INGUINAL CANAL DISRUPTION CLINICAL TIP

Remember, forces across the anterior pelvis are implicated in the aetiology of several of these conditions. Athletes who are subject to these forces may be suffering from two or more of these conditions concurrently.

be able to continue playing their sport, but the problem usually gets progressively worse. The pain is rarely excruciating and is often described more as ‘discomfort’. The most frustrating complaint is the inability to twist, turn or kick a ball properly, together with a loss of speed. This has an adverse effect on sporting performance.

Over a period of months there can be a significant deterioration in functional ability during sports. This frustrating decline is often compounded by a torturous referral pathway. It is not unusual for these patients to have been referred via several healthcare professionals, without effective treatment largely due to the difficulty of providing a definitive diagnosis. Several diagnostic investigations may have failed to show the underlying cause of the problem and these merely add to the diagnostic confusion.

Pain in the groin and pelvis can be referred from a number of problems in the groin and pelvic region, as well as injuries to the lumbar spine, the hip joint, the sacro-iliac joint, the abdomen and the genito-urinary system (see Table 1). This means that the diagnosis of inguinal canal disruption requires skilful differentia- tion. The diagnosis of inguinal canal disruption is based on the patient’s history and clinical signs. The most notable clinical sign is dilation of the superficial inguinal ring on the affected side, which can be palpated when the scrotum is inverted with the examiner's finger. The scrotal sac is inverted upwards following the direction of the spermatic cord. Dilation of the superficial inguinal ring and/or pain is a positive sign of inguinal canal disruption.

Where an inguinal hernia is present, this can be visualised using ultrasound scanning. The hernia protrusion can be seen to push through the posterior inguinal wall when the patient increases intra abdominal pressure by straining. In the case of Gilmore's groin, dilation of the superficial inguinal ring can be the sole objective finding. Because there is no herniated tissue, imaging cannot confirm the diagnosis.

MANAGEMENT STRATEGIES AND TREATMENT Conservative treatment cannot cure inguinal canal disruption. Conservative treatment can be used to improve sporting function and may allow an athlete to continue to compete for a period of weeks or even months, but it will not resolve the anatomical disruption of the inguinal canal. Physiotherapy treatment involves stabilising and strengthening the muscles of the pelvic region. Typically the athlete continues to perform wearing warm pants, until an opportune time can be arranged for surgery.

Inguinal canal surgery has evolved as surgeons continue to further understand the functional anatomy of the groin region. A range of surgical techniques can be applied to the spectrum of pathologies that are characterised by inguinal canal disruption. Many surgeons now perform inguinal hernia surgery under local anaesthetic. Depending on the individual circumstances of the patient, considering their age, occupation, general health and the size and

www.sportex.net

degree of the inguinal canal disruption, the surgical technique is chosen which is ‘tailored’ to the patient’s situation. ‘Mesh’ techniques have been developed for patients who have large defects in the wall of the inguinal canal or for older patients where the abdominal wall is weak. A square surgical mesh is stitched onto the muscle layers of the abdominal region in order to repair the hernia.

The minimal repair is an out patient technique that has been developed by Professor Ulrike Muschaweck of The Hernia Center, Munich. It is a mesh free technique which is used for patients who have a big defect in the transversalis fascia, while the muscle layers are still intact. A local anaesthetic is used and the patient can walk out of the operating room.

Gilmore’s groin repair is done under a general anaesthetic. The transversalis fascia and torn conjoined tendon are sutured. The repaired conjoined tendon is re-attached to the pubic tubercle and inguinal ligament; and the torn external oblique aponeurosis is repaired with sutures. The wound is closed with subcuticular sutures and steri-strips. Discharge from hospital is normally the day following surgery.

THE AUTHOR David Wales is a clinical specialist physiotherapist who has worked full time for Arsenal Football Club for the past six years. After graduating in physiotherapy at the University of Manchester, he was awarded a Masters degree in Sports Medicine and Rehabilitation from the University of the West of England. David is also Medical Director of www.PhysioRoom.com - the UK’s leading sports injury website.

References 1. Azurin DJ, Go LS, Schurit A, McShane J et al. Endoscopic preperitoneal herniorrhaphy in professional athletes with groin pain. Journal of Laparoendoscopic and Advanced Surgical Techniques 1997; 1:7-12 2. Beddy P, Ridgway PF, Geoghegan T, Peirce C, Govender P, Keane FBV, Torreggiani WC and Conlon KCP Inguinal hernia repair protects testicular function: A prospective study of open and laparoscopic herniorraphy. Journal of the American College of Surgeons 2006;1:17-23 3. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. The Surgical Clinics of North America 2003;5:1045-1051, v-vi 4. Teague DC. Inguinal anatomy and retropubicvascular hazards of the ilioinguinal approach. Operative Techniques in Orthopaedics 1997;3:175-183 5. Gilmore J. Groin pain in the soccer athlete: Fact, fiction and treatment. Clinics in Sports Medicine 1998;4:787-93, vi. 6. Williams P, Foster ME Gilmore’s Groin - or is it? British Journal of Sports Medicine 1995 29(3):206-208 7. Brannigan AE, Kerin MJ, and McEntee GP. Gilmore’s Groin repair in ath- letes. The Journal of Orthopaedic and Sports Physical Therapy 2000;30(6):329-332 8. Malycha P, and Lovell G. Inguinal surgery in athletes with chronic groin pain: The sportsman’s hernia. The Australian and New Zealand Journal of Surgery 1992;62(2):123-125 9. Simonet WT, Saylor HL III et al. Abdominal wall muscle tears in hockey players. International Journal of Sports Medicine 1995;16(2):126-128 10. Primatesta, P and Goldacre, MJ Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality, International Journal of Epidemiology 1996;25 (4):835-839 11. Fruchaud H. Anatomie chirurgicale des hernies de l’aine Gaston Doin & Cie, France, 1956 12. Lau H, Fang C, Yuen WK and Patil NG. Risk factors for inguinal hernia in adult males: A case-control study. Surgery (article in press available online 31 July 2006)

19