Overview
Definition:
Sports hernia, also known as athletic pubalgia, is a complex injury characterized by a disruption or strain of the posterior inguinal wall without a palpable hernia defect
It typically involves damage to the soft tissues in the pubic region, including the aponeurosis of the transversus abdominis muscle, conjoined tendon, or rectus abdominis muscle insertion
This condition is common in athletes involved in sports requiring sudden changes in direction, kicking, or explosive movements.
Epidemiology:
Sports hernia is most prevalent in athletes aged 15-35 years, with a higher incidence reported in male athletes
Sports commonly associated with this injury include soccer, ice hockey, rugby, and Australian football
The exact incidence is difficult to ascertain due to variations in definition and diagnosis, but it is estimated to affect up to 10-15% of athletes in high-risk sports
Recurrence rates vary depending on surgical technique and rehabilitation protocols.
Clinical Significance:
Athletic pubalgia is a significant cause of groin pain in athletes, often leading to prolonged absence from sport
Accurate diagnosis and timely, appropriate surgical intervention are crucial for successful return to play and preventing chronic disability
Understanding the surgical approaches and outcomes is vital for surgeons managing these athletes, particularly in the context of preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Dull, aching groin pain, typically worse with activity, especially twisting or turning movements
Pain may radiate to the inner thigh or scrotum
Tenderness to palpation in the pubic area
Weakness or sensation of groin instability
Absence of a visible or palpable bulge during physical examination in many cases
Pain that improves with rest but recurs with exertion.
Signs:
Tenderness on palpation over the pubic symphysis and adductor insertion
Pain elicited with resisted hip flexion, adduction, or external rotation
A positive "squeeze test" (pain with gentle compression of the testes) can be indicative
No distinct bulge or reducibility characteristic of a direct or indirect inguinal hernia
Palpation may reveal subtle widening or laxity of the posterior inguinal wall.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on a consistent history and physical examination findings
There are no universally accepted specific diagnostic criteria, but a constellation of symptoms and signs suggestive of posterior inguinal wall disruption without a true hernia defect is key
The Hilgenholzer criteria or similar clinical assessment tools can aid in diagnosis.
Diagnostic Approach
History Taking:
Detailed history of onset, mechanism of injury, and specific activities that exacerbate pain
Characterization of pain (location, radiation, intensity, timing)
Previous groin injuries or surgeries
Sport-specific demands and training regimen
Red flags for more serious conditions such as avascular necrosis, stress fractures, or malignancy.
Physical Examination:
Systematic examination of the groin, abdomen, and lower back
Palpation of the pubic symphysis, inguinal ligaments, and adductor tendons
Assessment of hip range of motion and strength, particularly with resisted movements
Evaluation for a true inguinal hernia
Dapatkan reflexes may be checked
Assessment for referred pain from the lumbar spine.
Investigations:
Imaging is often used to rule out other pathologies or to confirm soft tissue injury
Magnetic Resonance Imaging (MRI) is the preferred modality, demonstrating fascial defects, tendon avulsions, pubic symphysis inflammation, or fluid collections
Ultrasound can also be useful for dynamic assessment
Plain radiography may be performed to exclude bony pathology.
Differential Diagnosis:
Inguinal hernia (direct/indirect)
Ilioinguinal nerve entrapment
Rectus abdominis strain
Adductor tendinopathy
Osteitis pubis
Hip labral tear
Femoroacetabular impingement
Stress fracture of the pubic ramus or acetabulum
Femoral nerve entrapment
Varicocele.
Management
Initial Management:
Conservative management is typically the first line of treatment
This includes rest from aggravating activities, ice application, and anti-inflammatory medications (NSAIDs)
Physical therapy focusing on core strengthening, stretching, and gradual return to activity is essential.
Medical Management:
Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation
In some cases, corticosteroid injections into the pubic symphysis or adductor insertion may provide temporary relief
Physical therapy is a cornerstone of non-operative management.
Surgical Management:
Surgical repair is indicated for persistent pain and functional limitation that does not resolve with conservative treatment
The primary goal is to restore the integrity of the posterior inguinal wall
Techniques include: Open repair (e.g., Shouldice repair with modifications) to plicate or reinforce the posterior wall
Laparoscopic tension-free mesh repair (transabdominal preperitoneal - TAPP, or totally extraperitoneal - TEP) to reinforce the entire inguinal canal
Direct repair of torn tissues (e.g., transversus abdominis aponeurosis, conjoined tendon) may also be part of the procedure, especially in younger athletes.
Supportive Care:
Postoperative care involves pain management, wound care, and a structured rehabilitation program
Early mobilization is encouraged
Gradual progression of exercises, focusing on core stability, hip strength, and sport-specific movements, is crucial for optimal outcomes and return to play
Nutritional support to aid tissue healing is also important.
Complications
Early Complications:
Bleeding, hematoma formation, seroma formation, infection of the wound or mesh, urinary retention, nerve injury (ilioinguinal, genitofemoral), DVT/PE
Persistent pain or recurrence of symptoms.
Late Complications:
Chronic pain syndrome, mesh-related complications (infection, migration, chronic pain, adhesion formation), nerve entrapment, stiffness, reduced range of motion, scar tissue formation, recurrence of sports hernia.
Prevention Strategies:
Meticulous surgical technique, especially with mesh placement
Adequate preoperative assessment and patient selection
Comprehensive and progressive postoperative rehabilitation program
Avoiding premature return to sport
Proper warm-up and cool-down routines for athletes.
Prognosis
Factors Affecting Prognosis:
Severity and chronicity of the injury
Adherence to rehabilitation protocols
Type of surgical repair performed
Skill and experience of the surgeon
Individual athlete's biomechanics and tissue healing capacity
Promptness of diagnosis and intervention.
Outcomes:
Surgical repair generally offers good outcomes with significant pain relief and return to sport in most athletes
Success rates can be as high as 80-90% for carefully selected patients undergoing appropriate procedures
However, some degree of residual discomfort or a longer-than-expected return to full competition may occur.
Follow Up:
Regular follow-up appointments are scheduled post-operatively to monitor wound healing, assess pain levels, evaluate functional recovery, and guide rehabilitation progression
Long-term follow-up may be necessary to address any late complications or ensure sustained return to activity.
Key Points
Exam Focus:
Distinguish sports hernia from other groin pathologies based on clinical presentation
Understand indications for surgical intervention
Differentiate between open and laparoscopic repair techniques (TAPP/TEP)
Identify key complications and their management
Be aware of the importance of structured rehabilitation post-surgery.
Clinical Pearls:
Palpation of the posterior inguinal wall with resisted hip flexion/adduction is crucial
MRI is the gold standard for imaging to identify soft tissue disruptions
Surgical repair aims to restore posterior wall integrity, often with mesh reinforcement
Return to play is a phased process guided by rehabilitation, not just time.
Common Mistakes:
Delayed diagnosis due to atypical presentation or over-reliance on imaging alone
Inadequate conservative management before surgery
Inappropriate surgical technique for the specific pathology
Insufficient or premature return to sports activities without completing rehabilitation
Failure to consider and rule out referred pain from the spine or hip.