Sports Hernia Diagnosis and Treatment. Seth M. Weinreb, MD, FACS December 6, 2014

Transcription

1 Sports Hernia Diagnosis and Treatment Seth M. Weinreb, MD, FACS December 6, 2014

2 My story Hernia surgeon, Hernia patient Soccer Typical right inguinal hernia repair in college Training general surgery hernias and so much more Raleigh Surgical Group in 2001 > Rex Surgical Specialists in 2008 Distance running - marathons Disappearance of general surgery + Indoor soccer Hernia specialist Sports Hernia interest Deep dive into the field Everyone comes back from Philadelphia with a scar We want to keep these people here at home Team evolved 1

3 Groin pain with bulge: This is straightforward 2

4 Groin pain without bulge: Not straightforward 3

5 Sports Hernia: Typical Cases 20 yo College Student Soccer player Left groin pain started months ago After playing then when playing Acceleration Kicking No specific injury No problems walking Better w/ rest, recurs w/ resuming sport Could play through it not anymore NSAIDs helped at first not anymore Trainer > PT > Ortho > Hernia surgeon 45 yo Weekend Warrior Tennis player Right groin pain started months ago After playing then when playing Acceleration Serving No specific injury No problems walking Better w/ rest, recurs w/ resuming sport Could play through it not anymore NSAIDs helped at first not anymore PCP > PT > Pain Clinic > Hernia surgeon Now what? 4

6 Sports Hernia: Scope of the Problem True incidence difficult to estimate - registries Elite level Soccer: 7 injuries/yr/team, average time lost > 1 week Hockey: 890 injuries in 1400 athletes over 5 year period Sub-elite level 10-20% time loss injuries; true incidence 50-70%, most not time-loss, so unrecorded Risk Factors Age Usually athletes, but not always Prior groin injury Off-season training (controversial) Weakened adductor strength (controversial) Twisting, cutting, kicking, turning, rapid acceleration/deceleration sports Soccer, hockey, rugby, football, tennis 5

7 Sports Hernia: What s Going On Here? Confusing name Athletic pubalgia, Sports hernia Gilmore s groin, Iliopubic pain syndrome, Sportsmen s groin, Footballer s groin injury, Hockey syndrome, Athletic hernia, Inguinal disruption, Incipient hernia I ll try to answer some of these questions. 6

8 Sports Hernia: What s Going On Here? Complex anatomy Many muscles inserting on/originating from the pubic symphysis Nerves may or may not be playing a role Tremendous forces, shearing, opposing, torque all about this one area I ll try to answer some of these questions. 7

9 Sports Hernia: What s Going On Here? Unclear pathophysiology Shearing forces causing rectus-pubic insertion injuries and adductor-pubic complex injuries Weakened, deficient, even bulging posterior inguinal floor Nerve stimulation or entrapment I ll try to answer some of these questions. 8

10 Sports Hernia: What s Going On Here? I ll try to answer some of these questions. 9

11 Sports Hernia: Is It a Hernia or Not? Not a hernia No bulge on exam Hernias present differently Tremendous forces, shearing, opposing, torque all about this one area But Original description coupled groin pain with small direct inguinal hernia Current definitions include weakness of posterior wall of inguinal canal causing Sx Most current authorities cite usual presence of bulging posterior wall at surgery Inguinal floor is often markedly attenuated and even bulging Brunt, JM A localized bulging can compress the genital-femoral nerve Muschaweck, et al My experience the floor is usually as weak as some typical inguinal hernia cases Why important??? It depends who you ask. 10

12 Sports Hernia: Differential Diagnosis of Groin Pain Musculoskeletal Hip Labral tear FAI Snapping hip syndrome Stress Fx Hip osteoarthritis AVN femoral head Back Lumbar radiculopathy Groin Typical inguinal/femoral hernia Hydrocele/varicocele Adductor/flexor tendinitis Sports hernia Rectus-pubic aponeurotic injury Adductor-pubic aponeurotic injury Osteitis pubis Other GI IBD Appendicitis/diverticulitis Infectious Malignant GU Kidney stones Epididymitis/prostatitis UTI/urethritis/cystitis Misc. Lymphadenopathy FIbromyalgia Inflammatory conditions 11

13 Sports Hernia: Differential Diagnosis of Groin Pain Musculoskeletal Hip Labral tear FAI Snapping hip syndrome Stress Fx Hip osteoarthritis AVN femoral head Back Lumbar radiculopathy Groin Typical inguinal/femoral hernia Hydrocele/varicocele Adductor/flexor tendinitis Sports hernia Rectus-pubic aponeurotic injury Adductor-pubic aponeurotic injury Osteitis pubis Other GI IBD Appendicitis/diverticulitis Infectious Malignant GU Kidney stones Epididymitis/prostatitis UTI/urethritis/cystitis Misc. Lymphadenopathy FIbromyalgia Inflammatory conditions With experienced referrals, mostly it comes down to this. 12

14 Sports Hernia: Diagnosis - History History Onset is usually insidious (can follow acute injury however) Usually risk factors present the right sports, the right motions, etc. Pain usually dull, burning, deep in quality Better with rest, symptoms resume with resumption of sport With time, pain lasts longer, recurs earlier, eventually limits performance and/or play Pertinent negatives: Fever/chills, night pain, GI symptoms 13

15 Sports Hernia: Diagnosis Physical Exam Physical Exam Standing and supine, anterior and trans-scrotal, cough and Valsalva Careful exam for true inguinal and/or femoral hernias GU conditions especially involving the spermatic cord Careful palpation of all zones I like to divide into 5 zones Adductor/flexor palpation on stretch feet together, knees/hips flexed Resisted sit-ups FABER, FADDIR, other tests to rule out hip pathology 14

16 Sports Hernia: Diagnosis Imaging Plain films Useful mainly to rule out orthopedic hip pathology Sometimes required by insurance before approving MRI Ultrasound Static ultrasound usually unrevealing Often required by insurance before approving MRI Dynamic ultrasound used extensively in Europe CT No role unless pain is more superior and lateral mainly ruling out abdominal issues MRI Best test available Special athletic pubalgia protocols are imperative Experienced interpretation is also key Looking to confirm diagnosis, rule out hip pathology, and specify variant(s) 15

17 Adductor Tendon Tear (courtesy Dr. Charles Pope, MD) 16

18 Rectus Insertional/Aponeurotic Tear (courtesy Dr. Charles Pope, MD) 17

19 Osteitis Pubis (courtesy Dr. Charles Pope, MD) 18

20 Sports Hernia: Treatment Osteitis Pubis Rest and Rehab NSAIDS, Medrol dosepak Steroid injection into pubic symphysis No surgery! Adductor insertion injury Rest and Rehab Injectional management steroid, PRP If very high injury, consider surgery if all else fails, but weigh risk vs. benefit Rectus insertion injury Rest and Rehab if possible Surgery This is the group we can usually help with surgery It usually boils down to this. 19

21 Sports Hernia: Surgical Options Open Suture-only Muschaweck: Minimal repair Bassini-type repairs Meyers:??? Anterior mesh Posterior mesh Anterior + posterior mesh Adductor release Neurectomy Laparoscopic Posterior mesh (TEP & TAPP) All different techniques, All spectacular outcomes 20

22 Sports Hernia: Surgical Options Open Suture-only Muschaweck: Minimal repair Bassini-type repairs Meyers:??? Anterior mesh Posterior mesh Anterior + posterior mesh Adductor release Neurectomy Laparoscopic Posterior mesh (TEP & TAPP) 21

28 Sports Hernia: Findings at Surgery Torn external oblique aponeurosis, Angulated nerve 27

29 Sports Hernia: Findings at Surgery Sparse rectus attachments at pubis 28

30 Sports Hernia: Findings at Surgery Bulging posterior floor (direct space) 29

32 Sports Hernia: Do What Makes Sense Goals Relieve pain Repair weakness Unify structures Manage the nerves (Anterior) Unify structures Rectus-pubic insertional complex (Anterior and/or Posterior) Adductor-pubic insertional complex (Anterior) Leave groin as least susceptible to future real hernias Remember we will cause major scar tissue in operative field Remember there is almost always weakness of the direct space of inguinal floor Standard of care for hernia surgery is mesh repair Mesh makes sense 31

33 Sports Hernia: What Operation and Why? Open Suture-only Muschaweck: Minimal repair Bassini-type repairs Meyers:??? Anterior mesh Posterior mesh Anterior + posterior mesh Adductor release Neurectomy Laparoscopic Posterior mesh (TEP & TAPP) Process of elimination! 32

40 Sports Hernia: What Operation and Why? Open Suture-only Muschaweck: Minimal repair Bassini-type repairs Meyers:??? Anterior mesh Posterior mesh Anterior + posterior mesh Adductor release Neurectomy Laparoscopic Posterior mesh (TEP & TAPP) Two Options: Option 1 39

41 Sports Hernia: What Operation and Why? Open Suture-only Muschaweck: Minimal repair Bassini-type repairs Meyers:??? Anterior mesh Posterior mesh Anterior + posterior mesh Adductor release Neurectomy Laparoscopic Posterior mesh (TEP & TAPP) Two Options: Option 2 40

42 Sports Hernia: Technique Posterior Component of Case 41

43 Sports Hernia: Technique Anterior Component of Case 42

44 Sports Hernia: Technique Anterior Component of Case 43

45 Sports Hernia: Technique Anterior Component of Case Plus neurectomy! 44

46 Sports Hernia: Conclusions Not a hernia Groin pain without hernia, without hip pathology in an athlete with a good story/exam Team approach is vital: patient, family, trainer, PT, radiologist, surgeons Diagnosis of exclusion Careful exam is usually predictive of diagnosis, but not necessarily the correct subtype MRI is imaging modality of choice Three common variants: Rectus-pubic, Adductor pubic, Osteitis pubis Treatment should first be non-operative (if possible) Surgical options are available, but not appropriate for all patients We can treat these patients here at home! This is NOT a hernia. Or is it?!!! 45

47 Thank You 46