Hernia DOI 10.1007/s10029-015-1367-4
ORIGINAL ARTICLE
Sports hernias: experience in a sports medicine center O. L. Santilli1 • N. Nardelli1 • H. A. Santilli1 • D. E. Tripoloni2
Received: 10 November 2013 / Accepted: 8 March 2015 Springer-Verlag France 2015
Abstract Purpose Chronic pain of the inguino-crural region or ‘‘pubalgia’’ explains the 0.5–6.2 % of the consultations by athletes. Recently, areas of weakness in the posterior wall called ‘‘sports hernias,’’ have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by ‘‘pubalgia’’. Methods 1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic ‘‘TAPP’’ repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U MannWhitney test for continuous scale variables and the chi-
& O. L. Santilli [email protected] 1
Department of Surgery, Centro de Patologı´a Herniaria, CPH, Cervin˜o Street 4449, 9th floor (1425), Ciudad Auto´noma De Buenos Aires, Argentina
2
Department of Surgery, Sanatorio ‘‘Dr. Julio Me´ndez’’, Ciudad Auto´noma De Buenos Aires, Argentina
square test for dichotomous variables with p \ 0.05 as a level of significance. Results In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1 %) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 ‘‘sport hernias’’ in 769 patients with previous diagnosis of adductor muscle strain (10.92 %); on the other hand, in 127 (21.52 %) of our patients with ‘‘sport hernias’’ US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42 % and a specificity of 100 %; the positive and negative predictive values were 100 and 99.4 % respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81 %); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle. Conclusions Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of ‘‘pubalgia’’. ‘‘Sports hernias’’ are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care. Keywords Sportsman’s hernia Pubalgia Groin pain Muscle imbalance
123
Hernia
Introduction Chronic pain of the inguino-crural region or ‘‘pubalgia’’ explains the 0.5–6.2 % [1–5] of the consultations carried out by athletes. Historically attributed to osteoarticular, muscular and tendinous processes, in recent years areas of weakness in the posterior wall of the groin called ‘‘sports hernias’’, have been identified in some of these patients, capable of causing pain, which although it does not interfere with everyday life, it affects their performance during training and competition, for which reason it may put at risk the continuity of the sport career [6–8]. This injury has been recently defined as ‘‘an occult hernia caused by weakness or tear of the posterior inguinal wall, without a clinical recognizable hernia…’’ [9]; the absence of bulky peritoneal protrusion makes the diagnosis by physical examination extremely difficult requiring the use of studies by images that must be performed and interpreted by operators with dedication and experience in the exploration of the groin’s soft tissues. Under these conditions, both ultrasound (US) and magnetic resonance imaging (MRI) are useful, but the former offers the advantage of dynamic exploration; MRI allows the diagnosis of bone, articular, or tendinous lesions that should be considered in the differential diagnosis, but the static nature of scanning reduces its performance to identify little defects or protrusions of the posterior wall of the groin, even though some techniques of rapid exposure during the Valsalva maneuver have been described [10]. As regards the treatment, it have been published excellent results with open and laparoscopic techniques [11–14], but the latter might add the possibility of finding areas of weakness not identified by the imaging studies and proceed to its repair. Several authors [6, 7, 15, 16] have questioned the importance (and even the existence) of this type of hernias, giving rise to a controversy that still lingers. Due to the difficulty in designing prospective studies including professional athletes we believe that the only way to approach the truth is through a strong correlation between diagnostic and therapeutic instances. The present study aims to assess the performance of a diagnostic-therapeutic management based on physical examination and ultrasound followed by laparoscopic exploration and repair of the inguinal region in a consecutive batch of athletes affected by long-term pubalgia.
Patients and methods Between January 2004 and July 2011 1450 athletes affected by pubalgia were evaluated, coming from an orthopedic office of a center specialized in sports medicine.
123
All of them had presented long-standing pain without clear evidence of inguinal or femoral hernia. Before the authors’ intervention MRI had been performed diagnosing some osteoarticular or tendinous processes in 769 cases (753 adductor muscle strains, 16 osteitis pubis). These entities were considered ‘‘a priori’’ as responsible for pubalgia so started physiotherapy. However, the assessment for a surgeon was required to rule out an associated sportman’s hernia or because of lack of response to the treatment. In the remaining 681 patients no cause of pain had been diagnosed. All patient underwent clinical and ultrasonography assessment: we detected findings consistent with ‘‘sport hernia’’ in 84 patients from the group of osteitis and tendinitis and 506 in the group without apparent cause for pain, for which reason they underwent laparoscopic exploration. The remaining patients continued with physical therapy and a structured exercise program to stabilize the pelvis under supervision of physiotherapist and orthopedist. Population characteristics The group of ‘‘sports hernias’’ consisted of 539 men and 51 women, with a mean age of 33.91 years (SD = 11.33); 414 (70.2 %) of them were amateur and 176 (29.8 %) professionals (112 soccer players, 38 rugby players, 13 tennis players, 5 basketball players, 3 cyclists, 3 gymnasts, and 2 handball players). Conservative treatments were tried out (in 529 cases physical therapy and in 40 physical therapy plus infiltration with local anesthetics and corticosteroids), without obtaining response or with transient improvement followed by recurrence of pain upon restarting sports activity. Diagnosis Patients were asked about the characteristics of pain, its duration and relation to the efforts. Physical examination included digital palpation of the projection of inguinal rings by invagination of the scrotal pouch in men and direct palpation of the inguinal region in women. The appearance of pain with the same characteristics of that triggered by the exercise made us suspect the presence of sport hernias, for which reason ultrasound was indicated for confirmation. The evaluation was performed by operators with special interest in musculoskeletal imaging of the groin using ‘‘Xario’’ (Toshiba), ‘‘Nemio’’ (Toshiba) and ‘‘HDI 5000’’ (Philips) US unit equipped with 5–12 MHz multifrequency transducers.
Hernia
The exploration technique is the one described by Jamadar et al. [17]: the boundaries of the Hesselbach’s triangle (inferior epigastric artery, outer edge of the rectus abdominis muscle and the inguinal ligament) next to the pubic tubercle are the landmarks to be identified. For which purpose, the transducer is placed on the axial plane at the level of the navel, on the lateral edge of the rectus abdominis. Once the inferior epigastric artery is identified, it is followed in the cranio-caudal direction up to its origin in the external iliac artery as a reference point for defining the inner edge of the deep inguinal ring. Immediately below is located the inguinal ligament, which is identified as an echogenic band when slightly rotating the transducer abandoning the strict axial plane and orienting it toward the pubic tubercle. In a lateral and superior position to this osseous relief is identified the superficial inguinal ring. Once the anatomical repairs are found, the patient is examined at rest and with a gradual increase of the abdominal pressure, which allows to identify fatty protrusions, small pouches or expansions of the deep hole and/or the Hesselbach’s area, the exploration was bilateral in all patients. Surgical technique The laparoscopic ‘‘TAPP’’ approach was used in all cases under general anesthesia through a 10-mm umbilical port and two ports of 5 mm on the flanks. After the insufflation, the anterior abdominal wall was explored and then we proceeded to the opening of the parietal peritoneum of the affected side/s and to the invagination or resection of the sac or lipoma when they were found. Repair was performed with a 15 cm by 13 cm polypropylene mesh (Surgipro) fixed with tacks (Protack); the parietal peritoneum was closed with polyglactin 910 (Vicryl) 2/0 and the aponeurosis in the umbilical wound with polyglactin 910 (Vicryl ) 1. Postoperative stage and rehabilitation Ketorolac (30 mg intravenously) was administered at the end of the procedure and intake of liquids was allowed 2 h later; then, a general diet was started and a 20 mg-dose of ketorolac was administered sublingually. Early discharge was promoted: the patients who underwent surgery in the morning were released during the afternoon and those patients who underwent surgery after midday were released during the following morning. Seven days later, an office contact was performed and, after confirming a favorable evolution, some isometric exercises without overload (jogging, cycling), with increasing intensity, were started under the supervision of a physiotherapist. Then, different techniques of muscular
strengthening were developed to resume the specific sport activity. In professional athletes physical activity was initiated within the first 3 days following a standardized protocol. Thirty days after surgery, a new assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. Statistical analysis We used the U Mann-Whitney test for continuous scale variables and the Chi-square test for dichotomous variables with p \ 0.05 as a level of significance; calculations were performed using the SPSS package for Windows, version 17.0 (Chicago, Illinois, USA).
Results All patients reported pain of more than 6 months of evolution (median 12; interquartile period = 9–15); in 116 cases (19.6 %) of more than 1 year and in 70 (11.8 %) of more than 2 years, with improvement during rest or physiotherapy treatment followed by recurrences at the restart of physical activity. 217 Patients reported pain on both sides of the midline In all cases, palpation of the groin triggered sharp pain limited to an area equivalent to the finger pad, without radiation and with identical characteristics to that caused by exercise. No subject described the pain as neuralgia and in none of the physical explorations muscular hypotrophies, paresthesias, or Tinel’s sign were observed. In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, in which 498 of them coincided with areas affected by pain. In 127 patients, oedema of the adductor longus tendon was identified; this finding has not changed, in most cases, the behavior adopted regarding ‘‘sport hernia’’ but in seven of them we added a partial tenotomy by anterior approach (suggested by the orthopedic surgeon) because of the chronicity and lack of response to prolonged physiotherapy. The 17 patients in which ultrasound failed to detect a parietal defect underwent to laparoscopic exploration due to the high suspicion of ‘‘sport hernia’’. All ultrasound findings were confirmed by the laparoscopic exploration that also diagnosed associated contralateral and ipsilateral defects (mixed hernias), resulting in a total of 1006 hernias; 178 patients presented bilateral defects (all of them direct hernias) of which 133 were diagnosed preoperatively. We usually found the preperitoneal fatty tissue protruding through small tears of the posterior wall (Figs. 1 and 2); it
123
Hernia
(15.76 %), up to 24 months in 186 (31.52 %) and up to 36 months in 299 patients (50.67 %); 12 patients (2.03 %) were lost to follow-up during the second and third years after the operation. Seven patients suffered recurrence of pain. The ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis that was successfully treated with physical therapy and a structured exercise program. The remaining patients continue with their sports activities without pain or functional limitation. Comparison of the relevant variables in the amateur and professional athletes (Table 1) revealed a higher bilaterality rate in the last group. Fig. 1 Laparoscopic view of the right inguinal region: descended the peritoneum, we found a lump of preperitoneal fat near the pubis (arrow)
Fig. 2 Laparoscopic view of the right inguinal region: after removing the fatty tissue, a tear of the posterior wall (arrow) is observed
rarely protruded through the deep inguinal ring and never was observed the intestinal contents coming out freely through the inguinal canal. In all negative ultrasound’s cases, the defect was direct. Compared with findings of laparoscopy, ultrasound had a sensitivity of 95.42 % and a specificity of 100 %. The positive and negative predictive value was 100 and 99.4 %, respectively. The diagnostic process is summarized in Fig. 3. No intraoperative incidents or postoperative complications were reported. 583 patients resumed sport activity within 30 days of the procedure and only seven prolonged the period of rest, in all cases due to associated tendinopathies that responded to physical therapy. Postoperative contact (personal and telephone interviews) was maintained up to 12 months in 93 patients
123
Discussion Already in the 1970s, Norris [18] had recognized the deficiency of the posterior wall of the abdomen as a cause of inguino-pubic pain in athletes. In 1991 Taylor [19] coined the term ‘‘pubalgia’’ attributing the pain to a tear of the anterior rectus pubic insertion; the same year, Gilmore [13] described a condition characterized by pain and increase of tension at the inguinal and pubic level accompanied by dilatation of the superficial inguinal ring, which he termed ‘‘groin disruption’’, a term that refers to the idea of tearing. According to him, the damaged elements are the transversalis fascia and the conjoint tendon, which are separated from the inguinal ligament; the repair involves the plication of the fascia and the conjoint tendon with absorbable sutures and its suture to the inguinal ligament with nylon. In 1992, Malycha and Lovell [20] introduced the term ‘‘sports hernia’’ and in 1993 Hackney [21] described, in 15 athletes members of the British armed forces, lesions similar to direct and indirect hernias to which he applied the Gilmore technique achieving 87 % of success. Since then, a great variety of injuries (direct or indirect hernias, tears of the transversalis fascia or the oblique aponeurosis, etc.) have been published under this denomination, subjected to no less diverse repair techniques (with sutures, with prosthetic meshes, through an open or laparoscopic, ‘‘TAPP’’ or ‘‘TEP’’). Among recently published series, van Veen et al. [14] found hernias in all patients (55) that they explored via endoscopic preperitoneal TEP, while Kluin [3] identified 14 in 18 athletes approached by TAPP and TEP techniques, including 4 femoral hernias and one obturator hernia among them. Genitsaris et al. [12] performed bilateral TAPP repair to a series of 131 patients who had affected both groins in more than 30 % of cases.
Hernia Fig. 3 ‘‘Sports hernia’’: diagnostic management
1450 paents from orthopedic office Clinical assessment by ortophedist & MRI
769 tendinis, osteis pubis
681 no diagnosis
Clinical assessment by surgeon & US
73 "sports hernias"
11 suspected "sports hernias"
6 suspected "sports hernias"
500 "sports hernias"
Laparoscopic exploraon
1006 "sports hernias"
768 direct (178 bilateral)
Table 1 Comparison of professional and amateur athletes
221 indirect
17 mixed
Professionals (n = 176)
Amateurs (n = 414)
p value
Age (mean, SD)
33.69 (11.679)
34.43 (10.486)
0.247
Female/male
17/159
34/380
0.567
Bilaterality (%)
87 (49.4)
91 (21.9)
0.000
Other lesions (%)
34 (19.3)
93 (22.4)
0.395
SD standard deviation
No papers have been published that allow physicians to select from the above techniques: the Polglase study [5], the only randomized and controlled trial that was previous to the development of laparoscopic techniques, demonstrated the superiority of open repair over the physical therapy. However, other authors have denied the existence of sportmen´s hernias as being responsible for the chronic inguino-pubic pain. Among them, Diesen and Pappas [15] claim that the lesion affects the insertion of the abdomini
rectus muscle, for which reason they propose its reinsertion by suturing and advice not to perform the repair of the posterior wall because it fail to stabilize the pelvis. In a group of six soccer players, Williams and Foster [22] reported tears of the major oblique muscle that were successfully treated with suture; Lacroix et al. [23] described the same lesion in 11 professional hockey players, who responded favorably to the repair with suture complemented with ablation of the ilioinguinal nerve.
123
Hernia
Hyde, cited as a personal communication by Hackney, [21] solved more than 500 cases with the reinsertion of the conjoint tendon by suture and alluded to the condition as ‘‘chronic conjoint tendon syndrome.’’ Some articles published by orthopedists [2, 16, 24, 25] limit the causes of pubalgia to osseous, ligamental, muscular and articular processes without taking into account the hernias, to which they devote paragraphs that are brief and lacking in rigor. As an example, we can quote the work by Meyers et al. [6] stating ‘‘… in the vast majority of patients in this report, pain was near the pubis, not in the internal inguinal ring where you can find a hidden hernia,’’ which reveals the ignorance about the retroinguinal or direct hernias. The same author published in 2008 [7] the experience with 8490 patients treated throughout 20 years without finding an inguinal hernia in any of them, which could be explained, at least in part, by the lack of ultrasound studies and his favoritism for MRI. The analysis of the literature allows identifying several reasons that justify the existence of such dissimilar positions, namely: 1.
2.
3.
4.
5.
Methodological difficulties: the articles present a low level of evidence [1, 26], mainly attributable to the difficulty to randomize treatments in groups of high performance athletes. The heterogeneity of the methods hinders the elaboration of meta-analyses [26, 27] and transforms the non-systematic reviews [11, 28] in extensive lists of definitions, pathophysiological theories and surgical techniques that achieve, invariably and suspiciously, excellent results. Expertise bias: the physical examination is more likely to detect incipient hernias if performed by surgeons, and tendinous or articular lesions if conducted by orthopedists. Competition for the ‘‘territory’’: the differences observed in surgeons or orthopedist studies led us to suspect a struggle between both groups for the ‘‘domain’’ of the athlete’s pubalgias. Partial and univocal approaches: vouched for by the mentioned factors, they should be replaced by multidisciplinary approaches capable of understanding the complex functional and pathophysiological processes of the locomotor system at the groin level. Absence of typical pathological lesions and of anthropometric patterns in the inguino-pubic area: reasons for which the alterations described as ‘‘disinsertions’’ of the rectus abdominis, ‘‘tears’’ or ‘‘weaknesses’’ of the fascia transversalis or ‘‘widening’’ of the inguinal rings entail an inevitable burden of subjectivity.
The lack of full understanding of the pathophysiology of this process is reflected in the multiple speculations about
123
the injured anatomical element, to the point that all the muscles, tendons, bones and articulations of the inguinopubic region have been identified as being the causes of pain. Nowadays, there seems to be a consensus about an imbalance between the divergent forces that the muscles of thigh (adductors) and the lower abdomen (anterior rectus, obliques) exert on the pubis, a phenomenon called ‘‘muscle imbalance syndrome of the groin ‘‘ by Morales-Conde et al. [8] or ‘‘inguino-pubic pain syndrome’’ by Campanelli [1], although Hackney [21] had already recognized this mechanism as the probable origin of hernias and other conditions such as ‘‘osteitis pubis’’ and ‘‘medium adductor tendinitis’’, also common in athletes and with some clinical similarity. According to this hypothesis, the excessive traction exerted by hypertrophic muscular bodies on their insertion points and neighboring ligaments would be capable to cause osseous, muscular and tendinous lesions in the inguinal and pubic areas, whose nature and magnitude is variable and would depend on individual factors. Hemingway et al. [18] studied the strength of the muscle groups involved in the pelvic support in 16 athletes with groin pain compared to a control group. The oblique muscles of the affected side were the most debilitated and also the ones that showed a better recovery after the open mesh hernioplasty followed by rehabilitation exercises. Once the existence of lesions of the posterior wall of the groin is recognized, we should ask whether these may be considered true hernias or they constitute an entity different from those being present in the general population. The absence or poor development of peritoneal sac in most cases allows us to question its inclusion among the groin hernias, although it is possible that the parietal weakness may precede the peritoneal protrusion, for which reason they might be considered incipient or developing hernias. Other data against it are the constant presence of intense pain, the high rate of bilateral involvement and the prevalence of the ‘‘direct’’ type over the ‘‘indirect’’ type, contrary to what is observed in non-athletes. Different mechanisms of production could explain the differences between the lesions observed in athlete’s hernias and those affecting the general population. a—The study of the pathophysiology of the latter, has identified predisposing and triggering factors; among the former, the high insertion of the minor oblique and the transverse muscle, which determines an area of fascia transversalis devoid of muscle (William Hessert triangle), the persistence of the processus vaginalis and certain disorders (congenital or related to aging and smoking) in the constitution of collagen making up the tissue matrix.
Hernia
The drive on the weak area of the groin has been recognized as the triggering factor that results from the rising intra-abdominal pressure, typical of chronic obstructive pulmonary disease, constipation or urinary outflow obstruction. b—The effect of the acquired abnormalities of collagen in the hernias that afflict athletes could be discarded, given the youth and the low rate of smoking in this population in which neither are observed pathologies capable of increasing intra-abdominal pressure, although this may occur briefly during the act of kicking the ball. Instead, the presence of altered movement patterns during running has been postulated as predisposing, increases the likelihood of injuries. Current research has suggested that test assessing balance, strength, and range of motion simultaneously as called functional movement screen (FMS) may identify such patterns and to correct them, thus reducing the possibility of injuries. [29–31]. In addition to this factor, and perhaps most influential, the muscle forces to which the inguino-pubic area is subjected during the zigzagging in speed or upon violently pushing the ball, would act like real triggers capable of damaging the abdominal wall. According to the theory of muscle imbalance in the groin, a non-established ratio of inguinal hernias would be generated by divergent or traction forces rather than by push or drive, which could explain the high rate of bilateral involvement and the relative high frequency of direct hernias or ‘‘weaknesses in the posterior wall’’ found in our series and others [12, 19, 32]. While the drive only exerts its effect on the abdominal wall, traction does it on all the muscular and tendinous elements taking insertion into the ilio and ischio-pubic branches as well as in the pubic symphysis. This would determine, according to individual factors, the lesion of tendinous, muscular or articular elements associated or not to defects of the posterior wall. In this regard, Ekberg et al. [33] found more than 90 % of multiple injuries in athletes subjected to multidisciplinary diagnostic approach and Albers et al. [34] reported the simultaneous compromise of the posterior wall of the groin and other osseous and tendinous elements in more than 60 % of MRIs performed to a group of 32 athletes. Martens (cited by Hackney) [21] distinguished three types of syndrome according to the location of pain in the external, middle or inner groin areas, promoting the repair of the adductor longus, the posterior wall or the rectus abdominis muscle, respectively. We found 84 ‘‘sport hernias’’ in 769 patients with previous diagnosis of adductor muscle strain (10.92 %) and in 127 (21.52 %) of our patients with ‘‘sport hernias’’ US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy).
A remarkable finding in our study is the high rate of bilateral lesions, especially in professional athletes that could be attributed to the greater intensity of training and competition in this group of patients.
Conclusions It can be concluded that forces operating on the groin in those sports in which the direction and speed of the run is abruptly varied or the ball is kicked may lead to various injuries in the region with exclusive or concurrent compromise of fascias, tendons, muscles and joints. For all this, the athlete’s hernia should be understood as part of a complex of lesions that can involve other elements of the inguino-crural region rather than as a disease entity. The vast majority of muscular and tendon lesions respond to physical therapy and exercises to restore the functional balance of the pelvis; the failure of these treatments may be due to the presence of a concomitant ‘‘sport hernia’’. In our opinion, this term is appropriate since it refers to an inguinal wall weakness that responds to the repair with prosthetic meshes, and at the same time, it points out its particular pathophysiology, different from the acknowledged one for the general population hernias, and the probability of coexistence of osseous, muscular or tendinous lesions. The series presented is not excluded from the limitations of every retrospective study, but reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons to discard osseous, muscular and tendinous pathologies as recommended the recently published ‘‘Consensus Development Conference on endoscopic repair of groin hernias’’. [35] This explains the high frequency of hernias found, expected in patients who passed through the ‘‘filter’’ of orthopedic evaluation without reaching the diagnosis or in patients who do not respond to nonsurgical treatments. We believe that, in the absence of morphological and pathophysiological identity, only a high concordance among the diagnostic and therapeutic instances can ensure a rational approach. Conflict of interest OLS declares no conflict of interest; NN declares no conflict of interest; HAS declares no conflict of interest; DET declares no conflict of interest.
References 1. Campanelli G (2010) Pubic inguinal pain syndrome: the so-called sports hernia. Hernia 14:1–4
123
Hernia 2. Ho¨lmich P (2007) Long-standing groin pain in sports people falls into three primary patterns, a ‘‘clinical entity’’ approach: a prospective study of 207 Patients. Br J Sports Med 41:247–252 3. Kluin J, den Hoed PT, van Linschoten R, Ijzerman JC, van Steensel CJ (2004) Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 32:944–949 4. Lovell G (1995) The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport 27:76–79 5. Polglase AL, Frydman GM, Farmer KC (1991) Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust 155:674–677 6. Meyers WC, Foley DP, Garrett WE, Lohnes JH, PAIN group Mandlebaum BR (2000) Management of severe lower abdominal or inguinal pain in high-performance sports athletes. Am J Med 28:2–8 7. Meyers WC, McKechnie A, Philippon MJ, Horner MA, Zoga AC, Devon ON (2008) Experience with ‘‘sports hernia’’ spanning two decades. Ann Surg 248:656–665 8. Conde Morales (2010) Sportmen hernia: what do we know? Hernia 14:5–15 9. Farber AJ, Wilckens JH (2007) Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg 15:507–514 10. Garvey JFW, Read JW, Turner A (2010) Sportsman hernia: what can we do? Hernia 14:17–25 11. Fricker PA (1997) Management of groin pain in athletes. Br J Sports Med 31:97–101 12. Genitsaris M, Goulimaris I, Sikas N (2004) Laparoscopic repair of groin pain in athletes. Am J Sports Med 32:1238–1242 13. Gilmore OJA (1991) Gilmore’s groin: a ten years experience of groin disruption. Soft Tissue Trauma Sports Med 3:5–7 14. van Veen RN, de Baat P, Heijboer MP, Kazemier G, Punt BJ, Dwarkasing RS, Bonjer HJ, van Eijck CHJ (2007) Successful treatment of chronic endoscopic groin pain in athletes. Surg 21:189–193 15. Diesen DL, Pappas TN (2007) Sports hernias. Adv Surg 41:177–187 16. Fredberg U, Kissmeyer-Nielsen P (1996) The sportsman’s hernia—fact or fiction? Scand J Med Sci Sports 6:201–204 17. Jamadar DA, Jacobson JA, Morag Y, Girish G, Ebrahim F, Gest T, Franz M (2006) Sonography of inguinal region hernias. Am J Radiology 187:185–190 18. Hemingway AE, Herrington L, Blower AL (2003) Changes in muscle strength and pain in response to surgical repair of posterior abdominal wall disruption followed by rehabilitation. Br J Sports Med 37:54–58
123
19. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett WE (1991) Abnormalities in abdominal musculature as to cause of groin pain in athletes. Am J Sports Med 3:239–242 20. Malycha P, Lovell G (1992) Inguinal surgery in athletes with chronic groin pain: the ‘‘sportsman’s hernia’’. Aust NZ J Surg 62:123–125 21. Hackney RG (1993) The sports hernia: a cause of chronic groin pain. Br J Sports Med 27:58–62 22. Williams P, Foster ME (1995) ‘‘Gilmore’s groin’’—or is it? Br J Sports Med 29:206–208 23. Lacroix VJ, Kinnear DG, Mulder DS, Brown RA (1998) Lower abdominal pain syndrome in national hockey league players: a report of 11 cases. Clin J Sport Med 8:5–9 24. Puig PL, Trouve P, Savalli L (2004) pubalgia: from diagnosis to return to the sports field. Readapt Ann Med Phys 47:356–364 25. Renstro¨m P, Peterson L (1980) Groin injuries in athletes. Br J Sports Med 14:30–36 26. Jansen JA, Mens JM, Backx FJ, Kolfschoten N, Stam HJ (2008) Treatment of longstanding groin pain in athletes: a systematic review. Scand J Med Sci Sports 18:263–274 27. Swan KG Jr, Wolcott M (2007) The athletic hernia: a systematic review. Clin Orthop Relat Res 455:78–87 28. LeBlanc KE, LeBlanc KA (2003) Groin pain in athletes. Hernia 7:68–71 29. Cook G, Burton L, Hoogenboom B (2006) Pre-participation screening: the use of essential movements as an assessment of function—part 1. NAJSPT 1:62–72 30. Cook G, Burton L, Hoogenboom B (2006) Pre-participation screening: the use of essential movements as an assessment of function—part 2. NAJSPT 1:132–139 31. Kiesel KB, Plisky P, Butler RJ (2011) Functional movement test scores improve following a standardized off-season intervention program in professional football players. Scand J Med Sci Sports 21:287–292 32. Orchard JW, Read JW, Neophyton J, Garlic D (1998) Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in australian rules footballers. Br J Sports Med 32:134–139 33. Ekberg O, Persson NH, Abrahamsson PA, Westlin NE, Lilja B (1988) Longstanding groin pain in athletes. A multidisciplinary approach. Sports Med 6:56–61 34. Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC (2001) MR findings in athletes with groin injury. Skeletal Radiol 30:270–277 35. Poelman MM, van den Heuvel B, Deelder JD, Abis GSA, Beudeker N, Bittner RR, Campanelli G et al (2013) EAES consensus development conference on endoscopic repair of groin hernias. Surg Endosc. doi:10.1007/s00464-013-3001-9
ORIGINAL ARTICLE
Sports hernias: experience in a sports medicine center O. L. Santilli1 • N. Nardelli1 • H. A. Santilli1 • D. E. Tripoloni2
Received: 10 November 2013 / Accepted: 8 March 2015 Springer-Verlag France 2015
Abstract Purpose Chronic pain of the inguino-crural region or ‘‘pubalgia’’ explains the 0.5–6.2 % of the consultations by athletes. Recently, areas of weakness in the posterior wall called ‘‘sports hernias,’’ have been identified in some of these patients, capable of producing long-standing pain. Several authors use different image methods (CT, MRI, ultrasound) to identify the lesion and various techniques of repair, by open or laparoscopic approaches, have been proposed but there is no evidence about the superiority of one over others due to the difficulty for randomizing these patients. In our experience, diagnosis was based on clinical and ultrasound findings followed by laparoscopic exploration to confirm and repair the injury. The present study aims to assess the performance of our diagnostic and therapeutic management in a series of athletes affected by ‘‘pubalgia’’. Methods 1450 athletes coming from the orthopedic office of a sport medicine center were evaluated. In 590 of them (414 amateur and 176 professionals) sports hernias were diagnosed through physical examination and ultrasound. We performed laparoscopic ‘‘TAPP’’ repair and, thirty days after, an assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. We used the U MannWhitney test for continuous scale variables and the chi-
& O. L. Santilli [email protected] 1
Department of Surgery, Centro de Patologı´a Herniaria, CPH, Cervin˜o Street 4449, 9th floor (1425), Ciudad Auto´noma De Buenos Aires, Argentina
2
Department of Surgery, Sanatorio ‘‘Dr. Julio Me´ndez’’, Ciudad Auto´noma De Buenos Aires, Argentina
square test for dichotomous variables with p \ 0.05 as a level of significance. Results In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, which in 498 of them coincided with areas affected by pain. These findings were confirmed by laparoscopic exploration that also diagnosed associated contralateral (30.1 %) and ipsilateral defects, resulting in a total of 1006 hernias. We found 84 ‘‘sport hernias’’ in 769 patients with previous diagnosis of adductor muscle strain (10.92 %); on the other hand, in 127 (21.52 %) of our patients with ‘‘sport hernias’’ US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy). Compared with the findings of laparoscopy, ultrasound had a sensitivity of 95.42 % and a specificity of 100 %; the positive and negative predictive values were 100 and 99.4 % respectively. No postoperative complications were reported. Only seven patients suffered recurrence of pain (successful rate: 98.81 %); the ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis muscle. Conclusions Our series reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons in order to discard the most common causes of ‘‘pubalgia’’. ‘‘Sports hernias’’ are often associated with adductor muscle strains and other injuries of the groin allowing speculate that these respond to a common mechanism of production. We believe that, considering the difficulty to design randomized trials, only a high coincidence among the diagnostic and therapeutic instances can ensure a rational health care. Keywords Sportsman’s hernia Pubalgia Groin pain Muscle imbalance
123
Hernia
Introduction Chronic pain of the inguino-crural region or ‘‘pubalgia’’ explains the 0.5–6.2 % [1–5] of the consultations carried out by athletes. Historically attributed to osteoarticular, muscular and tendinous processes, in recent years areas of weakness in the posterior wall of the groin called ‘‘sports hernias’’, have been identified in some of these patients, capable of causing pain, which although it does not interfere with everyday life, it affects their performance during training and competition, for which reason it may put at risk the continuity of the sport career [6–8]. This injury has been recently defined as ‘‘an occult hernia caused by weakness or tear of the posterior inguinal wall, without a clinical recognizable hernia…’’ [9]; the absence of bulky peritoneal protrusion makes the diagnosis by physical examination extremely difficult requiring the use of studies by images that must be performed and interpreted by operators with dedication and experience in the exploration of the groin’s soft tissues. Under these conditions, both ultrasound (US) and magnetic resonance imaging (MRI) are useful, but the former offers the advantage of dynamic exploration; MRI allows the diagnosis of bone, articular, or tendinous lesions that should be considered in the differential diagnosis, but the static nature of scanning reduces its performance to identify little defects or protrusions of the posterior wall of the groin, even though some techniques of rapid exposure during the Valsalva maneuver have been described [10]. As regards the treatment, it have been published excellent results with open and laparoscopic techniques [11–14], but the latter might add the possibility of finding areas of weakness not identified by the imaging studies and proceed to its repair. Several authors [6, 7, 15, 16] have questioned the importance (and even the existence) of this type of hernias, giving rise to a controversy that still lingers. Due to the difficulty in designing prospective studies including professional athletes we believe that the only way to approach the truth is through a strong correlation between diagnostic and therapeutic instances. The present study aims to assess the performance of a diagnostic-therapeutic management based on physical examination and ultrasound followed by laparoscopic exploration and repair of the inguinal region in a consecutive batch of athletes affected by long-term pubalgia.
Patients and methods Between January 2004 and July 2011 1450 athletes affected by pubalgia were evaluated, coming from an orthopedic office of a center specialized in sports medicine.
123
All of them had presented long-standing pain without clear evidence of inguinal or femoral hernia. Before the authors’ intervention MRI had been performed diagnosing some osteoarticular or tendinous processes in 769 cases (753 adductor muscle strains, 16 osteitis pubis). These entities were considered ‘‘a priori’’ as responsible for pubalgia so started physiotherapy. However, the assessment for a surgeon was required to rule out an associated sportman’s hernia or because of lack of response to the treatment. In the remaining 681 patients no cause of pain had been diagnosed. All patient underwent clinical and ultrasonography assessment: we detected findings consistent with ‘‘sport hernia’’ in 84 patients from the group of osteitis and tendinitis and 506 in the group without apparent cause for pain, for which reason they underwent laparoscopic exploration. The remaining patients continued with physical therapy and a structured exercise program to stabilize the pelvis under supervision of physiotherapist and orthopedist. Population characteristics The group of ‘‘sports hernias’’ consisted of 539 men and 51 women, with a mean age of 33.91 years (SD = 11.33); 414 (70.2 %) of them were amateur and 176 (29.8 %) professionals (112 soccer players, 38 rugby players, 13 tennis players, 5 basketball players, 3 cyclists, 3 gymnasts, and 2 handball players). Conservative treatments were tried out (in 529 cases physical therapy and in 40 physical therapy plus infiltration with local anesthetics and corticosteroids), without obtaining response or with transient improvement followed by recurrence of pain upon restarting sports activity. Diagnosis Patients were asked about the characteristics of pain, its duration and relation to the efforts. Physical examination included digital palpation of the projection of inguinal rings by invagination of the scrotal pouch in men and direct palpation of the inguinal region in women. The appearance of pain with the same characteristics of that triggered by the exercise made us suspect the presence of sport hernias, for which reason ultrasound was indicated for confirmation. The evaluation was performed by operators with special interest in musculoskeletal imaging of the groin using ‘‘Xario’’ (Toshiba), ‘‘Nemio’’ (Toshiba) and ‘‘HDI 5000’’ (Philips) US unit equipped with 5–12 MHz multifrequency transducers.
Hernia
The exploration technique is the one described by Jamadar et al. [17]: the boundaries of the Hesselbach’s triangle (inferior epigastric artery, outer edge of the rectus abdominis muscle and the inguinal ligament) next to the pubic tubercle are the landmarks to be identified. For which purpose, the transducer is placed on the axial plane at the level of the navel, on the lateral edge of the rectus abdominis. Once the inferior epigastric artery is identified, it is followed in the cranio-caudal direction up to its origin in the external iliac artery as a reference point for defining the inner edge of the deep inguinal ring. Immediately below is located the inguinal ligament, which is identified as an echogenic band when slightly rotating the transducer abandoning the strict axial plane and orienting it toward the pubic tubercle. In a lateral and superior position to this osseous relief is identified the superficial inguinal ring. Once the anatomical repairs are found, the patient is examined at rest and with a gradual increase of the abdominal pressure, which allows to identify fatty protrusions, small pouches or expansions of the deep hole and/or the Hesselbach’s area, the exploration was bilateral in all patients. Surgical technique The laparoscopic ‘‘TAPP’’ approach was used in all cases under general anesthesia through a 10-mm umbilical port and two ports of 5 mm on the flanks. After the insufflation, the anterior abdominal wall was explored and then we proceeded to the opening of the parietal peritoneum of the affected side/s and to the invagination or resection of the sac or lipoma when they were found. Repair was performed with a 15 cm by 13 cm polypropylene mesh (Surgipro) fixed with tacks (Protack); the parietal peritoneum was closed with polyglactin 910 (Vicryl) 2/0 and the aponeurosis in the umbilical wound with polyglactin 910 (Vicryl ) 1. Postoperative stage and rehabilitation Ketorolac (30 mg intravenously) was administered at the end of the procedure and intake of liquids was allowed 2 h later; then, a general diet was started and a 20 mg-dose of ketorolac was administered sublingually. Early discharge was promoted: the patients who underwent surgery in the morning were released during the afternoon and those patients who underwent surgery after midday were released during the following morning. Seven days later, an office contact was performed and, after confirming a favorable evolution, some isometric exercises without overload (jogging, cycling), with increasing intensity, were started under the supervision of a physiotherapist. Then, different techniques of muscular
strengthening were developed to resume the specific sport activity. In professional athletes physical activity was initiated within the first 3 days following a standardized protocol. Thirty days after surgery, a new assessment was performed to determine the evolution of pain and the degree of physical activity as a sign of the functional outcome. Statistical analysis We used the U Mann-Whitney test for continuous scale variables and the Chi-square test for dichotomous variables with p \ 0.05 as a level of significance; calculations were performed using the SPSS package for Windows, version 17.0 (Chicago, Illinois, USA).
Results All patients reported pain of more than 6 months of evolution (median 12; interquartile period = 9–15); in 116 cases (19.6 %) of more than 1 year and in 70 (11.8 %) of more than 2 years, with improvement during rest or physiotherapy treatment followed by recurrences at the restart of physical activity. 217 Patients reported pain on both sides of the midline In all cases, palpation of the groin triggered sharp pain limited to an area equivalent to the finger pad, without radiation and with identical characteristics to that caused by exercise. No subject described the pain as neuralgia and in none of the physical explorations muscular hypotrophies, paresthesias, or Tinel’s sign were observed. In 573 patients ultrasound examination detected some protrusion of the posterior wall with normal or minimally dilated inguinal rings, in which 498 of them coincided with areas affected by pain. In 127 patients, oedema of the adductor longus tendon was identified; this finding has not changed, in most cases, the behavior adopted regarding ‘‘sport hernia’’ but in seven of them we added a partial tenotomy by anterior approach (suggested by the orthopedic surgeon) because of the chronicity and lack of response to prolonged physiotherapy. The 17 patients in which ultrasound failed to detect a parietal defect underwent to laparoscopic exploration due to the high suspicion of ‘‘sport hernia’’. All ultrasound findings were confirmed by the laparoscopic exploration that also diagnosed associated contralateral and ipsilateral defects (mixed hernias), resulting in a total of 1006 hernias; 178 patients presented bilateral defects (all of them direct hernias) of which 133 were diagnosed preoperatively. We usually found the preperitoneal fatty tissue protruding through small tears of the posterior wall (Figs. 1 and 2); it
123
Hernia
(15.76 %), up to 24 months in 186 (31.52 %) and up to 36 months in 299 patients (50.67 %); 12 patients (2.03 %) were lost to follow-up during the second and third years after the operation. Seven patients suffered recurrence of pain. The ultrasound ruled out hernia recurrence, but in three cases it diagnosed tendinitis of the rectus abdominis that was successfully treated with physical therapy and a structured exercise program. The remaining patients continue with their sports activities without pain or functional limitation. Comparison of the relevant variables in the amateur and professional athletes (Table 1) revealed a higher bilaterality rate in the last group. Fig. 1 Laparoscopic view of the right inguinal region: descended the peritoneum, we found a lump of preperitoneal fat near the pubis (arrow)
Fig. 2 Laparoscopic view of the right inguinal region: after removing the fatty tissue, a tear of the posterior wall (arrow) is observed
rarely protruded through the deep inguinal ring and never was observed the intestinal contents coming out freely through the inguinal canal. In all negative ultrasound’s cases, the defect was direct. Compared with findings of laparoscopy, ultrasound had a sensitivity of 95.42 % and a specificity of 100 %. The positive and negative predictive value was 100 and 99.4 %, respectively. The diagnostic process is summarized in Fig. 3. No intraoperative incidents or postoperative complications were reported. 583 patients resumed sport activity within 30 days of the procedure and only seven prolonged the period of rest, in all cases due to associated tendinopathies that responded to physical therapy. Postoperative contact (personal and telephone interviews) was maintained up to 12 months in 93 patients
123
Discussion Already in the 1970s, Norris [18] had recognized the deficiency of the posterior wall of the abdomen as a cause of inguino-pubic pain in athletes. In 1991 Taylor [19] coined the term ‘‘pubalgia’’ attributing the pain to a tear of the anterior rectus pubic insertion; the same year, Gilmore [13] described a condition characterized by pain and increase of tension at the inguinal and pubic level accompanied by dilatation of the superficial inguinal ring, which he termed ‘‘groin disruption’’, a term that refers to the idea of tearing. According to him, the damaged elements are the transversalis fascia and the conjoint tendon, which are separated from the inguinal ligament; the repair involves the plication of the fascia and the conjoint tendon with absorbable sutures and its suture to the inguinal ligament with nylon. In 1992, Malycha and Lovell [20] introduced the term ‘‘sports hernia’’ and in 1993 Hackney [21] described, in 15 athletes members of the British armed forces, lesions similar to direct and indirect hernias to which he applied the Gilmore technique achieving 87 % of success. Since then, a great variety of injuries (direct or indirect hernias, tears of the transversalis fascia or the oblique aponeurosis, etc.) have been published under this denomination, subjected to no less diverse repair techniques (with sutures, with prosthetic meshes, through an open or laparoscopic, ‘‘TAPP’’ or ‘‘TEP’’). Among recently published series, van Veen et al. [14] found hernias in all patients (55) that they explored via endoscopic preperitoneal TEP, while Kluin [3] identified 14 in 18 athletes approached by TAPP and TEP techniques, including 4 femoral hernias and one obturator hernia among them. Genitsaris et al. [12] performed bilateral TAPP repair to a series of 131 patients who had affected both groins in more than 30 % of cases.
Hernia Fig. 3 ‘‘Sports hernia’’: diagnostic management
1450 paents from orthopedic office Clinical assessment by ortophedist & MRI
769 tendinis, osteis pubis
681 no diagnosis
Clinical assessment by surgeon & US
73 "sports hernias"
11 suspected "sports hernias"
6 suspected "sports hernias"
500 "sports hernias"
Laparoscopic exploraon
1006 "sports hernias"
768 direct (178 bilateral)
Table 1 Comparison of professional and amateur athletes
221 indirect
17 mixed
Professionals (n = 176)
Amateurs (n = 414)
p value
Age (mean, SD)
33.69 (11.679)
34.43 (10.486)
0.247
Female/male
17/159
34/380
0.567
Bilaterality (%)
87 (49.4)
91 (21.9)
0.000
Other lesions (%)
34 (19.3)
93 (22.4)
0.395
SD standard deviation
No papers have been published that allow physicians to select from the above techniques: the Polglase study [5], the only randomized and controlled trial that was previous to the development of laparoscopic techniques, demonstrated the superiority of open repair over the physical therapy. However, other authors have denied the existence of sportmen´s hernias as being responsible for the chronic inguino-pubic pain. Among them, Diesen and Pappas [15] claim that the lesion affects the insertion of the abdomini
rectus muscle, for which reason they propose its reinsertion by suturing and advice not to perform the repair of the posterior wall because it fail to stabilize the pelvis. In a group of six soccer players, Williams and Foster [22] reported tears of the major oblique muscle that were successfully treated with suture; Lacroix et al. [23] described the same lesion in 11 professional hockey players, who responded favorably to the repair with suture complemented with ablation of the ilioinguinal nerve.
123
Hernia
Hyde, cited as a personal communication by Hackney, [21] solved more than 500 cases with the reinsertion of the conjoint tendon by suture and alluded to the condition as ‘‘chronic conjoint tendon syndrome.’’ Some articles published by orthopedists [2, 16, 24, 25] limit the causes of pubalgia to osseous, ligamental, muscular and articular processes without taking into account the hernias, to which they devote paragraphs that are brief and lacking in rigor. As an example, we can quote the work by Meyers et al. [6] stating ‘‘… in the vast majority of patients in this report, pain was near the pubis, not in the internal inguinal ring where you can find a hidden hernia,’’ which reveals the ignorance about the retroinguinal or direct hernias. The same author published in 2008 [7] the experience with 8490 patients treated throughout 20 years without finding an inguinal hernia in any of them, which could be explained, at least in part, by the lack of ultrasound studies and his favoritism for MRI. The analysis of the literature allows identifying several reasons that justify the existence of such dissimilar positions, namely: 1.
2.
3.
4.
5.
Methodological difficulties: the articles present a low level of evidence [1, 26], mainly attributable to the difficulty to randomize treatments in groups of high performance athletes. The heterogeneity of the methods hinders the elaboration of meta-analyses [26, 27] and transforms the non-systematic reviews [11, 28] in extensive lists of definitions, pathophysiological theories and surgical techniques that achieve, invariably and suspiciously, excellent results. Expertise bias: the physical examination is more likely to detect incipient hernias if performed by surgeons, and tendinous or articular lesions if conducted by orthopedists. Competition for the ‘‘territory’’: the differences observed in surgeons or orthopedist studies led us to suspect a struggle between both groups for the ‘‘domain’’ of the athlete’s pubalgias. Partial and univocal approaches: vouched for by the mentioned factors, they should be replaced by multidisciplinary approaches capable of understanding the complex functional and pathophysiological processes of the locomotor system at the groin level. Absence of typical pathological lesions and of anthropometric patterns in the inguino-pubic area: reasons for which the alterations described as ‘‘disinsertions’’ of the rectus abdominis, ‘‘tears’’ or ‘‘weaknesses’’ of the fascia transversalis or ‘‘widening’’ of the inguinal rings entail an inevitable burden of subjectivity.
The lack of full understanding of the pathophysiology of this process is reflected in the multiple speculations about
123
the injured anatomical element, to the point that all the muscles, tendons, bones and articulations of the inguinopubic region have been identified as being the causes of pain. Nowadays, there seems to be a consensus about an imbalance between the divergent forces that the muscles of thigh (adductors) and the lower abdomen (anterior rectus, obliques) exert on the pubis, a phenomenon called ‘‘muscle imbalance syndrome of the groin ‘‘ by Morales-Conde et al. [8] or ‘‘inguino-pubic pain syndrome’’ by Campanelli [1], although Hackney [21] had already recognized this mechanism as the probable origin of hernias and other conditions such as ‘‘osteitis pubis’’ and ‘‘medium adductor tendinitis’’, also common in athletes and with some clinical similarity. According to this hypothesis, the excessive traction exerted by hypertrophic muscular bodies on their insertion points and neighboring ligaments would be capable to cause osseous, muscular and tendinous lesions in the inguinal and pubic areas, whose nature and magnitude is variable and would depend on individual factors. Hemingway et al. [18] studied the strength of the muscle groups involved in the pelvic support in 16 athletes with groin pain compared to a control group. The oblique muscles of the affected side were the most debilitated and also the ones that showed a better recovery after the open mesh hernioplasty followed by rehabilitation exercises. Once the existence of lesions of the posterior wall of the groin is recognized, we should ask whether these may be considered true hernias or they constitute an entity different from those being present in the general population. The absence or poor development of peritoneal sac in most cases allows us to question its inclusion among the groin hernias, although it is possible that the parietal weakness may precede the peritoneal protrusion, for which reason they might be considered incipient or developing hernias. Other data against it are the constant presence of intense pain, the high rate of bilateral involvement and the prevalence of the ‘‘direct’’ type over the ‘‘indirect’’ type, contrary to what is observed in non-athletes. Different mechanisms of production could explain the differences between the lesions observed in athlete’s hernias and those affecting the general population. a—The study of the pathophysiology of the latter, has identified predisposing and triggering factors; among the former, the high insertion of the minor oblique and the transverse muscle, which determines an area of fascia transversalis devoid of muscle (William Hessert triangle), the persistence of the processus vaginalis and certain disorders (congenital or related to aging and smoking) in the constitution of collagen making up the tissue matrix.
Hernia
The drive on the weak area of the groin has been recognized as the triggering factor that results from the rising intra-abdominal pressure, typical of chronic obstructive pulmonary disease, constipation or urinary outflow obstruction. b—The effect of the acquired abnormalities of collagen in the hernias that afflict athletes could be discarded, given the youth and the low rate of smoking in this population in which neither are observed pathologies capable of increasing intra-abdominal pressure, although this may occur briefly during the act of kicking the ball. Instead, the presence of altered movement patterns during running has been postulated as predisposing, increases the likelihood of injuries. Current research has suggested that test assessing balance, strength, and range of motion simultaneously as called functional movement screen (FMS) may identify such patterns and to correct them, thus reducing the possibility of injuries. [29–31]. In addition to this factor, and perhaps most influential, the muscle forces to which the inguino-pubic area is subjected during the zigzagging in speed or upon violently pushing the ball, would act like real triggers capable of damaging the abdominal wall. According to the theory of muscle imbalance in the groin, a non-established ratio of inguinal hernias would be generated by divergent or traction forces rather than by push or drive, which could explain the high rate of bilateral involvement and the relative high frequency of direct hernias or ‘‘weaknesses in the posterior wall’’ found in our series and others [12, 19, 32]. While the drive only exerts its effect on the abdominal wall, traction does it on all the muscular and tendinous elements taking insertion into the ilio and ischio-pubic branches as well as in the pubic symphysis. This would determine, according to individual factors, the lesion of tendinous, muscular or articular elements associated or not to defects of the posterior wall. In this regard, Ekberg et al. [33] found more than 90 % of multiple injuries in athletes subjected to multidisciplinary diagnostic approach and Albers et al. [34] reported the simultaneous compromise of the posterior wall of the groin and other osseous and tendinous elements in more than 60 % of MRIs performed to a group of 32 athletes. Martens (cited by Hackney) [21] distinguished three types of syndrome according to the location of pain in the external, middle or inner groin areas, promoting the repair of the adductor longus, the posterior wall or the rectus abdominis muscle, respectively. We found 84 ‘‘sport hernias’’ in 769 patients with previous diagnosis of adductor muscle strain (10.92 %) and in 127 (21.52 %) of our patients with ‘‘sport hernias’’ US detected concomitant injuries of the adductor longus tendon, 7 of which merited additional surgical maneuvers (partial tenotomy).
A remarkable finding in our study is the high rate of bilateral lesions, especially in professional athletes that could be attributed to the greater intensity of training and competition in this group of patients.
Conclusions It can be concluded that forces operating on the groin in those sports in which the direction and speed of the run is abruptly varied or the ball is kicked may lead to various injuries in the region with exclusive or concurrent compromise of fascias, tendons, muscles and joints. For all this, the athlete’s hernia should be understood as part of a complex of lesions that can involve other elements of the inguino-crural region rather than as a disease entity. The vast majority of muscular and tendon lesions respond to physical therapy and exercises to restore the functional balance of the pelvis; the failure of these treatments may be due to the presence of a concomitant ‘‘sport hernia’’. In our opinion, this term is appropriate since it refers to an inguinal wall weakness that responds to the repair with prosthetic meshes, and at the same time, it points out its particular pathophysiology, different from the acknowledged one for the general population hernias, and the probability of coexistence of osseous, muscular or tendinous lesions. The series presented is not excluded from the limitations of every retrospective study, but reflects the multidisciplinary approach performed in a sports medicine center in which patients are initially evaluated by orthopedic surgeons to discard osseous, muscular and tendinous pathologies as recommended the recently published ‘‘Consensus Development Conference on endoscopic repair of groin hernias’’. [35] This explains the high frequency of hernias found, expected in patients who passed through the ‘‘filter’’ of orthopedic evaluation without reaching the diagnosis or in patients who do not respond to nonsurgical treatments. We believe that, in the absence of morphological and pathophysiological identity, only a high concordance among the diagnostic and therapeutic instances can ensure a rational approach. Conflict of interest OLS declares no conflict of interest; NN declares no conflict of interest; HAS declares no conflict of interest; DET declares no conflict of interest.
References 1. Campanelli G (2010) Pubic inguinal pain syndrome: the so-called sports hernia. Hernia 14:1–4
123
Hernia 2. Ho¨lmich P (2007) Long-standing groin pain in sports people falls into three primary patterns, a ‘‘clinical entity’’ approach: a prospective study of 207 Patients. Br J Sports Med 41:247–252 3. Kluin J, den Hoed PT, van Linschoten R, Ijzerman JC, van Steensel CJ (2004) Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 32:944–949 4. Lovell G (1995) The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport 27:76–79 5. Polglase AL, Frydman GM, Farmer KC (1991) Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust 155:674–677 6. Meyers WC, Foley DP, Garrett WE, Lohnes JH, PAIN group Mandlebaum BR (2000) Management of severe lower abdominal or inguinal pain in high-performance sports athletes. Am J Med 28:2–8 7. Meyers WC, McKechnie A, Philippon MJ, Horner MA, Zoga AC, Devon ON (2008) Experience with ‘‘sports hernia’’ spanning two decades. Ann Surg 248:656–665 8. Conde Morales (2010) Sportmen hernia: what do we know? Hernia 14:5–15 9. Farber AJ, Wilckens JH (2007) Sports hernia: diagnosis and therapeutic approach. J Am Acad Orthop Surg 15:507–514 10. Garvey JFW, Read JW, Turner A (2010) Sportsman hernia: what can we do? Hernia 14:17–25 11. Fricker PA (1997) Management of groin pain in athletes. Br J Sports Med 31:97–101 12. Genitsaris M, Goulimaris I, Sikas N (2004) Laparoscopic repair of groin pain in athletes. Am J Sports Med 32:1238–1242 13. Gilmore OJA (1991) Gilmore’s groin: a ten years experience of groin disruption. Soft Tissue Trauma Sports Med 3:5–7 14. van Veen RN, de Baat P, Heijboer MP, Kazemier G, Punt BJ, Dwarkasing RS, Bonjer HJ, van Eijck CHJ (2007) Successful treatment of chronic endoscopic groin pain in athletes. Surg 21:189–193 15. Diesen DL, Pappas TN (2007) Sports hernias. Adv Surg 41:177–187 16. Fredberg U, Kissmeyer-Nielsen P (1996) The sportsman’s hernia—fact or fiction? Scand J Med Sci Sports 6:201–204 17. Jamadar DA, Jacobson JA, Morag Y, Girish G, Ebrahim F, Gest T, Franz M (2006) Sonography of inguinal region hernias. Am J Radiology 187:185–190 18. Hemingway AE, Herrington L, Blower AL (2003) Changes in muscle strength and pain in response to surgical repair of posterior abdominal wall disruption followed by rehabilitation. Br J Sports Med 37:54–58
123
19. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett WE (1991) Abnormalities in abdominal musculature as to cause of groin pain in athletes. Am J Sports Med 3:239–242 20. Malycha P, Lovell G (1992) Inguinal surgery in athletes with chronic groin pain: the ‘‘sportsman’s hernia’’. Aust NZ J Surg 62:123–125 21. Hackney RG (1993) The sports hernia: a cause of chronic groin pain. Br J Sports Med 27:58–62 22. Williams P, Foster ME (1995) ‘‘Gilmore’s groin’’—or is it? Br J Sports Med 29:206–208 23. Lacroix VJ, Kinnear DG, Mulder DS, Brown RA (1998) Lower abdominal pain syndrome in national hockey league players: a report of 11 cases. Clin J Sport Med 8:5–9 24. Puig PL, Trouve P, Savalli L (2004) pubalgia: from diagnosis to return to the sports field. Readapt Ann Med Phys 47:356–364 25. Renstro¨m P, Peterson L (1980) Groin injuries in athletes. Br J Sports Med 14:30–36 26. Jansen JA, Mens JM, Backx FJ, Kolfschoten N, Stam HJ (2008) Treatment of longstanding groin pain in athletes: a systematic review. Scand J Med Sci Sports 18:263–274 27. Swan KG Jr, Wolcott M (2007) The athletic hernia: a systematic review. Clin Orthop Relat Res 455:78–87 28. LeBlanc KE, LeBlanc KA (2003) Groin pain in athletes. Hernia 7:68–71 29. Cook G, Burton L, Hoogenboom B (2006) Pre-participation screening: the use of essential movements as an assessment of function—part 1. NAJSPT 1:62–72 30. Cook G, Burton L, Hoogenboom B (2006) Pre-participation screening: the use of essential movements as an assessment of function—part 2. NAJSPT 1:132–139 31. Kiesel KB, Plisky P, Butler RJ (2011) Functional movement test scores improve following a standardized off-season intervention program in professional football players. Scand J Med Sci Sports 21:287–292 32. Orchard JW, Read JW, Neophyton J, Garlic D (1998) Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in australian rules footballers. Br J Sports Med 32:134–139 33. Ekberg O, Persson NH, Abrahamsson PA, Westlin NE, Lilja B (1988) Longstanding groin pain in athletes. A multidisciplinary approach. Sports Med 6:56–61 34. Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC (2001) MR findings in athletes with groin injury. Skeletal Radiol 30:270–277 35. Poelman MM, van den Heuvel B, Deelder JD, Abis GSA, Beudeker N, Bittner RR, Campanelli G et al (2013) EAES consensus development conference on endoscopic repair of groin hernias. Surg Endosc. doi:10.1007/s00464-013-3001-9
