The sport medicine expert should always bare in mind the complexity of this group of disorders and the multiple diagnoses that may be hidden under this general term and he should also perform a systematic and complete investigation. The correct diagnosis is of major importance for ensuring appropriate therapy. The doctor should refer the patient to fully specialized surgical centers with high rates of success concerning the specific operation.  This is the only way for the athletes to recover fast and to return on time back to the sports field.

 Athletes "hernia"

Injuries of the inguinal region comprise 2-5% of all sports injuries. Early diagnosis and correct treatment are of major importance in order to avoid long-term discomfort which would have devastating effects on the athlete’s career. Major stress upon the adductor muscles and symphysitis are the most common factors causing inguinal pain to the athlete. Often these two conditions are very similar and their diagnosis becomes harder. Other  causes of inguinal pain in athletes include: rupture of the posterior wall of the spermatic cord, iliopsoas bursitis, fractures, nerve compression and the snapping hip syndrome.

Diagnosis of the inguinal pain in athletes is difficult for two reasons: 1) anatomy of the region is complex 2) usually 2-3 different types of injury coexist. Initially the doctor should exclude intraabdominal conditions that may cause the same symptomatology, such as urinary tract problems, lumbar pain syndromes and hip joint problems. After exclusion of the conditions mentioned above, other factors causing myoskeletal disfunction should be sought.

This type of injury is more common in ice-hockey players, sabre sportsmen, handball players, skiers, obstacle race or high jump athletes. It may comprise 5-7% of all soccer injuries.

 Diagnosis is often very hard, especially for the athlete but also for the doctor himself, and remains non-specific in approsximately 30% of cases. Factors that contribute to a harder diagnosis are: complexity of the regional anatomy and the coexistence of many disorders.

A study from Dr. K.Konstantinidi’s group that was presented and awarded in the European Assocation of Laparoendoscopic Surgery meeting was about 92 professional and amateur athletes treated by laparoscopic repair. The results of the study showed that the technique is safe and effective in treatment of chronic inguinal pain of the athletes.

Athlete’s hernia (adductor syndrome) belongs to the gropud of anomalies of the posterior wall causing inguinal pain. It is caused by gradual loss of strength in the posterior wall of the inguinal canal, which ends up to a hidden direct or indirect hernia. Because of the fact that only the posterior wall is intruded, a clinically apparent hernia is almost never found on clinical examination. Some investigators believe that sportmen hernia is the commonest reason of chronic pain of athletes.

Athlete’s hernia is characterized by sudden start of pain, which is deeply seated in the inguinal region and which is gradually getting worse. It may radiate to the inguinal ligament (inguinal-femoral area), the perineum and the gluteal muscles. Maneuvers that increase intraabdominal pressure may increase the pain  (eg cough). Radiation of the pain towards the testicles is found in 30% of the patients.

Inguinal pain is particularly disturbing for the athlete and may affect his performance. It affectws mainly soccer maneuvers such as kicking, rapid acceleration and deceleration, rapid change of direction and sudden torsion of the body.

Clinically, it is difficult for one to differentiate between the sportsman hernia and the other causes of inguinal pain. However in the case of a hernia pain is usually located laterally and cranially which is in contrast to the rupture of the posterior wall of the spermatic cord.

Radiography, ultrasound and magnetic tomography may aid in exclusion of the other disorders causing inguinal pain, but are not of particular usefulness for diagnosing athlete’s hernias.

Non-operative treatments (non-steroidal anti-inflammatory medication and vitamin-B complex) usually fail but still can be tried in cases of uncertain diagnosis. If symptoms persist, the patient should undergo surgical exploration and repair. There are reports for succesful surgical outcome for 90% of the patients.
Two main techniques are used  in practice at the moment:

The classic “open” method, where a 6-10 centimeter incision is made and after recognition of the hernia, stitches are placed or a mesh is fixated for reinforcing the wall.

• Laparoscopic totally extraperitoneal mesh repair (TEP) is a more modern technique offering better results. Hernia repair is established through three 5mm skin incisions, without cutting through the muscle. The advantage is more obvious when the hernia is bilateral, since the repair can be performed through the same incisions. The surgeon uses a specialized laparoscopic HD camera and a magnification of 10-15 times and the operation is completed rapidly, without any blood loss and with high precision. Right after the operation, the patient feels a slight pain or no pain at all, and he may return to his sports activities within 4-6 weeks in contrast to the open surgical techniques in which the patients need to avoid any stress at the region for at least 3-4 months.
  

The most widely accepted opinion today is that these patients should be operated laparoscopically by a specialized team.