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175
17 Pubic Inguinal Pain Syndrome (PIPS): the Sportsman’s Hernia
and gracilis) from their bony attachments to the pubis. The secondary cleft is a
high signal arising from the superior most tendinous attachment of the adductor
longus to the pubic bone represents partial separation of the adductor longus and
its aponeurosis from the superior pubic tubercle (Fig. 17.4).
Fig. 17.3white arrow) and a left
adductor brevis grade 1 muscle strain (red arrow)
Fig. 17.4
superior cleft sign (arrow)
B
B
B
176
A.J. Sheen et al.
of hip shape. More advanced imaging such as MR arthrography can reliably detect
but ultrasound is better suited in the assessment of the inguinal region for posterior
17.4 Management
17.4.1 Physiotherapy
programme.
Unfortunately, often the culture in sport is for the player not to report the pain
until it is affecting their function and even then it does not limit their ability to train
test. Much of the literature is focused on diagnosis, treatment and management.
It is though accepted in the literature that due to the multi-faceted nature
multidisciplinary team approach [3]. Once an etiology is ascertained such as an
Ekstrand and Gillquist
177
17 Pubic Inguinal Pain Syndrome (PIPS): the Sportsman’s Hernia
of recovery and reducing the need for any surgical intervention [24].
Any rehabilitation generally concentrates on strengthening of the surrounding
to the functional rehabilitation must not occur too early due to the pressure on the
player to return. Rehabilitation can progress through outcome measures such as
and/or a bent knee fall out. These outcomes can be used as useful monitoring tests
to guide athlete’s progression through each stage of the rehabilitation.
may be another useful outcome to both measure and address in rehabilitation.
labrum and capsule and the more dynamic structures like the soft tissue cuff made
a prevention plan for an at-risk-athlete must identify abnormal motor patterning
[28, 29].
patterns and if the patient’s pain is controlled and their movement pattern is
restored they may not need further intervention.
17.4.2 Surgery
access techniques [30, 31]. A European survey of a large body of hernia surgeons
into mesh versus no mesh for open and for both minimal access techniques [32].
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A.J. Sheen et al.
laparoscopic choice is increasingly becoming more common [33] although open
especially as it has the advantage of no mesh/foreign body placement and an early
surgery is undertaken, a tailored rehabilitation programme to suit the needs of
open surgery possibly leading to a later return to sporting activity, although some
17.5 Conclusions
patients should be managed.
References
1. Moeller JL (2007) Sportsman’s hernia. Curr Sports Med Rep 6:111–114
primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J
Sports Med 41:247–252
179
17 Pubic Inguinal Pain Syndrome (PIPS): the Sportsman’s Hernia
3. Sheen AJ, Stephenson B, Lloyd DM et al (2014) Treatment of the sportsman’s groin: British
Hernia Society’s 2014 position statement based on the Manchester Consensus Conference.
Br J Sports Med 48:1079–1087
14:1–4
6. Mann CD, Sutton CD, Garcea G et al (2009) The inguinal release procedure for groin pain:
athlete. Int Sports Med J 1:1–20
8. Hackney RG (1993) The sports hernia: a cause of chronic groin pain. Br J Sports Med
27:58–62
Res 455:78–87
Med 17:787–793
prospective study of elite academy soccer players. Br J Sports Med 49:176–182
innovative open-suture repair to treat chronic inguinal pain. Hernia 14:27–33
67:17–27
Arthroplasty 22(Suppl 3):37–42
to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis
of the hip. J Bone Joint Surg Br 87:1012–1018
osteoarthritis of the hip. Clin Orthop Relat Res 417:112–120
18. Agricola R, Bessems JH, Ginai AZ et al (2012) The development of Cam-type deformity in
adolescent and young male soccer players. Am J Sports Med 40:1099–1106
Musculoskelet Disord 11:264
different pathologies and a case presentation. Muscles Ligaments Tendons J 5:214–222
43:2146–2151
Med 25:87–89
treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet
353:439–443
25. Domayer SE, Ziebarth K, Chan J et al (2011) Femoroacetabular cam-type impingement:
Radiol: 80:805–810
180
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epidemiologic study. Am J Sports Med 25:495–499
Med 17:803–807
Med 29:124–128
unsolved problem in sportsmen. Sports Med Soft Tissue Trauma 3:12–14
pain in athletes is more effective than nonoperative treatment: a randomised clinical trial
Surgery 150:99–107
investigation and management of the ‘sportsman’s groin’. Hernia 18:803–810
soccer players as treatment of chronic inguinal pain. Med Sci Monit 10: CR52–54
groin’. Br J Sports Med 49:764–765
pain in football players: a cluster-randomised trial. Scand J Med Sci Sports 20:814–821
181
G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_18, © Springer-Verlag Italia 2017
)
Beverly Hills Hernia Center, Cedars-Sinai Medical Center, Department of Surgery
Beverly Hills, California, USA
18
Obscure Groin Pain in Women
Shirin Towfigh
18.1 History of the Hidden Hernia
separately interested surgeons from the United States: William Webb from
Alabama and Jack Herrington from Wisconsin.
They presented similar to most other symptomatic inguinal hernias: groin pain
preoperative pain.
He referred to these as “female occult inguinal hernias”, and urged their early
182
S. Towfigh
The concept of the non-palpable, symptomatic, occult or hidden hernia did not
Abdominal Wall Hernias that this
st
century.
18.2 Anatomical Explanation for the Hidden Hernia
a thin round ligament and perhaps the genital branch of the genitofemoral nerve.
result, the insertion of the internal oblique and transversus abdominis muscles
is broader along Cooper’s ligament and further onto the rectus muscle. Also, the
from internal abdominal pressure are distributed more evenly along the pelvic
When standing, an impulse may be generated by Valsalva or cough. Using the
occult non-palpable hernia.
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18 Obscure Groin Pain in Women
18.3 Symptoms in Women
these symptoms are not similar to those typical of men, it can delay their diagnosis.
pressure onto the inguinal canal may also cause pain, such as prolonged sitting,
may also be distributed along the distribution of the ilioinguinal and genital nerves,
some of these patients undergo local nerve block to address the neuropathic pain.
If a hernia is the cause of the neuropathic type pain, I have noted that patients
believe that pain alone cannot be due to an inguinal hernia. This may be true
are labelled as having chronic pelvic pain, and inguinal hernia is not considered
to be the cause of their groin pain.
pain radiating pain from the groin into the vagina, to the upper inner thigh, to
radiating from the back to the groin and upper inner thigh.
18.1). This is analogous to the pain radiating to the base of penis and/or testicle in
184
S. Towfigh
as vulvodynia, pudendal neuralgia, and chronic pelvic pain. These diagnoses often
symptoms during their menses (Table 18.1). This is considered to be due to
direct contact and pressure on the groin. Similarly, vaginal penetration can cause
contraction against a full inguinal canal.
Table 18.1-
Symptoms Prevalence
Examination Findings
Operative Findings