Chronic Groin Pain: Sports Hernia
June 10, 2005
Amy Davis, M.Ed., ATC/L
Chronic groin pain affects about 5 percent of the athletic population. An athlete can perform for months to years with chronic groin pain without a conclusive diagnosis. Sports hernia is one among several possible diagnoses for chronic groin pain. Typically, sports hernias are found in male soccer and hockey players, due to the repetitive twisting and turning demands of their sport. The biomechanics of a shot putter that spins and drives (repetitive twisting or turning at speed) may predispose them to a possible sports hernia. Little research has been done on sports hernias, so prevention, rehabilitation, and treatment are still varied.
Sports hernia has only recently become a common diagnosis. A sports hernia can be defined as a weakening of the posterior inguinal wall without a palpable hernia upon exam. Athletes often complain of chronic groin pain located deeper and more proximal than a typical groin strain. Pain is first noticed with exercise, either near the end or after exercise. Overtime the pain can persist through exercise into the activities of daily living, such as getting into a car. Acute onset may be accompanied with a tearing sensation during exercise. Previous injuries may lead to long standing differences in muscle strength on one side of the body and may pre-dispose an athlete to sports hernia. Possible muscle imbalances exist with stronger adductors and weak lower abdomen muscles, causing a pelvic imbalance. The recent increasing awareness of sports hernia by athletic trainers and physicians has lead to a larger number of reported cases.
Possible diagnoses that can be confused with a sports hernia are chronic adductor strain, chronic rectus abdominus strain, and osteitis pubis. Chronic adductor strains are not uncommon in shot putters, whose hip and pelvis muscles are subject to repetitive high loads. Symptoms of an adductor strain include pain and tenderness along the inner thigh, swelling or discoloration, and a possible palpable defect along the muscle. Most adductor strains occur with a violent, sudden lengthening of the adductor muscle. A physician makes the diagnosis of a chronic adductor strain through physical examination and a MRI can determine the severity of the strain. Chronic rectus abdominus strains can have pain and tenderness in the lower abdomen over the pubic symphysis. Movements, such as sneezing, coughing and sit-ups, can cause pain in an athlete that has a rectus abdominus strain or a sports hernia. Osteitis pubis could mimic a sports hernia when compared to other possible diagnoses. Symptoms of osteitis pubis include pain at the pubic symphysis, which may refer to the lower abdomen, hip, or groin. The mechanism of injury, repetitive trauma, can be similar to a sports hernia. Physicians can diagnosis osteitis pubis through x-ray or bone scan.
Sports hernia falls under the umbrella of chronic groin pain. A physical examination can make the possible diagnosis. Symptoms of a sports hernia include chronic groin pain with activity progressing to pain while running, coughing and sneezing. Pain with a resisted sit-up can also be a sign of a possible sports hernia. An athlete may describe the pain as being deep and located more towards the groin region. Thirty percent of males with a possible sports hernia experience referred pain to the testicles. Upon physical exam by a physician, hip, abdominal, pelvic, lumbar, sacroiliac, and genital exams would all be within normal limits. Sports hernia may not have a palpable hernia, which can lead to further testing or a referral to a surgeon. It is important for a physician to rule out other diagnosis through the use of diagnostic imaging. The elimination of other possible injuries can also help athletic trainers or physical therapist develop an appropriate rehabilitation plan.
Diagnostic imaging is used to eliminate other possible causes of chronic groin pain and can lead to the diagnosis of a sports hernia. X-rays are taken to eliminate any bone problems, such as avulsion fractures, osteitis pubis and stress fractures. Further measures can be taken to rule out any suspicious images found on x-ray. Bone scans are also used to eliminate or diagnosis avulsion fractures, osteitis pubis and stress fractures. The use of MRIs and CT Scans have had limited usage in diagnosing sports hernia, but may rule out soft tissue injuries, such as adductor strains or hip subluxations. Endoscope can be used as a surgical technique to diagnosis sports hernias. The use of this method should be used to evaluate and treat groin pain that has been undiagnosed. A study in the June 1, 2004 issue of the "American Journal of Medicine" found that 17 out of 18 athletes with chronic groin pain were diagnosed with the use of endoscopic evaluation. The highest percentage (39percent) of athletes had chronic groin pain linked to the discovery of a sports hernia.
Once other possible groin injuries have been eliminated and the diagnosis of a sports hernia is established, the next step is treatment. Conservative treatment of a sports hernia consists of anywhere from 3 to 8 weeks of rest, 3 to 4 months of sports-specific rehabilitation with gradual return to activity. Time is sometimes not a luxury with the rigorous schedule of track and field and conservative treatment may fail. Surgery should be the last option following the failure of conservative treatment. Laparoscopic or endoscopic herniorrhaphy are surgical procedures used to repair a sports hernia. Incisions are typically kept to a minimum with entrance to the hernia through the abdomen and peritoneal space. A piece of mesh is used in surgery to reinforce the abdominal wall and strengthen the posterior inguinal wall. After surgery, precautions are taken place to have the athlete avoid sudden, sharp movements and heavy lifting. The gradual return to activity along with rehabilitation allows the athlete to return to participation within 6 to 12 weeks following surgery. Surgical success of repairing a sports hernia, which means returning to the level of activity pre-injury, varies from 63-95 percent.
Rehabilitation done post surgery will help athletes return to activity within 6 to 12 weeks. Our experience with rehabilitating post-surgical athletes with sports hernia has been to allow a week of rest after surgery to allow for the wounds to heal. An athlete may begin activity, such as using the elliptical trainer or jogging, within 10 to 14 days post-operation. Light weightlifting may occur 3 weeks post surgical sports hernia repair. A shot putter may have difficulty with the restriction on weight lifting because it is a vital component of their training. All aspects of core strengthening and flexibility should be addressed throughout the rehabilitation process. Core programs can include exercises done with a Swiss ball and light weightlifting. Other exercises should focus on strengthening the abdomen, hip adductors, hip flexors, and pelvis. Rehabilitation may vary depending on the athlete's condition and other overlapping conditions, such as a groin strain.
The awareness of sports hernias is increasing through the increasing knowledge of doctors and trainers. Any sport or activity, that involves repetitive twisting and turning at speed, can lead to a possible sports hernia. The technique of a shot putter, repetitive spinning or driving, along with heavy lower extremity weightlifting, might possibly lead to a sports hernia, but needs to be confirmed with further research.