Introduction

The proverb “one size does not fit all” definitely applies to the surgical treatment of athletic pubalgia (“sports hernia”). These are a variety of very specific injuries and one operation is not appropriate for all patients with these conditions. The most important thing is to dismiss the concept of hernia and to instead think in terms of the applicable anatomy and the likely pathophysiology of the injuries. Therefore, an accurate diagnosis must take into account a wide differential diagnosis. When a specific diagnosis is established, then one must consider the best operation for that particular patient. The term sports hernia conveys two large assumptions that are inaccurate: 1) that the cause of these sets of injuries has something to do with the presence of occult hernias; and 2) that these injuries can be lumped together into one entity and therefore be treated in a similar fashion.

Basic science

When treating these injuries, a detailed understanding of the musculoskeletal and visceral anatomy of the pelvis is necessary. One must also appreciate the physiologic concept that the pubic symphysis is a functional joint. The pubis is the center of normal symmetric motion—flexion, extension, abduction, adduction, and rotation—with naturally opposing groups of muscles and other soft tissues. We have described the musculoskeletal anatomy and the concept of the pubic joint in several publications.

Briefly, the musculoskeletal anatomic considerations are as follows. Consider mainly the anterior pelvis, excluding the spine, and then consider the anatomy inside and outside of the hip joint. It is easiest to think of the hip joint as a ball-and-socket joint that is relatively independent of the musculature outside of the socket. From the standpoint of anatomic proximity, it also seems logical to think that some interplay must occur between the hip joint and the pelvic musculature around it. If so, then injury to the adjacent musculature might also negatively affect the hip joint or vice versa, and primary and compensatory forces likely play important roles in the pathogeneses of these two types of injuries.

The hip is a synovial joint that is comprised of the femoral head and the acetabulum of the pelvis. The hip, which is also known as the acetabulofemoral joint, connects the lower limb to the axial skeleton. Both joint surfaces are covered in hyaline cartilage, and the acetabulum also has a fibrocartilaginous rim called the labrum that firmly holds the femoral head in place. In addition, the joint is encased in a fibrous capsule and stabilized by three ligaments: the iliofemoral ligament, the pubofemoral ligament, and the ischiofemoral ligament. The ligamentum teres, which is located at the femoral head, also serves to support joint integrity.

The pubic musculature outside of the hip joint consists of a vast set of muscles and soft tissues. The anterior pelvis includes multiple structures (excluding the hip, sacrum, and spine) such as the lower abdominal soft tissues; both sides of the pubic symphysis; and multiple thigh and pelvic adductors, abductors, flexors, extendors, and rotators. We think in terms of three compartments of muscles or other attachments that provide ligamentous- type support (Figure 38-1). The anterior compartment consists mainly of the abdominal muscles, including the sartorius, the anterior attachment of the psoas, portions of the quadriceps, and some complex interdigitations with fibers from the thighs and the medial and posterior pelvis. The posterior compartment consists primarily of the hamstrings, a portion of the adductor magnus, several key nerves, and an artery. The medial compartment consists of the most important thigh components, which include the three adductors that attach to the symphysis, the gracilis, the obturator externus, and several other structures.

Figure 38–1 A, Anterior view of muscle origins and insertions. Note that all adductors originate in the pubic ramus, and also note the relatively anterior location of insertion of the psoas tendon onto the lesser trochanter. B, Anterior view. C, Lateral view.

From: Meyers WC, Yoo E, Devon O, et al.,: Understanding “sports hernia” (athletic pubalgia): the anatomic and pathophysiologic basis for abdominal and groin pain in athletes. Oper Tech Sport Med. Elsevier, 15:4, pp 165-177, October 2007.

The muscular attachments provide different types of either central or strap supports, depending on their medial or lateral locations, insertions, or origins. For example, a combination of the rectus femoris and the obturator externus is particularly important for place kicking, and the adductor longus and magnus are particularly important as push-off muscles for pitching. We can think in terms of four groups of muscles: adductors, abdominal flexors, thigh flexors, and internal or external rotators. The most important adductors are the adductor longus, the adductor brevis, and the pectineus. The adductor magnus and gracilis usually play minor roles in pelvic stabilization. The rectus abdominis and, to a lesser degree, the obliques and the transversalis comprise the more superior or anterior flexors, and the psoas major and minor combine with other thigh flexors as key inferior or posterior flexors of the pubic joint. The rotators consist primarily of the obturator externus and internus and the quadrator femoris, although other muscles also play roles in rotation. One should not forget the importance of some of the back muscles, particularly the large transversus, which play important roles in both rehabilitation after injury and in performance in general.

Lastly, in addition to musculoskeletal tissue, one must take into account the solid and hollow viscera organs in the pelvis. These include the small and large intestine, the rectum, the genitourinary system, the gynecologic system, and some important blood vessels. Any of these systems can be involved in patients who present with sports hernia. The causes of pelvic pain can be many, and accurate diagnosis can be confusing. To make matters even more complex, visceral diseases can produce symptoms during exertion. Therefore, during the evaluation of the athlete or nonathlete with any type of pelvic pain, one needs to strongly consider possible visceral causes. Thus, one has three main things to consider as part of the differential diagnosis: 1) hip problems; 2) nonhip musculoskeletal problems; and 3) visceral problems. Remember, we are excluding the spine as part of this anatomy, because it rarely causes problems in this area.

Indications

History and physical examination

A careful history must take into account all of the previously mentioned systems and anatomy. One must remember that pelvic pain has a wide differential diagnosis and that these patients, who are for the most part young, can have pain from a wide variety of sources. For example, Crohn’s disease and endometriosis have mimicked musculoskeletal disorders, and they have initially presented with exertion-related pelvic pain. In addition, we have picked up a wide variety of malignancies, benign tumors, and unusual other problems involving the gastrointestinal, genitourinary, and gynecologic systems. More recently, now that trainers and team physicians are recognizing these problems earlier, we have also seen appendicitis as a primary cause of acute exertion-related pelvic pain in athletes.

One must also consider the historic differentiators between intra-articular hip problems and problems that involve the soft tissues outside of the hip. These can be tricky, particularly considering that there is considerable overlap among these symptoms. For the hip, one usually looks for pain with simple changes in posture that often involve minimal exertion. There can be a continuous nature to the pain, particularly after activity. Any inflammatory process (e.g., pubic osteitis) can cause the pain to have a continuous nature, but injuries to the soft-tissue structures outside of the hip joint usually cause pain with extremes of activity that is often reproducible with the same maneuvers.

During the physical examination, one looks primarily for pain with resistive maneuvers versus pain with passive range of motion of the hip. Each of the soft-tissue structures outside of the hip can be tested with specific physical tests. For example, one can easily differentiate among the three adductors that insert on the pubic symphysis, and one can also test individually for the adductor magnus, the rectus femoris, the sartorius, the iliopsoas, the gracilis, and other structures. Tenderness should immediately alert the observer to the possibility of an intraperitoneal problem. Hip examination is often particularly important for these patients. The examination should be thorough and consider all of the potential musculoskeletal and nonmusculoskeletal causes of pain; it definitely includes the examination of the abdomen and the chest as well as the scrutiny of the regional lymph nodes and the vascular system. This examination may even include rectal and gynecologic examinations.