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Inguinal and femoral hernias are not uncommon and can be symptomatic producing radiating pain diffusely in the groin area. In athletes with persistent pain, ‘sports hernia’ can be a cause of problems: this is a syndrome of weakness of the posterior inguinal wall causing chronic groin pain, but without a clinically recognizable hernia.

Inguinal hernia

An inguinal hernia is a protrusion of the contents of the abdomen through the peritoneal lining resulting from a weakness of the muscles and connective tissue layers of the abdominal wall. Of all hernias, 80% are inguinal and appear as swellings at some point along the inner half of a line between the pubic tubercle and anterior superior iliac crest. They can be the cause of pain in the groin which is triggered by exertion or even by coughing, sneezing, and straining. When the causes of vague pains in the groin are sought, the doctor usually checks for the presence of an inguinal hernia.

These hernias are treated by surgery, which may be endoscopic. The patient can often resume muscle exercises 1–2 weeks after the procedure. Return to strength training, however, should be postponed for 6–10 weeks, depending on the surgery.

Femoral hernia

Almost 10% of all hernias are femoral hernias, which protrude on the front of the upper thigh below the groin fold. The treatment is similar to that of inguinal hernia.

‘Sports hernias’

Hernias are increasingly recognized as a cause of persistent groin pain, in the absence of other pathological findings. Sports hernia syndrome is assumed to be caused by a congenital weakness of the posterior wall of the inguinal channel, causing chronic groin pain, but without a clinically recognizable hernia. Initially it results in a symptomatic bulging in active athletes, and probably later in life forms a fully developed hernia. The pain of this injury is located deeply in the groin area. The pain may progress and the discomfort may become more severe, making it impossible to stride properly during running or turn quickly without a stab of pain. The pain is often worse on one side, but may radiate laterally and across the midline down the inside of the thigh into the adductor area and into the scrotum and testicles. About half the athletes give a history of pain when coughing. Physical examination reveals the main tenderness to be worse over the pubic
tubercle of the affected side. The scrotum is then invaginated and the inguinal rings palpated from the inside. The area around the external ring is tender. Since this condition is difficult to detect by clinical
examination, a herniogram or a modified CT herniogram may be used for diagnosis.

The treatment of these hernias is surgical repair to the posterior inguinal wall. Reported results are excellent: 87% of athletes can return to full activity within 2 months and the remaining 13% are improved.

Incipient abdominal hernia

Pain with negative clinical findings is also associated with incipient hernias, which sometimes correspond to sports hernias. These are hernias within the abdomen that can cause pain radiating out towards the groin. Soccer players can develop these incipient hernias on the side of the dominant leg. Herniography, in which contrast medium is injected into the abdomen and allowed to sink down into the hernia, may reveal this lesion. Herniography is very sensitive and the results must be carefully correlated with presenting symptoms. Operative treatment of these incipient hernias gives excellent results, with an early return to sports.

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