Hernias and hockey
by Dr. James L. Moeller

Ice hockey is known for its speed and physical nature. Lately, one of the few noncontact injuries associated with the game has gained a great deal of attention. Groin and abdominal muscle strain injuries have sidelined many hockey stars in recent years. The "sports hernia" is a new concept, seen primarily in ice hockey and soccer athletes. It is difficult to diagnose and generally requires surgery for definitive treatment.

What is a hernia?

A hernia occurs when an organ or body part protrudes through the structure meant to contain it. This can happen just about anywhere in the body (for example, herniated intervertebral discs in the back).

The most common hernia is the inguinal, or groin, hernia. The pathway for an inguinal hernia is a remnant from fetal development known as the inguinal canal.

Hernias can occur at any age in both males and females.

What is a sports hernia?

A sports hernia is different from a regular hernia in one major way: It's technically not a hernia! There is no protrusion of an organ through its usual confines.

The sports hernia is a relatively new medical concept and not all physicians embrace it. The sports hernia is a disruption of the groin or lower abdomen characterized by weakening of the posterior, or inner, wall of the inguinal canal, which leads to unilateral groin or lower abdominal pain.

How do sports hernias occur?

Sports hernias may occur due to leg adductor action, or bringing the leg toward the middle of the body, during activity. Adduction creates shearing forces across the pubic symphysis, stressing the posterior inguinal wall. A sudden force or repetitive stress to the muscles in this region causes the muscles to separate from their attachment site. These types of forces are most commonly generated in sports like ice hockey and soccer.

How common are sports hernias?

According to a recent study, nearly 20 percent of professional ice hockey players suffered from groin and abdominal strain injuries, including hernia, during the 1996-97 season. That would be five players on a 25-player roster.

An older study showed that, during surgery, sports hernias were present in 50 percent of 186 male athletes who complained of groin pain that lasted longer than eight weeks.

How is the diagnosis made?

The key factors in making an accurate diagnosis are the medical history and physical examination findings. The history usually includes unilateral groin pain that may have come on slowly (more common in runners) or acutely (more common in ice hockey and soccer players), accompanied by a tearing sensation.

Activity made the pain worse, and the pain does not respond to conservative therapies such as ice, rest, stretching and over-the-counter medications.

Because there is no clinically detectable hernia, or protrusion, physical-exam findings may be subtle, if present at all. It is easy to see why this is such a hard entity to diagnose. Radiographic studies, such as X-rays and bone scans, are useful for ruling out certain problems such as fractures and osteitis pubis, but they do not establish the diagnosis of sports hernia.

Diagnosis is typically made at the time of surgery, when the anatomy of the posterior inguinal wall can be directly visualized. Treatment is also surgical, with most procedures being minor variations of a standard hernia repair.

Rates of surgical success, defined as a full return to pre-injury activity levels, are reported to be between 63 percent and 93 percent. Most of these patients were able to return to their sports within six to eight weeks of surgery.

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