Athletic Pubalgia (Sports Hernia)
Section snippets
Historical context
In 1980, Gilmore10 recognized and undertook to surgically repair groin disruption in a group of athletes who presented with a syndrome of chronic lower abdomen and groin pain. In 1992, he reported his experience in a large series of 313 athletes, most of whom were soccer players, who presented with groin pain and underwent surgery.10, 11 This entity of groin disruption that he identified associated with groin pain in athletes was subsequently called Gilmore’s groin.10 At that same time, there
Differential diagnosis of groin pain in athletes
Several clinical entities that revolve around the pubic bone and hip joint can be confused with athletic pubalgia (Box 1). Before diagnosing a sports hernia, many of the diseases listed in Box 1 must be considered, because many of these processes can cause symptoms that are similar to and in the same location as athletic pubalgia.9, 23, 24, 37, 38, 39, 40 However, athletic pubalgia in many cases is a clear and distinct clinical entity with typical history and physical findings, so that many of
Is nerve entrapment a cause for pain?
There is increasing speculation that nerve entrapment is a reason for chronic pain, and that either nerve release or nerve division should be incorporated into the operative procedure. This observation has been described in the literature as part of both laparoscopic and open approaches. It has been postulated that injury to the surrounding tissue can cause the nerve to become irritated or incorporated into scar tissue at some point along its course. There is little clarity as to which nerve in
Who is affected by athletic pubalgia?
Athletic pubalgia affects both professional and nonprofessional athletes, and may result in activity-limiting pain, which can shorten a professional athlete’s career48 or jeopardize an athlete’s opportunity for a college scholarship or playing time. Typically, athletes who suffer from this condition practice their sport at a high level and engage in high-intensity training. There is a growing trend toward treating recreational yet dedicated athletes who derive tremendous personal satisfaction
Presentation
Athletes typically present with the complaint of exercise-related lower abdomen and groin pain that may radiate to the perineum, inner thigh, and scrotum.3, 48 The pain is typically relieved with rest but returns on resumption of physical activity.5, 22, 27, 52, 53 Often the athlete describes the pain as a deep and intense pain that is unilateral.5, 54, 55 Typically, patients with sports hernia describe pain that is insidious in onset but some athletes recall an inciting event that may have
Physical examination findings
Physical examination findings include localized tenderness at or just above the pubic tubercle on the affected side, which can be elicited during a resisted sit-up.3, 48 On examination, the patient with a sports hernia does not have a detectable true inguinal hernia but the following findings may be present on examination; inguinal canal tenderness, dilated superficial inguinal ring, pubic tubercle tenderness, and tenderness at the hip adductor origin.3, 37
When we conduct a physical
Imaging
The most important diagnostic tool in the evaluation of a patient with chronic lower abdomen and groin pain is the history and physical examination. Several diagnostic tools may be used to help establish the presence of athletic pubalgia, or to rule out another disorder in the differential diagnosis of chronic lower abdomen and groin pain.
Plain radiography (radiograph) or computed tomography scanning may be helpful to rule out bony abnormalities, but MRI is essential to evaluate the entire
Nonsurgical treatment
Groin pain related to abdominal wall injury is a frequent occurrence. In many instances the injury goes on to heal and is self-limited. In some cases, chronicity occurs, and this subgroup of patients requires surgery. However, despite typical signs and symptoms, a trial of conservative therapy should be the first treatment plan, and surgery should be reserved for failures of conservative measures. For this reason, it is unusual to perform surgery earlier than 3 months from the onset of symptoms.
Surgical treatment
Athletes usually opt for surgery after completion of an athletic season. By the time we see them they have usually run the gamut of therapy, including periodic rest, physiotherapy, steroid injections, and nonsteroidal antiinflammatory drugs, with only temporary improvement and return of symptoms on return to sport. Typically, after 1 or 2 seasons of pain and disability, often increasing in intensity as the season progresses, and recurring despite the off-season, the athlete is left with few
Our operative approach
We prefer to perform an operation that is a McVay/Bassini variant. In our experience, the important elements of surgery are fixation of the rectus abdominis to the pubis as well as stabilization of the conjoined tendon/rectus abdominis interface. Unlike conventional hernia repair, more attention is devoted to the pillar of the rectus muscle by broadening its insertion. The same attention is devoted to the posterior wall of the inguinal canal as one might do in conventional groin hernia surgery,
Postoperative rehabilitation
The operation is performed as an outpatient surgical procedure. We use local anesthesia preemptively in the incision and perform ilioinguinal nerve blocks, give 1 mg Dilaudid subcutaneously in the postanesthesia care unit, and oxycodone as needed for postoperative pain control. We allow weight bearing as tolerated with relative rest for the first 10 days. The wound is then evaluated. For the next 2 weeks gentle hip range of motion and closed-chain lower extremity exercises are permitted. At
Summary
Athletic pubalgia is a distinct syndrome of lower abdomen and groin pain that is found predominantly in high-performance athletes. These individuals tend to have recurring pain, more pronounced with certain activities, and which affects athletic performance. Athletic pubalgia is probably a syndrome caused by muscle injury, because muscle disruption, detachment, or attenuation is frequently found, and muscle injury likely leads to failure of the transversalis fascia, with the resultant formation
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