Sports Hernia Surgery An Effective Treatment
For patients whose history and physical examination are consistent with a sports hernia, surgery is a very effective treatment.
Two different surgical procedures are used to treat sports hernias. One is the open operation. The other is a laparoscopic procedure with mesh. Both yield excellent results.
Dr. Brown prefers the open operation.
During the laparoscopic procedure the nerves and tendons cannot be fully evaluated because they cannot be seen. The laparoscopic procedure involves placing a large piece of plastic mesh to reinforce the lower abdominal wall; the muscles are not repaired; the mesh can potentially cause problems from shear stresses and nerve damage. The mesh is extremely difficult to remove if it becomes a problem.
The open procedure allows a full evaluation and repair of the damaged muscles. The nerves and tendons are then easily seen, evaluated and treated. Mesh is not needed. The laparoscopic procedure has to be done under general anesthesia, whereas the open procedure can be done easily with sedation and local anesthetic. General anesthesia is still an option for those patients that wish it.
All of the surgeons who have treated more than a few sports hernias are using the open procedure.
To fully treat the athlete, additional procedures are sometimes required, such as an adductor tenotomy or an ilioinguinal nerve neurectomy
The etiology of a sports hernia is thought to be an injury secondary to a simultaneous contraction of the oblique muscles and the adductor muscles. The adductor muscles are much stronger than the oblique muscles, so in this tug-of-war the oblique muscles are usually the ones to tear. Occasionally the adductor tendons are injured. The adductor longus muscle attaches directly to the bone instead of the periosteum. Because of this there is a poor blood supply to the origin of the adductor longus tendon and the tendon heals poorly. Even a minor injury to the adductor longus can result in chronic pain. Patients with chronic injury to the adductor muscles are best treated with a release of the adductor with reimplantation of the muscle into the adductor brevis. There’s no loss of strength. The tenotomy can be done at the same time as repair of the oblique muscles.
The ilioinguinal nerve travels through the inguinal canal on the anterior aspect of the spermatic cord. When the oblique muscles are torn, the cord can prolapse through this defect. This can cause some scarring and entrapment of the ilioinguinal nerve. This entrapment can sometimes be identified on physical examination with a positive Tinel sign at the level of the external inguinal ring. A ilioinguinal nerve block can help establish the diagnosis.
During the repair of the oblique muscles, the ilioinguinal nerve can be evaluated. If necessary a release or a neurectomy can be performed. A neurectomy will result in some areas of numbness, especially on the inside of the thigh and the outside of the scrotum. Some of this numbness may be permanent. Dr. Brown will discuss this with you in detail.
Other nerves will occasionally cause pain, including branches of the pudendal nerve, genital nerve, and the iliohypogastric nerve. If necessary, these nerves will also be evaluated.
When there is poor coordination between the contraction of the oblique muscles and the adductor muscles, then there is a strong shear stress across the symphysis pubis. If this joint shifts, then osteitis pubis can develop.
Osteitis pubis causes chronic pain just above the base of the penis. The pain is aggravated by exercise. It can also be visualized on MRI or bone scans. In patients with osteitis pubis, there should be strong consideration given to a release of the adductor longus tendon. This decreases the shear forces. Dr. Brown will discuss this with you if necessary.