Inguinal Hernia in Athletes: Role of Dynamic Ultrasound

Groin pain in soccer players: anatomy, clinical presentation, biomechanics, pathology and imaging findings

Groin pain is extremely common in soccer players, especially male soccer players, with nearly a third experiencing groin pain over the course of their careers. Despite its high prevalence, there continues to be some confusion and controversy regarding the detailed anatomy and recommended terminology related to groin pain in athletes. This article will review the anatomy, clinical presentation, biomechanics, pathology and imaging findings most commonly associated with groin pain in soccer players.

Diagnostic impact of using the semi-erect position in the evaluation of inguinal hernia with superficial sonography

<b>Introduction:</b> The main cause of groin pain is inguinal hernia (IH). The most commonly used imaging test for diagnosis is sonography, which is also useful in distinguishing between indirect and direct hernias.<b>Aim:</b> In this study, measurements were made with sonography in the semi-erect position (45) in addition to the supine position and the effectiveness of this position in detecting the defect was investigated.<b>Material and methods:</b> The IH cases diagnosed by ultrasound between March 2019 and October 2023 were evaluated retrospectively. According to the diameter of the defect in the supine position, the cases were divided into three groups: Group A (≤1.5 cm), Group B (1.5-3 cm), and Group C (≥3 cm). A total of 252 patients with unilateral IH were identified.<b>Results:</b> For Group A, the mean value was 1.09 0.23 (0.64-1.48) cm in the supine position and 1.28 0.26 (0.67) cm in the semi- -erect position (p<0.001). For Group B, the mean value was 2.29 0.29 (1.57-2.82) cm in the supine position and 2.41 0.31 (1.65-2.94) cm in the semi-erect position (p<0.001). For Group C, the mean value was 3.57 0.23 (3.28-4.05) cm in the supine position and 3.62 0.24 (3.32-4.10) cm in the semi-erect position (p<0.05).<b>Conclusions:</b> Superficial ultrasound, which provides reliable results in the diagnosis of IH, is an easily accessible modality. Unlike previous studies, this study was the first to examine the semi-erect position in IH patients. It showed that it is effective in determining the optimal diameter of the defect.

Telemedicine Evaluation of Hip Ailments

Background During the coronavirus disease 2019 (COVID-19) pandemic, telemedicine has provided new means of patient care while still allowing for physical examination and history to be obtained. Hip ailments are a common musculoskeletal problem leading to limited function. Today, we lack a standardized telemedicine hip evaluation protocol. Aim The aim of this manuscript is to provide an efficient means of extracting relevant information while performing telemedicine examinations of the hip. Methods The authors have created a step-by-step evaluation guide for physicians to evaluate hip complaints, including inspection, palpation, range of motion, strength testing, functional assessment, gait analysis, and special testing, with images of each maneuver. Results  We have developed a table of evaluation questions and instructions and a glossary of images of each maneuver to facilitate hip examination via telemedicine. Conclusions This manuscript provides a structured template for performing a telehealth examination of hip ailments.

Core Muscle Injury: Evaluation and Treatment in the Athlete

BACKGROUND

Pain in the groin region, where the abdominal musculature attaches to the pubis, is referred to as a "sports hernia,""athletic pubalgia," or "core muscle injury" and has become a topic of increased interest due to its challenging diagnosis. Identifying the cause of chronic groin pain is complicated because significant symptom overlap exists between disorders of the proximal thigh musculature, intra-articular hip pathology, and disorders of the abdominal musculature.

PURPOSE

To present a comprehensive review of the pathoanatomic features, history and physical examination, and imaging modalities used to make the diagnosis of core muscle injury.

STUDY DESIGN

Narrative and literature review; Level of evidence, 4.

METHODS

A comprehensive literature search was performed. Studies involving the diagnosis, treatment, and rehabilitation of athletes with core muscle injury were identified. In addition, the senior author's extensive experience with the care of professional, collegiate, and elite athletes was analyzed and compared with established treatment algorithms.

RESULTS

The differential diagnosis of groin pain in the athlete should include core muscle injury with or without adductor longus tendinopathy. Current scientific evidence is lacking in this field; however, consensus regarding terms and treatment algorithms was facilitated with the publication of the Doha agreement in 2015. Pain localized proximal to the inguinal ligament, especially in conjunction with tenderness at the rectus abdominis insertion, is highly suggestive of core muscle injury. Concomitant adductor longus tendinopathy is not uncommon in these athletes and should be investigated. The diagnosis of core muscle injury is a clinical one, although dynamic ultrasonography is becoming increasingly used as a diagnostic modality. Magnetic resonance imaging is not always diagnostic and may underestimate the true extent of a core muscle injury. Functional rehabilitation programs can often return athletes to the same level of play. If an athlete has been diagnosed with athletic pubalgia and has persistent symptoms despite 12 weeks of nonoperative treatment, a surgical repair using mesh and a relaxing myotomy of the conjoined tendon should be considered. The most common intraoperative finding is a deficient posterior wall of the inguinal canal with injury to the distal rectus abdominis. Return to play after surgery for an isolated sports hernia is typically allowed at 4 weeks; however, if an adductor release is performed as well, return to play occurs at 12 weeks.

CONCLUSION

Core muscle injury is a diagnosis that requires a high level of clinical suspicion and should be considered in any athlete with pain in the inguinal region. Concurrent adductor pathology is not uncommon.

The Prevalence of Inguinal Hernia Among Athletes in Saudi Arabia: A Cross-Sectional Study

Introduction An inguinal hernia is the most common type of hernia. It might manifest as a groin bulge, lump, or enlarged scrotum. Swelling may be uncomfortable and painful and even cause intestinal obstruction. This study aimed to measure the prevalence of inguinal hernia among athletes in Saudi Arabia. Subject and methods This is a cross-sectional study conducted among Saudi Arabian athletes. A self-administered questionnaire was distributed among athletes using an online survey through different Saudi Olympic Training and Fitness Centers throughout the kingdom. The questionnaire includes sociodemographic characteristics (i.e. age, gender, etc.), risk factors, and complications of inguinal hernia. Results Of the 594 athletes, 55.6% were females and 57.6% were aged between 18 and 24 years. The most common type of sport was running (31%). The most common risk factor for inguinal hernia was previous abdominal surgery (57.5%). The prevalence of inguinal hernia among Saudi athletes was 12.3%. Being older in age and being male were the independent significant predictors associated with increased risk for inguinal hernia, whereas weightlifting was the independent significant factor of decreased risk for inguinal hernia. Conclusion The prevalence of inguinal hernia among athletes was 12.3%. Older male athletes were most likely at a greater risk to suffer from inguinal hernia as compared to the rest of the athletes. Further research is needed to extract more data about the prevalence of inguinal hernia among Saudi Arabian athletes and determine its risk factors.

What’s the SCORE? Current management of symptomatic, clinically occult, radiologically evident inguinal hernias

Introduction

Symptomatic, clinically occult, radiologically evident inguinal hernias (SCORE-IH) are challenging due to diagnostic uncertainty and a lack of treatment consensus. This study explores current practice among surgeons treating SCORE-IH.

Methods

A trainee-led research collaborative (STEER) disseminated a validated online survey among UK and international consultants. Collated responses were analysed to determine surgeons’ experience and approach to the management of SCORE-IH.

Results

A total of 73 responses were received. Overall, 26% of respondents performed more than 100 IH repairs annually. Nearly two-thirds (62%) were unaware of SCORE-IH guidelines. Surgeons chose ultrasonography (31.5%) or ultrasonography with magnetic resonance imaging (24.6%) to manage SCORE-IH. Surgeons managed SCORE-IH conservatively or operatively in 31% and 36% of cases, respectively. Surgeons’ experience and laparoscopic capacity did not correlate with their approach to SCORE-IH management.

Conclusions

There is heterogeneity in SCORE-IH management, likely due to an absence of adequate guidelines. The results highlight that further SCORE-IH research is needed to achieve consensus.

Imaging Review of Hockey-related Lower Extremity Injuries

Hockey is a fast-paced contact sport with a high incidence of injuries. Although injuries are more frequent among elite players, recreational hockey injuries are a common issue faced by primary care and emergency physicians. Lower extremity injuries in hockey are particularly important because they account for approximately a third of all injuries and > 60% of all overuse injuries. This pictorial review provides the general and specialty trained radiologist with a knowledge of the patterns of lower extremity injury that occur in ice hockey.

Inguinal hernia – epidemiology, risk factors, treatment methods (literature review)

Inguinal hernias (IH) are widespread in the human population and occur in 27–43 % of men and 3–6 % of women. Many risk factors for IH have been overestimated in the last decade: male gender is considered the leading factor (the ratio between men and women is approximately 1:7), less significant factors are heredity (most significant for women), physical activity (more significant for men), age (peak prevalence of IH occurs at 5 years and 70–80 years), congenital or acquired connective tissue dysplasia, history of prostatectomy, low body mass index.Hernioplasty with the use of synthetic mesh prostheses remains the most popular technique for surgical correction of IH. Performing non-prosthetic hernioplasty is only recommended if mesh prostheses are not available, for example in poor countries. In open hernioplasty using mesh prostheses, different methods are used today: Plug & Patch, Prolene Hernia System, Parietene Progrip, sutureless plastic according to Trabucco, Stoppa, preperitoneal techniques TIPP (trans-inguinal pre-peritoneal), TREPP (transrectus pre-peritoneal), TEP (total extraperitoneal), however, none of them showed significant advantages over the gold standard of open hernioplasty – tensionfree repair according to Liechtenstein.Laparoscopic IH correction is represented by the TAPP (transabdominal preperitoneal) technique, performed through the abdominal cavity, and TEP (total extraperitoneal) – extraperitoneal prosthetic hernioplasty. None of them has a significant advantage in the treatment of IH; therefore, when choosing a treatment method, the surgeon should be guided by the cost of the operation and the level of proficiency in one or another hernioplasty technique.

Imaging modalities for inguinal hernia diagnosis: a systematic review

PURPOSE

The aim of the study was to determine which diagnostic modality [Computerized Tomography (CT), Magnetic Resonance Imaging (MRI), or ultrasound (US)] is more precise in terms of sensitivity and specificity in diagnosing inguinal hernia and sub-type of inguinal hernia (direct or indirect).

METHODS

This systematic review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and a search for relevant articles was undertaken in PubMed, Embase, and the Cochrane Library. Inclusion criteria were original studies that preoperatively diagnosed patients suspected of inguinal hernia by either CT, MRI, or US and compared diagnostic findings with operative findings or definitive follow-up. The main outcomes were the diagnostic certainty of inguinal hernia and type of hernia by sensitivity and specificity. All eligible studies were searched in the Retraction Watch database to ensure that all included studies were suitable for inclusion.

RESULTS

Bubble charts depicting the size of each patient cohort and percentual range for both sensitivity and specificity showed that US was better than CT and MRI in diagnosing inguinal hernia. Bubble charts for US and CT depicted high values within the studies that reported sensitivity and specificity in diagnosing type of hernia.

CONCLUSIONS

We found that US had the highest sensitivity and specificity. However, it must be taken into consideration that performance is highly dependent on the operator's level of expertise. Based on this systematic review, ultrasound may be the preferred imaging modality when physical examination is inconclusive, given that local expertise in performing US examination for hernia disease is adequate.

Long-standing groin pain in contact sports: a prospective case-control and MRI study

Objectives

We aimed to prospectively evaluate the prevalence of long-standing groin pain and related MRI findings in contact sports.

Methods

This case–control study followed three male elite-level soccer, ice-hockey and bandy teams (102 players) for 2 years. All athletes with long-standing groin pain lasting >30 days and age-matched controls (1:3) from the same teams were examined clinically, using pelvic MRI and Hip and Groin Outcome Scores (HAGOS). Primary outcome measures were annual prevalence of groin pain and underlying MRI findings.

Results

The annual prevalence of chronic groin pain was 7.5%. Training characteristics and pain scores of athletes were similar in all teams. On MRI, there was no significant difference in the percentage of pubic bone marrow oedema (p = 0.80) between symptomatic players (8/15; 53%) versus controls (20/43; 47%), but adductor tendinopathy and degenerative changes at the pubic symphysis were twice more common among players with pain. Rectus muscle or iliopsoas pathology were seldom observed. Lower HAGOS subscales (p < 0.01) were recorded in players who experienced groin pain compared with the controls.

Conclusion

Long-standing groin pain was observed annually in 1 of 14 athletes in contact sports. Abnormalities in the pubic symphysis were common MRI findings in both symptomatic and asymptomatic players.

Trial registration number

NCT02560480

Imaging of inguinal-related groin pain in athletes

Inguinal canal-related groin pain is common in athletes and may involve numerous structures such as the conjoint tendon and the transversalis fascia. Ultrasound is the only dynamic tool that shows the passage of preperitoneal fat at the level of the Hesselbach triangle and allows excluding true inguinal hernias. Fascia transversalis bulging and inguinal ring dilatation may also be described. MRI assesses injuries of rectus abdominis and adductor longus enthesis and osteitis symphysis but its accuracy for the diagnosis of inguinal-related groin pain remains debated.