Groin Pain Name Game – Sports Hernias

Man holds his groin as he hopes to identify the cause of a painful bulge in the groin as sports hernia

A hernia is a protrusion of anatomic structures from one body compartment into another that typically develops in natural transition areas and tissue seams. They can also appear at iatrogenic (surgical treatment) incisions. Hernias may describe conditions of the brain, vertebral discs of the spine, the ribs, the diaphragm, and abdominal, pelvic, or muscular structures.

However, a Sports Hernia is not, in fact, an actual hernia, as there is no bulge or protrusion out of a body compartment.  It is a condition of strain, injury, or irritation of the hip’s adductor-longus muscle and tendon where it attaches to the pubic bone. It occurs most often in athletes performing activities that cause high torque strain of core muscles and hips in abrupt and powerful movements. It is more appropriately termed Athletic Pubalgia, which better describes the discomfort of this area. The area where Athletic Pubalgia occurs is adjacent to and therefore commonly associated with an inguinal (groin) hernia.

An Inguinal Hernia is a weakness within the inguinal abdominal ring or canal, which is a portal of transition for blood vessels, nerves, and the vas deferens from the abdominal area into the scrotum of men or femoral compartments. Immediately beneath the inguinal ligament is the femoral ring, a potential site for a Femoral or upper thigh hernia.  The inguinal and femoral hernias may mimic one another depending on their contents.  While the Sports Hernia can represent laxity in this area and may lead to or cooccur with inguinal and femoral hernias, it is likely called a hernia because of the similar pain it causes.

Groin Hernias

Femoral or Inguinal Hernia range from small and uncomfortable to massive and nearly painless, with many variations. Patients can have either or both.  It’s interesting to note that the hernia itself is not necessarily a detriment. The compression of nerves or interrupted blood flow to hernia contents, such as the intestines, omentum, or bladder, can be problematic. Further, the hernia bulge or sac contents may be entirely asymptomatic for some.

Groin Hernia Diagnosis

A Femoral or Inguinal Hernia may be suspected based on a history of discomfort with or without a visible protrusion.  Diagnosis often requires a physical exam.  Occasionally, subtle hernias require imaging such as Ultrasound or CT Scan. These can also help rule out testicular, scrotal, or genitourinary conditions.  Rarely such a hernia may be identified incidentally during imaging or laparoscopy for other abdominal conditions.

Groin Hernia Treatment

Except in cases of higher risk of surgery or anesthesia, when a patient presents with a hernia, it is often best to have it surgically repaired.  An inguinal or femoral hernia with or without symptoms or complexities does not resolve on its own or improve with a change of activity or physical therapy.  At best, these hernias may remain stable in size over time, and occasionally patients may become comfortable ‘reducing’ or pushing hernias back in place. This is likely a temporary and sometimes very uncomfortable intervention we do not advise.  Restrictive garments or truss appliances have been used for millennia to keep reduceable hernias in place, but potential complications are real.  These hernias will often increase in size over time, significantly exacerbated by strenuous activity or weight gains and losses.

Surgical Repair of Groin Hernias

Repairing inguinal hernias is quite common, and the standard of care is surgical placement and fixation of a permanent mesh.  Wounds contaminated or at-risk for infection (such as in an infected hernia mesh removal and revision) might require biologic mesh or patch repair, but this is not common. Endoscopic or laparoscopic repairs are common. Open suturing with mesh reinforcement is still done, although less so.

Diagnosis and Noninvasive Treatment of Sports Hernias

Sports Hernias or Athletic Pubalgia is unlikely to resolve independently, and pain or limited mobility is usually the most dramatic consequence initially.  This condition can be suspected based on history or absence of abnormalities on physical Exam or routine diagnostic imaging.

When any tendonitis or musculoskeletal issues are suspected (usually identified by pain on examination during effort and range-of-motion testing), MRI is most beneficial to locate signals of inflammation, as would be evident in the case of Athletic Pubalgia. Although rest is often recommended initially, a term of Physical Therapy intended to strengthen muscular structures is usually prescribed before and following the procedure.  Anti-inflammatory medications, including corticosteroids, may be prescribed to decrease the inflammation near and including these tendons.

Invasive Treatment Options

For high-level athletes, the invasive treatment often promotes quicker and more definitive resolution.  Open surgical repair where the inflamed tendon is disrupted and repaired with permanent sutures is a well-established technique.  Occasionally, the tendon’s insertion is wholly disrupted, making smaller cuts along the tendon to ‘lengthen’ the structure.  Ilio-inguinal neurectomy (selective disruption or removal of a nerve) has demonstrated value with decreased postoperative pain on activity following groin pain procedures.  Minimally invasive techniques were developed to promote quicker healing and reduce recovery times.  Ultrasound-guided percutaneous needle tenotomy (for partial disruption or ‘lengthening’ of the tendon) and injection of corticosteroids are relatively newer techniques implemented over the past decade. PRP injection may require more significant expense, among other concerns, as it has not been cleared by the FDA, despite the data showing efficacy.

If you are experiencing groin pain, it may be one of several potential issues, including athletic pubalgia or an inguinal or femoral hernia. Most importantly, anyone experiencing abdominal pain should visit a qualified general surgeon such as those at MIIS to get a proper diagnosis and treatment plan.

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