Top athletes can fall prey to the elusive 'sportsman's hernia'

Credit: Robert Cianflone/Allsport
Ask almost any athlete about groin pain and they immediately think of a strained (pulled) groin muscle. Groin pain is pretty common in soccer, where up to one in four players has had some type of groin injury.

You also occasionally will hear about some professional athlete sidelined for weeks with a groin injury that sounds more serious than a strained muscle. And it is "sportsman's hernia" is a curious injury confined to certain athletes that can keep them out for weeks and lead to surgery and lengthy recovery.

Soccer, ice hockey, tennis and certain football players (like quarterbacks and defensive backs) are among the targets for this injury. There is pain during repetitive twisting and turning at speed. A single incidence is rarely mentioned as the cause of the injury. Whats happened is some tearing and inflammation of tissue very low in the abdomen near the inguinal canal, the traditional location for a hernia in a male.

Although very rare, this also can happen to females because ligaments holding reproductive organs in place attach to the abdominal wall in roughly the same area as the canal.

Usually, the doctor will examine for evidence of a hernia with the typical probing through the scrotum and a thorough series of questions about the pain. The pain is usually described as being of insidious onset, near the inguinal canal, that may radiate to the testicles or down the thigh, is aggravated by sharp movements, resisted sit-ups, coughing or sneezing.

The pain may go away with days or weeks of rest, but returns when they return to activity. A traditional hernia shows a visible bulge in the lower abdomen. Here, there is no bulge, just complaints of pain. Physicians unfamiliar with the injury will explore many diagnoses such as osteitis pubis, adductor tendonopathy, stress fracture of the pubic rami, and ilioinguinal or obturator neuropathies.

There is no definitive test for the sportsmans hernia (a.k.a. athletic pubalgia, Gilmores Groin) and no X-ray image that will prove the diagnosis. A herniography (an imaging method to detect a hernia) is not helpful in making a diagnosis and is not used by knowledgeable physicians.

So, if the player doesnt know how or when the nebulous pain started and the doctor is not real sure what diagnosis to make, treatment can be a challenge. Conservative methods (rest, stretching, strengthening) are a 50-50 shot. Some massage techniques have been tried with limited success.

Once all the other possible causes of the groin pain have been eliminated, the possibility of surgery is raised. A routine hernia repair (called a herniorrhaphy) can be performed. This is done by a general surgeon, and so far is more frequently performed for sportsmans hernia in Europe than in the United States. General surgeons are hesitant to do a hernia repair when there is no hernia present.

Reported success rates for the surgery range between 63 percent and 93 percent. Patients not helped by the surgery often had more than one reason for the pain, so success is linked to a definitive diagnosis. Rehab is a gradual (six to eight weeks) return to ballistic, twisting movements and improving strength, flexibility and stability of the pelvic region.

Two final notes about this injury. First, this really needs to be evaluated by a sports physician. Most family medicine physicians and internists are not familiar with the problem and will struggle with diagnosis and treatment.

Second, this injury seems to be confined (but not always) to athletes who compete at the highest level, mostly professional athletes.

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