Is a sports hernia a true hernia?
Are you athletic, and now suffering from groin pain? Have you been told you have a sports hernia? Before you undergo a hernia repair surgery, make sure you have an accurate diagnosis because many times a sports hernia is NOT actually a true hernia, and a routine hernia repair may not always alleviate your symptoms.
In fact, the true diagnosis is called athletic pubalgia (a synonym for sports hernia). The “sports hernia” has been a subject of debate and confusion for years, even among doctors and physical therapists. Athletic pubalgia is a general term for many of the pubic bone-based muscle or tendon injuries.
The underlying problem in athletic pubalgia is a sprain, tear, or avulsion of a muscle or tendon that originates or terminates on the pubic bone. These muscles and tendons may be part of your abdominal wall or your leg. This is often a result of repetitive kicking, twisting, or turning (for example, in soccer, football, basketball, tennis, or hockey), but it may also be caused by a single, abrupt movement. Overall, the etiology is likely a combination of overuse and imbalance of forces acting across the pelvis. Sometimes the swelling of these muscles can compress the nerves running within them causing referred pain from the groin elsewhere. Sometimes there is no obvious injury, and just a dilated internal ring, and this is one subtype of athletic pubalgia labeled as a sports hernia. Since this injury is commonly caused by repetitive activity, patients typically present with gradual onset of groin pain that worsens with activity. The pain can be aggravated by certain movements, or even coughing or sneezing. Inflammation of the pubic bone can result, and is called osteitis pubalgia ( or pubica).
The difficulty in diagnosis of a sports hernia lies in the fact that no “hernia” is evident on physical exam or imaging. Occasionally, a dilated internal ring is appreciated. Unlike the common inguinal hernia, the sports hernia (one type of athletic pubalgia) does not have an associated bulge or protrusion, even with different clinical maneuvers. A specific physical exam for groin pain can usually isolate the muscle group involved. MRI (magnetic resonance imaging) can be very useful in identifying different types of athletic pubalgias (for example, rectus abdominus insertion injury, adductor longus sprains or tears, or osteitis publagia); it may also help identify other causes of groin pain. If the MRI is completely normal, and there is pain in a dilated internal ring without a hernia, this is usually what becomes labeled as a sports hernia.
It is important to recognize that there are many different etiologies of groin pain, including muscular strains, bony pelvis injuries, spine or disc injuries, hip injuries, sports hernias, inguinal hernias, or even nonathletic causes such as gastrointestinal problems. The differential diagnosis is extensive, and more can be found by clicking here http://emedicine.medscape.com/article/87895-overview#aw2aab6b5
Furthermore, even if you are diagnosed with a hernia, this may not necessarily be the cause of your pain. Accordingly, your surgeon will need to assess the precise location of the pain and where it radiates, as well as what triggers the pain and what alleviates it. Unfortunately, surgical repair of a hernia is not the panacea for all groin pain. It is, therefore, critical to solicit the judgment of an experienced surgeon well-versed in sports injuries. Otherwise, if you undergo a routine hernia repair, you may find that your preoperative pain is not alleviated afterwards.
Treatment of a sports hernia (athletic pubalgia) is initially conservative, including rest, ice and heat, anti-inflammatory medications, and physical therapy lasting 2 – 8 weeks. However, often the pain will return when you attempt to resume physical activities too soon. Full compliance may take anywhere from 3 – 8 weeks of rest from the insulting activity. Gradual return to strenuous movements is the key. A therapy or rehab program will very gradually increase your exercise over several weeks. In cases where compliant rest and therapy fails to cure the pain, surgical treatment may be recommended.
Surgery for a sports hernia, a final resort, involves reinforcing the weak or torn posterior inguinal wall. This may be accomplished via an open or laparoscopic approach. In an “open” repair, a small incision (a few centimeters in length) is made in the groin. The structures in the inguinal region are dissected free, and the injury is identified. The area of weakness is reinforced, either by suturing your own tissues together or by using a piece of mesh. The laparoscopic approach is similar to laparoscopic repair of an inguinal hernia in which 3 small incisions (~1 cm or less) are made in the abdomen and a piece of mesh is placed internally, in the lower abdomen/groin. Some procedures may also involve resecting a nerve that could be contributing to the pain, or performing a muscle release. Often, the specific details of the repair are determined intraoperatively, when the surgeon is able to clearly identify the anatomy and injury. With proper treatment, most patients (>90%) are able to return to their previous activity level within weeks to months after surgery. However, remember that your pain may not all be alleviated.
So, is a sports hernia a true hernia? No. But it can be a serious injury requiring surgical treatment.
Please email us at firstname.lastname@example.org for questions, or to make an appointment to have your groin pain evaluated.