The Athletic Pubalgia, more commonly known as a “sports hernia” is not actually a hernia by the defined medical classification. It is actually an overuse injury caused by repetitive tissue stress. This injury is predominately found in athletes who participate in sports or activities requiring repeated high speed twisting movements, fast direction changes and/or forceful kicking motions. Sports hernias commonly occur in individuals who engage in sports such as soccer, tennis or ice hockey, but other sports may also lead to this type of injury. Sports hernias are not limited to the elite athlete; recreational athletes may also be afflicted with this type of injury. The commonality is the rotational torque found in many ground based activities.

Activities that place undue amounts of stress on the musculature of the hip adductors and external obliques may lead to a sports hernia. The exact root of the problem has not yet been pinpointed due to the variety of factors that may contribute to each individual case. The injury is the result of avulsion or tears in the muscle fibers in the lower abdomen. Several theories currently exist regarding the cause of sports hernia. The forefront leaders as to the probable cause are a tear in the external oblique causing a dilation of the inguinal ring; a torn conjoined tendon and/or a split between the conjoined tendon and the inguinal ligament due to some type of physical trauma.

Another theory has recently evolved which addresses an imbalance between the strength of the lower extremities and the lower abdominals. Off season strength training for the above mentions sports or activities may neglect the weaker muscle of the external obliques. Often excessive emphasis on flexion and extension in the sagittal plane are prioritized over transverse movements. The poor program design leads to imbalance in the trunk rotator musculature. Additionally when the hip adductors become disproportionately stronger than the weaker lower abdominals further imbalance is created. The external obliques become vulnerable to injury due the relative gains of the musculature of the legs and hip. Again it is a case of the weakest link within the kinetic chain.

Diagnosis
Diagnosis of a sports hernia is difficult since a protrusion is not apparent as with a traditional hernia. The traditional hernia characteristically includes a tear or weakened portion of the abdomen, from which the intestine protrudes or forms a sac. Without any physical signs of protrusion, it is difficult to differentiate a sports hernia from other groin injuries. There is usually localized tenderness at the location of the injury. The examining physician must take into account prior history and be experienced in the diagnosis of a sports hernia.

A few clues can be used to identify a sports hernia. Pain in the affected area increases with activity similar to other overuse injuries. The symptoms manifest predominately with the actions that caused the injury such as forceful rotation, bending, running, cutting or movements of the affected muscles. Individuals have also expressed symptoms such as pain in the lower abdomen or groin, pain radiating to the testicles, pain in the affected area with sneezing and coughing, and even a tearing sensation at the point of injury.

Treatment
The initial treatment for a sports hernia is rest. It is recommended to discontinue activities which may aggravate the injury. Treatment should include icing the area for 20 minutes 3 to 4 times a day. A health care provider may also suggest anti-inflammatory medication and/or physical therapy. If the symptoms do not resolve after six to eight weeks, another course of action is necessary.

Surgery is only required in cases that do not improve with non-operative treatment. But, due to the nature of the injury, conventional treatments usually do not resolve a sports hernia. The actual surgical procedure varies depending on the pathology of the injury. Since, a variety of injuries are grouped as sports hernia, it is difficult to identify a single surgical protocol for all sports hernias.

A laparoscopic technique is now commonly used for repairing most sports hernias. The surgeon makes a number of small incisions in the inguinal area and inserts a surgical camera. The camera pinpoints the exact location of the injury. Depending on the extent and location of the injury, the appropriate measures are taken to repair the torn muscle fibers. This type of surgery is less invasive than conventional surgery. The prior methods used larger incision and more invasiveness, which required longer length of recovery. In the case of an athlete, recovery time is crucial to minimize the effects of detraining and the cost of missing a season. In probably the most publicized sports hernia to date, Donovan McNabb, quarterback of the Philadelphia Eagles, suffered a sports hernia in the early 2005 costing him the ¾ of the season before surgical intervention.

Surgeons have reported a high success rates for surgical repairs of sports hernias. It has been reported that more than 90% of surgically treated athletes return to their prior level activity. Most athletes are able to return to their respective sports following 6-12 weeks of rehabilitation targeting abdominal strengthening, adductor muscle flexibility, and the attainment of criteria based “return to activity” milestones. Resuming activity too soon may aggravate the area which may result in permanent injury.

Prevention
Taking preventative measures to reduce the risk of a sports injury is much more effective than treating the injury after it occurs. Preventative measures should be taken into account for athletes who participate in sports or activities requiring repetitive twisting, cutting and/or high force kicking. Flexibility training should emphasize the hip adductors, abductors, flexors and abdominals. Reduced range of motion in these areas may result in a trauma when participating in the above activities.

Strength training programs should concentrate on balancing the musculature of the lower body and abdominals. Abdominal exercises, particularly those incorporated into total body movement, are frequently overlooked when training the lower body. The muscles of the abdominals, specifically the external obliques which are responsible for rotational movements should be emphasized with periodized strength training. Exercise prescriptions should use more sport specific movements and speeds to prepare the tissue for the force couples common to the activity. Exchange activities that isolate such as crunches and leg press, for activities that enjoin the muscle groups for successful movement attainment. Medicine ball rotational chops with squats and lunge with trunk rotation are common examples. Strengthening the abdominals and balancing the lower body strength can reduce the incidence of the sports hernia.

Addressing proper prevention techniques during training will decrease the susceptibility of an athlete to overuse injuries such as sports hernias. The time taken to prevent the injury through proper training is much less than the time it may take for full recovery from the injury. Do not neglect the musculature of the abdominals and the hips especially when training the lower body.

Common Symptoms of A Sports Hernia

• pain in the lower abdomen or groin
• pain when bending, cutting or lateral movement
• pain radiating to the testicles
• pain in the affected area with sneezing or coughing
• or even a tearing sensation at the point of injury