While the incidence of groin pain accounts for only approximately 5% of patient injuries, it is responsible for a very large proportion of time loss from competition (5,6). The sports hernia, also known as the hockey hernia, has become a more common injury in athletes participating in sports requiring repetitive twisting and turning such as ice hockey, tennis, field hockey, soccer, and American football. The incidence in several high level athletic groups has been documented to be significantly increased over the last decade (7). Although it is true that the increased frequency of this diagnosis may be partly attributable to the heightened awareness of trainers and physicians, there is also the notion that the increasingly rigorous off season conditioning programs that concentrate on strengthening the lower extremities, but neglect the abdominal and pelvic musculature cause a significant imbalance, and may contribute to this problem. In addition, various theories regarding contractures of the hip flexor and adductor muscles are developing as a result of this preferential strengthening of one muscle group over another. One study has attempted to document radiographically a lack of hip extension when pelvic tilt is controlled (8). In this study, 25 professional hockey players and 25 age-matched controls were evaluated using the Thomas test and an electrical circuit device to determine pelvic tilt motion. The results demonstrated that the players had a reduced maximum hip extension in comparison with age-matched controls. The authors theorized that hockey players demonstrated a decreased extensibility of the iliopsoas musculature.

In making the diagnosis of a sports hernia, the more appropriate term may be that of athletic pubalgia since in many cases an actual hernia is not seen (9). Although the definite pathophysiology behind the development of this problem has not been implicated in overuse syndrome, in most of the athletes involved, a series of hip abduction/adduction and flexion/extension maneuvers with the resultant pelvic motion may produce a shearing force across the pubic symphysis leading to stress in the inguinal wall musculature perpendicular to the fibers of the muscle. In these cases a chronic pull from the adductor musculature against a fixed lower extremity can cause significant shear forces across the hemipelvis with subsequent attenuation or tearing of the transversalis fascia or the conjoined tendon (10). In some studies there have also been changes noted at the rectus abdominis muscle insertion (9), while in some situations, avulsions of part of the internal oblique muscle fibers at the pubic tubercle have also been documented (11). One additional theory suggests that entrapment of the genital branches of the ilioinguinal or genital femoral nerves may be the source of pain in some patients (12).

In, summary, it is apparent that the variety of abnormalities that have been reported leading to the diagnosis of sports hernias are a clear indication for the need to further delineate this area through research. In order to understand the treatment, however, it is best to think of these problems as a relative incompetence of the abdominal wall musculature in the absence of a clinically detectable hernia bulge (Fig 29-1).

Although the diagnosis of a sports hernia is made in many patients retrospectively or after eliminating the more common injuries noted about the pelvis, it is important to know the common presenting symptoms. Often, there is an insidious onset of unilateral groin pain, although some present with bilateral symptoms. Many are evaluated for a common inguinal hernia that is not typically seen and are then further misdiagnosed. In some cases, an acute tearing sensation is felt by the patient, making a diagnosis somewhat more straightforward. In many cases pain usually occurs only during exercise. It does not typically become exacerbated with coughing or sneezing as is often seen in an inguinal hernia.

By definition, no clinically detectable hernia will be present during examination. The need for a thorough examination by an experienced examiner with an understanding of the anatomy cannot be over-emphasized. The physical examination includes a thorough assessment of the pelvic musculature and plain radiographs to assure no significant bony pathology is present. Tenderness is commonly seen over the conjoined tendon, pubic tubercle, and the mid inguinal region (13). In some cases, a tender internal inguinal ring is noted. While the diagnosis of an inguinal hernia is not typically missed as a result of the significant radiation into the groin, this needs to be assessed to assure that it is not a more common inguinal hernia. The most common clinical findings have been pain with resisted leg adduction in 88%, while only 22% had pubic tenderness (9). Commonly positive findings include pain with a resisted sit-up and pain reproduction with a valsalva maneuver.

Imaging modalities are typically employed including plain radiographs in order to evaluate for the possibility of either a different or coexisting pathology. Most commonly, there is a significant overlap with osteitis pubis as well as chronic adductor musculature irritation. In addition, herniography may be used as a treatment to evaluate the area and has had some support in the recent literature (14,15). In a study by Hamlin and Kahn (14) 333 consecutive herniographic studies were performed (14). An equivocal physical examination was the most common reason for requesting a herniogram. In 56 of the 57 patients who came to operation, the herniogram and the physical examination were concordant.

In a study by Sutcliffe et al. (15) a prospective study of 112 patients undergoing herniorrhaphy were evaluated over a 5-year period. In this study 30 hernias were diagnosed with one false positive and one false-negative examination, thus giving herniography a sensitivity of 96.6% and a specificity of 98.4%. There were no complications noted with the herniographic procedures.

Magnetic resonance imaging (MRI) has also been employed in these difficult patients (16). In one study, the MRI findings of athletic pubalgia were delineated in 32 athletes studied with T1 weighted and T2 weighted as well as STIR images. The abnormalities found included pubic symphysis abnormalities, abdominal wall defects, and musculature abnormalities including rectus abdominis, pectineus, and adductor muscle groups. The authors felt that pubalgia, although a complex process and frequently multifactorial, could be delineated with MRI. More importantly it was felt that MRI could alter the surgical approach.