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What's the best way to treat a sports hernia?

/ Source: The Associated Press

For nine months, Michael Joyce played high school football and then ran track despite groin pain so bad he could barely get out of bed the next day. Finally doctors diagnosed a sports hernia, a complaint among professional athletes that’s now hitting younger athletes and weekend warriors, too.

But exactly what a sports hernia is and what to do about it are matters of dispute.

On one thing doctors seem to agree: Despite the common name, it’s not actually a hernia. The medical term is “athletic pubalgia,” and it happens when muscle or other tissue pulls away from the pubic bone.

Only in about the past decade has this injury become a widely accepted diagnosis within the sports-medicine field. It’s a hot topic among the pros’ trainers, and seems most common among hockey and soccer players.

If you’re not an elite athlete, information’s hard to come by. Doctors who don’t treat many athletes usually are unfamiliar with it. Nor is there a diagnostic test. The diagnosis usually comes after trying rest and anti-inflammatory drugs, and after all other explanations for groin pain, such as more common muscle strains, are ruled out.

Then which surgical fix to try — sewing frayed tissue back together through an open incision or a newer “keyhole” operation that reattaches tissue to bone with a piece of mesh — boils down to the preference of the surgeon. A search of medical journals found no published studies that compare the options to determine the best treatment.

“There’s controversy at all levels: Does the diagnosis exist? How do you make the diagnosis? Once you make the diagnosis, what do you do with it?” says Dr. William O. Roberts of the University of Minnesota, past president of the American College of Sports Medicine.

That equals frustration for patients. And while there are no good estimates of how common the injury is, “we are seeing more players with it,” from the pros to school athletes to amateur leagues, says Dr. Richard P. Cattey, a Milwaukee surgeon who specializes in the laparoscopic, or keyhole surgery, repair.

'Waking from the pain'

What happens? A number of muscles attach to the top and side of the pubic bone. Different strenuous leg movements can pull those muscles until their attachments fray like a rope, develop tiny tears or completely tear. Dr. William Meyers of Drexel University, the field’s dean and champion of the open-surgery approach, says he’s documented 18 versions of this injury.

“I couldn’t roll over in bed without waking up from the pain,” recalls Joyce, then a high school athlete from Portland, Maine, who had never heard of a sports hernia when he began hurting last September.

At first, doctors called it a pulled muscle. It got worse, so he tried physical therapy and later took three months off of sports, hoping rest would heal. Nothing worked. Eventually his doctor diagnosed a sports hernia and sent Joyce to Cattey, at Milwaukee’s Columbia St. Mary’s Hospital.

Joyce had three tears and his bone was eroding. Cattey, operating through quarter-inch incisions, covered the damaged area with an index card-sized piece of mesh that he screwed into Joyce’s bone. Scar tissue grows into the netting, strengthening the spot to prevent future tears, says Cattey, who has used the procedure on several hundred patients.

Four weeks later, Joyce played pain-free in an all-star football game last month, and he’s headed for a college team.

Meyers, who has operated on 3,000 patients since helping pioneer open surgical repair, operates differently. An injury in one pelvic muscle can leave the whole area unstable, he explains.

Through an inch-long incision, Meyers sews up the tears in a way that tightens some abdominal wall attachments to the bone, and loosens others to restore stability. His patients play again by six weeks.

Meyers is critical of the laparoscopic approach, saying it can cause serious complications such as injuries to nearby blood vessels — and that he’s treated about 150 patients whose groin pain returned because the mesh didn’t fix the stability problem.

Cattey responds that patients sometimes need re-operating after open surgery, too, and that success depends most on finding an experienced laparoscopic surgeon.

What’s a patient to do? Most specialists urge a conservative approach first: The injury may heal with rest and physical therapy.

If not, ask surgeons how many operations they’ve done, how many were successful, and how many had to be redone, says Roberts, a family physician who has diagnosed sports hernias and, as a former amateur hockey player, once suffered one.