Sports Hernia (Sportsman's Groin)
Groin pain in sportsmen presents a diagnostic challenge. Common causes of groin pain include: adductor or rectus abdominis musculotendinous strains; inflammation of pelvis where to the two halves of the pelvis meet at the front in the midline and where there may be partial prolapse of the intervening fibrocartilaginous disc with associated bone degeneration either side (osteitis pubis); disruption of the inguinal canal with tearing of the superficial inguinal ring and thinning of the posterior wall of the canal (footballer’s hernia); and entrapment of groin nerves.
Diseases affecting back, hip and pelvis joints may also present with groin pain, as may fractures of the pelvis and thigh bone. Pain may also be referred from diseases affecting the pelvic or perineal organs such as the prostate.
What are the signs and symptoms of sports hernias / sportsman’s groin and its investigation?
Onset of groin pain is commonly insidious and the sportsman may achieve only 70% of his normal training or playing potential. Despite several weeks’ of rest, players find that their symptoms generally recur on resumption of training. An athlete or player with injury to adductor or rectus muscles can usually pinpoint the source of the pain, whereas inguinal canal disruption and osteitis pubis give rise to more diffuse symptoms affecting the lower abdominal wall, groin and perineum. Entrapment of nerves causes pain in the distribution of the relevant nerve (ilioinguinal, genitofemoral and obturator nerves).
Examination assesses both local and general factors including gait, back, hip and pelvic movements. Your specialist should examine the groin carefully for tenderness of the superficial inguinal ring and a cough impulse on the posterior wall of the inguinal canal to exclude a footballer’s hernia.
X-rays of pelvis, hips and lower spine can identify pathology which may give rise to groin pain. MRI and ultrasound scans can identify musculotendinous injuries. Diagnostic laparoscopy can identify occult groin hernias. Nerve entrapment syndromes may be diagnosed by injecting local anaesthesia into specific areas to abolish pain and therefore identify the offending nerve.
How is the sportsman’s groin treated?
Management of the different conditions causing sportsmen’s groin pain includes balanced muscle strengthening and stretching exercises, in conjunction with improvement of flexibility in the lumbar spine and hip joints and stabilisation of the pelvis. Any abnormality identified on gait analysis should be corrected appropriately. A sportsmen’s training program should be reviewed to minimise any form of repetitive strain that may aggravate shearing stresses across the pelvis. An appropriate balance must be achieved between work rate and the structured rest built into the training program.
Musculotendinous tears to the adductors and rectus muscle groups can be managed conservatively with the help of physiotherapy. An injection of local anaesthetic with corticosteroid may be useful, but some athletes with long-standing injuries occasionally require adductor tendon release. Osteitis pubis is the most difficult of these conditions to treat but again a combination of anti-inflammatory drugs and local injection of local anaesthetic with corticosteroid eases discomfort and may aid recovery. Those sportsmen who have disruption of the inguinal canal will require surgery to repair the defect. As these injuries are often bilateral, reflecting the nature of the shearing forces affecting the pelvis, the laparoscopic approach is favoured17. Entrapment syndromes are treated surgically by decompressing the affected nerve.
What is the realistic return to sports activities?
After operation, the sportsman requires a rehabilitation program to regain fitness and skill. There is always a temptation and pressure to allow the professional athlete or player back to ‘work’ too soon. This should be resisted until he is entirely symptom free, fully fit, has rwegained the expected skills and all causative factors have been eliminated.