Sportsman’s hernia
Published 26 February 2016
Over the last few decades many names have been used to describe the problem of chronic groin pain in athletes. The wide range of conditions that cause groin pain may cause confusion. However, the fact that one specific diagnosis has numerous names can be equally confusing.
One possible diagnosis, “Sportsman’s hernia” has also been called “athletic pubalgia”, “Gilmores groin” and more recently “inguinal disruption”. The term Sportsman’s hernia is still very popular despite no “true” hernia being present. A true hernia involves the presence of a “lump”, a result of a tissue pushing into an area where it has no right to be! No “lump” is found in a patient with a sportsman’s hernia.
In general, pain in sportsman’s hernia or inguinal disruption, is thought to be painful due to the overloading of soft tissue structures within the groin. Often however, more than one pathology may exist within the groin and the difficulty can be in identifying which abnormality requires treating to ease the symptoms.
The lower abdominal wall is made from layers of muscles with the lowest anatomical region lying just above the skin crease of the groin called the inguinal canal. This canal has walls (sides) formed by muscle layers and soft tissues. Structures such as nerves and blood vessels run through this “squashed” tunnel. At each end there are 2 openings, the internal (deep) ring and external (superficial) ring. Weakness to the muscular walls or dilatation of the rings can result in “inguinal disruption” and results in pain.
One difficulty in diagnosing the specific cause of groin pain is that many other medical problems may cause very similar symptoms within the region. As no specific investigation is able to confirm whether abnormalities of the inguinal regions soft tissues are under increased strain and thereby the cause of pain, the diagnosis therefor relies upon the clinical skills of the clinician involved.
It is essential that other conditions which cause similar symptoms to a sportsman’s hernia are considered and excluded before a diagnosis of the inguinal disruption is made. Other conditions to consider vary from hip joint problems and groin tendon injuries to conditions such as osteitis pubis. Despite many underlying causes of groin pain existing, some symptoms point more specifically towards sportsman’s hernia as the problem. Such symptoms include pain above the groin crease which is exacerbated by coughing, sneezing or straining. A full examination should include examination to identify if a lump (true hernia) exists but also if there is any dilatation of the muscular external ring as found with a sportsman’s hernia.
Women can suffer from the condition but it much less common than in men. The diagnosis is most commonly made in elite sportsmen however it is not an unusual diagnosis in amateur athletes. It is not unusual for a patient to consult with a number of clinicians to undergo a range of investigations including x-ray, ultrasound scans and MRI with no cause for the pain being found. Simple clinical assessment and examination however is able to identify sportsman’s hernia.
Imaging and blood tests are likely to appear normal but it is not unusual for such investigations to result in more questions than answers when abnormalities are detected on scanning. The reason for this is that not all “abnormalities” are clinically significant, i.e. not causing the symptom under investigation,. Investigations may however be very useful to exclude other problems such as tendon disease or hip joint problems but unfortunately are unable to diagnose a “sportsman’s hernia”, as mentioned earlier no “lump” is found on examination and nor is it present on imaging.
Surgery isn’t always required for inguinal disruption. The first line treatment for patients suffering from inguinal disruption is a formalised program of physiotherapy and core stability work. An assessment of the pelvic movements with appropriate correction and improvement of core and gluteal strength should be considered. If this conservative approach however fails, then a re-review of the diagnosis by a sports medicine specialist is highly appropriate and surgical treatment may then be advised to repair the weakness.
Following surgery, a rehabilitation program can be implemented quickly following discharge from hospital. It is usually advised for competitive contact sport to be with started after 6 weeks and despite some underlying discomfort being present even then sporting activity is possible. A full resolution of discomfort can sometimes take 2- 3 months and an immediate resolution of symptoms is unlikely and certainly doesn’t mean that the operation has been unsuccessful. A sports medicine doctor is an ideal person to consult about non-resolving groin pain problems. Understandably other specialities may be specifically more focussed upon their particular area of interest ie a hip surgeon focussing upon hip pathology.
A sports medicine clinician will allow all diagnoses to be considered and then the most appropriate surgeon to be involved if surgical intervention is deemed to be required. GP’s may provide a similar holistic approach but groin problems are a notoriously difficult area and many GPs may not feel comfortable making diagnosis of a less well understood problem, nor may they have the specialist clinical skills required to confidently assess the problem At Sports Medicine NE Dr Glen Rae has worked within numerous high level sports including over 15 years within professional football where sportsman’s hernia is reasonably common place. If you have groin pain and are concerned that sportsman’s hernia may be the undiagnosed cause, make an appointment to see Dr Rae at Spire Washington or Newcastle Sports Injury Clinic.