Sports Hernias. Matthew Gimre, MD ATC Conference, June 20, 2015

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1 Sports Hernias Matthew Gimre, MD ATC Conference, June 20, 2015

2 Sports hernia: So what is it? An injury to the rectus abdominis-common adductor aponeurosis, at the anterior/inferior aspect of the pubic bone. This can be a tear, partial tear, disruption, or avulsion. This initially was a diagnosis of exclusion, typically found during exploratory surgery (this is no longer the case). The term is a misnomer it is not a true hernia! The term has fallen out of favor in the academic setting, and it is recommended to avoid its use.

3 Sports hernia: So what do we call it? Athletic pubalgia. A clinical spectrum of disease associated with lower abdomen and groin injuries. Inguinal-related groin pain. Core muscle injury. Huh? Are these any better?

4 Sports hernia: So what do we call it? I use sports hernia! Shhhh! If you use sports hernia, just know it is not the favored academic term. But, at least most people in the sports medicine community will know what you mean.

and iliopsoas. Significant relationship between the core and hips.

5 Sports hernia: pathophysiology Athletic activity, particularly pivoting, cutting, and kicking cause significant torque at the pelvis, including the rectus abdominis, adductor, and iliopsoas. Significant relationship between the core and hips. Any weakness or imbalance can cause overload, and lead to soft tissue injury. Typically, this is an overuse injury.

6 Sports hernia: pathophysiology The opposing forces of the rectus abdominis and adductor longus at the pubic bone cause the injury.

7 Sports hernia: diagnosis Groin pain, adductor pain, and or lower abdominal pain with athletic activity. Variable intensity and level of dysfunction. Possible tenderness at the pubic bone and lower rectus abdominis insertion. In my opinion, there typically is minimal to no tenderness along the adductor longus.

8 Sports hernia: diagnosis. Exam findings can include weakness and provocative pain with resisted hip adduction, abdominal crunch, and with a combined maneuver of simultaneous abdominal crunch and resisted hip adduction.

9 Sports hernia: diagnosis Direct examination of the inguinal canal may find mild dilatation of the external inguinal ring compared to the contralateral side, and possible pain with posterior inguinal wall pressure. No bulge.

10 Sports hernia: diagnosis Pelvis x-ray negative. With x-ray, you are looking for other possible pathology.

11 Sports hernia: diagnosis In the past, MRI could not find this. Today, a good MRI can find this, and is very useful! Findings are subtle! Normal appearance on sagittal cut through the pubic bone. Abnormal finding, with abnormal soft tissue edema consistent with injury.

12 Sports hernia: diagnosis Abnormal coronal plane. Abnormal transverse plane.

13 Simple, right? Maybe, but the history, exam, and diagnostics can be subtle. Plus

14 Differential diagnosis True inguinal hernia. Osteitis pubis. Stress fracture. Intra-articular pathology, including hip impingement. Apophysitis/avulsion. Peripheral neuropathy. Radiculopathy. Other muscle/tendon injuries. Other!

15 Treatment Non-surgical. Rest. Rehab to balance/strengthen hip and core musculature. Surgical. Can be considered if nonsurgical treatment is not working after about 6 weeks.

Treatment Surgical treatment consists of repair and tightening of pelvic floor. This is general surgery, not orthopaedic surgery. Open. Typical return to sports in 12-16 weeks. Laparoscopic with mesh.

16 Treatment Surgical treatment consists of repair and tightening of pelvic floor. This is general surgery, not orthopaedic surgery. Open. Typical return to sports in weeks. Laparoscopic with mesh. Return to play in about 6 weeks. Minimally invasive open, with localized repair (guided by high-res ultrasound), and decompression of genital branch of genitofemoral nerve. Pioneered in Germany. Return to play in 4-5 weeks, sometimes sooner (!). All can have good results.

17 Thank you!

Hip Pain in the Athlete: A Diagnostic Challenge

Hip Pain in the Athlete: A Diagnostic Challenge : A Diagnostic Challenge Matthew Gimre MD Sports Medicine 11 th Annual Sports Medicine Conference Presented June 17, 2017 on: Month day, Year Presented to: Insert relevant presenter information Calibri