What is a “sports hernia”?
A hernia is an out pouching (turning or bulging out) of tissue through a space which it is not intended to pass through. As a result, the trapped tissue often becomes painful. Common examples of hernias include a herniated disk or the classic “hernia” (in medical terms, an inguinal hernia).
In a herniated disk, the tough outer layer (annulus fibrosis) of an intervertebral disk (the cushion between the vertebral bones forming the spinal column) tears and allows the inner, jelly-like nucleus pulposis to slip - or herniate - through the tear. In an inguinal hernia, a small weakening of the inner abdominal wall allows the bowel to slip through during times when the pressure within the abdomen increases, such as heavy lifting, coughing, or straining.
A sports hernia, however, is not a “true” hernia; that is, there is no abnormal out pouching of bowel or any other tissue associated with this disease. Rather, a sports hernia or “athletic pubalgia,” as it is also called, is a tearing of the tissue that forms the inner part of the abdominal wall and inserts into the pubic bone.
How do we diagnose a sports hernia?
The diagnosis of sports hernia is difficult, and symptoms often overlap with those seen in an inguinal hernia. The chief complaint for both entities is groin pain, which is often chronic (present for several weeks) and worsens with strenuous activity. The typical patient with a sports hernia has pain that is minimal at rest and at the beginning of the game but increases steadily throughout the game. Often, the pain prevents full strides over the last 20 minutes of the game.
The key to differentiating an inguinal hernia from a sports hernia is physical examination. While probing of the area next to the pubic bone can cause pain for those with either disorder, only in patients with an inguinal hernia will the examiner feel the herniated bowel, which can be maximized by having the patient cough. Usually, those with a sports hernia will have increased groin pain while doing sit-ups, particularly sit-ups with resistance.
“Sports hernia” remains a clinical diagnosis. In other words, no imaging study, like X-ray, CT scan, and MRI, can be used to reliably diagnose a sports hernia. These studies are useful, however, in excluding or diagnosing other disorders, such as hip labral tears, that can commonly be confused with sports hernia.
Why do sports hernias happen?
The pubic bone is the anchor point for several strong muscles, including the abdominal muscles and the adductor muscles. The adductor muscles - a group of muscles of the inner thigh - are important during cutting (quick directional shifting) activities and are injured during “groin strains” or “groin pulls.”
In sports, such as soccer, where frequent cutting is required, the adductor muscles become extremely well-developed. In sports hernias, an imbalance occurs between the adductor muscles and the abdominal muscles; the stronger adductor muscles pull the pubic bone downward, thus stretching and eventually tearing the abdominal muscles.
How do we treat sports hernias?
Initial treatment of sports hernias should include rest from sporting activities, anti-inflammatory medication to diminish pain, and physical therapy to restore balance of the core muscles. Unfortunately, sports hernias often do not resolve with non-operative measures and usually surgery is necessary for alleviation of symptoms and return to play.
Surgery should be considered for those who have tried rest and therapy for up to three months. The surgical procedure, which is often done through a fiber optic scope, involves a combination of (1) a repair of the abdominal wall injury, with or without a synthetic mesh for reinforcement, and (2) cutting a portion of the adductor attachment to make it weaker. Most athletes can return to play within months of surgery, depending on the extent of the tear and method of repair.
Robert A. Gallo, MD
2007 Fellow, Sports Medicine Service
Hospital for Special Surgery