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JOURNAL CLUB: SPORTS HERNIA – WHERE’S THE HERNIA?

Journal Club Episode 9

Presenter:  Dr. Neil Dilworth – UofT Primary Care Sports Medicine Journal Club Director
Date:  June 9, 2015
Special Guest:  Dr. Lloyd Smith Chief of General Surgery at North York General Hospital

Podcast:

Presentation:

Articles Reviewed:

1)  Paajanen H, Brinck T, Hermunen H, Airo I (2011) Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsmans hernia (athletic pubalgia). Surgery 150(1):99–107

2)  Santilli OL, Nardelli N, Santilli HA, Tripoloni DE.Sports hernias: experience in a sports medicine centerHernia. 2015 Mar 18.

Background Definitions of Sport Hernia:
Definitions:
Gilmore’s groin – combination of a torn external oblique aponeurosis, a torn conjoined tendon, and dehiscence between the inguinal ligament and the torn conjoined tedon.
Taylor – pubalgia – result of musculotendinous strains of adductor muscle and other muscles in the absence of an inguinal hernia.
Meyers – Pubic serves as a point into which both the adductor muscles and rectus abdominis insert causing one muscle to antagonize the other, leading to an injury of the weaker muscles.
48% of his patients had an external oblique aponeurosis defect, 17% had a “thin” rectus abdominus insertion in 17%
Paajanen – abnormalitiy of conjoint tendon, tendonopathy of inguinal ligament, incipient osteitis pubis

Anatomy Review:

Paajanen Rehab Protocol post-surgical:

Post op daysRehab
0-7Resume ADLs, abstain from lifting exercises. Begin walking and increase as tolerated
7-10Post pelvic tiltMild resistive exercises – pool walking, partial squats, standing hip adduction/abduction/flexion/extension, heel raisingGentle stretching (Side bending, hip extension, psoas/groin/hamstring/quads)
10Begin light jogging and deep tissue massage of adductor muscle belliesProgressive resistive exercises
11-21Hip flexion, adduction, abduction, extensions (add wt. in 2 lb increments)Pool exercises (Running backward/forward, cariocas, side slides, jumping jacks – no arms, scissors, swimming-flutter kicks only)Jogging (1/2-1mile, including backwards)

Strength training: Sprinting (50 yd, no sudden start/stop), cross overs/straddles. Fig 8’s, lunges, plyometrics, stairmaster (20min), calisthenics

Upper body exercises

Sport Specific Activities

 

Summary:

Criteria for referral for Laparoscopic Repair for Sport hernia (Inguinal-related groin pain in Athlete in absence of a true hernia):

 

A.  History features that must be present:

1) Athletic Injury – overuse/gradual onset.

2) Worse with twisting, sprinting, change of directions, and mechanical provocation.

AND

3) Pain greater than 6 months ( > 6 weeks if professional/elite athlete)

B. Examination features that must be present:

1) Pain over inguinal ligaments and location of external and internal rings

AND

2) Absence of true inguinal hernia

C.  Imaging features that must be present:

1) Ultrasound – demonstrating no true inguinal hernia

AND

2) MRI groin pain protocol – Negative for other causes of groin pain

References:

Sheen AJ, Stephenson BM, Lloyd DM, Robinson P, Fevre D, Paajanen H, de Beaux A, Kingsnorth A, Gilmore OJ, Bennett D, Maclennan I, O’Dwyer P, Sanders D, Kurzer M. Treatment of the sportsman’s groin': British Hernia Society’s 2014 position statement based on the Manchester Consensus Conference. Br J Sports Med. 2014 Jul;48(14):1079-87. doi: 10.1136/bjsports-2013-092872. Epub 2013 Oct 22.

Ellsworth AA, Zoland MP, Tyler TF. Athletic pubalgia and associated rehabilitation. Int J Sports Phys Ther. 2014 Nov;9(6):774-84.

Šebečić B, Japjec M, Janković S, Vencel Čuljak, Dojčinović B, Starešinić M. Is chronic groin pain a Bermuda triangle of sports medicine? Acta Clin Croat. 2014 Dec;53(4):471-8.

Omar IM, Zoga AC, Kavanagh EC, Koulouris G, Bergin D, Gopez AG, Morrison WB, Meyers WC. Athletic pubalgia and “sports hernia”: optimal MR imaging technique and findings. Radiographics. 2008 Sep-Oct;28(5):1415-38. doi: 10.1148/rg.285075217. Review.

Kopelman D, Kaplan U, Hatoum OA, Abaya N, Karni D, Berber A, Sharon P, Peskin B The management of sportsman’s groin hernia in professional and amateur soccer players: a revised concept. Hernia. 2014 Nov 8

Rambani R, Hackney R. Loss of range of motion of the hip joint: a hypothesis for etiology of sports hernia. Muscles Ligaments Tendons J. 2015 Mar 27;5(1):29-32. eCollection 2015 Jan-Mar.

Srinivasan A, Schuricht A (2002) Long-term follow-up of laparoscopic
preperitoneal hernia repair in professional athletes.J Laparoendosc Adv Surg Tech 12(2):101–106

Steele P, Annear P, Grove JR (2004) Surgery for posterior
inguinal wall deficiency in athletes. J Sci Med Sport 7(4):
415–421 discussion 422–3

Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR
(2000) Management of severe lower abdominal or inguinal pain
in high-performance athletes. PAIN (Performing Athletes with
Abdominal or Inguinal Neuromuscular Pain Study Group). Am J
Sports Med 28(1):2–8

Meyers WC, Lanfranco A, Castellanos A (2002) Surgical management
of chronic lower abdominal and groin pain in highperformance
athletes. Curr Sports Med Rep 1(5):301–305

Paajanen H, Brinck T, Hermunen H, Airo I (2011) Laparoscopic
surgery for chronic groin pain in athletes is more effective than
nonoperative treatment: a randomized clinical trial with magnetic
resonance imaging of 60 patients with sportsman’s hernia (athletic
pubalgia). Surgery 150(1):99–107

Genitsaris M, Goulimaris I, Sikas N (2004) Laparoscopic repair
of groin pain in athletes. Am J Sports Med 32(5):1238–1242

Muschaweck UU, Berger LML (2010) Sportsmen’s groin-diagnostic
approach and treatment with the minimal repair technique:
a single-center uncontrolled clinical review. Sports Health
2(3):216–221

Santilli OL, Nardelli N, Santilli HA, Tripoloni DE.Sports hernias: experience in a sports medicine center. Hernia. 2015 Mar 18.