DIAGNOSIS AND TREATMENT

DIAGNOSIS AND TREATMENT OF INGUINAL CANAL DISRUPTION

- A COMMON CAUSE OF GROIN PAIN IN ATHLETES

By David Wales MCSP MSc

INTRODUCTION Inguinal canal disruption occurs frequently in sports such as soccer, rugby, hockey, and gaelic football. Azurin et al (1) have reported that 80% of athletes who presented with chronic groin pain were found to have inguinal canal disruption upon surgical investigation. Beddy (2) has postulated that up to 10% of the population suffer from an inguinal hernia at some time in their life. Generally, hernia repair is the most commonly performed general surgery procedure (3) with almost 800,000 cases per year in the US.

Numerous conditions affecting the inguinal canal have been described in the literature - sports hernia, inguinal hernia, Gilmore's groin, posterior abdominal wall disruption and posterior inguinal wall disruption. The common finding in these conditions is inguinal canal disruption, although the common nomenclature tends to be a 'hernia', whether there is a hernia present or not.

External oblique muscle Internal oblique muscle Transversalis fascia

Deep inguinal ring

Liguinal ligament

Conjoined tendon

Superficial inguinal ring

The most common forms of inguinal canal disruption in professional soccer players are inguinal hernia and Gilmore’s groin. An inguinal hernia refers to any protrusion of the abdominal con- tents through a weakness in the posterior wall and crural orifices of the inguinal canal. Inguinal hernias are classified as either ‘indirect’ and 'direct'. Indirect inguinal hernias are the most common type of hernia, occurring in a pre-formed sac within the inguinal canal.

Lacunar ligament

Figure 1: The anatomy of the inguinal canal 16

Spermatic cord

Symptoms of an indirect inguinal hernia include groin pain and visible bulging on exertion, and a positive cough reflex can occur in any age, without sporting or work related stress. In contrast 'direct' inguinal hernias are acquired due to work and sporting exertions. They account for 10-15% of all herniae. Direct inguinal hernias develop through the posterior wall of the inguinal canal. There is no visible bulging.

Gilmore’s groin is characterised by a torn external oblique www.sportex.net

For such a common condition, there is still a lack of consensus over the management of inguinal canal disruption. This article aims to give an overview of the most common conditions that affect the inguinal canal in sporting individuals.

PATHOGENESIS The inguinal canal is the region between the abdomen and inner thigh, through which the testes and spermatic cord (or round ligament in females) descend. The posterior wall, or ‘floor’, of the inguinal canal is formed by the transversalis fascia and the conjoined tendon of the internal oblique and transversus abdominus muscles, which is attached to the pubis at the point directly behind the superficial inguinal ring. The anterior wall of the inguinal canal is formed by the external oblique aponeurosis, with the termination of this aponeurosis at the inguinal ligament forming the inferior boundary of the inguinal canal (4).

A range of pathological findings involving the inguinal canal have been described, including tears of the external oblique aponeurosis (5-7), herniation through the posterior inguinal wall (8), tears to the internal inguinal ring and internal oblique muscle (9), torn conjoined tendon detached from the pubic tubercle and dehiscence between the conjoined tendon and inguinal ligament (5).