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G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_17, © Springer-Verlag Italia 2017
A.J. Sheen ()
Department of General and Hernia Surgery, Central Manchester Foundation Trust,
Manchester, United Kingdom
e-mail: aali.sheen@cmft.nhs.uk
17
Pubic Inguinal Pain Syndrome (PIPS): the
Sportsman’s Hernia
Aali J. Sheen, Waqar Bhatti, Max Fehily, Saurabh Jamdar,
David Jones, and Doug Jones
17.1 Introduction
all is a common theme debated in the hernia circles [3]. In Europe, the term “pubic
States, “athletic pubalgia” is more commonly used and preferred [4]. Recently,
a consensus meeting in Manchester concluded that “inguinal disruption” is the
groin pain.
pain either and/or around the inguinal ligament, the perineum, the origin of
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hockey, rugby and martial arts are the kind of sports that are more likely to present
the elite athletes [6].
17.1.1 Definitions
mainly in professional and amateur persons that undertook sports. “Athletic
peripheral nerve entrapment syndrome [3]. “Inguinal disruption” concentrated on
the fact that there are differential reasons in the groin for pain, but by a process
likely cause [3].
The Manchester statement also understood that one or more pathologies
multidisciplinary background [3].
allude to the fact that the pain is arising possibly from the inguinal canal [4].
arose as a result of no clear evidence but merely recognition of a condition that
has a multidisciplinary etiology centred around the groin and pubic area [4, 8].
being evident, there are some reports of an undetectable direct inguinal hernia as
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17 Pubic Inguinal Pain Syndrome (PIPS): the Sportsman’s Hernia
by Gilmore [10].
17.2 Differential Diagnosis
17.2.1 Inguinal-related Pain
ligament itself arises from the anterior superior iliac spine and inserts into the
adductor longus tendon. Therefore, there are a number of forces that are either
Fig. 17.1 Anatomical
illustration depicting the
inguinal ligament, adductor
longus and rectus abdominis
on the pubic tubercle
Inguinal
ligament
Adductor tendon pull
Rectus abdominis pull
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A.J. Sheen et al.
genitofemoral nerve being under “tension”. Division of this nerve has therefore
trial setting.
[13]: femoroacetabular impingement (FAI), labral tears, adductor tendinopathy,
testing a patient’s balance, spinal curvature and of course groin tenderness, especially
17.2.2 Hip-related Pain
common cause in the athletic population is femoroacetabular impingement (FAI).
head or the shape or position of the acetabulum.
bony rim of the acetabulum and the soft cartilaginous rim (labrum) that is attached
The etiology of both pathologies is not though fully understood. The presence
of a symptomatic cam deformity does seem to be more common in the athletic
population [14] and probably begins to form in early adolescence. It is more
commonly seen on the right hand side as that tends to be the dominant side [15].
It is clear that the development of symptomatic impingement requires a
and level of activity.
Symptomatic hip impingement is most common in certain sports such as
distance running, football, rugby, squash and martial arts [17,18]. All of these
involve repetitive loading and unloading of the hip. It is less common in non-
also common in sports such as gymnastics and ballet, but this may be due to
impingement occurring secondary to an abnormal hip range of movement, rather
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17 Pubic Inguinal Pain Syndrome (PIPS): the Sportsman’s Hernia
regions.
trigger the presenting pain.
or minus steroids/hyaluronic acid) can be a very useful diagnostic tool in differ-
entiating hip and inguinal pain [19].
There have been increasing numbers of published papers looking at patient
17.2.3 Adductor-related Pain
On clinical evaluation, pain elicited over the inguinal ligament is more indicative
related pathology [20], although it is accepted that an adductor tendinopathy can
sports that require the strong eccentric contraction are more likely to promote
action of the adductor muscle group is to adduct the thigh in the open kinetic
the closed kinetic chain. The adductor longus is the most likely muscle in this
advantage (due to its anatomical origin and insertion) possibly renders it more
susceptible to a strain. As discussed later, the need to strengthen and improve the
stability of the adductor muscle group becomes essential in reducing the time an
intervention [24].
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A.J. Sheen et al.
17.3 Imaging Investigations
on ultrasound or magnetic resonance imaging (MRI) are clinically important and
that they can be found in an asymptomatic individual [11].
formulate an optimal management plan.
pubis should be used (Fig. 17.2).
is an acquired cleft formed by separation of the short adductors (adductor brevis
Fig. 17.2arrow)
B