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
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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
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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
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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
succes verder