Results of inguinal canal repair in athletes with sports hernia

Departments of Surgery, Public Health Medicine* and Centre for Sports Medicine** University Hospital, Nottingham NG7 2UH, UK

Introduction Patients and methods Operative technique

Results Discussion References

Aims: To evaluate the role of surgical exploration and repair of the inguinal canal in athletes suspected of having a sports hernia. Methods: Thirty-five (34 males, 1 female) athletes with a suspected sports hernia underwent surgical exploration and inguinal hernia repair. After six months, all athletes were sent questionnaires to assess any improvement in analogue pain scores, return to sport, recurrence of symptoms and the overall result of surgery. Results: Operative findings revealed a tear in the external oblique aponeurosis with or without a significant posterior bulge (n=20), a lone significant posterior bulge (n=10), a tear in the conjoint tendon with dilated superficial ring (n=3), small direct hernial sac (n=1) and lipoma of the spermatic cord (n=1). Surgery consisted of repair of external oblique tear (when present) and prolene darn or lichtenstein mesh repair of the posterior inguinal canal. Twenty-seven patients replied to the questionnaire giving a response rate of 78%; of these, 25 patients (93%: 95% CI 83-100) had returned to normal athletic activities at pre-injury level. There was a marked improvement in level of pain (median pain level=8 pre-operative vs 2 post-operative, p<0.001). Eleven patients (41%) rated the results as excellent, eleven (41%) as good and five (18%) as fair and none worse. Six patients complained of occasional discomfort related to the scar. Three patients complained of recurrence of their symptoms after 4 to 5 months following strenuous exercise. Conclusion: Sports hernia presents with a spectrum of surgical findings. Athletes with sports hernia should be considered for routine hernia repair, as the majority of the patients benefit from surgery. It is important to offer a structured rehabilitation programme to maximise the benefits of surgery.

Keywords: sports hernia, inguinal canal, mesh repair

J.R.Coll.Edinb., 47 June 2002, 561-565 

INTRODUCTION

Approximately 5% of all sports injuries in sportsmen and women are related to the groin area. ¹ Symptomatic groin injuries, resulting in persistent disabling groin pain, constitute a serious problem in twisting/cutting sports such as soccer, ice hockey, badminton, rugby, tennis and fencing. Review of the differential diagnosis of groin pain secondary to sports injuries list multiple causes, which include strain injury to the muscles of the groin region, including adductors and flexors of the hip and rectus abdominus, osteitis pubis, orthopaedic and inguinal canal lesions.^2-4 There is considerable evidence to support that inguinal canal disruptions without a clinically detectable hernia are not uncommon causes of chronic groin pain in athletes, especially in cases resistant to conservative treatment. ^5-7 In some series, the prevalence of this condition among athletes with chronic groin pain has been reported to be as high as 50%.³ These disruptions, with tears of the external oblique aponeurosis, conjoint tendon injury, weakening of the transversalis fascia with separation from the conjoint tendon and incipient direct inguinal hernia with an associated bulge in the posterior inguinal wall, are often termed a ‘sports hernia’, ‘sportsman’s hernia’, ‘conjoint tendon lesion’, ‘athletic pubalgia’ or ‘crypt hernia’. Gilmore (1992) described a disruption to the inguinal canal characterised by three specific surgical findings: (1) a torn external oblique aponeurosis causing dilatation of the superficial inguinal ring; (2) a torn conjoint tendon; and (3) a dehiscence between the torn conjoint tendon and the inguinal ligament, constituting the major injury. 8 Researchers suggest that these injuries occur because adductor action during supporting activity creates shearing forces across the pubic symphysis that can stress the posterior inguinal wall. ^5,6 Consequent repetitive stretching of, or a more intense sudden force to, the transversalis fascia and the internal oblique can lead to their separation from the inguinal ligament. This mechanism may also account for the common finding of co-existing osteitis pubis and adductor tenoperiostitis in these patients.

Despite growing interest in sports hernia, the actual source of pain and best methods for pre-operative diagnosis remain unclear. 9 Over the last decade, there have been many reports of success following surgery to the inguinal canal in these patients. Good or excellent results following hernia repair in these patients have consistently been reported from Europe, Australia, United States and Scandinavia.^{7, 10, 11} However, debate still persists over the specific pathophysiology and operative repair in athletes with sports hernia. ⁵ This retrospective follow-up study was undertaken to evaluate the specific pathophysiology and role of surgical exploration and repair of the inguinal canal in thirty-five athletes with suspected sports hernia from 1994 to 1999 at our institution.

PATIENTS AND METHODS

Thirty-five athletes who underwent groin surgery for sports hernia between March 1994 and March 1999 were evaluated.

Patients were referred from a Sports Injury Clinic principally by a Consultant in Sports Medicine with an interest in groin pain. The diagnosis was based on history, clinical examination and investigations where appropriate. All patients had a typical history of chronic groin pain, exacerbated by sport or straining such as sneezing or coughing. Their symptoms were resistant to the conservative treatment typically consisting of stretch and strengthening programme for the abdominal and adductor muscles. Clinical examination concentrated on the inguinal canal, groin musculature, lower back, hips, pelvis and scrotum. The inguinal canal was examined with the patient standing and lying to exclude an inguinal hernia and to note the site of tenderness. All patients had focal tenderness in the region of the inguinal canal and pubic tubercle, which was made worse by coughing or resisted sit-up. In addition, some patients had a dilated superficial inguinal ring and positive cough impulse but no definite hernia was palpable. Appropriate clinical tests such as a pelvic radiograph, bone scan and magnetic resonance imaging scan were performed in athletes suspected of having co-existing causes for chronic groin pain. Patients were not included in this study if clinical examination or investigations suggested multiple pathology. Athletes had either ceased playing sport or had marked impairment of performance.

OPERATIVE TECHNIQUE

Thirty-five patients who met the criteria were operated upon between March 1994 and March 1999. The surgery was performed by two surgeons in a single unit. The inguinal canal was exposed under general anaesthesia and the presence of an indirect inguinal hernia was sought in all patients. Tears in the external oblique aponeurosis and conjoint tendon and dilated superficial ring were noted. The posterior inguinal wall was examined for weakness and the presence of a significant bulge. Surgery consisted of open repair of the external oblique tear (when present) and prolene darn or lichtenstein mesh repair of the posterior inguinal canal. The ilioinguinal and genitofemoral nerves were found to be uncompromised and protected in all patients.

Following discharge from hospital patients were encouraged to walk. They were advised to begin light training at three to four weeks avoiding twisting and cutting. Graduated return to active sport occurred at six to eight weeks. Since athletes returned to sport after 3 to 4 months, follow-up was under-taken after 6 months. All patients were sent a questionnaire after six months. Non-responders received a reminder questionnaire. They were asked to complete an analogue pain scale from zero (no pain) to ten (severe pain), to compare their preoperative and post-operative pain, their ability to participate in sport, to rate the success of their operation (excellent, good, fair or worse) and any recurrence of pain or discomfort.

STATISTICAL ANALYSIS

Pain scores were found to be non-parametrically distributed and therefore p values were calculated using the Wilcoxon signed ranks test. Median values of pain scores are quoted.

RESULTS

Thirty-five athletes were operated upon between March 1994 and March 1999. There were 34 males and 1 female. All patients were actively involved in sport and had a median age of 30 years (23 to 45 years). The patients had either stopped playing sport because of chronic pain or had noted impairment in performance. Twenty-six athletes were soccer players, two were rugby players, one each was a cricketer, squash player and golfer, two were ice hockey, and badminton players, respectively. Table 1 shows the patient characteristics, type of sport, operative findings and, the type of repair undertaken in the 27 respondents.

Figure 1: Pain score results from questionnaires completed after 6 months comparing pre-surgery and post-surgery pain levels

SPB: Significant posterior bulge; EOA: External oblique aponeurosis; CT: Conjoint tendon

Table 1: Patient characterisitics, type of sport, operative findings, type of hernia and pain scores before and after the operation in 27 respondents

Operative findings revealed a tear in the external oblique apo-neurosis, with or without a significant bulge, in the posterior inguinal wall in 20 patients. Ten patients had only a significant posterior bulge, three patients had a tear in the conjoint tendon with dilated superficial inguinal ring, one patient had a small direct hernial sac and one patient was discovered to have a lipoma of the spermatic cord in addition to a significant posterior bulge.

Twenty-seven patients replied to the questionnaire giving a response rate of 78%. Of these, 25 patients (93%: 95% CI 83-100) had returned to normal athletic activities to pre-injury level. Eleven patients (41%) rated the results as excellent, eleven (41%) as good, five as improved. The return to full sport activity was after an average of 14 weeks (6 to 24 weeks).

While no patient claimed to have been made worse by the operation, six patients complained of occasional discomfort related to the scar. Three patients complained of recurrence of their groin symptoms 4 to 5 months of strenuous exercise. Eight patients, who had not replied to the reminder questionnaire, could not be contacted due to changes of address.

Pain scores using an analogue scale were completed by 27 patients (Figure 1). The pre-operative median score was 8 (range 2 to 9). The post-operative median pain score was 2 (range 0 to 6), (p<0.001).

DISCUSSION

Thirty-five athletes with a suspected sports hernia were referred from the sports clinic for inguinal hernia repair. Thirty-three patients were found to have lesions of the inguinal canal. Surgery consisted of open repair of the external oblique tear (when present) and nylon darn or synthetic mesh repair. Following hernia repair, there was a marked improvement in the median pain score and 93% of the patients were able to return to sport after a median of 14 weeks.

It has been suggested that pain in patients with a sports hernia may be caused by distention of the peritoneum and stretching of the ilioinguinal nerve or tears in the external oblique apo-neurosis and conjoint tendon. ^8,12,13 Thirty-four of the patients had lesions of the inguinal canal while one patient, in addition had a lipoma of the spermatic cord to account for his symptoms. Although we cannot discount the possibility of some degree of recall bias, our results support the previously published data of successful outcomes following surgery ranging from 63% to 93%. ^7,14 A variety of techniques have been described, most of which are minor variations of a standard hernia repair.5 Simonet et al (1995) reported use of synthetic mesh repair on their patients with sports herniae and found that their results were similar to that of previous authors performing prolene darn repair.⁶ Our observation appears to supports this notion, as both prolene darn and synthetic mesh repairs proved to be effective, although the patients undergoing the two different techniques were not controlled. The present series, therefore, represents the simultaneous experience of two techniques. No difference in outcome of mesh/darn repairs was noted in the present series.

The notion that patients undergoing sports hernia repair recover because of a period of enforced rest has been postulated previously. It seems unlikely to have been the mechanism of benefit in the present series as all patients had experienced periods of prolonged rest (more than 3 months) prior to surgery. Moreover, active physiotherapy was commenced within 3 weeks of surgery and any placebo effect is unlikely to extend through any prolonged period of return to full activity and, thus, 6 months is a reasonable initial length of follow-up. The follow-up of 6 months may not be sufficient to comment on the incidence of recurrence of symptoms. The published data provides a little information on long-term results of open repair of sports hernia, which remains to be evaluated. We are accumulating the long-term data.

A few studies have demonstrated successful outcome following laparoscopic repair of sports herniae. ^15,16 Evans (1999), in a series of 194 athletes, reported that 85% of patients were symptom free at a follow-up of 3 months to over 4 years following laparoscopic repair of a sports hernia. ¹⁵ Eighty percent of their patients returned to full sport activity within 3 weeks. Early return to sport is vital for the professional athlete, with potential laparoscopic advantages of less post-operative pain and scar-related problems.¹⁶ Six patients in the present series reported occasional discomfort related to the surgical scar. It has been suggested that the posterior position of the mesh behind the conjoint tendon and pubic bone should create a stronger repair than conventional surgery using anterior mesh placement.¹⁶ Moreover, bilateral and potential herniae can be repaired at the same time laparoscopically, although, the ability of laparoscopic repair to treat isolated external oblique tears has yet to be determined. The overall complication rate of the technically more demanding laparoscopic sport hernia surgery is poorly documented in the literature and remains to be determined.

Three patients reported recurrence of their symptoms after 4 to 5 months following strenuous exercise. The injury to the inguinal canal is most likely to be an overuse syndrome with over stretching of the posterior inguinal wall due to excessive demands and aggravated by the anatomy of the region. It is possible that these patients may have recurrent injuries to the inguinal canal due to lack of compliance to post-operative rehabilitation after repair of groin disruption. Alternatively, recurrence of symptoms in these patients may be due to a different new patho physiological disturbance as a result of strenuous exercise. These patients are being investigated for their recurrent symptoms.

In conclusion, this study has demonstrated that a sports hernia presents with a spectrum of surgical findings. The principle damage in such a hernia was to the external oblique aponeurosis with a bulge in the posterior inguinal wall. Athletes with sports hernia should be considered for routine hernia repair. It is important, however, to offer a structured rehabilitation programme to these patients to maximize the benefit. A prospective randomized controlled trial is needed to evaluate the advantages of laparoscopic repair over conventional surgery in patients with groin disruption and, furthermore, to assess the efficacy of pre-and post-operative physical therapy.

ACKNOWLEDGEMENTS

The authors wish to thank Liz Reavill and Janet Duffin for their excellent technical support.

REFERENCES

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Copyright: 8 April 2002

Correspondence to: Mr A Kumar, Section of Surgery, E Floor, West Block, University Hospital, Nottingham NG7 2UH, UK, e-mail: adarshkumar25@hotmail.com

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