Of all the conditions evaluated in my office the one with the honor of having the most money and time spent on it with the least satisfactory results prior to our evaluation are the patients with “sports hernias”. Not everyone is a “professional” or even a serious athlete although those groups do tend to dominate when it comes to spending a lot of their money on MRIs, physical therapy, acupuncture and visits to their favorite Orthopedic surgeon. I see plenty of casual athletes, clumsy gardeners, former active duty military, and yoga moms with the same complaints as famous athletes. The problem is the name. Hernias are supposed to be holes and “sports hernias” don’t have holes.
Orthopedic surgeon’s training focuses on bones, joints, cartilage and the structures that hold these things together- they don’t fix “holes”. General Surgeons are trained to do many complicated things that typically involve the softer part of our anatomy like the skin, breast disease, abdominal organs, etc. We are great at fixing “holes” in things be it in the intestine, a blood vessel or the abdominal wall (hernias). We have national societies in the field of General Surgery that are single-mindedly devoted to just fixing hernias. Some General Surgeons devote their entire career to figuring out how combine anatomy, technology and mesh products to give patients the best and most durable hernia repairs.
When an injured patient has exhausted and frustrated him or herself trying to get their groin pain to go away they may end up in the office of a General Surgeon at some point. If the gold-standard “turn your head and cough” fails to reveal a obvious outward bulge through the muscle (indicating a repairable defect or “hole” in the muscle), the patient is often told that they don’t seem to have a hernia and the cycle starts again with imaging studies, physical therapy and trips to the Orthopedic Surgeon.
So… who is right and who is wrong? Crazy as it seems everyone is right. The patient really has a problem, the Orthopedic Surgeon is correct in finding nothing wrong with the bone or joints and the General Surgeon is correct in stating that you do not have a hernia. What you have typically is a very poorly named constellation of injuries and partial tears in the lower abdominal wall that was created when your torso twisted one way while your leg was going the other. That torque creates tears in the tissues of the abdominal wall muscles and the fibers that anchor it to the pelvic bone. Repetitive activity makes it worse, rest may allow repair to occur in most people but not all. Because the pain often is localized to the inguinal crease or groin the patient may describe a pain pattern that sounds like hernia in the same region. Thus the name “sports hernia” has been inappropriately born and assigned.
It is hard for any applied therapy to have good results in any area of medicine if the physician involved is not really certain what they are treating. This is one of the reasons there is so much disagreement among “experts” and why there are so many variable therapies with variable results. To use a really horrible sports analogy- some times we get lucky and hit the ball even if our eyes are closed. It is not that anyone is intentionally doing the wrong thing it is just hard to get good results when the problem is not well defined or well understood. To be blunt most General Surgeons have never been trained how to evaluate a sports hernia and many have never thought about the issue till someone shows up in their office. In that circumstance it makes sense to “do no harm” and send the patient back to the referring doctor save someone from what might be a pointless and potentially chronically painful operation.
Even among those Surgeons who either intentionally or unintentionally become involved in the evaluation of the “sports hernia” there is no universal agreement on what repair to do. Some have devoted their entire practice to the endeavor and most have settles into a routine surgical procedure that makes the most sense to them and gives them functional outcomes that they feel are predictable and reasonable. These procedures are typically done with an open groin incision. They can be fairly complicated and often require a specific post-operative regiment of physical therapy to achieve a maximal benefit. Patient will often travel great distances and spend a lot of time, effort and money seeking out these devoted centers. Some like myself believe that the majority of patients will do quite well with a laparoscopic minimally invasive repair with a rapid recovery and reserve the more intense “open” repairs for specific cases or treatment failures. The laparoscopic repair allows the damaged tissue to be reinforced or “splinted” internally with a lightweight mesh. It probably doesn’t hurt any of my patient’s feelings that their insurance actually covers these repairs and it is rare that any post surgical “rehab” is required.
It is hard to accurately judge the results of interventions when it comes to the “sports hernia” patient. There currently exists no standard of care with respect to evaluation and intervention. How can one really judge the failure of conservative management of these conditions when every patient has different expectations of physical performance? How do we evaluate the quality of the surgery when there are no standards of when to intervene or what to do when we get to the operating room? Fortunately this is a benign condition and for most patients they have the luxury of time to find a treating physician that understands this badly named problem.
G. Kevin Gillian, M.D., F.A.C.S.
Virginia Hernia and Heartburn Institute