Sports Hernia (Atheletic Pubalgia)

 

Pubalgia is a fairly uncommon condition seen chiefly in young athletes.

  • males > females

  • common in hockey players and soccer players

Also known as athletic pubalgia, sportsman’s hernia, sports hernia, Gilmore’s groin, pubic inguinal pain syndrome-PIPS, sportsmen’s groin, footballer’s groin injury complex, hockey player’s syndrome, athletic hernia…

At least three of the five clinical findings should be present to make a diagnosis of sportsman’s hernia, i.e.:

  • 1) Point sensitivity where the conjoint tendon adheres to the public tubercle

  • 2) Sensitivity to palpation in the deep inguinal ring

  • 3) Pain and/or dilation in the outer inguinal ring without apparent hernia

  • 4) Pain at the origin of adductor longus muscle

  • 5) Diffuse inguinal pain extending to the perineum, inner surface of the femur and crossing the midline

French Orthopedics have devided the Atheletic pubalgia into 3 groups

  1. Abdominal level:

    1. Attachement or the rectus abdominalis (abdominal aponeurosis)

    2. A sports hernia does not cause a visible bulge in the groin, like the more common, inguinal hernia does. Over time, a sports hernia may lead to an inguinal hernia. With sportsman’s hernia, the posterior wall of the inguinal canal (transversalis fascia) is weak. Some sportsmen also present with disruption of the aponeurosis of the external oblique muscle.

    3. Inguinal and/or genital neuropathy .

      Muschaweck and Berger [21] postulated that pressure on the genital femoral nerve from the bulging posterior inguinal floor can be a source of pain. As a result, selective resection of the genital nerve is performed as a part of their repair

  2. Symphysis level: degenerative changes

  3. Adductor level : tendinopathy or avulsion

 Symtoms: The primary symptom is exercise-related inguinal pain. The pain is typically localized on the lower lateral end of the rectus abdominis muscle and it may extend to the testicle, perineum, suprapubic region, origin of adductor longus and inner surface of the femur

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The pubic aponeurosis is created by the confluence of the rectus abdominus, the conjoint tendon (a fusion of the internal oblique and transversus abdominus), and the external oblique. This pubic aponeurosis is also confluent with the origin of the a…

The pubic aponeurosis is created by the confluence of the rectus abdominus, the conjoint tendon (a fusion of the internal oblique and transversus abdominus), and the external oblique. This pubic aponeurosis is also confluent with the origin of the adductor and gracilis, the combination of which is termed the rectus abdominus/adductor aponeurosis

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Matalon, S. (2017). Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. RadioGraphics, 37(4), 1218–1235.

Matalon, S. (2017). Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. RadioGraphics, 37(4), 1218–1235.

Matalon, S. (2017). Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. RadioGraphics, 37(4), 1218–1235.

Matalon, S. (2017). Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. RadioGraphics, 37(4), 1218–1235.

Matalon, S. (2017). Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. RadioGraphics, 37(4), 1218–1235.

Matalon, S. (2017). Don’t Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma. RadioGraphics, 37(4), 1218–1235.

 
 

Differential diagnosis

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Imaging

Osteolysis

Osteolysis

Ossification of the adductor tendon

Ossification of the adductor tendon

 
Adductor tendon avuslionBrennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Adductor tendon avuslion

Brennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Cleft signBrennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Cleft sign

Brennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Cleft sign + avulsion of gracilisBrennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Cleft sign + avulsion of gracilis

Brennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

 
Brennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Brennan 2005. Secondary Cleft Sign as a Marker of Injury in Athletes with Groin Pain: MR Image Appearance and Interpretation. Radiology, 235(1), 162–167.

Arthro- MRI showing the secondary cleft sign

Arthro- MRI showing the secondary cleft sign

 

Dynamic ultrasonography is a promising method for the diagnosis of sportsman’s hernia. A radiologist with plenty of experience in ultrasonography may identify the significant protrusion of transverse fascia during Valsalva maneuver using a high-frequency probe (Figure 3) (30). Slight bulge in the posterior inguinal wall may often be asymptomatic

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Treatment

 

First line Treatment : NSAIDs, Rest, Physical therapy, injection if enthesopathy (steroids vs steroids)

Surgery is indicated if conservative treatment fails

Hopkins, J. N., Brown, W., & Lee, C. A. (2017). Sports Hernia. JBJS Reviews, 5(9), e6. doi:10.2106/jbjs.rvw.17.00022 

Hopkins, J. N., Brown, W., & Lee, C. A. (2017). Sports Hernia. JBJS Reviews, 5(9), e6. doi:10.2106/jbjs.rvw.17.00022 

External oblique aponeurosis weakness and thinning in an athlete undergoing athletic pubalgia surgery

External oblique aponeurosis weakness and thinning in an athlete undergoing athletic pubalgia surgery

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PhysiotherapyBritish Hernia Society’s 2014 position statement based on the Manchester Consensus Conference

Physiotherapy

British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference

PhysiotherapyBritish Hernia Society’s 2014 position statement based on the Manchester Consensus Conference

Physiotherapy

British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference