The sportsman’s hernia

The condition of sports hernia or footballer’s hernia is well-recognised, but often misunderstood, in fact it’s not a hernia at all!

This article describes the recognition of the condition, along with its symptoms and signs and illustrates how it may be successfully treated by a combination of surgery and physiotherapy, in the vast majority of sufferers, allowing them to return to normal activities.

This article on sports hernia is written by Simon Marsh, Consultant Breast, Groin and Hernia Surgeon, London.

The news that a Premiership footballer is having a hernia repaired is not particularly surprising. What you may find surprising is that most of these sportsmen will not have a hernia at all! 

They will actually be suffering from anther type of groin injury known as a Gilmore’s Groin (also called a groin disruption). This is a condition first recognised, and successfully treated, by the London surgeon Jerry Gilmore in 1980. He operated on a small series of 3 professional footballers, none of whom had been able to play because of severe groin pain. All of them subsequently returned to top flight football. 

During the surgery, he was able to see the way that the muscles had been displaced and was able to restore the normal anatomy of the groin, allowing them to return to their sport. What they didn’t have was a hernia. With a hernia, there is a definite hole in the muscles of the groin allowing the intestines to poke through. With a Gilmore’s Groin, there is no defect but the muscles have been pulled away from their normal positions.

You can picture the muscles of the wall of the abdomen in 3 layers. The outer layer runs at about 45 degrees downwards and inwards. The middle layer runs at 45 degrees upwards and inwards (at right angles to the outer layer). The inner layer runs straight across. Towards the middle, all these muscle fuse together into a common tendon and are fixed to the pelvis in the middle. They also become fused with the muscles of the leg at the top of the groin.

In men, the outer layer has an archway in it through which the blood vessels and nerves go down into the testicle, along with the vas deferens. When the groin is torn this archway opens up and becomes much wider. There are also tears in the muscle around the archway. The middle layer is pulled up and away from the pelvis, allowing the unsupported inner layer to become loose and floppy.

Sufferers get a fairly characteristic set of symptoms including pain with running, twisting, turning and kicking. After playing sport, they are stiff and sore and this is often much worse the next day.

Rising from a low position (for example getting out of bed, or in and out of a car) and coughing and sneezing make the pain worse. Only a third of patients can remember a specific injury, usually involving overstretching.

The diagnosis depends on taking an accurate history and performing a thorough examination. In order to feel the muscles at the back of the groin, it is necessary to push a finger up into the scrotum, something which is always uncomfortable, but in the presence of a groin tear it is possible to feel the dilated archway in the outer layer of muscle along with the tears.

It is also possible to feel the loose inner layer that is exposed because the middle layer has been pulled up and away. It may be an understatement to say that examination on the affected side is more uncomfortable than on the normal side!

Successful treatment depends on accurate realignment of the groin muscles in each layer. The whole length of the groin muscles needs to be exposed to allow a proper repair to be carried out in all the layers. This means that an incision of about 7.5cm (3 inches) is made. This allows full exposure of all the muscle layers along the length of the disruption. Following surgery, there is a rehabilitation program that must be followed over the next 4 to 6 weeks.

Surgery is required in sportsmen who are unable to play their sport, or in cases that have not responded to physiotherapy. Gilmore’s Groin is most commonly seen in footballers, but is also seen in rugby (union and league), athletics, racquets sports, cricket and hockey as well as those undertaking general fitness training for other sports. Correct assessment, diagnosis and treatment means that the vast majority can return to their normal activity between 4 and 8 weeks after their operation.

Between 1980 and 2005, over 6,000 cases were referred and 3,600 operations performed. The operation is successful in 97% of professional soccer players and 85 English league clubs have referred players whilst many have come from other parts of the UK and abroad. In this period, 364 international sportsmen and women were successfully treated.

So, what is a sportsman’s hernia? It’s a groin disruption, not a hernia!!

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