance imaging (MRI) criteria. Those assessed as having a non-hip-related cause for their chronic groin injury were treated principally by 12 weeks of complete rest from active weightbearing activities. Response to treatment was assessed at different stages of rehabilitation by recording the number of athletes who had returned to playing football and the number of athletes without symptoms.

RESULTS

Twenty-seven athletes were considered to have chronic groin injury. Clinical and MRI (pubic bone marrow edema N = 26 [96%]), hyperintense line N = 25 [93%]) criteria suggested a pubic bone stress injury as diagnosis for the chronic groin injury. Eighty-nine percent of athletes returned to sport in the subsequent playing season, with 100% having returned by the second playing season after diagnosis. Forty-one percent of the athletes were without symptoms at the commencement of the following playing season, rising to 67% by the end of that playing season.

CONCLUSIONS

Conservative management of athletic chronic groin injury resulted in an excellent outcome when assessed by the return to sport criterion. However, the results were only satisfactory if the criterion of ongoing symptoms after treatment was used. More research is needed to compare the efficacy of all treatments that are used in this troublesome condition.

Patterns of Bone and Soft-Tissue Injury at the Symphysis Pubis in Soccer Players: Observations at MRI

OBJECTIVE

The objectives of our study were, first, to use MRI to determine the prevalence of osteitis pubis and of adductor dysfunction at the symphysis pubis in soccer players presenting with pubalgia and, second, to determine whether the two entities are mechanically related and whether one of the entities precedes or predisposes the development of the other.

MATERIALS AND METHODS

One hundred consecutive soccer players with debilitating groin pain were referred for MRI. One hundred asymptomatic age- and sex-matched elite athletes were included as control subjects. The "secondary cleft" sign was used to indicate an adductor microtear at the symphyseal enthesis. Osteitis pubis was recorded if paraarticular bone edema was identified along the symphyseal margins but was remote from the adductor attachment. Images were reviewed independently by two radiologists who were blinded to the side of symptoms. Statistical analysis was performed using the chi-square test.

RESULTS

Of 100 patients, groin pain was directly attributed to inflammation at the symphysis pubis or its muscular attachments in 97 (isolated adductor microtears, n = 47; isolated osteitis pubis, n = 9; both, n = 41). An "accessory cleft," reflecting an adductor enthetic microtear, was identified in 88 of these patients (p < 0.001); it correlated with the side of symptoms in all cases. Bone edema was identified in 91 of 100 patients: 49 had focal edema at the attachment site of the adductor tendons accompanying an adductor microtear, two patients had focal edema without an adductor tear, and 40 patients had diffuse edema in the pubic bones secondary to osteitis pubis. There was no evidence of either adductor dysfunction or symphyseal inflammation in the control subjects (p < 0.001).

CONCLUSION

In soccer players with pubalgia, adductor dysfunction is a more frequent MRI finding than osteitis pubis. The findings of this study suggest that both entities are mechanically related and that osteitis pubis and adductor dysfunction frequently coexist but, because adductor dysfunction is commonly identified in the absence of osteitis, that adductor dysfunction most likely precedes the development of osteitis pubis in soccer players. The presence of edema on fat-suppressed images of the symphysis is a strong predictor of abnormality at this site in soccer players when compared with age- and sex-matched control subjects.

Adductor-related groin pain in athletes: correlation of MR imaging with clinical findings

OBJECTIVE

To evaluate gadolinium-enhanced MR imaging in athletes with chronic groin pain and correlate with the clinical features.

DESIGN AND PATIENTS

MR examinations performed in 52 athletes (51 male, 1 female; median age 26 years) with chronic groin pain and 6 asymptomatic control athletes (6 male; median age 29 years) were independently reviewed by two radiologists masked to the clinical details. Symptom duration (median 6 months) and clinical side of severity were recorded. Anatomical areas in the pelvis were scored for abnormality (as normal, mildly abnormal or abnormal) and an overall assessment for side distribution of abnormality was recorded, initially without post-gadolinium sequences and then, 3 weeks later (median 29 days), the post-gadolinium sequences only. Correlation between radiological and clinical abnormality was calculated by Spearman's correlation.

RESULTS

Abnormal anterior pubis and enthesis enhancement significantly correlated with clinical side for both radiologists (both P=0.008). Abnormal anterior pubis and adductor longus enthesis oedema was significant for one radiologist ( P=0.009). All other features showed no significant correlation ( P>0.05). In the control cases there was no soft tissue abnormality but symphyseal irregularity was present ( n=2). For both radiologists assessment of imaging side severity significantly correlated with clinical side for post-gadolinium ( P=0.048 and P=0.023) but not non-gadolinium sequences ( P>0.05).

CONCLUSION

The extent and side of anterior pubis and adductor longus enthesis abnormality on MR imaging significantly and reproducibly correlates with the athletes' current symptoms in chronic adductor-related groin pain.

Endoscopic evaluation and treatment of groin pain in the athlete

BACKGROUND

Chronic groin pain in athletes forms a major diagnostic and therapeutic challenge.

HYPOTHESIS

Evaluate and treat undiagnosed groin pain in the athlete by endoscopy.

STUDY DESIGN

Prospective cohort study.

METHODS

Athletes who were referred to the Ikazia Hospital with undiagnosed chronic groin pain between January 1998 and August 2001 were included. Radiography, bone scintigraphy, and ultrasonography were performed. In 14 athletes, groin pain remained undiagnosed. Ten patients complained of unilateral, 4 of bilateral groin pain. Patients underwent a transabdominal or extraperitoneal diagnostic endoscopy.

RESULTS

All patients were operated ambulatory without significant difficulties. Pathology found by endoscopy was hernia inguinalis (n = 9), hernia femoralis (n = 4), preperitoneal lipoma (n = 3), and hernia obturatoria (n = 1). Only once was there no pathology. In 17 groins, a Prolene mesh was placed preperitoneally. Thirteen patients (93%) returned to full activity within 3 months of surgery. One year after surgery, one patient had minor symptoms and one patient had persistent symptoms. All other patients had no complaints.

CONCLUSIONS

An occult hernia should be high on the list of differential diagnoses in undiagnosed chronic groin pain in athletes. Operative treatment can return the patient to his sport within 3 months.

Painful incarcerated hernia following a rugby union lineout

Discussion related to hernias in sport usually involves the diagnosis and treatment of chronic musculotendinous groin disruption. A case of acute trauma in an incarcerated inguinal hernia, occurring in a rugby union player during a lineout, is presented. The injury arose as a result of a change in the laws of the game.

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 of groin pain.

METHODS

Thirty five professional Australian footballers with and without groin pain were investigated blind with a dynamic high resolution ultrasound technique for presence of posterior wall deficiency.

RESULTS

Fourteen players had a history of significant recent groin pain and ten of these were found to have bilateral inguinal canal posterior wall deficiency (p < 0.01). The relative risk for a history of groin pain with bilateral deficiency was 8.0 (95% confidence interval 1.73 to 37.1). Groin pain was also found to be associated with increasing age (p < 0.01) which was an independent risk factor. Surgical, clinical, and ultrasound follow up for players who underwent hernia repair confirmed the validity of ultrasound as a diagnostic tool.

CONCLUSIONS

Dynamic ultrasound examination is able to detect inguinal canal posterior wall deficiency in young males with no clinical signs of hernia. This condition is very prevalent in professional Australian Rules footballers, including some who are asymptomatic. There was a correlation between bilateral deficiency and groin pain, although the temporal relationship between the clinical and ultrasound findings is not established by the current study. Ultrasound shows promise as a diagnostic tool in athletes with chronic groin pain who are considered possible candidates for hernia repair.

The 'sports hernia': a common cause of groin pain

Athletes who participate in sports 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.