Long-Standing Groin Pain in a Male Athlete
The groin is defined as the area delineated by the anterior super-ior iliac spine, the pubis and the inguinal ligament, as well as all containing structures. Groin pain seen in athletes has been categorized using many different terms—sports hernia, athletic pubalgia, and hockey groin. First described by Gilmore in 1980 as a dilation of the superficial inguinal ring, current research speculates that the etiology is multifactorial. Now a common diagnosis in high- intensity athletes involved in sports requiring rapid changes of direction while running, a sports hernia is any condition causing unilateral pain in the groin region without a demonstrable hernia. This pain may arise from muscles, tendons, bones, bursa, fascia, nerves and joints.1 In this paper, a clinical case will be presented followed by a discussion of sports hernias including the proposed pathophysiology, diagnosis, and treatment, as well as a case-specific discussion of the topic.
BH is a 21-year-old male who presented for an acupuncture evaluation after complaining of groin pain since age 16. He was an avid lacrosse player in high school and had to stop playing due to the severity of the pain. On a scale of one to ten, BH stated the pain was a ten at its worst. He described the pain as stabbing and pulling in nature with an insidious onset. It was exacerbated by heavy activity and alleviated by sitting still. The pain started in the right lower quadrant of the abdomen and radiated to the right testicle.
BH sought medical care at the age of sixteen. He had an extensive workup by an urologist and all tests were negative; sexually transmitted diseases, testicular torsion and epididymitis, among other conditions, were ruled out. Feeling relieved that the pain was not caused by a “serious” condition but frustrated at not having an explanation, BH then saw an orthopedic surgeon. The patient underwent another expensive workup and was incidentally found to have a central broad-based disc herniation at L4-5. He left this second doctor and another costly workup feeling frustrated and without an explanation for his groin pain. Finally, after several years of dealing with the pain on a daily basis, he sought acupuncture as a last resort.
On physical exam, BH was a healthy-appearing, muscular man in no apparent distress. The groin pain described in the patient’s history was reproduced with flexion of hip and knee to 90 degrees on the right; in other words, BH had a positive ‘step sign’ (see Figure 1). However, when the hip was flexed and the knee extended, the pain was not reproduced (see Figure 2).
The patient had full (five out of five) muscle strength in all muscle groups in the lower extremity bilaterally. The patient was neurovascularly intact and had normal reflexes with a +2 patellar and Achilles reflex and down-going Babinskis bilaterally. Range of motion was tested and was with in normal limits with the exception of a decrease in anteversion (hip internal rotation). Many special tests were performed as presented in Table 1. All tests were negative except for a decrease in sensation over the L4 dermatome as expected from the MRI results.
|Test Name||What it tests||Result|
|Heel walking||Tibialis Anterior L4, L5, S1||Negative bilaterally|
|Toe Walking||Gastrocnemius S1||Negative bilaterally|
|Seated straight leg raise||Disk herniation||Negative bilaterally|
|Lasegue (straight leg test)||Disk herniation||Negative bilaterally, pain at 80|
|Bragger’s (straight leg test with dorsiflexion)||Sciatica or nerve root irritation||Negative bilaterally|
|Flip Sign||Radicular pain||Negative bilaterally|
|Slump||Radicular pain||Negative bilaterally|
|Faber’s||Sacroilitis||WFL left, right decrease anteversion|
|Thomas||Iliopsoas contracture||Negative bilaterally|
|Thompson test||Achilles tendon rupture||Negative bilaterally|
Discussion of Sports Hernias
Representing 5-7% of all injuries, sports hernias are common among athletes involved in sports that require cutting, pivoting, kicking and sharp turns such as soccer, football and lacrosse.2 In recent years, more attention has been paid to sports hernias with well-known and successful athletes, such as Donovan McNabb, succumbing to their affliction. In 2005, McNabb underwent season-ending surgery after a hard tackle exacerbated his sports hernia. Despite the media hype, the etiology, onset, and even terminology vary widely in the literature.1 Generally thought to be the result of repetitive microtrauma, sports hernias typically develop in an insidious fashion with symptoms arising from lower abdominal musculature and muscles of the upper thigh. The term ‘sports hernia’ is misleading since there is no demonstrable hernia. They are more commonly seen in males, with the pain being described as unilateral and diffuse with possible radiation to the medial thigh, perineum and testicles (see Table 2). The pain is aggravated by heavy activity, laughing and valsalva maneuvers.3
While the symptoms are not disputed, various pathophysiologies have been described in the literature. Some define sports hernias as a bulge or defect in the posterior inguinal wall resulting in a loss of integrity of the inguinal canal without the presence of an obvious hernia4; while others attribute the condition to a muscular defect or avulsion of the muscles of the pubic tubercle that leads to weakness of the inguinal wall or ring.5 Other studies have shown the pain to be due to an actual nerve entrapment causing referred groin pain. The rectus abdominus, in combination with adductor pathology, have been cited as the most common soft tissue defects together with iliopsoas, rectus femoris and sartorius involvement as the most frequently affected non-adductor groups.6