Sports Hernias and Chronic Groin Pain
Probably the most important aspect to understand about sports hernias
is that it is not truly a 'hernia'. A hernia by definition is a hole in the muscle through which
fat and/or intestines push through. However, in a sports hernia, there is a tear in the muscle,
but no fat or intestine pushing through. The damaged muscle is what causes the pain and other symptoms.
Second, there are NO consensus statements about exactly what a sports hernia is, what causes it,
and how to repair it! Any hernia surgeon that claims to know everything about sports hernias isn't being
honest with him or herself, and likely their patients. Dr. Harris frequently sees patients with
chronic groin pain, many of which are referred from
Sports Medicine Physicians in Southern California and beyond. Below is what we believe at California
Hernia Specialists and a small sample of photos we have taken during our sports hernia repairs.
What is a Sports Hernia?
We believe that a sports hernia is a tear of the outer layer of muscle in the groin. This tear is often seen in athletes who have very strong thigh and abdominal muscles which pull against each other in the groin area. With this constant stress pulling down in the thigh, and up in the abdomen, a tear can occur in the outer layer of muscle in the groin area. This tear is what most describe as a 'sports hernia'.
Again, a sports hernia isn't a true hernia in the strictest sense, since there is no fat or intestine pushing through the torn muscle. The muscle tear causes pain with sitting, standing, athletic activity or anytime the groin is used. What usually differentiates a sports hernia from just a pulled muscle is the chronic nature of the injury; sports hernias do not improve with rest since the tear never heals itself.
We often see these injuries in athletes who play soccer, hockey, football, and other sports which develop strong thigh muscles and abdominal muscles. Sometimes the symptoms of a sports hernia can persist for many years before a patient ultimately finds treatment, or the symptoms become severe enough for that patient to seek treatment.
How do we fix Sports Hernia?
We believe that since a sports hernia initiates from a tear in a weakened layer of the
external oblique muscle fibers, simply sewing
this muscle closed could lead to recurrences. The muscle fibers tear because of a reason; the muscle
is weak. Thus, we feel the muscle fibers need to be reinforced to help prevent them from tearing again
in the future. Therefore we perform a mesh repair similar to what would be done
during an inguinal hernia repair.
The nerves that run through the inguinal canal (ilio-inguinal and ilio-hypogastric) must be examined for trauma and scar formation. Often during years of repeated injury the nerves can become permanently injured. In these cases, the nerves will be purposefully cut to help prevent continued chronic pain after the surgery. These nerves DO NOT control any muscle function or other male functions. They are simply cutaneous (sensation) nerves of the groin which, when removed, results in some minimal numbness of the groin (not of the male organs).
Actual Case Presentations and Photos
(Click a description to view the case details)
The photo below was taken on a patient during a normal inguinal hernia repair. This patient did not have a sports hernia type injury and thus his outer layer of muscle, the external oblique, is completely normal. There is no separation of the muscle fibers since the hernia is on the inside layers of muscle.
1. 54yo Triathlete
This patient had almost 6 years of left groin pain. He was an avid athlete and had felt a 'tear' in his left groin. Ultrasounds and CT scans failed to show an inguinal hernia however his pain continued. Over the years, the pain got worse and traveled further up and down his groin.
Ultimately he sought help at California Hernia Specialists where a tentative diagnosis of a sports hernia was made based on his symptoms. No inguinal hernia could be felt on examination before surgery.
The intra-operative photo above shows an obvious tear in the external oblique, which is the outer layer of muscle in the groin. In the photo, the yellow fat from underneath the muscle is seen between two edges of the white muscle fascia which have torn. The tear was about 4 inches long, and about a 0.5 inch wide. This was repaired with a mesh under the tear, and by closing the tear with sutures.
2. Marathon runner
The photo below is from a 50 year old patient showing the same tear in the external oblique. He was a multiple marathon runner and a competitive triathlete. During his cycling and running he would have disabling pain in the left groin. After resting for several months, the pain returned without improvement.
3. Hockey player from Alaska
Again, the patient shown below was a hockey player in Alaska and was an avid skier. Over the past 6 years he developed worsening pain in the left groin. This increased to the point that even with the lightest activity he would develop acute left groin pain. He presented to California Hernia Specialists for evaluation and treatment.
4. 19yo college soccer player
This patient was a 19yo college soccer player who had been treated for a groin strain for over a year. His pain would return almost immediately after resuming soccer but had no pain at rest. Despite months of physical therapy and sports medicine treatments, he continued to have pain. His parents contacted California Hernia Specialists to have him evaluated and treated.
On examination, his left groin was extremely tender with pressure. This, along with his history, suggested the diagnosis of a left groin sports hernia. He underwent open exploration of the groin which demonstrated a clear tear in the external oblique muscle. This tear was repaired using a small mesh under the muscle, and the nerve that was damaged from the tear was treated.
This first image shows the large tear in the muscle fibers of the external oblique. The pink/purple area should be a healthy white color just like the edges of the tear. The retractor is helping expose the lower end of the external oblique.
The second image shows more of the normal white color of the healthy external oblique fascia. The retractor is showing the area higher in the groin towards the left hip bone. There is still some slight thinning and separation of the muscle fibers, but much less than the area below.
After surgery the paitent recovered for 6 weeks during the summer off season. He started training in the late summer and went on to have a pain free fall season at college.
Normal External Oblique
The photo below shows a normal external oblique which is white throughout with no yellow of fat from underneath and no tear.
Laparoscopic Sports Hernia Repairs?
Laparoscopic repair is NOT usually recommended in sports hernias since most doctors believe that the cause of a sports hernia is a tear in the OUTER layer of the muscle in the groin (see above). Laparoscopic surgery cannot reach those outer layers of muscle, and can only repair the inner layer of muscles. This approach is fine for inguinal hernias where there is a hole of the inner muscles of the groin. But for sports hernias, this is not the case.
About Sports Hernias Video
In the video below, Dr. Todd S. Harris describes what a sports hernia is, and how they form. He also discusses how they are treated and the expected recovery.
Causes of groin pain:
Sports hernias are more a diagnosis of exclusion, when all other causes of groin pain are ruled out. Since most tests are normal during work up for a sports hernia, they can be very difficult to diagnose. Hip pain, strained or pulled muscles, an actual inguinal hernia, are among things which are the most common causes of groin pain.
Occasionally an MRI can show areas of abnormality around the pubic bone in the groin. These abnormalities can help indicate a muscle injury, but again are sometime very vague and are not always helpful.
Important points to consider when choosing a hernia surgeon:
- The newest, advanced lightweight mesh can reduce not only recurrence rates for hernias, but also reduces the chance of postoperative mesh pain to almost zero.
- Being treated at a specialized hernia center with an in-house accredited ASC provides the highest quality care before, during, and after your hernia surgery.
- Patients should be seen by a surgeon who can offer all forms of hernia surgery, including open lightweight mesh techniques, as well as advanced laparoscopic techniques. This ensures the surgeon can offer the best technique tailored for each patient.
- Costs for uninsured patients are approximately $1500 for the surgeon fees, and $2000 for the surgery center fees (including OR time, materials, and recovery) for a total of approximately $3500.
- Some laparoscopic patients experience less pain post-operatively and may be able to return to normal activities sooner (when compared to traditional hernia repair). Laparoscopic hernia surgery can result in better patient experiences for some patients.
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Dr. Harris sees patients from all over Southern California, the greater US, and Canada. Our Newport Beach office is conveniently located in Central Orange county adjacent to John Wayne Airport between the 405, 73, and 55 highways.
Our office staff are experienced in verifying insurance coverage for each patient, as well as offering excellent pricing for patients without insurance (see costs above). We are happy to discuss all forms of payments with patients as needed.