[

RESIDENT’S CASE PROBLEM

]

CASEY A. UNVERZAGT, PT, DPT, CSCS1 • TERESA SCHUEMANN, PT, SCS, ATC, CSCS2 • JEFFREY MATHISEN, MD3

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Differential Diagnosis of a Sports Hernia in a High-School Athlete hronic groin pain in athletes can be confusing and misleading, as it can have a multitude of individual or concomitant etiologies.22 Its frequency, nonetheless, is relatively common; it has been reported that approximately 5% of all soccer injuries involve the groin,12 accounting for a disproportionately large amount of time lost from sport.1,4 Meyers et al17 noted that chronic groin pain in a number of prominent athletes in professional sports, including the

C

National Football League, National Hockey League, and major league soccer, has heightened awareness of the condition among players and sports medicine teams. T STUDY DESIGN: Resident’s case problem. T BACKGROUND: Chronic anterior hip and groin pain is a growing concern among high-performance athletes. This manuscript enforces the need for physical therapists to remain current with its complex differential diagnosis, as it can be debilitating for the athlete and equally frustrating for the sports medicine team. This resident’s case problem details the account of an 18-year-old highschool wrestler who presented to the high-school sports medicine team without physician referral. His chief complaint was chronic right anterior hip and groin pain, which had been variable in frequency and intensity for 3 years.

T DIAGNOSIS: A screening examination for serious underlying pathology was negative. After physical examination, it was determined that this individual had signs and symptoms consistent with a sports hernia. He was referred to a general surgeon who diagnosed him with a symptomatic inguinal hernia

Etiology There are a number of conditions that can lead to anterior hip and groin pain that are most often seen in the adolescent population. These conditions include, but and later performed laparoscopic evaluation and treatment. The patient had a moderate-size indirect inguinal hernia sac, which was carefully dissected away from the remaining contents of the spermatic cord and was repaired with a Parietex mesh. At a 2-week postoperation follow-up, the patient was asymptomatic and cleared to return to wrestling and baseball without limitations.

T DISCUSSION: This resident’s case problem demonstrates the debilitating and often elusive nature of a sports hernia. It suggests that the diagnosis is not well understood and emphasizes the importance of a robust medical foundation for each member of the sports medicine team conducting athletic evaluations. T LEVEL OF EVIDENCE: Diagnosis, Level 4. J Orthop Sports Phys Ther 2008;38(2):63-70. doi:10.2519/jospt.2008.2626 T KEY WORDS: abdomen, abdominal, athletic pubalgia, groin

are not limited to, Legg Calve Perthes disease, epiphyseal fracture, slipped capital femoral epiphysis, and acetabular labral derangement.12,22 Nerve entrapments of 1 or more of the inguinal nerves should be considered as possible causes of groin pain as well. These nerves include the ilioinguinal, iliohypogastric, obturator, genitofemoral, and the lateral cutaneous nerve (most commonly meralgia paresthetica).1,9,10,12,22 Underlying or associated musculoskeletal problems include osteitis pubis, adductor tenoperiostitis, or a stress fracture of the pubic rami.1,9,12,22,25 Urologic diseases referring pain to the inguinal region include prostatitis, epididymitis, urethritis, hydrocele, and varicocele.22 Groin pain has long been cited as a common complaint among individuals with a hernia as well.18 There are 2 main types of inguinal hernias: (1) a direct inguinal hernia, in which a sac formed by the peritoneum, and containing a portion of the intestine, pushes directly outward through the weakest point in the abdominal wall,6,18 and (2) an indirect hernia, which travels downward through the internal inguinal ring into the inguinal canal through which the testes descend into the scrotum during infancy (males) or to the labia (females).6,18 FIGURE 1 demonstrates the anatomy of an indirect inguinal hernia. The indirect inguinal hernia is most common in infants and adolescents,

1

Physical Therapist (at time of study), Skyline Hospital Physical Therapy and Sports Medicine, White Salmon, WA. 2 Director of Physical Therapy and Director of Sports Physical Therapy Residency (at time of study), Skyline Hospital Physical Therapy and Sports Medicine, White Salmon, WA. 3 General Surgeon, Mid Columbia Surgical Specialists, The Dalles, OR. This case was seen at Skyline Hospital Physical Therapy and Sports Medicine Department, White Salmon, WA. At the time of the case, Casey Unverzagt was completing a sports physical therapy residency under the mentorship of Teresa Schuemann. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of Skyline Hospital or Mid Columbia Surgical Specialists. Address correspondence to Dr Casey Unverzagt, Proaxis Therapy, 1650 Skylyne Drive, Suite 110, Spartanburg, SC 29307. Email: [email protected] journal of orthopaedic & sports physical therapy | volume 38 | number 2 | february 2008 |

63

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

[

RESIDENT’S CASE PROBLEM

FIGURE 1. An indirect hernia follows the inguinal canal, the pathway that the testicles descend into the scrotum during infancy (males) or to the labia (females). This pathway normally closes before birth but remains a location susceptible to herniation. (Illustration compliments of Theresa Perry).

particularly in males because it follows the tract that develops when the testes descend into the scrotum before birth.6 Of note, an indirect hernia is always anterolateral to the epigastric vessels, whereas a direct hernia is anteromedial. Due to the often vague complaints and frequent comorbidities related to an inguinal hernia, a careful examination of the lumbar spine, pelvis, abdomen, sacroiliac joint, peripheral nervous system, gastrointestinal system, and genitourinary system is vital.3

Pathology Despite the prevalence of the condition, the literature is filled with confusing and contradictory information regarding the etiology, presentation, diagnosis, and management of an inguinal hernia with chronic anterior hip and groin pain.22 There have been a number of names used in the literature that have attempted to describe this condition: sportsmens hernia, footballers hernia, inguinal insufficiency, conjoint tendon tear, hockey players groin, athletic pubalgia, and Gilmore’s groin.1,5,4,10,11,16,17,22,23 The term sports hernia has recently been favored despite an

actual protrusion rarely being associated with this type of condition.1,11,17,21 Kemp and Batt10 defined a sports hernia as “a disruption of the inguinal canal without a clinically detectable hernia.” Taylor et al23 add to the definition with “chronic inguinal or pubic-area pain in athletes that is exertional only and not explainable preoperatively by a palpable hernia or other medical diagnosis.” The definition is further specified by Swan and Wolcott,22 who hypothesize the pathology to be due to a weakened posterior wall of the inguinal canal (transversalis fascia). By definition, the location, physical findings, and pathology of a sports hernia are often subtle. As suggested by the numerous similar, but subtly different, definitions, the term sports hernia encompasses several different structural abnormalities with a variety of underlying etiologies. The first and most commonly hypothesized etiology is secondary to overuse of abduction, adduction, flexion, and extension moments about the hip, which results in excessive pelvic motion producing a shear across the pubic symphysis, thus leading to stress on the inguinal wall musculature perpendicular to the fascial fibers.1 Another possible etiology is pulling from the adductor musculature against a fixed lower extremity, causing shear forces across the hemipelvis.1,5 Anderson et al1 also cite increasingly rigorous off-season conditioning programs that strengthen the lower extremity but neglect abdominal musculature as a cause of pelvic imbalance; this could potentially lead to subtle contractures of the hip flexor or adductor muscles, thus increasing the risk of creating a sports hernia. As illustrated in FIGURE 2, attenuation or tearing of the transversalis fascia or conjoined tendon has been suggested as the location of anatomic abnormality.1,7 Other studies suggest an anatomic abnormality at the insertion of the rectus abdominis,1,17,23 avulsions of the internal abdominal oblique at the pubic tubercle,23 or anomalies about the external abdominal oblique and aponeurosis could lead to a hernia.12,13

]

FIGURE 2. A proposed mechanism of a sports hernia,1,7 Hackney7 cites an imbalance existing between strong adductor muscles (arrow) and relatively weak lower abdomen, which may lead to attenuation or avulsion of the pelvic floor structures (as shown in inset). Reprinted with permission from Anderson et al.1

These aforementioned anatomic abnormalities, collaboratively termed a sports hernia, can include the more specific diagnosis of an inguinal hernia. The inguinal canal, which carries the spermatic cord in males and the round ligament in females, is a passage approximately 4 cm in length running obliquely toward the groin just above the inguinal ligament.18,22 The borders of the inguinal canal are the external oblique aponeurosis and the internal oblique muscles anteriorly, and the fascia transversalis posteriorly. The fascia transversalis is reinforced by the internal oblique and transversis abdominis conjoined tendon; the superficial inguinal ring is positioned anterior to this conjoined tendon.10 The conjoined tendon consists of the internal abdominal oblique and transversis abdominis aponeurosis, which fuses medially before its insertion onto the pubic tubercle.22 An athlete with a sports hernia typically presents with an insidious unilateral onset of inguinal pain, though some individuals will report a sudden tearing sensation. Either onset typically progresses to pain and dysfunction with cutting, turning, and striding out, and can progress to dysfunction with sagittal plane running as well. Kemp and Batt10

64 | february 2008 | volume 38 | number 2 | journal of orthopaedic & sports physical therapy

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

note that pain is usually localized to the conjoined tendon and inguinal canal, though it may radiate contralaterally to the perineum, rectus, or adductor muscles.15 It has been demonstrated that in patients with posterior wall defects, up to 40% can demonstrate a discrepancy between the side of pain and the side of the defect discovered during laparoscopy. 3,22 Hackney8 found that 30% of males who were treated for a sports hernia complained of associated testicular pain preoperatively. This pain is typically brought on by sudden movements, namely cutting and twisting, and can be exacerbated by coughing or sneezing. Athletes who participate in sports requiring repetitive, high-velocity twisting and cutting, such as ice hockey, lacrosse, and soccer, are at greatest risk of developing a sports hernia.1,2,7,9-12,19,21,22 Additionally, it appears that kicking sports may predispose an athlete to this injury.22 Typical symptoms before diagnosis range in duration from 6 weeks to 5 years, with a mean duration of 20 months.7,15

Diagnosis The sports hernia is a clinical diagnosis, with no definite diagnostic test available9; nonetheless, diagnostic imaging is important for several reasons. Radiographs and bone scans are important to investigate possible comorbidities, including symphyseal instability, bony tumors, osteitis pubis, adductor tenoperiosteal lesions, and hip osteoarthritis.1 A herniography can be performed, in which fluoroscopic examination is augmented by an intraperitoneal injection of positive-contrast material, while the patient performs several Valsalva-type maneuvers. A positive study would show abnormal flow of contrast outside the normal contours of the peritoneum.22 Despite its purpose, however, herniography is typically not utilized, as its effectiveness in detecting sports hernias has yet to be demonstrated.17 Ultrasonography would theoretically be well suited for diagnosis of this condition, but its accuracy is debatable and it is operator dependent.1 Lastly, using so-

nography for the diagnosis of an inguinofemoral hernia, Robinson et al20 found that of 59 consecutive patients there was only 1 false negative. However, Robinson et al20 did not specifically investigate posterior inguinal wall deficits, and thus the results should be interpreted with prudence. To the author’s knowledge there are no published data on the sensitivity, specificity, positive predictive value, or negative predictive value of sonography to diagnose a sports hernia. Typically, sports hernias are both diagnosed and treated endoscopically. In 2004, Kluin et al11 found that 17 of 18 athletes with chronic groin pain were diagnosed and concomitantly treated with the use of endoscopic techniques. To evaluate for a protruding indirect hernia, examination for a dilated superficial inguinal ring may be done by inverting the scrotum with the little finger, finding localized tenderness over the conjoined tendon, pubic tubercle, and midinguinal region; a small cough impulse may be detected, but is not diagnostic.10 Physical examination has a sensitivity of 75%, and specificity of 96% for the detection of an indirect inguinal hernia.24

Intervention As an initial intervention, several weeks of relative rest, followed by functional rehabilitation for up to 3 months, is considered reasonable.9 Should conservative intervention fail, or should symptoms be chronic in nature and limit an athlete’s participation in sport, surgery is typically recommended.3 Herniorrhaphy can be effective with either a conventional or laparoscopic approach.1,23 Taylor et al23 describe the pelvic floor repair as a broad surgical reattachment of the anterolateral edge of the rectus abdominus with its fascial investment to the pubis and adjacent anterior ligaments. Myers at al17 add that the operation is similar, but not identical, to a Bassini hernia repair in that the pelvic floor repair focuses on attaching the rectus abdominus muscle fascia to the pubis. A traditional Bassini repair focuses on protecting the inguinal floor near

the internal ring. Therefore, the primary difference between the pelvic floor repair and Bassini repair is the orientation of the suture: the internal ring is usually left intact.17 Regardless of whether surgery is performed laparoscopically or with an open approach, the standard of care includes the utilization of mesh, even in young athletes. Postoperatively, most athletes return to sports within 6 to 12 weeks after performing a specific rehabilitation program targeting abdominal strengthening, adductor muscle flexibility, and a gradual return to sport.1,10,23 Outcomes of this surgery appear to be favorable. Simonet et al21 reported on 10 elite-level hockey players with chronic groin pain who underwent surgical repair and subsequently returned to their sport. Malaycha and Lovell16 reported on 50 athletes with chronic undiagnosed groin pain who underwent surgical exploration and inguinal hernia repair. Six months later, all athletes were sent questionnaires to assess their return to sport, level of pain (using analogue pain scores), and the overall result of their surgery. Fortyone athletes (93% of respondents) had returned to normal activities. Pain scores indicated a marked improvement in their level of pain (P .001). A similar percentage of athletes returning to sport (93.8%) was reported by Poglase et al19 following hernia repair. Genitsaris et al3 reported on 131 athletes who underwent repair for a sports hernia, including unilateral defect of the posterior inguinal wall and deficiency of the internal inguinal ring; 127 (96.9%) returned to recreational pursuits within 1 week, and to full sporting activities within 2 to 3 weeks. The remaining 4 patients (3.1%) reported thigh pain, which resolved spontaneously after 3 to 6 weeks. At a mean follow-up of 5 years (range, 4 months to 10 years), there was only 1 recurrence (0.76%), which was corrected laparoscopically. The only prospective, randomized clinical trial investigating the outcomes of surgical intervention for a sports hernia included 66 soccer players.2 All patients had pathologic findings with herniogra-

journal of orthopaedic & sports physical therapy | volume 38 | number 2 | february 2008 |

65

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

[

RESIDENT’S CASE PROBLEM

phy or a nerve block test. The subjects were randomized into 1 of 4 groups, each being evenly matched for age, number, activity level, and duration of symptoms. The 4 groups included (1) a control group, (2) nonsteroidal anti-inflammatory medication and physical therapy, (3) individual physical training, and (4) open surgical repair with ilioinguinal and iliohypogastric neurotomy. At a 6month follow-up, the authors reported that the only substantial and statistically significant improvement in symptoms and return to sport frequency was for the surgical group. This study helped confirm what had long been postulated: patients with chronic groin pain secondary to a sports hernia do not get better with conservative measures, and typically require surgical intervention.2,22 While the majority of literature regarding groin pain in athletics has emerged from Europe and Australia, a large uncontrolled series of North American athletes was studied by Myers et al.17 They evaluated 276 high-performance athletes with severe chronic lower abdominal or inguinal pain, 76% of which were soccer, hockey, or football players. They diagnosed and repaired 160 sports hernias in 157 patients. Seventy-nine percent of those treated with surgery were of collegiate, professional, or regional/national amateur level. Mean follow-up was 3.9 years (range, 25 months to 12 years). TABLE 1 displays the symptoms of the 157 athletes at the time of initial preoperative evaluation. TABLE 2 displays their associated objective physical examination findings as performed by physicians at either the University of Massachusetts Medical School or Duke University Medical Center during or since 1987. TABLE 3 reports on the surgical findings of the 160 repairs on the 157 athletes. After surgical repair, all but 5 patients reported performing as well or better than before injury. There were 152 (97%) athletes who returned to their preinjury level of play. A successful procedure was reported by 142 athletes (89%), which was defined by the patient reporting no or minimal pain at 6 months

TABLE 1

]

Symptoms Reported at Initial Evaluation Prior to Physical Examination for the Patients in the Case Series by Meyers et al 17

Symptoms

Patients Reporting Symptoms (n = 157)

Remembered a distinct injury during exertion

112 (71%) 10%

Pain with coughing, sneezing, or Valsalva maneuver Had completely stopped competing at time of evaluation

151 (96%)

Unilateral pain

89 (57%)

Bilateral pain

68 (43%)* 105 (67%)†

Initially reported pain with resisted hip adduction Pain with hip flexion

14 (9%)

Mean (range) duration of symptoms for entire group

1.2 y (10 d-6 y)

* 62 of 68 patients progressed from unilateral to bilateral pain. † In 70 of 105 patients the pain with resisted hip adduction began after the lower abdominal pain.

Physical Exam Findings at Initial Evaluation for the Patients in the Case Series by Meyers et al 17

TABLE 2 Physical Examination Findings

Positive Tests (n = 157)

Pain with resisted hip adduction

138 (88%)

Pain with resisted sit-up

72 (46%)

Pubic or peripubic tenderness

35 (22%)

Adductor longus tenderness near pubis

57 (36%)

Direct pubic symphysis tenderness

14 (9%)

Inguinal or lower abdominal tenderness

11 (7%)

Testicular tenderness

2 (1%)

TABLE 3

Operative Findings for the Patients in the Case Series by Meyers et al 17

Operative Findings

Number of Patients (n = 157)

“Loose feeling” of inguinal floor (Hesselbach’s triangle)*

89 (57%)

Obvious defects of external oblique aponeurosis

75 (48%)

“Thin” insertion of the rectus abdominis on involved side*

27 (17%)

Clearcut tear of rectus abdominis muscle insertion

9 (6%)

* Surgeon’s subjective description.

after surgery with a complete return to preinjury level of playing performance. The surgery was found to be moderately successful for 10 patients (6%), as defined if the athlete returned to a level of performance similar to his or her preoperative level, with improved but persistent pain. Minimal success was noted in 3 patients (2%), which meant subjective improvement, but not to the preoperative level.

Five surgeries (3%) were unsuccessful noting no or minimal improvement. The top 3 nonmusculoskeletal causes for pain found in 26 patients during preoperative evaluation included irritable bowel, endometriosis, and urologic problems. Of interesting note for the aforementioned study17 is that of 20 females (7% of patients) who were evaluated for a potential sports hernia, 19 (95%) had

66 | february 2008 | volume 38 | number 2 | journal of orthopaedic & sports physical therapy

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

other causes for their pain. The most frequent causes of their anterior hip and groin pain included, in order of frequency, endometriosis, other gynecological problems (ovarian cystic disease, pelvic inflammatory disease, severe adhesions possibly representing endometriosis), and Crohn’s disease. The authors postulated 2 possible explanations for this sex difference: (1) relatively low participation (until recently) of women in highly competitive sports, and, more likely, (2) a difference in pelvic anatomy. While Meyers et al7 published the largest case series of athletes in North America with sports hernias, the results must be interpreted with caution. First, a case series typically results in inflation of a treatment effect. Additionally, one is unable to determine the relevance of the percent of positive findings in this population; the authors failed to report on how many of the athletes who were not diagnosed and treated for a sports hernia actually had the same symptoms as those who were diagnosed and treated. These 2 points do not negate the findings of the study, but they must be identified as limitations. There is little research in the physical therapy literature featuring the presentation, diagnosis, and management of individuals with chronic groin pain. This lack of information may be because current evidence does not support conservative therapy for the management of this often disabling condition. Nonetheless, it is essential that physical therapists working in an athletic environment be able to identify this condition and understand how to appropriately manage it. The current resident’s case problem, which details the history and clinical presentation of a young athlete with chronic groin pain, demonstrates the importance of an accurate diagnosis and referral for individuals with a suspected sports hernia.

Patient Characteristics and History The patient was an 18-year-old otherwise healthy white male high-school senior (height, 177 cm; body mass, 65.8

kg; body fat, 9.3%) with complaints of chronic right anterior hip and groin pain for the past 3 years. The individual described the pain as dull, diffuse, and often achy. He was active in varsity baseball and wrestling, and believed that he may have sustained the injury while striding out during a baseball game his freshman year (3 years ago). He noted that the pain is typically brought on with cutting and twisting activities, which forced him to change his batting stance from batting right handed to left during his junior year. Rest from activity decreases symptoms severity, but it quickly comes back when he returns to sport. The patient initially sought treatment from a chiropractor his freshman year. He reported never receiving a formal diagnosis at the time, but did report that he received multiple lumbar manipulations over the course of 1 to 2 weeks. Additionally, the patient’s mother recalls that he received several “energy balancing treatments” before manipulation; chiropractic treatment provided no long-lasting benefits. He visited his primary care physician his sophomore year, approximately 11 months after the initial injury, and was diagnosed with a hip strain and received no treatment. However, considering the chronicity of the pain, he was referred to an orthopaedic surgeon for consultation. The orthopaedic surgeon reported an unremarkable physical examination, though was suspicious of a hairline fracture in the shaft of the proximal femur in a radiographic frog-leg view. The fracture was not visible in the anterior-posterior view nor in subsequent frog-leg views; nonetheless, an unenhanced magnetic resonance imaging (MRI) study was ordered of his hip and proximal femur, and the individual was held from sport until follow-up consultation. The MRI of his hip and proximal femur came back unremarkable and the patient was released to full recreation without further diagnostic testing or intervention. The individual returned to his primary care physician at the start of baseball season his junior year (last year) reporting

similar pain. He was advised to hit lefthanded and was given instructions on massage and aspirin intake. He was also told to call in 2 weeks if his pain continued. The patient failed to follow-up with his physician.

DIAGNOSIS

S

tudent athletes are regularly seen in the high school setting. During a routine visit, the patient approached the senior author reporting chronic anterior hip and groin pain, which was recently exacerbated during wrestling practice. A detailed past medical history was obtained, which revealed no remarkable findings. A review of systems was performed, which revealed no apparent abnormalities, and revealed no history of low back or sacroiliac joint pain. The individual reported no family history of similar complaints, nor any family history of related cancer. The physical examination revealed normal and symmetrical hip range of motion and age-appropriate muscle strength. Circulation was assessed at the femoral, popliteal, and dorsalis pedis arteries, each demonstrating strong and regular pulses that were symmetrical bilaterally. No point tenderness was noted about the pubic symphysis, anterior superior iliac spine, posterior superior iliac spine, or iliac crests. Mild discomfort was noted about the ipsilateral (right) symptomatic inguinal ligament; this pain was similar, though less intense, to the “dull ache” he described as occurring during exacerbations of pain. Coughing, sneezing, and bearing down did not cause pain. Iliosacral alignment appeared within normal limits. No limb length discrepancy was noted per gross visualization, measuring of anterior superior iliac spine to the medial malleolus, nor with the supine-to-sit test. Sensation was reportedly normal over the cutaneous surface innervated by the ilioinguinal, genitofemoral, and lateral cutaneous nerve of the thigh, noting that the patient denied any numbness or tingling in the groin region. Testing re-

journal of orthopaedic & sports physical therapy | volume 38 | number 2 | february 2008 |

67

[

RESIDENT’S CASE PROBLEM

TABLE 4

]

Differential Diagnosis

Competing Diagnosis

Supporting Evidence

Leg-Calve-Perthes disease

• Location of pain

Challenging Evidence

Clinical Suspicion

• Negative radiographs

Low

• Negative MRI Slipped capital femoral epiphysis

• Location of pain

• Patient age, race

• Duration of symptoms

• Patient not sedentary

Low

• Negative radiographs • Negative MRI Urologic dysfunction (prostatitis,

• Location of pain

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

epididymitis, urethritis, hydrocele, varicocele)

• No systemic signs of fever or general malaise

Low

• No report of penile or testicular pain • Exertional pain with hip or trunk rotation

Nerve entrapment (ilioinguinal,

• Location of pain consistent with iliohypogastric,

iliohypogastric, obturator, genitofemoral,

ilioinguinal, genitofemoral, and obturator

lateral cutaneous nerve of the thigh)

distributions

• Pain that increases nearly exclusively with hip or

Low

trunk rotation • Pain that subsides with rest • Pain described as dull and diffuse • Normal sensory and motor function

Acetabular labral derangement

• Location of pain • Pain with hip or trunk rotation

• Equal hip external rotation and internal rotation

Moderate

motion bilaterally

• Chronicity of pain

• Negative special testing (scour, femoral log roll, Patrick’s)

• Positive resisted straight-leg raise

• No report of clicking, pinching, or giving way • Negative MRI (though not gadolinium enhanced)

Osteitis pubis

• Location of pain

• Negative radiographs

• Duration of symptoms

• No pubic misalignment noted on examination

Moderate

• No point tenderness over pubic symphysis Adductor tenoperiostitis

• Location of pain

• Age-appropriate hip adductor muscle strength

• Pain with cutting

• No point tenderness over pubic symphysis

Moderate

• No pelvic misalignment noted on examination Stress fracture (femoral neck,

• Location of pain

pubic symphysis)

• Pain with activity

Hernia (direct or indirect)

• Negative radiographs greater than 1 year after

Moderate

original injury

• No pain with extended cessation of activity

• Negative MRI

• Location of pain

• Young age (for direct hernia)

• Pain with exertion

• Patient remembers mechanism of injury (indirect)

High

• Long-standing pain • Negative radiographs • Negative MRI Sports hernia

• Location of pain

• Not “elite” athlete

• Pain with exertion

• Does not participate in sports typically associated

• Pain with rotation of trunk or symptomatic hip

High

with sports hernia

• Long-standing pain • Multiple prior medical examinations • Negative radiographs • Negative MRI • Point tenderness along inguinal ligament

vealed a painful straight-leg raise and resisted sit-up, both of which vaguely reproduced the patient’s pain that he

typically experienced with rotational movement of the hip and trunk. Negative Patrick’s, Thomas, Ober’s, hamstring con-

tracture, femoral log roll, and scour tests were noted. TABLE 4 provides an outline of the differential diagnosis process. Con-

68 | february 2008 | volume 38 | number 2 | journal of orthopaedic & sports physical therapy

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sidering his history of pain with hip and trunk rotation during sport, the lack of conclusive testing indicative of musculoskeletal pathology and the longstanding nature of his pain, we suspected that this individual had a sports hernia and felt a referral to a general surgeon was indicated. An examination of the superficial inguinal ring was not conducted. This individual sought consultation soon after with a general surgeon, who noted that, in standing, there was point tenderness over the right superficial inguinal ring and the proximal spermatic cord region; this region was tender with Valsalva, and a small impulse was appreciated, though no large bulge was noted. He was diagnosed with a right symptomatic inguinal hernia and was scheduled for laparoscopic right inguinal hernia repair.

Intervention With laparoscopic evaluation, the patient had a moderate-size indirect inguinal hernia sac, which was carefully dissected away from the remaining contents of the spermatic cord. Parietex mesh was placed into the preperitoneal space covering the indirect, direct, and femoral hernia spaces on the right side (FIGURE 3), which was held in place by several titanium tacks. The individual returned for a follow-up examination 2 weeks later and was given clearance to return to competitive sports without restrictions.

DISCUSSION

T

his resident’s case problem illustrates the clinical decision making in successfully referring a patient for appropriate surgical care for chronic anterior hip and groin pain. After a thorough review of the individual’s past medical history, assessing his presenting symptoms, and after careful physical examination, it became evident that medical referral was indicated for likely laparoscopic evaluation of the inguinal space. Intraoperatively, it was determined that this individual had a congenital indirect

FIGURE 3. Similar to the procedure described by Genitaris et al,3 Parietex mesh was placed into the preperitoneal space, located on the posterior surface of the abdominal wall, and covering an area from the pubic bone to the anterior superior iliac spine. This covered the indirect, direct, and femoral hernia spaces on the right side. The mesh was later fixed with titanium tacks and the peritoneum was sutured over the mesh with a running absorbable suture. Reprinted with permission from Genitsaris M et al.3

inguinal hernia. As previously described, the term “sports hernia” is a catch-all term for several different musculoskeletal pathologies about the inguinal canal, though it is typically used in reference to those individuals with a posterior inguinal wall deficiency. This particular individual’s surgical diagnosis (indirect hernia, FIGURE 1) was more specific than our clinic suspicion of a sports hernia. Additionally, his hernia was congenital; however, it can be speculated that, as a result of abnormal shear forces about the posterior inguinal wall, the congenital hernia could have been aggravated and became symptomatic. Therefore, from a diagnostic perspective in outpatient physical therapy, the difference between the indirect hernia and a sports hernia is insignificant; the significance will only be appreciated intraoperatively. The course of this individual’s pain and dysfunction is very consistent with that reported by several authors for this condition. Lovell14 noted that 50% of 186 males with groin pain lasting longer than 8 weeks had a laparoscopically diagnosed sports hernia. Meyers et al17 add that out of 157 patients with a diagnosed sports hernia, the mean duration of symptoms was 1.2 years (range, 10 days to 6 years). Furthermore, being as though the rotational pain actually lead this individual

to change his batting stance from batting right handed to batting left, a logical etiology can be linked to a sports hernia. Postoperative management is certainly surgeon-specific after laparoscopic repair of the sports hernia. Considering that the etiology is rarely an issue of actual strength or flexibility and is rather an anatomic weakening of the posterior wall of the inguinal canal, acute postoperative physical therapy is rarely indicated. However, considering the risk factors for a sports hernia, the question arises whether or not proper “prehabilitation” should be utilized to decrease the chances of obtaining a sports hernia. Currently, there is no evidence addressing any prevention programs. At the time of submission of this article, the athlete was 12 weeks postsurgery. He had returned to playing varsity baseball and was without pain or dysfunction for the first time in 3 years. We anticipate a problem-free long-term outcome considering excellent results for similar athletes who were managed with a similar surgery.2,3,16,17,19,22 As part of the sports medicine team, it is within our scope of practice to refer an individual with a suspected sports hernia. Additionally, considering the difficulty of diagnosis and the chronicity of the condition, it is likely that we as physical therapists will encounter this type of patient at some point in the continuum of their care.

CONCLUSION

T

he sports hernia is a frequently missed diagnosis that leads to a disproportionately high loss of playing time. This resident’s case problem highlights the importance of differential diagnosis and a broad pathoanatomical knowledge base when evaluating athletes presenting with chronic groin pain. This individual complained of anterior hip and groin pain for approximately 3 years and had sought consultation from 3 different practitioners; nonetheless, the underlying cause of his pain and dysfunction was

journal of orthopaedic & sports physical therapy | volume 38 | number 2 | february 2008 |

69

[

RESIDENT’S CASE PROBLEM

never determined. It is important that physical therapists be able to identify a sports hernia and refer the patient to the appropriate provider, to prevent extended pain and reduction in function.T

Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on January 15, 2017. For personal use only. No other uses without permission. Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

REFERENCES 1. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29:521-533. 2. Ekstrand J, Ringborg S. Surgery versus conservative treatment in soccer players with chronic groin pain: a prospective randomized study in soccer players. Eur J Sports Traumatol Rel Res. 2001;23:141-145. 3. Genitsaris M, Goulimaris I, Sikas N. Laparoscopic repair of groin pain in athletes. Am J Sports Med. 2004;32:1238-1242. 4. Gilmore J. Groin pain in the soccer athlete: fact, fiction, and treatment. Clin Sports Med. 1998;17:787-793, vii. 5. Gilmore OJ. Gilmore’s groin. Sportsmed Soft Tissue Trauma. 1992;3:12-14. 6. Goodman C. The gastrointestinal system. In: Goodman CC, Boissonnault WG, Fuller KS, eds. Pathology, Implications for the Physical Therapist. St Louis, MO: Saunders; 2003:658-661. 7. Hackney R. The sports hernia. Sports Med Arthrosc Rev. 1997;5:320-325. 8. Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med. 1993;27:58-62.

9. Johnson JD, Briner WW. Primary care of the sports hernia: recognizing an often-overlooked cause of pain. The Physician and Sportsmedicine. 2005;33:35-39. 10. Kemp S, Batt ME. The ‘sports hernia’: a common cause of groin pain. The Physician and Sportsmedicine. 1998;26:36-44. 11. Kluin J, den Hoed PT, van Linschoten R, JC IJ, van Steensel CJ. Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med. 2004;32:944-949. 12. Lacroix VJ. A complete approach to groin pain. The Physician and Sportsmedicine. 2000;28:66-86. 13. Lacroix VJ, Kinnear DG, Mulder DS, Brown RA. Lower abdominal pain syndrome in national hockey league players: a report of 11 cases. Clin J Sport Med. 1998;8:5-9. 14. Lovell G. The diagnosis of chronic groin pain in athletes: a review of 189 cases. Aust J Sci Med Sport. 1995;27:76-79. 15. Lynch SA, Renstrom PA. Groin injuries in sport: treatment strategies. Sports Med. 1999;28:137-144. 16. Malycha P, Lovell G. Inguinal surgery in athletes with chronic groin pain: the ‘sportsman’s’ hernia. Aust N Z J Surg. 1992;62:123-125. 17. Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR. Management of severe lower abdominal or inguinal pain in high-performance athletes. PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med. 2000;28:2-8. 18. Nichols AW. Abdominal and thoracic injuries. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic Injuries and Rehabilitation. Philadelphia,

]

PA: WB Saunders Company; 1996:487-489. 19. Polglase AL, Frydman GM, Farmer KC. Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust. 1991;155:674-677. 20. Robinson P, Hensor E, Lansdown MJ, Ambrose NS, Chapman AH. Inguinofemoral hernia: accuracy of sonography in patients with indeterminate clinical features. AJR Am J Roentgenol. 2006;187:1168-1178. 21. Simonet WT, Saylor HL, 3rd, Sim L. Abdominal wall muscle tears in hockey players. Int J Sports Med. 1995;16:126-128. 22. Swan KG, Jr., Wolcott M. The athletic hernia: a systematic review. Clin Orthop Relat Res. 2007;455:78-87. 23. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett WE, Jr. Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia. Am J Sports Med. 1991;19:239-242. 24. van den Berg JC, de Valois JC, Go PM, Rosenbusch G. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34:739-743. 25. Verrall GM, Slavotinek JP, Fon GT, Barnes PG. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007;35:467-474.

@

70 | february 2008 | volume 38 | number 2 | journal of orthopaedic & sports physical therapy

MORE INFORMATION WWW.JOSPT.ORG