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Sports Hernia. CC / HPI 19 y/o male lacrosse player with 3 month history of left lower abdominal pain and left groin pain. Insidious in onset. No hx of trauma. No parethesias. No bowel or bladder dysfxn. Pain spikes with exercise. Sharp and stabbing quality. 7/10 max. Usu 0/10.

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Sports Hernia

  • CC / HPI

  • 19 y/o male lacrosse player with 3 month history of left lower abdominal pain and left groin pain. Insidious in onset. No hx of trauma. No parethesias. No bowel or bladder dysfxn.

  • Pain spikes with exercise. Sharp and stabbing quality. 7/10 max. Usu 0/10.

  • Sprints and leg lifts recreate pain.


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Sports Hernia

  • 2 months of rest not effective at relieving pain

  • Meds Mobic (NSAID) and Norgesic Forte (orphenadrine, ASA and caffeine)

  • No physical therapy attempted


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Sports Hernia

  • Physical Exam

  • NAD, Normal gait.

  • Ab: Full ROM. Lower left ab minimal tenderness to palpation. Nonerythematous/no ecchymosis. No evidence of abdominal hernia.

  • Genitalia: No evidence of inguinal hernia. No testicular or scrotal pain.

  • Pelvis: Moderate pain with pelvic manipulation near symphysis.

  • Hips: Full ROM and 5/5 strength. No maneuvers able to illicit pain.


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Imaging

Labs

none

Sports Hernia


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Differential Diagnosis

Localization

Sports Hernia


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Sports Hernia

  • Differential Diagnosis

    • Osteitis pubis – pain over symphysis

    • Adductor tendonopathy – localized pain and pain with adductor resistance

    • Stress fx of pubic ramus

    • Ilioinguinal or obturator (supplies adductors) neuropathies

    • Hockey Player’s Syndrome (contralateral pain with slap shot)


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Sports Hernia

  • Anatomy

    • Inguinal canal

    • Medial

      • Superficial inguinal ring

    • Lateral

      • Deep inguinal ring

    • Posterior

      • Fascia transversalis w/ conjoined tendon


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Anatomy

Anterior

External oblique aponeurosis

Internal oblique muscle

Sports Hernia


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Sports Hernia

  • Pathophysiology

    • Disruption of conjoined tendon

      • Torn ex. Oblique aponeuroisis leading to dilation of superficial inguinal ring

      • Torn conjoined tendon

      • Dehiscence b/w conjoined tendon and inguinal ligament

    • Weakening of transversalis fascia with separation from the conjoined tendon


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Sports Hernia

  • Pathophysiology

    • Tear in the internal oblique muscle

    • Direct inguinal hernia w/bulge in posterior inguinal wall (inferior epigastric vessels)


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Sports Hernia

  • Pathophysiology

    • Tear of external oblique at the site of the emergence of iliohypogastric nerve

      (passes superior to the deep inguinal ring and provides sensory innervation to the skin superior to the pubis)


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Sports Hernia

  • Pathophysiology

    • Suggested that the injuries occur because adductor action during sports creates shearing forces across the pubic symphysis that can stress the posterior inguinal wall.

    • Repetitive stretching of, or a more intense sudden force to, the transversalis fascia and internal oblique can lead to their separation from the inguinal ligament.

    • This mechanism may also account for the common finding of coexisting osteitis pubis and adductor tenoperiostitis.


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Sports Hernia

  • Typical Hx and PE

    • Unilateral groin pain noted during exercise

    • Typically insidious in runners or sudden in hockey and soccer players

    • Pain may radiate to perineum or testicles

    • May be aggravated by sudden movement or coughing or sneezing

    • Resistant to conservative tx

    • Dilated superficial inguinal ring

    • Local tenderness over conjoined tendon and inguinal canal

    • No hernia clinically detectable


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Sports Hernia

  • Radiologic studies to rule out other pathology

  • Plain film may show osteitis pubis, adductor tenoperiosteal lesions, symphyseal instability, hip osteoarthritis, and bone tumors

  • Bone scan to help dx osteitis pubis, tenoperiosteal lesions and stress fractures

  • Herniography – intraperitoneal injection of contrast to evaluate integrity of posterior inguinal wall and inguinal canal


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Sports Hernia

  • Treatment

    • Conservative (rest, ice, NSAIDS, PT) especially with coexisting pathology)

      2. Surgery after failure or initially if sports hernia is strongly suggested or professional athlete


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Sports Hernia

  • Surgery

    • Modified herniorraphy

    • Success rates 63-93% with full return to preinjury levels


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Sports Hernia

  • Rehabilitation

    • Rehab that avoids sudden, sharp movements should allow return to participation in 6-8 weeks.

    • Pelvic flexibility, strength and stability emphasized

    • Isometric abdominal and adductor exercises on day one then increase

    • Walk by 1st week

    • Jog by 10 days

    • Straight sprinting by day 21

    • Sport specific exercises by 6-8 weeks



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References

1. Kemp, S et al: The ‘Sports Hernia’: A Common Cause of Groin Pain. Phys Sportsmed 1998;26(1).

2. Fon, L. et al: Sportsman’s Hernia. Br J Sports Med 2000;87(5):545-552.

3. Lacroix, VJ: A Complete Approach to Groin Pain. Phys Sportsmed 2000; 28(1).


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