here is a link to a brief article that shows the nerves that can be irritated in the sports hernia

its an article on groin pain with some fairly weak graphics for description, yet they are so good since they are very informative. i have mentioned before the entrapment of the ilioinguinal and iliohypogastric nerves, as well as the genital branch of the genitofemoral nerves, and how scar tissue from injuries like the sports hernia can form in the inguinal area and cause nerve pain. these neuromas can form from microtears and can cause chronic pain.
http://www.capitalherniacenter.com/groin_pain.htm

more pics

http://www.sportnetdoc.com/injury/09-02.htm

a great, detailed article on the groin anatomy

this one is very detailed, hard to read, but explains a lot of the terms you read about when researching groin pain and sports hernias.

http://www.medscape.com/viewarticle/420354_2

good article on sports hernia variations

here is a link to an article that explains the variations of sports hernias, ie slapt shot gut, disrutption, and the like.
in the article, tears in obliques, conjoint tendon, transversalis fascia, and more are discussed.

http://64.233.169.104/search?q=cache:OdWYwh4cI3sJ:www.smbs.buffalo.edu/ortho/journal/sportshernia.pdf+mri+to+diagnose+hernia+lipomas&hl=en&ct=clnk&cd=10&gl=us

i'd really like to see some comments and/or posts

i'd like to know that this blog is serving a purpose. it gives me drive to post more often.
as i do this research i am thinking of all the people out there with similar groin pain. i really am doing this in order to help educate people who are in need of solving this pain when the doctors don't know what to do. in my own injury, if i hadn't done all this research i'd still be screwed because there were no doctors that were able to help. some were not even willing to help since they thought that my condition might have been psychsomatic, which we all know is a heap of crap. any doctor who doubts that the sports hernia exists is only fooling themselves and showing us that they need some continuing education.
so, please post some comments or questions or complaints or whatever. it costs nothing to register to be able to post, and takes only a couple of minutes. to those that did post, i thank you for doing so, it makes me feel like this blog is worth my time by being able to lend a hand to those who need it.

inguinal ring and oblique tearing

in tearing the external oblique aponeurosis, the ilioinguinal and/or iliohypogastric nerve(s) can be entrapped in scar tissue or may simply be irritated by the layers of muscle sliding across one another during movements. think about it- two layers of muscle, fairly thin, with nerves not only passing through the muscle itself but also in between the two layers. each layer is responsible for your torso moving/twisting/bending in unique ways; the grain of the muscle fibers run in different directions for each layer.
note the inguinal ring's location along the obliques. think about how that ring can be stretched or even torn. note the nerve bundle and veins that pass through that ring. when that ring is physically altered, don't you think that that vascular and nervous bundle would also be alterted and irritated?
incidentally, that bundle also contains the spermatic cord. under the cord is the genital branch of the genitofemoral nerve. naturally, an injury in this area can cause nerve irritation which equals pain in the pathways of those nerves and the spermatic cord.

nerve pathways and how they relate to your groin pain

this is a very good article that informs the reader, with great images, of specific nerve pathways in the pelvis. i found this to be a good tool for understanding the nerves that are indicated in sports hernia and related or co-injuries.
http://www.pelvicpain.org/resources/2004Presentations/Peripheral%20Subcutaneous%20Stimulation.pdf

nerve pathways

many people with this condition feel pain along the pathways of these two nerves. in the ap injury, the genital branch genitofemoral nerve (not pictured here) is also injured and inflamed.

torn external oblique aponeurosis

sometimes in sports hernia injuries, the sufferer can also have an injury to the aponeurosis of the external oblique and/or the muscle itself. this happens most often in hockey players, and has been termed "hockey groin syndrome." the tearing of the tissue can cause scarring and entrapment of the ilioinguinal nerve.
i am not sure if some methods of ap surgery can actually see this tearing in addition to the transverse fascial tearing that is always tended to.
the ilioinguinal nerve has been the cause of chronic groin pain for many people. the path of the nerve passes right down to the pubic bone and branches off from there....if it is entrapped and irritated enough, there can be nerve cross-talk in the area which can only make matters worse for the sufferer.

anatomy view of pelvis and abdomen

note the nerve pathways

and the muscles. the psoas can play a large part in the pain and dysfunction associated with long-term sports hernia.

a good picture of the transversalis fascia and surrounding structures

the transverse fascia is what is stretched and/or torn in the sports hernia. sometimes the oblique aponeurosis is as well.

visceral manipulation for buildup of scar tissue around groin

this is an osteopathic approach developed by respected osteopath jean pierre barral of france. he has spent over 30 years working on this manual therapy as a way to relieve a person of chronic pains and ailments. it is essentially osteopathic manipulation of the organs in the abdomen, pelvis, and chest. it can work wonders for those who have suffered extensive damage during a long-term sentence with a sports hernia. it can help undo some of the nerve irritation and then some.
http://www.iahe.com/index.jsp for more info.

scar tissue as cause of chronic pain in sports hernia injuries

the sports hernia involves stretching and possible tearing of soft tissues in and around the groin.
unfortunately, there is often a period of time between the actual injury onset and the treatment of this condition in which compsenatory patterns and strains develop within those involved muscle groups. these strains that happen can cause microtearing of the tissues that are being strained. tendons, periosteum, muscle fibers, fascia, can all be damaged through movements that cause strain. the result is scar tissue.
scar tissue is well known to cause pain in bodies that have suffered damage whether it be from injury or surgery. the hard tissue can press against a nerve, or may act as a distruption or interference point within the fascial system. scars can cause tugging of tissues and organs within the body, causing pain and nerve irritation.
lj smith, a football player for the philadelphia eagles, underwent sports hernia surgery in summer of 2007. a few months later, despite physical therapy efforts, he was still in pain and had to undergo more surgery to clear out painful scar tissue that was a result of the injury and its microtears.
so some of you who are still experiencing post op pain can feel somewhat confident that there is a bunch of scar tissue in there. who knows whether or not it is the cause of pain. my surgeon told me that my nerve irritation is due to scar tissue. that is why i began structural integration treatments and then neural therapy treatments to follow. both modalities tend to scarring.
structural integration: http://theiasi.org/index.php
neural therapy: http://www.neuraltherapy.com/

ilioinguinal nerve

this nerve seems to be a major problem with sports injuries...it can be entrapped when there is all kinds of tissue damage in the groin. that is one of the nerves that i have entrapped form the sh injury and associated microtearing with such a long tiime of misdiagnosis. it will cause pain through the inguinal area as well as adductors (off corner of pubic bone), testicle, hip, si joint area, and the root of the penis (ouch!). keep that in mind when you see a ur for your problem...

lots of info

on the letsrun.com site, under message board, do a search for sports hernia. i have been posting there under the name johnny for quite some time. the forum has been invaluable to many including myself.
i still post there all the time since i don't know how many people use this blog to help them through everything.
but not everyone runs nor will find that site. that is why i started this one.

more later.

neural therapy, pt 1

a week ago i had some neuraltherapy injections along with manipulations performed by a skilled osteopath. one theory with neural therapy is that it works via releasing scar tissue in the body, allowing proper energy to flow through the nervous system. i happen (happened?) to have a TON of scar tissue around the left inguinal area and above the pubic bone. much of this tissue had been released with the structural integration sessions that i have been through, but due to the nature of the nerve pain, some of that scar tissue was/is just too tough and the nerves too deep to tend to it with fingers alone (at least that is my understanding of it).
the doctor pointed out my scars on my left knee (where i have had 2 surgeries and pain issues) and shot them up first, immediately afterwards working the scars with what felt like pretty great force. apparently that caused a good release in the groin scarring.
then cam injections into the sports hernia scars themselves, plus just above the pubic bone, and another into a trigger point along the edge of the rectus. again, he worked over the scars.
i felt pretty immediate relief, but then again i had anesthesia in me. but the tissues were much looser feeling.
i went through the next 2 days feeling ok till after i swam for about 45 minutes then rode a bike on flat pavement for about 15 minutes. since then i have had flareups of sharp pains like i remember in the beginning of some of the structural integration sessions.
today is one week later and i swam 45 minutes this morning, and just got in from a 1 hour walk with hills involved. i feel pretty good, and the scar tissue is still much softer than it was before the shots.
i am scheduled for more injections (etc?) in 2 weeks.

chronic nerve pain and the sports hernia

there have been lots of studies on chronic pain and how it comes to be. of course the AP injury can be the cause or such a nerve dysfunction. the groin contains many sensitive nerve endings.
we know that the genital branch of the genitofemoral nerve is affected in the sports hernia.
the ilioinguinal and iliohypogastric nerves can also be involved, especially if osteitis pubis sets in. as the rectus retreats from the pubic bone, those two nerves would tend to get irritated by the fascial changes.

another thing to consider is scar tissue, especially for those cases where the tear is severe enought to cause pain and is left untreated, while the condition worsens such as with an sports hernia-> osteitis pubis setup. as the microtears continue to happen, there will be more scar tissue growth. that scar tissue alone can irritate nerves, especially if it grows around the nerve, causing nerve ending entrapment.

with chronic pain, this long-term irritation has worked its way into the nerve ganglions up into the roots (found along spine). this basically means that the nervous system has reset its default settings and may be firing pain signals all the time, even after the injury has healed. with AP being an elusive diagnosis, one can see how this condition of chronic nerve irritation can happen.
more later.

another doctor is excited to learn about the sports hernia

so i had an appt with an osteopath who works in a neurology group. she used to practice prolotherapy in her own practice, but unfortunately insurance won't cover prolotherapy (of course not, right?) and she couldn't afford to keep her own practice. she no longer practices prolotherapy in the group she now works with.

i told her my story and she told me that she has a patient who is a physical therapist who has all the symptoms i described. she believes now that he has ap. he also was misdiagnosed with epididymitis then non-bacterial prostatitis. then eventually groin strain. then the next. years later he is still in pain. she actually listened to my story, unlike previous doctors, and was open to learning more about this injury since she was an authentic and good doctor. i didn't feel like a patient that was viewed as either a pain in the ass with a phantom, probably psychosomatic, injury- quite the contrary.

well, another doctor learns about the dreaded injury. 9 months ago, i had a young and athletic hernia specialist say he doesn't even believe ap exists and it's a crap story. perhaps we can all share the info with our doctors and hope they will listen and learn about the injury on their own time. if you want, email me and i can send you a copy of an article written by an expert ap surgeon. you can print it out to mail to doctors that told you that you have anything but ap since they have never heard of it.

going to receive neural and prolo therapies

as stated in the earlier post (one below), these two therapies can hopefully help with lingering nerve pains due to the damage that ap can cause.

i have an appointment with a doctor in nyc next week who does both these treatments plus others, and has treated ap before. at last a doctor near me who apparently knows the injury!

i will report on what he says after my first appt. if any of you sufferers are from nyc area, and think you want to see this doctor, contact me and i will get you his info.

neural therapy and prolotherapy

i recently learned that neural therapy is used in germany to tend to the nerve pains brought about by ap. i know they use a special approach with the neural therapy, but i am not sure how that differs from the neural therapy i have read about online.

from what i have learned, the dreaded sh injury can cause your body to go into all kinds of musculoskeltal imbalnces (which also can be a predisposition to ap). the si joint can go out of whack, which in itself is very painful (take it from me).

prolotherapy is commonly used for strengthening up the connective tissues at problem areas/joints such as a hypermobile si joint. it is also used for relieving pain from such injuries.
neural therapy is used for pain via a neuropathy of sorts as well as nerve pain from scar tissue. injections are both placed into scar tissue and also into the nerve root. apparently it is great for chronic pain such as with a long-standing ap injury.

not too many doctors do these therapies. in fact it is very hard to find good ones with experience. but if you suffer from lingering nerve pain then it might be worth it to find one or two docs to choose from.

recovery from nerve pain due to ap

dr muschaweck in munich recommends taking a lot of vitamin b (in particular 6 and 12) as well as painkillers like advil. high doses should be ingested.

over in munich, when there is a patient with lingering post-op pain, she often sends them to see a homeopath who administers treatments. of course, homeopathy does originate in germany, so maybe that has something to do with it. but, the main doctor for bayern munich, the respected team from munich, is a homeopath that is respected all over europe.

this homeopath agrees with dr muschaweck in that no physical activity can be resumed until the nerves have calmed down, which can take a good long while if the patient has suffered from the injury long enough. in my personal case, i had the pains very bad for 18 months pre-op. but, i beleive i began the injury in 1999, and then had a second bout of bad pain, perhaps a worsening of the condition, again in 2002. so who knows how long i really had the condition. that said, i am not sure if the dr would consider me as having the injury for 18 months or 5 years before surgery.

some signs and symptoms of a sports hernia

many people have groin pain that is chronic. sufferers of athletic pubalgia have symptoms that also exist in numerous other pathologies.
obviously, the worse the injury, combined with chronicity of the condition, can have a exacerbating effects of the symptoms. it can also be noted that a chronic sports hernia causes muscle imbalances in the pelvis, back, and legs which in themselves can be painful but repairable conditions. here are some syptoms reported by some sufferers...

• dull ache, often accompanied by sharp pains, especially after activity involving hip flexion and/or twisting. such an activity can be as simple as raking leaves or someting more demanding such as playing soccer or moving furniture.
• pain is often felt off of the corner of the pubic bone, and can radiate to the testicle(s) in males.
• there is almost always accompanied adductor muslce tightness and often pain in the adductors. it can be difficult to adduct (squeeze them together) the leg(s) because of this.
• pain can also be felt while twisting, from the pubic bone up to the inguinal ligament. this pain can also wrap around to the hip and lower back.
• there can be irritation of the nerves that travel to the perineum and genitals.
• it can be painful to externally rotate your bent leg, but it can also hurt to internally rotate your femur. this can be interpereted as a pathology involving the hip. attempting to kick a soccer ball with the inside of your foot is such a movement that can induce sharp pain, as can sitting cross-legged, or "Indian style."
• there can be intense pain while trying to get up out of bed, causing the sufferer to need to roll off of the bed as opposed to sitting up first.
• in general, bearing down, as in coughing, can be painful, just as in an inguinal hernia.

a couple of misdiagnoses

some conditions are "diagnosed" when a sports hernia might actually be the culprit:

1) pulled groin/groin strain: so while one may in fact pull/strain the groin or adductor muscles during sports or the overload that a sports hernia is caused by, a patient who see such a chronic groin strain that will not go away should seek out more advice from a more experienced doctor of physical/sports medicine. sure the injury can be chronic, but if you are in doubt of the diagnosis, and the mri doesn't show any tears....

2) inguinal hernia: as we know, ap/sports hernia is NOT an inguinal hernia. if a doctor tells you it is, and he has never heard of AP, then he or she is in left field. if an inguinal hernia was also called AP, you would think that any doctor would have heard of it by now, considering thousands of inguinal hernias are diagnosed every day. i had to tell this to several orthopedic surgeons, even after the surgeries i had for AP. one of them would not budge, so i printed out info on sports hernias and mailed it to him (needless to say, i have no interest in going back to see him)! when i left his office, he told me i have something totally unrelated, which was proven wrong by the next 2 practitioners i saw afterwards.

3) non-bacterial prostatitis (chronic): obviously applies to only males. since the phantom pains are in the groin, your doctor might send you to see a urologist. the ur will natrually assume that the problem is under his speciality range and will do his/her best to diagnose you. when the nerves around the groin are irritated (such as when you get kicked in the groin), the body reacts by tightening up the muscles in that area. with severe, chronic nerve irritation, the tissues will also be chronically tightened. such a scenario can cause the prostate gland to be swollen as well, seeing how the gland is attached to the pelvic floor via connective tissues. the ur won't think of this, and if you suggest a muscular issue (like i did), he might tell you that you are wrong and you have this mysterious swelling in your prostate that might be caused by a bacteria, which they cannot find. hmmm, makes you wonder. this is what happened to me, and i was put on levaquin for 35 days! after 7 months, i had given up on my ur and went my own route. chronic prostatitis has no cure as far as the ur's are concerned, basically because all eitologies are theoretcial. that is another reason why all doctors should have basic knowledge of sports hernias and their prevelence; chronic prostatitis is a much worse diagnosis than a sports hernia.

there are more to come...

to stretch or not to stretch?

i did a bunch of stretching before my surgeries (as instructed by a pt) as well as afterwards.

for the last 2 months i have not been stretching, and it has made a difference. an irritated nerve can be more irritated by stretching it. it would make sense to me, that a deep lunge/psoas stretch would more than likely irritate those nerves that are located in the fascia of the psoas. note the nerves that are often irritated in the sports hernia: ilionguinal, iliohypogastric, and genitofemoral nerves.

i wish a doctor would post here and provide insight on the irritation of these nerves. from what i understand, in many cases of ap there is a tearing of the obliques. the ilioinguinal and iliohypogastric nerves pass bewteen the layers of obliques. i can only assume that is why reaching overhead and twisting is painful to so many that suffer from this injury.

so, i think that stretching was bad for me. that is, until the nerves really began to calm down through a period of NOT STRETCHING. by the time i had my surgeries, i was no longer in shape, in fact, i had lost about 27 pounds due to lack of mobility and desire to eat due to pain, and sickness from the antibiotics i was carelessly put on.
as my nerves are slowly becoming less irritated, my mobility has begun to really come back. i can bend over without pain most of the time.

recoup time different for everyone

this is the lesson i need to learn myself. an example of one who took a long time to recouperate: nba star grant hill had actually retired due to this injury and, i think, post-op pains that lingered on for a long time. now he is back in action and playing.

another example: hockey goaltender dominick hasek went through the 90's with a chronic groin injury and had to eventually retire after being in and out of the game. since then he has found the right doctor and thus had surgery. now he is playing again. what i find interesting is that he definitely was pushing himself despite the injury, which i would think could make the nerve irritation (the pain of the injury) worse. at least that would make sense. goalie spilts (butterflies) and whatnot could be very taxing on abdominal and groin tissues that are already damaged.

there are more examples.
the bottom line is, the doctors who do this surgery really don't know how long it takes to recover. if you are a paid athlete, chances are you are monitored better than non-pros, thus you can get surgery in prompt time: thus better the chances you can recover properly. but as you can see that is not necessarily true just from looking a the two above examples.
if you have no helpful doctors near you, then it is really up to you to find the right doctor/physio/pt/etc that is willing to listen to your story and maybe a good physical therapy or similar protocol can be developed to your individual case.

i too am guilty of worry that i will not recoup enough to function without pain. but i am slowly seeing the light at the end of the tunnel, thanks in part to others that have suffered and shared their stories. mine has been a long recovery but then again my case is different than many in the fact that i also had developed postural issues in my back, hip, knee, and ankle. these things oocured from years of wear n tear and unattended injuries. the sports hernia was probably just the icing on the cake. it is common that people develop compensatory patterns and thus painful muscle imbalances when they are chronically injured. in the case of ap, the longer you go with it, the worse imbalances become. i was out of balance before my injury became full blown. add 18 months of misdiagnosis, and *whammo*...

link to a loooong thread on sports hernias

most of you have probably found this already, but a good discussion on sports hernias can be found on a thread here:
http://www.letsrun.com/forum/search.php?board=1

type in "sports hernia" in the search bar and go from there. people discuss their personal stories in dealing with the injury.

A better definition of a "sports hernia"

It is not a true hernia. It is when the posterior inguinal wall has been overstretched due to movements such as in athletics, and is thus causing pressure against a nerve. There is no visible inguinal hernia but instead there is swelling of that stretched the posterior wall tissue. This swelling can be felt with an experienced finger, and an ultrasound can help confirm the diagnosis.
The transversalis fascia (the encasing around the transverse abdominus muscle) becomes dilated at the weakest point in the inguinal wall (called Hesslebach's Triangle), causing the weaker tissue to widen. At that point, when the sufferer tenses his/her abdominal muscles such as while working out, the swelling increases and more pressure is placed on the sensitive nerve that passes behind the posterior inguinal wall.
The nerve that is irritated is the genital branch of the genitofemoral nerve.
As the Hesslebach's triangle tissues widen, it yeilds an increase in pressure on the rectus abdominus muscle and the rectus then retracts away from the pubic bone. That is what can cause the pain along the pubic bone that is commonly seen in athletes with this injury. When this happens it is called pubalgia.

At least that is what I can come up with through all my reading. I hope it helps others to better understand what is going on with their groin pains. I know it helped me tremendously to understand the etiology; that way I can better explain it to a doctor that is willing to listen to patients...

i'm back

sorry about being off the blog for a while. computer issues and whatnot. from now on i will be able to update the blog.

joe and april- sorry to hear of your pains. i know what it is like. i do know of the running forum's thread, i have been on it for a long time now. i will probabll post about this blog on it soon.

this injury can be very painful and unfortunately tends to be undetected due to lack of knowledge on the doctors' parts.
i went 18 months before surgeries for bileteral ap.

i am 10+ months post op and still suffer from nerve pains. my surgeon does not recommend nerve injections yet although i am told that my pains are due to strictly nerve irritation.
i recently had a pelvic mri done (the first one since my accident-no doctor would approve of one till now) which thankfully came up negative but at the same time leaves me wondering how long the pain will stick around.

Doctors

So, you probably know that ultimately, surgery is really the cure for the sports hernia.

There are two doctors in the US that have successfully done many of these sugeries.
1) Dr William Meyers, out of Drexel University in Philadelphia. I have personally spoken with his assistant and have traded emails with the doctor himself. Each of my experiences with communicating with them was excellent. Dr Meyers seems to be genuine in his care of his patients and has performed thousands of these operations on people of different backgrounds, both pro athletes and non athletes. He claims there are 17+ variations of the injury.
2) Dr Cattey out of Wisconsin. I don't know much about him other than some people have had great success with him.

In the world, the most experienced surgeon for AP is Dr Ulrike Muschaweck, who is based in Munich, Germany. She has performed over 14,000 hernia operations. She tends to operate on pro soccer players worldwide, as this injury is more or less common amongst soccer players. She has developed an approach that she calls the "minimally invasive technique." She has a very high success rate. That is who did my surgeries (I had bilateral AP). I had a great experience with her and her staff. She performs 5 to 6 surgeries a day, 6 days per week.
The website for her clinic is www.hernien.de and is worth a visit if you are suspecting that you have a sports hernia. By the way, she only performs surgery in Germany at her clinic, with her experienced staff, so if you want her to do your operations, then you must travel to Munich.

First Attempt

Hello,
If you are viewing this blog then chances are you are having the symptoms of Athletic Pubalgia, also called a "sports hernia," "athletic hernia," and "sportsman's groin," among other names out there. I too am a sports hernia sufferer. This can be an extremely painful condition that can go from bad to worse without warning. Even more disturbing is the lack of knowledge about this injury amongst healtcare professionals. Chances are, you too are having issues with finding the correct answers for why you are experiencing these pains.
Keep in mind that I am no doctor, nor do I claim to have a better understanding of this injury than doctors. However, I have been studying many angles of the sports hernia and related conditions for over 2 years, in an attempt to rid myself of this horrible condition. In doing so I have obtained a decent grasp on what the sports hernia is, and where one can go to achieve relief.
My personal goal is to help others by either providing any information that I have learned as well as to help point people in the right direction when it comes to surgery and rehab. I only hope that I can be of help to those many sufferers.
So please post here as you wish, the more the better. It will be the only way that we as sports herniacs can learn about what we have going on down there. This collaboration can go a long way and hopefully may opend doors for future study of Athletic Publagia.