Tier 2 MSK Clinic GP Message of the Month June Sportsman s groin (inguinal disruption).

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Caroline Neal
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1 Tier 2 MSK Clinic GP Message of the Month June 2014 Sportsman s groin (inguinal disruption). This month s MoM presents a case of bilateral inguinal disruption (ID) presenting as chronic (right) groin pain. GP referral letter to the MSK Tier 2 clinic (end of March 2013) Many thanks for seeing this fit, healthy 32-year-old man who has had right hip pain since before Christmas last year. Usually, he plays hockey on a regular basis with training once or twice a week and a full match weekly. He is also a keen runner. He has been unable to do any of this since before Christmas, when he developed right hip pain and groin pain. He initially noticed pain in the right inner thigh two to three days after a hockey match. He denies any direct trauma to the area but did notice bruising on the right inner thigh. He has had discomfort in adducting his right leg ever since and also reports discomfort on running. He was seen by a colleague who questioned whether there was a possible sportsman s hernia and referred him on to the surgeons. The surgeons advised there was no inguinal hernia but he does have a small femoral hernia and they have listed him for repair of this. They report that this is not the cause of his right groin pain. Certainly, it does seem more related to the joint itself and to pain on adduction. He has slight limitation of movement in full flexion of the hip and adduction. It is significantly impacting on his ADL and he reports quite significant weight gain since before Christmas as a result of a reduction in his exercise. I would be very grateful for your input and that of the rest of the MSK team. Tier 2 assessment (early May 2013) History - Keen hockey player and runner. Noticed right groin pain after an endof-season game in December Also noticed bruising along upper inner thigh a few days after the game but thought nothing of it, and the symptoms settled. - Return to hockey in February 2013 but experienced severe pain in right groin (some radiation to right testicle) and was unable to continue playing. Also noticed pain with running and ABDuction/ADDuction movements of the thigh (e.g., getting in/out of a car), and pain with coughing or sneezing. 1

2 - Recent consultation with upper GI general surgeon (who, by his own admission, was not a specialist in groin pain). Diagnosed with small right inguinal hernia. Patient was due to have surgical repair of this hernia in a week s time but felt that this was a pre-existing (and separate) problem. - Symptoms always felt better with rest but returned when he resumed certain activities. No response to physiotherapy treatment. - Otherwise in good health and systems review was clear. - Non-smoker/30 units of alcohol per week. - PMH unremarkable (mild asthma) and no significant PMH. Examination findings: key points - Hip and spine examination essentially normal. - Pain with resisted right thigh ADDuction and at end-range passive ABDuction. - Slight tenderness on palpation over the pubic symphysis and adductor muscle origin. Clinical impression 1. Possible Gilmore s groin (sportsman s hernia) +/- osteitis pubis and adductor tedinopathy. 2. Small right inguinal hernia Tier 2 management Possible diagnoses discussed with patient, who then spoke with his GP. Right inguinal hernia surgery deferred pending second opinion. Referral made to general surgeon with a specialist interest in chronic groin pain in athletes. Secondary care review (July 2013): Examination findings Abdomen soft and non-tender. Adductor longus and rectus abdomius muscle tenderness on the right side. Evidence of posterior wall weakness bilaterally. Testicular examination was normal. Impression Right groin strain (adductor longus injury) but MR and dynamic US requested to check for evidence of sportsman s hernia. Management plan Refer to physiotherapy (core stability programme) and consider local steroid injection if things do not settle. Follow up in 6 to 8 weeks with results of imaging. 2

3 Secondary care follow-up review (September 2013): Imaging results MR pelvis: There is evidence of osteitis pubis with some degenerative changes and thinning of the articular disc. No hernia or any other significant finding. US right groin and adductor region: There is mild thickening of the adductor insertion with minimal osteophytes consistent with mild adductor tendonitis. NO definite hernia is noted. Posterior wall weakness noted again on repeat examination. Management plan Laparoscopic repair with posterior wall strengthening, followed by physiotherapy treatment. The patient underwent a laparoscopic inguinal disruption repair plus strengthening of the abdominal wall using prolene mesh on both sides. The patient is now playing hockey on a regular basis and is delighted with the results of his surgery. He is continuing with his physiotherapy input and is due to be reviewed by the general surgeons later this year. Key notes for general practice Inguinal disruption (ID) is commonly seen in very active sports people and can be defined as pain in the inguinal region near the pubic tubercle, which may have an insidious or acute onset and where no obvious other pathology exists to explain the symptoms (Sheen et al, 2014, p.1086).the diagnosis of ID can be made if at least 3 of 5 clinical signs are present (Table 1). Table 1 (from Sheen et al, 2014) 1. Pin-point tenderness over the pubic tubercle at the point of insertion of the conjoint tendon. 2. Palpable tenderness over the deep inguinal ring. 3. Pain and/or dilation of the external ring with no obvious hernia present. 4. Pain at the origin of the adductor longus tendon. 5. Dull, diffuse ache in the groin, often radiating to the perineum and inner thigh, or across the midline. - It is most common in sports that involve twisting and turning of the trunk and lower extremities (e.g., football, hockey). - No true hernia exists with ID. It is thought that abnormal tension exists in the inguinal canal and this is recognised as posterior wall weakness, external ring dilation, conjoint tendon damage, and tears in the inguinal ligament. 3

4 - There are several theories of causation, e.g., reduction in internal rotation of the hip (leading to shearing forces across the symphysis pubis, which then stresses the inguinal wall musculature), imbalance between hip and abdominal musculature, significant limb length discrepancy, and excessive demands of the sporting activities themselves. - The anatomical defects in the wall (i.e., the inguinal rings) may account for the predominance in the male it is rarely seen in females. Examination of the inguinal rings and cough impulse must be done via the scrotum (Figs. 1 & 2). - Must exclude other causes of groin pain, e.g., gastrointestinal, genitourinary, systemic. - Osteitis pubis and adductor muscle injuries often coexist with ID. Fig. 1 (from Brown, 2013) The external ring can be palpated by inverting the scrotum with the finger (Fig. 2.). Normally, only the tip of the finger can be passed through the external inguinal ring. In cases of a sports hernia a finger easily passes through the external inguinal ring. Palpation of the external inguinal ring will often reproduce the patient s pain. Often, the floor of the inguinal canal can be palpated and the thickness and strength can be compared to the contralateral side. A thin and weak inguinal floor is characteristic of a sports hernia. 4

5 Fig. 2 (from Brown, 2013) References Brown, W. (2013). Sports hernia (online). Available at: (accessed 06 July, 2014). Sheen, A. J., et al. (2014). " Treatment of the Sportsman's groin : British Hernia Society's 2014 position statement based on the Manchester Consensus Conference." British Journal of Sports Medicine 48(14): Bibliography Garvey, J., et al. (2010). "Sportsman hernia: what can we do?" Hernia 14(1): Gilmore, C., et al. (2014). Sports Hernia - History and Physical Examination: Making the Diagnosis with Confidence. Sports Hernia and Athletic Pubalgia: Diagnosis and Treatment. D.R. Diduch and L.M. Brunt (eds.). New York Springer Science+Business Media Hackney, R. G. (2012). "Groin pain in athletes." Orthopaedics and Trauma 26(1): Authors Dr Janet Suckley: Consultant Physiotherapist & Registered Osteopath, Tier 2 MSK Clinic, Longsight Health Centre ( /1255). Dr Bharat Nanavati: General Practitioner, Ailsa Craig GP Practice, and GPwSI in MSK medicine. Please forward any comments/queries to janet.suckley@cmft.nhs.uk Next month s MOM: groin pain another diagnosis. 5

Dr Sanjay Pandanaboyana

Dr Sanjay Pandanaboyana General and Laparoscopic Surgeon Specialist General Hepatobiliary and Pancreatic Surgeon Auckland 16:30-16:50 It's Just a Hernia! Its just a hernia! Mr. Sanjay Pandanaboyana MS,