I, too, am going to underwhelm you with data because this field is, or a paucity of data because this field doesn't really have any. Most that's published out there are single center series for the most part, and outcomes always look like about 90 percent of people get better, or 90 percent plus, no matter what anybody does, which means that it's ripe for more research. So core muscle injuries or sports hernias really result from a strain or a tear of the soft tissues right at the medial aspect of the groin. So either the lower abdominal musculature or the adductor longus tendon or adductor tendons in general. And this is the area we're talking about. It's been termed the pubic joint by some providers, and I think that's a great name. The anatomical description really extends our understanding of this, and you can see the rectus muscle above that pulls up the adductor longus tendon down, and these two opposing forces, they have a common tendinous insertion on the pubic bone, if you will. And then just lateral to that is the area of the inguinal canal, which is probably not so familiar to most people in orthopedic or musculoskeletal specialty, but is really the home of the general surgeon, because this is where hernias happen. And with this pathophysiology, we generally see some degree of injury or laxity in this area from a number of different causes, which are very hard to delineate preoperatively what those causes are. This is just a true anatomical drawing where you can see, again, the tendon and the muscles coming down from above. And so the pathophysiology of sports hernia, I think to most simply reduce it to that is it's an overuse or an acute injury of the thigh and lower abdominal muscles, which results in a weakness or strain or a tear of those muscles inserting into the pubic bone, resulting in pain. And the acute injuries can happen when there's a loss of core control, and then you get an acute tear or strain, and that's typically seen in the adductor longus tendon or the very lower part of the rectus muscle. And when it's a chronic, more insidious type of injury, it's probably more aware and tear where you can see, again, some degree of tenderness and insertional tendinopathy, if you will, in that area, as well as potentially these injuries just lateral to that in the inguinal canal. When you look at the differential diagnosis of groin pain, it's extensive. You can rule out most of these and just narrow it down just by talking to the patient pretty quickly to either true hernia pathology, core muscle injury or sports hernia, or potentially hip pathology. The hip pathology and the core muscle injuries, though, can be much more confusing because they do tend to go hand in hand to some extent. So the thing about this disease process is really, I think, the diagnosis can be made just by history, history, history, and physical exam. I think in most cases, you do not even really need any imaging to decide if it is a sports hernia or a core muscle injury and how you are going to treat this patient. All that being said, by the time most people have seen me, they've already been imaged. They've oftentimes seen multiple providers. A lot of people are asking for imaging no matter what. So to me, one of the most important aspects is really delineating the pain that people are having. I'm really big on asking people because they start to use all sorts of terms, which really don't mean anything. Last week, someone was telling me all about the pain in his artery, and I was going to ask him what the name of the artery was because I had no idea, but I was afraid maybe I missed that day in medical school. But point with one finger where your pain is is really telling to me because lots of times if people go right to the pubic tubercle and they start to extend down into their adductor longest tendon, I know probably we're dealing with some kind of core muscle injury sports hernia. The characteristics of the pain, the timing of that pain, when it's happening, what exacerbates it. I'm big on asking about pain with coughing or sneezing or pain with getting out of bed. That can overlap a lot with regular hernia, but you don't really tend to see that with more of the hip pathology or some of the other causes related to that. And if it radiates into the testicle, radiates into the inner groin, and then, of course, asking about the contralateral side. The history, again, is important. Were there any inciting events? Did this happen from a specific injury, or was it more insidious in nature? And you can see the rest here. I ask them if they've ever noticed a bulge, suggestive of a true hernia, symptoms bilateral, and then always look for associated hip symptomatology and try to discern, are you having pain on that more lateral, that C aspect around the side of your pelvis, or is it really more medial, or both? And then, of course, if they've had any previous pelvic operations, because that gets you kind of down a whole different pathway, whether that's neuralgia from a previous inguinal hernia surgery, or in the case of female patients who may have had C sections or more of a fan and steel incision, you could potentially have a neuralgia from that as well. And the physical exam is focused on activating that lower rectus and the adductor muscle. I saw them do a lot of active adduction to see if that stimulates the pain. Resisted sit-up to engage the lower rectus muscles, does that engage the pain? Both of which you commonly see in the sportorneal world. Look for real hernias, palpate everywhere, and then do all the range of motion of the hip to see if their hip freely moves without any pain, or is this picture a little bit fuzzier? Again, imaging, some people do dynamic ultrasound. If we get imaging, I've relied heavily on MRI. Again, if people come to me without imaging and they have a classic story, I don't get any. When they come and the history and physical are not clear, and or there may be associated hip pathology, we'll add an MRI. This MRI shows a significant inflammatory processes down in the adductor and then the classic double cleft sign and edema of the pubic bone. A question that some people ask is sometimes you'll be seeing someone for groin pain. Sometimes I'll look at their MRI that they come in beforehand and I'll say, ooh, that right side looks pretty bad, left side not so bad. I'll go in and see them and say, is your right groin hurting you? They say, no, right groin's fine, doesn't bother me at all. It's the left side I'm here for. And so again, the MRI itself, I think you have to interpret that heavily in the context of symptomatology. So the treatment of these, without taking into concerns anybody's professional goals and the high school athlete and the runner who runs too much and overuse injury, always some component of rest, ice, NSAIDs if it's really acute. Most of the time when I'm seeing people, they've already gone down this pathway. Most people have gone down a physical therapy pathway. If they have not and it's a relatively acute injury, I definitely insist on a period of rest followed by physical therapy if that doesn't resolve it. And the physical therapy focuses on core strengthening, a lot of postural retraining and engagement of the core. The common questions I get, which are challenging is, if I feel like I can play the rest of the season, am I going to make things worse? Can I go out there and do that? And I've taken a real practical approach because, again, we don't have data to guide this. If this is not an acute injury and it's something that's happened more insidious, you know, I've had this now for, I had a little bit in preseason and it's been going on for the last four weeks, but I feel like I can play. I let them play. If it's a more acute injury, I try to insist that there's a period of rest. The other thing that I get is, I don't have time to try other things. Can I just get a surgery? That's obviously a much different discussion in a collegiate or professional athlete. If they are not in that role, in most circumstances, I try not to go down a surgery pathway. You know, the high school athlete who's participating in a number of sports, I just tell them they're going to have to take time off and see what happens. Oftentimes I will, I'll say we can schedule a surgery so we have something on the books, but we have to give this a trial to get better in that way. If it doesn't, we can move forward in a timely fashion. Surgical management, which I'll end with, again, I want to stress that if there's anything to walk away from, it's based upon the history of physical and the symptoms, not necessarily the imaging findings and the response to their previous treatments that determine the need for operative intervention. And should be considered when the non-operative approaches have failed to make the patient better. I should also mention there are, we do use some adjuncts into these patients in their non-operative management. If there's someone who's experiencing symptoms who says, look, I'm going to get an operation, but I'd like to play the last four days, four weeks of the season or something like that, we will use steroid injections to see if we can improve their symptomatology in the meantime. Acute injuries, we also consider the use of PRP. I don't have any objection to the use of PRP. I haven't seen any substantial heterotopic ossification secondary to that, but some people do describe that. So this is the algorithm that we use, and really for the most part, it just highlights the fact that if it's acute, rest, if it's persist, physical therapy, and then if they fail to get better, that's when we consider surgical treatment. A lot of the considerations that I have is that if they've had a previous groin operation and this is not clearly associated with a sports incident, we look for neuralgia and we give them a nerve block to see what that does. That doesn't necessarily mean that they don't have an associated sports hernia, but it's helpful to understanding that whatever I do, I'm going to have to consider doing a iliinguinal neurectomy as part of their treatment. Do they have hip pathology considered? If so, work with a partner, a hip surgeon, to consider adding that. I really focus on whether or not they have symptoms in their adductor, and if they do, I feel that doing a procedure that addresses the adductors should be part of what you do. And then really seeing if someone has bilateral symptoms. And then real briefly, just to go over the operations, all the operations that have been described really, I think, when you look at what the goals of the operation are, are similar. They change the tension or the pull on the pubic joint. They reinforce the weakness in that area that is occurring secondary to tear, so that usual motion in the floor of the inguinal canal, and they relieve compression of the nerves. And so this can be done a number of ways, laparoscopically, which is essentially glorified laparoscopic hernia repair in most instances, open repairs with mesh, which most people do stay away from, though some people still use this, or doing some kind of primary repair, and then particularly in athletes that have mostly adductor symptoms, doing a standalone adductor tenotomy. Some people really advocate for that or adding it to what you do. This is a view from the laparoscopic standpoint, where you can see on the inside, we're looking behind the muscle, the rectus muscle is highlighted there, the floor of the canal. You can see coming up, that's where the area of hernia is. And so this is just reinforced with a mesh, which prevents that extra movement and redistributes some of the tension. And then open repairs, if you look at this anatomical schema, they all have some variation of changing the vectors of pull of the muscle and reinforcing the floor of the canal there. And so when you do a mesh, you really don't change the vectors of pull, but you reinforce the canal. And people who do mesh repairs report upwards of 85% success for people with this pathology. I don't think that's enough in most cases, because you're really not addressing any reinforcement of the rectus adductor complex. Primary hernia repairs, this is what this is a representation of. Two, don't do the same thing of changing the distribution of tension on that rectus adductor complex. And then other types of repairs, this is described by a surgeon in Germany, where there's a plication of the floor of the canal with a lateralization of that rectus muscle, which changes the vectors of pull on the pubic bone. The repair described out of Philadelphia, this probably doesn't quite adequately represent the extent of lateralization of the rectus muscle, partial adductor longus tenotomy with flipping up that overlying fascial sheath to help tack down the rectus muscle. I do a variation of that operation in most patients. And then whether or not you do a standalone or a full adductor longus tenotomy in patients that really have adductor symptoms should be considered. So again, postoperatively, we get people into therapy right away, escalate them. The recovery in most cases is about a seven to eight week back to full activity. I find that a lot of people aren't pain free till about 12 weeks, and it needs to vary. And again, this is our protocol of decision making that we base to guide our management of these patients, though clearly it's nuanced in a lot of scenarios. Thank you.

core muscle injuries

sports hernias

soft tissues

laparoscopic repair

recovery time