Hernia DOI 10.1007/s10029-014-1322-9
ORIGINAL ARTICLE
The management of sportsman’s groin hernia in professional and amateur soccer players: a revised concept D. Kopelman • U. Kaplan • O. A. Hatoum • N. Abaya • D. Karni • A. Berber • P. Sharon B. Peskin
•
Received: 9 November 2013 / Accepted: 26 October 2014 Ó Springer-Verlag France 2014
Abstract Background Chronic groin pain appears in athletes with a diverse etiology. In a select few, it can be defined as a sportsman’s hernia, that may be related, among other pathologies, to weakness of the posterior inguinal wall and may successfully respond to surgery. Hypothesis Surgical repair of the sportsman’s hernia is associated with good functional outcomes, if the diagnosis is based on meticulous examination and follows a simple selection flowchart. Study design Prospective case cohort study. Methods The study assessed patients recruited from 2006 until the present assessed by a dedicated team with clinical and radiographic features of a sportsman’s hernia who had failed a specified period of conservative therapies. Surgery was performed using a tension-free mesh open inguinal hernia repair. Results Of 246 male patients with chronic groin pain, 51 underwent surgery (mean age 20.7 years, range 14–36 years) with 58 inguinal procedures performed. Of
D. Kopelman (&) U. Kaplan O. A. Hatoum N. Abaya D. Karni Department of Surgery B, HaEmek Medical Center, Afula, Israel e-mail:
[email protected] D. Kopelman O. A. Hatoum B. Peskin Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel D. Kopelman A. Berber P. Sharon B. Peskin Maccabi Haifa Football Club, Sports Medicine Center, Haifa, Israel B. Peskin Knee and Arthroscopy Unit, Orthopedic Division, Rambam Medical Center, Haifa, Israel
the operated group, seven underwent bilateral surgery with a direct hernia found in 9/58 operated sides (15.5 %), an indirect hernial sac in 8/58 (14 %) and a direct and indirect hernia being found in 3/58 (5 %) of operated sides. There was no post-operative morbidity (median follow-up 36.1 months; range 1–74 months), with two failures (3.45 % of operated sides). All other patients were asymptomatic, returned to full sports activity within 4.3 weeks (range 3–8 weeks) after surgery, and required no analgesics or further treatment. Conclusion Selective surgical hernia repair, based on meticulous anamnesis and physical examination is effective in the management of chronic groin pain in athletes. Keywords
Sportsman’s hernia Groin pain in athletes
Introduction ‘‘Sportsman’s’’ hernia is a clinical entity represented by a constellation of chronic symptoms. It is used to describe a wide variety of entities in the groin and is a poor term for the real condition we are being asked to evaluate as general surgeons. Its diagnosis requires a careful history and examination to rule out other similar but disparate disorders which require differing treatments [1, 2]. Despite this, it is the commonest cause of a painful groin in professional athletes, almost exclusively occurring in males and very often developing in soccer players, where specific activities and stresses involve rapid accelerations and decelerations with sudden directional changes [3, 4]. Soccer players suffer sometimes from chronic inguinal pain which can become a serious debilitating condition and which may interfere with professional activity and may even put the player’s career at risk. The pain may be of musculoskeletal
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origin on both sides of the pubic bone (such as an adductor tendinitis or rectus abdominis tendinopathy) or due to a weakness of the inguinal canal structures and posterior inguinal wall [5]. The etiological basis of this clinical entity amongst athletes, professional and recreational alike, is mixed. The diagnosis ‘‘sportsman’s hernia’’ is itself controversial since this term has been used to describe numerous conditions including a weakness or disruption of the musculotendinous portion of the posterior inguinal wall, a tear in the transversalis fascia [6, 7] specific nerve entrapments [8] as well as symptoms which are in complete accordance with an inguinal hernia which is neither demonstrable preoperatively during physical examination nor which is detected at the time of surgical exploration (a so-called imminent or early direct inguinal hernia) [9–11]. For this reason, it has been suggested that this global variable entity should be renamed as a ‘‘syndrome of muscle imbalance of the groin’’ and that the sportsman’s hernia may be considered as one entity included within this broader syndrome [4]. The typical muscle imbalance amongst soccer players is caused by a combination of adductor and lower abdominal muscle strains, which are the commonest stresses which occur in kicking sports. The diagnostic path is problematic due to considerable etiological variability and the fact that most injuries are not identifiable on physical examination or even with specialized imaging [12]. Further, there is no evidence-based consensus available to guide decision-making and most studies available concerning investigation and management are only level IV recommendations at best [5, 13–16]. The aim of this single-arm, open-label, prospective study was to evaluate a novel anatomically based concept for decisionmaking in soccer players who present with chronic groin pain and to evaluate the surgical and functional results of an open variation of mesh inguinal hernia repair in this specific patient cohort.
Materials and methods A prospective cohort study was commenced in June 2006 in order to evaluate the outcome of soccer players referred to our clinic because of chronic ([3 weeks duration) groin pain. Soccer is the most common sport that our clinic evaluates for groin pain. Between June 2006 and August 2012, 246 players were referred to this specialized clinic with groin pain. The study was approved by the local Institutional Review Board and all patients involved in treatment provided signed informed consent for participation. All patients were diagnosed and treated in accordance with an algorithm developed by the Maccabi Haifa Football Club Sports Clinic Team (Fig. 1) aimed at separating
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inguinal region etiology from other closely related entities that are usually included in the general definition of sportsman’s hernia. Multidisciplinary team approach The medical team of the specialized center for sports medicine of the Israeli Football Club Maccabi Haifa includes a sports physician, an orthopedic surgeon, a general surgeon and expert professional physiotherapists. All team members have established experience in the routine management of sport-related injuries. The team members are involved in all aspects of the preoperative diagnostic workup, the referral process to sports accredited surgeons and parameters of post-operative treatment. The imaging guidelines of the group are defined in Fig. 1. Minor deviations from this protocol resulted due to the fact that some patients were referred to our center after preliminary diagnostic workup done elsewhere. The conservative management protocol of the team is shown in the algorithm. A basic therapeutic course includes 14 days of complete rest without any sports activities plus a 7–10-day course of non-steroidal anti-inflammatory therapy. Such treatment may be repeated twice or even three consecutive times if partial improvement has been initially achieved. The surgical procedure All patients underwent the surgical procedure under spinal anesthesia combined with mild sedation. A 5–6 cm long inguinal incision is made above the inguinal canal. The ‘‘roof’’ of the inguinal canal is opened through the external oblique aponeurosis from the level of the internal inguinal ring to the opening of the external ring. The inguinal cord is lifted with neurectomy of the ilioinguinal nerve and its adjacent branches in the surgical field. The proximal segment of the cord is dissected up to the parietal peritoneum searching for an indirect hernial sac. The transversalis fascia is reinforced with a continuous 3/0 prolene suture. The inguinal canal ‘‘floor’’ is then supported with a partially absorbable light-weight, multi-filament mesh (Ethicon Vipro II, Johnson & Johnson Medical Ltd, Livingston, Scotland). The mesh is cut according to the individual inguinal anatomy to fit a tension-free support of Hasselbach’s triangle, being anchored with 3–4 3/0 prolene sutures to the inguinal ligament laterally and to the conjoint tendon medially. An opening is cut in the proximal lateral part of the mesh exactly above the internal ring through which the inguinal cord enters the inguinal canal. The external oblique aponeurosis is incised medially, 1–2 cm, at its most distal part approximately 2 cm proximal to its pubic insertion. The external ring (constituting the inguinal canal ‘‘roof’’) is reconstructed by re-suturing both sides of
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Fig. 1 An algorithm for the management of acute and chronic groin pain in athletes (these subsegments of the groin area are shown in Fig. 2). The number of patients (in pink) treated in each category of the workup algorithm
Fig. 2 Schematic representation of subregions of groin symptoms. A Inguinal region B Adductor region C Suprapubic region
the external oblique aponeurosis. The reconstructed tension-free external ring is usually 1–2 cm more proximal than its original location. Scarpa’s fascia is closed with a continuous absorbable 3/0 suture and the skin is approximated with metallic clips. Post-operative rehabilitation and follow-up All operated patients were observed and treated on a daily basis by the professional physiotherapy team at the specialized center for sports medicine of the Maccabi Haifa
football club. Patients commenced physiotherapy and physical rehabilitation 1-week following the surgical procedure. Each patient was followed closely by the team and the permission to join his team’s regular practice schedule was provided on an individual basis. Patients were discharged from the hospital 24 h after the procedure. Postoperative follow-up included two visits, the first 5–7 days after surgery during which the metal skin clips were removed and the second visit 3 weeks after the procedure during which further instructions with regard to physical rehabilitation and advice regarding a return to full sports activity was provided. Two phone interviews were made with the patients 4–6 months after surgery and during a 2-month period prior to construction of this manuscript. The phone interviews inquired about details of general physical status and professional activity, inguinal and/or groin symptoms and the length of the rehabilitation period required before return to full athletic physical fitness. Postoperative pain evaluation by VAS (visual analog score) was made three times: On the first day post-operative, and in the two follow-up visits at the clinic. At the phone interview the patients were asked if they have any symptoms related to the surgical procedure.
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Hernia Table 1 Diagnostic imaging use and findings
Table 2 Inguinal hernia surgery findings
Group according to symptomatic region
A
B
A?B
C
Total
Group according to symptomatic region
A
B
A?B
C
Total
# of patients
31
129
73
13
246
# of patients
31
129
73
13
Dynamic US performed to
All patients
246 patients
Number of operated patients
21
15
14
1
51 patients
Dynamic US findings Non-inguinal pathologies pubic and suprapubic edema/ inflammation
4
–
–
9
13
Weakness of the posterior inguinal canal wall
14
33
26
–
73
MRI performed to
18
38
29
13
98
9
14
4
–
1
29.4
27.5
*2
67.7
11.6
19.1
7.7
3
2
1
2
–
9 sides (15.5 %)
14
Short (\4 cm) indirect sac
3
1
4
–
7
8 sides (14 %)
Combined posterior wall weakness ? indirect sac
1
2
–
3 sides (5 %)
5
–
20
Hip joint pathologies Bone scan performed to
– –
1 2
2 3
– 9 7
Bone scan findings –
7 patients 58 sides
4
15
–
–
3
–
–
1
Total number of operated sides Operative findings
100
Impression of significant weakness of the posterior wall of the inguinal canal
Adductor longus injuries
Suggesting of osteitis pubis
41
% of the presenting symptom group Bilateral repair
MRI findings Suggesting of osteitis pubis
% of operated patients
Results During the study period, 246 patients were assessed. All patients were male (mean age 20.7 years, range 14–36 years). Imaging studies Dynamic US, MRI and bone scan
–
depending on the specific diagnosis and according to individual patient evaluation: physiotherapy, shock wave treatments, local steroid injections, local platelet rich plasma injections, combined with anti-inflammatory medications or in very selected cases surgery.
All patients in this series underwent dynamic US examination of the groin including the pubic and adductor insertion regions of the lower abdomen and the proximal medial aspect of the thigh. 98 patients had MRI of the same regions. The decision when to refer a patient for MRI was not consistent and was primarily based on positive pathological ultrasonographic findings and influenced by multiple additional considerations including availability, cost, preliminary results of conservative treatments, patient’s demand etc. Only 14 patients were referred to bone scan. Summary of the imaging findings is described in Table 1.
Referrals to inguinal hernia surgery
Non-inguinal pathologies
Fifty-one patients were operated for inguinal hernia repair. Subdivisions of this group according to presenting symptomatology and operative findings are described in Table 2. The intraoperative findings included a direct hernia as shown by a significant weakness of the inguinal canal ‘‘floor’’, an absence or tear of the transversalis fascia and/or a significant bulging of the tissue at the site of Hasselbach’s triangle. No elongated direct hernial sacs were found. The level of weakness of the inguinal canal floor was not
Imaging evidence of non-inguinal pathology was found in 37 patients (15 %). These findings were of inflammatory pathologies of the pubic bone and symphysis pubis, rectus abdominis muscles, and hip joint pathologies that were diagnosed and supported both by dynamic ultrasound and magnetic resonance (MR) imaging, these patients were referred to a variety of non-hernia treatments that included,
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Of the 73 patients with positive finding of weakness of the posterior inguinal wall 42 (58 %) were eventually referred to surgery. Nine additional patients with negative findings both in US and MRI were also operated. Seven were from symptoms group A and two from group A ? B. Total of 51 patients (20.73 %) were referred for hernia repair (mean age 23.9 years, range 14–36 years), 158 (64.23 %) treated conservatively without any surgical intervention. Surgical findings
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measured. We did not use an objective numerical scale for grading such findings, but just a descriptive impression as very mild, mild, significant or actual sac. In 38 out of 58 operated groins (65 %) no abnormalities were found, either in the preoperative imaging workup as well as during the operative procedure itself (Table 2). Post-operative evaluation There was no post-operative morbidity recorded during follow-up (median follow-up 36.1 months; range 1–74 months) and only one patient was lost to follow-up. The average post-operative pain evaluation by VAS score on the 1st post-operative day was 4.8 (range 3–8), on the 1st visit at the outpatient clinic the average was 2.2 (range 0–6), and on the 2nd visit 3 weeks after the procedure the average was 0.9 (range 0–4). Follow-up revealed two failures (3.45 % of operated sides) with one early failure and one late (30 months) recurrence. In the first case, the patient’s symptoms did not improve up to 6 weeks post-hernia repair and he chose to be operated again overseas without known details concerning the reoperative procedure or outcome. The second patient underwent repeat hernia repair of a direct hernia in the inferior aspect of the mesh immediately above the pubic bone, with an uneventful outcome that remains asymptomatic after 26 months follow-up. All other patients returned to full sports activity. The median period of time until resumption of full sport activity was 4.28 weeks (range 3–8 weeks). No wound problems, no mesh related chronic pain, nor were feelings of foreign body recorded.
Discussion Regional subdivision of the groin Our group used a different clinical approach towards those athletes presenting with acute or chronic groin pain where a ‘‘sportsman’s hernia’’ is identified. In this respect, we have outlined three critical anatomical sites in the groin region and tried to attribute the patient’s complaints and physical findings to either one or two of these areas (inguinal, adductor and suprapubic regions). Since adductor, rectus abdominis and pubic bone pathologies may occur in the absence of a definitive hernia and since other treatments, (both surgical and non-surgical), have been proposed for these specific conditions [17–21], our view was to separate these entities on the basis of an accurate description of the pain and meticulous physical examination. Our results suggest that pubic and suprapubic symptomatology (area C) should be carefully differentiated from inguinal and adductor complaints and should not be considered as representing sportsmen hernia. Hernia repair was then
selectively offered only to patients whose predominant complaints and physical findings were focused at the inguinal region with or without radiation to the medial aspect of the proximal thigh with failed response to conservative therapy. In this regard, area A, the region medial to the inguinal ligament includes the inguinal canal, the external and internal inguinal rings and the conjoint tendon up to the lateral border of the rectus abdominis sheath. Diagnostic imaging The diagnostic value of imaging in these patients appears to be relatively limited, mostly being used in order to exclude alternative diagnoses including osteitis pubis, adductor tendinitis or tears and hip joint pathologies. Most candidates for surgery undergo both ultrasound and MR imaging with bone scanning being used when chronic skeletal injuries are suspected. We usually use a dynamic ultrasound study performed by an ultrasonographer experienced in sports-related injuries, conducting the examination during coughing and after performance of the Valsalva maneuver. This permits detection of internal inguinal ring dilatation and posterior wall weakness in some patients with no clinical signs of a hernia. It is logical to expect less posterior wall weakness being detected during surgery compared to the preoperative dynamic ultrasound findings, as was evident in this study. Ultrasound examination is widely available, inexpensive and involves no radiation exposure, yet it has been claimed that there is no demonstrable difference in the outcome of inguinal surgery between patients who have an abnormal or a normal groin ultrasound examination [5, 16]. In this respect, the absence of definitive ultrasonographic findings should not preclude surgery if the clinical picture is compelling. By contrast, a significant difference in outcome has been reported between patients who did or did not have a positive bone scan with increased uptake at the symphysis pubis or the superior edge of the pubis. In our series and the accepted consensus in the literature is that such findings should be considered as contraindication to inguinal hernia surgery [26–28]. The decision to perform inguinal hernia surgery was more difficult in patients of group B, who had no inguinal symptoms. In spite of the fact that this group was the largest group with 129 patients only 15 patients (11.6 %) of this group were operated. The decision in these patients was based on the combination of weakness of the floor on US and failure of conservative therapy. The role of inguinal surgery Most patients of this cohort did not require surgery. Symptomatology subsided with conservative treatment alone. This fact support the widely accepted understanding
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that the term hernia is a misnomer and that the symptoms represent variety of phenomena like musculoskeletal disbalance, tears, tensions, and chronic inflammatory conditions. It is of special importance to note that the majority of patients in our series presented with symptoms of the anteromedial aspect of the proximal thigh, which is the region of the adductor muscles; 129 patients (group B, 52.4 % of the total series population) presented such symptoms only and only 15 (11.6 %) required an operation. Only between 10 and 20 % of patients presenting with adductor region symptoms (groups B and A ? B) will require surgical hernia repair. Strains and tears of the adductor muscles are common among soccer players. Pain in this region may result directly from such injuries but may also radiate from the inguinal region. Groin pain due to acute musculoskeletal injuries may be a self-limited condition, frequently resolving within days or weeks. Those patients suffering from chronic groin pain have usually undergone most aspects of conservative treatment without success. The strategy and decision-making prior to surgery has been summarized in our unit’s algorithm. In the literature there is no uniform consensus concerning the pathogenesis, diagnosis and therapeutic approach in this patient group with current literature showing no clear benefit for a range of non-surgical treatments [29, 30]. Evidence from this small cohort suggests that unnecessary surgery is avoided with careful patient selection, resulting in a relatively low failure rate of surgery. Corroboration of this view has been reported by others with such a selective approach with between 80 and 100 % of cases returning to regular activity after hernia repair either performed in open fashion similar to that we have described [5, 7, 22, 23] or via a laparoscopic approach [11, 24, 25]. We believe that no one would argue that sportsman’s hernia is merely a misnomer that symptoms are actually not related to a real hernia, yet fortunately the surgical hernia repair procedure helps to alleviate those symptoms in most cases. The open inguinal repair The surgery we describe is a variant of a groin reinforcement technique of the abdominal wall muscles and the transversalis fascia with our group and others suggesting that the open approach is favored in these specialized circumstances in an effort to reduce secondary adductor strain which may require additional delayed tenotomy [20, 21, 31]. It is obvious that the ‘‘open’’ tension-free repair was extremely successful in alleviating the symptoms in this series. Why? What can be a good explanation for these results? Our open approach developed as part of the belief that it provides a better opportunity to perform neurectomy of the ilioinguinal nerve where nerve entrapment may play a role in chronic groin pain arising from the inguinal
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region. In this regard, Akita et al. [8] have shown several anatomical variations in the cutaneous ilioinguinal branches present in the inguinal region where additional communications occur with the genital branches of the genitofemoral nerve in 35 % of cases, where the genital branch and the ilioinguinal nerve unite in the inguinal canal in 13 % of patients and where the genital branch pierces the inguinal ligament to enter the inguinal canal in 11 % of cases. Equally, we suggest that the open approach better provides ability to release the external oblique aponeurosis where physical examination of 65 % of the operated patients revealed significant sensitivity to manual palpation of the external ring. The external oblique aponeurosis that comprises the external ring is a superficial structure that in regular hernia repair is not closed in a tension-free manner like the inner layers. Symptoms arising from possible minor tears of this structure may be alleviated by tension reduction at this point. It is our view that the above mentioned two ancillary procedures are best performed via a standard relatively short inguinal incision combined with a tension-free mesh repair. An obvious drawback of this series is the fact that it includes seven patients that were operated with a different type of light-weight mesh. The possible impact of the difference between Vipro mesh and Physio mesh is limited mainly to the post-operative evaluation. Most aspects of this study namely the significance of specific symptomatic regions, diagnostic flow chart, and other principles of the surgical technique are not related or expected to be influenced by the choice of mesh. Furthermore, both mesh types belong more or less to the same group of composite light, large porous meshes. Post-operative evaluation The post-operative pain in all the operated patients was evaluated using VAS only. In all cases the immediate postoperative pain was mainly described to be at and around the surgical site, namely area A. Even those patients, who presented with painful complaints in adjacent areas B or C, did not mention any pain at other area then the surgical site itself. The average VAS results demonstrate relatively sharp yet expected drop in pain towards the 1st and 2nd follow-up visits. The pattern according to which the postoperative pain gradually subsided was not different than what we experience with non-sportsmen hernia inguinal repairs, yet this was merely an impression of the surgeons at the follow-up clinic.
Conclusion Although chronic groin pain which can disturb an athlete’s career is relatively common, the majority of cases can be
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managed conservatively with intensive specialized treatment algorithms. A thorough history and examination defines those patients with a sportsman’s hernia suitable for inguinal repair. The medium-term results in our selected series with a specified open approach and tension-free mesh hernioplasty shows very low morbidity with a high rate of return to athletic activity after a short recuperative period.
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