RICE & MICE: The sports hernia

Danny Briere has had a couple, Mike Richards has had at least one, Dan Carcillo had one last offseason and now, Kris Versteeg is the latest Flyer to undergo surgery to repair a sports hernia.

A sports hernia is different from a traditional inguinal hernia that occurs when there is a significant area of the abdominal wall in the area of the inguinal canal that allows a pouch of herniated tissue to bulge through and cause pain.  The inguinal canal is created by several abdominal muscles and ligaments and through the canal passes the spermatic cord and the ilioinguinal nerve in males and the round ligament in females accompanied by the same nerve. Take a minute to lie on your back and feel the front of your hip bone with your fingers, then place the heel of your hand on your hipbone with your fingers pointing toward your pubic bone. The area that your hand covers is roughly where the inguinal canal is located.

Sports hernias, also sometimes referred to as athletic pubalgia, Gilmore’s groin sportsman’s groin or slapshot gut, do not produce a hernia that can be felt.

Of course, those are all older terms and now most of the time the injury is referred to as a sports hernia. The groin area, actually includes the muscles that flex the hip (bend it up towards the torso), the muscles that adduct the hip (think add together, meaning the muscle responsible for pulling your legs together toward each other), so when groin pain is talked about it is done in a generalized sense to describe pain in the area of the hip flexors and adductors.

In sports that require forceful cutting, such as football, ice hockey, tennis and soccer, the injury can happen when the abdominal muscles and the hip adductors both contract causing a tug of war between the two muscle groups on the pubic bone where the muscles attach. The abdominal muscles typically are weaker than the adductor muscles, causing stretching and tearing of the abdominal muscles.

Sometimes athletes will complain about groin pain, pain in the lower abdomen or, in males, there may be complaints of pain in the testicles. At first the pain can be a dull, aching or nagging pain that doesn’t resolve with rest. Sometimes the initial groin pain resolves, while there is lingering pain in the lower abdomen.  Over time the pain worsens and can affect a players speed and explosiveness.

One school of thought is that a groin pull is the initial injury that can predispose an athlete to a sports hernia. There are certainly enough groin strains and pulls throughout the NHL season to go around. James van Riemsdyk and Kimmo Timonen are two of the Flyers that suffered a pulled groin and hip flexor, respectively.

Sports hernias are difficult to diagnose because there are often no definitive findings on exam and oftentimes they are only detected by someone that specializes in treating groin pain. An MRI may be ordered to detect the subtle signs of a sports hernia. Sometimes there are no findings on an MRI and exploratory surgery is used to detect the problem area(s).

Treatment is usually rest in the beginning of the injury, often because it is thought to be a groin pull, is conservative and consists or rest, ice and gentle stretching. Sometimes the area is supported and reinforced with taping, wrapping or neoprene type of braces. If the pain persists after this conservative approach, other sources of groin pain are evaluated and if a sports hernia is detected, surgical repair is considered. Most techniques for repair will vary from surgeon to surgeon.

Some surgeons prefer laparoscopic repair (with small incisions and camera), while others prefer open repair. The repair consists of reinforcement with a special kind of mesh or suturing technique of the lower abdominal wall. Sometimes there is an imbalance of hip adductor strength and a portion of the tendon attachment to the pelvis is cut or released. A complication of this surgery is impingement or scar tissue irritation of the ilioinguinal nerve (the nerve that passes through the inguinal canal) and this nerve can be removed, leaving the skin in that area permanently numb, but also alleviating the pain caused by the nerve compression.

Rehabilitation involves a structured step-by-step program that begins with walking and movement and gradually moves athletes to resistance exercise to build core muscle strength.  Speed and sports specific exercises are the last to be incorporated into the rehab program. Most players recover in 4-8 weeks.

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