The Sports Hernia. Russell Steves M.Ed, ATC, PT Princeton University

Transcription

1 The Sports Hernia Russell Steves M.Ed, ATC, PT Princeton University

2 Why Should I Care? You may run into it An athlete with groin pain not getting better You may read about it An athlete may read about it It s a difficult diagnosis to get right

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4 Why Is It Tough to Get Right? Broad area for symptoms Many possible diagnoses Unfamiliar anatomy Interchangeable names for sports hernias

5 Today s Purpose Explain the different pathologies that are described as sports hernias Teach clinicians how to identify sports hernias in their athletes Describe the effective treatments for sports hernias Surgery

6 Where does it hurt?

7 Many Causes of Groin Pain

8 Groin Pain Pathologies Musculo-tendinous Injury Hip flexors Hip adductors Abdominals Enthesopathy Adductor longus Rectus abdominus

9 Groin Pain Pathologies Hip joint pathology Sprain Arthritis OA DJD Acetabular labral tear Femoral head/neck AVN

10 Groin Pain Pathologies Stress fractures Pubic rami Femoral head/neck Avulsion fractures AIIS/ASIS Lesser trochanter Pubic symphysis

11 Groin Pain Pathologies Iliopectineal bursitis Osteitis pubis Pelvic girdle dysfunction Lumbar spine pathology Facet joint injury Disk protrusion Spondylolysis/spondylolisthesis

12 Groin Pain Pathologies Nerve entrapment Ilioinguinal Genitofemoral Obturator Prostatitis Varicocele testis Osteomyelitis at pubic symphysis

13 Groin Pain Pathologies Sports hernias Gilmore s groin Athletic Pubalgia Symphysis syndrome Hockey groin syndrome Hernia Conventional Occult (Sportsman s)

14 Regional Anatomy

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16 Clemente CD. Anatomy. Baltimore. Williams & Wilkins

17 Fitzgibbons RJ Jr. Nyhus-Condon s Hernia. Phila. Lippincott Williams & Wilkins

18 Netter FH. Atlas of Human Anatomy. Teterboro,NJ. Icon Learning Sys

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20 Identifying Sports Hernias

21 Common History Gradual onset Unilateral pain, but not exclusively Males Pain in groin and lower abdominal regions May extend into genitals Pain with activity and ceases with rest, only to return with activity Doesn t feel like a muscle strain

22 Physical Exam Hip ROM Flexion Flexion and IR Flexion, adduction, IR IR and ER FABERE s

23 Physical Exam Resisted hip motions Flexion (knee flexed/slr) Adduction Diagonal adduction Passive hip motions Hip extension Abduction

24 Physical Exam Resisted abdominal movements Sit-up Sit-up with rotation Pelvic curl-up

25 Physical Exam Palpation Inguinal ligament as dividing line Special tests Bilateral adduction Bilateral adduction with fingertip pressure

26 Physical Examination No visible or palpable signs of hernia Pain with resisted bilateral hip adduction Provocative test Fingertip pressure over inguinal canal Palpable tenderness Inguinal canal Adductor longus

27 Physical Examination Doesn t fit with other pathologies Negative x-ray and MRI Herniography? Diagnostic US?

28 Typical MRI

29 Typical MRI

30 Diagnostic US

31 Diagnostic US

32 Diagnostic US

33 Types of Sports Hernias

34 Gilmore s Groin Pathology Tear in external oblique aponeurosis Conjoined tendon tears from pubic tubercle Conjoined tendon splits from inguinal ligament Gilmore J. Clinics in Sports Med

35 1 3 2 Netter FH. Atlas of Human Anatomy. Teterboro,NJ. Icon Learning Sys

36 Gilmore s Groin Identified by tenderness and dilation of external inguinal ring Repaired by suturing tears Return to full activity in 4 weeks

37 Athletic Pubalgia Chronic inguinal or pubic area pain Pain only on exertion No other medical diagnosis Biomechanical injury Weak lower abdominals Resulting in anterior pelvic tilt Overuse of adductors and lower abs Meyers WC et al. Am J Sports Med

38 Athletic Pubalgia Identified by tenderness in the region and frustration Surgical repair Reinforce conjoined area with suturing and adductor release Full recovery in 3 months

39 Skandalakis JE et al. World J Surg

40 Rohen JW et al. Color Atlas of Anatomy. Phila. Lippincott Williams & Wilkins

41 Symphysis Syndrome Dilation of superficial inguinal ring Weakness of external oblique aponeurosis Deficiency of inguinal canal posterior wall Identified by tenderness in inguinal region Biedert RM et al. Clin J of Sports Med

42 1 2 3 Fitzgibbons RJ Jr. Nyhus-Condon s Hernia. Phila. Lippincott Williams & Wilkins

43 Symphysis Syndrome Surgical repair Reinforce conjoined area Release and denervation of rectus abdominus insertion Release of adductor longus and gracilis Full recovery in 8-12 weeks

44 Hockey Groin Syndrome Tear of external oblique aponeurosis Entrapment of ilioinguinal nerve Irshad K et al. Surgery

45 Hockey Groin Syndrome Identified by Tenderness in inguinal region Dilated external inguinal ring Gap in external oblique aponeurosis upon exertion Surgery Repair tear with synthetic mesh Excise nerve Full Recovery in 8 weeks

46 Fitzgibbons RJ Jr. Nyhus-Condon s Hernia. Phila. Lippincott Williams & Wilkins

47 Sports(man s) Hernia Conventional hernias Femoral Obturator Umbilical Inguinal Direct Indirect

48 Indirect Direct Fitzgibbons RJ Jr. Nyhus-Condon s Hernia. Lippincott Williams & Wilkins

49 Both Femoral Fitzgibbons RJ Jr. Nyhus-Condon s Hernia. Lippincott Williams & Wilkins

50 Sports Hernia Occult hernia Not visible or palpable Defect in the posterior wall of inguinal canal A hole or a thinning of the tissue Genetic?

51 Sports Hernia Identified by tenderness in inguinal region Herniography Dye injected into peritoneum Not common in US Diagnostic ultrasound Exertion manuever Also not common in US

52 Sports Hernia Surgical repair same as conventional hernias Suture posterior wall Synthetic mesh over posterior wall Laparoscope with mesh Full recovery in 4 to 6 weeks

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54 Open Surgical Repair Modified Bassini procedure Shouldice technique

55 Open Surgical Repair Fitzgibbons RJ Jr. Nyhus-Condon s Hernia. Lippincott Williams & Wilkins

56 Open Surgical Repair

57 Open Surgical Repair

58 Open Repair with Mesh Lichtenstein technique Tension-free procedure

59 Mesh Repair Bendavid R. World J Surg

60 Closed Surgical Repair Laparoscopic technique with mesh TAPP repair TransAbdominal Pre-Peritoneal

61 Laparoscopic Repair

62 Laparoscopic Repair

63 Rehabilitation Conservative management Get through season, then surgery Post-operative rehab

64 Conservative Treatment Pain Control NSAIDs Therapeutic modalities Cortico-steroid injections Spica wrap or girdle Therapeutic Exercise Muscle balancing about the pelvis

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66 Therapeutic Exercise Leg raises (with draw-in) Flexion Abduction Extension Adduction Horizontal abduction Diagonal adduction

67 Therapeutic Exercise Core exercises Partial sit-up Sit-up with rotation Pelvic curl-up Side lifts Opposite arm/leg lift Double leg lifts

68 Therapeutic Exercise Flexibility exercises Hamstrings Adductors Hip flexors Posterior hip Modified hurdler s stretch

69 Post-op Rehab 0-2 Weeks Rest Allow incision to heal Post-op pain to subside After 1 week, begin walking Not power walking

70 2 4 Weeks Begin strengthening/stretching exercises Leg raises Core activation (draw-in) Passive hip stretches Stationary bike for fitness Wall squats Without, then with, ball squeeze

71 4 6 Weeks Progress to more intense exercises Partial sit-ups Begin skating or jogging Progress to running Initiate sport-specific drills Shooting, kicking, or throwing Continue with lower intensity weight lifting

72 6 Weeks Resume normal conditioning and weight lifting programs Return to full sports activity with asymptomatic: Full speed sprint Lateral movement Cutting/pivotting Shuttle sprint

73 Princeton s Program Athlete presents to ATC with groin pain ATC evaluation raises suspicions Begin conservative care Refer to MD Early, if suspicions are high After no progress

74 Princeton s Program MD evaluation Hernia check Get x-ray and MRI General surgeon consult Diagnostic US in office Schedule surgery When schedule allows

75 Princeton s Program Return to ATC for post-op rehab Return to full participation Excellent results in 26/26 patients

76 Key Points Groin pain is fairly common in athletes Some problems are very resistant to getting better Keep in mind that these pathologies exist Realize there are very few ways to accurately identify their presence Very commonly identified outside US

77 Key Points Which pathology applies is very surgeon dependent All have in common a reinforcement of the inguinal region Recovery rates after surgery are excellent

78 Thank You

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80 References Sports hernia Joesting DR. Curr Sports Med Rep. 2002;1: Fon LJ, Spence RAJ. Br J Surg. 2000;87: Azurin DJ, et al. J Lap Adv Surg Tech. 1997;7:7-12. Ingoldby CJH. Br J Surg. 1997;84: Malycha P, Lovell G. Aust NZ J Surg. 1992;62: Polglase AL, et al. Med J Aust. 1991;155:674-7.

81 References Gilmore s groin Gilmore J. Clinics in Sports Med. 1998;17: Athletic pubalgia Meyers WC, et al. Am J Sports Med. 2000;28:2-8. Symphysis syndrome Biedert RM, et al. Clin J Sports Med. 2003;13: Hockey groin syndrome Irshad K, et al. Surgery. 2001;130:

82 References Herniography Kesek P et al. Acta Radiol Nov;43(6): Helse CP et al. Ann Surg Jan;235(1): Gwanmesia II et al. Postgrad Med J Apr;77(906): Leander P et al. Eur Radiol. 2000;10(11): Yilmazlar T et al. Acta Chir Belg Jun;96(3): Makela JT et al. Ann Chir Gynaecol. 1996;85(4):300-4.

83 References Diagnostic US Steele P et al. J Sci Med Sport Dec;7(4): Bradley M et al. Ann R Coll Surg Engl May;85(3): Lilly MC, Arregui ME. Surg Endosc Apr;16(4): Orchard JW et al. Br J Sports Med Jun;32(2):134-9.

84 Literature Review Rates of full recovery Gilmore s groin 1164/1200 (97%) Athletic pubalgia 152/169 (90%) Symphysis syndrome 24/24 (100%) Hockey groin syndrome 52/56 (93%) Sports hernia 219/243 (90%) Combined /1692 (95%)