In this week’s installment of Ask the Expert, Dr. Bryan Kelly and Dr. Danyal Nawabi, Orthopedic Surgeons, answer your questions on sports hernia injuries:
Q1. What is a sports hernia?
A sports hernia is a term used to describe a large variety of groin injuries involving the pelvic and abdominal musculature above and below the pubic symphysis and external to the ball-and-socket hip joint. The pathophysiologic processes involved in the injury have not been definitively established and currently, the condition remains poorly defined and understood. The use of the term hernia implies that the symptoms are attributable to abdominal contents protruding through a defect in the abdominal wall. However, since a lump or swelling is rarely present in a sports hernia, it is not unsurprising that the condition has been described by some as an occult hernia caused by weakness of the posterior inguinal wall, leading to chronic groin pain. Recently, however, it has been observed that even occult (hidden) hernias are not present in these patients, and instead predominantly involve injury to muscles that attach to the pubic bone, most commonly the rectus abdominis above the pubis and adductor longus below the pubis. Therefore, this condition is also referred to as athletic pubalgia in the literature.
Q2. What are the common symptoms of a sports hernia?
One of the common symptoms of a sports hernia includes dull pain in the groin that often radiates to the perineum and inner thigh. Also, the pain is usually chronic in nature, resistant to non-operative measures, typically more intense with athletic activity, and can be aggravated by sudden movements, coughing, sneezing, performing sit-ups, sprinting, and kicking. Lastly, athletes typically report the inability to achieve a satisfactory level of play.
Q3. Are sports hernias easy to diagnose?
Given that the etiology of a sports hernia is unclear, the diagnosis of this condition is difficult at best. A broad differential diagnosis must be considered during the history and physical examination of a patient with groin pain in order to avoid mismanaging a patient and perhaps missing a potentially life-threatening disorder. The alternative diagnoses to consider and rule out include nerve compression syndromes, soft-tissue tumors of the pelvis, hip pathology including femoroacetabular impingement (FAI) and stress fractures, and urological problems.
Investigations that may be helpful include plain x-rays (to rule out fractures and neoplasms), MRI, ultrasound and diagnostic injections. An MRI is an excellent mean to assess soft tissue pathology and is also effective at diagnosing bone marrow edema about the pubic symphysis, which may be indicative of chronic tendon inflammation or a tear. Importantly, MRI can also rule out FAI in the hip joint as source of groin pain.
Q4. What can be done in terms of treatment?
By definition, these patients have chronic symptoms that have not improved with non-operative measures (NSAIDs, physical therapy, injections including PRP). Other options include reattachment of the rectus abdominis to the pubic bone, release of the adductor longus tendon in a small percentage of patients, and reinforcement of the posterior abdominal wall, similar to traditional hernia repair procedures
Q5. Is there a high success rate with sports hernia procedures?
Excellent outcomes with up to 90% return to pre-injury levels have been reported in high-performance athletes. When sports hernia surgery has been combined with hip arthroscopy to address concomitant FAI, the reported results are better than a single procedure. The results are less predictable in non-athletes. Also, the condition is much less common in females and therefore, the results in this group are under-reported.
Dr. Bryan T. Kelly is a specialist in sports medicine injuries and arthroscopic and open surgical management of non-arthritic disorders around the hip at Hospital for Special Surgery. He cares for several sports teams serving as the Head Team Physician for the New York Rangers, and Associate Team Physician for the New York Giants and the New York Red Bulls MLS team. Dr. Kelly currently serves as Chief for the Center for Hip Preservation, which is designed to provide multi-disciplinary care for patients at all levels with hip injuries.
Dr. Danyal H. Nawabi assisted Dr. Kelly with the following blog post. Dr. Nawabi is an Assistant Attending Orthopedic Surgeon on the Sports Medicine Service at the Hospital for Special Surgery. He specializes in the surgical treatment of sports injuries and arthritis of the hip and knee joints. He completed his fellowship training in sports medicine and joint replacement at the Hospital for Special Surgery