Understanding A Sports Hernia

What is the Definition of a Sports Hernia?

The easy, basic definition for the person without a lot of knowledge in this area is that a Sports Hernia is a condition that mimics the symptoms of common inguinal hernia, but without the presence of an inguinal hernia.

Essentially, a sports hernia is defined as groin pain that is present when performing activities such as running or sports with lateral movements ( ie football, hockey, basketball, tennis, lacrosse, etc..) which the same pain experienced by patients having a common inguinal hernia. However, on examination, an inguinal hernia is not appreciated (diagnosed) by the examiner. Imaging with an ultrasound or a pelvic CT scan will also be negative for findings of a typical inguinal hernia in the sports hernia patient. An MRI, which is more specific for soft tissue injuries, may show a signal change within the soft tissue of the groin such as the adductor tendon of the inner leg muscle which attaches to the pubis. However, this signal change is not always seen and not necessary to diagnose a sports hernia.

Most experts now believe that a weakness of the tissue of the groin known as “inguinal disruption” causes strain to that area of the groin during intense physical activity. As the athlete changes the dynamics of the abdominal wall to favor that groin and take some pressure off of it during activity, this causes more strain on attached structures such as the adductor longus muscle which inserts into the pubic bone at the groin and meets the rectus abdominis muscle of the abdominal wall. This leads to a chronic inflammation or tendonitis of the adductor and/or rectus tendons and thus the pain which is reproducible when the activity is performed.

Thus, the sports hernia is thought to be a weakness of the medial portion of the inguinal canal in much the same manner as a common “direct” inguinal hernia, but no true herniation is present.

At least not one that is appreciated on exam or typical imaging.

There is an effort to get away from the more generic term of “sports hernia” as other terms such as “athletic pubalgia” and “inguinal disruption” are probably more specific as to the cause of groin pain. A typical groin muscular strain should heal with rest by 6 weeks and does not require surgery. Sports hernia caused pain persists for months or longer and often requires surgery to resolve.

How is a Sports Hernia Diagnosed?

Groin pain that occurs with strenuous activity and persists longer than 6 weeks may represent a sports hernia. The description of the pain may be sharp and stabbing or a persistent dull ache within the groin of the affected side, the lower abdomen, or shooting pain from the groin toward the genitals or the inner leg. The pain is worsened with direct strain to the area such as running uphill, sprinting, abdominal crunches, or lateral movements, and jumping. Rest should improve the pain and prolonged rest should resolve it unless the activity is repeated. When a provider examines a patient with sports hernia there may be tenderness at the inguinal ring or the over the pubis, but a true inguinal hernia is not present on exam. An ultrasound or pelvic CT scan may be useful to rule out a small inguinal hernia that was not able to be appreciated on physical exam, but these studies are not able to diagnose the sports hernia directly. An MRI may diagnose the Sports Hernia if a signal change within the soft tissues of the adductor longus tendon or rectus abdominis tendon at the pubis.

How is a Sports Hernia Treated?

Rest of the affected groin and avoiding the activities which cause the patient’s pain are first line treatments. Application of ice to the acute injury or heat to the chronic injury after two weeks are applicable. Physical therapy has been shown to improve symptoms with pelvic tilt type movements and core exercises. However, for a true sports hernia, the pain persists for 3 months or longer, even after completely avoiding groin strain for 6 consecutive weeks. If the patient is again experiencing the same pain upon trying to return to the activity after that 3 months, I recommend surgical treatment.

The most important goal of surgical treatment of sports hernia is to strengthen the area of weakness at the medial aspect of the inguinal canal. It is not surprising that there are different techniques and acceptable approaches to repair sports hernias since there are multiple techniques and approaches to repair typical inguinal hernias. I perform both open as well as laparoscopic inguinal hernia repairs in my practice every week. I choose the approach based on patient factors. A posterior, laparoscopic repair may cure some patients with a sports hernia, but I prefer an open, anterior approach for Sports Hernia through a small inguinal incision for two reasons. First, the open approach allows placement of a mesh product which can have both a posterior as well as anterior reinforcement in which the weak, medial floor of the inguinal canal is “sandwiched” between the reinforcing mesh. I also ensure overlap of the anterior mesh overlay upon the pubic tubercle. As this repair heals and contracts, it radically strengthens the area of insertion of the inferior rectus muscle and the adductor longus as well. Second, the open approach allows direct palpation of the adductor longus tendon insertion at the pubis and if the surgeon desires, the adductor tendon can be cut at the time of repair. I do not routinely perform this and if the patient is able to rest the groin from strenuous activity and no intense core exercise for 6 weeks, I am not sure it is necessary. However, some experts will cut the tendon insertion to alleviate the strain on the adductor. This appears to have no measurable effect on the athlete's performance. Even professional, elite athletes may return to their previous levels of play within a period of a few weeks.

Call our office at 208.321.4790 or submit a contact form to request a consultation and examination if you have groin pain consistent with a sports hernia that has persisted after an appropriate period of abstaining from the offending activity.

Sports Hernia Repair Options
Straight from Dr. Williams