SOFT-TISSUE REHABILITATION

HERNIA MANAGEMENT AND REHABILITATION

By David Fevre, MCSP, MSc

Non-traumatic hernias Recognition of the sportsman’s hernia, or Gilmore’s groin as it was originally labelled, only occurred from the early 1980s. More modern and anatomically cor- rect names include indirect hernia, poste- rior wall disorder or groin disruption syn- drome.

For the purpose of this article, the condi- tion will be described as a posterior abdominal wall disruption (PAWD) injury. This is a condition that can be repaired surgically with a recovery period of 4-6 weeks post-operatively. It is most common in men due to the embryonic descent of the testes and can cause many months of problems before a firm diagnosis has been made. Some players who have such an injury have continued to play for many months following diagnosis, or without recognising the problem, though this depends on the ability of the individual to cope with the sensation of pain. Functionally though it becomes more and more difficult for a player to maintain fit- ness levels and perform various activities in the game situation.

It must also be recognised that such chronic groin pain may be due to an incompetent abdominal wall, with or with-

out a detectable inguinal hernia (4). In terms of reaching a diagnosis, the majori- ty of indications to the problem come in the subjective examination rather than the physical, objective assessment.

Traumatic hernias Traumatic abdominal groin injuries, often labelled as a ‘sportman’s hernia’, do occur in the high impact, collision sports of rugby league and rugby union (5). Players describe very different signs, symptoms and causes to this injury scenario.

Clinical symptoms ● Rarely a specific date of trauma with a gradual onset of symptoms ● Dull, intermittent ‘toothache’ type pain ● Intensity of pain eases as the level of activity increases and then becomes more severe as fatigue sets in ● Very rarely are there any associated adductor symptoms ● 15% of players will complain of bilateral symptoms ● Coughing, sneezing, kicking, sprinting and getting out of bed/car, particularly the day after a game aggravates the pain ● Physical symptoms include a dilated superficial inguinal ring on palpation, a positive cough impulse and tenderness on the affected side. The size of the inguinal ring though is not a watertight physical sign, as a tight inguinal ring may suggest the absence of an indirect hernia. Exploratory surgery has often refuted the reliability of this test, with indi- cations of early hernia-type changes in the external oblique and posterior wall.

The typical history of the injured player includes: ● A specific moment of trauma ● Formation of a visible haematoma in the lower abdomen, genitals and adductor region ● Associated sharp pain, swelling, temper- ature, discoloration and loss of function ● Constant pain ● Muscular injury to the lower abdomen and adductor regions (often delayed awareness) ● Unilateral symptoms

Treatment tends to be conservative initial- ly, even though there are more external signs than those of the degenerative her- nias, to allow the acute symptoms time to settle. Surgery may well be necessary if the player fails to make sufficient functional progress within 2-3 weeks, with the appro- priate medical and rehabilitative care.

Abdominal repair and adductor release pro- cedures are totally dependent on the symptoms of the individual. This is not to say that PAWD injuries (non-traumatic groin injuries) do not occur in rugby play- ers. With league and union both being pro-

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