UC DavisUC Davis Previously Published Works

TitleSports Hernia: Definition, Evaluation, and Treatment.

Permalinkhttps://escholarship.org/uc/item/565051qt

JournalJBJS reviews, 5(9)

ISSN2329-9185

AuthorsHopkins, Justin NealBrown, WilliamLee, Cassandra Alda

Publication Date2017-09-01

DOI10.2106/jbjs.rvw.17.00022

Copyright InformationThis work is made available under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives License, availalbe at https://creativecommons.org/licenses/by-nc-nd/4.0/ Peer reviewed

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Sports Hernia: Definition, Evaluation,and Treatment

Justin Neal Hopkins, MD

William Brown, MD

Cassandra Alda Lee, MD

Investigation performed at theDepartment of Orthopaedic Surgery,University of California Davis,Sacramento, California

COPYRIGHT © 2017 BY THEJOURNALOF BONE AND JOINTSURGERY, INCORPORATED

Abstract» Sports hernia is a non-anatomic, non-diagnostic term that has beenattributed to many different causes of groin pain.

» Sports hernia is better described as pain localized anatomically to theinguinal region of an athlete without an actual hernia.

» Nonoperative management including core stability while avoidingextreme hip range of motion should be attempted for at least 2months prior to any operative intervention.

» Associated pathology such as femoroacetabular impingement oradductor tear should be addressed.

» If a sports hernia is not responsive to rehabilitation, referral to ageneral surgeon is appropriate.

Thesports physician com-monly encounters athleteswith groin pain. The differ-ential diagnosis is broad, in-

cluding both orthopaedic disease andvisceral diseasemore appropriately treated bya general surgeon. Sports hernia is one suchcause of groin pain, although it is “one of theleast understood, poorly defined, and under-researched conditions in medicine.”1 Muchof the evidence that is available stems fromoutside the orthopaedic literature. However,the orthopaedic team physician should behighly experienced in both recognizing andappropriately treating the spectrum of groinpathology. Furthermore, if nonoperativemeasures fail, the orthopaedic surgeon shouldrefer the patient appropriately for definitivetreatment. Because of the broad differentialdiagnosis, attempts have been made to stan-dardize the terminologyandactualdiagnosisofa sports hernia. With more precise terminol-ogy, treatment algorithms may be developed.

Definition and EpidemiologyThe definition of a sports hernia rangesfrom a syndrome including chronic groin

pain1 to a groin disruption resulting fromfunctional pelvic instability2. Nonspecificterms include sportsman’s hernia, sports-man’s groin, athletic pubalgia, sportspubalgia, incipient hernia, Gilmore groin,and hockey groin3-8. Athletes presentingwith groin symptoms often come in withone of these generalized diagnoses; how-ever, the bestway to target a goodoutcome isto clarify amore anatomic diagnosis for theirsymptoms. One such classification systemuses adductor, iliopsoas, pubic, or inguinal-related groinpain,with inguinal-relatedpainmost closely representing a sports hernia3

(Fig. 1). Furthermore, the term inguinaldisruption has been coined to replace sportshernia, because no true hernia exists5.

The epidemiology of sports hernia isdifficult to elucidate, given the lack of aconsistent definition. In patients withchronic groin pain, sports hernia was foundto be the primary diagnosis in 95 (50%) of189 patients9; 40 (80%) of 50 patientswith groin pain of unknown etiology werefound to have a bulge in the posterioringuinal wall at the time of the surgicalprocedure10. Therefore, sports hernia

Disclosure: There was no source of external funding for this work. The Disclosure of Potential

Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/

JBJSREV/A259).

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accounts for substantial debilitationgiven the prevalence of groin pain beingapproximately 6%of all athletic injuries11.The majority of symptomatic sportshernias requiring operation occur in malepatients who play soccer, hockey, football,basketball, cricket, or rugby1,2,7,9,12.The median age of athletes with sports-related groin pain ranges from 26 to28 years, andonly 11 (5%)of 207patientswith sports-related groin were female13.

Pathology and MechanismIn attempting to define the underlyingpathology for sports hernias, severaldifferent hypotheses have emerged. Themost commonly cited mechanism isincreased tension in the groin due tohigh levels of “twisting, turning, sprint-ing and kicking.”5 This tension appearsto cause tears or attenuation of inguinalstructures that manifests as pain.

Furthermore, loss of hip internal orexternal rotation may contribute to theetiology of sports hernias given the cor-relation between loss of range of motionand ipsilateral sports hernia in athletes14.Loss of motion of the hip may stress thepubic symphysis and lead to instability,suggesting a target of focus for nonop-erative treatment. Similarly, femo-roacetabular impingement places stresson the hip, which could also predisposeto an inguinal injury15.

Nerve compression or conjoinedtendon inflammation may also be thesource of pain as a series of patients hadbeen treated successfully withoutaddressing the posterior abdominal wallitself16. Instead, these 36 patients receivedradiofrequency denervation of the ilioin-guinal nerve and inguinal ligament, withconsiderable relief compared with corti-costeroid injection and prior surgical at-tempt at repair. However, this treatmentis more aimed at the symptoms ratherthan the underlying pathology.

Muscular balance offers anotherdimension. During 1-leg stance, as occursin multiple sports, the adductor muscleswork with the abdominal muscles tocontrol and stabilize the pelvis as the hiprotates, adducts, and flexes. Weakness ofany of these structures may lead to eitherinstability, stress, or overuse in these soft-tissue structures6,7. For that reason, sportshernia may be approached as a syndromethat includes abdominal and adductorpain, in addition to the inguinal pain17.

A single pathology does not definesports hernia; abnormal tension exists inthe inguinal canal, causing pain. Thistension may manifest as posterior ab-dominal wall weakness, superficial in-guinal ring dilation, and tears of theconjoined tendon, external obliquemuscle, or inguinal ligament5. Althoughthese specific processes may not be

present, they all point to a deficit of theinguinal canal without true herniation.

AnatomyThe anatomy of the groin is complex,with a coalescence of muscles, tendons,and nerves12, which is why sports herniais so confusing. All of these structureshave proximity to the pubic symphysisand the balance point between the ad-ductor and abdominal muscles.

Beginning superficially in the ab-domen, the external oblique muscleoriginates on the ribs and inserts on theiliac crest, anterior superior iliac spine,and pubic tubercle. The inferior apo-neurosis runs from the anterior superioriliac spine to the pubic tubercle and istermed the inguinal ligament. The in-ternal oblique muscle originates on therib costocartilage, iliac crest, and lateralinguinal ligament, serving as the supe-rior portion of the inguinal canal andwrapping around the spermatic cord orround ligament as it runs through theinguinal canal. The transversus abdom-inis originates on the thoracolumbarfascia, rib costocartilage, iliac crest, andlateral inguinal ligament. The transver-sus abdominis and internal obliquemuscles combine to form the conjoinedtendon at the medial aspect of the in-guinal canal. The deepest structure ofthe abdominal wall is the transversalis

Fig. 1Illustration showing the anatomic loca-tionsofgroinpain including theadductortendon, iliopsoas tendon, pubic sym-physis, and inguinal-related locations.Inguinal-related pain most closely repre-sents a sports hernia.

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fascia7. Superficially at the superior lat-eral pubic tubercle lies the external in-guinal ring where the spermatic cord orround ligament exit the external obliquemuscle. The pubic aponeurosis is acombination of the rectus abdominis,conjoined tendon, and external obliquemuscle, and it also connects thesestructures to the adductor origin7, thus

creating the most critical structuralbalance between the adductors andabdominal muscles8 (Fig. 2).

The ilioinguinal nerve runs deep tothe external oblique muscle to innervatethe medial aspect of the thigh and scro-tumor labiamajora. The iliohypogastricnerve runs superior to the ilioinguinalnerve. After piercing the transverse

abdominis muscle, it innervates the hy-pogastric area and iliac crest. Lastly, thegenitofemoral nerve runs anteriorly tothe psoas major muscle before splittingand innervating the skin of the upperthigh and anterior scrotum or mons.The genital branch of the genitofemoralnerve and the ilioinguinal nerve runthrough the inguinal canal along with

Fig. 2Illustration of the abdominal wall layersand their contributions to the inguinalcanal.

Fig. 3Illustration showing the iliohypogastric,ilioinguinal, and genitofemoral nervepathways and correspondingdermatomes.

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the spermatic cord or round ligament18

(Fig. 3).

Differential DiagnosisThe differential for groin pain includesintra-abdominal disorders, inguinalhernia, urogenital pathology, lumbardisc disease, intra-articular hip pathol-ogy, muscle or ligament strain, nerveentrapment, bursitis, fracture, sacro-tuberal ligament pain, sacroiliac jointdysfunction, piriformis-related pain,pelvic floor-related pain, and a soft-tissuemass12,13,16,19. It is important todistinguish a sports hernia from othercauses of inguinal pain that are derivedfrom different anatomic locations or mayoccur concurrently with it (Table I).

Furthermore, 69 (33%) of 207athletes with groin-related pain werefound to have a secondary or tertiaryclinical entity in addition to their pri-mary diagnosis. Commonly adductor,rectus, and iliopsoas-related pain werefound together, further confoundingthe anatomic classification scheme(Fig. 1). Osteitis pubis and adductor-related pain may even be a part ofthe same clinical entity or syndromegiven the close interplay of thesestructures13,17.

Other important concurrent pa-thology in sports hernia includes

femoroacetabular impingement. Un-derlying femoroacetabular impinge-ment has been found to be present in 37(86%) of 43 patients treated for sportshernia. Those patients had continuedgroin pain despite treatment for thehernia alone. Femoroacetabular im-pingement on imaging may be predic-tive of poor outcomes after groinsurgery; however, perhaps concomitantorthopaedic treatment of impingementcould lead to a more successfuloutcome20.

PresentationSufficient time should be allotted withthe patient to obtain a good history andperform a careful physical examination.Often, the diagnosis can be determinedwithout theneed for advanced imagingorultrasound.

HistoryPatients report groin pain that is primarilyat the pubic symphysis and radiatesthrough the rectus abdominis or adductortendon. Symptoms are worsened by ath-letic activity such as kicking, cutting, orsprinting, especially with acceleration anddeceleration, and are alleviated by rest2,21.Coughing may cause pain, and the painmay radiate into the thighortesticlesgivennearby nerve distributions21.

Physical ExaminationFor sports hernia, examination often re-veals tenderness to palpation of the in-guinal region just above the inguinalligament and near the pubis22. Thecrunch test (resisted sit-up)producespainat the pubic crest2. Also, there may betenderness at the superficial inguinal ringwithout appreciation of a frank hernia2.Hip internal and external rotationmaybedecreased2,14. Other anatomic sources ofpain should also be assessed throughphysical examination. Palpation of theadductororiginandassessmentof resistedadduction are important to assess foradductor-type pain. Iliopsas-type pain isassessed with palpation of the abdomenjust proximal and distal to the inguinalligament, as well as pain with passive ex-tension of the hip. There may be snap-ping of the iliopsoas tendon as well.Palpation of the insertion of the rectusabdominis on the pubic bone and pain inthe abdominal musculature with resistedcontraction are diagnostic techniques toassess for rectus abdominis-type pain andmay be a more specific diagnosis thanpubic pain. A visible or palpable inguinalmass, if present, points to a frank herniacompared with a sports hernia.

Our Suggestions for Clinical Workupof a Suspected Sports HerniaBegin by eliciting the patient’s historyto determine the most likely locationof the pain.

Pubic SymphysisOsteitis pubis is themost likely etiology.This patient is often a distance runner.Rolling over in bed is painful.With rest,the pain improves. The pain is usuallyinsidious in onset. There is usually painwith direct pressure over the symphysispubis and the edges of the joint are ir-regular. To confirm the diagnosis, injectthe symphysis with lidocaine. In under-weight or normal-weight patients, thiscan be easily done with palpation. Inoverweight or obese patients, ultrasoundcan serve as a guide. In patients with os-teitis pubis, the joint is damaged and willeasily accept10mLof lidocaine,whereas anormal, undamaged joint will accept only

TABLE I Differential Diagnosis of Inguinal Pain

Proposed causes of sports hernia

Conjoined tendon inflammation or tear5,16

Inguinal ligament tear5

External oblique muscle tear5

Posterior abdominal wall attenuation5,10

Superficial inguinal ring dilation5

Inguinal location not attributable to sports hernia

Inguinal hernia11

Nerve compression11,16

Other key diagnoses or associated pathology

Pubic instability14

Osteitis pubis13

Adductor strain or tear13

Femoroacetabular impingement21

Iliopsoas strain or tear11,13

Snapping iliopsoas11,13

Rectus abdominis strain or tear11,13

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a few milliliters of lidocaine. The athleteshould be warned that the injection isusually painful. After receiving the lido-caine injection, the athlete will experiencea fairly immediate relief of pain and mayresume athletic activities. However, be-cause lidocaine is short-acting, the injec-tion is for diagnostic purposes and isnot a long-term solution.

External Inguinal Ring (LateralBorder of the Origin of the RectusAbdominis Muscle)This often involves an injury to the ex-ternal oblique muscle. The patient

participates in a sport that requires rapidchange of direction such as soccer orhockey. The onset is usually insidious.Pressure over the external ring with con-traction of the core muscles will oftenreproduce the pain.When the scrotum isdigitally inverted, a normal external in-guinal ringwill usually only accept the tipof the finger. However, in athletes with atear of the external oblique muscle, theexternal ring is enlarged and the tip of thefingerpasses easily into the inguinal canal.Coughing with the scrotum inverted inthis manner will reproduce the patient’spain. To confirm the diagnosis, lidocainecan be injected just deep to the externaloblique muscle at the external inguinalring. As above, the athlete will experiencea fairly immediate relief of pain after re-ceiving the lidocaine injection and mayresume athletic activities, but only for ashort period of time.

Pubic TubercleThis often represents an injury to theinguinal ligament. The athlete reportschronic pain at that site that is aggra-vated by acceleration and cutting. Thepain usually has a slow onset. Directpressure over the pubic tubercle and themedial attachment of the inguinal liga-ment causes pain. The pubic tubercle isoften thickened when compared withthe contralateral side. To confirm, lido-caine can be injected into the medial at-tachmentof the inguinal ligament.Again,the lidocaine injection, although short-acting, will result in the athlete experi-encing a fairly immediate relief of pain

and being able to resume athletic activi-ties, but only for a short period of time.

Vague or Diffuse LowerAbdomen PainNerve pain often runs from near theanterior superior iliac spine toward thepubic symphysis. It will often involvethe inside of the thigh and the lateralaspect of the scrotum or mons pubis.The pain is aggravated by twisting mo-tions and insidious inonset.Often, therewill be sensory changes as well. Occa-sionally, there is a trigger point, butmore commonly the examination is be-nign. Perform an ilioinguinal and ilio-hypogastric nerve block using theanterior superior iliac spine as a land-mark to confirm the diagnosis by reliefof the pain (Fig. 4).

Adductor Longus TendonPain high on the medial aspect of thethigh is almost always an injury to theadductor longus tendon. The athletewill report pain with cutting, withkicking a ball with the inside of thefoot, and with acceleration. Often, theathlete will remember a pop at the timeof the original injury. The pain is locatedat the origin or approximately 10 cmbelow and pain will be reproduced withresisted hip adduction. Often, the ten-don will be of small caliber but remainattached. To inject the origin of the ad-ductor longus, the patient should liesupine. The knee should then be flexedand the hip should be abducted toidentify the origin. Again, the athlete

Fig. 4A photograph showing that pain sec-ondary to ilioinguinal and iliohypogas-tric nerves can be confirmed byperforming a lidocaine injection usingthe anterior superior iliac spine (ASIS)as a landmark. If positive, vague painradiating toward the groin from thelower abdomen will be relieved.

TABLE II Criteria for the Diagnosis of Sports Hernia as Described by the British Hernia Society5*†

1 Pain that is described as dull or diffuse and radiates to the medial aspect of the thigh, perineum, orcontralateral side

2 Tenderness to palpation over the pubic tubercle at the insertion of the inguinal ligament

3 Tenderness to palpation of the deep inguinal ring

4 Tenderness to palpation of the adductor longus tendon

5 Tenderness or dilation of the superficial inguinal ring

*Three criteriamustbemet fordiagnosis.†Data for this tablewereobtained from: SheenAJ, StephensonBM, LloydDM,RobinsonP,Fevre D, Paajanen H, de Beaux A, Kingsnorth A, GilmoreOJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, KurzerM. ‘Treatment ofthesportsman’sgroin’: BritishHerniaSociety’s2014positionstatementbasedontheManchesterConsensusConference.BrJSportsMed. 2014 Jul;48(14):1079-87. Epub 2013 Oct 22.

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should be able to briefly resume athleticactivities nearly pain-free after theinjection.

Criteria for DiagnosisOverall, the sports hernia diagnosis canbemadeon the basis of 3 of the following5 signs: (1) pain that is described as dullor diffuse and radiates to the medial as-pect of the thigh, perineum, or contra-lateral side; (2) tenderness to palpationover thepubic tubercle at the insertionofthe inguinal ligament; (3) tenderness topalpation of the deep inguinal ring; (4)tenderness to palpation of the adductorlongus tendon; and (5) tenderness ordilation of the superficial inguinal ring5

(Table II).

ImagingRadiographs of the pelvis and hip are animportant first step to evaluate the os-seous structures and to rule out otherdiagnoses in the differential21. Ultra-sound and computed tomography (CT)may also be used to show an inguinalbulge that is not appreciated on exami-nation21-23. Magnetic resonance imag-ing (MRI) remains the primary tool indiagnosis, as it is able to rule out or toidentify associated pathologies. It is

therefore important that the field ofview is sufficiently large.

The most common MRI findingis an ipsilateral rectus abdominis strainor tear from the pubic ramus and apartial or complete adductor longusdetachment1,21 (Fig. 5). MRI had asensitivity of 68% and specificity of100% for rectus abdominis tendon in-jury (91 patients) and a sensitivity of86%and specificity of 89% for adductortendon injury (74 patients)4. Pubicsymphysis bone edema may bepresent20,22 and may increase after sur-gical intervention. However, up to one-third of patients may not have any notedpathology on MRI1.

CT arthrography with injectioninto the pubic symphyseal fibrocartilagi-nous discmay elucidate tears of the rectusor adductors not appreciated by MRI23.CT arthrography may be therapeutic, inrelieving groin pain, as well as diagnostic.

Such injections can also be madethrough fluoroscopic or ultrasound-guidedmeans, again allowing visualizationof the dye if it were to track into the rectusabdominis or adductor aponeurosis21.

In contrast to the above studies forsports hernia, femoroacetabular

impingement must also be evaluated. Alabral tear can also be present. Deep painor impingement on examination mayindicate the need for false-profile andmodified Dunn radiographs24. Fur-thermore, MR arthrography may bewarranted to further assess this commonconcurrent pathology7.

Treatment and OutcomesGiven the variety of treatment options inthe literature, the British Hernia Societyrecommends that the choice of surgeryand operative approach be based onsurgeon experience5. A minimum of2 months of rehabilitation prior to anysurgical intervention should be attemp-ted first, whereas other studies haverecommended waiting 3 to 6 monthsprior to surgical treatment inathletes7,22.

The initial nonoperative manage-ment protocol should include posturaland range-of-motion assessment. Spe-cific exercises should include strength-ening of the gluteus medius andmaximus, transversus abdominis, erec-tor spinae, lateral abdominals, hipflexors, and hamstrings. Focus should beon core strengthening with avoidance of

Fig. 5Oblique axial fat-suppressed MRI show-ing a complete avulsion and retraction ofthe right adductor longus tendon. Thepubic symphysis has hypertrophicchanges and irregularity.

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deep hip flexion. Modalities used caninclude Swiss balls, core exercises,medicine balls, pulleys and clinibands,dynamic posture stability, stretching,swimming, and yoga. The overall goal ofnonoperative management is to em-phasize the stabilizers of functionalmovement and posture. Furthermore, itis important to make the treatment assport-specific as possible5,7. Given thehigh correlation between sports herniaand femoroacetabular impingement,stretching and range-of-motion regi-mens can sometimes exacerbatesymptoms21.

Other nonoperative treatmentprotocols described include an initialrest, activity modification, and coremuscle strengthening incorporating atransition from non-weight-bearingpositions to functional upright pos-tures25. As the patient demonstratesappropriate form, resistance is graduallyadded.Eventually, speed andplyometricactivities are included when the patientcan perform a supine crunch withoutpain. A return to sport-specific activitiesis also added at this time.

If pain continues after 2 to 6months of nonoperative rehabilitation, a

surgical procedure is indicated. A surgi-cal procedure for sports hernia can beperformed through open, minimallyinvasive, or laparoscopic repair tech-niques (Fig. 6). A laparoscopic approachwith extraperitoneal inguinal hernia-type repair with synthetic mesh andconcomitant adductor longus tenotomyhas been shown to return athletes tosports-related activity at a mean timeof 24 days postoperatively1. Adductortenotomy has also been used inisolation26.

In contrast, Mei-Dan et al. con-ducted a retrospective, nonrandomized

Fig. 6Figs.6-A through6-H Intraoperativephotographs fromopensportshernia repair andadductor tenotomy.Fig.6-ATheexternalobliquemuscle, indicatedby the asterisks, is torn with the underlying spermatic cord between the upper and lower edges. Fig. 6-B A Penrose drain is placed around the spermaticcord (SC), retracting it inferiorly to show the transversalis fascia (arrows) torn with fat underneath. Fig. 6-C The transversalis fascia is repaired back tothe inguinal ligamentwith sutures to reconstruct the floor of the inguinal canal. Fig. 6-D The lower edge of the external obliquemuscle is pulled up for thefirst layer of repair. Fig. 6-E The upper edge of the external oblique muscle is pulled down for the second layer of repair. Fig. 6-F The spermatic cord isbrought back into place over the external oblique muscle with the ilioinguinal nerve intact (arrowhead). Fig. 6-G A separate incision shows the adductorlongus insertion with a scar (arrowhead) consistent with a chronic tear. Inferiorly, the adductor longus tendon is visible with healthier-appearing tissue.Fig. 6-H The adductor longus tenotomy has been completed.

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study of 155 soccer players diagnosedwith sports hernia on ultrasound whoalso had adductor tendon pain8. Nosignificant difference was found be-tween the 96 patients treated with ad-ductor tenotomy only comparedwith combined adductor tenotomywithlaparoscopic hernia treatment withmesh in terms of time to return to play,subjective outcomes, and activity level.Adductor release may correct the im-balance across the pubic symphysis,and, for that reason, patients in thisseries all underwent bilateral adductorreleases.

With regard to hernia repair, bothopen and minimally invasive methodsare supported16,21,27,28. A retrospectivestudy compared an open modified-typerepair to an open minimally invasiverepair29. The modified techniqueemployedplicating the rectus abdominisfascia to the pubis and inguinal ligamentto strengthen the posterior abdominalwall. However, the newer minimallyinvasive technique incorporated de-compression of the genital branch of thegenitofemoral nerve and opening theposterior abdominal wall with repair ofthe transversalis fascia. The authorsfound that athletes returned to play at amean time of 5.6 weeks with the mini-mal repair, compared with 25.8 weeksfor those who underwent the largeropen repair. The authors suggested thatthe minimal iatrogenic soft-tissuedamage and the nerve decompressionwere important for the early return.Similarly, endoscopic repair usingmesh was shown to provide signifi-cantly lower pain scale scores comparedwith nonoperative treatment27. Be-cause of chronic pain, 7 (23%) of 30patients switched over to the opera-tively treated group.

For National Hockey Leagueplayers undergoing various surgicalprocedures for sports hernia, Jakoi et al.showed that players were often able toreturn to a similar level of performanceafter the surgical procedure28. Thoseplayers with.7 years of experience whounderwent an operation played in fewergames, scored fewer goals, obtained

fewer assists, and had less mean time onthe ice. Younger players only saw a dif-ference in the number of games played.Productivity, as defined by minutes pergoal, did not change in either group.This supports the statement that theoverall surgical approach should bebased on surgeon preference andexperience.

Nerve decompression can also beperformed without opening the poste-rior abdominal wall. As previouslymentioned, in a randomized clinicaltrial, the authors compared radiofre-quency denervation of the ilioinguinalnerve and ligament with local anestheticinjection16. Radiofrequency denerva-tionwas successful in treating groin painup through 6 months and also success-fully treated pain in those patients withfailed surgical treatment, whereas injec-tion only relieved symptoms for 1 week.The authors questioned the need to ad-dress the posterior abdominal wall sur-gically and also provided a treatmentthat could defer a definitive treatmentuntil offseason. This could also poten-tially prevent complications of surgicalprocedures and allow continuedperformance.

Finally, as discussed earlier, Econ-omopoulos et al. showed femo-roacetabular impingement to be a poorpredictor of successful surgery29. Larsonet al. supported this conclusion in theirretrospective study of 37 patients withsymptomatic sports hernia-type pathol-ogy and intra-articular hip pathology7.They found that 11 (69%)of 16patientswho underwent a sports hernia surgerysubsequently required hip arthroscopyand 3 of 8 patients who underwent a hiparthroscopy eventually needed a sportshernia procedure. Furthermore, eitherconcurrent or staged surgical proceduresincorporating both procedures led to animproved Harris hip score, with 24(89%) of 27 patients returning to un-restricted sports, and no difference if theprocedures were staged or concurrent.This calls for a multidisciplinary ap-proachbetween general andorthopaedicsurgeons. The ultimate surgicalchoice should be based on surgeon

preference, but most importantly, allpathologic structures involved shouldbe addressed.

ConclusionsGroin pain is a commonly encounteredsymptom for the orthopaedic teamphysician; it is important to understandthe anatomy that clarifies the differentialand diagnostic criteria for sports hernia.Although a variety of definitions exist inthe literature, pain centered at the in-guinal canal, without frank hernia, bestdefines a sports hernia.Multiple injuriescan fall within this non-diagnostic term.Upon diagnosis, nonoperative treat-ment should be initiated, followed byreferral to a general surgeon if recalci-trant to therapy. Associated conditionsshould also be treated, such as femo-roacetabular impingement or adductortears. If appropriately managed, sportshernia treatment can be successful, andtherefore it is important for the ortho-paedic surgeon to be knowledgeable ofthis pathology.

NOTE: The authors would like to ac-knowledge Michelle Hecht for creatingthe medical illustrations for this manu-script for Figures 1, 2, and 3.

Justin Neal Hopkins, MD1,William Brown, MD2,Cassandra Alda Lee, MD1

1Department of Orthopaedic Surgery,University of California Davis,Sacramento, California

2SportsHernia.com, Fremont, California

E-mail address for J.N. Hopkins:hopkins@ucdavis.eduE-mail address for W. Brown:drbrown@sportshernia.comE-mail address for C.A. Lee:casslee@ucdavis.edu

ORCID iD for C.A. Lee: 0000-0003-2610-9584

References1. Rossidis G, Perry A, AbbasH,Motamarry I, LuxT, Farmer K, Moser M, Clugston J, Caban A,Ben-David K. Laparoscopic hernia repair withadductor tenotomy for athletic pubalgia: anestablished procedure for an obscure entity.

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Surg Endosc. 2015 Feb;29(2):381-6. Epub 2014Jul 2.

2. Garvey JF, Hazard H. Sports hernia or groindisruption injury? Chronic athletic groin pain: aretrospective study of 100 patients with long-term follow-up. Hernia. 2014;18(6):815-23.Epub 2013 Oct 12.

3. Weir A, Brukner P, Delahunt E, Ekstrand J,Griffin D, Khan KM, Lovell G, Meyers WC,Muschaweck U, Orchard J, Paajanen H,PhilipponM,ReboulG, RobinsonP, SchacheAG,Schilders E, SernerA, Silvers H, Thorborg K, TylerT, Verrall G, de Vos RJ, Vuckovic Z, Holmich P.Doha agreement meeting on terminology anddefinitions in groin pain in athletes. Br J SportsMed. 2015 Jun;49(12):768-74.

4. Zoga AC, Kavanagh EC, Omar IM, MorrisonWB, Koulouris G, Lopez H, Chaabra A, DomesekJ, Meyers WC. Athletic pubalgia and the “sportshernia”: MR imaging findings. Radiology. 2008Jun;247(3):797-807.

5. Sheen AJ, Stephenson BM, Lloyd DM,Robinson P, Fevre D, Paajanen H, de Beaux A,Kingsnorth A, Gilmore OJ, Bennett D,Maclennan I, O’Dwyer P, Sanders D, Kurzer M.‘Treatment of the sportsman’s groin’: BritishHernia Society’s 2014 position statement basedon the Manchester Consensus Conference. Br JSports Med. 2014 Jul;48(14):1079-87. Epub2013 Oct 22.

6. Farber AJ, Wilckens JH. Sports hernia:diagnosis and therapeutic approach. J AmAcadOrthop Surg. 2007 Aug;15(8):507-14.

7. LarsonCM, Pierce BR, GiveansMR. Treatmentof athletes with symptomatic intra-articular hippathology and athletic pubalgia/sports hernia:a case series. Arthroscopy. 2011 Jun;27(6):768-75.

8.Mei-DanO, Lopez V, CarmontMR,McConkeyMO, Steinbacher G, Alvarez PD, Cugat RB.Adductor tenotomy as a treatment for groinpain in professional soccer players.Orthopedics. 2013 Sep;36(9):e1189-97.

9. Lovell G. The diagnosis of chronic groin painin athletes: a reviewof 189 cases. Aust J Sci MedSport. 1995 Sep;27(3):76-9.

10. Malycha P, Lovell G. Inguinal surgery inathletes with chronic groin pain: the‘sportsman’s’ hernia. Aust N Z J Surg. 1992Feb;62(2):123-5.

11. Suarez JC, Ely EE, Mutnal AB, FigueroaNM, Klika AK, Patel PD, Barsoum WK. Com-prehensive approach to the evaluation of groinpain. J Am Acad Orthop Surg. 2013 Sep;21(9):558-70.

12. Nam A, Brody F. Management and therapyfor sports hernia. J AmColl Surg. 2008 Jan;206(1):154-64. Epub 2007 Oct 18.

13. Holmich P. Long-standing groin pain insportspeople falls into three primary patterns,a “clinical entity” approach: a prospectivestudy of 207 patients. Br J Sports Med. 2007Apr;41(4):247-52; discussion 252. Epub 2007Jan 29.

14. Rambani R, Hackney R. Loss of range ofmotionof thehip joint: ahypothesis for etiologyof sports hernia. Muscles Ligaments Tendons J.2015 Mar 27;5(1):29-32.

15. Strosberg DS, Ellis TJ, RentonDB. The role offemoroacetabular impingement in coremuscleinjury/athletic pubalgia: diagnosis andmanagement. Front Surg. 2016 Feb 12;3:6.

16. Comin J, Obaid H, Lammers G, Moore J,Wotherspoon M, Connell D. Radiofrequencydenervation of the inguinal ligament for thetreatment of ‘sportsman’s hernia’: a pilot study.Br J Sports Med. 2013 Apr;47(6):380-6. Epub2012 Sep 5.

17. Biedert RM, Warnke K, Meyer S. Symphysissyndrome in athletes: surgical treatment forchronic lower abdominal, groin, and adductorpain in athletes. Clin J SportMed. 2003 Sep;13(5):278-84.

18. Dimitrakopoulou A, Schilders E.Sportsman’s hernia? An ambiguous term. J HipPreserv Surg. 2016 Feb 24;3(1):16-22.

19.Mullens FE, Zoga AC, Morrison WB, MeyersWC. Review of MRI technique and imagingfindings in athletic pubalgia and the “sportshernia”. Eur J Radiol. 2012 Dec;81(12):3780-92.Epub 2011 Sep 3.

20. Economopoulos KJ, Milewski MD, Hanks JB,Hart JM, Diduch DR. Radiographic evidence offemoroacetabular impingement in athleteswith athletic pubalgia. Sports Health. 2014Mar;6(2):171-7.

21. Larson CM. Sports hernia/athletic pubalgia:evaluation and management. Sports Health.2014 Mar;6(2):139-44.

22. Kuikka L, HermunenH, PaajanenH. Effect ofpubic bone marrow edema on recovery fromendoscopic surgery for athletic pubalgia. ScandJ Med Sci Sports. 2015 Feb;25(1):98-103. Epub2013 Dec 18.

23. McArthur TA, Narducci CA, Lopez-Ben RR.The role of pubic symphyseal CT arthrographyin the imaging of athletic pubalgia. AJR Am JRoentgenol. 2014 Nov;203(5):1063-8.

24.Meyer DC, BeckM, Ellis T, Ganz R, Leunig M.Comparison of six radiographic projections toassess femoral head/neck asphericity. ClinOrthop Relat Res. 2006 Apr;445:181-5.

25. Becker LC, Kohlrieser DA. Conservativemanagement of sports hernia in a professionalgolfer: a case report. Int J Sports Phys Ther. 2014Nov;9(6):851-60.

26. Akermark C, Johansson C. Tenotomy of theadductor longus tendon in the treatment ofchronic groin pain in athletes. Am J SportsMed.1992 Nov-Dec;20(6):640-3.

27. Paajanen H, Brinck T, Hermunen H, Airo I.Laparoscopic surgery for chronic groin pain inathletes is more effective than nonoperativetreatment: a randomized clinical trial withmagnetic resonance imaging of 60 patients withsportsman’s hernia (athletic pubalgia). Surgery.2011 Jul;150(1):99-107. Epub 2011 May 5.

28. Jakoi A, O’Neill C, Damsgaard C, Fehring K,Tom J. Sports hernia in National Hockey Leagueplayers: does surgery affect performance? Am JSports Med. 2013 Jan;41(1):107-10. Epub 2012Oct 29.

29. Economopoulos KJ, Milewski MD, Hanks JB,Hart JM, Diduch DR. Sports hernia treatment:modified Bassini versus minimal repair. SportsHealth. 2013 Sep;5(5):463-9.

S p o r t s H e r n i a : D e f i n i t i o n , E v a l u a t i o n , a n d Tr e a tm e n t |

SEPTEMBER 2017 · VOLUME 5, ISSUE 9 · e6 9