Prof. dr. C.H.J. van Eijck Afd. Heelkunde Sportershernia/plaatsen matje.

Prof. dr. C.H.J. van Eijck

Afd. Heelkunde

“Sportershernia/plaatsen matje”

Chirurg

Clubarts

Sportsman’s hernia

Sportsman’s hernia

• Chronic groin painChronic groin pain– Incidence: 6%– 60% during active soccer carier– 50% > 20 weeks complaints

• Differential diagnosisDifferential diagnosis

Differential diagnosis Groin injury

• Muscle and tendon injuryMuscle and tendon injury– Tendon-bone or tendon-muscle – Avulsion fracture

• Adductor longus, rectus femoris or Adductor longus, rectus femoris or abdominisabdominis

• X-Pelvis, bone scan, ultrasound or X-Pelvis, bone scan, ultrasound or

MRIMRI

Differential diagnosis Groin injury

• Osteïtis pubisOsteïtis pubis– Painfull symfysis and adductor-

tenoperiostitis– Direct trauma– Pelvic instability/Sacroiliacal

abnormalities

• 25% Radiologic abnormalities25% Radiologic abnormalities

• X-Pelvis, X-Pelvis, bone scan, ultrasound or , ultrasound or MRIMRI

Osteïtis pubisOsteïtis pubis

Osteïtis pubisOsteïtis pubis

Differential diagnosis Groin injury

• StressfractureStressfracture– Ramus inferior os pubis (5%)– Collum femoris avascular

necrosis Femur head

• X-Pelvis, bone scan, (MRI)X-Pelvis, bone scan, (MRI)

Differential diagnosis Groin injury

• Urologic diseaeUrologic diseae– Prostatitis– Epididymitis– Urethritis– Hydrocèle testis– Non-descending testicle

• Rectal toucher, bact. culture, Rectal toucher, bact. culture, ultrasoundultrasound

Differential diagnosis Groin injury

•Hip en Spine diseaseHip en Spine disease

– Osteochondritis lumbal verterbra– M. Scheuermann– Discus pathology., L1 en L2

– Cam type femoroacetabular impingement– Congenital hipdysplasia– Epifysiolysis femur headkop– Avascular necrosis femur head

•X-LWK (+3/4), X-femur (Faux-profile), bone scan and X-LWK (+3/4), X-femur (Faux-profile), bone scan and CT-scan (arthography)CT-scan (arthography)

Differential diagnosis Groin injury

• Nerve entrapment/previous Nerve entrapment/previous surgerysurgery– N. ilio-inguinalis (symfysis)– N. genitofemoralis (testicle)

Differential diagnosis Groin injury

• Nerve entrapment/previous Nerve entrapment/previous surgerysurgery– N. ilio-inguinalis (symfysis)– N. genitofemoralis (testicle)– N. obturatorius (med. thigh and

adductor weakness)

• Proof blockade and/or EMGProof blockade and/or EMG

N. obturatorius (med. thigh and adductor

weakness)

Nerve entrapmentNerve entrapmentN. obturatorius (med. thigh and

adductor weakness)

Physical examination Groin injury

Renee DannenburgRenee Dannenburg

Physical examination Groin injury

• Lower back, SI Joint and hipLower back, SI Joint and hip• Abdominal musclesAbdominal muscles• Muscles of the upper legsMuscles of the upper legs• Rectal toucherRectal toucher• Palp funiculus and testiclesPalp funiculus and testicles

Physical examination Groin injury

• Lower back, SI Joint and hipLower back, SI Joint and hip• Abdominal musclesAbdominal muscles• Muscles of the upper legsMuscles of the upper legs• Rectal exam., palp funiculus and Rectal exam., palp funiculus and

testiclestesticles

• Painfull int. and ext. annulus with Painfull int. and ext. annulus with elevated intra-abdominal pressureelevated intra-abdominal pressurePainfull int. and ext. annulus Painfull int. and ext. annulus with elevated intra-abdominal with elevated intra-abdominal

pressurepressure

Sportsman’s hernia

• Weakness of the post. inguinal wallWeakness of the post. inguinal wall• Symptomatic non-palpable herniaSymptomatic non-palpable hernia• Disruption of the ext. obl. Disruption of the ext. obl.

aponeurosisaponeurosis• PubalgyPubalgy

Complaints

• Long existing groin painLong existing groin pain• Pain around the external annulusPain around the external annulus• Combination with adductor-Combination with adductor-

tendopathytendopathy• Good reaction on NSAID’sGood reaction on NSAID’s• Increased pain with elevated intra-Increased pain with elevated intra-

abdominal pressureabdominal pressure

PathofysiologySportsman’s hernia

Post wall inguinal canal: fascia Post wall inguinal canal: fascia transversalistransversalis

No striated muscle fibersNo striated muscle fibers

Funiculus through the int. annulusFuniculus through the int. annulus

PathofysiologySportsman’s hernia

PathofysiologySportsman’s hernia

Post wall inguinal canal: fascia Post wall inguinal canal: fascia transversalistransversalis

No striated muscle fibersNo striated muscle fibersFuniculus through the int. annulusFuniculus through the int. annulus

Weakness post. wallWeakness post. wallLat. HerniaLat. Hernia

Tension peritoneumTension peritoneumNerve entrapmentNerve entrapment

TreatmentSportsman’s hernia

• ConservativeConservative– Rest, Fysiotherapy and

NSAID’s

Renee Dannenburg

TreatmentSportsman’s hernia

• ConservativeConservative– Rest, Fysiotherapy and

NSAID’s

• OperativeOperative– Strengthening of the post.

Wall of the inguinal canal– Conventional (Lichtenstein-

plastiek)– Laparoscopic

PatientsSportsman’s hernia

• Since 1998 till present: n=240Since 1998 till present: n=240

• (Semi)professional n=98 (4 women) (4 women)• 76 soccer, 4 atletics , 3 tennis, 4 76 soccer, 4 atletics , 3 tennis, 4

cycling, 11 misc.cycling, 11 misc.

• Amateur n=142 (3 women) (3 women)• 127 soccer, 15 misc.127 soccer, 15 misc.

• Mean Age: 25 Mean Age: 25 ± 4.5± 4.5 year (17-36) year (17-36)

• Time complaints: 3 months till >2 Time complaints: 3 months till >2 yearsyears

PatientsSportsman’s hernia

DiagnosticsSportsman’s hernia

• Herniografie (n=7)– High false-negative

percentage

• Ultrasonography (n=167) • X-pelvic and femur

(n=68)• Bone scan (n=53)• CT-scan (n=22)• MRI (n=57)• Laparoscopy (n=1)

Indirect H .inguinalis

1

2

• Open Lichtenstein n=3Open Lichtenstein n=3• Laparoscopic TEP Laparoscopic TEP

n=237n=237• Tenotomy n=12Tenotomy n=12

• Left n=86Left n=86• Right n=89Right n=89• Both n=65Both n=65

PatientsSportsman’s hernia

Total Extra Perinoneal (TEP)

Total Extra Perinoneal (TEP)

Total Extra Perinoneal (TEP)

LaparoscopyTEP right

Total Extra Perinoneal (TEP)

Laparoscopy

Laparoscopy

Laparoscopy

Total Extra Perinoneal (TEP)

Total Extra Perinoneal (TEP)

• (Min.) lateral hernia n=65(Min.) lateral hernia n=65• (Min.) medial hernia n=24(Min.) medial hernia n=24• Preperitoneal lipoma n=39Preperitoneal lipoma n=39• Enlarged lymph nodes n=32Enlarged lymph nodes n=32• No abnormallities n=80No abnormallities n=80

Peroperative findingsSportsman’s hernia

• Sup. woundinfection (S.aureus) Sup. woundinfection (S.aureus) (n=4)(n=4)

• Adductor longus tendinopathy Adductor longus tendinopathy (n=14)(n=14) tenotomie (n=4)tenotomie (n=4)

• Mesh irritation/seroma (ProleneMesh irritation/seroma (Prolene®®) ) (n=12)(n=12)

• Mesh displacement ( n=4)Mesh displacement ( n=4)• Giant cell tumor re prox. femur Giant cell tumor re prox. femur

(n=1)(n=1)

• Sports recoverySports recovery

ComplicationsSportsman’s hernia

Sportsman’s herniaTime RevalidationWeek 0 - 1

Renee Dannenburg

Week 1 - 2

Week 2 - 3

Week 3 - 5

Week 6

Sportsman’s herniaTime Purpose TherapyWeek 0 - 1 Wound recovery

Pain management

Walking 5 km/h

Week 1 - 2 Optimizing scar tissue

Preventing muscle atrophia

Aqua training

Power walking

Cycle ergometer

Isometric training Rect. Abd.

Steps

Week 2 - 3 Dynamic training Rect. Abd.

Functional exercise

Sit-ups

Running

Lunges

Week 3 - 5 Sport specific training Weight training

Normal training

Week 6 Normal training

Sportsman’s hernia

Sportsman’s hernia• RecoveryRecovery

– Without tenotomy: 4-8 weeksWithout tenotomy: 4-8 weeks

– With tenotomy: 8- 16 weeksWith tenotomy: 8- 16 weeks

Conclusion

The TEP is an efficient The TEP is an efficient method for the treatment of method for the treatment of

patients with apatients with a

Sportsman’s hernia Sportsman’s hernia

Dank voor jullie aandacht en veel

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