Yet another one (pretty much the last, for now) from the archives. This article comes from the BJGP of March 2013.
‘Sports hernia’ – also known as sportsman’s hernia, athletic pubalgia, and Gilmore’s groin – is not, in fact, a hernia. It’s a weakness of the posterior wall of the inguinal canal, caused by a set of injuries to the abdominal and pelvic musculature outside the hip joint.
Epidemiology: The typical patient is a young male who actively participates in sport, especially football, hockey or athletics. It’s considerably less common in women and in people who don’t participate in sport (although it can affect both these categories) and is rare in children and older people.
- Dull, poorly localised groin pain
- Caused by exertion but can persist for days or weeks following exertion
- Above the inguinal ligament and radiating towards the scrotum/inner thigh
- Can cross the midline or be bilateral in nature
- Absent or mostly so when patient resting from sport; recurs when they take the sport up again
- Often insidious onset
- Tenderness over pubic symphysis and/or pubic tubercle
- Exquisite tenderness when the superficial inguinal ring is directly palpated via scrotal inversion with the little finger
- The ‘direct stress test’ – palpation over the superficial inguinal ring is uncomfortable while the patient is lying supine but pain is increased (and similar to presenting complaint) when the patient straight-leg raises while palpation continues.
- Resisted sit-ups are painful.
Investigation: Ultrasound or MRI are useful both in helping with the diagnosis and assisting with other pathologies.
Treatment: Start with conservative management for 6 – 12 weeks. This includes rest, NSAIDs, steroid injections and physio. A patient who is pain-free following this should attempt to return to sport.
If this isn’t successful (more often than not it isn’t), move on to surgical management, which consists of reinforcement of the posterior abdominal wall either by open or laparoscopic surgery, followed up by physio. Normally patients can return to full activity between 6 and 12 weeks. Surgery is successful in over 90% of cases.
Plan: If suspicion of a sports hernia is high based on history and examination, start with conservative management. If there is diagnostic uncertainty, arrange scan as above. If symptoms persist and are impacting on the patient’s quality of life, the patient is suitable for surgery, and other causes of groin pain have been ruled out, or if there is diagnostic uncertainty, then refer to a general surgeon with a particular interest in sports hernias.