Sports Hernia: A Bilateral Disease

Background Groin pain in athletes is a common source of frustration for the athlete and the treating physician. Sports hernia is one type of groin injury that can be very debilitating. Sports hernia is defined as chronic, activity related groin pain which has been unresponsive to conservative therapy and is caused by a variety of anatomic injuries to posterior wall, conjoint tendon abdominal musculature and adductor muscle origin complex. Methods A total of seventy five patients underwent a laparoscopic total extraperitoneal approach (TEP) for sports hernia between June 22, 2007 and August 31, 2012. A retrospective chart review was performed. Results Of the seventy five patients, bilateral attenuation of the posterior floor was noted in seventy four athletes (98.7%). Unilateral findings were demonstrated in just one patient (1.3%). Occult inguinal hernia was noted and repaired in eleven patients (14.7%). Conclusions Sports hernia is a bilateral disease. The laparoscopic approach affords the opportunity to visualize both groins simultaneously. An added advantage is the ability to diagnose and correct a concomitant occult inguinal hernia. Key Terms Sports hernia, Athletic pubalgia, Groin pain, Adductor muscle Introduction Groin pain in athletes is a common source of frustration for all parties involved, including the athlete and the treating physician. Estimates suggest between 5-28% of all sports injuries occur in the groin. 23,26,33 The etiologies include a wide array of musculoskeletal problems including myotendinous injuries of the hip and abdominal wall, spine and hip disorders, neurologic and genitourinary injuries. Sports hernia, also commonly referred to as sportsman’s hernia, Gilmore’s groin, and more recently, athletic pubalgia, is one type of groin injury that can be debilitating; leading to shortened athletic seasons and careers. Originally described as an injury most commonly seen in hockey and soccer players, 8,9 it is now more often seen in all types of sports. Gilmore originally describe a number of distinct pathologies that later were lumped together as disorders of the inguinal wall. In 1992, Malycha and Lovell developed the term “sports hernia” to describe a bulge in the posterior inguinal wall that represents an incipient inguinal hernia. Sports hernia is largely a clinical diagnosis, but recent advances in MRI and musculoskeletal ultrasound have help to aid in more accurate diagnosis. 3,24,27,38,42 Sports hernia is believed to develop because of a strength mismatch between the abdominal musculature and the adductors. This relative imbalance can lead to injuries of either the central abdominal wall muscles or the upper common insertion of the adductors. Swan suggested that shearing forces across the hemi-pelvis created by the strong pull of the adductors against the relatively under conditioned abdominal muscles may cause attenuation or frank tearing of the transversalis fascia and overlying musculature. Others have suggested that a reduction in hip joint rotation may induce greater shear forces across the pubic symphysis from the pull of the more powerful adductors. These theories lend support to the suggestion that sports hernia is caused more often by chronic repetitive injury to the abdominal wall, rather than acute trauma. Conservative measures such as rest, physical therapy, corticosteroids, NSAIDS, local analgesic injections, and platelet rich plasma injection have been reported 12, , but most of literature supports surgical repair as the most effective. In this article, the term sports hernia is defined as chronic, activity related groin pain which has been unresponsive to conservative therapy and is caused by variety of anatomic injuries to posterior inguinal wall, conjoint tendon abdominal musculature and adductor muscle origin complex. Controversy exists within the literature as to which type of surgical repair is the most successful, and whether or not a sports hernia contains a hernia at all. The crux of this argument is that a sports hernia is not a true hernia because it lacks a herniation or protrusion of a visceral sac. 8,9 However, despite the lack of herniation and strict anatomic purity of the term, the sports hernia surgical repair is very similar to that of an inguinal hernia repair and the popularity of the term in the lay public and frequent usage in the medical literature seems to have cemented the term. We propose that sports hernia is a bilateral disease, and therefore the laparoscopic approach affords the ability to address both sides simultaneously during the same surgical procedure. It also addresses the weakness in the pelvic floor without surgically disrupting the adductor muscle.