Sports hernia: what it is, how it's diagnosed and how it's treated

Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, it's Dr. Sebastian Gonzales with the Performance Place Sports Care Podcast again. Today, we are doing one on sports hernias. And sports hernia is one of the actually very interesting topics that I have found lately. I've been very, very intrigued by sports hernias and the ability to diagnose them via ultrasound and also the amount of uncertainty that people have with it.

And I did do a YouTube video on it a while back. I've learned a lot since then. And I've had quite a few actually come into my office. And they are very, they're very complex cases. And it's really funny, the two that I can remember off the top of my head, they both had a really short timeline of when they had to get better. One guy was actually, he was doing a spurt of military stuff in Afghanistan. So he had about 11 months over there, and he had about one month over here. So there wasn't a lot of time to do a bunch of stuff. But the idea was to help him be able to rehab himself, at least while he's over there, because he didn't have anyone to help, or at least no one that he wanted to help.

But he had groin pain right around the pelvic bone. And if you actually feel down, and if you're feeling kind of like right above like your pubic area, there's a bone right there, and that is a pubic bone. So right there is kind of where he felt a lot of his stuff. And he didn't have any confirming images to tell him what it was, and so on. We ended up doing an ultrasound, and we found it was a sports hernia. And the reason why you really want to find out if these sports hernias are there is because it really changes the course of treatment. So I'll start first before I get tangented off to some of the other stories. We'll go back to YouTube here.

And here is the question. So Doc, I feel a sudden pain in my groin that gradually fades after a few seconds. But it occurs oftenly now, which is bothersome. A few months back, I already felt it, but seldomly do I have a sports hernia because I don't have any bulges in my groin area. So before I start on this, also, if you want to have your question on air, go on to p2sportscare.com. We have a site, which basically in the middle of the page there, it's called Speak Pipe. It's a voicemail button, and that'll help email your questions or comments directly to us. Me and my staff look through them, and the ones that are more detailed and give me something to talk about, I want to talk about, and that's what a lot of these podcasts are going to be on, at least in sporadicness.

But the first thing I think about with this question here is that, number one, they have a misunderstanding of what a sports hernia is because they're talking about a bulge in the area. And there's a few different diagnoses which encompass around that same region, kind of around the groin. And if you don't know where sports hernias are, they're kind of around, again, that pubic bone or in the groin region, kind of where the thigh or front side of the thigh meets the rest of the body. Now, this is an area where you can have a real hernia, which is where your intestines basically kind of start poking out of the muscle and skin layer between the rest of the world and your insides.

And this is more of, that is a hernia. And you can have a couple different types of hernias. We won't go into that because this isn't about hernias. This is about sports hernias. Sports hernias is actually more so just a tearing, especially a chronic tearing of the fascia, which is almost like, it's like when you get a chicken breast and there's that slime all over the chicken breast. That's a, that's fascia. It's not muscle, it's not tendon, it's fascia. It's just kind of like tissue around it. So it's kind of a tearing right there where the adductor that comes up from the thigh, it's kind of like your groin muscle, one of them, comes up into the pubic bone and also where your six-pack muscle, the rectus abdominis, goes in and attaches from there.

It's very diffuse in nature. And what I mean by that is people tend to not be able to be able to pinpoint where it's at. Sometimes it's on one side, sometimes it's on both sides, but it's really, really hard to pinpoint. And that's what I experienced with the, with this guy that I was talking about that I only had a month with. Every time he'd come in, he's like, oh, it hurts right here. And then I'd push on the spot and he's like, I don't know, it's over here and so on. And it really makes me consider the possibility he had a sports hernia. And he eventually did when we took him in for imaging.

Also too, there's a dull burning. It's very dull and burning in nature. I've had people chase this pain all the way down into the thigh, to the scrotum, to the other side of the thigh. And I know you might be laughing in the scrotum thing, but it's common. It's common. When a guy comes in, and especially this more happens with guys than girls, they will probably talk about almost like a tightness in the scrotum. And it won't even always hurt. It just feels odd in there. Females only have this, I think, about 3% to 15% of the time. It's usually very young, active men. Usually with cutting, sprinting, twisting sports like hockey, baseball, soccer.

These all can happen. A couple different names for sports hernias. There's sportsman hernia. There's athletic pubalgia. I always love that one. But for the most part, just realize what it is. It's not an actual hernia. It's not an actual, the intestines coming out of the abdominal wall. It's more so just a tearing of the fascia. The last thing it could usually be is, or actually two things, is one is it could be a labral tear. And a labral tear would be within the hip, deep inside the hip. But it kind of creates that same type of diffused pain around the front side there of the hip, groin area.

And it's really, really hard for people to pinpoint because it's so deep as well. That is a whole different treatment plan. That's why it's important to get diagnosed correctly with this. Lastly, it could actually be an adductor strain or a groin strain. And this is what a lot of people come in saying they have. It's usually not recognized or not correctly diagnosed for months to years. It's probably going to be that person who says they have a chronic groin strain. And it just doesn't go away completely. So back to this question here. I mean, it sounds like it's been bothering for a couple months.

They don't know what it is. They haven't been diagnosed. It can be sharp. And it also does get better for a period of time. To me, it sounds like there is a possibility that this person needs an image to confirm. Because obviously, they need to go see somebody. They need to go see a doc who can diagnose them correctly. Because a sports hernia versus a hernia versus a hip labral tear all have very different treatment plans. Hip labral tear, we're probably looking at more of, especially depending upon the degree of it, it might be a surgical procedure to go and recorrect that specific structure.

Plus trunk stabilization and stuff into the actual hip. A hernia, they might opt to go in and put a mesh in to hold the contents back in the abdominal cavity or the stomach area. A sports hernia, we can treat a little bit more conservatively for a period of time. And what I mean by that is we can try to rehab it for a couple months to three months or so. And hopefully, this person gets better. And sometimes you have to take them off of activity completely. So, if this person is still running, cutting, sprinting, they're not doing themselves any favors. And they're creating chronic tears. And what we can see actually under ultrasound is we can see the surface of the bone, of the pubic bone, or the pubic symphysis right there, it starts to look very cloudy in appearance.

And the significance of that is that it's usually smooth as a board. The surface of the bone is really smooth. But in these cases where it's chronic, it's just, it looks like clusters of clouds in the image rather than a smooth, crisp white line. So, usually, if we can get these people to six to 12 weeks of non-operative rehab and they improve, we can see if they're successful in returning to their normal activity. And obviously, that's a slow progression upward. If they were sprinting, perhaps they want to jog first. And then we might do lunges. Then we might do partial sprints. Then we might do all-out sprints and so on.

There's progressions of getting back into play, not just if your rehab is complete or not. Because although the rehab might be complete for that one structure for the sports hernia, it doesn't mean that you're conditioned to do your sport. But if you don't respond well after six to 12 weeks and it really still does bother you, there are surgical procedures out there. And there's a laparoscopic one, which, according to the reference that I was seeing, it's like 96% successful. And laparoscopic, if you don't know what it is, they basically take a fiber optic instrument, insert it into the abdominal area or the wall, just to kind of view, to see what they're doing.

So they know specifically what they're working on. It's not a blind thing. They have a camera. So it's really, really important to know what you have. Because if it's unsuccessful, there's a really high success rate procedure to do. And it's really going to save you a lot of grief. And one thing I do consistently see throughout some of these forums that I'm reading is that there's a lot of frustration. People are really, really not happy with their progression. They say they've had stuff for a couple of years and so on. There's no reason for that unless you're really, really a hard case. And that does happen.

But the majority of people aren't. We're going to go with the typical treatment plan. And a lot of them will get better. And it can be customized to you individually. But for the most part, we need to do the basics first. And this is actually one of the reasons why I put my courses online. And you can find those courses at performancehb.com. Just go under courses. My goal was to get people to come in with a better base amount of knowledge about their condition. Now, obviously, they had to already be diagnosed correctly. But let's just say with rotator cuff tears with pictures, since it's really common.

There's a few exercises like internal external rotation, scapation, shoulder blade movement that, I mean, we spend, I mean, I'd say one to two hours teaching these. And throughout the teaching process, I get a lot of questions. You know, why are we doing this? How does this work? And so on. So we put these courses online to really get that as a home teaching course. And we get to those secondary level questions because those basic questions, I mean, they are important. And I do really want you guys to know them or know the answers to them. I want you to know the basic rehab and so on. But a lot of it is, again, very standard or boilerplate.

Unless there's pain through certain ranges of motion, we're going to keep those same exercises in the infancy of these rehab conditions. Beyond that, that is when you need to go in or if you've already looked at these and you're educated about it, that's when you go in and you're like, I would probably say, hey, we're going to start with external rotation of the shoulder. And you're like, you know what? I've already done that. I'd be like, great, show me. So you'd show me. I'd be like, you know what? You did that actually perfectly. Let's go to internal. And you'll show me that. And I'll be like, wow, that's great.

Where'd you learn this stuff? Oh, you did the course online? Awesome. That's all I need to see. Let's go on to the secondary level stuff. So with cases like, we'll go back into sportsman hernia. If rehabbed well, I'm sorry, if there was actually a study they did where it was 12 months in. So at 12 months, 97% of the operative groups were fully participating in sports compared to 50% of the non-oper rehab group. And this isn't to say rehab doesn't work, but I think it's helpful to know that you need to find out what you have and really commit to care when we know what it is. Because if you're not responding, let's just get something done.

Let's get something done that's going to be helpful because if not, you're not going to be playing sports for a long time. It's really going to be irritating to life. It's going to be a big lifestyle change. You're going to be sitting here watching TV and Cheetos, which is kind of what I did after I had my first hamstring tear. It was funny that with that hamstring tear, I really got a glimpse of what it's like to be a patient again to have an injury because I remember when I was in high school, when I had my first injury, I didn't really know that much. I mean, I was only 15 and I did the rehab that was asked of me.

But for the most part, I felt really like I was not in control of my condition. So when things didn't work, it was really frustrating and I just hang out there with an ice bag on my back and so on. But the second time around or this time around with a hamstring tear, I really did know a lot. And still, I sat here for, I want to say, about two, three months just, you know, watching prison break and having an ice bag on me and elevating my leg and, you know, doing basic stretches. And finally, I broke out of it and I said, look, I told myself, I need to do the most research I possibly can do on this condition while I'm sitting here.

And I'm going to write a huge article on it so I can rehab myself. And so I can know what is true. I can know it works. And every time I'm sitting here soaking, thinking about how sad it is that I can't play this week, I am going to start doing some rehab and take control of this. So I sat down and I wrote down all the things I knew to be true. Well, running to the mailbox in the morning, which was one of my favorite things to do because it was an opportunity for me to test the area and I thought overnight it was going to actually get better. I knew that was my outcome measure. I knew that was what I needed to feel to know that I was improving.

So as I started to run in the mailbox more and more, I started to feel a little bit better. And it broke me out of the mental rut, which was just sitting there eating Cheetos, watching TV, and I started to rehab it better. So my goal for you guys with sports hernias is I want you to become educated about it. I want you to see someone who can diagnose you properly. And let's make sure you don't have a hip labral tear, an actual hernia, or a groin strain. If it is a sportsman hernia, which probably you're going to have to get an image to confirm because it's really diffuse and vague, then you can start to rehab.

And if it doesn't work, you can get a surgery on it. MRI and ultrasound are the best ways to diagnose this, in case I didn't mention it already. I personally have a musculoskeletal ultrasound unit in my office. It is so much easier than an MRI, and it's very, very quick. The two that I had this, that I'm talking about, specifically the two cases, we did ultrasounds on. You can tell within less than five minutes if this person had a sports hernia. And the great news is all you had to do was have them lift their shorts up really high. You get the probe right up close to the bone, and you can see whether it's torn.

Or not. And MSK, or musculoskeletal ultrasound, is a really, really great option. It's cheaper than an MRI, and it's much quicker to get into. So if you guys are looking for that, just reach out to me. I know a couple people in Southern California who can do it. One guy in Texas. But there's not a lot of people out there who can do it well. There are techs that can do it, but for the most part, you want someone who really knows their anatomy. Because this is an area that I don't think we want to mess up on. Because your care plan really is dictated based upon the findings here. Now, I'm going to create an authority page on this.

And what I mean by authority page is, you know how when you look up, let's just say the last time you looked up sports hernia, it probably shoots you to WebMD or ortho.net. And you'll find all the stuff they probably wrote a couple years ago on it. And it says rest, ice, heat, compression, PT, surgery, things of that nature. And it kind of describes your condition. Those are what we call an authority page, mainly because everybody references it. Now, my goal is to create an authority page on a few different topics. And I've started with rotator cuff tears for pictures, and I've done hip impingement or labral tears as well.

I'm still working on a few of these. But my next one I'm working on is sports hernias. And what I'm looking to do is make it so robust with information that you won't even want to look at WebMD or ortho.net or anything, because all the current research is going to be on. There's going to be great anatomy pictures. There's going to be infographics. There's going to be suggestions of rehab. There's going to be ultrasounds. There's going to be MRIs. There's going to be all this stuff. So it's going to be a place that a blog, maybe somebody who's talking about sports hernias because they have one and it's important to them, is going to start referencing.

And so my goal is to create that and create a course so you guys can be educated about the topic. I think you can get better from sports hernias, personally. I know it is a very frustrating topic to a lot of people. So really become educated about what you have going on, and I think I'll leave it at that. So if you guys have any voicemail or questions that you want me to feature on air, or you have even a wife or a spouse or a husband who has a condition that they just keep talking about and they don't ever want to go and see somebody for, just have them submit their question on here. And it's not intended to be a substitution for an exam since I obviously have not seen you yet.

It should be helpful to the masses. And I truly believe we should encounter people in our life and leave them better than how we found them. And this is the way I can possibly do it. So I'm not allowed to, by law, create suggestions or create treatment plans for people who submit their questions online. So don't even ask. I will probably just ignore the question, sadly, because I get that question a lot. But submit your question online and really be detailed. The more detail you can give me, the more information I can go into on these podcasts. And if you're looking for the podcast, it's Performance HB.

Or sorry, it's Performance Place Sports Care Podcast. And you can find it on iTunes. Please share with friends and review it. That is the only way I start sharing information more. The courses, if you're looking for them, they're on Performance Place HB. There are free ones, but there's paid ones as well. And the paid content, I am obviously putting really good stuff on the free content. But the paid one is just going to blow the free content and any other content on the Internet about the topic out of the water. So I want you to go on and check that out. I'll talk to you guys soon. And if you want to get in contact with me directly, p2sportscare.com.

That's the main site that we check. Talk to you guys soon.