Sports Hernia Surgery An Effective Treatment
There are two different surgical procedures used to treat sports hernias. One is the open operation. The other is a laparoscopic procedure with mesh. Both can yield excellent results.
Dr. Brown prefers the open operation.
During the laparoscopic operation, it is difficult to see all the nerves and tendons. Thus some damage may be missed and not treated. The laparoscopic procedure also involves placing a large piece of plastic mesh to reinforce the lower abdominal wall; the muscles are not repaired only patched; the mesh can potentially cause problems from shear stresses and nerve damage and shrinkage. The mesh is tough 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 operation 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
Treatment of an Adductor Longus Tendon Injury
An adductor longus injury occurs when there is 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 usually tear first. Occasionally the adductor longus tendon is injured. The adductor longus has an inadequate blood supply and a very narrow attachment to the pubic bone. Because of these factors, even a minor injury to the adductor longus tendon often will not heal, resulting in chronic pain. On physical examination, there is pain at the origin of the adductor longus tendon that is aggravated by active adduction of the hip against resistance. Sometimes the pain resolves with a steroid injection. If injections fail, then surgery is very effective. The tendon is released off of the bone and then reattached. There is no loss of strength. The range of motion is often improved. The adductor reconstruction can be done at the same time as the repair of the oblique muscles.
The ilioinguinal nerve travels through the inguinal canal on the anterior aspect of the spermatic cord. When there is a tear of the oblique muscles, the cord can prolapse through this defect, stretching the ilioinguinal nerve. The ilioinguinal nerve can become entrapment and painful. This entrapment can cause a positive Tinel’s sign at the level of the external inguinal ring. An ilioinguinal nerve block can help establish the diagnosis.
During the repair of the oblique muscles, the ilioinguinal nerve is evaluated. If necessary a release or a neurectomy can be performed. A neurectomy will result in some areas of numbness. 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.
When there is poor coordination between the contraction of the oblique muscles and the adductor muscles, then there are shear stresses 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.
Learn more about Dr. Brown’s approach to the treatment of sports hernias or contact Dr. Brown for additional information.