Introduction: Case Report

A 32 year-old male notices the gradual onset of a heavy “dragging” left groin pain. The pain is intermittent and seems to be associated with coughing, sneezing, or defecation. He then notices that it is worse during deadlifts and overhead presses, most pronounced on lockout. Over the course of several workouts, the discomfort becomes worse. He does not notice a bulge and has no other symptoms. The pain is located above the groin crease and close to the midline. He has no scrotal pain. He has no medical history, but does have a family history of inguinal hernias. After a particularly uncomfortable workout, he presents to his doctor, who finds no groin mass but does appreciate an “impulse” on digital exam of the inguinal canal during Valsalva (“turn your head and cough”). The physician makes the diagnosis of an inguinal hernia and refers the athlete to a surgeon.

Terminology

The term hernia refers to any anatomical situation in which a structure is displaced from its usual body cavity and displaces (herniates) into an adjoining cavity or to the outside. For example, the brain can be displaced from the cranial vault by an expanding mass (blood or tumor) and herniate across the midline, through the tentorium, or down the foramen magnum, the hole at the base of the skull. This is not ideal. Similarly, in the setting of thoracoabdominal trauma, a rent in the diaphragm can cause the stomach and other abdominal contents to herniate into the chest cavity.

In common parlance, of course, “hernia” usually refers to a situation in which abdominal contents protrude through the abdominal wall into the groin area (inguinal hernia), or into the thigh (femoral hernia).

Anatomy

An inguinal hernia occurs when the lower abdominal wall fails and allows contents to displace into a more superficial position in the groin, outside the abdominal cavity proper. The abdominal wall is a complex structure composed of multiple layers of tissue: skin, subcutaneous tissue, layers of fascia, several layers of muscle (including external oblique, internal oblique, transversus abdominus), the transversalis fascia, a layer of pre-peritoneal fat, and the peritoneum itself, which is the lining of the abdominal cavity that contains the peritoneal organs, including the intestines. These layers and their relative coverage and strength are not of course uniform across the abdominal wall, but in healthy individuals they do constitute a thick barrier to protect the ventral abdominal organs, which have little or no direct skeletal protection.

Two areas of interest concern us. The first is the inguinal triangle, also known as Hesselbach’s triangle, after the 18th century German physician and surgeon Franz Kaspar Hesselbach, who was a pioneer in the surgical management of inguinal hernias. Hesselbach’s triangle is a relatively weak space in what we loosely call “the groin.” Its inferior border is the inguinal ligament, also known eponymously as Poupard’s ligament, which runs from the anterior superior iliac spine to the pubic tubercle, and corresponds more-or-less to the “groin crease.” The medial border of the triangle is the lateral border of the rectus sheath – basically the outside edge of your six pack (if you have a six pack, which, if properly trained and fed, you don’t). The superolateral border of the triangle is formed by the inferior epigastric vessels – artery and vein. These vessels are the anatomical landmark that discriminates the two major types of inguinal hernias. It will perhaps be amusing to some that the classic med-school mnemonic for the triangle is RIP: Rectus sheath, Inferior epigastric vessels, Poupard’s (inguinal) ligament. This triangular area has layers of fascia, but is relatively lacking in muscle (even if you do have a six-pack).

The other structure of concern is the inguinal canal, which runs along the inguinal ligament from its deep “entrance” in the transversalis fascia, just above the midpoint of the inguinal crease, to its superficial termination in the connective tissue (aponeurosis) of the external oblique muscle, just lateral to the midline and above the pubis. The deep inguinal ring marks the “entrance” to this passageway, and the superficial inguinal ring the “exit.” In adult males, the inguinal canal contains the spermatic cord (itself a complex structure) on its way to the testes in the scrotum, along with the ilioinguinal nerve. In females, the round ligament of the uterus and the ilioinguinal nerve are in the canal. The deep inguinal ring closes early in life…unless it doesn’t, in which case the individual is predisposed to hernia. The deep inguinal ring and canal are smaller in females, resulting in a lower incidence of inguinal hernia. The relevant anatomy of these structures is depicted in Figure 1.

Pathophysiology

The two primary types of inguinal hernia are the direct inguinal hernia and the indirect inguinal hernia. Technically, the direct inguinal hernia is a herniation of abdominal contents through the abdominal wall medial to the epigastric vessels, while an indirect inguinal hernia is a herniation violates the abdominal wall lateral to the epigastric vessels (Figure 1). However, it is more useful and practical to think of the direct inguinal hernia as a herniation directly through the abdominal wall, and the indirect hernia as a herniation that exits indirectly through the deep inguinal ring.

The indirect hernia tunnels around. The direct plows right through. Surgeons will shriek at this, but I’ve always enjoyed hearing them shout and growl, so it’s all good. This simplification will do for our purposes.

Weakness of the abdominal wall in the area of the transversalis fascia will predispose to a direct inguinal hernia. The abdominal wall weakens with age and sedentary lifestyle, predisposing adults of both sexes to direct inguinal hernia. These hernias exit the abdominal cavity through a defect in the transversalis fascia medial to the inferior epigastric vessels.

Failure of the deep inguinal ring to completely close in development after descent of the gonads will predispose the individual to an indirect inguinal hernia, in which abdominal contents herniate through the deep inguinal ring lateral to the inferior epigastric vessels, protruding some distance down the inguinal canal, sometimes herniating into the scrotum. These hernias are about 25 times more common in males.

In both types of hernias, the most commonly extruded abdominal contents are preperitoneal fat, peritoneal membrane, and small bowel. Other structures can herniate, but these situations are unusual and generally associated with other disease processes such as cancer.

Thus, an inguinal hernia is said to have three components (Fitzgibbons et al 2015):

1. The neck – the defect in the abdominal wall;
2. The sack – the peritoneal membrane that protrudes into the neck; and
3. The contents – the tissue or structures that protrude through the neck into the hernia sac.

A patient may present with a neck or a neck and sack only; it is not uncommon to find a defect without bowel or other contents.

In clinical practice, one way to classify hernias is by their reducibility – whether or not they can be reduced, or pushed back into the abdominal cavity. Hernias that are more acute, smaller in size, and associated with larger defects are generally more easy to reduce, and manual reduction may constitute the entire therapy on a first visit, pending later surgical correction of the defect. A hernia that cannot be manually reduced and is trapped in the defect is said to be incarcerated. This may require urgent operative reduction, at the discretion of the surgeon. Incarceration is not necessarily an emergency situation, but it can lead to a gradual reduction of blood flow (ischemia) to the herniated tissue, or strangulation. Strangulation is a true medical emergency. It can result in dead bowel, which is a catastrophe with a high mortality, and this situation requires immediate surgical evaluation and correction.

Femoral hernias are distinct from inguinal hernias. They occur when abdominal contents herniate below the inguinal ligament and into the upper thigh (Figure 1). They often present, like inguinal hernias, with a groin mass. Pain may be absent. They are less common than inguinal hernias, but more common in women than in men, particularly women who have given birth multiple times. Incarceration and strangulation is far more likely than in inguinal hernias, and the approach to repair is different, although it may involve mesh repair. Because of the relative infrequency of femoral hernias and the relative dearth of literature on their assessment and treatment in athletes, the remainder of this article will focus on inguinal hernias. The frequently-used term “sports hernia” does not necessarily indicate a true hernia. In fact, the use of this term is so varied and lacking in precision that in the opinion of this writer it should not be used in clinical or coaching practice. The use of this terminology in the literature is confusing, as it sometimes includes not only defects in the abdominal wall and subclinical hernias, but also a range of soft tissue-related clinical presentations not associated with herniation, such as osteitis pubis or adductor tendinopathy. These conditions result from defect or injury to soft tissue without herniation, and in this author’s opinion they are diagnoses of exclusion – hernia must be ruled out clinically before these diagnoses should be entertained.

Indeed, at the 2012 conference of the British Hernia Society, the term “inguinal disruption” was adopted to refer to any condition in which the abdominal wall and/or inguinal canal are disrupted, but no herniation is present. Diagnostic and therapeutic approaches will overlap considerably with those of true inguinal hernias, depending on the actual pathology.

Epidemiology

The major risk factors for inguinal hernia are male sex, increasing age, and family history. The risk of sustaining an inguinal hernia increases consistently over time, from about 0.25% in late adolescence to about 4% at the end of the seventh decade of life. This corresponds to the gradual weakening of the abdominal wall with aging, particularly in untrained individuals. A positive family history appears to increase the risk of inguinal hernia, by as much as 800% in some reports. Chronic degenerative diseases of aging, including vascular disease, obstructive pulmonary disease, and kidney disease appear to increase risk in some studies (although see Ruhl et al, discussed below, who found no association with COPD). Again, this is probably due at least in part to the lack of physical activity in these populations. Connective-tissue disorders and collagen-vascular diseases also appear to increase risk.

In a comprehensive and well-conducted analysis of NHANES data, Ruhl et al (2007) found a lower association of inguinal hernia in men with a greater BMI and maximal lifetime weight. For reasons that are not entirely clear, current smokers had a “borderline” lower risk of hernia. Most importantly, the authors found recreational and nonrecreational physical activity were not related to hernia incidence. Similarly, a systematic review by Svendson et al (2013) commissioned by the Danish Working Environment Research Fund, found no compelling epidemiological evidence to support causal associations between occupational mechanical loading or strenuous events and hernia incidence, and pointed out major problems with this literature in general. Their conclusions are similar to others in the literature (see for example Smith 1996). However, Flich et al came to a contrary conclusion in their 1992 case series. The authors retrospectively compared 128 hernia cases to 174 randomly selected controls from the population who had not had an inguinal hernia. They divided the cases into subjects who engaged in little or no effort, light effort, medium effort (including "violent sport," whatever that means), and "high effort" (port loaders, acrobats, and metal melters). They found a relative risk of 23 for hernia between people who engage in high effort and those who engage in low effort and suggest that humans should use machines to lift heavy stuff. Metallurgy and acrobatics are best left to androids and robots, one assumes. These results seem impressive, except the authors don't really give us a good value for the denominator. Even if they had, they don't control for the distribution of men and women in the high effort group – we can assume that most Spanish port workers, metal melters, and quarry workers are male, and males have more hernias because of anatomical and developmental factors. This study might be a major data point for those who implicate effort in the pathogenesis of inguinal hernia, but the methods and analysis are so problematic as to shed little light on the question. In summary, there is no dispositive evidence that mechanical loading is a primary etiological mechanism for the development of inguinal hernias. Genetic predisposition, aging, and abdominal weakness appear to be the principle determinants of risk.

Clinical Evaluation

Diagnosis of inguinal hernia is usually clinical, based on history and physical examination. A history of groin pain, with or without associated effort or lifting, worsened by Valsalva or effort, and a palpable mass in the groin all point to hernia. Physical exam has a high specificity, in the 90%-plus range, when the findings are positive, but sensitivity values in the literature are as low as 75% or less. Occult hernias are a clearly recognized phenomenon, and an inguinal defect may be present even if a mass cannot be palpated. If the history suggests hernia and the exam is not dispositive, imaging with ultrasound, CT, or MRI may be indicated. Imaging modalities can help the physician distinguish between inguinal hernia, femoral hernia, “sports hernia” presentations, and other entities that properly belong in the differential diagnosis, including aneurysms, tumors, hydroceles, epididymitis, and other disorders. This underscores an important consideration: not all groin pain is hernia. The differential diagnosis for this presentation is broad.

Treatment

The range of treatment options for inguinal hernias is fairly broad in principle, but in practice the correct options for the athlete with an inguinal hernia are limited. Conservative therapy or “watchful waiting” for asymptomatic or minimally symptomatic hernias has been advocated in the past for the general population. However, even in the general population, this approach appears only to delay the inevitable. In the opinion of this author, inguinal hernia in a strength or power athlete indicates operative repair.

Repair (herniorrhaphy) can be performed open or laparoscopically. Open repairs come in two major flavors: sutured repair, in which the inguinal defect is closed under tension with sutures; and tension-free mesh repair. Mesh repairs are used more frequently in North America, require less complex dissection than the commonly used Shouldice suture repair, and are strongly preferred unless peculiar circumstances (such as a contaminated surgical field) contraindicate the placement of a prosthesis. Open repair can be done under local anesthesia or epidural.

Laparoscopic repair can use either an abdominal approach, in which the surgeon approaches the defect from the peritoneal cavity, or via a totally extraperitoneal approach by dissecting between the peritoneum and the muscle layers of the abdominal wall, often with a dissecting balloon, as described and illustrated in detail in the 2015 review by Fitzgibbons and Forse. Laparoscopic repair is generally performed with mesh, and is associated with quicker recovery and return to activity and less postoperative pain. It is important to note, however, that lap herniorrhaphy requires general anesthesia. That may not be a big deal to you, but some of us are not particularly sanguine about the prospect.

(Like your Humble Narrator: I intubate other people. Other people do not intubate me.)

Mesh repair is the preferred approach for athletes, but is not without its complications. Like any prosthetic, mesh can become infected, migrate, degrade, fail, or adhere to adjacent structures. Erosion into other tissues can result in perforation, adhesions can result in bowel obstruction, and abscesses and seromas are known complications. In general, however, mesh repair is well-tolerated by athletes and allows conservative early return to training and gradual resumption of heavy activity. A 2018 Cochrane review (Lockhart et al) of the relevant literature found that while both non-mesh and mesh repair were generally effective, mesh repair probably results in less recurrence, reduced hospital stay, and earlier return to function. Repair may involve either a synthetic mesh or a biological mesh; synthetic mesh is stronger and in the opinion of this author is probably to be preferred for strength athletes, although no dispositive data on this point is available.

A curious approach most recently described by Le et al (2020) bears mentioning. In a case series of 93 (the closest to strength athletes among the cohort were football players) the authors report “good outcome” after laparoscopic preperitoneal repair with mesh and adductor tenotomy, to ablate a “dysfunctional traction-countertraction relationship between the adductor (groin) muscles and the weaker abdominal muscles." That’s right: They disconnected the adductor longus at its origin on the pubic bone. The literature on this approach appears to focus on track and soccer athletes, and reports high rates of return-to-play, but the outcome in strength athletes is not at all clear. Re-routing of the tendons to maintain adductor function has been described. Nevertheless, in strength athletes, who rely heavily on adductor function for the execution of heavy compound barbell movements such as the snatch and squat, such a procedure can reasonably be argued to be one of last resort. Careful shared decision-making with a surgeon who understands the patient’s priorities is indicated in such a scenario. I for one would demur. Not these adductors, pal.

Prophylactic Bilateral Repair

This option is debated in the surgical literature. Because inguinal hernia has a strong gender and genetic component, the factors predisposing to herniation on one side will be present on the contralateral side. A 2016 retrospective review by Zheng et al of over 32,000 patients undergoing herniorrhaphy found that 10.8% required contralateral repair within 10 years, with the mean time to repeat surgery being about 3.5 years. On this basis, the authors suggest that “an argument…can be made” for routine contralateral laparoscopic evaluation in the setting of repair. However, a much smaller retrospective review by Saggar and Sarangi (2006) found a lower contralateral incidence, and concluded that prophylactic bilateral repair was not warranted. Kockerling’s review of 9395 cases (2015) found an increased risk of bladder injury with bilateral repair using the extraperitoneal laparoscopic approach, and Jacob’s review of 15,000 cases undergoing transabdominal laparoscopic repair found that complications were twice as likely in prophylactic bilateral repair (1.9% vs 0.9%), but also that surgical experience had a profound effect on complication rate. Lal et al (2010) found no increase in complications with bilateral repair and concluded, provocatively, that unilateral repair was a “job half done.”

On this author’s reading, the question of whether a hernia repair should include prophylactic repair or mesh placement in the contralateral groin is in equipoise, which is a fancy way of saying we don’t know. The matter therefore lies entirely in the realm of shared decision-making between patient and surgeon. Given the rate of contralateral herniation (about 1% per year), if I needed herniorrhaphy, and if my surgeon was highly experienced in the operative approach, I would, as a strength athlete, probably choose to err on the side of bilateral mesh placement.

Training Post-Herniorrhaphy

There is a striking dearth of literature on the proper resumption of resistance training after herniorrhaphy and the incidence of training-related recurrence. Resumption of training before healing of the incision and some consolidation and integration of the mesh would seem to be ill-advised. A layoff of 2-3 weeks, engaging in tolerated active rest, with resumption at very low loading—something akin to a Starr Rehab for muscle belly tears—would be this author’s approach. Once the athlete is moving without discomfort and a week or so of light training has not resulted in misadventure, a moderately conservative reloading with a remedial LP can be safely undertaken in most cases. I have to say that resumption of training is best undertaken with the knowledge and endorsement of the surgeon because (a) that makes sense; and (b) if I don’t say that, they’ll come and get me. Surgeons are fearsome. They’d just as soon disembowel an ER doc as look at him, and they have the skills to do it.

On the other hand, there is absolutely no evidence whatsoever that surgical correction of an uncomplicated inguinal hernia generally contraindicates future heavy training, and a surgeon who avers otherwise has no business doing so unless special circumstances obtain. In an ideal world, you will consult with a surgeon who understands that you are a strength trainee and an athlete, and that you have every intention of resuming training. If on your initial visit the surgeon frowns and says something like “Well, of course you have a hernia, you do all this terrible weightlifting stuff,” you should consider terminating the interview to seek out another surgeon.

Again, we do not know the incidence of training-related misadventures post-herniorrhaphy, but it is prudent to keep some red flags in mind. Failure and re-opening of the incision (dehiscence) can occur. You’ll be the first to know. This situation indicates immediate cessation of physical activity and urgent evaluation. Signs of incisional infection include redness, swelling, pain and tenderness, undue warmth at the site, and discharge. Seek care at once. Abdominal pain, constipation, difficulty with urination, difficulty with defecation or passing gas, nausea, vomiting, and fever all require emergency medical evaluation. This should all come across as common-sense stuff, and it is, but common sense is uncommon. Don’t be dumb. If something doesn’t look or feel right, stop lifting and get it checked right now.

Case Conclusion: 

The athlete underwent physical examination and was found to have a left inguinal hernia. He underwent laparoscopic repair using a preperitoneal “balloon dissection” approach with mesh. After a prescribed layoff of three weeks and an actual layoff of 12 days, he resumed training at very light loading with five sets of 15. After a few days of this protocol with minimal discomfort and no complications, he transitioned to a remedial linear progression without difficulty and subsequently resumed intermediate programming. At 1 year post-op, he had no recurrence and had exceeded his preoperative loading on all lifts.

Summary

Groin pain and groin injuries are common in athletes, and include a range of conditions including inguinal hernia. Inguinal hernias are themselves common entities, representing a failure of the inferomedial abdominal wall to contain abdominal contents. This failure is primarily due to genetic and developmental factors, and inguinal hernias have a heavy male predominance. Diagnosis is primarily clinical, but liberal use of imaging modalities is indicated in cases where the diagnosis is not clear, because the differential of groin pain is broad and includes serious and even malignant entities. Once the diagnosis of inguinal hernia is established, operative repair, either open or laparoscopic, is clearly indicated, especially in athletes. Athletes must have a clear understanding with their prospective surgeon that they intend to return to heavy training. Mesh repair has a very good track record, and synthetic mesh repair would be the recommendation of this author for all individuals engaged in heavy training. Once surgery has cleared the athlete to return to training (usually within 10-21 days), loading should remain light for a brief transitional period before assumption of a remedial linear progression, with conservative increases giving way to more aggressive but judicious loading after a few weeks. Long-term prognosis for the athlete is excellent overall, and hernia repair does not contraindicate any of the major compound barbell movements or any particular level of loading.

The author thanks James Tyburski MD, Associate Chair of the Department of Surgery at Wayne State University and Chief of Surgery at Detroit Receiving Hospital, who reviewed the manuscript.

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