What is a Sports Hernia?
A sports hernia also known as athletic pubalgia, Gilmore’s groin, and slap shot gut, is an uncommon, but often missed cause of groin pain in high level athletes. It is poorly understood and poorly defined in the medical community. It is also very difficult to identify based on history and physical exam of an athlete with groin pain. The name sports hernia is a misnomer as well because there is no discernable hernia (or protrusion of abdominal cavity contents) present in this condition.
Who gets a Sports Hernia?
Sports hernia is a diagnosis almost exclusively of very high level male athletes. It is a common diagnosis in athletes with chronic longstanding groin pain that does not respond to a very long (often years) course of non-operative treatment. Typically athletes involved in repetitive twisting sports such as ice hockey, soccer, Australian rules football, and tennis. Recent well known athletes such as Donovan McNabb of the Philadelphia Eagles, Tomas Holmström of the Detroit Red Wings and Jeremy Shockey of the New Orlean’s Saints have all had surgery to repair a sports hernia.
Hockey player’s syndrome otherwise known as “slap shot gut” is a variant of a sports hernia unique to high level ice hockey athletes. It is due to repetitive twisting motions of the torso common in hockey such as with taking a slap shot. The result is a tearing over time of the covering (fascia) lining the lower abdominal oblique muscles. It is most often seen on the side opposite the player’s forehand slap shot. There may also be an associated inguinal nerve irritation. This may explain why the pain seen in hockey player’s syndrome often travels to the scrotal region. The treatment involves a repair similar to that in many sports hernias.
This is in contradistinction to a typical hernia where there is a protrusion of abdominal contents such as fatty tissue or bowel through a well-defined defect in the inguinal canal of the groin. Despite this, the name sports hernia has persisted because many of the surgical treatments are similar to that of a typical hernia.
How does a Sports Hernia happen?
Repetitive twisting and shear forces encountered during high level athletics can lead to injury of the lower abdominal wall. This may be exacerbated by the typical strong thigh adductors (muscles that bring the thighs closer together) compared with often weaker lower abdominal muscles.
How is the diagnosis of a Sports Hernia made?
Athletes typically complain of a longstanding history of pain in the inguinal (groin) region. They often complain simply that their performance has deteriorated below a satisfactory level. Often the pain is not present during periods of inactivity, rest or periods away from athletic involvement. However, symptoms classically reappear with return to the athletic activities responsible for the injury in the first place. The pain may travel, or radiate, from the groin into other areas like the testes, lower abdominal musculature and the inner thigh region. The pain is often exacerbated by coughing or sneezing as well as by athletic movements like sit-ups and kicking motions.
On physical examination, there may be groin pain to palpation in the region of various structures along the wall of the lower abdomen. These may include anatomic regions like the inguinal ring and canal as well as the pubic symphysis (central fusion point of the 2 halves of the pelvis in the front/center of the pelvic region). There is however no classic inguinal hernia detectable on exam as there is no defect in the inguinal wall and no intra-abdominal contents that herniated through. Patients will have pain with a resisted abdominal contraction such as with a sit-up. This may be worsened by doing so with the thighs squeezed together (adduction).
What else can masquerade as a Sports Hernia?
There are many possible causes of groin pain in athletes. Sports hernia is a rarely confirmed diagnosis, and therefore it is extremely important to be sure that other conditions are not the source of an athlete’s symptoms. Some conditions that can mimic a sports hernia include:
● Pulled Groin Muscle (Hip Flexor/Adductor Strain)
● Hip impingement
● Inguinal hernia
● Osteitis pubis (inflammation of the pubic symphysis: joint connecting the 2 halves of the pelvis)
● Stress fracture
● Snapping hip
● Labral tears
● Nerve entrapment
● Avulsion fractures in teenagers and children
● Non-orthopaedic causes of pain such as those involving the genitourinary system
How is a Sports Hernia treated?
Special emphasis should be given to core stabilization exercises as well as countering any imbalance between the various hip, pelvis and thigh musculature. An evaluation by a highly specialized physical therapist is necessary to help the athlete along with their rehab program and identify and treat these imbalances. A good example to improve this imbalance is Hip Abductor Stength
For more information on treatment including several other instructional core strength exercises as well as hip strengthening videos, please click the following link. Surgical information is also provided in this link
Sports Hernia & Athletic Pubalgia
What is the prognosis for recover?
About 90% of athletes who have surgery for a sports hernia are able to return to competition at the same level or higher to where they were prior to their injury. The timing of return to competition for laparoscopic surgery is typically within 6 weeks while for open surgery it is usually a few months to as long as 6 months.