Involving Adductor Tenotomy, Ilioinguinal Neurectomy and Osteitis Pubis
An appendix follows this protocol for examples of exercises in each phase of rehabilitation. There is little research available on the protocol for sports hernia rehabilitation. The following protocol is what I have found to be successful in rehabilitation of a post operative sports hernia repair.
Additional information and resources can be attained through Dr. Brown at (http://www.sportshernia.com/meet-dr-brown/) or through my contact information listed below:
Ryan Monagle, PT, DPT
Personally Fit, Inc.
Download the Rehabilitation of a Sports Hernia protocol (pdf format).
We thank Ryan Monagle for this submission and valuable contribution.
On 12-28-12 I visited Dr. Brown for what I termed a quadruple sports hernia and five surgeries. To treat my injury Dr. Brown performed surgery to my oblique muscles (R&L) and the adductor muscles (R&L). The adductor muscles are much stronger than the oblique muscles, so in this tug-of-war the oblique muscles tore, but the adductor tendons were injured. As a result Dr. Brown performed a “release of the adductors” with re-implantation of the muscle into the adductor brevis. The adductor tenotomy was done at the same time as repair of the oblique muscles. Dr.
Brown also performed an ilioinguinal nerve neurectomy on the right side.
See www.sportshernia.com for details as this was found during surgery. The neurectomy resulted in numbness on the inside & outside of the right thigh. I was advised this numbness may be permanent, but mine was gone in a week. Finally, because of the contraction of the oblique muscles and the adductor muscles I developed shear stress across the symphysis pubis which led to osteitis pubis. Dr. Brown performed the release of the adductor longus tendon to decreases the shear forces and gave me a steroid shot.
After three months the pain and numbness were gone. Dr. Brown gave me back my athletic life, but I also want to thank my post-surgery physical therapist, Ryan Monagle www.personallyfitonline.com and Dan Selstad www.danselstad.com, a Credentialed ART Provider. Active Release Therapy (ART) is a patented, state-of-the-art system that treats problems with muscles, tendons, ligaments, fascia, and nerves.
Hormones are the chemical messengers and regulators in our body. After the age of 50 these levels drop significantly. Previously, physicians just have accepted this as a part of the natural aging process. But if these hormone levels are replaced back to levels that we enjoyed when we were 30 years old, there is documented significant health benefits. Weight loss. Increase of muscle mass. Improved immune system. Increase in cognitive skills. Return of libido. More energy. Increased bone density. Healthier skin. Decrease in visceral fat. Decrease in blood lipids.
Every older athlete needs to consider bio identical hormone replacement at some part of his health regimen.
I was pleased to find many postive comments about my sports hernia approach and sports hernia practice on this website:
Patient feedback is very important and useful to me. You can post your comments on our blog or use our convenient contact form if you prefer.
Dr. William Brown
The best single test to evaluate for athletic pubalgia is a MRI with the athletic pubalgia protocol. If your doctor is unfamiliar with the protocol, below is a link to the protocol from the Thomas Jefferson University:
How to interpret the MRI is contained in the following article:
Note from Dr. Brown: Though this patient did not have a sports hernia, it does explain one reason I do not use mesh.
Dear Dr. Brown:
I had suffered well over 3 years when I met Dr. Brown. A routine 1cm umbilical hernia repair, with mesh, left me unable to sit and barely able to walk. I had been off work for over 2 years. More mesh (inguinal) was implanted about one year before I met Dr. Brown. I was on opiates, sedatives, and muscle relaxers, yet my pain was still never less than a “5.” I was bedridden 16-20 hours/day.
Dr. Brown was the first doctor to tell me the mesh could be the source of my pain.
When Dr. Brown took the mesh out it was as hard as a brick. This was a delicate surgery, but Dr. Brown successfully removed all the mesh.
It has now been 3 years since Dr. Brown operated on me. My recovery is ongoing, but I can now walk very well again – about 200 miles/month! I’m off ALL pills! I can sleep again, and now I’m OUT of bed 16 hours/day.
My journey with pain started mere days after an umbilical hernia – over 6 years ago.
My recovery, thank God, began the day I met Dr. Brown.
Thank you Dr. Brown!
There are three nerves that provide sensation to the skin in the region of the pubic hair, scrotum or mons pubis, and the medial thigh. These nerves are the ilioinguinal nerve, the iliohypogastric nerve, and the genital nerve. Some athletes with a sports hernia will have symptoms related to one of these nerves. The commonly involved nerve is the ilioinguinal nerve. The athlete will report that there is an electrical or burning pain that radiates down the medial thigh or towards the scrotum or onto mons pubis. The diagnosis can be confirmed by direct pressure or tapping on the ilioinguinal nerve (Tinel sign). In addition, the athlete will have significant relief with an ilioinguinal nerve block. The nerve can sometimes be imaged with ultrasound or MRI. At the time of surgery, the nerve is examined. If there are adhesions around the nerve then these are lysed. If there has been a significant injury to the nerve, then a neurectomy should be performed. After a neurectomy, there is numbness of the skin. Most of the numbness resolves with time. A neurectomy does not affect sex.
The adductor muscles are located on the medial aspect of the thigh. These muscles adduct the hip joint. Of the adductor muscles, the adductor longus is the most commonly injured. This is because of its limited attachments at the pubic bone and poor mechanical advantage. An injury results in pain high on the inside of the thigh with sports (especially soccer and hockey). The pain can be reproduced by active contraction and palpation of the adductor longus tendon at it origin. Prevention, involves pre-season training to improve the strength of the adductors relative to the abductors and improved flexibility. Once injured, the tendon is very slow to heal because of a poor blood supply at its origin.
Conservative treatment consists of analgesics to control discomfort with active physical therapy. If conservative treatment fails then steroid injections can be helpful. An operation is sometimes required, if other treatments have failed. Surgery consists of a tenotomy of the adductor longus tendon and reattachment. Limiting the release and reattachment of the tendon helps to prevent any weakness.
Hölmich P, Uhrskou P, Ulnits L, Kanstrup IL, Nielsen MB, Bjerg AM, Krogsgaard K. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999 Feb 6;353(9151):439-43.
Martens MA, Hansen L, Mulier JC. Adductor tendinitis and musculus rectus abdominis tendopathy. Am J Sports Med. 1987 Jul-Aug;15(4):353-6.
Robertson IJ, Curran C, McCaffrey N, Shields CJ, McEntee GP. Adductor tenotomy in the management of groin pain in athletes. Int J Sports Med. 2011.Jan;32(1):45-8. Epub 2010 Nov 25.
Orchard JW, Cook JL, Halpin N. Stress-shielding as a cause of insertionaltendinopathy: the operative technique of limited adductor tenotomy supports this theory. J Sci Med Sport. 2004 Dec;7(4):424-8.
The objective of surgery is to help the patient. The surgeon wants to repair the injury but at the same time To Do No Harm. To help me achieve these goals I follow the following rules during hernia surgery.
- Handle the tissues delicately and with care.
- Minimize the use of the cautery. The heat and current can damage remote tissues.
- Minimize the dissection of the spermatic cord.
- Use absorbable sutures as much as possible.
- Do not place sutures in the region of the pubic tubercle or near the medial
attachment of the inguinal ligament.
- When repairing the inguinal floor, avoid placing sutures in the internal oblique
muscle. The iliohypogastric nerve sometimes courses through this muscle. Use
the transversalis for the repair.
- Handle the nerves little as possible.
- Know where the nerves are.
- If neurectomy is required, excise the nerve distally and bury the nerve proximally.
- Have plans to do with any unforeseen problems.
- Be sure the patient understands the procedure and has reasonable expectations
View the image below to see why I do not use mesh unless necessary.
This athelete’s vas deferens was scarred to the mesh. It was difficult to remove the mesh without damage to the testicle.
The second image shows the mesh after it has been removed. The mesh is stiff and fibrotic.