INGUINAL CANAL DISRUPTION

and the superficial inguinal ring. This gender difference in anatomy has been proposed as the reason why the incidence of inguinal canal disruption is higher in males. Primatesta and Goldacre (10) estimated that the lifetime risk of inguinal hernia in men is about 27%, which is 9-fold the risk for women. Rutkow (3) states that inguinal hernia repairs are carried out at a 12:1 male:female ratio in the United States.

Fruchaud (11) classically stated that the essential conditions for the development of inguinal canal disruption are: i) increases in intra abdominal pressure (provided by work and sports) and ii) weaknesses in the posterior wall of the inguinal canal and crur- al orifices

aponeurosis (producing dilation of the superficial inguinal ring); torn conjoined tendon detached from the pubic tubercle; and a sep- aration (dehiscence) of the conjoined tendon from the inguinal lig- ament. There is no herniation with Gilmore’s groin.

In men the spermatic cord descends through the inguinal canal, through the myo-pectineal orifice, between the deep inguinal ring

TYPICAL PRESENTATION

It is widely believed that the tissues which form the inguinal canal are subject to shearing forces during sports and work activities, but there is no objective evidence for this. However the tissues of the inguinal canal can become stretched during kicking and other movements that require an extreme range of hip abduction. This stretched tissue is then subject to an outward force from intra abdominal pressure. During standing normal intra abdominal pres- sure is around 15-20 mmHg. When straining during work and sports this pressure can rise to between 100 and 150 mmHg (11). The transervalis fascia, oblique muscle layers and conjoined tendon can become stretched as a reaction to extreme strains during this stress

TABLE 1: DIFFERENTIAL DIAGNOSIS AND POTENTIAL CAUSES OF GROIN PAIN DIFFERENTIAL DIAGNOSIS

Tendinopathy in the adductors/ Gradual onset, worsening with activity. Can be iliopsoas/rectus femoris

localised with muscle testing. Osteoarthritis of the hip Acetabular labrum tears

Stress fractures of the pelvis and hip

More prevalent with advancing age. Capsular pattern; Trendelenburg gait.

History of hip trauma during work or sport. Pain or 'catching' on specific hip movements.

pain in the hip and groin region, which may refer down the thigh.

Slipped upper femoral epiphysis Onset aged 10-14 typically. Vague groin, hip and thigh pain, may be accompanied by a limp.

Osteitis pubis/pelvic instability Gradual onset of groin and pubic pain. Acute tenderness on palpation of the pubis.

Lumbar spine pathology Obturator nerve entrapment Benign bone tumours Varicocoele Genito urinary problems www.sportex.net Facet syndrome and herniated disc at L1 - L2

levels can produce referred pain in the groin region. Back pain may not be present.

Exercise can induce pain and there may be pain and weakness on hip adduction.

Can produce vague hip and groin pain with a gradual onset that may be exacerbated by activity.

‘Bag of worms’ swelling that disappears when lying supine; maybe accompanied by an ache in the groin.

Pain and/or discharge with micturation. Swollen testes. Skin changes.

17 Nerve conduction studies X-ray Frog view x-ray ■ Stork x-ray

■ MRI ■ Corticosteroid injection

MRI Lx spine INVESTIGATIONS MRI preferable to US as a wider picture

of pathology can be seen. Isolated US can sometimes miss extent of tissue damage.

X-ray

MRI arthrogram (CT arthrogram if loose bodies suspected)

Gradual onset, exacerbated by activity. Diffuse aching MRI