INTRODUCTION — The term "sports hernia" is used to describe a condition characterized by groin pain, often in an athlete, in which there is no demonstrable hernia. The term is a misnomer because there is typically no true hernia or defect in the groin or abdominal wall [1].
A variety of other terms have been used interchangeably to describe this condition including "sportsman's hernia", "hockey groin", and "athletic pubalgia". Over the last decade this condition has become more commonly described as several well-known professional athletes have undergone surgical treatment of this condition.
Sports hernia was described initially in Europe but has become a common diagnosis in high intensity athletes in the United States as well. It is not confined to professional athletes, however, and has been described in youth, college and recreational athletes.
The diagnosis and treatment of sports hernia will be discussed here. True groin hernias are discussed separately. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Overview of treatment for inguinal and femoral hernia in adults".)
DEFINITION — The basic definition of sports hernia is any condition causing persistent unilateral pain in the groin without demonstrable hernia. Sports hernia, therefore, is a clinical diagnosis. Inguinal hernia is clinically absent, but in virtually all reported series a small number of occult hernias are identified at the time of surgical exploration.
ETIOLOGY — Sports hernias result from chronic, repetitive trauma or stress to the musculotendinous portions of the groin. They typically develop in an insidious fashion without sudden or dramatic pain. Symptoms typically come from overuse of the lower abdominal musculature and the muscles of the upper thigh.
Sports hernias are more common in men than in women, and are more common with sports such as hockey, soccer, rugby, and American football, in which the athlete bends or leans forward. However, virtually all sports can produce sports hernia because leaning or bending forward into the typical "athletic stance" is a common pose in any athletic endeavor. Additionally, high speed twisting, turning and torquing the groin likely contribute to the development of the condition.
Risk factors for the development of sports hernia were investigated in high-performance hockey players [2]. Subjects were evaluated for degree of off-season training, peak isometric adductor torque, total hip abduction flexibility, prior injury, degree of National Hockey League (NHL) experience and measurement of skate blade hollowness. Variables predictive of groin injury were confined to those with prior injury, those who did not condition aggressively during the off-season, and veteran (older) players. Similar findings have been reported in other series examining a greater variety of athletes.
A retrospective review of over 200 professional American football players at the National Football League (NFL) scouting combine reported an association between low vitamin D levels and a history of sports hernias or lower extremity strains [3]. Low vitamin D may increase susceptibility to injury or muscle dysfunction. (See "Vitamin D and extraskeletal health", section on 'Muscle function'.)
PATHOPHYSIOLOGY AND CLINICAL ANATOMY — Variable pathologic abnormalities have been described, all related to repetitive strain in the inguinal region. Early reports suggested that the primary culprit was a tear of the external oblique aponeurosis (figure 1 and figure 2) with subsequent injury to the ilioinguinal nerve as it coursed through this area (figure 3) [4]. Other conditions thought to be responsible for the condition include osteitis pubis (inflammation of the pubic tubercle) and musculotendinous strain to the adductor muscles (figure 4) [5].
A study from the United Kingdom performed exploratory inguinal surgery on 35 patients with groin pain [6]. Nearly two-thirds of patients had a tear in the external oblique aponeurosis. Other patients were found to have torn conjoined tendons, small direct hernias, weak posterior wall, and lipomas of the spermatic cord.
HISTORY AND PHYSICAL EXAMINATION — The diagnosis of sports hernia is made in a patient who participates in high intensity sports and has typical symptoms with no evidence of hernia or other common injuries (eg, adductor muscle strain) on physical examination. Groin pain is the predominant symptom and is often exacerbated by sudden increases in intra-abdominal pressure, as can accompany coughing or sneezing. Straining at defecation can also cause mild discomfort.
Frequently, symptoms can be reproduced by simple maneuvers such as performing sit-ups or crunches [7]. Examination of the groin fails to detect the bulge or "silky" sensation of an impulse with coughing or straining that is typical of an inguinal hernia. Palpation of the superficial (external) inguinal ring via the scrotum, as performed to assess for a hernia, typically reveals point tenderness and dilation of the ring, and provokes symptoms (figure 5) [8]. Tenderness may be present at the pubic tubercle where the conjoint tendon inserts or over the deep (internal) inguinal ring (figure 1).
Further examination is performed with the patient in a supine position with their knees bent and heels together (so-called frog position). If the patient has pain or discomfort with forced adduction against the examiner's resistance this too is suggestive of a sports hernia. Additional tests include putting the athlete into positions of stress from their particular sport and applying resistance to see if this reproduces symptoms. An example would be to have a soccer player assume the position of kicking across their body and resist the internal rotation and adduction of the lower leg.
DIAGNOSTIC IMAGING — In general, most surgeons order an imaging study prior to surgical treatment; the choice of magnetic resonance imaging (MRI) or ultrasound depends upon local expertise and availability. In patients with sports hernia, MRI may reveal abnormalities of the pectineus and rectus abdominus [9-12], and a large field view that includes the pubic symphysis can provide important information about the extent and location of injury [13,14].
Ultrasound, particularly dynamic ultrasound, probably offers the best method for diagnosing abnormalities in the inguinal canal. However, ultrasound is operator-dependent and the diagnosis of sports hernia requires a radiologist or clinician with expertise [15,16]. Ultrasound examination of the floor of the inguinal canal by an experienced ultrasonographer may demonstrate occult hernias and occasionally demonstrates conjoint "tendonitis," attenuation of the conjoint tendon, and indirect evidence of tendonitis of the adductor longus [17].
If osteitis pubis is considered in the differential diagnosis, technetium-99m bone scan may be obtained and generally demonstrates increased uptake in the region of the pubis and loss of the "clear stripe" that separates the bony margins of the symphysis. Such findings are not present with sports hernia. Anteroposterior (AP) plain radiographs of the pelvis are generally not helpful but if obtained, they may demonstrate boney abnormalities consistent with osteitis pubis.
DIAGNOSIS — Sports hernia is a clinical diagnosis made based on a suggestive history and examination findings after other causes of groin pain (eg, inguinal hernia, adductor injury) have been ruled out. The majority of patients are young males participating in high-intensity sports (eg, ice hockey, soccer, rugby, American football) that place repetitive strain on the musculotendinous structures of the inguinal region and who complain of groin pain. Palpation of the superficial (external) inguinal ring via the scrotum, as performed to assess for a hernia, typically reveals point tenderness and dilation of the ring, and provokes symptoms.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis for sports hernia includes the large differential of groin pain (table 1). Included in this differential are osteitis pubis, distal abdominal rectus strain or avulsion, adductor tenoperiostitis, and rupture of the adductor longus. A simple adductor muscle strain (ie, "groin pull"), or a true hernia that was missed initially on physical examination, should also be considered. The approach to undifferentiated groin pain in the athlete and active adult is reviewed in detail separately. (See "Approach to hip and groin pain in the athlete and active adult".)
TREATMENT
Initial treatment — Following acute injury, the application of ice packs to the affected area three to four times per day for approximately 10 minutes at a time is beneficial. Treatment with ibuprofen or another non-steroidal anti-inflammatory medication reduces pain and acute inflammation. Once acute symptoms subside, gentle rehabilitation exercises performed under the guidance of a knowledgeable physical therapist, athletic trainer, or other clinician may be helpful. Rest is a simple but important part of initial care. Patients who insist on continuing athletic endeavors soon after injury take considerably longer to heal any injury to the groin.
Often, the simple initial interventions described here do not provide long-term relief. Typically, after a brief period of rest, the athlete experiences a recurrence of symptoms when they renew their activity. Treatment options for these individuals include physical therapy and surgical repair. Many professional athletes find it difficult to take the prolonged rest necessary to heal the groin completely and opt for surgery.
Physical therapy — For high-performance athletes seeking a quick return to sport, the delay caused by a lengthy period of rest or physical therapy is often unacceptable, and thus surgical repair has been their preferred treatment approach for sports hernia. However, several observational studies suggest that for athletes willing to participate in a well-designed physical therapy program focused on increasing the strength and improving the coordination and mechanics of the muscles of the pelvis, hips, and lower extremities, outcomes comparable to surgery can be achieved [18-20].
As an example, a prospective observational study of 205 athletes with anterior hip and groin pain (pain or tenderness at the pubic aponeurosis was the presenting finding in 64 percent) of at least four weeks duration reported substantial improvements in hip and groin function and strength, and in running mechanics, sufficient to enable 73 percent of athletes to return to play pain-free at a mean of 9.9 weeks [19].
Physical therapy is a reasonable approach for patients who can afford to resume sports or work activities at a slower pace. Patients who do not improve with a trial of conservative treatment that includes a well-designed physical therapy program, but who wish to resume their prior level of activity, should be referred to a surgeon.
Surgery — Surgical exploration and repair is the most common treatment for sports hernia, although few randomized trials have been performed to confirm the effectiveness of this approach. In one such randomized trial of 60 patients, including many high level athletes, with chronic groin pain diagnosed as sports hernia (minimum three months of symptoms), 27 of the 30 patients treated with laparoscopic surgery and mesh placement returned to full sport activity within three months of the procedure, compared to 8 of 30 managed with physical therapy and other nonsurgical interventions [21]. At one-year follow up, 29 of 30 surgical patients had returned to full activity, while seven of the patients treated conservatively during the study period subsequently opted for surgery and also returned to full sport activity; the remainder of the nonsurgical patients continued to experience disabling symptoms.
Before proceeding to surgery, it is important to rule out adductor muscle injury as the cause of symptoms. Adductor injuries are best treated with physical therapy, although in rare cases (eg, complete tendon rupture) surgery may be needed. (See "Adductor muscle and tendon injury".)
Surgical exploration can be performed either laparoscopically or open using an anterior approach. The former restricts the surgeon to simply placing prosthetic mesh in the preperitoneal space and dividing nerve fibers (specifically the genito-femoral nerve as it passes through the internal ring) [22,23]. Others, particularly within the European community, have advocated convincingly for a transabdominal pre-peritoneal approach [24].
The standard preperitoneal laparoscopic approach involves using polypropylene or polyester mesh, though biologic inserts have also been employed with good results [25]. A potential complication of mesh hernia repair, the development of infection, is discussed separately. (See "Overview of treatment for inguinal and femoral hernia in adults".)
Alternatively, an open anterior approach allows for greater precision in identifying the abnormality and in tailoring the corrective surgery to the specific pathophysiologic abnormality [4,6]. In most cases, anterior approaches will demonstrate injury to the aponeurosis of the external oblique with an associated injury to the ilioinguinal nerve. Neurectomy or neural ablation is often employed to minimize long-term persistent dysesthesia. Standard anterior hernia approaches are also used with good effect [26]. A mini-open incision sports hernia repair has been described [27].
In a multicenter randomized trial involving 65 athletes (approximately one-half soccer players), no significant differences in long-term pain relief or return to activity were found between patients treated with open minimal suture repair (OMSR) compared with endoscopic extraperitoneal repair (EER), although pain resolved more quickly in patients treated with ER [28]. By 3 months, 25 of 31 patients in the OMSR group and 31 of 34 patients in the EER group had achieved full recovery, and nearly all patients were pain-free.
In select patients, some surgeons report good results performing tenotomy of the adductor longus, but evidence is limited to small case series [29,30]. Tenotomy can be done either as an isolated procedure or in conjunction with a more traditional sports hernia repair.
OUTCOMES — Observational studies suggest that long-term improvement is seen in up to 90 percent of surgically treated patients, although relapses can occur in a small number [23,31]. The large majority of athletes return to play and performance is not impaired by surgical repair [32-35]. Outcomes in reported series do not appear to depend on the approach used [6,36]. However, only one prospective study involving 16 subjects has objectively evaluated strength outcomes following surgery and rehabilitation [37]. Its authors concluded that pain may reduce lower limb strength as a result of disuse atrophy or pain-related muscle inhibition, and that relief of pain following surgery and rehabilitation can improve performance.
Complications from sports hernia repair appear to be uncommon. In an observational study of 5460 procedures, hematomas developed in 0.3 percent of patients, superficial surgical site infections occurred in 0.4 percent, and 0.3 percent of patients developed dysesthesias of the ilioinguinal, genitofemoral, and anterior or lateral femoral cutaneous nerves [31]. Dysesthesias resolved in half of affected patients within 12 months.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hip and groin pain".)
SUMMARY AND RECOMMENDATIONS
●Definitions – Painful, unilateral groin pain is a common complaint of high-performance as well as recreational athletes. In the absence of a true hernia or other common injuries (eg, adductor muscle strain), this condition may be referred to as "sports hernia." (See 'Definition' above.)
●Etiology and anatomy – The cause of sports hernia is multifactorial but often involves injury and disruption of the aponeurosis of the external oblique muscle with concomitant injury to the ilioinguinal nerve (figure 1). (See 'Pathophysiology and clinical anatomy' above.)
●Epidemiology and symptoms – Sports hernia occurs most often in men who participate in high intensity sports such as hockey, soccer (football), rugby, and American football. Groin pain is the predominant symptom and is often exacerbated by sudden increases in intra-abdominal pressure, as can accompany coughing or sneezing. (See 'Etiology' above and 'History and physical examination' above.)
●Presentation, examination, and imaging – Groin pain is the main symptom of sports hernia. Pain is often exacerbated by any sudden increase in intra-abdominal pressure (eg, coughing, sneezing). Frequently, symptoms can be reproduced by performing abdominal crunches. Examination does not detect the bulge or "silky" sensation of an impulse with coughing or straining that is typical of an inguinal hernia. Palpation of the superficial (external) inguinal ring via the scrotum typically reveals point tenderness and dilation of the ring, and provokes symptoms (figure 5). Tenderness may be present at the pubic tubercle where the conjoint tendon inserts (figure 1). Discomfort with adduction against the examiner's resistance is suggestive. Dynamic ultrasound and magnetic resonance imaging (MRI) often reveal characteristic lesions. (See 'History and physical examination' above and 'Diagnostic imaging' above.)
●Management – When symptoms do not resolve with rest and appropriate physical therapy, we suggest surgical repair (Grade 2C). For high performance athletes unwilling to accept the lengthy delays in return to play required for appropriate rest or physical therapy, surgical referral is appropriate. Both laparoscopic and anterior approaches have been used with equivalent outcomes. (See 'Treatment' above.)
●Outcomes – According to observational studies, long-term outcomes are successful in up to 90 percent of surgical patients, with appropriate rehabilitation, stretching, and conditioning. (See 'Outcomes' above.)
