Abdominal musculature abnormalities cause of groin pain in athletes Inguinal
hernias and DEAN C.
JOSEPH A.
MOYLAN,§
as a
pubalgia* TAYLOR,†‡ CPT, MC, USA, WILLIAM C. MEYERS,§ MD, LOHNES,† PA-C, FRANK H. BASSETT,† MD, AND WILLIAM E. GARRETT, Jr,† MD, PhD
MD, JOHN
From the
†Divisions of Orthopaedic Surgery and §General Surgery, Duke University Medical Center, Durham, North Carolina of this condition with herniorrhaphy athlete to his sport within 3 months.
ABSTRACT There has been increasing interest within the European sports medicine community regarding the etiology and treatment of groin pain in the athlete. Groin pain is most commonly caused by musculotendinous strains of the adductors and other muscles crossing the hip joint, but may also be related to abdominal wall abnormalities. Cases may be termed "pubalgia" if physical examination does not reveal inguinal hernia and there is an absence of other etiology for groin pain. We present nine cases of patients who underwent herniorrhaphies for groin pain. Two patients had groin pain without evidence of a hernia preoperatively (pubalgia). In the remaining seven patients we determined the presence of a hernia by physical examination. At operation, eight patients were found to have inguinal hernias. One patient had no hernia but had partial avulsion of the internal oblique fibers from their insertion at the pubic tubercle. The average interval from operation to return to full activity was 11 weeks. All patients returned to full activity within 3 months of surgery. One patient had persistent symptoms of mild incisional tenderness, but otherwise there were no recurrences, complications, or persistence of symptoms. Abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the internal oblique muscle, can be an overlooked source of groin pain in the athlete. Operative treatment
can
return the
Groin pain is becoming increasingly recognized as a common condition in athletes. The etiology of pain in such patients may be difficult to determine and the results of treatment
frustrating. The problem has been extensive in Eu(Refs. 5, 6, 8; V. Smodlaka, personal communication, rope 1987), where groin injuries are commonly seen in soccer players. Renstrom and Peterson’ reported that 5% of all soccer injuries are localized to the groin region, and others have reported that up to 28% of soccer players will have a history of groin injury.’ The most common etiology of groin pain is a strain injury to the muscles of the groin region, including the adductor longus, rectus abdominus, iliopsoas, and rectus femoris muscles.s These injuries may be acute or chronic. The insertion can
be
sites for these muscles are illustrated in Figure 1. Other causes of groin pain include ilioinguinal neuralgia, genitourinary afflictions (prostatitis, epididymitis, urethritis, hydrocele, etc.), osteitis pubis (including the gracilis syndrome), bursitis around the hip joint, and arthritis of the hip. 2,1,9 One etiology that often is overlooked in the evaluation of groin pain is an incompetent abdominal wall in the groin with or without a detectable inguinal hernia. Similar conditions causing groin pain, where the etiology is obscure, have been termed as pubalgia in Europe.’ We present in this study a small series of athletes with groin pain caused by abnormalities of the abdominal wall musculature.
*Presented at the 15th annual meeting of the AOSSM, Traverse City, 1989 The opinions expressed m this article are those of the individual authors and do not necessarily reflect the opmons of the Army Medical Department, the Department of the Army, or the Department of Defense t Address correspondence and repnnt requests to Dean C Taylor, MD, Box 3435, Duke University Medical Center, Durham, NC 27710 0
Michigan, June
MATERIALS AND METHODS The
case
Bassini 239
histories of nine athletes who underwent modified were reviewed. The
herniorrhaphies for groin pain
240
patients included three collegiate soccer players, two professional baseball players, two marathon runners, one collegiate basketball player, and one collegiate football player. There and two women, with an average age of 23. Two patients had groin pain without preoperative evidence of hernia (one had bilateral groin pain). In the other seven patients, we diagnosed inguinal hernias (one had bilateral hernias) by physical examination. These seven patients presented with groin pain complaints, and in four cases the patients had noted an associated inguinal mass. The other three of these seven patients (one having bilateral hernias) had not appreciated a mass themselves, but were noted to have small hernias on physical examination. The herniorrhaphies were performed with the patients under general (seven cases) or spinal (two cases) anesthesia. Postoperatively, the patients were restricted from heavy lifting and strenuous exercise for 6 weeks, followed by a gradual return to full activity. At final followup, patients were interviewed to determine the prevalence of persistent symptoms and their level of return to athletics. were seven men
RESULTS Of the seven patients with preoperative diagnosis of hernia, four patients were found at surgery to have direct inguinal hernias, including one patient with bilateral direct inguinal hernias. We found an indirect hernia in another of these seven patients at surgery, and in the last two of these seven cases, we could not specify the type of hernia as direct or indirect. One of these seven patients also had a lipoma of the spermatic cord. Additionally, one of the four patients who had a direct hernia had had bilateral inguinal hernior-
rhaphies as a young child. The findings in the two patients who had no preoperative evidence of hernia are as follows. In the patient who had bilateral groin pain without palpable hernia, we noted small direct inguinal hernias at surgery. In the other patient without palpable inguinal hernia, we found no evidence of hernia at surgery; however, there was partial avulsion of the internal oblique muscle fibers from their insertion at the pubic tubercle, with thinning of the transversalis fascia and transversalis. All of the patients had complete relief of their symptoms at the time of final followup, with the exception of one patient who had persistent mild incisional tenderness but was otherwise pain-free. The average interval from operation to return to full activity was 11 weeks. There were no surgical complications or recurrences. All of the patients returned to their previous level of athletic activity within 3 months of surgery.
CASE EXAMPLES Groin
pain
without detectable hernia
Case 1. A 20-year-old collegiate soccer goalkeeper was referred to our sports medicine clinic with a 7 month history
A
1
$
Figure 1. Insertion sites for muscles strain injuries resulting in groin pain.
that
commonly
1
sustain
of
right-sided groin pain that had been treated unsuccessfully by several different physicians as a presumed muscle
strain. Treatment had included nonsteroidal antiinflammatory drugs, adductor strengthening exercises, and heat therapy. His pain was characterized as dull, becoming sharp with activity, and worse with sit-ups or twisting motions. He also complained of muscle soreness in both lower extremities. He did not recall a specific isolated injury and had no other significant medical history. Physical examination revealed tenderness at the right inguinal ring and the right adductor magnus origin. No hernia could be felt by physical examination. The patient noted significant pain in the inguinal region when doing situps, particularly resisted sit-ups. Radiographs were unremarkable, but a bone scan revealed increased uptake in the
right groin. The patient was referred to a general surgeon (WCM) and subsequently underwent a right modified Bassini herniorrhaphy under spinal anesthesia. Intraoperatively, the internal oblique insertion was avulsed partially from the pubic tubercle and there was thinning of the transversalis fascia within Hesselbach’s triangle (Fig. 2). The patient gradually returned to full activity over the ensuing 3 months. At 18 months postoperation, he had no recurrence of symptoms and was the starting goalie for his Division I college soccer team.
241
Figure 2. Diagrammatic representation of injury to the conjoined tendon. Microscopic tears or avulsion injuries in the circled region may cause pubalgia. Groin
pain with detectable hernia
Case 2. A 22-year-old collegiate soccer player presented with a 1 month history of left groin pain associated with activity. He was seen by a physician in the training room, had a left inguinal hernia detected by physical examination, and was referred to a general surgeon (JAM). He underwent a left modified Bassini herniorrhaphy under general anesthesia. Intraoperatively, a direct inguinal hernia was noted. Six weeks postoperatively the patient resumed running, and by 8 weeks he felt that he was back to his preoperative level of competition. Twenty-six months postoperatively the patient reported no recurrence of symptoms and was playing professional
soccer.
DISCUSSION
general, abdominal wall abnormalities are not commonly thought of as a cause of groin pain. Muscle strains, particularly hip adductor strains, are much more likely to cause groin pain in the athlete. Inguinal hernias and subclinical abdominal wall defects without herniation are frequently In
overlooked among the
more common
muscle strains and the
wide variety of other etiologies. Additionally, diagnosing the cause of groin pain can be difficult because there may be more than one contributing factor, as shown by Ekberg et a1.2 Thus, many cases of abdominal wall abnormalities are likely to be overlooked in the athlete unless a thorough, multidisciplinary approach is used. In this study we looked at a small number of patients with groin pain due to abdominal wall abnormalities. Because of the factors stated above, there may have been more patients, especially those without hernias clinically, that were overlooked. In cases of groin pain with no palpable hernia and no other etiology for the groin pain, the diagnosis and management can be particularly troublesome. This condition has been termed pubalgia in the European literature. We consider the causes of pubalgia to include nonpalpable small direct and indirect hernias or microscopic tears or avulsions of the internal oblique muscle in the area commonly referred to as the &dquo;conjoined tendon&dquo; (Fig. 2). In groin pain due to abdominal wall abnormalities, one finds a history of inguinal pain that worsens with strenuous activity, especially activity stressing the abdominal muscles such as sit-ups. On physical examination there is tenderness of the inguinal ring or pubic tubercle. Pain is often elicited with Valsalva’s maneuver, and can be present with resistance testing of lower extremity muscles such as the hip adductors. However, the absence of tenderness in these muscle groups helps to differentiate pubalgia from muscle strains. Radiographically, in cases of pubalgia there may be nonspecific changes of the pubis or pubic symphysis, but usually radiographs are normal. Many times cases can be termed pubalgia because etiologies other than nonpalpable hernia and microscopic internal oblique muscle tears have been ruled out, or treatment regimens have resulted in little
improvement. Several diagnostic imaging techniques may be helpful. Technetium scanning can provide nonspecific information, as in Case 1, or rule out other etiologies of groin pain. Although not used in this study, herniography has also been used to diagnose nonpalpable hernias, lipomas, and insufficiency of the inguinal floor.2-4.7 Smedberg et al.’ demonstrated an 84% incidence of inguinal hernia by herniography in soccer players with groin pain. Only 8% had hernias revealed by physical examination.’ Finally, magnetic resonance imaging may provide valuable information in examining the soft tissues in groin pain patients. In patients with inguinal hernias, herniorrhaphy should result in relief of groin pain and return to activity within 3 months, as was the case in the patients in this study. If no hernia is detected, but the history and physical findings are consistent with pubalgia, then conservative treatment with rest, antiinflammatory agents, stretching and strengthening exercises should be attempted. If conservative measures are unsuccessful, then herniorrhaphy should result in resolution of groin pain. Ekberg et a1.33 reported that 16 of 17 patients with nonpalpable hernias
242
detected by herniography had relief of groin pain following
herniorrhaphy. Smedberg et al.’ reported that in athletes with herniographic findings of inguinal hernias or weakness of the abdominal wall, herniorrhaphy was curative in 70% and a further 20% of patients were improved. Chronic tenoperiostitis, prostatitis, and hip joint arthrosis were etiologies listed as responsible for persistent pain in those patients not cured by herniorrhaphy. In three patients (5% of the 63 operations) the reason for persistent groin pain was unclear.’ Additionally, according to Smodlaka (personal communication, 1987), Nesovic has been instrumental in establishing herniorrhaphy as a treatment for pubalgia, having treated several hundred athletes with pubalgia operatively with modified Bassini herniorrhaphies. In summary, abnormalities of the abdominal wall in the
groin region, including palpable hernias, nonpalpable hernias, and microscopic tears or avulsions of the internal oblique muscle, are uncommon causes of groin pain that can be overlooked.
Diagnosis is usually based on history and physical findings, although several imaging techniques may be helpful. If conservative treatment measures are unsuccessful, herniorrhaphy is a curative treatment that will allow the athlete to return to full activity within 3 months. REFERENCES 1
Brunet B, Brunet-Geudj E, Genety J, et al La pubalgie syndrome "fourretout" pour une plus grande rigueur diagnostique et therapeutique Intantanes Medicaux 55 25-30, 1984 2. Ekberg O, Persson NH, Abrahamsson P-A, et al Longstanding groin pain in athletes A multidisciplinary approach Sports Med 6 56-61, 1988 3. Ekberg O, Blomquist P, Olsson S Positive contrast herntography in adult patients with obscure groin pain Surgery 89 532-535, 1981 4. Gullmo A Holography The diagnosis of hernia in the groin and incompetence of the pouch of Duglas and pelvic floor Acta Radiol (Suppl) 361
1-76, 1980 5. Peterson L, Renstrom P Sports Injuries Their Prevention and Treatment London, Martin Dunitz, 1983 6. Renstrom P, Peterson L: Groin Injuries in athletes Br J Sports Med 14
30-36, 1980 7
Smedberg SGG,
Broome AEA, Gullmo A, et al Hermography in athletes with groin pain. Am J Surg 149. 378-382, 1985 8. Smodlaka VN: Groin pain in soccer players Physician Sportsmed 8(8)
9.
Wiley
57-61, 1980 JJ: Traumatic osteitis pubis The Med 11. 360-363, 1983
gracilis syndrome
Am J
Sports
DISCUSSION Per A. Renstrom, MD, PhD, Burlington, Vermont: Groin constitutes one of the greatest challenges in sports medicine. This is not only a diagnostic problem, it is also a therapeutic problem. In a prospective study of 70 soccer teams over 2 years in Goteborg, Sweden, we found that 5% of all injuries were located through the groin area. There are many causes for groin pain. It is therefore important to have a broad differential diagnostic background. Every article about groin pain is therefore valuable. The authors have presented nine cases of hernias giving groin pain. Two patients had groin pain without evidence of hernias preoperatively. In our study from Goteborg with over 100 patients with groin pain, which I presented to this group in Lake Tahoe in 1981, hernias were present in 4%. However, the most common cause of groin pain is chronic inflammation of partial tears of the adductor muscles and tendons, and especially the adductor longus. Of these nine patients, two had groin pain without evidence of a hernia. Incipient hernia is a differential diagnosis in groin pain. This was first described by Gullmo in 1980 and then by Ekberg in 1981 in Sweden. They used herniography, which involves injection of contrast intraperitoneally. The contrast is then allowed to sink down, allowing visualization of hernias that cannot be felt. They reported 101 painful groins without palpable hernias in 92%. Hernias were found in 84% of the symptomatic groins. Sixty-three of 101 patients were operated on and 70% were cured and 20% were improved. Hernias are only part of the groin pain problem. Groin pain constitutes a great problem in sports such as soccer, ice hockey, fencing, etc. Intensive preventive stretching programs of the groin muscles and tendons are compulsory in the warm-up for these sports. This has decreased the problem dramatically in Europe, but we still have a long way to go. It is important to have a multidisciplinary approach to these problems involving different kinds of surgeons. The authors should be complimented for involving different specialties and for focusing our attention on this difficult problem.
pain
hernias and DEAN C.
JOSEPH A.
MOYLAN,§
as a
pubalgia* TAYLOR,†‡ CPT, MC, USA, WILLIAM C. MEYERS,§ MD, LOHNES,† PA-C, FRANK H. BASSETT,† MD, AND WILLIAM E. GARRETT, Jr,† MD, PhD
MD, JOHN
From the
†Divisions of Orthopaedic Surgery and §General Surgery, Duke University Medical Center, Durham, North Carolina of this condition with herniorrhaphy athlete to his sport within 3 months.
ABSTRACT There has been increasing interest within the European sports medicine community regarding the etiology and treatment of groin pain in the athlete. Groin pain is most commonly caused by musculotendinous strains of the adductors and other muscles crossing the hip joint, but may also be related to abdominal wall abnormalities. Cases may be termed "pubalgia" if physical examination does not reveal inguinal hernia and there is an absence of other etiology for groin pain. We present nine cases of patients who underwent herniorrhaphies for groin pain. Two patients had groin pain without evidence of a hernia preoperatively (pubalgia). In the remaining seven patients we determined the presence of a hernia by physical examination. At operation, eight patients were found to have inguinal hernias. One patient had no hernia but had partial avulsion of the internal oblique fibers from their insertion at the pubic tubercle. The average interval from operation to return to full activity was 11 weeks. All patients returned to full activity within 3 months of surgery. One patient had persistent symptoms of mild incisional tenderness, but otherwise there were no recurrences, complications, or persistence of symptoms. Abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the internal oblique muscle, can be an overlooked source of groin pain in the athlete. Operative treatment
can
return the
Groin pain is becoming increasingly recognized as a common condition in athletes. The etiology of pain in such patients may be difficult to determine and the results of treatment
frustrating. The problem has been extensive in Eu(Refs. 5, 6, 8; V. Smodlaka, personal communication, rope 1987), where groin injuries are commonly seen in soccer players. Renstrom and Peterson’ reported that 5% of all soccer injuries are localized to the groin region, and others have reported that up to 28% of soccer players will have a history of groin injury.’ The most common etiology of groin pain is a strain injury to the muscles of the groin region, including the adductor longus, rectus abdominus, iliopsoas, and rectus femoris muscles.s These injuries may be acute or chronic. The insertion can
be
sites for these muscles are illustrated in Figure 1. Other causes of groin pain include ilioinguinal neuralgia, genitourinary afflictions (prostatitis, epididymitis, urethritis, hydrocele, etc.), osteitis pubis (including the gracilis syndrome), bursitis around the hip joint, and arthritis of the hip. 2,1,9 One etiology that often is overlooked in the evaluation of groin pain is an incompetent abdominal wall in the groin with or without a detectable inguinal hernia. Similar conditions causing groin pain, where the etiology is obscure, have been termed as pubalgia in Europe.’ We present in this study a small series of athletes with groin pain caused by abnormalities of the abdominal wall musculature.
*Presented at the 15th annual meeting of the AOSSM, Traverse City, 1989 The opinions expressed m this article are those of the individual authors and do not necessarily reflect the opmons of the Army Medical Department, the Department of the Army, or the Department of Defense t Address correspondence and repnnt requests to Dean C Taylor, MD, Box 3435, Duke University Medical Center, Durham, NC 27710 0
Michigan, June
MATERIALS AND METHODS The
case
Bassini 239
histories of nine athletes who underwent modified were reviewed. The
herniorrhaphies for groin pain
240
patients included three collegiate soccer players, two professional baseball players, two marathon runners, one collegiate basketball player, and one collegiate football player. There and two women, with an average age of 23. Two patients had groin pain without preoperative evidence of hernia (one had bilateral groin pain). In the other seven patients, we diagnosed inguinal hernias (one had bilateral hernias) by physical examination. These seven patients presented with groin pain complaints, and in four cases the patients had noted an associated inguinal mass. The other three of these seven patients (one having bilateral hernias) had not appreciated a mass themselves, but were noted to have small hernias on physical examination. The herniorrhaphies were performed with the patients under general (seven cases) or spinal (two cases) anesthesia. Postoperatively, the patients were restricted from heavy lifting and strenuous exercise for 6 weeks, followed by a gradual return to full activity. At final followup, patients were interviewed to determine the prevalence of persistent symptoms and their level of return to athletics. were seven men
RESULTS Of the seven patients with preoperative diagnosis of hernia, four patients were found at surgery to have direct inguinal hernias, including one patient with bilateral direct inguinal hernias. We found an indirect hernia in another of these seven patients at surgery, and in the last two of these seven cases, we could not specify the type of hernia as direct or indirect. One of these seven patients also had a lipoma of the spermatic cord. Additionally, one of the four patients who had a direct hernia had had bilateral inguinal hernior-
rhaphies as a young child. The findings in the two patients who had no preoperative evidence of hernia are as follows. In the patient who had bilateral groin pain without palpable hernia, we noted small direct inguinal hernias at surgery. In the other patient without palpable inguinal hernia, we found no evidence of hernia at surgery; however, there was partial avulsion of the internal oblique muscle fibers from their insertion at the pubic tubercle, with thinning of the transversalis fascia and transversalis. All of the patients had complete relief of their symptoms at the time of final followup, with the exception of one patient who had persistent mild incisional tenderness but was otherwise pain-free. The average interval from operation to return to full activity was 11 weeks. There were no surgical complications or recurrences. All of the patients returned to their previous level of athletic activity within 3 months of surgery.
CASE EXAMPLES Groin
pain
without detectable hernia
Case 1. A 20-year-old collegiate soccer goalkeeper was referred to our sports medicine clinic with a 7 month history
A
1
$
Figure 1. Insertion sites for muscles strain injuries resulting in groin pain.
that
commonly
1
sustain
of
right-sided groin pain that had been treated unsuccessfully by several different physicians as a presumed muscle
strain. Treatment had included nonsteroidal antiinflammatory drugs, adductor strengthening exercises, and heat therapy. His pain was characterized as dull, becoming sharp with activity, and worse with sit-ups or twisting motions. He also complained of muscle soreness in both lower extremities. He did not recall a specific isolated injury and had no other significant medical history. Physical examination revealed tenderness at the right inguinal ring and the right adductor magnus origin. No hernia could be felt by physical examination. The patient noted significant pain in the inguinal region when doing situps, particularly resisted sit-ups. Radiographs were unremarkable, but a bone scan revealed increased uptake in the
right groin. The patient was referred to a general surgeon (WCM) and subsequently underwent a right modified Bassini herniorrhaphy under spinal anesthesia. Intraoperatively, the internal oblique insertion was avulsed partially from the pubic tubercle and there was thinning of the transversalis fascia within Hesselbach’s triangle (Fig. 2). The patient gradually returned to full activity over the ensuing 3 months. At 18 months postoperation, he had no recurrence of symptoms and was the starting goalie for his Division I college soccer team.
241
Figure 2. Diagrammatic representation of injury to the conjoined tendon. Microscopic tears or avulsion injuries in the circled region may cause pubalgia. Groin
pain with detectable hernia
Case 2. A 22-year-old collegiate soccer player presented with a 1 month history of left groin pain associated with activity. He was seen by a physician in the training room, had a left inguinal hernia detected by physical examination, and was referred to a general surgeon (JAM). He underwent a left modified Bassini herniorrhaphy under general anesthesia. Intraoperatively, a direct inguinal hernia was noted. Six weeks postoperatively the patient resumed running, and by 8 weeks he felt that he was back to his preoperative level of competition. Twenty-six months postoperatively the patient reported no recurrence of symptoms and was playing professional
soccer.
DISCUSSION
general, abdominal wall abnormalities are not commonly thought of as a cause of groin pain. Muscle strains, particularly hip adductor strains, are much more likely to cause groin pain in the athlete. Inguinal hernias and subclinical abdominal wall defects without herniation are frequently In
overlooked among the
more common
muscle strains and the
wide variety of other etiologies. Additionally, diagnosing the cause of groin pain can be difficult because there may be more than one contributing factor, as shown by Ekberg et a1.2 Thus, many cases of abdominal wall abnormalities are likely to be overlooked in the athlete unless a thorough, multidisciplinary approach is used. In this study we looked at a small number of patients with groin pain due to abdominal wall abnormalities. Because of the factors stated above, there may have been more patients, especially those without hernias clinically, that were overlooked. In cases of groin pain with no palpable hernia and no other etiology for the groin pain, the diagnosis and management can be particularly troublesome. This condition has been termed pubalgia in the European literature. We consider the causes of pubalgia to include nonpalpable small direct and indirect hernias or microscopic tears or avulsions of the internal oblique muscle in the area commonly referred to as the &dquo;conjoined tendon&dquo; (Fig. 2). In groin pain due to abdominal wall abnormalities, one finds a history of inguinal pain that worsens with strenuous activity, especially activity stressing the abdominal muscles such as sit-ups. On physical examination there is tenderness of the inguinal ring or pubic tubercle. Pain is often elicited with Valsalva’s maneuver, and can be present with resistance testing of lower extremity muscles such as the hip adductors. However, the absence of tenderness in these muscle groups helps to differentiate pubalgia from muscle strains. Radiographically, in cases of pubalgia there may be nonspecific changes of the pubis or pubic symphysis, but usually radiographs are normal. Many times cases can be termed pubalgia because etiologies other than nonpalpable hernia and microscopic internal oblique muscle tears have been ruled out, or treatment regimens have resulted in little
improvement. Several diagnostic imaging techniques may be helpful. Technetium scanning can provide nonspecific information, as in Case 1, or rule out other etiologies of groin pain. Although not used in this study, herniography has also been used to diagnose nonpalpable hernias, lipomas, and insufficiency of the inguinal floor.2-4.7 Smedberg et al.’ demonstrated an 84% incidence of inguinal hernia by herniography in soccer players with groin pain. Only 8% had hernias revealed by physical examination.’ Finally, magnetic resonance imaging may provide valuable information in examining the soft tissues in groin pain patients. In patients with inguinal hernias, herniorrhaphy should result in relief of groin pain and return to activity within 3 months, as was the case in the patients in this study. If no hernia is detected, but the history and physical findings are consistent with pubalgia, then conservative treatment with rest, antiinflammatory agents, stretching and strengthening exercises should be attempted. If conservative measures are unsuccessful, then herniorrhaphy should result in resolution of groin pain. Ekberg et a1.33 reported that 16 of 17 patients with nonpalpable hernias
242
detected by herniography had relief of groin pain following
herniorrhaphy. Smedberg et al.’ reported that in athletes with herniographic findings of inguinal hernias or weakness of the abdominal wall, herniorrhaphy was curative in 70% and a further 20% of patients were improved. Chronic tenoperiostitis, prostatitis, and hip joint arthrosis were etiologies listed as responsible for persistent pain in those patients not cured by herniorrhaphy. In three patients (5% of the 63 operations) the reason for persistent groin pain was unclear.’ Additionally, according to Smodlaka (personal communication, 1987), Nesovic has been instrumental in establishing herniorrhaphy as a treatment for pubalgia, having treated several hundred athletes with pubalgia operatively with modified Bassini herniorrhaphies. In summary, abnormalities of the abdominal wall in the
groin region, including palpable hernias, nonpalpable hernias, and microscopic tears or avulsions of the internal oblique muscle, are uncommon causes of groin pain that can be overlooked.
Diagnosis is usually based on history and physical findings, although several imaging techniques may be helpful. If conservative treatment measures are unsuccessful, herniorrhaphy is a curative treatment that will allow the athlete to return to full activity within 3 months. REFERENCES 1
Brunet B, Brunet-Geudj E, Genety J, et al La pubalgie syndrome "fourretout" pour une plus grande rigueur diagnostique et therapeutique Intantanes Medicaux 55 25-30, 1984 2. Ekberg O, Persson NH, Abrahamsson P-A, et al Longstanding groin pain in athletes A multidisciplinary approach Sports Med 6 56-61, 1988 3. Ekberg O, Blomquist P, Olsson S Positive contrast herntography in adult patients with obscure groin pain Surgery 89 532-535, 1981 4. Gullmo A Holography The diagnosis of hernia in the groin and incompetence of the pouch of Duglas and pelvic floor Acta Radiol (Suppl) 361
1-76, 1980 5. Peterson L, Renstrom P Sports Injuries Their Prevention and Treatment London, Martin Dunitz, 1983 6. Renstrom P, Peterson L: Groin Injuries in athletes Br J Sports Med 14
30-36, 1980 7
Smedberg SGG,
Broome AEA, Gullmo A, et al Hermography in athletes with groin pain. Am J Surg 149. 378-382, 1985 8. Smodlaka VN: Groin pain in soccer players Physician Sportsmed 8(8)
9.
Wiley
57-61, 1980 JJ: Traumatic osteitis pubis The Med 11. 360-363, 1983
gracilis syndrome
Am J
Sports
DISCUSSION Per A. Renstrom, MD, PhD, Burlington, Vermont: Groin constitutes one of the greatest challenges in sports medicine. This is not only a diagnostic problem, it is also a therapeutic problem. In a prospective study of 70 soccer teams over 2 years in Goteborg, Sweden, we found that 5% of all injuries were located through the groin area. There are many causes for groin pain. It is therefore important to have a broad differential diagnostic background. Every article about groin pain is therefore valuable. The authors have presented nine cases of hernias giving groin pain. Two patients had groin pain without evidence of hernias preoperatively. In our study from Goteborg with over 100 patients with groin pain, which I presented to this group in Lake Tahoe in 1981, hernias were present in 4%. However, the most common cause of groin pain is chronic inflammation of partial tears of the adductor muscles and tendons, and especially the adductor longus. Of these nine patients, two had groin pain without evidence of a hernia. Incipient hernia is a differential diagnosis in groin pain. This was first described by Gullmo in 1980 and then by Ekberg in 1981 in Sweden. They used herniography, which involves injection of contrast intraperitoneally. The contrast is then allowed to sink down, allowing visualization of hernias that cannot be felt. They reported 101 painful groins without palpable hernias in 92%. Hernias were found in 84% of the symptomatic groins. Sixty-three of 101 patients were operated on and 70% were cured and 20% were improved. Hernias are only part of the groin pain problem. Groin pain constitutes a great problem in sports such as soccer, ice hockey, fencing, etc. Intensive preventive stretching programs of the groin muscles and tendons are compulsory in the warm-up for these sports. This has decreased the problem dramatically in Europe, but we still have a long way to go. It is important to have a multidisciplinary approach to these problems involving different kinds of surgeons. The authors should be complimented for involving different specialties and for focusing our attention on this difficult problem.
pain
