Sports Hernia (athletic Pubalgia)

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What is Sports Hernia (athletic pubalgia)

Sports hernia (athletic pubalgia) is a type of soft tissue injury that causes groin pain. Any strain or tear in the soft tissues of the groin or lower abdomen can be called a sports hernia.

It is a common overuse injury in athletes who play sports that involve a lot of repetitive kicking and twisting motions or sudden changes in direction.

A sports hernia is not the same kind of injury as other types of hernias. With a sports hernia, there is usually no opening in the muscles of the groin or abdomen for tissue to bulge through.

A sports hernia or inguinal disruption is a general term for pain that localizes to the inguinal area of an athlete without evidence of a definite herniation. Anatomically it is ill defined and is attributed to tension placed on the inguinal structures causing tearing and eliciting pain.

Physical examination findings are subtle showing a dilated and tender superficial inguinal ring in the absence of a hernia and a tender pubic tubercle where the conjoined tendon inserts.

A resisted sit-up can elicit pain at the pubic crest. Conservative treatment often fails, and laparoscopic surgical repair is usually successful.

Athletic pubalgia in characterized by lower abdominal or groin pain worsened by physical exertion and relieved with rest.
•There is no consensus on etiology. Traditionally athletic pubalgia is due to an occult hernia in the posterior inguinal wall.
•Other proposed etiologies include strain/tear of the conjoined tendon, inguinal ligament, transversalis fascia, rectus abdominis aponeurosis, and external/internal obliques

The unifying terms pubic inguinal pain syndrome (PIPS) and core muscle dysfunction have been proposed because of the overlap with other syndromes.
•Athletic pubalgia is most common in sports that require sudden changes in direction or twisting (e.g., soccer, ice hockey, wrestling, football).
•Clinical diagnosis is one of exclusion with no specific assessment tool.
•Athletic pubalgia may occur concurrently with other groin pathology (e.g., osteitis pubis, adductor strain).
•It typically affects men more than women.
•In one study it was found in 50% of athletes with groin pain of more than 8 weeks’ duration.

What are the causes?

This condition is caused by muscle strain, usually from overuse. It may also be caused by weakness or imbalance in your abdominal muscles.

What increases the risk?

Sports hernias are more common in males. You may have a higher risk of this condition if you are an athlete who plays:

Ice hockey.
Football.
Wrestling.
Soccer.
Rugby.

Reduced hip range of motion.
•Pelvic muscle imbalance, typically with strong adductors and relatively weak lower abdominal muscles.
•Limb length discrepancy

What are the symptoms?

Groin pain is the main symptom of this condition. Pain is typically sharp with activity and better with rest. Pain typically increases with:

Running, especially sprinting.
Running and changing directions quickly (cutting).
Abdominal exercises.
Twisting or kicking motions.
Coughing or sneezing.
Pressure over the injured area.

•Unilateral pain in the groin area. Typically of insidious onset.
•In some cases, can progress to bilateral pain over time.
•Often described as a “deep” pain in the lower abdomen or groin.
•Pain occurs with kicking, sprinting, cutting, coughing, sneezing, or performing situps.
•Often disabling, preventing many athletes from achieving a satisfactory level of play.
•Pain is typically relieved with rest and returns with the of onset of activity.
•Pain may radiate to the testis, suprapubic region, or origin of the adductor longus.

Physical Examination

•Tenderness to palpation in the groin or above the pubis, especially over the anterior pubic tubercle, conjoined tendon, and mid-inguinal region.
•The external inguinal ring is often dilated and/or tender.
•No obvious detectable or visible hernia bulge.
•Pain with lower abdominal and hip flexion (performing a situp).
•Pain with resisted hip adduction.
- •Adductor squeeze test: patient lies supine with hips abducted and flexed at 80 degrees. Positive if pain occurs with resisted adduction.

How is this diagnosed?

This condition is diagnosed based on your symptoms, medical history, and physical exam. During the exam, your health care provider may feel for areas of tenderness or ask you to do certain movements to test for pain. You may have imaging studies to confirm the diagnosis and rule out other causes of pain. These may include X-rays or an MRI.

You may also see a type of health care provider who specializes in reducing pain and increasing mobility (physical therapist).

•Most imaging studies are normal, but they are useful to rule out alternative diagnoses.

•X-ray: Erect pelvic and flamingo stress views of the pubic symphysis. Greater than 2 mm of motion across the symphysis pubis in the flamingo view identifies instability. However, functional instability can occur at less than 2 mm.

•MRI: Low specificity. Many athletes have no pathologic findings on MRI, but it is useful to rule out stress fractures and osteonecrosis of the femoral head. There is often concurrent osteitis pubis and adductor strain.

•Bone scan: Lacks specificity. Associated risks are well known. Helpful to rule out osteitis pubis, symphyseal instability, osteoarthritis, and tumor.

•Herniography: Popular in Europe but rarely used in the United States. Controversial due to potential risks and high false-positive rate. It involves injecting a radioopaque dye into the peritoneal cavity.

•Ultrasound: Results are of limited use owing to interoperator variability. Allows visualization during dynamic maneuvers (e.g., a situp) that can be used to bring out a convex anterior bulge and ballooning of the inguinal canal. However, there is a high prevalence of abnormal findings in asymptomatic athletes.

•If the patient does not have a history of activity that might lead to a sports hernia or has developed a fever or subjective chills, one should consider ruling out of osteomyelitis of the pubic symphysis or genitourinary pathology. A complete blood count (CBC) with erythrocyte sedimentation rate (ESR) as well as urinalysis should be obtained. Blood cultures may be considered based on clinical presentation.

How is this treated?

Treatment for this condition includes:

Stopping all activities that cause pain or make your condition worse.
Using ice to relieve pain and inflammation.
Taking NSAID medicines or getting corticosteroid injections to reduce pain and swelling.
Doing range-of-motion and strengthening exercises (physical therapy) as told by your health care provider or physical therapist.

You may need surgery to help repair and stabilize the injured area if other treatments do not work.

•Fundamentals include rest, antiinflammatory medication, physical therapy, and possible surgical repair.
•First 7 to 10 days: avoidance of activities that produce pain, with relative rest encouraged.
•A course of nonsteroidal antiinflammatory drug therapy should be attempted.
•For severe pain: consideration for a short course of oral corticosteroids or local corticosteroid injection. Recently some providers have attempted prolotherapy or injections of platelet-rich plasma (PRP) prior to surgical referral.
•After 2 weeks: initiate physical therapy with a focus on improving strength and flexibility in the abdominal and inner thigh muscles via graduated stretching and strengthening.
- •Focus on adductor muscles, abdominal wall muscles, iliopsoas, quadriceps, and hamstrings. Important to focus on motor control and strength in single-leg stance.
- •Should progress from strengthening to functional activity to sport-specific exercise.
- •Rehabilitation can include manual therapy, joint manipulation, acupuncture, therapeutic modalities, taping techniques, sport-specific rehabilitation, and plyometrics.
•Two rehabilitation protocols well described in the literature include a four-phase rehabilitation program by Larson and Lohnes and a divided regimen of manual therapy and exercise rehab by Kachingwe and Grech.
•Conservative therapy should be tried for 4 to 6 weeks prior to surgical repair.
•There is no consensus to support any one surgical repair over another. However, some data suggests a faster return to play with laparoscopic (2–6 weeks) versus open (1–6 months) repair.
•Fundamentals of surgical repair involve reinforcement of the posterior abdominal wall with mesh followed by postoperative rehabilitation.
- •Concomitant repair of the conjoint tendon, transverse adductor tenotomy, and obturator nerve release may be attempted.

When to Refer

•Failed conservative therapy after 4 to 6 weeks
•Athlete recalls an acute tearing or ripping sensation
•Professional athletes for whom a long trial of conservative rehabilitation is not possible

Follow these instructions at home:

Take over-the-counter and prescription medicines only as told by your health care provider.
If directed, apply ice to the injured area.
- Put ice in a plastic bag.
- Place a towel between your skin and the bag.
- Leave the ice on for 20 minutes, 2–3 times a day.
Practice stretches and movements that are recommended by your physical therapist.
Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
Keep all follow-up visits as told by your health care provider. This is important.

Differential Diagnosis

•Adductor strain—typically adductor longus
•Iliopsoas strain, bursitis, or tendonitis
•Rectus abdominis strain
•Osteitis pubis
•Stress fracture—proximal femur, femoral neck, superior pubic ramus
•Apophyseal avulsion fracture in a skeletally immature athlete
•Ilioinguinal nerve entrapment neuropathy
•Intra-articular hip pathology
•Inguinal hernia
•Lumbar disc disease
•Slipped capital femoral epiphysis
•Snapping hip syndrome
•Seronegative spondyloarthropathies
•Osteomyelitis
•Genitourinary pathology—urinary tract infection, prostatitis, urolithiasis, endometriosis, ovarian torsion, ovarian cysts
•Abdominal disorders
•Other groin pathology: Gilmore groin, gracilis syndrome, hockey groin syndrome

How is this prevented?

Warm up and stretch before being active.
Cool down and stretch after being active.
Give your body time to rest between periods of activity.
Make sure to use equipment that fits you.
Maintain physical fitness, including:
- Strength.
- Flexibility.

Contact a health care provider if:

Your pain and tenderness continue or get worse after treatment.

Prognosis

•Many cases may resolve with 4 to 6 weeks of physical therapy, although some studies suggest that conservative therapy often fails to provide relief.
•For athletes requiring surgery, most are able to return to sports 6 to 12 weeks after surgery.
•Return to activity following surgical repair (across all surgical approaches) ranges from 62% to 100%. However, many surgical approaches report greater than 90% success rates.
•Maintaining rotational control and stability of the pelvis is the most important factor in preventing injury and reinjury.

•Asymptomatic direct inguinal hernias are common in the general population. Patients must have pain during exercise or provocative maneuvers and an appropriate examination and/or imaging findings for proper diagnosis.
•Return to sport can occur when the following are displayed: pain-free and strong adductor squeeze test, minimal adductor guarding, pain-free pubic symphysis shear test into extension, pain-free brisk walking before running. There should be no pain with sport-specific drills and movements prior to full return to sport.

Instructions for the Patient

•This condition may sometimes resolve with 6 to 8 weeks of rehabilitation as directed by your physical therapist. However, some cases that do not resolve require surgery to achieve relief.
•Most patients, even those who require surgery, can return to sport or activity within 3 months.
•You should continue a fitness program that does not aggravate your symptoms while your injury heals.
•It is important to incorporate strength and flexibility training in a single-leg stance during your rehabilitation process.

Considerations in Special Populations

•Consideration of apophyseal avulsion injury should be given in skeletally immature populations.
•For professional athletes who are unwilling to try a long course of conservative therapy, earlier referral for surgical evaluation may be considered.

Sports Hernia Rehabilitation

Ask your health care provider which exercises are safe for you. Do exercises exactly as told by your health care provider and adjust them as directed. It is normal to feel mild stretching, pulling, tightness, or discomfort as you do these exercises, but you should stop right away if you feel sudden pain or your pain gets worse. Do not begin these exercises until told by your health care provider.

Stretching and range of motion exercises

These exercises warm up your muscles and joints and improve the movement and flexibility around your hip and pelvis.