What is a Sports Hernia?
A sports hernia also known as athletic pubalgia, Gilmore’s groin, and slap shot gut, is an uncommon, but often missed cause of groin pain in high level athletes. It is poorly understood and poorly defined in the medical community. It is also very difficult to identify based on history and physical exam of an athlete with groin pain. The name sports hernia is a misnomer as well because there is no discernable hernia (or protrusion of abdominal cavity contents) present in this condition.
This is in contradistinction to a typical hernia where there is a protrusion of abdominal contents such as fatty tissue or bowel through a well-defined defect in the inguinal canal of the groin. Despite this, the name sports hernia has persisted because many of the surgical treatments are similar to that of a typical hernia.
Who gets a Sports Hernia?
Sports hernia is a diagnosis almost exclusively of very high level male athletes. It is a common diagnosis in athletes with chronic longstanding groin pain that does not respond to a very long (often years) course of non-operative treatment. Typically athletes involved in repetitive twisting sports such as ice hockey, soccer, Australian rules football, and tennis. Recent well known athletes such as Donovan McNabb of the Philadelphia Eagles, Tomas Holmström of the Detroit Red Wings and Jeremy Shockey of the New Orlean’s Saints have all had surgery to repair a sports hernia.
Hockey player’s syndrome otherwise known as “slap shot gut” is a variant of a sports hernia unique to high level ice hockey athletes. It is due to repetitive twisting motions of the torso common in hockey such as with taking a slap shot. The result is a tearing over time of the covering (fascia) lining the lower abdominal oblique muscles. It is most often seen on the side opposite the player’s forehand slap shot. There may also be an associated inguinal nerve irritation. This may explain why the pain seen in hockey player’s syndrome often travels to the scrotal region. The treatment involves a repair similar to that in many sports hernias.
What is the anatomy of the region where a Sports Hernia occurs?
There are numerous structures that may be involved in the groin (inguinal) region of an athlete. These include injury to the lower abdominals as well as to the normally tough lining of the lower pelvis. The common denominator is dilation and weakness of the internal inguinal ring.
How does a Sports Hernia happen?
Repetitive twisting and shear forces encountered during high level athletics can lead to injury of the lower abdominal wall. This may be exacerbated by the typical strong thigh adductors (muscles that bring the thighs closer together) compared with often weaker lower abdominal muscles.
Sports Hernia diagnosis
Athletes typically complain of a longstanding history of pain in the inguinal (groin) region. They often complain simply that their performance has deteriorated below a satisfactory level. Often the pain is not present during periods of inactivity, rest or periods away from athletic involvement. However, symptoms classically reappear with return to the athletic activities responsible for the injury in the first place. The pain may travel, or radiate, from the groin into other areas like the testes, lower abdominal musculature and the inner thigh region. The pain is often exacerbated by coughing or sneezing as well as by athletic movements like sit-ups and kicking motions.
On physical examination, there may be groin pain to palpation in the region of various structures along the wall of the lower abdomen. These may include anatomic regions like the inguinal ring and canal as well as the pubic symphysis (central fusion point of the 2 halves of the pelvis in the front/center of the pelvic region). There is however no classic inguinal hernia detectable on an exam as there is no defect in the inguinal wall and no intra-abdominal contents that herniated through. Patients will have pain with a resisted abdominal contraction such as with a sit-up. This may be worsened by doing so with the thighs squeezed together (adduction).
What else can masquerade as a Sports Hernia?
There are many possible causes of groin pain in athletes. Sports hernia is a rarely confirmed diagnosis, and therefore it is extremely important to be sure that other conditions are not the source of an athlete’s symptoms. Some conditions that can mimic a sports hernia include:
● Pulled Groin Muscle (Hip Flexor/Adductor Strain)
● Hip impingement
● Inguinal hernia
● Osteitis pubis (inflammation of the pubic symphysis: joint connecting the 2 halves of the pelvis)
● Stress fracture
● Snapping hip
● Labral tears
● Nerve entrapment
● Avulsion fractures in teenagers and children
● Non-orthopaedic causes of pain such as those involving the genitourinary system
What advanced imaging tests may be helpful in making the diagnosis of a Sports Hernia?
A variety of imaging tests may be performed for a sports hernia, however they are mainly important for ruling out other causes of groin pain in an athlete. Radiographs should be normal. An ultrasound and MRI may demonstrate abnormal findings in the abdominal wall, however there may be similar abnormal findings in asymptomatic athletes as well. There may be abnormal signals seen in the bones of the pelvis and lower abdomen on MRI or a bone scan, but again these findings are not specific only to a sports hernia. Herniography, or injection of dye along with a plain xray, is used frequently in Europe for assisting in the diagnosis. They have a high complication rate with such adverse consequences as perforation of abdominal organs, infection and hematoma to name a few. Therefore, herniography is rarely used in the United States for the work-up of a sports hernia.
How is a Sports Hernia treated?
Initial treatment like that for most injuries normally includes a trial of non-operative treatment. The athlete should take anti-inflammatory medications, avoidance of aggravating athletic activities, heat and ice, deep tissue massage and physical therapy.
Special emphasis should be given to core stabilization exercises as well as countering any imbalance between the various hip, pelvis and thigh musculature. An evaluation by a highly specialized physical therapist is necessary to help the athlete along with their rehab program and identify and treat these imbalances.
What does surgical repair consist of?
Often in the case of a sports hernia, an athlete does not respond to physical therapy and non-operative treatments. In this situation if other sources of groin pain have been eliminated, surgical repair should be considered. The actual surgical repair technique used varies somewhat, however they all involve reinforcing and repairing the wall of the inguinal canal in the lower abdomen. Synthetic mesh reinforcement is sometimes used as well. Surgical repair of the abdominal wall can be done with a traditional small incision or with the assistance of a small camera through a few very small incisions (laparoscopic surgery). The actual specifics of the surgical repair and whether it can be done with a laparoscopic approach depend on the assessment of the treating surgeon and may vary on a case by case basis.
When there is an imbalance of hip adductor strength present, a release of the adductor tendon attachment to the pelvis can provide long term pain relief as a procedure done in conjunction with a hernia repair. There does not seem to be any adverse consequences on athletic performance with releasing the tendons.
What happens after surgery?
After surgery there must be a period of recovery to allow the surgical incisions as well as the repair to heal. This recovery is significantly longer when surgery is performed through a more traditional open incision. This is because the lower abdominal musculature must be allowed to properly heal as it is spread apart during the open surgery. The athlete needs to begin a structured physical therapy program post-operatively to strengthen the lower abdominals and correct any abdominal and thigh muscle imbalances prior to returning to athletic participation.
Sports hernia recovery time
About 90% of athletes who have surgery for a sports hernia are able to return to competition at the same level or higher to where they were prior to their injury. The timing of return to competition for laparoscopic surgery is typically within 6 weeks while for open surgery it is usually a few months to as long as 6 months.
Getting a Second Opinion
A second opinion should be considered when deciding on a high-risk procedure like surgery or you want another opinion on your treatment options. It will also provide you with peace of mind. Multiple studies make a case for getting additional medical opinions.
In 2017, a Mayo Clinic study showed that 21% of patients who sought a second opinion left with a completely new diagnosis, and 66% were deemed partly correct, but refined or redefined by the second doctor.
You can ask your primary care doctor for another doctor to consider for a second opinion or ask your family and friends for suggestions. Another option is to use a Telemedicine Second Opinion service from a local health center or a Virtual Care Service.
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- Kluin J, den Hoed PT, van Linschoten R, IJzerman JC, van Steensel CJ: Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 2004;32:944-949.
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- Irshad K, Feldman LS, Lavoie C, Lacroix VJ, Mulder DS, Brown RA: Operative management of “hockey groin syndrome”: 12 years of experience in National Hockey League players. Surgery 2001;130:759-764.
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