Ian Kinsler, the second baseman for the Texas Rangers, just got put on the disabled list for the rest of the year because of a "sports hernia". Ian Kinsler can wield some wicked lumber. He leads the American League in hits and runs. So why is he out for the year? What is the deal with this "sports hernia" business? It just so happens that I had a conversation with my pretend friend the other day about this very issue. Here's a transcript.
Sports hernia? Sounds cooler than a regular old hernia.
Let's get something straight. Sports hernias are not hernias. A hernia is an abnormal protrusion from one body cavity into another. Think of the body as multiple hollow cavities lined by muscle and tough fibrous tissue. Any weakness or defect in this lining can lead to a hernia. With true hernias, you'll see a bulge or a lump, especially with coughing or straining.
So sports hernias aren't a defect?
Not at all. The actual name for the syndrome is athletic pubalgia. If you read twenty articles on sports hernia, you'll find 20 different descriptions of the cause and presentation. That's usually a red flag in medicine. It means, we don't know what the hell we're talking about.
How do you know if I have a sports hernia or a real inguinal hernia?
An inguinal hernia is easily appreciated on physical exam. A bulge will be present at the external ring opening or the inguinal floor may protrude with coughing. Sometimes the findings are subtle but if there is any doubt, my policy is to assume that the patient's symptoms are likely secondary to some other cause. Sports hernias do not have consistently characteristic findings. Other than pain with palpation, you will not identify a bulge or protrusion.
What about Xrays?
Sports hernias are a diagnosis of exclusion. MRI's and CT scans are done to rule the existence of other causes, like osteitis or muscle tears or inguinal hernias. There is no pathognomic radiographic finding.
What would do for a guy with a sports hernia?
After first ruling the possibility of an occult inguinal hernia, I would simply recommend rest and NSAIDS and patience. My feeling is that this constellation of symptoms is best explained by some sort of muscle strain or ligamentous tear. The surgical repairs described in the literature usually involve reinforcing the inguinal floor with mesh, but there isn't a standardized approach. One wonders about placebo effects....
Then why are all these high profile athletes rushing off to surgery for their sports hernias?
Because professional athletes don't like to hear that the pain they're having is some sort of vague, non-specific muscle strain that will only heal with months of rest. They want a solution. They want a plan of action. They want to get back on the field as soon as possible. So it's reassuring to find a surgeon who can tell them they have a "sports hernia" and that the treatment is a "special surgery". And that recovery from the surgery will take months.
I dug this up out of the January 2008 edition of the Journal of the American College of Surgeons:
Interestingly, many authors describe tears in the muscle, fascia, or aponeuroses as the causes of groin pain. But the majority of general surgeons are trained to palpate or visualize wide holes or defects in the aponeuroses of the inguinal region. To a trained eye or finger, these small tears may appear as bulges or asymmetric findings on physical examination. On the other hand, these tears may not be diagnosed until surgical exploration is performed. Although several series describe a variety of tears and even microtears, there appears to be a lack of pictures or even line drawings detailing these injuries. Even using the magnification offered through laparoscopy, the literature does not provide a variety of pictures detailing these inguinal tears.
Sounds pretty shady to me. And here's Dr. David Farley from the Mayo Clinic:
The best treatment for sports hernias is nature's own -- to lay off the offending activity and rest for a period ranging from a few weeks to a few months. It is also useful to engage in exercises that strengthen the abdominal muscles and increase their flexibility. This course is especially effective for professional athletes; because they are young and strong, they tend to have tremendous recuperative powers. On the other hand, they also tend to be exceptionally eager to get back in the game and seek a quick fix.
But quick, reliable fixes are not to be had. While surgical procedures exist -- suturing the tear (if it can be isolated) or patching the area with a synthetic mesh -- they offer no guarantee of solving the problem or preventing its recurrence.
The surgeon who taught me the most about inguinal hernias when I was a resident, Keith Millikan MD, also didn't buy into the whole sports hernia deal. Until we get better evidence (randomized controlled trials) I suspect my management of chronic groin pain won't be changing anytime soon.