II. Definitions

  1. Sports Hernia (Athletic Pubalgia)
    1. Lower abdominal or inguinal pain, outside the ball and socket Hip Joint, in athletes

III. Background

  1. First described in 1980-1990s with rupture of the oblique aponeurosis and conjoined tendon
  2. As of 2019, there are 19 distinct syndromes of defects grouped under Sports Hernia

IV. Risk Factors

  1. Male gender (>85% of cases)
  2. Participation in kicking, cutting, sudden forceful twisting and turning (e.g. american football, ice hockey, baseball)

V. Pathophysiology

  1. See Pubic Joint for anatomy of muscle complex insertions (abdominal and thigh flexors, abductors and rotators)
    1. Strength, flexibility or coordination imbalance of these opposed muscles places the athlete at risk of injury
    2. Sudden hyperextension and twisting of the trunk combined with muscle imbalance results in injury
  2. Weakening of posterior Inguinal Canal wall (85% of cases)
    1. Results in occult, non-palpable Hernia

VI. Types

  1. Adductor-Related Groin Pain
  2. Iliopsoas-Related Groin Pain
  3. Pubic-Related Groin Pain

VII. Symptoms

  1. Characteristics
    1. Chronic, progressive unilateral deep Groin Pain and hip adductor pain in athlete
  2. Timing
    1. Insidious onset with gradual worsening, worse with activity and better with rest
  3. Radiation
    1. Inguinal ligament
    2. Thigh and Perineum
    3. Rectus muscles
    4. Testicular Pain (30%)
  4. Provocative
    1. Increased intra-abdominal pressure (Valsalva Maneuver, coughing, sneezing, sit-ups)
    2. Resistance Training of abdominal muscles
    3. Sprinting, kicking or cutting in sports

VIII. Signs

  1. See Hip Pain for full exam
  2. Difficult to diagnose except during surgery
  3. Inguinal Hernia not detectable (affects posterior wall)
  4. Tenderness to palpation over conjoint tendon, pubic tubercle, midinguinal
  5. Provocative Tests
    1. Also see diagnosis as below
    2. Direct Stress Test (with Straight Leg Raise)
      1. Examiner palpates Superficial Inguinal Ring, while patient lies supine
      2. Increased pain when patient performs Straight Leg Raise (reproduces patient's symptoms)
    3. Sit-ups
      1. Tenderness on palpation of rectus abdominis insertion on pubic ramus while patient performs sit up
      2. Resisted sit-up also provokes pain
    4. Other positive findings
      1. Adductor Squeeze Test
      2. Resisted hip adduction related pain (at 0, 45 or 90 degrees of hip flexion)

IX. Differential Diagnosis

  1. See Groin Injuries in Athletes
  2. See Hip Pain Causes
  3. Distal rectus strain or avulsion
  4. Groin Disruption (medial and inferior to Sports Hernia)
  5. Adductor Strain
  6. Femoroacetabular Impingement (FAI)
  7. Osteitis Pubis
  8. Snapping Hip
  9. Nerve Entrapment
    1. Genitofemoral nerve entrapment
      1. Upper anterior thigh and Groin Pain
      2. Follows abdominal surgery (also seen in cyclists)
    2. Ilioinguinal Nerve Entrapment
      1. Upper medial thigh or genital pain
    3. Obturator Nerve Entrapment
      1. Medial thigh and adductor region pain

X. Diagnosis: Requires 3 of 5 to be present

  1. Pubic tubercle point tenderness (conjoint tendon insertion)
  2. Deep Inguinal Ring point tenderness
  3. Superficial Inguinal Ring tenderness or dilation without obvious Hernia (scrotal inversion with finger)
  4. Adductor longus tendon origin pain
  5. Groin Pain that is dull, diffuse
    1. May radiate to perineum, inner thigh or across the perineum

XI. Imaging

  1. Imaging typically rules out other diagnoses and in some cases may identify findings suggestive of Sports Hernia
  2. XRay
    1. Evaluates for Fractures and Stress Fractures
    2. Femoroacetabular Impingement (FAI) is found in 80% of surgery confirmed Athletic Pubalgia
  3. Ultrasound
    1. In skilled hands, exam augmented by Bedside Ultrasound can be useful
    2. May demonstrate Tendinopathy (hypoechoic regions)
    3. Herniation during valsalva may be visualized in some patients
  4. MRI
    1. Common rectus abdominis - adductor longus aponeurosis Injury

XII. Management

  1. Conservative therapy trial for 4-8 weeks
    1. Relative rest from provocative activity
    2. NSAIDS
    3. Stretching and strengthening in a physical therapist directed program
    4. Consider Ultrasound-guided injection of Corticosteroids or plasma-rich platelets
  2. Surgical exploration if conservative therapy fails
    1. Multiple repair strategies exist
    2. Successful return to sport in 90% of cases

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