Jerry Weniger, MPAS, PA-C, MEd, ATC UVA Department of Orthopaedic Surgery

3. Incompetent post ab wall - A tear or laxity in the transversalis fascia No clinically evident hernia Entrapment of these afferent nerve fibers within the tearIncompetent post ab wall - A tear or laxity in the transversalis fascia No clinically evident hernia Entrapment of these afferent nerve fibers within the tear

4. “Prevalance in european…..” Post wall def could be congen…… High incidence in males as a result of the embryonic descent of the testes from the abdomen“Prevalance in european…..” Post wall def could be congen…… High incidence in males as a result of the embryonic descent of the testes from the abdomen

5. Prob from anatomic differences rather than greater participation of men in sports Think about hockey or soccer player taking a shot “Intense discomfort over 2-6 months”Prob from anatomic differences rather than greater participation of men in sports Think about hockey or soccer player taking a shot “Intense discomfort over 2-6 months”

6. Some disagreement in literature 2 areas that seem important These movements tend to put stress on the pubic bone where both the lower abdominal muscles and the proximal thigh muscles attachSome disagreement in literature 2 areas that seem important These movements tend to put stress on the pubic bone where both the lower abdominal muscles and the proximal thigh muscles attach

8. Burning type pain may be from nerve involvement 30% will c/o testicular painBurning type pain may be from nerve involvement 30% will c/o testicular pain

9. Forward bending b/c compressing that nerve that is already angry Think about hockey and football players leaning forward in stanceForward bending b/c compressing that nerve that is already angry Think about hockey and football players leaning forward in stance

10. Along pubic symphysis where conjoint….Along pubic symphysis where conjoint….

12. Most common cause of groin pain in athletes adductor strainMost common cause of groin pain in athletes adductor strain

13. So if it’s a Dx of exclusion - exam and imaging should try r/o these other causes of groin pain Avulsion fractures, maybe stress fractures U/S to abd wall=trying in Australia, but not sensitive enough (good for true hernias) Again, X-ray, MRI, and U/S cannot diagnose or exclude the diagnosis of sports herniaSo if it’s a Dx of exclusion - exam and imaging should try r/o these other causes of groin pain Avulsion fractures, maybe stress fractures U/S to abd wall=trying in Australia, but not sensitive enough (good for true hernias) Again, X-ray, MRI, and U/S cannot diagnose or exclude the diagnosis of sports hernia

14. Icing that area is not much fun “sports hernia belt” mis-marketing If and when conservative therapy fails – surgical explorationIcing that area is not much fun “sports hernia belt” mis-marketing If and when conservative therapy fails – surgical exploration

15. Two procedures, each very different from one another, have come to the forefront of surgical management Augmented with placement of….Two procedures, each very different from one another, have come to the forefront of surgical management Augmented with placement of….

16. don’t always address the nerve Successful return to sport in 65-90% of cases – anderson K “hip and groin injuries in athletics” AJSM 2001don’t always address the nerve Successful return to sport in 65-90% of cases – anderson K “hip and groin injuries in athletics” AJSM 2001

19. About 30% pts present with adductor pain – consider tenotomy at surgery time or later with persistent pain About 30% pts present with adductor pain – consider tenotomy at surgery time or later with persistent pain

20. Outpatient center is really Muschaweck officeOutpatient center is really Muschaweck office

21. above picture shows tear of external oblique fascia. The superior and inferior borders are not supposed to be separatedabove picture shows tear of external oblique fascia. The superior and inferior borders are not supposed to be separated

22. Tear of inguinal floorTear of inguinal floor

26. Research Questions Why does surgery work? Is pain coming from tear in fascia or nerve compression/entrapment? Cause? increased abdominal pressure during sporting activities? muscular imbalance? congenital? In general, surgery does vey well – no matter which you do! Several studies show significant improvement with surgery (80-90% RTP @ same level of compet) Not many outcomes (Sweden surg vs conser = conser no work) No surgery #1 vs surgery #2 brings me to how I got involved: UVA study – not enough data yet Question remains whether pain is related to nerve distension (or lipoma/lymph node)In general, surgery does vey well – no matter which you do! Several studies show significant improvement with surgery (80-90% RTP @ same level of compet) Not many outcomes (Sweden surg vs conser = conser no work) No surgery #1 vs surgery #2 brings me to how I got involved: UVA study – not enough data yet Question remains whether pain is related to nerve distension (or lipoma/lymph node)

27. Research Questions Sure it’s longer, but it actually describes the injury….and there’s an acronymSure it’s longer, but it actually describes the injury….and there’s an acronym

28. Tom Brady – 2006 - Quarterback, New England Patriots Marcelo Gallardo – 2008 - DC United Sergei Zubov – 2008 – Defensemen, Dallas Stars Jeremy Shockey – 2008 – Tight End, New Orleans Saints Donovan McNabb - 2005 – Quarterback, Philadelphia Eagles