Friday, July 22, 2011

Sizemore Opts for "Sports Hernia" Surgery

Washed up Indians center fielder Grady Sizemore was just put on the disabled list following surgery for a "sports hernia". This news came as a bit of a surprise to those of us masochists who follow the Tribe because press releases last week indicated that Sizemore would be out of action for a few days due to a "bruised knee" sustained while running the bases. Apparently, he had also been suffering from groin pain and his doctors felt that, as long as he was going to be out with a knee injury, he might as well undergo the procedure on the groin.

Sizemore hasn't played a full season of baseball since 2009. He had microfracture knee surgery last Spring. He was batting in the .230's and striking out every three trips to the plate this year. The guy is clearly going to pieces. I feel bad for him. But sports hernia? I hope to God Sizemore isn't thinking this is going to help him rediscover the art of actually making contact with the baseball.

The sports hernia craze is nothing short of amazing. It truly amazes me that such a procedure is being done so commonly on world class athletes. I've read the literature. I've done the research. And I still have no clear idea what a "sports hernia" is. I've read that it is everything from a "weakness" or a "bulge" in the inguinal floor, to a torn adductor muscle, to an entrapment of the obdurator nerve. What is it? Is it simply a Syndrome of Pathology? Is it multifactorial?

And what exactly is being done in the operating room? It sounds like most of these repairs involve placing a synthetic polypropylene mesh in the inguinal area, either via an anterior Lichtenstein approach or a laparoscopic, preperitoneally placed mesh in the Space of Retzius. I found one randomized trial on PubMed comparing conservative therapy with laparoscopic surgery. The mystery and lack of uniformity surrounding the technique certainly raises a few questions.

The mesh repair seems a little dubious to me. In true hernia repairs, the mesh acts as scaffolding, to allow natural scar tissue to form and strengthen the fascial defect. The mesh actually bridges the fascial defect. There are no anatomic fascial defects in the sports hernia. It's not clear to me, therefore, why exactly one needs to be implanting mesh in these patients. If you tear a muscle in your calf and I take you to the OR, stitch a piece of mesh over your muscle and tell you not to do anything strenuous for three months, there's a real good chance you'll feel pretty darn good after three months. But if you rest anything for 3-6 months, I suspect most will see significant improvement with or without surgery.

Here's what I propose to those who are advocates of sports hernia surgery:

1) Someone write an expository paper with pictures or intra-operative video footage detailing the exact technique of the repair.

2) I would love to see a randomized controlled trial comparing a sham surgery with real surgery in patients who have experienced 6 months or more of refractory groin pain despite conservative management. If something like this demonstrated statistically significant improved outcomes, I could be persuaded that maybe, just maybe, sports hernia is a real live entity.


Anonymous said...

I share all of your thoughts. What I struggle with is what to do with these patients that have groin pain/sport's hernia? MRI all of them? Send them all to ortho/neurosurgery/urology? Many of them get upset with "expectant mangement" although I am convinced as well that is the way to go.

Orthopedic Surgeon Florida said...

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Anonymous said...

I am currently suffering from a "sports hernia." It is very painful and debilitating. I will not comment on whether or not it should be called a sports hernia or what the best treatment is. I will say that, like you, most doctors do not have compassion for their patients when it comes to this. I am an ex-athlete who has made running a part of my daily life. For the last four months I have been resting. I still don't have abdominal strength and there is a sharp pain when I go through specific movements. I have an MRI that shows a significant tear. My question is this...what would you do?

swag said...

Since the latest SESAP teaches that the appropriate treatment for a "sports hernia" is surgery, I'm frantic, myself, to figure out what the hell it is and what operation is best ;-)

Chuck Sheaff
general surgeon

Rocky Hudson said...

Nice post, thanks a lot.

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John said...

Interesting article. I was wondering if this sport hernia is the same as Gilmore's Groin? What type of surgical mesh is used in the repair surgery? Does the surgeon performing this operation needs some special training?