Dr. Brown’s Approach to a Sports Hernia Diagnosis
Now that you have a patient in the office, what do you do? Be sure to allot sufficient time with the patient, get a good history, and carefully examine the athlete. Often, you will determine the diagnosis without the need for MRI or ultrasound. The correct diagnosis leads to appropriate treatment.
From the patient’s history determine the site of the pain and work from there.
- For the athlete who complains of pain near the symphysis pubis (in the middle of the pubic hair above the base of the penis); osteitis pubis is the most likely etiology. This patient is often a distance runner. Many patients report that rolling over in bed is painful. With rest the pain improves. The pain is usually insidious in onset. On physical examination there is usually pain with direct pressure over the symphysis pubis and the edges of the joint are irregular. To confirm the diagnosis inject the symphysis with lidocaine. In low BMI patients this can be easily done with palpation. In the heavier patient ultrasound can serve as a guide. In patients with osteitis pubis the joint is damaged and the will easily accept 10ml or more of lidocaine. A normal joint will accept only a few ml of lidocaine. You need to warn the athlete that the injection is very unpleasant. Afterward ask the athlete to run around your office building. If you have the correct diagnosis they will be almost pain free and with a smile.
- For the athlete who complains of pain near the external inguinal ring (pain along the lateral border of the origin of the rectus abdominis muscle), this is usually an injury to the external oblique. This patient likely will be an athlete involved in a sport that requires rapid changes in direction such as soccer and hockey. The onset is usually insidious. Pressure over the external ring with contraction of the core muscles will often reproduce the pain. When the scrotum is digitally inverted, a normal external inguinal ring will usually only accept the tip of the finger. In athletes with a tear of the external oblique the external ring is enlarged and the tip of the finger passes easily into the inguinal canal. While the finger has inverted the scrotum, ask the athlete to cough. This will reproduce the patient’s pain. If unsure about the diagnosis, inject lidocaine just deep to the external oblique around the external inguinal ring and ask the athlete to run around the building. If you have the correct diagnosis, they will be almost pain free.
- For the athlete who complains of pain near the pubic tubercle, this often represents an injury to that ligament. The athlete will report some chronic pain at that site and the pain will be aggravated by acceleration and cutting. The pain usually has a slow onset. There will be pain with direct pressure over the pubic tubercle and the medial attachment of the inguinal ligament. Sometimes you will notice that the pubic tubercle is thickened when compared to the contralateral side. Inject the medial attachment of the inguinal ligament with lidocaine and again ask the athlete to run around the building. They will be almost pain free.
- For vague and diffuse pain in the left lower abdomen, do not forget the nerves. Nerve pain often runs just above the inguinal ligament from near the anterior superior iliac spine and runs down toward the pubic hair. It will often involve the inside of the thigh and the lateral aspect of the scrotum or mons. The pain will aggravate by twisting motions. The pain will be insidious in onset. There will often be skin sensation changes on the affected side when compared to the contralateral side. Sometimes you can find a trigger point that aggravates the pain, but most commonly there is nothing specific on Physical Examination. Perform a nerve block in the office. Using the anterior superior iliac spine as a landmark, it is simple and safe to perform. The athlete will be often be very thankful.
- Pain high on the medial aspect of the thigh is almost always an injury to the adductor longus tendon. The athlete will report pain with cutting, kicking a ball with the inside of the foot, and with acceleration. Often the athlete will remember a “pop” at the time of the original injury. They will often point to the origin of the adductor longus as the site of their pain or a point about 10 cm below the origin. On examination, there will be pain with adduction against resistance of the hip. Often the tendon will be thinner than the contralateral side. It is very rare that the tendon will actually be torn off the bony attachment. To inject the origin of the adductor longus with lidocaine, ask the athlete to lie supine. Bend the lower extremity at the knee and allow the knee to fall towards side of the examination table. The adductor longus will under tension and be easily seen and its origin easily identified. After injection, ask the athlete to run around the building. If you have the correct diagnosis, they will be significantly better.
- There is often hip pathology associated with one of the above injuries. Many athletes with a sports hernia will have limited range of motion of the hips. If you are concerned that the hip may be the source of the athlete’s pain, inject the hip with lidocaine and ask the athlete if there is any improvements.